Hydroxychloroquine as a Preventive and Therapeutic Option in Preeclampsia - a Literature Review

Prediction of Early- and Late-Onset Pre-Eclampsia in the Preclinical Stage via Placenta-Specific Extracellular miRNA Profiling

Pre-eclampsia (PE) is one of the severe complications of pregnancy in 3-8% of all cases and is one of the leading causes of maternal and perinatal mortality. The fundamental role in the pathogenesis of PE is assigned to maternal and/or placental factors, whereby the combination and manifestation of which determines the time of onset of the clinical symptoms of PE (before or after 34 weeks of gestation) and their severity. It is known that the expression level of miRNAs, the regulators of signaling cascades in the cell, depends on gestational age. In the present study, we focused on the identification of the placenta-specific miRNAs that differentiate between early- and late-onset pre-eclampsia (ePE and lPE) throughout pregnancy, from the first to the third trimester. A total of 67 patients were analyzed using small RNA deep sequencing and real-time quantitative PCR, which resulted in a core list of miRNAs (let-7b-5p, let-7d-3p, let-7f-5p, let-7i-5p, miR-22-5p, miR-451a, miR-1246, miR-30e-5p, miR-20a-5p, miR-1307-3p, and miR-320e), which in certain combinations can predict ePE or lPE with 100% sensitivity and 84-100% specificity in the 1st trimester of pregnancy. According to the literature data, these miRNA predictors of PE control trophoblast proliferation, invasion, migration, syncytialization, the endoplasmic reticulum unfolded protein response, immune tolerance, angiogenesis, and vascular integrity. The simultaneous detection of let-7d-3p, miR-451a, and miR-1307-3p, resistant to the repeated freezing/thawing of blood serum samples, in combination with biochemical (b-hCG and PAPP-A) and ultrasound (UAPI) parameters, allowed us to develop a universal model for the prediction of ePE and lPE onset (FPR = 15.7% and FNR = 9.5%), which was validated using a test cohort of 48 patients and demonstrated false-positive results in 26.7% of cases and false negatives in 5.6% of cases. For comparison, the use of the generally accepted Astraia program in the analysis of the test cohort of patients led to worse results: FPR = 62.1% and FNR = 33.3%.

Preeclampsia in women with lupus - Influence of aspirin and hydroxychloroquine on pregnancy outcome

Systemic lupus erythematosus is associated with increased rates of preeclampsia. Both aspirin and hydroxychloroquine are recommended for preeclampsia prophylaxis in women with lupus but there are no studies examining related outcomes in an Australian cohort. This was a single centre retrospective study of lupus affected pregnancies. The association between hydroxychloroquine, aspirin and preeclampsia was examined using adjusted logistic regression models. In 95 pregnancies, hydroxychloroquine was associated with a significantly lower risk of preeclampsia (adjusted OR 0.16, 95 % CI 0.04-0.64) but there was no association between aspirin and preeclampsia (adjusted OR 1.34, 95 % CI 0.33-5.40).

Perinatal Outcome and Its Association with Blood Pressure Levels in Women with Preeclampsia

Background: Timing and mode of delivery in women with preeclampsia remains challenging, often balancing the risk of severe maternal complications and preterm delivery with its risks for the newborn. It is known that women with very high blood pressure levels in pregnancy have more unfavourable outcomes, but there is little data on neonatal outcome in these cases and the effect of the delivery mode. Methods: We included 158 preeclamptic women in our single-centre retrospective cohort study. Patients were divided into three subgroups depending on blood pressure levels, and delivery mode as well as neonatal outcomes were analysed. Furthermore, the effect of gestational age at delivery was assessed. Results: Maternal blood pressure levels correlated negatively with gestational age at delivery (p = 0.007) and positively with delivery via caesarean section (p = 0.003). Induction of labour was more frequent in women with lower blood pressure levels (p = 0.008) and higher gestational age (p < 0.001). If labour was induced, vaginal delivery was achieved equally often in all gestational ages. Neonatal outcome appears to be more favourable after vaginal delivery compared to planned caesarean section (p < 0.001). Conclusions: Induction of labour should be discussed generously in preeclamptic women, even if blood pressure levels are high and/or gestational age is young, as success rates seem to be adequate and neonatal outcome is more favourable after vaginal delivery. Large prospective trials are needed to better evaluate success rates, risks and complications of induced labour and the effects of delivery mode on neonatal outcome in preeclampsia.

Blood Pressure Levels and Maternal Outcome in Women with Preeclampsia – a Retrospective Study from a Large Tertiary Obstetric Centre

Introduction Patients with high blood pressure levels are at high risk for acute complications as well as serious long-term consequences. Women with preeclampsia often experience very high blood pressure levels during pregnancy and postpartum and are also known to have a higher cardiovascular risk in later life.

Material and Methods In our single-centre retrospective cohort study, we analysed 158 pregnancies complicated by preeclampsia in regard to maternal outcome. We divided the patient cohort into three subgroups according to the blood pressure levels during hospital stay.

Results Pre-existing arterial hypertension was significantly more common in patients with a hypertensive crisis (systolic blood pressure ≥ 180 mmHg and/or diastolic blood pressure ≥ 120 mmHg) during pregnancy than in patients with moderate or severe hypertension (p = 0.001). Women with a hypertensive crisis had an unfavourable outcome compared to women with lower blood pressure levels. These women developed a HELLP-syndrome significantly more often (p = 0.013). Moreover, most of the women with a hypertensive crisis during pregnancy were still hypertensive at hospital discharge (p = 0.004), even though they were administrated antihypertensive agents more often (p < 0.001) compared to women with lower blood pressure values.

Conclusion Preeclamptic women with hypertensive crises should be identified quickly and monitored closely to avoid further complications. Standardized follow-up programs are lacking, but especially these patients seem to be at high risk for persistent hypertension and increased cardiovascular morbidity and therefore should receive specialist follow-up, including hypertensiologists, cardiologists and gynaecologists. Large prospective trials are required for a better understanding of these interrelations and to develop a specific follow-up program.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Cardiovascular Risk Reduction in Women Following Hypertensive Disorders of Pregnancy - a Prospective, Randomised, Controlled Interventional Study

Background Women have a markedly increased lifetime risk for cardiovascular morbidity and mortality following hypertensive disorders of pregnancy. Arterial stiffness is regarded as a target parameter for reducing cardiovascular risk and can be modified by lifestyle changes.

Methods In a prospective, randomised, controlled interventional study, starting 6 weeks postpartum, the effect of nutritional intervention combined with an intensive 6-month cardiovascular exercise programme on arterial stiffness was investigated by means of pulse wave velocity (PWV) in 38 women with severe hypertensive disorder of pregnancy (preeclampsia with or without pre-existing hypertension and/or HELLP syndrome). A reference group was formed with postpartum women without pregnancy complications or known cardiovascular risk and the arterial stiffness was studied by means of PWV at the time of delivery. The PWV was measured in the intervention and control groups within a week after delivery and after 32 weeks (6 weeks + 6 months). A feasibility analysis was performed in addition.

Results 29 of 38 women with severe hypertensive disorder of pregnancy and 38 postpartum women in the reference group were included in the analysis (intervention group n = 14; control group n = 15; reference group n = 38). Adherence to a) the nutritional counselling and b) the intensive cardiovascular exercise programme was 73% and 79% respectively. A clinically significant difference (d = 0.65) in pulse wave velocity between the intervention and control groups was found after 6 months (6.36 ± 0.76 vs. 7.33 ± 2.25 m/s; group × time: p = 0.632). The PWV of the intervention group corresponded to that of the reference group at the end of the study (6.36 ± 0.76 m/s vs. 6.5 ± 0.70; d = 0.19), while the results in the control group differed markedly from this (7.33 ± 2.25 m/s; d = 0.56).

Conclusion The study documents the feasibility of lifestyle intervention with physical exercise after delivery (starting 6 weeks postpartum). The intervention showed a significant clinical effect by reducing arterial stiffness to the level of the reference group. Before this intervention can be included in the standard of care and prevention, follow-up studies must confirm these results and the medium-term effects on cardiovascular risk.

The Role of microRNA Let-7d in Female Malignancies and Diseases of the Female Reproductive Tract

microRNAs are small noncoding RNAs that regulate gene expression at the posttranscriptional level. Let-7d is a microRNA of the conserved let-7 family that is dysregulated in female malignancies including breast cancer, ovarian cancer, endometrial cancer, and cervical cancer. Moreover, a dysregulation is observed in endometriosis and pregnancy-associated diseases such as preeclampsia and fetal growth restriction. Let-7d expression is regulated by cytokines and steroids, involving transcriptional regulation by OCT4, MYC and p53, as well as posttranscriptional regulation via LIN28 and ADAR. By downregulating a wide range of relevant mRNA targets, let-7d affects cellular processes that drive disease progression such as cell proliferation, apoptosis (resistance), angiogenesis and immune cell function. In an oncological context, let-7d has a tumor-suppressive function, although some of its functions are context-dependent. Notably, its expression is associated with improved therapeutic responses to chemotherapy in breast and ovarian cancer. Studies in mouse models have furthermore revealed important roles in uterine development and function, with implications for obstetric diseases. Apart from a possible utility as a diagnostic blood-based biomarker, pharmacological modulation of let-7d emerges as a promising therapeutic concept in a variety of female disease conditions.

Vitamin D alleviates hypoxia/reoxygenation-induced injury of human trophoblast HTR-8 cells by activating autophagy

INTRODUCTION

Attenuation of trophoblast cell dysfunction would be beneficial for retarding pre-eclampsia (PE). Vitamin D has been reported to improve trophoblast cell function in early PE, but the mechanism involved is not fully elucidated. This study is aimed to investigate whether vitamin D alleviates trophoblast cell dysfunction via regulating autophagy.

METHODS

Human trophoblast HTR-8 cells were cultured in hypoxia/reoxygenation (H/R) condition to simulate the oxidative stress state of early PE in vitro. MTT, Transwell and tube formation assays were respectively applied to assess cell proliferation, invasion, and angiogenesis abilities. DCFH-DA staining was performed to detect cellular reactive oxygen species levels. GFP-RFP-LC3 plasmid transfection and transmission electron microscopy were subjected to monitor autophagy. Enzyme-linked immunosorbent assay and Western blot analysis were used to detect autophagy-related and pyroptosis-associated molecules.

RESULTS

H/R led to severe impairments on the bio-function of HTR-8 cells, as evidenced by the deficiency of cell proliferation, invasion, and angiogenesis abilities, and the increase of cellular ROS production. Simultaneously, H/R inhibited autophagy and triggered pyroptosis. 1,25(OH)₂D₃, the hormonally active form of vitamin D, dramatically attenuated H/R-induced trophoblast dysfunction. Also, 1,25(OH)₂D₃ activated autophagy and inhibited pyroptosis. Additionally, autophagy-enhancer rapamycin exerted similar protective effect to that of 1,25(OH)₂D₃, whereas autophagy-inhibitor 3-methyladenine blocked the protective effect of 1,25(OH)₂D₃.

DISCUSSION

The mechanism that vitamin D alleviates trophoblast cell dysfunction is associated with autophagy induction and pyroptosis inhibition.