Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data

Preeclampsia pathogenesis and prediction - where are we now: the focus on the role of galectins and miRNAs

Preeclampsia is a complex, progressive multisystem hypertensive disorder during pregnancy that significantly contributes to increased maternal and perinatal morbidity and mortality. Two screening algorithms are in clinical use for detecting preeclampsia: first-trimester screening, which has been developed and validated for predicting early-onset preeclampsia but is less effective for late-onset disease; and the sFlt-1:PlGF biomarker ratio (soluble tyrosine kinase and placental growth factor) used in suspected cases of preeclampsia. This ratio has a high negative predictive value, allowing for the reliable exclusion of the disease. Both of these screening tests have not met expectations. This review attempts to summarize the current knowledge on the pathogenesis and prediction of preeclampsia and to draw attention to novel biomarkers with a focus on microRNAs and galectins. Although these molecules belong to two distinct biological classes, they functionally converge in regulating placental and immune pathways. Ample evidence supports their involvement in the molecular mechanisms underlying preeclampsia. Based on current knowledge, galectin-13, C19MC members, and miRNA-210 are associated with the trophoblast/placenta and conditions of placental ischemia or hypoxia. Their levels differ significantly in pregnant women at risk of preeclampsia as early as the late first and early second trimester, making them potential markers for predicting preeclampsia.

Targeting oxidative stress in preeclampsia

Preeclampsia is a complex condition characterized by elevated blood pressure and organ damage involving kidneys or liver, resulting in significant morbidity and mortality for both the mother and the fetus. Increasing evidence suggests that oxidative stress, often caused by mitochondrial dysfunction within fetal trophoblast cells may play a major role in the development and progression of preeclampsia. Oxidative stress occurs as a result of an imbalance between the production of reactive oxygen species (ROS) and the capacity of antioxidant defenses, which can lead to placental cellular damage and endothelial cell dysfunction. Targeting oxidative stress appears to be a promising therapeutic approach that has the potential to improve both short- and long-term maternal and fetal outcomes, thus reducing the global burden of preeclampsia. The purpose of this review is to provide a comprehensive account of the mechanisms of oxidative stress in preeclampsia. Furthermore, it also examines potential interventions for reducing oxidative stress in preeclampsia, including natural antioxidant supplements, lifestyle modifications, mitochondrial targeting antioxidants, and pharmacological agents.A better understanding of the mechanism of action of proposed therapeutic strategies targeting oxidative stress is essential for the identification of companion biomarkers and personalized medicine approaches for the development of effective treatments of preeclampsia.

Aspirin 162 mg vs 81 mg for preeclampsia prophylaxis in high-risk obese individuals: a comparative effectiveness open-label randomized trial (ASPREO)

BACKGROUND

In the United States, leading medical societies recommend 81 mg of aspirin daily for the prevention of preeclampsia in women at risk, whereas the NICE guidelines in the United Kingdom recommend a dose as high as 150 mg of aspirin. Recent data also suggest that in the obese population, inadequate dosing or aspirin resistance may impact the efficacy of aspirin at the currently recommended doses.

OBJECTIVE

We evaluated whether daily administration of 162 mg aspirin would be more effective compared with 81 mg in decreasing the rate of preeclampsia with severe features in high-risk obese pregnant individuals.

STUDY DESIGN

We performed a randomized trial between May 2019 and November 2022. Individuals at 12-20 weeks of gestational age with a body mass index ≥30 kg/m2 at the time of enrollment and at least 1 of 3 high-risk factors: history of preeclampsia in a prior pregnancy, at least stage I hypertension documented in the index pregnancy, pregestational diabetes or gestational diabetes diagnosed before 20 weeks of gestational age were randomized to either 162 mg or 81 mg of aspirin daily till delivery, participants were not blinded to treatment allocation. Exclusion criteria were multifetal gestation, known major fetal anomalies, seizure disorder, baseline proteinuria, on aspirin because of other indications, or contraindication to aspirin. The primary outcome was preeclampsia with severe features (preeclampsia or superimposed preeclampsia with severe features; eclampsia; or hemolysis, elevated liver enzymes, low platelet count syndrome). Secondary outcomes included rates of preterm birth because of preeclampsia, small for gestational age, postpartum hemorrhage, abruption, and medication side effects. A sample size of 220 was needed using a preplanned Bayesian analysis of the primary outcome to estimate the posterior probability of benefit or harm with a neutral informative prior.

RESULTS

Approximately 220/343 (64.1%) individuals were randomized. The primary outcome was available for 209/220 (95%) individuals. Baseline characteristics were similar between groups, with the median gestational age at enrollment being 15.9 weeks in the 162 mg aspirin group and 15.6 weeks in the 81 mg aspirin group. Enrollment before 16 weeks occurred in 55 of 110 of those assigned to 162 mg and 58 of 110 of those assigned to 81 mg of aspirin. The primary outcome occurred in 37 of 107 individuals (35%) in the 162 mg aspirin group and 41 of 102 individuals (40%) in the 81 mg aspirin group (posterior relative risk, 0.88; 95% credible interval, 0.64-1.22). Bayesian analysis indicated a 78% probability of a reduction in the primary outcome with 162 mg aspirin compared with 81 mg aspirin dose. Rates of indicated preterm birth because of preeclampsia (21% vs 21%), small for gestational age (6.5% vs 2.9%), abruption (2.8% vs 3.0%), and postpartum hemorrhage (10.0% vs 8.8%) were similar between groups. Medication adverse effects were also similar.

CONCLUSION

Among high-risk obese individuals, there was a 78% probability of benefit that 162 mg aspirin compared with 81 mg will decrease the rate of preeclampsia with severe features. With the best estimate of a 12% reduction when using 162 mg of aspirin compared with 81 mg of aspirin in this population. This trial supports doing a larger multicenter trial.

Fetal death: Expert consensus of the French College of Obstetricians and Gynecologists

Fetal death is defined as the spontaneous cessation of cardiac activity after 14 weeks gestational age (GA). Regarding prevention of fetal death in the general population, it is not recommended to counsel or prescribe rest, aspirin, vitamin A, vitamin D, or micronutrient supplementation; systematically look for nuchal cord during prenatal screening ultrasound; or perform systematic antepartum monitoring by cardiotocography for the sole purpose of reducing the risk of fetal death. It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2. Regarding evaluation in the event of fetal death, it is recommended that a fetal autopsy and anatomopathologic examination of the placenta be performed; chromosomal analysis be performed by microarray testing, rather than by conventional karyotype (with postnatal sampling of the fetal placental surface preferred for genetic purposes); testing for antiphospholipid antibodies be performed, with systematic Kleihauer-Betke testing and for irregular agglutinins; and summary consultation to discuss these examination results be offered. Regarding announcement and support, it is recommended that fetal death be announced without ambiguity, using simple words adapted to each situation, after which the couple should be supported with empathy across the different stages of their care. Regarding patient management in cases of fetal death, it is recommended that: in the absence of risks for disseminated intravascular coagulation or maternal demise, the patient's wishes regarding the timing between the fetal death diagnosis and labor induction should be considered; return home is possible, according to the patient's wishes; in all situations except maternal life-threatening emergencies, the preferred mode of delivery is vaginal, regardless of previous cesarean section(s); mifepristone 200 mg be prescribed at least 24 h before induction; and perimedullary analgesia be initiated at the start of induction if requested by the patient, regardless of GA. Of note, there is insufficient evidence to recommend either the administration route (i.e., vaginal or oral) of misoprostol or prostaglandin type. Regarding the risk of recurrence after unexplained fetal death: the incidence does not appear to be increased in subsequent pregnancies; in cases with a history of fetal death due to vascular problems, low-dose aspirin is recommended to reduce perinatal morbidity (otherwise, evidence is insufficient to recommend the prescription of aspirin); no optimal delay in initiating another pregnancy should be recommended based solely on a history of fetal death; fetal heart rate monitoring is not indicated based solely on a history of fetal death; although systematic labor induction is not recommended, induction may be considered depending on the context and parental request, and considering fetal age, benefits, and risks, especially before 39 weeks GA. Note that if the cause of fetal death is identified, management should be adjusted on a case-by-case basis. Regarding fetal death in a twin pregnancy, it is recommended that the surviving twin be examined immediately upon fetal death diagnosis; in a dichorionic twin pregnancy, preterm delivery induction is not recommended; in a monochorionic twin pregnancy, the surviving twin should be immediately evaluated for signs of acute fetal anemia, with weekly ultrasound monitoring for the first month, though immediate labor induction is not recommended.

Identification of syncytiotrophoblast-derived cf-RNA OPA1 to predict the occurrence of preeclampsia

BACKGROUND

Pre-eclampsia (PE) poses a significant threat to mothers and infants worldwide. Studies indicate that taking low-dose aspirin before the 16th week of pregnancy may prevent approximately 70 % of PE cases, highlighting the importance of predicting PE. Cell-free RNA (cf-RNA) exhibits significant changes in the maternal peripheral blood during early pregnancy, making cf-RNA analysis a promising and less invasive method for predicting PE.

METHODS

The two datasets, GSE192902 and GSE149440, were analyzed to identify differentially expressed cf-RNAs, followed by the calculation of their AUC values Subsequently, these cf-RNAs were validated using placental tissues, as well as late- and early-stage plasma samples collected from both healthy individuals and patients with PE. Furthermore, we performed tissue localization and functional analyses on the ultimate candidate gene.

RESULTS

Mitochondrial Dynamin-Like GTPase (OPA1) emerged as the molecule with the most consistent and statistically significant alterations in placental tissues and serum samples from patients with PE across various gestational weeks. Notably, the combination of OPA1 levels and mean arterial pressure (MAP) yielded an AUC of 0.825 (95 % CI: 0.759-0.879) for predicting PE. Additionally, we verified that OPA1 is predominantly expressed in placental syncytiotrophoblast (STB) cells, and its downregulation negatively impacts STB mitochondrial function, angiogenic potential, and cell proliferation.

CONCLUSIONS

OPA1 holds the potential to emerge as a novel cf-RNA for predicting PE.

[Screening and prevention of preeclampsia using the Fetal Medicine Foundation algorithm]

OBJECTIVE

In order to identify women at high risk of pre-eclampsia and offer them aspirin prophylactic treatment, the Fetal Medicine Foundation (FMF) recommends a first-trimester screening test. The commonly used threshold for aspirin administration is a risk >1/100, which implies treating an important number of patients. We aimed to assess the use of this strategy with a more restrictive threshold: risk >1/70 and evaluate the impact of this strategy on the prevalence of pre-eclampsia with premature delivery in nulliparous women.

METHODS

A before-and-after cohort study conducted from 01/09/2014 to 01/12/2018, including nulliparous women undergoing first-trimester ultrasound at the University Hospital of Toulouse. Between 09/2014 and 09/2016 ("before cohort"), women did not undergo pre-eclampsia screening. Between 01/2017 and 12/2018 ("after cohort"), women underwent targeted pre-eclampsia screening using the FMF algorithm, and those with a risk >1/70 received 100mg aspirin. The primary outcome was pre-eclampsia with premature delivery. A univariate and then a multivariate analysis were performed to take into account potential confounding factors.

RESULTS

Among the 1030 women of the before cohort, 17 women (1.7%) experienced pre-eclampsia with premature delivery, compared to 8 women (1.3%) among the 629 of the after cohort, with no significant difference between the two groups (Adjusted Odd Ratio (95%CI)=0.73 [0.31-1.74]). In the after cohort, 18 women (2.9%) had a risk greater than 1/70 and therefore received aspirin. According to the FMF screening test, 89 women (14.1%) had a risk>1/100, which is the usual threshold for prescribing aspirin for prophylaxis. This means that 71 women had a risk greater than 1/100 but less than 1/70 and therefore did not receive aspirin in this study, even though they would have received aspirin at the usual threshold.

CONCLUSIONS

The screening and prevention strategy for pre-eclampsia using restrictive thresholds did not decrease the rate of preeclampsia with premature delivery.

Aspirin dosage for preeclampsia prophylaxis: an argument for 162-mg dosing

The optimal aspirin dose for preeclampsia prevention remains controversial, with international guidelines lacking consensus on the most effective regimen. Aspirin is a proven intervention for reducing the risk of preeclampsia, particularly when initiated early in pregnancy. Its benefits stem from the selective inhibition of cyclooxygenase-1 (COX-1), reducing thromboxane A2 synthesis while preserving prostacyclin production, thereby restoring the vascular balance essential for placental health. A dose-response relationship has been established, with doses ≥100 mg showing significantly greater efficacy than lower doses. Furthermore, aspirin's pharmacological effects remain highly specific to COX-1 at the 162 mg dose, minimizing concerns about broader prostaglandin inhibition. Emerging evidence suggests that certain patient factors, such as altered pharmacokinetics during pregnancy or obesity, may reduce aspirin's effectiveness at lower doses (e.g., 81 mg). In these studies, aspirin resistance was successfully overcome with a 162 mg dose. While concerns regarding safety at this dose have been raised, contemporary randomized controlled trials utilizing a 150 mg dose have shown no increase in adverse effects compared to placebo. As such, current evidence increasingly supports 162 mg as the optimal dose for preeclampsia prevention, offering greater effectiveness than the commonly used 81 mg dose, without significant evidence of increased risk.

Modified lipoprotein-induced sFlt1 production in human placental trophoblasts is mediated by protein kinase C

BACKGROUND

Preeclampsia is prevalent in women with diabetes, but the mechanism is unclear. We previously found that oxidized, glycated lipoproteins robustly upregulated soluble fms-like tyrosine kinase-1 (sFlt1), a key mediator of preeclampsia. Here, we determined the role of protein kinase C (PKC) and its subtypes in sFlt1 regulation in placental trophoblasts, and whether this mechanism might mediate the effect of modified lipoproteins.

METHODS

Cultured human HTR8/SVneo and BeWo trophoblasts were treated with the PKC activator phorbol-12-myristate-13-acetate (PMA) for 24h, ± PKC inhibitors GF109203X (general), Ro31-8220 (PKCα-selective), LY333531 (PKCβ-selective) and rottlerin (PKCδ-selective). The effect of 'heavily oxidized, glycated' low-density lipoproteins (HOG-LDL) vs. native LDL (N-LDL), ± high glucose (30 mM), was evaluated in HTR8/SVneo cells. sFlt1 secretion (ELISA), mRNA expression (RT-qPCR), and cellular PKC activity were measured.

RESULTS

PMA stimulated robust sFlt1 release and mRNA expression in both cell lines; these effects were inhibited by GF109203X, Ro31-8220 and LY333531 in a concentration-dependent manner. Rottlerin inhibited sFlt1 in BeWo, but modestly enhanced it in HTR8/SVneo cells. HOG-LDL enhanced PKC activity vs. N-LDL in HTR8/SVneo cells. Also, HOG-LDL, but not high glucose, significantly increased sFlt1 secretion and mRNA expression; this response was inhibited by GF109203X, Ro31-8220 and LY333531 at concentrations comparable to those that blocked PMA induction of sFlt1.

CONCLUSION

Modified lipoproteins upregulate sFlt1 in trophoblasts via a PKC-mediated mechanism, involving at least α and β isoforms. The data suggest potential therapeutic targets to reduce the risk of preeclampsia in women with diabetes.

Hypertension Management in Pregnancy

Chronic hypertension and preeclampsia spectrum disorders in pregnancy are important contributors to long-term maternal morbidity and mortality. Due to physiologic changes during pregnancy and the postpartum period, blood pressure expectations differ between primary care providers and obstetricians. The goal of this article is to describe the pathophysiology and definitions of hypertension in the obstetric context and review current evidence for management during pregnancy and the postpartum period. Longitudinal follow-up with a primary care provider after delivery is crucial for long-term cardiovascular risk reduction in hypertensive patients.

Efficacy of combining aspirin with hydroxychloroquine in pregnancies at high risk for pre-eclampsia: a prospective, multicentre, open-label, single-arm clinical trial, investigator-initiated study (HUGS study)

INTRODUCTION

The use of hydroxychloroquine (HCQ) during pregnancies complicated by systemic lupus erythematosus or refractory antiphospholipid antibody syndrome has demonstrated a significant ability to prevent pre-eclampsia (PE). As such, the potential for the administration of HCQ to prevent PE in other high-risk pregnancies is an important clinical research agenda among maternal and fetal medicine specialists. Mechanistically, the anti-inflammatory and immunomodulatory effects of HCQ can offer vascular protection and inhibit the placental dysfunction-associated thrombotic changes underlying the pathophysiology of PE, fetal growth restriction (FGR) and fetal death in utero (FDIU). Placenta-mediated complications exhibit a distinctive overlapping syndrome between pregnancies, and low-dose aspirin is the only prevention method currently in use. This study investigated the effects of improvements in outcomes with HCQ administration in high-risk pregnancies complicated by a previous experience of PE, FGR or FDIU.

METHODS AND ANALYSIS

This multicentre, open-label, single-arm trial commenced on 31 May 2022, in three tertiary hospitals in Korea. Pregnant women with a prior history of PE, FGR or FDIU are eligible to participate. This single-arm study set the previous study with the most similar inclusion criteria, aspirin dose and drug administration period as the comparison group. The required sample size was determined to be 58, with an expected dropout rate of 10%.

ETHICS AND DISSEMINATION

This study protocol was approved by the following institutions and committees: Institutional Review Boards of Chung-Ang University Gwangmyeong Hospital (2304-082-056), Samsung Medical Center (2021-11-087-003) and Kyungpook National University Chilgok Hospital (2021-06-005-006) and the Ministry of Food and Drug Safety. The results will be disseminated to the general public, grant funder, maternal-fetal medicine specialists and other researchers.

TRIAL REGISTRATION NUMBER

NCT05287321.

Impact of low-dose aspirin exposure on obstetrical outcomes: a meta-analysis

OBJECTIVE

To assess the impact of low-dose aspirin (LDA) on obstetrical outcomes through a meta-analysis of placebo-controlled randomized controlled trials (RCTs).

METHODS

A systematic search of the PubMed, Cochrane Library, Web of Science and Embase databases from inception to January 2024 was conducted to identify studies exploring the role of aspirin on pregnancy, reporting obstetrical-related outcomes, including preterm birth (PTB, gestational age <37 weeks), small for gestational age (SGA), low birth weight (LBW, birthweight < 2500g), perinatal death (PND), admission to the neonatal intensive care unit (NICU), 5-min Apgar score < 7 and placental abruption. Relative risks (RRs) were estimated for the combined outcomes. Subgroup analyses were performed by risk for preeclampsia (PE), LDA dosage (<100 mg vs. ≥100 mg) and timing of onset (≤20 weeks vs. >20 weeks).

RESULTS

Forty-seven studies involving 59,124 participants were included. Compared with placebo, LDA had a more significant effect on low-risk events such as SGA, PTB and LBW. Specifically, LDA significantly reduced the risk of SGA (RR = 0.91, 95% CI: 0.87-0.95), PTB (RR = 0.93, 95% CI: 0.89-0.97) and LBW (RR = 0.94, 95% CI: 0.89-0.99). For high-risk events, LDA significantly lowered the risk of NICU admission (RR = 0.93, 95% CI: 0.87-0.99). On the other hand, LDA can significantly increase the risk of placental abruption (RR = 1.72, 95% CI: 1.23-2.43). Subgroup analyses showed that LDA significantly reduced the risk of SGA (RR = 0.86, 95% CI: 0.77-0.97), PTB (RR = 0.93, 95% CI: 0.88-0.98) and PND (RR = 0.65, 95% CI: 0.48-0.88) in pregnant women at high risk of PE, whereas in healthy pregnant women LDA did not significantly improve obstetrical outcomes, but instead significantly increased the risk of placental abruption (RR = 5.56, 95% CI: 1.92-16.11). In pregnant women at high risk of PE, LDA administered at doses ≥100 mg significantly reduced the risk of SGA (RR = 0.77, 95% CI: 0.66-0.91) and PTB (RR = 0.56, 95% CI: 0.32-0.97), but did not have a statistically significant effect on reducing the risk of NICU, PND and LBW. LDA started at ≤20 weeks significantly reduced the risk of SGA (RR = 0.76, 95% CI: 0.65-0.89) and PTB (RR = 0.56, 95% CI: 0.32-0.97).

CONCLUSIONS

To sum up, LDA significantly improved neonatal outcomes in pregnant women at high risk of PE without elevating the risk of placental abruption. These findings support LDA's clinical application in pregnant women, although further research is needed to refine dosage and timing recommendations.

Time trends in antithrombotic therapy during pregnancy and maternal and perinatal outcomes in the Netherlands (2013-19): a nationwide cohort study

BACKGROUND

Considering the paucity of data, we aimed to describe nationwide time trends in antithrombotic therapy during pregnancy and risks of maternal and perinatal outcomes in the Netherlands.

METHODS

In this nationwide cohort study, all female individuals aged 16-45 years with delivery records in the Dutch perinatal registry between Jan 1, 2013, and Dec 31, 2019, and their infants, were included. Individually linked data from Statistics Netherlands on outpatient medication prescriptions, in-hospital diagnoses, and mortality were used to evaluate time trends in antithrombotic therapy during pregnancy, and risks of maternal and perinatal outcomes (including thromboembolism, bleeding, preeclampsia and eclampsia, and low birthweight).

FINDINGS

A total of 1 122 711 pregnancies and 1 139 116 infants were included (median maternal age 30·5 years [IQR 27·3-33·7]; 886 085 [78·9%] White; median gravidity 2 (IQR 1-3); and median gestational age at delivery 39 weeks [IQR 38-40]). Low-molecular-weight heparin (LMWH) was the most commonly (more than 99%) prescribed anticoagulants during pregnancy, which slightly increased from 0·7% (1063 of 163 479) in 2013 to 0·9% (1352 of 158 654) in 2019. LMWH was generally started at 5-8 weeks' gestation when oral anticoagulant prescriptions dropped. Antiplatelet drug prescriptions increased from 0·7% (1129 of 163 479) to 4·8% (7671 of 158 654), which primarily initiated around week 12. Maternal risks of venous and arterial thromboembolism and bleeding remained constant from 2013 to 2019; the risk of preeclampsia and eclampsia gradually increased from 1·70% (95% CI 1·63-1·76) in 2013 to 2·05% (1·98-2·13) in 2017, after which it decreased to 1·83% (1·77-1·90) in 2019. There was a significant decrease (2019 vs 2013) in low birthweight (adjusted odds ratio 0·92 [0·90-0·94]; p<0·0001), whereas 28-day neonatal bleeding risk remained unchanged.

INTERPRETATION

Exposure to anticoagulants during pregnancy is not uncommon, and health-care providers and female individuals of reproductive age should be mindful of this to avoid unintended oral anticoagulant exposure. Adhering to guidelines for aspirin use to prevent preeclampsia might lead to a population-level reduction in disease burden and potential improvement in neonatal prognosis.

FUNDING

None.

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

Living Donation and Pregnancy-Related Complications: State of the Evidence and Call To Action for Improved Risk Assessment

Living kidney donation and living liver donation significantly increases organ supply to make lifesaving transplants possible, offering survival benefits to the recipients and cost savings to society. Of all living donors, 40% are women of childbearing age. However, limited data exist regarding the effect of donation on future pregnancies and of pregnancy-related complications on postdonation outcomes. In February 2023, the American Society of Transplantation Women's Health Community of Practice held a virtual Controversies Conference on reproductive health, contraception, and pregnancy after transplantation and living donation. Experts in the field presented the available data. Smaller breakout sessions were created to discuss findings, identify knowledge gaps, and develop recommendations. We present the conference findings related to living donation. The evidence reviewed shows that gestational hypertension and gestational diabetes mellitus before kidney donation have been associated with an increased risk of developing postdonation hypertension and diabetes mellitus, respectively, without increasing the risk of developing an eGFR <45 ml/min after donation. The risk of preeclampsia in living kidney donors increases to 4%-10%, and low-dose aspirin may help reduce that risk. Little is known about the financial burden for living donors who become pregnant, their risk of postpartum depression, or the optimal time between donation and conception. The data on living liver donors are even scarcer. The creation of a registry of donor candidates may help answer many of these questions and, in turn, educate prospective donors so that they can make an informed choice.

Aspirin dose for preeclampsia prophylaxis: an argument for 162-mg dosing

The optimal aspirin dose for preeclampsia prevention remains controversial, with international guidelines lacking consensus on the most effective regimen. Aspirin is a proven intervention for reducing the risk of preeclampsia, particularly when initiated early in pregnancy. Its benefits stem from the selective inhibition of cyclooxygenase-1 (COX-1), reducing thromboxane A2 synthesis while preserving prostacyclin production, thereby restoring the vascular balance essential for placental health. A dose-response relationship has been established, with doses ≥100 mg showing significantly greater efficacy than lower doses. Furthermore, aspirin's pharmacological effects remain highly specific to COX-1 at the 162 mg dose, minimizing concerns about broader prostaglandin inhibition. Emerging evidence suggests that certain patient factors, such as altered pharmacokinetics during pregnancy or obesity, may reduce aspirin's effectiveness at lower doses (e.g., 81 mg). In these studies, aspirin resistance was successfully overcome with a 162 mg dose. While concerns regarding safety at this dose have been raised, contemporary randomized controlled trials utilizing a 150 mg dose have shown no increase in adverse effects compared to placebo. As such, current evidence increasingly supports 162 mg as the optimal dose for preeclampsia prevention, offering greater effectiveness than the commonly used 81 mg dose, without significant evidence of increased risk.

Aspirin dosage for preeclampsia prophylaxis: an argument for 81-mg dosing

Research conducted over the past few decades has shown that low-dose aspirin can effectively reduce the risk of developing preeclampsia. Consequently, numerous prominent organizations have adopted the recommendation to use low-dose aspirin during pregnancy to prevent preeclampsia. However, the optimal dosage of low-dose aspirin (81mg versus 162mg) remains a subject of debate. Currently, there is insufficient high-quality data to justify the use of a higher dosage of low-dose aspirin. In this review, we review the existing evidence that supports the continued use of 81mg of aspirin over a higher dose and emphasize the need for high-quality research to alter current recommendations.

Prediction and prevention of late-onset pre-eclampsia: a systematic review

Background

Pre-eclampsia is a major cause of perinatal morbidity and mortality worldwide. Late-onset pre-eclampsia (LOP), which results in delivery ≥34 weeks gestation, is the most common type. However, there is a lack of knowledge in its prediction and prevention. Improving our understanding in this area will allow us to have better surveillance of high-risk patients and thus improve clinical outcomes.

Methods

A systematic review was performed using a search of articles on PubMed. The search terms were ((late-onset) AND (pre-eclampsia)) AND ((risk factor) OR (risk) OR (prediction) OR (management) OR (prevention)). Primary literature published between 1 January 2013 and 31 December 2023 was included. Human studies assessing the prediction or prevention of late-onset pre-eclampsia were eligible for inclusion.

Results

Sixteen articles were included in the final review. The key risk factors identified were Body Mass Index (BMI), chronic hypertension, elevated mean arterial pressures (MAPs), nulliparity, and maternal age. No clinically useful predictive model for LOP was found. Initiating low dose aspirin before 17 weeks gestation in high-risk patients may help reduce the risk of LOP.

Conclusion

While aspirin is a promising preventor of LOP, preventative measures for women not deemed to be at high-risk or measures that can be implemented at a later gestation are required. Biomarkers for LOP need to be identified, and examining large cohorts during the second or third trimester may yield useful results, as this is when the pathogenesis is hypothesized to occur. Biomarkers that identify high-risk LOP patients may also help find preventative measures.

Inflammasome-targeted therapy might prevent adverse perinatal outcomes of recurrent chronic intervillositis of unknown etiology

Chronic histiocytic intervillositis of unknown origin (CHI) is a rare placental disorder associated with adverse pregnancy outcomes, frequent recurrence, and a lack of effective preventive strategies. Recent insights indicate a potential link between CHI-associated inflammatory lesions and the inflammasome pathway, suggesting innovative therapeutic avenues. Here we show a potential role of the inflammasome pathway in CHI through comprehensive transcriptomic analysis of grade 2 or 3 histopathologic CHI samples, paired with placental controls. Additionally, we present case studies of three individuals with recurrent CHI, who have undergone treatment with anakinra and colchicine throughout pregnancy, resulting in improved perinatal outcomes. Notably, all cases are characterized by the birth of healthy, full-term infants, with reduced or absent intervillositis recurrence. Placental assessment unveils heightened activation of the NLRP3-PYCARD inflammasome pathway and IL-1β processing in CHI samples, with downregulation observed in treated pregnancy samples, devoid of intervillositis. Collectively, these findings suggest a potential therapeutic role for targeting the inflammasome pathway in preventing recurrent CHI in pregnant individuals.

First-trimester uterine artery pulsatility index and preeclampsia risk in pregnancies after artificial frozen embryo transfer: analysis of over 27,000 pregnancies

BACKGROUND

Accumulating evidence indicates that pregnancies after artificial cycle frozen embryo transfer are associated with an increased risk of preeclampsia. Uterine artery Doppler, along with maternal factors and serum biomarkers, is a crucial biomarker for first-trimester preeclampsia screening, aiding in identifying "high-risk" patients. Guidelines strongly recommend administering aspirin (150 mg/d) in these women, owing to robust evidence demonstrating a 62% reduction in the incidence of preeclampsia. Although previous studies suggested lower uterine artery pulsatility index after frozen embryo transfer, no previous studies explored the impact of the type of endometrial preparation in Uterine Artery Doppler or its influence on estimating first-trimester preeclampsia risk.

OBJECTIVE

The study aims to evaluate the possible impact of endometrial preparation for frozen embryo transfer on the uterine artery pulsatility index during the first-trimester preeclampsia screening.

STUDY DESIGN

This is a retrospective single-center study including 27,289 singleton pregnancies (naturally conceived or after assisted reproductive treatment) who underwent the first-trimester ultrasound screening at our University Hospital between January 2010 and May 2023. Overall, 27,289 pregnancies were included: 23,410 naturally conceived and 3879 following assisted reproductive technologies including 391 after ovulation induction and intrauterine insemination, 888 in vitro fertilization and fresh embryo transfer, and 2600 natural or artificial frozen embryo transfer cycles. An analysis of covariance was conducted to assess if there is an association between the uterine artery pulsatility index value and the mode of conception, adjusting for confounding factors (age, weight, smoking, and oocyte donation).

RESULTS

Overall, pregnancies after artificial frozen embryo transfer demonstrated significantly lower first-trimester uterine artery pulsatility index as compared with all other modes of conception in a multivariable regression analysis adjusted for age, weight, smoking, and oocyte donation. The percent difference was 22.6 [confidence interval, CI 95%: 20.6; 24.5] compared to naturally conceived pregnancy, 24.5 [CI 95%: 20.7; 28.1] to ovulation induction or intrauterine insemination, 24.8 [CI 95%: 22.9; 27.6] to fresh embryo transfer and 21.7 [CI 95%: 17.6; 25.5] compared to natural cycle frozen embryo transfer. When calculating the risk for initiating preventive aspirin administration, the number of patients with increased risk (>1/100) who initiated prophylactic aspirin was significantly lower in the artificial cycle frozen embryo transfer group (7.8% vs 16.0% in natural cycle P<.001 vs 11.0% in Fresh embryo transfer P=.01 vs 10.5% in ovulation induction or intrauterine insemination P=.14 vs 9.3% in naturally conceived pregnancy P=.03). Surprisingly although significantly fewer patients were considered at high risk for preeclampsia in the artificial cycle frozen embryo transfer group, analysis of the actual incidence of preeclampsia demonstrated 3 times higher preeclampsia incidence in artificial cycle group 5.3% (122/2284) as compared with naturally conceived 1.4% (321/23,410), ovulation induction and intrauterine insemination 1.3% (5/391) or natural cycle pregnancies 1.6% (5/316) and more than 2 times higher when compared to fresh embryo transfer pregnancies 2.3% (20/888), P<.001.

CONCLUSION

Pregnancies following frozen embryo transfer in artificial cycle are associated with significantly lower uterine artery pulsatility index during first-trimester preeclampsia screening. This results in a significantly lower number of patients being classified as high-risk for developing preeclampsia, despite accumulating evidence that artificial cycles are linked to an increased risk of preeclampsia. Therefore, the first-trimester preeclampsia risk algorithm should be adjusted to accurately assess risk for those patients undergoing artificial cycle frozen embryo transfer, to prevent the undertreatment of patients who are at very high risk of developing preeclampsia and may benefit from prophylactic aspirin.

[Fetal death: Expert consensus from the College of French Gynecologists and Obstetricians]

Fetal death is defined as the spontaneous cessation of cardiac activity after fourteen weeks of amenorrhea. In France, the prevalence of fetal death after 22 weeks is between 3.2 and 4.4/1000 births. Regarding the prevention of fetal death in the general population, it is not recommended to counsel for rest and not to prescribe vitamin A, vitamin D nor micronutrient supplementation for the sole purpose of reducing the risk of fetal death (Weak recommendations; Low quality of evidence). It is not recommended to prescribe aspirin (Weak recommendation; Very low quality of evidence). It is recommended to offer vaccination against influenza in epidemic periods and against SARS-CoV-2 (Strong recommendations; Low quality of evidence). It is not recommended to systematically look for nuchal cord encirclements during prenatal screening ultrasounds (Strong Recommendation; Low Quality of Evidence) and not to perform systematic antepartum monitoring by cardiotocography (Weak Recommendation; Very Low Quality of Evidence). It is not recommended to ask women to perform an active fetal movement count to reduce the risk of fetal death (Strong Recommendation; High Quality of Evidence). Regarding evaluation in the event of fetal death, it is suggested that an external fetal examination be systematically offered (Expert opinion). It is recommended that a fetopathological and anatomopathological examination of the placenta be carried out to participate in cause identification (Strong Recommendation. Moderate quality of evidence). It is recommended that chromosomal analysis by microarray testing be performed rather than conventional karyotype, in order to be able to identify a potentially causal anomaly more frequently (Strong Recommendation, moderate quality of evidence); to this end, it is suggested that postnatal sampling of the placental fetal surface for genetic purposes be preferred (Expert Opinion). It is suggested to test for antiphospholipid antibodies and systematically perform a Kleihauer test and a test for irregular agglutinins (Expert opinion). It is suggested to offer a summary consultation, with the aim of assessing the physical and psychological status of the parents, reporting the results, discussing the cause and providing information on monitoring for a subsequent pregnancy (Expert opinion). Regarding announcement and support, it is suggested to announce fetal death without ambiguity, using simple words and adapting to each situation, and then to support couples with empathy in the various stages of their care (Expert opinion). Regarding management, it is suggested that, in the absence of a situation at risk of disseminated intravascular coagulation or maternal vitality, the patient's wishes should be taken into account when determining the time between the diagnosis of fetal death and induction of birth. Returning home is possible if it's the patient wish (Expert opinion). In all situations excluding maternal life-threatening emergencies, the preferred mode of delivery is vaginal delivery, regardless the history of cesarean section(s) history (Expert opinion). In the event of fetal death, it is recommended that mifepristone 200mg be prescribed at least 24hours before induction, to reduce the delay between induction and delivery (Low recommendation. Low quality of evidence). There are insufficient data in the literature to make a recommendation regarding the route of administration (vaginal or oral) of misoprostol, neither the type of prostaglandin to reduce induction-delivery time or maternal morbidity. It is suggested that perimedullary analgesia be introduced at the start of induction if the patient asks, regardless of gestational age. It is suggested to prescribe cabergoline immediately in the postpartum period in order to avoid lactation, whatever the gestational age, after discussing the side effects of the treatment with the patient (Expert opinion). The risk of recurrence of fetal death after unexplained fetal death does not appear to be increased in subsequent pregnancies, and data from the literature are insufficient to make a recommendation on the prescription of aspirin. In the event of a history of fetal death due to vascular issues, low-dose aspirin is recommended to reduce perinatal morbidity, and should not be combined with heparin therapy (Low recommendation, very low quality of evidence). It is suggested not to recommend an optimal delay before initiating another pregnancy just because of the history of fetal death. It is suggested that the woman and co-parent be informed of the possibility of psychological support. Fetal heart rate monitoring is not indicated solely because of a history of fetal death. It is suggested that delivery not be systematically induced. However, induction can be considered depending on the context and parental request. The gestational age will be discussed, taking into account the benefits and risks, especially before 39 weeks. If a cause of fetal death is identified, management will be adapted on a case-by-case basis (expert opinion). In the event of fetal death occurring in a twin pregnancy, it is suggested that the surviving twin be evaluated as soon as the diagnosis of fetal death is made. In the case of dichorionic pregnancy, it is suggested to offer ultrasound monitoring on a monthly basis. It is suggested not to deliver prematurely following fetal death of a twin. If fetal death occurs in a monochorionic twin pregnancy, it is suggested to contact the referral competence center, in order to urgently look for signs of acute fetal anemia on ultrasound in the surviving twin, and to carry out weekly ultrasound monitoring for the first month. It is suggested not to induce birth immediately.

Comparison of National Factor-Based Models for Preeclampsia Screening

OBJECTIVE

 This study aimed to compare the predictive values of the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), and the Society of Obstetricians and Gynecologists of Canada (SOGC) factor-based models for preeclampsia (PE) screening.

STUDY DESIGN

 We conducted a secondary analysis of maternal and birth data from 32 hospitals. For each delivery, we calculated the risk of PE according to the ACOG, the NICE, and the SOGC models. Our primary outcomes were PE and preterm PE (PE combined with preterm birth) using the ACOG criteria. We calculated the detection rate (DR or sensitivity), the false positive rate (FPR or 1 - specificity), the positive (PPV) and negative (NPV) predictive values of each model for PE and for preterm PE using receiver operator characteristic (ROC) curves.

RESULTS

 We used 130,939 deliveries including 4,635 (3.5%) cases of PE and 823 (0.6%) cases of preterm PE. The ACOG model had a DR of 43.6% for PE and 50.3% for preterm PE with FPR of 15.6%; the NICE model had a DR of 36.2% for PE and 41.3% for preterm PE with FPR of 12.8%; and the SOGC model had a DR of 49.1% for PE and 51.6% for preterm PE with FPR of 22.2%. The PPV for PE of the ACOG (9.3%) and NICE (9.4%) models were both superior than the SOGC model (7.6%; p < 0.001), with a similar trend for the PPV for preterm PE (1.9 vs. 1.9 vs. 1.4%, respectively; p < 0.01). The area under the ROC curves suggested that the ACOG model is superior to the NICE for the prediction of PE and preterm PE and superior to the SOGC models for the prediction of preterm PE (all with p < 0.001).

CONCLUSION

 The current ACOG factor-based model for the prediction of PE and preterm PE, without considering race, is superior to the NICE and SOGC models.

KEY POINTS

· Clinical factor-based model can predict PE in approximately 44% of the cases for a 16% false positive.. · The ACOG model is superior to the NICE and SOGC models to predict PE.. · Clinical factor-based models are better to predict PE in parous than in nulliparous..

Hypertensive Disorders of Pregnancy in Saudi Arabia: Evaluating Maternal and Neonatal Risks, Outcomes, and Aspirin Prophylaxis: A Review Article

Hypertensive disorders during pregnancy, including pre-eclampsia and eclampsia, pose significant risks to both maternal and neonatal health. This review article evaluates the prevalence, maternal and neonatal outcomes, and the efficacy of aspirin prophylaxis in managing these conditions in Saudi Arabia. Utilizing data from multiple retrospective studies and recent guidelines, we highlight the regional variations in the outcomes of hypertensive disorders of pregnancy. Severe complications such as Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome occurred in 6.6% of cases, while eclampsia was reported in 6.7% of cases. Cesarean sections were notably high, with rates reaching up to 79% among affected pregnancies. Maternal risk factors identified include chronic hypertension (prevalence 17%), diabetes (ranging from 10.4% to 26.3%), and advanced maternal age. Neonatal complications often involve preterm birth, reported in 26.5% to 26.7% of cases, intrauterine growth restriction (ranging from 15.7% to 25%), and increased NICU admissions, reported in 2.4% of cases. No data were found in the included studies to evaluate the prophylactic use of low-dose aspirin in reducing the incidence of pre-eclampsia or improving fetomaternal outcomes. Despite the effectiveness of aspirin, awareness and implementation of prophylaxis guidelines remain suboptimal among healthcare providers in Saudi Arabia. A national survey revealed that only a fraction of obstetrical care providers were fully knowledgeable about aspirin prophylaxis guidelines. This review underscores the necessity for enhanced educational programs and standardized guidelines to improve maternal and neonatal outcomes in hypertensive pregnancies within the region.

Incidence of and risk factors for small vulnerable newborns in north India: a secondary analysis of a prospective pregnancy cohort

BACKGROUND

Globally, recent estimates have shown there have been 3·6 million stillbirths and neonatal deaths in 2022, with nearly 60% occurring in low-income and middle-income countries. The Small Vulnerable Newborn Consortium has proposed a framework combining preterm birth (<37 weeks of gestation), small for gestational age (SGA) by INTERGROWTH-21st standard, and low birthweight (<2500 g) under the category small vulnerable newborns (SVN). Reliable data on SVN from sub-Saharan Africa, central Asia, and south Asia are sparse. We aimed to estimate the incidence of SVN and its types, and quantify risk factors, both overall and trimester-specific, from a pregnancy cohort in north India.

METHODS

In the GARBH-Ini (Interdisciplinary Group for Advanced Research on Birth Outcomes-DBT India Initiative) pregnancy cohort, 8000 participants were enrolled with less than 20 weeks' gestation between May 11, 2015, and Aug 8, 2020, at a secondary-care hospital in north India. The cohort was followed up across the antenatal period for a detailed study on preterm birth. We conducted a secondary analysis of cohort data for the outcome of SVN, classified into its types: preterm-SGA, preterm-nonSGA, and term-SGA. We estimated the relative risk and population attributable fraction of candidate risk factors for SVN (modified Poisson regression) and its types (multinomial regression).

FINDINGS

7183 (89·9%) of 7990 participants completed the study. Among 6206 newborns included for analysis, the incidence of SVN was 48·4% (35·1% term-SGA newborns [n=2179], 9·7% preterm-nonSGA newborns [n=605], and 3·6% preterm-SGA newborns [n=222]). Compared with term-nonSGA newborns, proportions of stillbirths and neonatal deaths within 72 h of birth among SVN were three times and 2·5 times higher, respectively. Preterm-SGA newborns had the highest incidence of stillbirth (15 [6·8%] of 222) and neonatal deaths (six [4·2%] of 142). Low body-mass index (BMI <18·5 kg/m2) of participants at the start of pregnancy was associated with higher risk for preterm-SGA (adjusted relative risk [RR] 1·61 [95% CI 1·17-2·22]), preterm-nonSGA (1·35 [1·09-1·68]), and term-SGA (1·44 [1·27- 1·64]), with population attributable fraction ranging from 8·7% to 13·8%. Pre-eclampsia (adjusted RR 1·48 [95% CI 1·30-1·71]), short cervical length (1·15 [1·04-1·26]), and bacterial vaginosis (1·13 [0·88-1·45]) were other important antenatal risk factors.

INTERPRETATION

In a comprehensive analysis of SVN and its types from north India, we identified risk factors to guide prioritisation of interventions. Complemented with risk-stratification tools, this focused approach will enhance antenatal care, and accelerate achievement of Sustainable Development Goals-namely, to end preventable deaths of newborns and children younger than 5 years by 2030 (target 3·2).

FUNDING

Department of Biotechnology, Government of India and Grand Challenges India-Biotechnology Industry Research Assistance Council, Government of India.

TRANSLATION

For the Hindi translation of the abstract see Supplementary Materials section.

A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses

BACKGROUND

Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs.

OBJECTIVE

The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs.

METHODS

A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted.

RESULTS

Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children.

CONCLUSIONS

Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.

Therapeutic Value of Low-Dose Acetylsalicylic Acid for the Prevention of Preeclampsia in High-Risk Bulgarian Women

Introduction Preeclampsia (PE) is a syndrome that affects pregnant women after 20 weeks of gestation and involves numerous organ systems. Screening for PE is essential to prevent complications and guide management. Some existing guidelines for screening have limitations in terms of detection rates and false positives. The aim of this study is to assess the therapeutic value of low-dose acetylsalicylic acid (ASA) for the prevention of PE in high-risk Bulgarian women. Methodology A prospective cohort research was carried out, encompassing women who were recruited from several routine consultations, such as booking, scanning, and regular prenatal visits. We utilized the purposive sampling technique to carefully choose potential participants. The study was conducted by a maternal-fetal medicine center located in Plovdiv, Bulgaria. The data-gathering period spanned from January 2018 to November 2020. At the appointment, the following procedures were conducted: 1) recording history; 2) assessing height, weight, and blood pressure; 3) collecting blood specimens for biochemical markers; and 4) ultrasound examination. Results A total sample size of 1,383 individuals was categorized into two distinct groups: high-risk patients (n = 506) and low-risk patients (n = 877). The mean uterine artery pulsatility index (UtA-PI) and mean arterial pressure (MAP) ratios were all greater in high-risk group women (p < 0.05). The data revealed that a significant number of high-risk women failed to adhere to the prescribed dosage or regular use of ASA as recommended by their doctor. There were only 384 (75.9%) high-risk women who took low-dose ASA regularly. Conclusion The findings emphasize the importance of personalized prenatal care and early risk assessment to improve maternal and fetal outcomes. Therefore, it is crucial to educate pregnant women, considering the benefits and risks of low-dose ASA when appropriately indicated.

Development and validation of prediction models for fetal growth restriction and birthweight: an individual participant data meta-analysis

Background

Fetal growth restriction is associated with perinatal morbidity and mortality. Early identification of women having at-risk fetuses can reduce perinatal adverse outcomes.

Objectives

To assess the predictive performance of existing models predicting fetal growth restriction and birthweight, and if needed, to develop and validate new multivariable models using individual participant data.

Design

Individual participant data meta-analyses of cohorts in International Prediction of Pregnancy Complications network, decision curve analysis and health economics analysis.

Participants

Pregnant women at booking. External validation of existing models (9 cohorts, 441,415 pregnancies); International Prediction of Pregnancy Complications model development and validation (4 cohorts, 237,228 pregnancies).

Predictors

Maternal clinical characteristics, biochemical and ultrasound markers.

Primary outcomes

fetal growth restriction defined as birthweight <10th centile adjusted for gestational age and with stillbirth, neonatal death or delivery before 32 weeks' gestation birthweight.

Analysis

First, we externally validated existing models using individual participant data meta-analysis. If needed, we developed and validated new International Prediction of Pregnancy Complications models using random-intercept regression models with backward elimination for variable selection and undertook internal-external cross-validation. We estimated the study-specific performance (c-statistic, calibration slope, calibration-in-the-large) for each model and pooled using random-effects meta-analysis. Heterogeneity was quantified using τ2 and 95% prediction intervals. We assessed the clinical utility of the fetal growth restriction model using decision curve analysis, and health economics analysis based on National Institute for Health and Care Excellence 2008 model.

Results

Of the 119 published models, one birthweight model (Poon) could be validated. None reported fetal growth restriction using our definition. Across all cohorts, the Poon model had good summary calibration slope of 0.93 (95% confidence interval 0.90 to 0.96) with slight overfitting, and underpredicted birthweight by 90.4 g on average (95% confidence interval 37.9 g to 142.9 g). The newly developed International Prediction of Pregnancy Complications-fetal growth restriction model included maternal age, height, parity, smoking status, ethnicity, and any history of hypertension, pre-eclampsia, previous stillbirth or small for gestational age baby and gestational age at delivery. This allowed predictions conditional on a range of assumed gestational ages at delivery. The pooled apparent c-statistic and calibration were 0.96 (95% confidence interval 0.51 to 1.0), and 0.95 (95% confidence interval 0.67 to 1.23), respectively. The model showed positive net benefit for predicted probability thresholds between 1% and 90%. In addition to the predictors in the International Prediction of Pregnancy Complications-fetal growth restriction model, the International Prediction of Pregnancy Complications-birthweight model included maternal weight, history of diabetes and mode of conception. Average calibration slope across cohorts in the internal-external cross-validation was 1.00 (95% confidence interval 0.78 to 1.23) with no evidence of overfitting. Birthweight was underestimated by 9.7 g on average (95% confidence interval -154.3 g to 173.8 g).

Limitations

We could not externally validate most of the published models due to variations in the definitions of outcomes. Internal-external cross-validation of our International Prediction of Pregnancy Complications-fetal growth restriction model was limited by the paucity of events in the included cohorts. The economic evaluation using the published National Institute for Health and Care Excellence 2008 model may not reflect current practice, and full economic evaluation was not possible due to paucity of data.

Future work

International Prediction of Pregnancy Complications models' performance needs to be assessed in routine practice, and their impact on decision-making and clinical outcomes needs evaluation.

Conclusion

The International Prediction of Pregnancy Complications-fetal growth restriction and International Prediction of Pregnancy Complications-birthweight models accurately predict fetal growth restriction and birthweight for various assumed gestational ages at delivery. These can be used to stratify the risk status at booking, plan monitoring and management.

Study registration

This study is registered as PROSPERO CRD42019135045.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/148/07) and is published in full in Health Technology Assessment; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.

Controversies and Clarifications Regarding the Role of Aspirin in Preeclampsia Prevention: A Focused Review

Preeclampsia is one of the leading causes of maternal and perinatal morbidity and mortality worldwide. In recent decades, many studies have evaluated different interventions in order to prevent the occurrence of preeclampsia. Among these, administration of low-dose aspirin from early pregnancy showed consistent evidence of its prophylactic role. In this article, we review the scientific literature on this topic, highlighting the rationale for aspirin use, who should be treated, the timing of initiation and cessation of therapy, the importance of proper dosing, and its role in the prevention of other adverse outcomes.

Current obstetric outcomes in Jamaican women with sickle hemoglobinopathy - a balance of risks for aspirin?

OBJECTIVES

Sickle cell disease (SCD) occurs in 2.8 % of our Jamaican antenatal population with homozygous HbSS being most associated with adverse maternal and perinatal outcomes.

METHODS

A retrospective comparative analysis of HbSS, HbSC and HbSβThal pregnancy outcomes at the University Hospital of the West Indies (UHWI) between January 2012 and December 2022 was conducted.

RESULTS

Of 120 patients (138 pregnancies), obesity occurred in 36 % (20/56) of the 'non-HbSS' group, i.e. HbSβThal (55 %, 5/9) and HbSC (32 %, 15/47) combined vs. 9.7 % of the HbSS (8/82). HbSS patients had more crises requiring transfusions, acute chest syndrome (ACS), maternal 'near-misses' (OR=10.7, 95 % 3.5-32.3; p<0.001), hospitalizations (OR 7.6, 95 % CI 3.4-16.9; p<0.001), low birth weight (LBW) neonates (OR 3.1, 1.1-8.9; p=0.037) and preterm birth (OR=2.6, 1.2-5.8; p=0.018) compared to HbSC and HbSβThal. Low dose aspirin was prescribed in 43 %. Logistic regression showed those NOT on aspirin (n=76) had more miscarriages (22 v. 2 %), were LESS likely to have a live birth (75 v. 95 % (0.2, 0.04-0.57, p=0.005)), but surprisingly had fewer painful crises (28 v. 46 % (0.5, 0.03-0.9, p=0.03)).

CONCLUSIONS

HbSS women had a 10-fold excess of maternal near-misses. Additional research may further clarify the effects of aspirin on pregnancy outcomes as related to SCD genotypes.

Antiplatelet Drugs Use in Pregnancy-Review of the Current Practice and Future Implications

When clinicians opt for antithrombotic therapy to manage or prevent thrombotic complications during pregnancy, it is imperative to consider the unique physiological state of the pregnant woman's body, which can influence the pharmacokinetics of the drug, its ability to traverse the placental barrier, and its potential teratogenic effects on the fetus. While the efficacy and safety of aspirin during pregnancy have been relatively well-established through numerous clinical studies, understanding the effects of newer, more potent antiplatelet agents has primarily stemmed from individual clinical case reports necessitating immediate administration of potent antiplatelet therapy during pregnancy. This review consolidates the collective experiences of clinicians confronting novel thrombotic complications during pregnancy, often requiring the use of dual antiplatelet therapy. The utilization of potent antiplatelet therapy carries inherent risks of bleeding, posing threats to both the pregnant woman and the fetus, as well as the potential for teratogenic effects on the fetus. In the absence of official guidelines regarding the use of potent antiplatelet drugs in pregnancy, a plethora of cases have demonstrated the feasibility of preventing recurrent thrombotic complications, mitigating bleeding risks, and successfully managing pregnancies, frequently culminating in cesarean deliveries, through meticulous selection and dosing of antiplatelet medications.

Evaluation of Low-Dose Aspirin to Prevent Preeclampsia in Pregnant People with Chronic Hypertension

OBJECTIVE

Our objective was to evaluate if the use of low-dose aspirin (LDA) among pregnant individuals with chronic hypertension (CHTN) reduces the rate of superimposed preeclampsia or other adverse maternal and neonatal outcomes.

STUDY DESIGN

Our study included single-center cohort of pregnant individuals with CHTN who had a live birth after 23 weeks' gestation, between 2013 and 2018. The primary exposure was the use of LDA in pregnancy and the primary outcome was superimposed preeclampsia. LDA use was also evaluated by the timing of initiation, before or after 16 weeks' gestation. Secondary outcomes included preeclampsia subtypes (e.g., preeclampsia with severe features, early-onset disease), as well as adverse maternal and neonatal outcomes. Differences were analyzed by χ 2, Fisher's exact, or t tests, with logistic regression to adjust for confounders.

RESULTS

Of 11,825 deliveries during the study period, 494 (4.2%) occurred in women with CHTN. Among those with CHTN, 174 (35%) were prescribed LDA, most often 81 mg daily (173 out of 174, 99%). Baseline characteristics were similar between groups, but the history of preeclampsia was more common in those prescribed LDA. The rate of superimposed preeclampsia was no different among those with CHTN-prescribed LDA compared with those who were not (36% vs. 30%, p = 0.2), even when restricting the analysis to those prescribed LDA before 16 weeks' gestation (33 vs. 30%, p = 0.2). In addition, LDA did not lead to a reduction in the rate of preeclampsia with severe features, early-onset preeclampsia, or other adverse maternal outcomes. However, the composite rate of adverse neonatal outcomes was lower in LDA users versus nonusers (4.0 vs. 13%, p = 0.002), which persisted after multivariable adjustment (adjusted odds ratio: 0.28, 95% confidence interval: 0.12-0.67).

CONCLUSION

Among pregnant individuals with CHTN, LDA did not decrease the rate of superimposed preeclampsia. Further studies are warranted to validate our observed reduction in adverse neonatal outcomes and to determine if aspirin is more beneficial at dosages greater than 81 mg daily.

KEY POINTS

· Superimposed preeclampsia rates are the same regardless of LDA.. · Decreased rate of adverse neonatal outcomes is seen with LDA.. · No decrease in adverse maternal outcomes is seen with LDA..

Efficacy and Safety of Aspirin 162 mg for Preeclampsia Prophylaxis in High-Risk Patients

OBJECTIVE

The aim of this study was to compare the safety and efficacy of aspirin 162 mg to the standard recommended dose of 81 mg for preeclampsia prevention.

STUDY DESIGN

A retrospective cohort study of patients at risk for preeclampsia who delivered between January 2013 and December 2020 at Henry Ford Health was performed. Patients were divided into three groups: a no aspirin group, a group treated under an 81 mg aspirin preeclampsia prophylaxis protocol, and a group treated under a 162 mg protocol. Univariate and multivariable logistic regression analyses compared rates of preeclampsia and secondary outcomes between groups. Clinical side effects traditionally associated with aspirin use were also assessed.

RESULTS

Of 3,597 patients, 2,266 (63%) were in the no aspirin group, 944 (26%) were in the 81 mg group, and 387 (11%) were in the 162 mg group. The rate of preeclampsia was significantly lower in the 162 mg group (10.1%, odds ratio, 0.68; 95% confidence interval, 0.46-0.99) compared with the 81 mg group (14.2%). The rate of preeclampsia was identical in the no aspirin and 81 mg groups. The rate for postpartum hemorrhage, postpartum hematoma, and intraventricular hemorrhage of the newborn were not significantly different between patients in the 162 and 81 mg groups.

CONCLUSION

We observed a significantly lower rate of preeclampsia in high-risk patients who were treated with the 162 mg dose of aspirin for preeclampsia prophylaxis, and bleeding complications were not seen with the higher dose. Our study suggests that aspirin 162 mg may be considered for prophylaxis in patients at high risk for preeclampsia.

KEY POINTS

· Aspirin 81 mg is currently standard for preeclampsia prophylaxis.. · Preeclampsia rate is significantly lower among high-risk patients taking aspirin 162 mg compared with 81 mg.. · Bleeding complications are not increased among those taking aspirin 162 mg..

Feasibility of Universal Screening for Preeclampsia Risk and Aspirin Recommendation in the Ultrasound Unit

OBJECTIVE

 To evaluate the feasibility and impact of using the first-trimester ultrasound visit to identify and counsel women at increased risk of preeclampsia about the benefits of low-dose aspirin (LDA) for preventing preeclampsia. We also assessed patient-reported utilization of LDA, perceived risk for preeclampsia, and clinical outcomes.

STUDY DESIGN

 Women presenting for routine first-trimester nuchal-translucency (NT) ultrasounds were screened for clinical preeclampsia risks using a self-administered risk assessment. Women at moderate or high risk for preeclampsia were counseled to take LDA, if not already taking it. LDA utilization and perceived risk for preeclampsia were assessed during the second-trimester ultrasound. Factors associated with LDA utilization were analyzed. Pregnancy outcomes were compared between those who used LDA and those who did not.

RESULTS

 Slightly more than 20% of patients (765/3,669) screened at increased risk for developing preeclampsia. Of those, 67.8% (519/765) had not received LDA recommendations from their referring obstetrician and 97 had not been taking LDA despite being advised to do so. Combined, 94.6% (583/616) of these patients eligible to start LDA prophylaxis received the indicated counseling during the ultrasound visit. A total of 61.4% (358/583) of women completed the follow-up form and of those 77.9% (279/358) reported taking LDA. Screening at increased risk for preeclampsia and perception of increased risk were positively associated with LDA utilization, whereas concerns for LDA safety were negatively associated with use. African American/Black patients and Medicaid recipients were less likely to use LDA. Pregnancy outcomes were similar between those who used LDA and those who did not.

CONCLUSION

 Assessing preeclampsia risk and counseling patients about LDA at the time of the NT ultrasound are feasible in the ultrasound unit and led to good LDA utilization among women at increased risk for preeclampsia. This intervention may standardize patient care and help close the disparity in maternal health.

KEY POINTS

· A simple intervention captured 2/3 of eligible patients.. · Aspirin utilization rate was good after the intervention.. · Screening high risk for preeclampsia and self-perception of risk correlated with aspirin use..

Arterial hypertension and smoking in pregnant women in the Valencian Community: maternal and neonatal outcomes

OBJECTIVE

Hypertension and smoking during pregnancy have been linked to various adverse maternal and fetal outcomes. The objective of this work is to study how the smoking influences the development of hypertension, its effects on the pregnant woman, and on the newborn.

MATERIALS AND METHODS

An observational study in two phases was carried out: the descriptive first phase allows characterization of the sample and the analytical second phase is a case-control nested in a retrospective cohort corresponding to pregnancy.

RESULTS

A total of 712 women were included in the study. Of the 672 (94.4%) non-hypertensive women, 533 (79.3%) were non-smoking and 139 (20.7%) smoking. For the 40 (5.6%) hypertensive women, 30 (75.0%) were non-smoking and 10 (25.0%) smoking. The prevalence of hypertension was of 5.6%. Women who quit smoking before pregnancy saw a reduced risk of hypertension. For women who smoke during pregnancy, those of younger ages, with a normal body mass index, who are primiparous, employed and with a low-medium level of education have higher risk of hypertension. The risk of hypertension according to the level of physical activity during leisure time follows a "U" shape, with those who perform light physical activity at the lowest risk of hypertension. Hypertensive women have a higher risk of small for gestational age newborns. Smoking does not pose an additional risk for adverse outcomes once hypertension is diagnosed.

CONCLUSIONS

Future studies should aim to determine the role of smoking habit in the appearance of hypertension in pregnancy in order to establish adequate intervention guidelines that may aid in reducing the prevalence of hypertension.

Aspirin for preeclampsia prevention in low- and middle-income countries: mind the gaps

Preeclampsia is a syndrome that continues to be a major contributor to maternal and neonatal mortality, especially in low-income countries. Low-dose aspirin reduces the risk of preeclampsia, but the mechanism is still unknown. Risk factors to identify women at risk of preeclampsia are based on clinical characteristics. Women identified as high-risk would benefit from aspirin treatment initiated, preferably at the end of the first trimester. Current efforts have largely focused on developing screening algorithms that incorporate clinical risk factors, maternal biomarkers, and uterine artery Doppler evaluated in the first trimester. However, most studies on preeclampsia are conducted in high-income settings, raising uncertainties about whether the information gained can be totally applied in low-resource settings. In low- and middle-income countries, lack of adequate antenatal care and late commencement of antenatal care visits pose significant challenges for both screening for preeclampsia and initiating aspirin treatment. Furthermore, the preventive effect of first-trimester screening based on algorithms and subsequent aspirin treatment is primarily seen for preterm preeclampsia, and reviews indicate minimal or no impact on reducing the risk of term preeclampsia. The lack of evidence regarding the effectiveness of aspirin in preventing term preeclampsia is a crucial concern, as 75% of women will develop this subtype of the syndrome. Regarding adverse outcomes, low-dose aspirin has been linked to a possible higher risk of postpartum hemorrhage, a condition as deadly as preeclampsia in many low- and middle-income countries. The increased risk of postpartum hemorrhage among women in low-income settings should be taken into consideration when discussing which pregnant women would benefit from the use of aspirin and the ideal aspirin dosage for preventing preeclampsia. In addition, women's adherence to aspirin during pregnancy is crucial for determining its effectiveness and complications, an aspect often overlooked in trials. In this review, we analyze the knowledge gaps that must be addressed to safely increase low-dose aspirin use in low- and middle-income countries, and we propose directions for future research.

The optimal dosage of aspirin for preventing preeclampsia in high-risk pregnant women: A network meta-analysis of 23 randomized controlled trials

This study aimed to assess the effectiveness and optimal dosage of aspirin in preventing preeclampsia in high-risk pregnant women. Traditional and network meta-analyses were conducted on data from 23 randomized controlled trials involving 10 547 pregnant women. The findings demonstrated that aspirin significantly reduced the incidence of preeclampsia (OR = 0.66, 95%CI [0.58, 0.75]), with the best preventive effect observed at a dosage of 80-100 mg/day (OR = 0.51, 95%CI [0.36, 0.72]). No significant differences were found in the occurrence of postpartum hemorrhage (OR = 1.03, 95%CI [0.79, 1.33]), small for gestational age (OR = 0.83, 95%CI [0.50, 1.35]), placental abruption (OR = 0.96, 95%CI [0.53, 1.73]), and intrauterine growth restriction (OR = 0.63, 95%CI [0.45, 1.86]) between women taking aspirin and those taking placebos. Different doses of aspirin showed a reduction in preeclampsia incidence, but there was no significant difference in efficacy between the dosage groups. Side effects did not significantly differ between placebo and different aspirin dosage groups. SUCRA analysis suggested that 80-100 mg/day may be the optimal dosage, prioritizing both effectiveness and minimizing side effects. Sensitivity analysis confirmed the robustness of the findings. However, improvements are needed in addressing issues like loss to follow-up, reporting bias, and publication bias. In conclusion, a dosage of 80-100 mg/day is recommended for preventing preeclampsia in high-risk pregnant women, although individual circumstances should be considered for optimizing the balance between effectiveness and safety.

Low dose aspirin prevents endothelial dysfunction in the aorta and foetal loss in pregnant mice infected with influenza A virus

Influenza A virus (IAV) infection in pregnancy resembles a preeclamptic phenotype characterised by vascular dysfunction and foetal growth retardation. Given that low dose aspirin (ASA) is safe in pregnancy and is used to prevent preeclampsia, we investigated whether ASA or NO-conjugated aspirin, NCX4016, resolve vascular inflammation and function to improve offspring outcomes following IAV infection in pregnant mice. Pregnant mice were intranasally infected with a mouse adapted IAV strain (Hkx31; 104 plaque forming units) and received daily treatments with either 200µg/kg ASA or NCX4016 via oral gavage. Mice were then culled and the maternal lungs and aortas collected for qPCR analysis, and wire myography was performed on aortic rings to assess endothelial and vascular smooth muscle functionality. Pup and placentas were weighed and pup growth rates and survival assessed. IAV infected mice had an impaired endothelial dependent relaxation response to ACh in the aorta, which was prevented by ASA and NCX4016 treatment. ASA and NCX4016 treatment prevented IAV dissemination and inflammation of the aorta as well as improving the pup placental ratios in utero, survival and growth rates at post-natal day 5. Low dose ASA is safe to use during pregnancy for preeclampsia and this study demonstrates that ASA may prove a promising treatment for averting the significant vascular complications associated with influenza infection during pregnancy.

First Trimester Preeclampsia Screening and Prevention: Perspective in Chinese Mainland

Preeclampsia (PE), a multisystem disorder in pregnancy, is one of the leading causes of perinatal morbidity and mortality that poses financial and physical burdens worldwide. Preterm PE with delivery at <37 weeks of gestation is associated with a higher risk of adverse maternal and perinatal outcomes than term PE with delivery at ≥37 weeks of gestation. A myriad of first trimester screening models have been developed to identifying women at risk of preterm PE. In fact, the Fetal Medicine Foundation (FMF) first trimester prediction model has undergone successful internal and external validation. The FMF triple test enables the estimation of patient-specific risks, using Bayes theorem to combine maternal characteristics and medical history together with measurements of mean arterial pressure, uterine artery pulsatility index, and serum placental growth factor. Establishing a quality control process for regular monitoring and to ensure data standardization, reliability, and accuracy is key to maintaining optimal screening performance. The rate of preterm PE can be reduced by 62% by using the FMF prediction model, followed by the administration of low-dose aspirin. Recent evidence has also demonstrated that metformin has the potential for preventing PE in patients at high-risk of the disorder. In this article, we will summarize the existing literature on the different screening methods, different components of risk assessment, therapeutic interventions, and clinical implementation of the first trimester screening and prevention program for PE with specific considerations for Chinese mainland.

Hydroxychloroquine in obstetrics: potential implications of the prophylactic use of hydroxychloroquine for placental insufficiency during pregnancy

Proper placentation during early pregnancy is a key factor for maintaining a healthy pregnancy. Placental insufficiency leads to critical complications such as preeclampsia, fetal growth restriction, and fetal demise. These complications are often associated with pathological findings of restricted remodeling and obstructive lesions of the myometrial spiral arteries, which have high recurrence rates during subsequent pregnancies. Currently, there are no pharmacological interventions other than aspirin for the prevention of preeclampsia. Hydroxychloroquine (HCQ), a well-known antimalarial drug, reduces inflammatory and thrombotic changes in vessels. For decades, the use of HCQ for autoimmune diseases has resulted in the successful prevention of both arterial and venous thrombotic events and has been extended to the treatment of lupus and antiphospholipid antibody syndrome during pregnancy. HCQ reduces the risk of preeclampsia with lupus by up to 90%. Several recent studies have investigated whether HCQ improves pregnancy outcomes in women with a history of poor outcomes. In addition, in vitro and animal studies have demonstrated the beneficial effects of HCQ in improving endothelial dysfunction and alleviating hypertension and proteinuria. Therefore, we hypothesized that HCQ has the potential to attenuate the vascular inflammatory and thrombogenic pathways associated with placental insufficiency and conducted a multicenter clinical trial on the efficacy of combining aspirin with HCQ for pregnancies at high risk for preeclampsia in Korea. This study summarizes the potential effects of HCQ on pregnancies with placental insufficiency and the implications of HCQ treatment in the field of obstetrics.

Expert Perspective on a Clinical Challenge: Lupus and Pregnancy

Systemic lupus erythematosus (SLE), a multiorgan systemic inflammatory disorder, predominantly affects women during their reproductive years. In this review, we summarize the state of knowledge about preconception planning and management of SLE during pregnancy. Achieving remission or low disease activity for several months on medications compatible with pregnancy prior to conception is essential to decreasing the risk of disease flare and improving pregnancy outcomes, including pre-eclampsia, preterm birth, and intrauterine growth restriction. With close management and well-controlled disease before and during pregnancy, <10% of patients flare. All patients with SLE should remain on hydroxychloroquine unless contraindicated. Expectant mothers with a history of antiphospholipid syndrome should be treated with anticoagulant therapy during pregnancy. Women with anti-Ro/SSA or anti-La/SSB antibodies require additional monitoring because their offspring are at increased risk for congenital heart block. Patients with SLE should be offered low-dose aspirin starting at the end of the first trimester to reduce the risk of pre-eclampsia. Flares of SLE during pregnancy require escalation of therapy. The immunosuppressives azathioprine, tacrolimus, and cyclosporine are compatible with pregnancy, and biologic agents can also be considered. Glucocorticoid use in pregnancy should be limited to the lowest effective dose. Mycophenolate mofetil/mycophenolic acid, methotrexate, leflunomide, and cyclophosphamide are known to be teratogenic and are contraindicated in pregnancy. Distinguishing a flare of lupus nephritis during pregnancy from pre-eclampsia can be particularly challenging. Overall, outcomes in pregnancy for women with lupus are improving, but gaps in knowledge about optimal management strategies persist.

Prevention of preeclampsia

Preeclampsia is a relatively common pregnancy complication and constitutes a major cause of morbidity and mortality for mothers and children worldwide. It disproportionally affects low-resource countries. Appropriate identification of individuals at increased risk and prevention of the disease and its complications remain healthcare and research priorities, and the investigation of potential interventions to prevent preeclampsia has driven much of the obstetric research in recent decades. In this article, we review the scientific literature on the topic, highlighting established benefits and remaining questions regarding different non-pharmacological and pharmacological strategies, including exercise, the timing of birth, aspirin and calcium use, among others, as well as potential novel therapies under investigation.

Risk of Hypertensive Disorders and Preterm Birth in Pregnant Women With Systemic Vasculitides: A Nationwide Population-Based Cohort Study

OBJECTIVE

Even though systemic vasculitides (SVs) affect primarily patients over 50 years of age, they can occur among women of childbearing age. Preterm birth (PTB) and hypertensive disorders are frequent complications of pregnancy in SVs. This study aims to evaluate the risk of hypertensive disorders and PTB among pregnant women with SVs, and to identify associated risk factors.

METHOD

Using the French health insurance data warehouse, we conducted a nationwide cohort study including all pregnancies between 2013 and 2018 in women with SVs. Theses pregnancies were matched to pregnancies among women without SVs. We estimated risk of hypertensive disorders and PTB risk during pregnancy among women with SVs and investigated associated risk factors using a nested case-control design.

RESULTS

Among 3,155,723 pregnancies, we identified 646 pregnancies in women with SVs, matched to 3,230 controls. SVs were significantly associated with hypertensive disorders (odds ratio [OR] 1.7, 95% confidence interval [95% CI] 1.3-2.2) and PTB (OR 1.8, 95% CI 1.4-2.3). Chronic renal failure before pregnancy, history of or treated arterial hypertension, the occurrence of vasculitides flare during pregnancy, and the subgroup of SVs were independently associated with the occurrence of hypertensive disorders. Maternal age at delivery, chronic renal failure before conception, and the occurrence of vasculitides flare during pregnancy were independently associated with the occurrence of PTB.

CONCLUSION

About one of seven pregnancies in women with SVs is associated with hypertensive disorders or preterm birth. The occurrence of vasculitides flare was associated with these complications. Our findings support the importance of prepregnancy counseling to ensure disease stability.

Chinese guideline for the diagnosis and treatment of Takayasu's arteritis (2023)

Takayasu's arteritis (TAK) is a chronic granulomatous inflammatory disease that involves aorta and its primary branches. It is characterized by wall thickening, stenosis/obliteration or aneurysm formation of the involved arteries. In order to standardize the diagnosis and treatment of TAK in China, a clinical practice guideline with an evidence-based approach is developed under the leadership of National Clinical Medical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID). Eleven recommendations for 11 clinical questions that are important to the diagnosis and treatment of TAK are developed based on the latest evidence and expert opinions combined with real clinical practice in China.

Chronic Hypertension in Pregnancy and Placenta-Mediated Complications Regardless of Preeclampsia

BACKGROUND

The prevalence of chronic hypertension in women of reproductive age is on the rise mainly due to delayed childbearing. Maternal chronic hypertension, prevailing prior to conception or manifesting within the early gestational period, poses a substantial risk for the development of preeclampsia with adverse maternal and fetal outcomes, specifically as a result of placental dysfunction. We aimed to investigate whether chronic hypertension is associated with placenta-mediated complications regardless of the development of preeclampsia in pregnancy.

METHODS

This was a population-based, retrospective cohort study from 'Soroka' university medical center (SUMC) in Israel, of women who gave birth between 1991 and 2021, comparing placenta-mediated complications (including fetal growth restriction (FGR), placental abruption, preterm delivery, and perinatal mortality) in women with and without chronic hypertension. Generalized estimating equation (GEE) models were used for each outcome to control for possible confounding factors.

RESULTS

A total of 356,356 deliveries met the study's inclusion criteria. Of them, 3949 (1.1%) deliveries were of mothers with chronic hypertension. Women with chronic hypertension had significantly higher rates of all placenta-mediated complications investigated in this study. The GEE models adjusting for preeclampsia and other confounding factors affirmed that chronic hypertension is independently associated with all the studied placental complications except placental abruption.

CONCLUSIONS

Chronic hypertension in pregnancy is associated with placenta-mediated complications, regardless of preeclampsia. Therefore, early diagnosis of chronic hypertension is warranted in order to provide adequate pregnancy follow-up and close monitoring for placental complications, especially in an era of advanced maternal age.

Aspirin at 75 to 81 mg Daily for the Prevention of Preterm Pre-Eclampsia: Systematic Review and Meta-Analysis

Background: Aspirin at 150 mg daily, initiated in the 1st trimester of pregnancy, prevents preterm pre-eclampsia. We aimed to estimate whether a dose of 75 to 81 mg daily can help to prevent preterm pre-eclampsia as well. Methods: A systematic search was conducted using multiple databases and meta-analyses of randomized controlled trials (RCTs) that compared aspirin initiated in the first trimester of pregnancy to placebo or no treatment, following the PRISMA guidelines and the Cochrane risk of bias tool. Results: We retrieved 11 RCTs involving 13,981 participants. Five RCTs had a low risk of bias, one at unclear risk, and fiver had a high risk of bias. A pooled analysis demonstrated that doses of 75 to 81 mg of aspirin, compared to a placebo or no treatment, was not associated with a significant reduction in preterm pre-eclampsia (8 studies; 12,391 participants; relative risk, 0.66; 95% confidence interval: 0.27 to 1.62; p = 0.36), but there was a significant heterogeneity across the studies (I2 = 61%, p = 0.02). Conclusion: It cannot be concluded that taking 75 to 81 mg of aspirin daily reduces the risk of preterm pre-eclampsia. However, given the significant heterogeneity between the studies, the true effect that such a dose of aspirin would have on pregnancy outcomes could not be properly estimated.

Challenges in Conducting Clinical Trials for Preeclampsia

PURPOSE OF REVIEW

To review recent data describing the challenges and innovations in therapeutic research focused on the prevention and treatment of preeclampsia.

RECENT FINDINGS

Pregnant individuals have traditionally been excluded from therapeutic research, resulting in a paucity of innovation in therapeutics for pregnancy-specific medical conditions, especially preeclampsia. With the increased awareness of maternal morbidity and mortality, there is significant interest among researchers to expand therapeutic research in pregnancy. Several medications, including aspirin, pravastatin, metformin, and esomeprazole, which are commonly used in non-pregnant populations, are now being investigated for preeclampsia prevention. However, given the historic precedent of exclusion, along with the regulatory, ethical, and feasibility concerns that accompany this population, the study of these and novel medications has been complicated by numerous challenges. While complex, and laden with challenges, there is great ongoing need for therapeutic research to address preeclampsia. Aspirin, pravastatin, metformin, and esomeprazole have all shown promise as potential therapeutic agents; however, their use remains to be optimized, and innovative therapeutics need to be developed.

Potential impact on using aspirin as the primary prevention of adverse pregnancy outcomes in twins conceived using ART

With the development of assisted reproductive technology, the number of twin pregnancies is increasing year by year. Given the increased risk of pregnancy complications associated with twin pregnancies, and the fact that these babies are rare and difficult to obtain through assisted reproductive technology, clinicians urgently require finding effective and safe drugs to improve pregnancy outcomes. Low-dose aspirin can not only promote placental blood supply, but also effectively anti-inflammatory. Whether Low-dose aspirin can effectively reduce the risk of pregnancy complications in this special group needs to be clarified. We therefore retrospectively analyzed 665 twin pregnancies from assisted reproduction technology, grouped according to aspirin use, and followed pregnancy outcomes to assess bleeding risk. Low-dose aspirin was found to be effective in preventing preeclampsia without a significant risk of bleeding. However, aspirin does not prevent specific complication in twin pregnancies and seems to have a better preventive effect only when the mother is under 30, which should alarm clinicians should not blindly using aspirin in this particular group.

An Examination of the Effect of Aspirin and Salicylic Acid on Soluble Fms-like Tyrosine Kinase-1 Release from Human Placental Trophoblasts

Low-dose aspirin (LDA) is efficacious in preventing preeclampsia, but its mechanism of action is unclear. Conflicting evidence suggests that it may inhibit placental trophoblast release of soluble fms-like tyrosine kinase-1 (sFlt1), a key mediator of preeclampsia. We examined whether, and at what concentrations, aspirin and its principal metabolite, salicylic acid, modulate sFlt1 release and/or expression in trophoblasts. Human trophoblast lines BeWo and HTR-8/SVneo were cultured; BeWo cells were also treated with 1% oxygen vs. normoxia to mimic hypoxia in preeclamptic placentas. Cells were treated with aspirin or salicylic acid vs. vehicle for 24 h at concentrations relevant to LDA and at higher concentrations. Protein concentrations (ELISA) and mRNA expression (RT-PCR) of sFlt1 were determined. Under normoxia, LDA-relevant concentrations of aspirin (10-50 µmol/L) or salicylic acid (20-100 µmol/L) had no significant effect on sFlt1 protein release or mRNA expression in BeWo cells. However, inhibition was observed at higher concentrations (1 mmol/L for aspirin and ≥200 μmol/L for salicylic acid). Hypoxia enhanced sFlt1 protein release and mRNA expression in BeWo cells, but these responses were not significantly affected by either aspirin or salicylic acid at LDA concentrations. Similarly, neither drug altered sFlt1 protein secretion or mRNA expression in normoxic HTR-8/SVneo cells at LDA concentrations. We suggest that direct modulation of trophoblast release or expression of sFlt1 is unlikely to be a mechanism underlying the clinical efficacy of LDA in preeclampsia.

[Preeclampsia: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate).

CONCLUSION

The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.

First trimester screening for pre-eclampsia and targeted aspirin prophylaxis: a cost-effectiveness cohort study

OBJECTIVE

Investigate cost-effectiveness of first trimester pre-eclampsia screening using the Fetal Medicine Foundation (FMF) algorithm and targeted aspirin prophylaxis in comparison with standard care.

DESIGN

Retrospective observational study.

SETTING

London tertiary hospital.

POPULATION

5957 pregnancies screened for pre-eclampsia using the National Institute for Health and Care Excellence (NICE) method.

METHODS

Differences in pregnancy outcomes between those who developed pre-eclampsia, term pre-eclampsia and preterm pre-eclampsia were compared by the Kruskal-Wallis and Chi-square tests. The FMF algorithm was applied retrospectively to the cohort. A decision analytic model was used to estimate costs and outcomes for pregnancies screened using NICE and those screened using the FMF algorithm. The decision point probabilities were calculated using the included cohort.

MAIN OUTCOME MEASURES

Incremental healthcare costs and QALY gained per pregnancy screened.

RESULTS

Of 5957 pregnancies, 12.8% and 15.9% were screen-positive for development of pre-eclampsia using the NICE and FMF methods, respectively. Of those who were screen-positive by NICE recommendations, aspirin was not prescribed in 25%. Across the three groups, namely, pregnancies without pre-eclampsia, term pre-eclampsia and preterm pre-eclampsia there was a statistically significant trend in rates of emergency caesarean (respectively 21%, 43% and 71.4%; P < 0.001), admission to neonatal intensive care unit (NICU) (5.9%, 9.4%, 41%; P < 0.001) and length of stay in NICU. The FMF algorithm was associated with seven fewer cases of preterm pre-eclampsia, cost saving of £9.06 and QALY gain of 0.00006/pregnancy screened.

CONCLUSIONS

Using a conservative approach, application of the FMF algorithm achieved clinical benefit and an economic cost saving.

Effect of Reduced INR in Early Pregnancy on the Occurrence of Preeclampsia: A Retrospective Cohort Study

To investigate the effect of reduced early-pregnancy activated partial thrombin time (APTT), prothrombin time (PT), and international standardized ratio (INR) on the risk of preeclampsia. A total of 8549 pregnant women with singleton births were included. Early pregnancy APTT, PT, and INR levels, with age, birth, prepregnancy body mass index, fibrinogen (FBG), thrombin time (TT), D-dimer (DD2), antithrombin III (ATIII), fibrin degradation products (FDP) as confounders, generalized linear model of APTT, the relative risk of PT and INR when INR reduction. After adequate adjustment for confounders, the relative risk of preeclampsia was 0.703 for every 1 s increase in plasma PT results in early pregnancy, and for every 0.1 increase in plasma INR results, the relative risk of preeclampsia was 0.767. With a PT less than the P25 quantile (<11 s), the relative risk of preeclampsia was 1.328. The relative risk of preeclampsia at an INR less than the P25 quantile (<0.92) was 1.24. There was no statistical association between APTT on the risk of preeclampsia. The relative risk of preeclampsia is strongly associated with a decrease in PT and INR in early pregnancy. PT and INR in early pregnancy were a potential marker in the risk stratification of preeclampsia. Focusing on reduced PT and INR levels in early pregnancy can help to identify early pregnancies at risk for preeclampsia.