Perinatal outcomes in preeclampsia that is complicated by massive proteinuria

Hypertensive Disorders of Pregnancy: Diagnosis, Management and Timing of Birth

Hypertensive disorders of pregnancy are significant contributors to maternal and perinatal morbidity and mortality. The definition, classification, and management of these disorders have evolved over time. Notably, the disease classification enables caretakers to manage the disease as well as safeguard maternal and fetal health. The approach and management for pregnancies with gestational and chronic hypertension or pre-eclampsia with or without severe features should be adequately elucidated to mitigate adverse perinatal outcomes. This review aimed to present the most recent definition and classification of hypertensive disorders of pregnancy to address their management, determine the optimal timing of birth, and establish short- and long-term follow-up protocols following parturition.

Obstetrical outcomes of women with new-onset isolated proteinuria diagnosed after 24 weeks' gestation

PURPOSE

To assess a possible association between marked proteinuria and the risk of preeclampsia with severe features, as defined by the American College of Obstetricians and Gynecologists.

METHODS

This retrospective study included data recorded at a tertiary university-affiliated hospital between 2017 and 2022. Women at or beyond 24 weeks of gestation with proteinuria (protein levels > 300 mg in a 24 h urine collection) and normal blood pressure during the initial 48 h of admission were included. Obstetrical and neonatal outcomes were compared between women with mild proteinuria (300-1000 mg/24 h) and marked proteinuria (≥ 1000 mg/24 h).

RESULTS

Among the women with marked proteinuria (n = 48) compared to those with mild proteinuria (n = 108), the incidences were higher of preeclampsia (50.0% vs. 22.2%, p = 0.001) and of preeclampsia with severe features (18.8% vs. 2.8%, p < 0.001). In multivariate analysis that adjusted for maternal age, primiparity, multiple pregnancy, uric acid level > 6 mg/dL and aspirin treatment, marked proteinuria was a risk factor for preeclampsia with severe features (adjusted odds ratio [aOR] = 10.2, confidence interval [CI] 95% 1.9-54.0, p = 0.007) and for small-for-gestational-age infants (aOR = 2.4, 95% CI 1.02-5.6, p = 0.001). Among women with marked compared to mild proteinuria, rates were also higher of labor induction (58.3% vs. 25.9%, p < 0.001), indicated preterm delivery (41.7% vs. 25.0%, p = 0.04) and admission to the neonatal intensive care unit (44.1% vs. 25.8%, p = 0.017).

CONCLUSIONS

Women with marked compared to mild isolated proteinuria showed higher risk of developing preeclampsia with severe features and of delivering small-for-gestational-age neonates.

Proteinuria in predicting adverse outcomes in women with severe features of pre-eclampsia from a developing country: A prospective cohort study

OBJECTIVE

To study the adverse maternal and perinatal outcomes in women with severe pre-eclampsia (SPE) among different ranges of proteinuria.

METHODS

This prospective cohort study was conducted in Jawaharlal Institute of Postgraduate Medical Education and Research, India. After obtaining informed written consent, the 202 singleton women fulfilling the criteria of severe features of pre-eclampsia were stratified based on the value of urine protein-creatinine ratio (UPCR) as mild, moderate, severe, and massive proteinuria during pregnancy. Clinical outcomes were assessed and patients were followed up until 12 weeks postpartum to identify persistent proteinuria and hypertension.

RESULTS

Of the 202 women with SPE, adverse maternal outcomes were seen in 34.65% (n = 70) and adverse perinatal outcomes in 75.74% (n = 153). The demographic and clinical factors were similar among women with increasing severity of proteinuria, except for mean systolic blood pressure, serum creatinine and total serum protein. UPCR was found to have a significant correlation with composite adverse perinatal outcome (P < 0.001) and individual outcomes of neonatal intensive care unit admission for >48 h (P = 0.01) and neonatal sepsis (P = 0.02) but not adverse maternal outcomes (P = 0.201). The optimum UPCR cutoff for adverse perinatal outcomes was 1.6 (sensitivity, 73.2%; specificity, 52.7%). In addition, 14.85% of the women had a persistently elevated UPCR and 3.96% had hypertension at 3 months postpartum.

CONCLUSION

In women with SPE, severe and massive proteinuria were related to composite adverse perinatal outcome but not composite adverse maternal outcome. Moreover, antenatal 24-h proteinuria was significantly associated with persistent proteinuria. Significant proteinuria in women with SPE poses a risk for chronic renal dysfunction, requiring follow-up.

Amount of Proteinuria and Duration of Expectant Management in Severe Preeclampsia

OBJECTIVE

The aim of the study is to evaluate the association between the amount of proteinuria at the time of diagnosis of preeclampsia with severe features (severe preeclampsia [SPE]) and duration of expectant management (EM) and other perinatal outcomes.

STUDY DESIGN

This is a retrospective cohort study of patients with SPE delivering live, non-anomalous singletons at 230/7 to 342/7 weeks' estimated gestational age (EGA) at a single tertiary center 2016 to 2018. Patients with proteinuria assessment (24-hour total urine protein or urine protein-to-creatinine ratio extrapolation) within 3 days of SPE diagnosis were included. Patients delivered for an indication other than SPE were excluded. Patients were categorized by amount of proteinuria (mg): none (≤300), mild (301-1,000), moderate (1,001-3,000), and massive (≥3,001). The primary outcome was the proportion of potential EM time achieved (%EM), i.e., days of EM divided by days from SPE diagnosis to 34 weeks. Secondary outcomes included delivery EGA, days of EM, and perinatal outcomes. Bivariable and multivariable analyses compared outcomes across groups.

RESULTS

Of 295 patients included, 21% had no proteinuria, 33% mild, 19% moderate, and 27% massive. Groups differed by EGA at diagnosis, age, parity, chronic hypertension, and renal disease. %EM was not significantly different between groups (adjusted β coefficient 4.1 [95% CI -5.3, 13.5] for mild proteinuria vs. none, -4.1 [95% CI -14.9, 6.6] for moderate proteinuria vs. none, and -5.6 [95% CI -16.0, 4.7] for massive proteinuria vs. none). Increasing proteinuria was associated with earlier delivery EGA but only days of EM in the mild versus no proteinuria groups. There was no significant association between proteinuria and maternal composite morbidity, but patients with mild and massive proteinuria had higher odds of neonatal composite morbidities compared with no proteinuria.

CONCLUSION

Among patients with SPE, proteinuria level was not consistently associated with duration of EM. However, patients with the greatest amounts of proteinuria may have worse neonatal and selected maternal outcomes.

KEY POINTS

· Amount of proteinuria was not associated with the duration of expectant management.. · Greater proteinuria was associated with earlier delivery in severe preeclampsia.. · Massive proteinuria in preeclampsia was associated with select adverse maternal and neonatal outcomes..

[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.

Twenty-four-hour proteinuria levels are associated with adverse pregnancy outcomes among women with CKD

Background

Proteinuria is commonly measured to assess the renal status of chronic kidney disease (CKD) patients before the 20th week of gestation during pregnancy. High levels of proteiuria have been associated with adverse pregnancy outcomes. However, researchers have not clearly determined what baseline proteinuria levels would be associated with adverse pregnancy outcomes. This study aimed to analyse associations between proteinuria levels and adverse pregnancy outcomes among CKD patients treated with or without steroids/immunosuppressive therapy in early pregnancy.

Methods

This retrospective study included the clinical information of 557 pregnant patients with CKD from 1 January 2009 to 31 December 2021. A multivariable logistic regression analysis was conducted to evaluate the risk of adverse pregnancy outcomes across various proteinuria ranges, which were further stratified by whether the patients were receiving steroids/immunosuppressive therapy.

Results

(i) Proteinuria was assessed on 24-h urine collection. The median (quartile) baseline proteinuria levels were 0.83 g (0.20, 1.92) and 0.25 g (0.06, 0.80) in the steroids/immunosuppressive therapy and therapy-free groups, respectively. (ii) CKD patients with adverse pregnancy outcomes had significantly higher proteinuria levels in the first trimester than patients without adverse pregnancy outcomes. (iii) The risk of adverse pregnancy outcomes increased with increasing baseline proteinuria levels (P < .001). (iv) In the early-pregnancy steroids/immunosuppressive therapy group, the risk of severe preeclampsia was higher in patients with higher baseline proteinuria levels (P < .007) [odds ratio (OR) 30.86 for proteinuria ≥5.00 g/24 h]; in the therapy-free group, the risks of severe preeclampsia, very-low-birth-weight infants, early preterm birth and foetal-neonatal death were higher in patients with higher baseline proteinuria levels (OR 53.16 for proteinuria ≥5.00 g/24 h; OR 37.83 for proteinuria ≥5.00 g/24 h; OR 15.30 for proteinuria ≥5.00 g/24 h; and OR 18.83 for proteinuria ≥5.00 g/24 h, respectively; P < .001, P < .001, P < .001 and P = .006, respectively).

Conclusions

As shown in the present study, a baseline 24-h proteinuria level >1.00 g was associated with adverse maternal outcomes. Furthermore, a 24-h proteinuria level >2.00 g increased the incidence of adverse foetal events among CKD patients.

Evaluation of Fetal Cardiac Functions in Preeclampsia: Does the Severity or Proteinuria Affect Fetal Cardiac Functions?

OBJECTIVE

To compare the fetal cardiac functions in preeclampsia and control group, and determine whether the severity or amount of proteinuria affects fetal cardiac functions.

METHODS

This prospective case-control study involves 48 pregnant women with preeclampsia and 48 healthy women. Pulsed wave Doppler, M-mode, and tissue Doppler imaging were used to measure the cardiac function between the 32 and 34 gestational weeks in each group. All Doppler indices and cardiac function parameters were also compared in subgroups with mild and severe preeclampsia and between subgroups with proteinuria >3 g/24 hours and <3 g/24 hours.

RESULTS

Decreased diastolic function (decreased E, A, E', and A' values in mitral/tricuspid valves and increased isovolumetric relaxation time) and decreased systolic functions (decreased mitral and tricuspid annular plane systolic excursion and S' value in mitral/tricuspid valves) were detected in the preeclampsia group. Decreased tricuspid E value in severe preeclampsia compared with mild preeclampsia was shown in the present study.

CONCLUSION

Preeclampsia may cause changes in systolic and diastolic functions in the fetal heart. Subclinical functional changes of these fetuses can be detected earlier and more sensitively with the help of tissue Doppler imaging. Biventricular diastolic functional changes are more prominent in preeclamptic cases with proteinuria >3 g/24 hours.

Expression pattern and clinical significance of microRNA-let-7a and IFN-gamma in placental tissue of patients with preeclampsia with severe features

OBJECTIVES

Preeclampsia with severe features (PECsf) is a common disease in pregnant women. let-7a and IFN-gamma (interferon-gamma) are involved in diagnosis and prognosis of preeclampsia. This study explored effects of let-7a and IFN-gamma on PECsf patients.

METHODS

The placental tissue of 21 PECsf, 19 preeclampsia without severe features (PEC), and 20 normal pregnant women were collected, and clinical data were recorded. let-7a and IFN-gamma expressions in placental tissue were detected. The correlation between let-7a/IFN-gamma expression and clinical indexes was analyzed. According to let-7a and IFN-gamma expressions, PECsf patients were assigned into Hlet-7a group (let-7a high expression group), Llet-7a group (let-7a low expression group), HIFN-gamma group (IFN-gamma high expression group) and LIFN-gamma group (IFN-gamma low expression group). The incidence of adverse prognosis was compared.

RESULTS

let-7a and IFN-gamma were highly expressed in placental tissue of preeclampsia patients, with significant differences between PEC and PECsf. The high expressions of let-7a and IFN-gamma were positively correlated with mean arterial pressure, lactate dehydrogenase, and 24 h urinary protein in placental tissues of PECsf patients. High let-7a and IFN-gamma expressions were correlated with adverse outcomes of PECsf.

CONCLUSIONS

High let-7a and IFN-gamma expressions were correlated with clinical features, and could be used as biomarkers for treatment and poor prognosis of PECsf.

The association between protein levels in 24-hour urine samples and maternal and neonatal outcomes of pregnant women with preeclampsia

Objective

Hypertensive diseases of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide. The aim of this study was to evaluate the association between protein levels in 24-hour urine samples and maternal and perinatal outcomes in preeclamptic patients.

Material and Methods

This retrospective cohort study was conducted with pregnant women who were diagnosed with preeclampsia (PE) and delivered in our clinic between 2010 and 2018. Patients were divided into those with a proteinuria value below 300 mg/24 h (non-proteinuria), proteinuria value between 300-2000 mg/24 h (mild proteinuria), proteinuria value between 2000-5000 mg/24 h (severe proteinuria) and proteinuria value >5000 mg/24 h (massive proteinuria) and were compared in terms of maternal and perinatal outcomes. Demographic characteristics (age, body mass index in kg/m2, gravidity), PE-related clinical symptoms (epigastric pain, neurological and respiratory symptoms), laboratory findings (24 h protein level, lactate dehydrogenase, aspartate aminotransferase, platelet count and creatine levels) were recorded in all patients.

Results

A total of 1,379 patients meeting the study criteria were included. There were 315 (23%) patients in the non-proteinuria group, 704 (51%) in the mild proteinuria group, 234 (17%) patients in the severe group and 126 (9%) patients in the massive proteinuria group. The massive proteinuria group was found to have the highest rates of maternal and prenatal complications. The Apgar score, umbilical cord pH value, birth weight, gestational week at delivery, intrauterine growth restriction and intrauterine fetal death were significantly higher in the massive proteinuria group.

Conclusion

Our data showed that the degree of proteinuria appears to be associated with maternal, fetal and neonatal outcomes among women diagnosed with PE. Women with proteinuria of >5000 mg/24 hours had notably poorer natal outcomes.

Preeclampsia: state of art and future perspectives. A special focus on possible preventions

Preeclampsia (PE) is characterised by the new onset of hypertension after the 20th week of pregnancy, with or without proteinuria or hypertension that leads to end-organ dysfunction. Since the only definitive treatment is delivery, PE still represents one of the leading causes of preterm birth and perinatal mobility and mortality. Therefore, any strategies that aim to reduce adverse outcomes are based on early primary prevention, prenatal surveillance and prophylactic interventions. In the last decade, intense research has been focussed on the study of predictive models in order to identify women at higher risk accurately. To date, the most effective screening model is based on the combination of anamnestic, demographic, biophysical and maternal biochemical factors. In this review, we provide a detailed discussion about the current and future perspectives in the field of PE. We will examine pathogenesis, risk factors and clinical features. Moreover, recent developments in screening and prevention strategies, novel therapies and healthcare management strategies will be discussed.

Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance

Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.

Changes in rate of preterm birth and adverse pregnancy outcomes attributed to preeclampsia after introduction of a refined definition of preeclampsia: A population-based study

INTRODUCTION

Since 2013, various guidelines for hypertension in pregnancy have been refined, no longer requiring proteinuria as a requisite criterion for preeclampsia. We aimed to evaluate the impact of the new definition on preterm birth (PTB) and adverse pregnancy outcomes.

MATERIAL AND METHODS

Women delivering in Ontario between April 2012 and November 2016 were included. Delivery <24+0/7 weeks, major fetal anomalies or preexisting renal disease were excluded. The primary outcome was livebirth <37, <34 or <32 weeks. Rates, adjusted rate ratios (aRR) and ratio of the rate ratio (RRR) were used to compare outcomes in the 2 years after the new Society of Obstetricians and Gynaecologists of Canada (SOGC) guideline (December 2014-November 2016; period 2) vs the 2 years before (April 2012-March 2014; period 1), among women with and without preeclampsia.

RESULTS

In all, 268 543 and 267 964 births in periods 1 & 2, respectively, were included. Respective preeclampsia rates increased significantly from 3.9% to 4.4% (p < 0.001), with no change in maternal morbidity rates. In preeclamptic women, respective rates of PTB <37 weeks were 21.0% and 20.7% (aRR 1.01, 95% confidence interval [CI] 1.00-1.02), with significant aRR for PTB <34 (0.86, 95% CI 0.77-0.96) and <32 weeks (0.79, 95% CI 0.67-0.94). A similar aRR was observed in women without preeclampsia. In preeclamptic women, composite severe neonatal morbidity decreased after guideline change (aRR 0.95, 95% CI 0.91-0.99), a finding not observed in women without preeclampsia (RRR 0.95, 95% CI 0.91-0.99).

CONCLUSIONS

The new definition of preeclampsia was associated with increased disease rates, a modest reduction in adverse neonatal outcomes and no change in maternal outcomes.

Progression from isolated gestational proteinuria to preeclampsia with severe features

INTRODUCTION

The association between the degree of isolated gestational proteinuria and preeclampsia with severe features and other placental-mediated complications is controversial. The aim of this study was to evaluate whether a higher isolated proteinuria level is associated with an increased frequency of preeclampsia with severe features.

MATERIAL AND METHODS

This retrospective cohort study included pregnant women who were past 24 weeks of gestation and were diagnosed as having new-onset proteinuria ≥300 mg in a 24-h urine collection. Exclusion criteria included diagnosis of preeclampsia within 72 h from admission, chronic renal disease or chronic hypertension. The study population was divided into tertiles by proteinuria level and the association with preeclampsia with severe features was assessed in both bivariable and multivariable analysis. The main outcome measures was the development of preeclampsia with severe features.

RESULTS

Overall, 165 women were diagnosed with isolated gestational proteinuria, and 38 (23.0%) of them developed preeclampsia with severe features. Women in the increasing proteinuria tertile were more likely to develop preeclampsia with severe features (5.5%, 21.8%, 41.8%, respectively; p = 0.004). A multivariable logistic regression model controlling for background characteristics as well as gestational age at diagnosis, blood pressure, and kidney and liver function tests showed an increased risk of 14% to develop preeclampsia with severe features for every 500-mg rise in proteinuria level (adjusted odds ratio = 1.14, 95% confidence interval 1.03-1.27).

CONCLUSIONS

A higher isolated gestational proteinuria level was associated with an increased risk to develop preeclampsia with severe features among pregnant women past 24 weeks of gestation.

Earlier onset of proteinuria or hypertension is a predictor of progression from gestational hypertension or gestational proteinuria to preeclampsia

Although gestational hypertension (GH) is a well-known disorder, gestational proteinuria (GP) has been far less emphasized. According to international criteria, hypertensive disorders of pregnancy include GH but not GP. Previous studies have not revealed the predictors of progression from GP to preeclampsia or those of progression from GH to preeclampsia. We aimed to determine both sets of predictors. A retrospective cohort study was conducted with singleton pregnant women who delivered at 22 gestational weeks or later. Preeclampsia was divided into three types: new onset of hypertension/proteinuria at 20 gestational weeks or later and additional new onset of other symptoms at < 7 days or at ≥ 7 days later. Of 94 women with preeclampsia, 20 exhibited proteinuria before preeclampsia, 14 experienced hypertension before preeclampsia, and 60 exhibited simultaneous new onset of both hypertension and proteinuria before preeclampsia; the outcomes of all types were similar. Of 34 women with presumptive GP, 58.8% developed preeclampsia; this proportion was significantly higher than that of 89 women with presumptive GH who developed preeclampsia (15.7%). According to multivariate logistic regression models, earlier onset of hypertension/proteinuria (before or at 34.7/33.9 gestational weeks) was a predicator for progression from presumptive GH/GP to preeclampsia (odds ratios: 1.21/1.21, P value: 0.0044/0.0477, respectively).

Proteinuria may be an indicator of adverse pregnancy outcomes in patients with preeclampsia: a retrospective study

BACKGROUND

Proteinuria is one of the common manifestations of patients with preeclampsia (PE), but whether the severity of proteinuria is related to the pregnancy outcome of patients with preeclampsia remains controversial. The present study aimed to determine the relationship between 24-h proteinuria and adverse outcomes in patients with preeclampsia.

METHODS

The present retrospective study included 329 pregnant women in Chongqing, China. Patients were divided into PE group and non-PE group. PE group was stratified into three subgroups based on the level of 24-h proteinuria. Correlation analysis was used to analyze the correlation between biochemical indexes and adverse pregnancy outcome, and Logistic regression analysis was used to analyze the risk factors of adverse pregnancy outcome. The receiver operating characteristic curve (ROC) was used to evaluate the ability of 24-h urinary protein to distinguish the adverse pregnancy outcome in patients with preeclampsia.

RESULTS

(1) Between PE and non-PE group, cesarean section rate in PE group was significantly higher than that in non-PE group (84.4% vs. 25.9%, p <  0.001). Laboratory findings such as uric acid and creatinine level in PE group were higher than those in non-PE group. (2) Among mild (proteinuria < 0.3 g/24 h), moderate (0.3 g/24 h ≦ proteinuria < 2 g/24 h) and massive (proteinuria ≧ 2 g/24 h) groups, the frequencies of induced labor (p = 0.006) and stillbirth (p = 0.002) increased with the increase of 24-h proteinuria. (3) Adverse outcomes were positively correlated with 24-h proteinuria (adverse maternal outcomes: r = 0.239, p = 0.002; adverse fetal outcomes: r = 0.336, p <  0.001). (4) The best 24-h proteinuria cutoff values to determine stillbirth, premature and fetal distress were 3965.0 mg/24 h, 984.75 mg/24 h and 1503.85 mg/24 h and their odds ratio (95% confidence interval) were 12.46 (3.46-44.88), 2.48 (1.15-5.37) and 10.02 (2.14-46.80), respectively.

CONCLUSIONS

The severity of 24-h proteinuia may forecast adverse outcomes in women with preeclampsia. We suggest proteinuria should be retained as one of the monitoring indexes in patients with preeclampsia.

TRIAL REGISTRATION

Retrospectively registered. (LTMCMTS202001).

Association between proteinuria and maternal and neonatal outcomes in pre-eclampsia pregnancy: a retrospective observational study

Objectives

To evaluate the association between proteinuria and maternal and neonatal outcomes in pregnant women with pre-eclampsia.

Methods

This retrospective study included patients beyond 20 weeks of gestation diagnosed with pre-eclampsia, who were admitted to Suzhou Municipal Hospital between December 2013 and December 2015. Demographic and clinical data were extracted from clinical records, including age, body mass index, newborn weight and Apgar score. Pre-eclampsia risk factors and perinatal outcomes were analysed.

Results

A total of 407 patients were enrolled, of whom, 402 with pre-eclampsia were included in the final analyses, divided into two groups: patients with proteinuria (n = 364 [90.55%]) and patients without proteinuria (n = 38 [9.45%]). Newborn 5-min Apgar scores were statistically lower in the proteinuria group versus the group without proteinuria (9.77 versus 9.95). Compared with patients without proteinuria, patients with proteinuria had a significantly higher rate of births before 37 weeks of gestation (50.80% versus 31.60%), but the incidence of preterm membrane rupture was significantly lower (3.8% versus 13.2%).

Conclusion

Proteinuria may be associated with adverse maternal and neonatal outcomes in cases of pre-eclampsia.

Adiponectin as a Potential Biomarker for Pregnancy Disorders

Adiponectin is an adipocyte-derived hormone that plays a critical role in energy homeostasis, mainly attributed to its insulin-sensitizing properties. Accumulating studies have reported that adiponectin concentrations are decreased during metabolic diseases, such as obesity and type 2 diabetes, with an emerging body of evidence providing support for its use as a biomarker for pregnancy complications. The identification of maternal factors that could predict the outcome of compromised pregnancies could act as valuable tools that allow the early recognition of high-risk pregnancies, facilitating close follow-up and prevention of pregnancy complications in mother and child. In this review we consider the role of adiponectin as a potential biomarker of disorders associated with pregnancy. We discuss common disorders associated with pregnancy (gestational diabetes mellitus, preeclampsia, preterm birth and abnormal intrauterine growth) and highlight studies that have investigated the potential of adiponectin to serve as biomarkers for these disorders. We conclude the review by recommending strategies to consider for future research.

Diagnostic accuracy of random urinary protein-to-creatinine ratio for proteinuria in patients with suspected pre-eclampsia

PURPOSE

To evaluate the correlation between urine protein/creatinine ratio (UPCR) and proteinuria in a 24-h urine collection and to calculate the predicative accuracy of different cutoffs of UPCR for the diagnosis of proteinuria.

METHODS

A retrospective cohort study including women who admitted for the evaluation for suspected preeclampsia (PET) beyond 20 weeks of gestation in a single tertiary center. Both UPCR test and quantification of proteinuria using 24-h urine collection were obtained during their index hospitalization no more than 48 h apart. Women with pre-existing diabetes mellitus, known renal disease or proteinuria prior to pregnancy or chronic hypertension were excluded. Predictive accuracy of UPCR for several cutoffs of proteinuria was evaluated. Multivariate logistic regression analysis was used to assess diagnostic accuracy of UPCR in sub-populations according to obstetrical characteristics.

RESULTS

Overall 463 patients were included. Of them 316 (68.3%) have 24-h urine protein collection of ≥ 300 mg/day. Mean gestational age at evaluation was 34.0 ± 3.4 weeks. Median (and interquartile range) time interval between UPCR and 24-h urine collection was 1.8 (1.6-1.9) days. Sensitivity and specificity of UPCR of 0.3 for predicting proteinuria ≥ 300 mg/day were 90.1% and 63.3%, respectively. The corresponding values for difference proteinuria cutoffs: ≥ 1000 mg/day and 5000 mg/day were 98.4, 100% and 29.1, 36.0%, respectively. The optimal UPCR thresholds for 24-h urine protein collection of ≥ 300 mg/day,  ≥ 1000 mg/day and 5000 mg/day were 0.31, 0.70 and 2.49, respectively. The predictive accuracy of UPCR > 0.30 in predicting proteinuria was unaffected by demographic and obstetrical characteristics as maternal age, pre-pregnancy BMI, gestational age at examination, creatinine levels or by multiple gestation [adjusted OR 18.27 (95% CI 9.97-33.47)].

CONCLUSION

UPCR was strongly correlated with various cutoffs of proteinuria obtained by 24-h urine collection. UPCR cutoff varied depending on the specific measured outcome. This correlation was not affected by gestational age at examination.

Hypoproteinemia as a parameter of poor perinatal/neonatal outcomes in women with preeclampsia diagnosed as hypertension plus proteinuria

OBJECTIVES

To investigate the relationship between serum total protein (TP) levels and maternal/neonatal outcomes among pregnant women with preeclampsia.

STUDY DESIGN

TP was measured at preeclampsia diagnosis and delivery in 94 women with singleton pregnancies and preeclampsia as hypertension with proteinuria who delivered at ≥ 22 gestational weeks (GWs). As a control group, measurements were also made in 188 women with singleton pregnancies without hypertension and/or proteinuria.

MAIN OUTCOME MEASURES

The relationship between serum TP levels and maternal outcomes.

RESULTS

Serum TP levels showed a significantly negative relationship with urine protein-to-creatinine (P/C) ratio at preeclampsia diagnosis and delivery. Serum TP levels at delivery in the preeclampsia group (53 ± 7 g/L) were lower than in the control group (61 ± 4 g/L, P < 0.0001). In each group, there was no relationship between the daily decrease in TP and the daily increase maternal body weight. However, there was a positive relationship between the daily increase in P/C ratio and the daily increase in maternal body weight in the preeclampsia group (P = 0.0021). Severe hypoproteinemia at preeclampsia diagnosis was a predictor of abruptio placentae (TP < 49 g/L; odds ratio, 21.3) and peripartum cardiomyopathy (TP < 45 g/L; odds ratio, 43.5). Furthermore, women with severe hypoproteinemia at delivery had higher morbidity due to pulmonary edema (TP < 55 g/L; odds ratio, 26.4) and central serous chorioretinopathy (TP < 42 g/L; odds ratio, 264).

CONCLUSIONS

Serum TP levels and proteinuria severity at preeclampsia diagnosis and delivery showed a positive relationship and predicted poor maternal outcome.

Expectant management in HELLP syndrome: predictive factors of disease evolution

Objective: HELLP syndrome is a rare and severe pregnancy complication which exposes to severe maternal and fetal morbidity. Management of HELLP syndrome occurring before 34 weeks of gestation (WG) is still controversial but conservative management may be beneficial in patients with stable HELLP syndrome. The aim of the study was thus to identify which maternal and fetal prognostic factors could be predictive of HELLP syndrome evolution.Methods: From 2003 to 2016, all patients with HELLP syndrome occurring between 26 and 34 WG were retrospectively enrolled. Study population was stratified according to obstetrical management. Patients in whom delivery was initiated within 48 h following diagnosis constituted the active management group. In the expectant management group, pregnancy was prolonged until maternal or fetal follow up indicated delivery.Results: Ninety-nine patients were included in our study. Among them, 61 were managed expectantly. At baseline, the active management group was more likely to suffer from persistent hyperreflexia (p < .001), headache (p = .006) and confusion (p < .01). Moreover, this group was associated with worst biological and ultrasound features, namely decreased prothrombin ratio (p = .04), increased creatinine value (p = .01), and increased rates of pathological umbilical cord flow (p = .05) and abnormal ductus venosus flow (p = .007). After logistic regression, baseline significant prognostic factors were hyperreflexia (RR = 12.35; CI = 3.8 - 39.9), creatinine level (RR = 1.03; CI = 1002 - 1058) and abnormal umbilical cord flow (RR = 3.95; CI = 1.05 - 14.81). Last, expectant management leads to longer gestation time after diagnosis with an average value of 7.75 days without increasing maternal nor fetal mortality.Conclusion: While expectant management in HELLP syndrome might be beneficial through its reduction of prematurity, it cannot be conducted in all patients. Identification of baseline parameters predictive of disease evolution is thus of tremendous importance to define which obstetrical approach should be prioritized.

Reappraisal of the relationship between 24-hour proteinuria and preeclampsia in terms of the maternal and perinatal outcomes

Objective: This study evaluated the association between proteinuria levels and maternal, and perinatal outcomes of preeclampsia patients and determined the cutoff values for predicting severe complications.Methods: We retrospectively evaluated the records of 412 patients with proteinuric preeclampsia.Results: Median proteinuria levels were significantly higher in patients with severe maternal and adverse perinatal outcomes than in those without such outcomes, except in cases of placental abruption and late preterm delivery.Conclusion: Proteinuria levels may aid in diagnosing preeclampsia and indicating early intervention. The revised guidelines do not suggest that proteinuria encountered during pregnancy is clinically insignificant.

Severe proteinuria as a parameter of worse perinatal/neonatal outcomes in women with preeclampsia

OBJECTIVES

The present study aimed to determine the relationship between the severity of proteinuria and maternal/neonatal outcomes among women with preeclampsia.

STUDY DESIGN

Proteinuria severity was measured at preeclampsia diagnosis and at delivery in 94 women with preeclampsia (among 2904 women with singleton pregnancies, who delivered after 22 gestational weeks). Preeclampsia was defined as hypertension with proteinuria.

MAIN OUTCOME MEASURES

Protein:creatinine (P/C) ratio to worse the maternal outcome was 4.8 among women with preeclampsia.

RESULTS

The frequencies of HELLP syndrome and maternal pulmonary edema in women with a P/C ratio ≥5.0 (35.5% and 35.5%, respectively) were significantly higher than those in women with a P/C ratio <5.0 (12.7%, P = 0.014 and 6.4%, P < 0.001, respectively). The best P/C ratio cutoff value to determine early-onset preeclampsia and early preterm birth (EPB) was 4.1 (P < 0.001 and P < 0.001, respectively). The best P/C ratio cutoff values to determine the interval between the preeclampsia diagnosis and delivery <7 days and the need to undergo cesarean section were 1.8 and 1.5, respectively. The best P/C ratio cutoff value to determine maternal pulmonary edema and central serous chorioretinopathy (CSC) was 4.8 (P = 0.020 and P = 0.014, respectively). Finally, the best P/C ratio cutoff values to determine EPB and maternal CSC in women with preeclampsia were 4.1 (odds ratio, 10.9; 95% confidence interval; 4.08 to 29.2, P < 0.0001) and 4.8 (odds ratio, 17.6; 95% confidence interval; 0.898 to 344, P = 0.0008), respectively, according to the multivariate analysis.

CONCLUSIONS

A higher P/C ratio at delivery in women with preeclampsia might cause EPB and CSC.

ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia

Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.

Hypertensive Disorders of Pregnancy

The 4 categories of hypertensive disorders of pregnancy are chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. These disorders are among the leading causes of maternal and fetal morbidity and mortality. Proper diagnosis in the emergency department is crucial in order to initiate appropriate treatment to reduce the potential harm to the mother and the fetus. Prompt management should be undertaken when the blood pressure is greater than 160/110 mm Hg or there are other severe features such as acute kidney injury, elevated liver function tests, severe abdominal pain, pulmonary edema, and central nervous system disturbances.

The importance of proteinuria in preeclampsia and its predictive role in maternal and neonatal outcomes

OBJECTIVE

To evaluate impact of 24-h proteinuria level in preeclampsia on maternal/perinatal outcomes.

METHODS

Singleton pregnancies with preeclampsia delivered after 24 weeks of gestation were included. Patients were divided into mild (0.3 to <2 g) (n=72), severe (2 to <5 g) (n=30), and massive (≥5 g) (n=24) proteinuria groups, and cut-off values of 24-h proteinuria for composite adverse maternal and neonatal outcomes were calculated.

RESULTS

Twenty-four hour  proteinuria level cut-offs for composite adverse outcomes were 3275 mg (72.2% sensitivity, 85.6% specificity) and 2395 mg (72.7% sensitivity, 78% specificity) respectively.

CONCLUSION

Severe and massive proteinuria were related to poor maternal, perinatal, and neonatal outcomes.

Increase in the number of patients diagnosed using the new classification of hypertensive disorders of pregnancy in Japan

AIM

This study aimed to examine how the number of patients diagnosed with pre-eclampsia increased according to the Japanese classification of hypertensive disorders of pregnancy (HDP) that was revised in 2018. The effect of new classification on perinatal outcomes was also analyzed.

METHODS

We enrolled 181 women with HDP who delivered at Hokkaido University Hospital between February 2011 and December 2017. All women were reclassified on the basis of the new classification, in which proteinuria was not required to diagnose pre-eclampsia in patients with maternal organ damage. The number and reasons of reclassification and the admission rate to the neonatal intensive care unit (NICU) and gestational age (GA) at the onset of HDP and at delivery were analyzed.

RESULTS

In this cohort, 17 (9.4%) of 181 women with HDP were reclassified. Low platelet count (41.2%) and uteroplacental dysfunction (41.2%) were the two main causes for reclassification. GA at the onset of HDP (33.6 [29.9-36.1] weeks vs 37.4 [35.7-38.4] weeks; P < 0.001) and at delivery (35.9 [32.4-37.3] weeks vs 38.1 [37.3-39.6] weeks; P < 0.001) were significantly earlier in women with reclassification than women without reclassification. The NICU admission rate was higher in women with reclassification than women without reclassification (70.6% vs 20.4%; P < 0.001).

CONCLUSION

Almost 10% of pregnant women were newly diagnosed with pre-eclampsia as per the new Japanese classification of HDP. Women with reclassification as pre-eclampsia had a greater risk of preterm delivery and NICU admission than those who were not reclassified.

Conservative versus active management in HELLP syndrome: results from a cohort study

OBJECTIVE

HELLP syndrome exposes to severe maternal and fetal complications. Prompt delivery is thus recommended after 34 weeks of gestation, or earlier in case of nonreassuring maternofetal conditions. However, no consensus has been raised in the treatment of HELLP syndrome occurring before 34 weeks of gestation, when both maternal and fetal conditions are stable: it remains still unclear whether an active attitude should be prioritized over expectant management. Herein, we aimed to compare mother and child outcomes according to the type of obstetrical management, either active or conservative.

STUDY DESIGN

Retrospective and multicenter study involving two tertiary care units. In Center A, obstetrical attitude consisted in expectant management: all women received full antenatal betamethasone therapy and pregnancy was prolonged until maternal or fetal follow up indicated delivery. In Center B, management was active: all deliveries were initiated within 48 hours following diagnosis.

RESULTS

From 2003 to 2011, 118 patients were included (87 in Center A, 31 in Center B). Both groups of patients were similar regarding maternal and fetal features at baseline. Active management led to increased risks of post-partum hemorrhage (relative risks (RR) = 5.38, 95%CI: 1.2-24.06) and neonatal morbidity including respiratory distress syndrome (RR = 3.1, 95%CI: 1.4-7.1), sepsis (RR = 2.5, 95%CI: 1.1-6.0), necrotizing enterocolitis (RR = 4.8, 95%CI: 1.1-21.2), intracerebral hemorrhage (RR = 5.4, 95%CI: 2.1-13.6), and blood transfusion (RR = 6.1, 95%CI: 1.7-21.7).

CONCLUSIONS

Conservative management may be beneficial for both mother and newborn in patients with stable HELLP syndrome. Identification of maternal and fetal specific prognostic factors would allow a better stratification of women with HELLP syndrome according to illness progressive potential, resulting in a more personalized management.

MiR-210 and miR-155 as potential diagnostic markers for pre-eclampsia pregnancies

Pre-eclampsia (PE) is one of the leading causes of maternal and neonatal morbidity and mortality. In recent years, many studies have shown that microRNAs (miRNA) play important roles in the development of PE. However, the molecular pathogenesis of PE remains unknown.In the present study, we performed a case-control study to verify the differential expression of 4 candidate miRNAs (miR-210, miR-155, miR-125b-5p, and miR-125a-5p) in 20 PE pregnancies and 20 healthy pregnancies. The real-time quantitative reverse transcriptase-polymerase chain reaction has been utilized to estimate the Ct values in both groups.Our results have shown that miR-210 and miR-155 were upregulated in serum of PE pregnancies, which suggest a potential association between these 2 miRNAs and the pathogenesis of PE. Further studies showed that the area under the receiver operating characteristic curve (AUC) of miR-210 and miR-155 were 0.750 and 0.703, respectively. The AUC of the expression ratio of miR-210 (serum/urine) and miR-155 (serum/urine) were 0.761 and 0.718, respectively. Moreover, 24-hour urine proteins have positive correlation with urine miR-210 and miR-155.Our findings indicated that serum miR-210 and miR-155 could be 2 sensitivity and specificity biomarkers for the diagnosis of PE while urine miR-210 and miR-155 both could be used to evaluate the severity of kidney injury. Using these miRNAs may provide a novel diagnosis method for identifying pregnant women who are at risk for developing PE.

Is massive proteinuria associated with maternal and fetal morbidities in preeclampsia?

Objective

The aim of this study was to investigate whether massive proteinuria in preeclampsia is associated with maternal and fetal complications.

Methods

We retrospectively analyzed the clinical records of 233 patients who were diagnosed with preeclampsia. We divided the preeclamptic patients into three groups based on the amount of proteinuria: massive (≥5 g/24 hr), moderate (2 to 5 g/24 hr) and mild (<2 g/24 hr) proteinuria group. We analyzed the clinical characteristics and maternal and neonatal complications among three groups.

Results

Gestational age at diagnosis and delivery were lower in women with massive and moderate proteinuria group than women with mild proteinuria group (31.5±3.1 vs. 32.3±3.6 vs. 34.0±3.5 weeks, P<0.001 for gestational weeks at diagnosis; 34.6±3.6 vs. 35.1±4.1 vs. 36.9±4.0 weeks, P=0.001 for gestational age at delivery). In maternal complications, the incidences of pleural effusion and retinal detachment were significantly different among three groups (29.9% vs. 22.4% vs. 9.0%, P=0.004 for pleural effusion; 11.5% vs. 3.0% vs. 1.3%, P=0.009 for retinal detachment). Creatinine levels were higher and albumin levels were lower in the massive proteinuria group than in the moderate and mild groups. However, other maternal and neonatal complications were not significantly different among three groups.

Conclusion

Massive proteinuria might be associated with renal albumin excretion-related morbidity, such as pleural effusion, retinal detachment, and low serum albumin levels. Furthermore, it was associated with early-onset preeclampsia and early delivery.

Proteinuria in preeclampsia: Not essential to diagnosis but related to disease severity and fetal outcomes

Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality globally and proteinuria can be one of the cardinal features of this disease. However, studies about the association of the amount of proteinuria and the severity of preeclampsia, and perinatal outcomes are limited. Data on 239 women with preeclampsia were retrospectively collected from a university teaching hospital from September 2011 to June 2013 and analysed. Data included all clinical parameters and proteinuria in a 24h urine collection. In cases of severe preeclampsia, significantly fewer patients had proteinuria levels <0.3g/L in comparison to any of the other groups with proteinuria >0.3g/L, but there was no difference in cases of severe preeclampsia when proteinuria levels were >0.3g/L. Furthermore, when proteinuria levels were >0.3g/L, the frequency of severe preeclampsia in each group was significantly higher than the frequency of mild pre-eclampsia cases. Time of onset was significantly earlier in patients with proteinuria >3g/L in a 24h urine collection, but time between the onset of preeclampsia and delivery was not correlated with the amount of proteinuria. The birth weight was significantly lower in patients with proteinuria >3g/L. The incidence of fetal growth restriction or stillbirth was significantly higher in patients with proteinuria >5g/L. Our data demonstrate that the amount of proteinuria is not associated with the severe of preeclampsia, once proteinuria is detected, but is related to the severity of preeclampsia. The adverse fetal outcomes appear to be the function of prematurity rather than proteinuria itself.

Massive Urinary Protein Excretion Associated with Greater Neonatal Risk in Preeclampsia

Objective The objective of this study was to compare clinical outcomes of preeclamptic pregnancies according to the proteinuria level. Study Design Secondary analysis of a multicenter prospective cohort study of women with preeclampsia (PE) symptomatology. Nonproteinuria, mild-proteinuria, and massive-proteinuria PEs were defined as: < 165 mg in 12 hours or < 300 mg in 24 hours, 165 mg to 2.69 g in 12 hours or 300 mg to 4.99 g in 24 hours, and ≥ 2.7 g in 12 hours or ≥ 5.0 g in 24 hours, respectively. Individual and composite maternal, fetal, and neonatal outcomes were compared among the PE groups. Results Of the 406 analyzed pregnancies, 36 (8.8%) had massive-proteinuria PE, 268 (66.0%) mild-proteinuria PE, and 102 (25.1%) nonproteinuria PE. Compared with the other groups, massive-proteinuria PE women had significantly higher blood pressures (p < 0.001), epigastric pain (p = 0.007), and uric acid serum levels (p < 0.001) prior to delivery. Composite maternal morbidity was similar across the groups. Delivery < 34^0/7 weeks occurred in 80.6, 49.3, and 22.5% of massive-proteinuria, mild-proteinuria, and nonproteinuria PE groups, respectively (p < 0.0001). Composite adverse neonatal outcomes were significantly higher in the massive-proteinuria PE compared with the other groups (p = 0.001). Conclusion While potentially not important diagnostically, massive proteinuria is associated with more severe clinical manifestations of PE prompting earlier delivery.

Effect of a small dose of aspirin on quantitative test of 24-h urinary protein in patients with hypertension in pregnancy

The aim of the present study was to determine the effect of a small dose of aspirin on a quantitative test of 24-h urinary protein in patients with hypertension in pregnancy. In total, 224 patients with hypertension in pregnancy were continuously selected and were randomly divided into the control group (50 cases with conventional therapy), aspirin 50 mg/day group (60 cases), aspirin 75 mg/day group (58 cases), and aspirin 100 mg/day group (56 cases). Clinical effects were compared from 16 gestational weeks to childbirth. According to the comparison in the four groups, there was no statistical difference in the mean arterial pressure, pre-eclampsia rate, gestational weeks, and caesarean section rate (p>0.05). The 24-h urinary protein and endothelin-1 (ET-1) level were significantly decreased following treatment, and were less than the control and 50 mg/day groups. The superoxide dismutase (SOD) level was significantly increased, and higher than the control and 50 mg/day groups. In terms of the 75 and 100 mg/day, control and 50 mg/day groups, there was no statistical difference (p>0.05). A comparison of the complication rate in the four groups of fetuses during the perinatal period, no statistical difference was observed (p>0.05). Thus, the results show that, regarding patients with hypertension in pregnancy, 75 mg/day aspirin can decrease the 24-h urinary protein, SOD, and ET-1 level. However, the results remain to be confirmed to improve maternal and infant outcome in delivery.

Specialized Diagnostic Investigations to Assess Ocular Status in Hypertensive Diseases of Pregnancy

This review describes specialized diagnostic investigations to assess ocular status in hypertensive diseases of pregnancy. Ocular assessment can aid in early detection for prompt multidisciplinary treatment, obstetric intervention and follow-up. The investigations accurately predict the possible causes of blindness in hypertensive diseases of pregnancy. The investigations include fluorescein angiography, ophthalmodynamometry, fluorophotometry, imaging modalities, OCT, ultrasonography, doppler velocimetry and blood chemistry analysis. The review includes a summary of imaging techniques and related recent developments to assess the neuro-ophthalmic aspects of the disease. The imaging modalities have been instrumental in understanding the complex neuropathophysiological mechanisms of eclamptic seizures. The importance of blood chemistry analysis in hypertensive diseases of pregnancy has been emphasized. The investigations have made a significant contribution in improving the standards of antenatal care and reducing maternal and fetal morbidity and mortality.

Pregnancies complicated by preeclampsia and non-preeclampsia-related nephrotic range proteinuria

OBJECTIVE

To examine the impact of nephrotic range proteinuria during pregnancy on renal, maternal and fetal outcomes.

METHODS

A retrospective study of pregnant women with proteinuria greater than 3 g/24 h. Outcome measures included: gestation and mode of delivery, maternal high dependency unit admission, birth weight, maternal blood pressure and proteinuria at time of last follow-up, renal biopsy.

RESULTS

Two hundred and sixty four pregnancies in 262 women were reviewed. Postnatal data were available in 180; of these 104 (57%) had urinary protein quantified postnatally. Sixty three (60%) were pure preeclampsia and nine (9%) super-imposed preeclampsia. Biopsy-proven renal disease was newly diagnosed in nine (9%). Sixty three per cent required caesarean section and 34% required high dependency unit admission. There were no maternal deaths. Birth weight corrected for gestation was below the fifth centile in 33%.

CONCLUSIONS

The incidence of underlying renal pathology in this cohort is significant and highlights the importance of careful follow-up.

Pre-eclampsia, severe pre-eclampsia and hemolysis, elevated liver enzymes and low platelets syndrome: what is new?

Pre-eclampsia and eclampsia have been known to us for centuries. Significant improvements have been made in our knowledge of the disease, however, delivery remains the only effective form of treatment. There is widespread variation of practice in the management of hypertensive disease in pregnancy, which may lead to substandard care. The use of aspirin in preventing pre-eclampsia, the lack of correlation between urinary protein and adverse outcome, and the ineffectiveness of corticosteroids in the management of hemolysis and elevated liver enzymes and low platelets syndrome are a few of the developments that will alter the way this condition is managed. This article aims to provide a general overview of pre-eclampsia, eclampsia and hemolysis, hemolysis and elevated liver enzymes and low platelets syndrome supported by the latest evidence, which will help the care provider adopt a focused approach and use the latest knowledge to understand and manage this old condition.

Maternal plasma concentrations of angiogenic/anti-angiogenic factors are of prognostic value in patients presenting to the obstetrical triage area with the suspicion of preeclampsia

OBJECTIVE

To determine whether maternal plasma concentrations of placental growth factor (PlGF), soluble endoglin (sEng), soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) and -2 could identify patients at risk for developing preeclampsia (PE) requiring preterm delivery.

STUDY DESIGN

Patients presenting with the diagnosis "rule out PE" to the obstetrical triage area of our hospital at <37 weeks of gestation (n = 87) were included in this study. Delivery outcomes were used to classify patients into four groups: I) patients without PE or those with gestational hypertension (GHTN) or chronic hypertension (CHTN) who subsequently developed PE at term (n = 19); II): mild PE who delivered at term (n = 15); III): mild disease (mild PE, GHTN, CHTN) who subsequently developed severe PE requiring preterm delivery (n = 26); and IV): diagnosis of severe PE (n = 27). Plasma concentrations of PlGF, sEng, sVEGFR-1 and -2 were determined at the time of presentation by ELISA. Reference ranges for analytes were constructed by quantile regression in our laboratory (n = 180; 1046 samples). Comparisons among groups were performed using multiples of the median (MoM) and parametric statistics after log transformation. Receiver operating characteristic curves, logistic regression and survival analysis were employed for analysis.

RESULTS

The mean MoM plasma concentration of PlGF/sVEGFR-1, PlGF/sEng, PlGF, sVEGFR-1 and -2, and sEng in Group III was significantly different from Group II (all p < 0.05). A plasma concentration of PlGF/sVEGFR-1 ≤ 0.05 MoM or PlGF/sEng ≤0.07 MoM had the highest likelihood ratio of a positive test (8.3, 95% CI 2.8-25 and 8.6, 95% CI 2.9-25, respectively), while that of PlGF ≤0.396 MoM had the lowest likelihood ratio of a negative test (0.08, 95% CI 0.03-0.25). The association between low plasma concentrations of PlGF/sVEGFR-1 (≤0.05 MoM) as well as that of PlGF/sEng (≤0.07 MoM) and the development of severe PE remained significant after adjusting for gestational age at presentation, average systolic and diastolic blood pressure, and a history of chronic hypertension [adjusted odds ratio (OR) = 27 (95% CI 6.4-109) and adjusted OR 30 (95% CI 6.9-126), respectively]. Among patients who presented <34 weeks gestation (n = 59), a plasma concentration of PlGF/sVEGFR-1 < 0.033 MoM identified patients who delivered within 2 weeks because of PE with a sensitivity of 93% (25/27) and a specificity of 78% (25/32). This cut-off was associated with a shorter interval-to-delivery due to PE [hazard ratio = 6 (95% CI 2.5-14.6)].

CONCLUSIONS

Plasma concentrations of angiogenic/anti-angiogenic factors are of prognostic value in the obstetrical triage area. These observations support the value of these biomarkers in the clinical setting for the identification of the patient at risk for disease progression requiring preterm delivery.

Evaluation and management of severe preeclampsia before 34 weeks' gestation

OBJECTIVE

We sought to review the risks and benefits of expectant management of severe preeclampsia remote from term, and to provide recommendations for expectant management, maternal and fetal evaluation, treatment, and indications for delivery.

METHODS

Studies were identified through a search of the MEDLINE database for relevant peer-reviewed articles published in the English language from January 1980 through December 2010. Additionally, the Cochrane Library, guidelines by organizations, and studies identified through review of the above documents and review articles were utilized to identify relevant articles. Where reliable data were not available, opinions of respected authorities were used.

RESULTS AND RECOMMENDATIONS

Published randomized trials and observational studies regarding management of severe preeclampsia occurring <34 weeks of gestation suggest that expectant management of selected patients can improve neonatal outcomes but that delivery is often required for worsening maternal or fetal condition. Patients who are not candidates for expectant management include women with eclampsia, pulmonary edema, disseminated intravascular coagulation, renal insufficiency, abruptio placentae, abnormal fetal testing, HELLP syndrome, or persistent symptoms of severe preeclampsia. For women with severe preeclampsia before the limit of viability, expectant management has been associated with frequent maternal morbidity with minimal or no benefits to the newborn. Expectant management of a select group of women with severe preeclampsia occurring <34 weeks' gestation may improve newborn outcomes but requires careful in-hospital maternal and fetal surveillance.

Protein creatinine ratio in random urine sample of hypertensive pregnant women: maternal and perinatal outcomes

Objective. To compare protein/creatinine ratio (PCR) in random urine sample levels and adverse outcomes in hypertensive pregnant women. Methods. A total of 370 medical charts from hypertensive pregnant women were reviewed and stratified into three groups according to different PCR in random urine sample levels (group 1: PCR < 0.3 mg/mg; group 2: PCR 0.3-1.99 mg/mg; group 3: PCR ≥ 2.0 mg/mg) and compared with composite maternal and perinatal outcomes. Those outcomes were severe hypertension, thrombocytopenia, high lactate dehydrogenase count, disseminated intravascular coagulation, abruptio placentae, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, eclampsia, perinatal death, newborn cerebral hemorrhage, respiratory distress syndrome of newborn, neonatal sepsis, and newborn small for gestational age. Results. To obtain a composite maternal adverse outcome the odds ratio [ORs] between PCR groups were 1.8 (95% confidence interval [CI]: 1.1-3.2) between groups 1 and 2, and 3.1 (95% CI: 1.5-6.3) between groups 1 and 3; for composite perinatal adverse outcomes, the ORs were 3.0 (95% CI: 1.5-5.9) between groups 1 and 2, and 3.4 (95% CI: 1.6-7.5) between groups 1 and 3. Conclusions. Hypertensive pregnant women with a PCR ≥ 0.3 mg/mg, had worse maternal and perinatal outcomes than those with PCR < 0.3 mg/mg. Above the cut-off of 0.3 mg/mg, higher PCRs are not associated with a significant increase in maternal and perinatal morbidity.

Microbial invasion of the amniotic cavity in preeclampsia as assessed by cultivation and sequence-based methods

OBJECTIVE

Infection has been implicated in the pathogenesis of preeclampsia, yet the association between microbial invasion of the amniotic cavity (MIAC) and preeclampsia has not been determined. The aim of this study was to determine the prevalence, and microbial diversity associated with MIAC, as well as the nature of the host response to MIAC in patients with preeclampsia.

METHOD OF STUDY

Amniotic fluid (AF) from 62 subjects with preeclampsia, not in labor, was analyzed with both cultivation and molecular methods. Broad-range and group-specific PCR assays targeting small subunit ribosomal DNA, or other gene sequences, from bacteria, fungi and archaea were used. Results were correlated with measurements of host inflammatory response, including AF white blood cell count and AF concentrations of glucose, interleukin-6 (IL-6) and MMP-8.

RESULTS

1) The rate of MIAC in preeclampsia was 1.6% (1/62) based on cultivation techniques, 8% (5/62) based on PCR, and 9.6% (6/62) based on the combined results of both methods; 2) among the six patients diagnosed with MIAC, three had a positive PCR for Sneathia/Leptotrichia spp.; and 3) patients with MIAC were more likely to have evidence of an inflammatory response in the amniotic cavity than those without MIAC, as determined by a higher median AF IL-6 [1.65 ng/mL interquartile range (IQR): 0.35-4.62 vs. 0.22 ng/mL IQR: 0.12-0.51; P=0.002).

CONCLUSION

The prevalence of MIAC in preeclampsia is low, suggesting that intra-amniotic infection plays only a limited role in preeclampsia. However, the unexpectedly high number of positive AF specimens for Sneathia/Leptotrichia warrants further investigation.

Interpreting abnormal proteinuria in pregnancy: the need for a more pathophysiological approach

This review and opinion article focuses on the definitions and meanings of abnormal protein excretion in pregnancy, asking the following questions: Are our tests to determine abnormal proteinuria adequately performed? Are current guidelines for diagnosis of excessive proteinuria, especially when used to identify preeclampsia, supported by adequate data? Can the magnitude of proteinuria be used as a reliable clinical biomarker of the gravity of preeclampsia? Should timed urine collections, primarily 24-hour excretions, be supplanted by the urine protein/creatinine ratio in clinical practice? The answers to most of these questions are: We are not sure, or some guidelines are poorly supported by data and may prove erroneous. We suggest a more physiologic approach to assessment of proteinuria and believe that if clinicians and investigators looked at proteinuria in terms of how the kidney handles protein in health and disease it would lead to a more rational and evidence-based approach to proteinuria in pregnancy. Finally, we recommend that current cutoff for abnormal proteinuria be used to diagnose preeclampsia, but the level of proteinuria should not guide management. Other variables, such as status of blood pressure control, evidence of increasing organ damage in the liver and hematological systems, evidence of falling glomerular filtration rate, and signs of neurological involvement, are more reliable indicators of severity of preeclampsia.