Relationship between Thrombophilic Disorders and Type of Severe Early-Onset Hypertensive Disorder of Pregnancy

RISK OF PLACENTA-ASSOCIATED COMPLICATIONS AT PREECLAMPSIA IN PREGNANT WOMEN WITH THROMBOPHILIA

OBJECTIVE

The aim: To study the distribution and influence of coagulation factor gene polymorphisms, endothelial dysfunction, blood pressure regulator on the development of obstetric and perinatal complications in women with preeclampsia (PE).

PATIENTS AND METHODS

Materials and methods: The prospective cohort study included 46 women with PE and maternal or fetal complications and 87 pregnant women with PE, without complications. Genetic polymorphisms of coagulation factors and fibrinolysis (1691 G→A FVL, 20210 G→A prothrombin, 675 5G/4G PAI-1, 455 G→A fibrinogen β), endothelial dysfunction (192 Q→R PON-1, 677 C→T MTHFR) and blood pressure regulator (235 M→T angiotensinogen II) were studied with the help of allele-specific polymerase chain reaction.

RESULTS

Results: Markers of predisposition to the development of obstetric and perinatal complications in pregnant women with PE are the following genotypes: 1691 GA by V Leiden factor gene - increases the risk in 2.9 times (95% CI 1.94-4.33), 20210 GA by prothrombin gene - in 2.36 times (95% CI 1.54-3.6), 20210 AA by prothrombin gene - in 3.12 times (95% CI 2.4-4.0). Pathological polymorphisms in the genes of angiotensinogen II 235 M→T, PAI-1 5G/4G, fibrinogen β 455 G→A, paraoxonase-1 192 Q→R do not significantly affect the development of complications during preeclampsia.

CONCLUSION

Conclusions: The development of PE against the background of the existence of acquired and hereditary types of thrombophilia is associated with a more severe course, early-onset and the development of life-threatening complications for a mother and fetus.

Do adverse pregnancy outcomes contribute to accelerated cardiovascular events seen in young women with systemic lupus erythematosus?

Cardiovascular events (CVEs) are prevalent in patients with systemic lupus erythematosus (SLE), and it is the young women who are disproportionately at risk. The risk factors for accelerated cardiovascular disease remain unclear, with multiple studies producing conflicting results. In this paper, we aim to address both traditional and SLE-specific risk factors postulated to drive the accelerated vascular disease in this cohort. We also discuss the more recent hypothesis that adverse pregnancy outcomes in the form of maternal-placental syndrome and resultant preterm delivery could potentially contribute to the CVEs seen in young women with SLE who have fewer traditional cardiovascular risk factors. The pathophysiology of how placental-mediated vascular insufficiency and hypoxia (with the secretion of placenta-like growth factor (PlGF) and soluble fms-tyrosine-like kinase-1 (sFlt-1), soluble endoglin (sEng) and other placental factors) work synergistically to damage the vascular endothelium is discussed. Adverse pregnancy outcomes ultimately are a small contributing factor to the complex pathophysiological process of cardiovascular disease in patients with SLE. Future collaborative studies between cardiologists, obstetricians, obstetric physicians and rheumatologists may pave the way for a better understanding of a likely multifactorial aetiological process.

Associations between phenotypes of preeclampsia and thrombophilia

OBJECTIVES

Preeclampsia complicates 2-8% of all pregnancies. Studies on the association of preeclampsia with thrombophilia are conflicting. Clinical heterogeneity of the disease may be one of the explanations. The present study addresses the question whether different phenotypes of preeclampsia are associated with thrombophilia factors. Study design We planned a retrospective cohort study. From 1985 until 2010 women with preeclampsia were offered postpartum screening for the following thrombophilia factors: anti-phospholipid antibodies, APC-resistance, protein C deficiency and protein S deficiency, hyperhomocysteineamia, factor V Leiden and Prothrombin gene mutation. Hospital records were used to obtain information on phenotypes of the preeclampsia and placental histology.

RESULTS

We identified 844 women with singleton pregnancies who were screened for thrombophilia factors. HELLP complicated 49% of pregnancies; Fetal growth restriction complicated 61% of pregnancies. Early delivery (<34th week) occurred in 71% of pregnancies. Any thrombophilia factor was present in 29% of the women. Severe preeclampsia was associated with protein S deficiency (p=0.01). Fetal growth restriction was associated with anti-phospholipid antibodies (p<0.01). Early onset preeclampsia was associated with anti-phospholipid antibodies (p=0.01). Extensive placental infarction (>10%) was associated with anti-phospholipid antibodies (p<0.01). Low placental weight (<5th percentile) was associated with hyperhomocysteineamia (p=0.03). No other associations were observed.

CONCLUSIONS

Early onset preeclampsia, especially if complicated by fetal growth restriction, are associated with anti-phospholipid antibodies. Other phenotypes of preeclampsia, especially HELLP syndrome, were not associated with thrombophilia. We advise only to test for anti-phospholipid antibodies after early onset preeclampsia, especially if complicated by fetal growth restriction. We suggest enough evidence is presented to justify no further studies are needed.

Prediction of adverse pregnancy outcome by the presence of lupus anticoagulant, but not anticardiolipin antibody, in patients with antiphospholipid antibodies

OBJECTIVE

To investigate which serologic and clinical findings predict adverse pregnancy outcome in patients with antiphospholipid antibody (aPL) and to test the hypothesis that a pattern of clinical and serologic variables can identify women at highest risk of adverse pregnancy outcome.

METHODS

Women enrolled in a multicenter prospective observational study of risk factors for adverse pregnancy outcome in patients with aPL (lupus anticoagulant [LAC], anticardiolipin antibody [aCL], and/or antibody to β2-glycoprotein I [anti-β2 GPI]) and/or systemic lupus erythematosus (SLE) were recruited for the present prospective study. Demographic, clinical, serologic, and treatment data were recorded at the time of the first study visit. The relationship between individual and combined variables and adverse pregnancy outcome was assessed by bivariate and multivariate analysis.

RESULTS

Between 2003 and 2011 we enrolled 144 pregnant patients, of whom 28 had adverse pregnancy outcome. Thirty-nine percent of the patients with LAC had adverse pregnancy outcome, compared to 3% of those who did not have LAC (P<0.0001). Among women with IgG aCL at a level of ≥40 units/ml, only 8% of those who were LAC negative had adverse pregnancy outcome, compared to 43% of those who were LAC positive (P=0.002). IgM aCL, IgG anti-β2 GPI, and IgM anti-β2 GPI did not predict adverse pregnancy outcome. In bivariate analysis, adverse pregnancy outcome occurred in 52% of patients with and 13% of patients without prior thrombosis (P=0.00005), and in 23% with SLE versus 17% without SLE (not significant); SLE was a predictor in multivariate analysis. Prior pregnancy loss did not predict adverse pregnancy outcome. Simultaneous positivity for aCL, anti-β2 GPI, and LAC did not predict adverse pregnancy outcome better than did positivity for LAC alone.

CONCLUSION

LAC is the primary predictor of adverse pregnancy outcome after 12 weeks' gestation in aPL-associated pregnancies. Anticardiolipin antibody and anti-β2 GPI, if LAC is not also present, do not predict adverse pregnancy outcome.

Low-molecular-weight heparin added to aspirin in the prevention of recurrent early-onset pre-eclampsia in women with inheritable thrombophilia: the FRUIT-RCT

BACKGROUND

Early-onset hypertensive disorders (HD) of pregnancy and small-for-gestational age infants (SGA) are associated with placental vascular thrombosis, these often recur and are also associated with inheritable thrombophilia. Aspirin reduces the recurrence risk.

OBJECTIVES

Adding low-molecular-weight heparin (LMWH) to aspirin at < 12 weeks gestation reduces the recurrence of HD in women with previous early-onset HD (pre-eclampsia, hemolysis, elevated liver enzymes and low platelets [HELLP] syndrome and eclampsia) and/or SGA, in the context of inheritable thrombophilia without antiphospholipid antibodies.

PATIENTS/METHODS

In a multicenter randomized control trial (RCT), 139 women included were< 12 weeks gestation.

INCLUSION CRITERIA

previous delivery< 34 weeks gestation with HD and/or SGA; inheritable thrombophilia (protein C deficiency, protein S deficiency, activated protein C resistance, factor V Leiden heterozygosity and prothrombin gene G20210A mutation heterozygosity); and no antiphospholipid antibodies detected.

INTERVENTION

either daily LMWH (dalteparin, 5000 IU weight-adjusted dosage) with aspirin 80 mg or aspirin 80 mg alone.

MAIN OUTCOME MEASURES

PRIMARY OUTCOMES

recurrent HD onset (i) < 34 weeks gestation and (ii) irrespective of gestational age.

SECONDARY OUTCOMES

recurrent SGA, preterm birth, maternal/neonatal hospitalization, spontaneous abortion and individual HD. Analysis by intention-to-treat.

RESULTS

Low-molecular-weight heparin with aspirin reduced recurrent HD onset < 34 weeks gestation (risk difference [RD] 8.7%: confidence interval [CI] of RD 1.9–15.5%; P = 0.012; number needed to treat [NNT] 12). Recurrent HD irrespective of gestational age was not different between the arms. No women withdrew as a result of adverse effects.

TRIAL REGISTRATION

http://www.isrctn.org) (isrctn87325378).

CONCLUSIONS

Adding LMWH to aspirin at < 12 weeks gestation reduces recurrent HD onset < 34 weeks gestation in women with inheritable thrombophilia and prior delivery for HD/SGA <34 weeks. However, close monitoring of the mother and fetus remains important throughout pregnancy.

Association of anticardiolipin antibodies with preeclampsia: a systematic review and meta-analysis

OBJECTIVE

To systematically review the evidence of the association of anticardiolipin antibodies with preeclampsia.

DATA SOURCES

PubMed and LILACS were perused up to June 2009, citations were searched using the ISI Web of Knowledge database, textbooks and reference lists were reviewed, and experts were contacted. Search terms included "antiphospholipid syndrome," "Hughes' syndrome," "anticardiolipin antibodies," "antiphospholipid antibodies," "anti-cardiolipin," "preeclampsia," and "pre-eclampsia."

METHODS OF STUDY SELECTION

Inclusion criteria were: cohorts, case-control, or controlled cross-sectional studies; healthy pregnancy as controls; no autoimmune diseases; immunoglobulin (Ig)G, IgM anticardiolipin antibody of at least 20 units by enzyme-linked immunosorbent assay, or both; and end-point preeclampsia.

TABULATION, INTEGRATION, AND RESULTS

Our search generated 68,528 entries and 64 full-text articles were reviewed. Twelve studies were included in the meta-analysis. Pooled odds ratio (OR) for association of anticardiolipin antibodies with preeclampsia was 2.86 (95% confidence interval [CI], 1.37-5.98). Pooled OR for anticardiolipin antibodies and severe preeclampsia was 11.15 (95% CI 2.66-46.75). Funnel plot showed minor asymmetry, and the Egger test was not significant (P=.359). Meta-regression identified study design and size as related to heterogeneity.

CONCLUSION

Moderate-to-high levels of anticardiolipin antibodies are associated with preeclampsia, but there is insufficient evidence to use anticardiolipin antibodies as predictors of preeclampsia in clinical practice.

[Late prognosis after preeclampsia]

Preeclampsia, eclampsia and HELLP syndrome are severe complications of pregnancy associated with a high morbidity and mortality for both mother and foetus. The issue of prognosis with regards to risk of relapse is therefore of upmost importance for both the patients and doctors managing their subsequent pregnancies. The overall risk of relapse is estimated to be less than 10%. The risk is especially increased in case of early onset, before the 28(th) week of amenorrhea. In such patients, an underlying renal disease, essential hypertension or secondary hypertension might be identified. A renal consultation must ensure the complete resolution of the hypertension and proteinuria, otherwise investigations need to be carried out looking for an underlying renal or vascular disease affecting the renal parenchyma or outflow. Screening for a hereditary thrombophilia is performed in the immediate post-partum period following and early onset PE, especially if associated with an IUGR, fetal death, or in an early and severe relapse. A renal biopsy is only rarely considered: it is either performed within the first post-partum days whenever a systemic disease flare-up is suspected (i.e. SLE), or late if the proteinuria failed to settle beyond 6 months post-part. Severe PE is a marker of a vascular disease of short duration, but must be considered a risk factor for later atherosclerosis with cardiovascular complications, justifying long term cardiovascular, renal and metabolic follow-up.