Prediction of preeclampsia: can it be achieved?

Prepregnancy Endocrine, Autoimmune Disorders and the Risks of Gestational Hypertension-Preeclampsia in Primiparas: A Nationwide Population-Based Study in Taiwan

(1) Objective: To assess the risks of gestational hypertension/preeclampsia (GH-PE) in women with prepregnancy endocrine and autoimmune disorders such as polycystic ovarian syndrome (PCOS) and systemic lupus erythematosus (SLE). (2) Methods: In a nationwide population-based longitudinal study, data were retrieved from the 1998 to 2012 Taiwan National Health Insurance Research Database. ICD9-CM codes 256.4, 710.0, and 642.X were identified for the corresponding diagnoses of PCOS, SLE, and GH-PE, respectively, which were further confirmed by inspection of medical claims data for ultrasonography findings, laboratory tests, blood pressure measurements and examinations of urine protein to ensure the accuracy of the diagnoses. To clarify the risks of primiparous GH-PE, the study excluded women diagnosed with PCOS or SLE at <15 or >45 years of age, pre-existing chronic hypertension, GH-PE before PCOS and SLE, and abortion or termination before 20 weeks' gestation. For women affected by prepregnancy PCOS or SLE individually, each pregnant woman was age-matched to four pregnant women without PCOS or SLE. Logistic regression analyses were applied to report odds ratios (ORs) for the risks of GH-PE after adjustment for age, occupation, urbanization, economic status, and other co-morbidities. (3) Results: Among 8070 and 2430 women with prepregnancy PCOS and SLE retrieved from a population of 1,000,000 residents, 1953 (24.20%) and 820 (33.74%) had subsequent primiparous pregnancies that were analyzable and compared with 7812 and 3280 pregnancies without prepregnancy PCOS and SLE, respectively. GH-PE occurred more frequently in pregnancies with prepregnancy PCOS (5.79% vs. 2.23%, p < 0.0001) and SLE (3.41% vs. 1.80%, p < 0.01) as compared to those without PCOS and SLE. Further analysis revealed that prepregnancy PCOS (adjusted OR = 2.36; 95%CI: 1.83-3.05) and SLE (adjusted OR = 1.95; 95%CI: 1.23-3.10) were individually associated with GH-PE. The risk of GH-PE was not reduced in women with prepregnancy PCOS receiving metformin treatment (p = 0.22). (4) Conclusions: Prepregnancy PCOS and SLE are independent and significant risk factors for the occurrence of GH-PE. Because the peripartum complications are much higher among pregnancies with GH-PE, the at-risk woman should be informed and well-prepared during her pregnancy and delivery.

Provoking factors for postpartum chronic hypertension in women with preceding gestational hypertension/preeclampsia: A longitudinal cohort study of 22,798 pregnancies

Background: A proportion of women with pregnancies complicated by gestational hypertension/preeclampsia (GH-PE) will have persistent postpartum chronic hypertension (CHTN). Common risk factors for postpartum CHTN include older age, pre-existing CHTN, smoking, pre-pregnancy obesity (elevated BMI), and co-morbidities such as thyroid disorders. However, most of explored risk factors are pre-pregnancy factors, and were mainly based on studies with small sample size. Methods: To investigate provoking pre-pregnancy and intra-pregnancy factors for postpartum CHTN in women with preceding GH-PE, the cohort study enrolled 22,798 index pregnancies to analyze individual characteristics, co-morbidities and postpartum outcomes after excluding women with pre-existing CHTN. Results: Among 2,132 GH-PE pregnancies, 428 (20.1%) were complicated with postpartum CHTN. After adjustment, logistic regression analysis revealed excessive pregnant weight gain (≥10 kgw at 28 weeks' gestation) (OR: 14.50, 95% CI: 11.02-19.08) and gestational diabetes mellitus (GDM) (OR: 6.25, 95% CI: 4.98-7.85) were major risk factors for developing CHTN, other than age (OR: 1.80, 95% CI: 1.68-1.93), pre-pregnancy BMI (OR: 3.15, 95% CI: 2.75-3.60), severity of GH-PE (OR: 2.46, 95% CI: 1.97-3.07), smoking (OR: 1.79, 95% CI: 1.35-2.38), and overt DM (OR: 2.30, 95% CI: 1.73-3.06). Conclusion: Excessive pregnant weight gain and GDM are major intra-pregnancy risk factors for postpartum CHTN in women with preceding GH-PE. Future studies should investigate interventions such as a healthy diet, appropriate physical exercise and avoidance of excessive pregnant weight gain as a means to reduce the frequency of CHTN following pregnancy.

Intrauterine growth restriction and placental gene expression in severe preeclampsia, comparing early-onset and late-onset forms

OBJECTIVE

To evaluate placental gene expression in severe early- or late-onset preeclampsia with intrauterine growth restriction compared to controls.

STUDY DESIGN

Chorionic villus sampling was conducted after cesarean section from the placentas of five women with early- or late-onset severe preeclampsia and five controls for each preeclampsia group. Microarray analysis was performed to identify gene expression differences between the groups.

RESULTS

Pathway analysis showed over-representation of gene ontology (GO) biological process terms related to inflammatory and immune response pathways, platelet development, vascular development, female pregnancy and reproduction in early-onset preeclampsia. Pathways related to immunity, complement and coagulation cascade were overrepresented in the hypergeometric test for the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. Ten genes (ABI3BP, C7, HLA-G, IL2RB, KRBOX1, LRRC15, METTL7B, MPP5, RFLNB and SLC20A) had a ≥±1 fold expression difference in severe early-onset preeclampsia group compared to early controls. There were 362 genes that had a ≥±1 fold expression difference in severe early-onset preeclampsia group compared to late-onset preeclampsia group including ABI3BP, C7, HLA-G and IL2RB.

CONCLUSION

There are significant differences in placental gene expression between severe early- and late-onset preeclampsia when both are associated with intrauterine growth restriction. ABI3BP, C7, HLA-G and IL2RB might contribute to the development of early form of severe preeclampsia.

Risk of gestational hypertension-preeclampsia in women with preceding endometriosis: A nationwide population-based study

OBJECTIVE

To investigate the association between preceding endometriosis and gestational hypertension-preeclampsia (GH-PE).

METHODS

In this nationwide population-based longitudinal study, data from 1998-2012 Taiwan National Health Insurance Research Database were used. We used ICD9-CM codes 617.X and 642.X respectively for the diagnoses of endometriosis and GH-PE, which were further confirmed by examining medical records of surgeries, blood pressure and urine protein to ensure the accuracy of the diagnoses. The study excluded women diagnosed with endometriosis at < 15 or > 45 years of age, chronic hypertension, and GH-PE prior to endometriosis. Each pregnant woman with a prior diagnosis of endometriosis was matched to 4 pregnant women without endometriosis by age. Logistic regression analysis was used to calculate odds ratios (ORs) for the risk of GH-PE with adjustment for age, occupation, urbanization, economic status and comorbidities.

RESULTS

Among 6,300 women with a prior endometriosis diagnosis who were retrieved from a population of 1,000,000 residents, 2,578 (40.92%) had subsequent pregnancies that were eligible for further analysis and were compared with 10,312 pregnant women without previous endometriosis. GH-PE occurred more in women with prior endometriosis as compared to those without endometriosis (3.88% vs. 1.63%, p<0.0001). Further analysis revealed prior endometriosis was associated with GH-PE (adjusted OR = 2.27; 95% CI:1.76-2.93). For danazol-treated and non-danazol-treated subgroups, the incidences of GH-PE were 3.13% (15/480) and 4.05% (85/2,098), respectively. Although the risk for subsequent GH-PE was lower (adjusted OR = 1.49; 95% CI:0.86-2.56) after receiving danazol treatment than average (adjusted OR = 2.27; 95% CI:1.76-2.93) for women with preceding endometriosis, the reduction of risk was not statistically remarkable for danazol-treated (adjusted OR = 1.49) vs. non-danazol-treated (adjusted OR = 2.48) subgroups (p heterogeneity = 0.12).

CONCLUSIONS

Preceding endometriosis is an independent and significant risk factor for the occurrence of GH-PE.

Assessment of serum β-hCG and lipid profile in early second trimester as predictors of hypertensive disorders of pregnancy

OBJECTIVE

To assess and compare the ability of serum β-human chorionic gonadotropin (β-hCG) and serum lipid profile in early second trimester as predictors of hypertensive disorders of pregnancy.

METHODS

The present hospital-based prospective study was conducted between November 24, 2012, and April 30, 2014, at a tertiary hospital in Mangalore, India. Women of any parity with a pregnancy of 14-20 weeks were included. Venous blood (3 mL) was collected, and serum β-hCG and lipid profile were estimated by enzyme-linked immunosorbent assay and an enzymatic colorimetric test with lipid clearing factor, respectively. A cutoff value of β-hCG for predicting hypertensive disorders was obtained by receiver operating curve analysis.

RESULTS

Serum β-hCG was significantly higher among women who subsequently developed hypertension (71 142 IU/L [n=27]) than among those who did not (20 541 IU/L [n=137]; P<0.001). The sensitivity and specificity of serum β-hCG to predict hypertension were 92.6% and 94.9% respectively. The positive and negative predictive values were 78.1% and 98.5%, respectively.

CONCLUSION

Serum β-hCG might be used as a predictor of hypertensive disorders that complicate pregnancy. Dyslipidemia was not found to be a useful marker.

First trimester placental retinol-binding protein 4 (RBP4) and pregnancy-associated placental protein A (PAPP-A) in the prediction of early-onset severe pre-eclampsia

OBJECTIVE

In a retrospective case-control study, we examined the levels of placental retinol-binding protein 4 (RBP4) and pregnancy-associated placental protein A (PAPP-A) in first-trimester maternal serum samples as well as maternal characteristics to predict early-onset and severe pre-eclampsia.

METHODS

In this retrospective case-control study, we identified females who delivered a singleton pregnancy on or after 24 weeks' gestation from 2003 to 2010 at Oulu University Hospital and had a retrospective first trimester trisomy screening, including serum PAPP-A measurement. Within this cohort, we identified 65 females who experienced early onset pre-eclampsia (EO-PE) and 742 controls who had uncomplicated deliveries. Retrospectively, we thawed all previously collected serum samples to measure placental retinol binding protein 4 (RBP4). PAPP-A and RBP4 were measured using automatic immunoassay systems and converted to multiples of the median (MoMs). Logistic regression analysis was performed to determine whether these biomarkers separately and in combination with maternal characteristics (maternal age, weight and smoking status) can be used to predict the development of early onset pre-eclampsia.

RESULTS

The expected log(10) PAPP-A concentration and the expected log(10) RBP4 concentration in the control group were both affected by maternal weight and smoking status. The expected log(10) PAPP-A concentration was also affected by gestational age (GA). RBP4 levels in first-trimester serum were significantly higher in females who subsequently developed EO-PE outcome compared to those with normal pregnancy outcome (1.14 vs. 1.01 MoMs, p<0.0001). Maternal serum PAPP-A levels from the same pregnancy period were significantly lower in the EO-PE group compared to controls (0.80 vs. 1.05 MoMs, p=0.005). The risk model including maternal characteristics with PAPP-A log(10) MoM and RBP4 log(10) MoM had the best EO-PE prediction ability. It detected 34% (23%-46%) of females with subsequent EO-PE with a 10% false positive rate.

CONCLUSION

This study showed that first-trimester maternal serum RBP4 was significantly increased and that PAPP-A decreased in pregnancies that ended in EO-PE compared to normal pregnancies. Thus, these markers may be useful members in a panel of markers for the early detection of early-onset and severe pre-eclampsia.

Preeclampsia-eclampsia

Preeclampsia and eclampsia are grave complications of pregnancy responsible for morbidity and mortality. National Eclampsia Registry of the FOGSI has helped in quantifying the magnanimity and also the clinical relevant pointers which can help in improving the health care delivery. Many complex pathogenic mechanisms are now implicated to be responsible for this disease rightfully called the GESTOSIS which means pregnancy going abnormal. Many preventive strategies have been suggested but only a few are scientifically proved to be useful. Early antenatal care, clinical risk assessment, biomarkers, close vigilance, calcium and nutritional supplementation are useful.

First-trimester assessment of placenta function and the prediction of preeclampsia and intrauterine growth restriction

Preeclampsia and intrauterine growth restriction (IUGR) are major contributors to perinatal mortality and morbidity worldwide. Both are characterized by impaired trophoblastic invasion of the maternal spiral arteries and their conversion from narrow muscular vessels to wide non-muscular channels. Despite improvement in the understanding of the pathophysiology of these conditions, ability to accurately identify pregnant woman who will develop them is limited. This greatly impairs the development and testing of preventive interventions. While different measures of placental dysfunction have been associated with increased risk for adverse pregnancy outcomes, the ability of any single one to accurately predict these outcomes is poor. Developing predictive tests is further challenged by difficulty in the timing of the measurements, as both the structural and biochemical characteristics of the placenta change with increasing gestational age. The ideal screening test would accurately predict the development of adverse pregnancy outcomes early enough to provide a window for preventive interventions. Improvement in ultrasound technology provides potentially useful novel tools for evaluating placental structure, but measurements need to be standardized in order to be useful. Maternal serum analyte screening is a noninvasive test of placental biochemical function, but present serum marker alone is not sufficiently accurate to suggest its routine use in clinical practice. The use of first trimester biochemical markers in combination with uterine artery Doppler screening is promising as a potential screening tool. Prospective longitudinal studies using standardized methodology are necessary to further evaluate the choice of parameters and strategies of combination to achieve the best predictive models.

Prediction of preeclampsia by analysis of cell-free messenger RNA in maternal plasma

OBJECTIVE

The purpose of this study was to predict the occurrence of preeclampsia in a series of patients at gestational week 15-20 weeks, with the use of a panel of messenger RNA markers.

STUDY DESIGN

Data from 62 patients with preeclampsia who were asymptomatic at the time of blood testing and 310 control subjects were analyzed. Multivariable analysis was performed with discriminant analysis.

RESULTS

Univariable analysis identified vascular endothelial growth factor receptor 1 as the marker with the highest detection rate; placenta-specific 1 with the lowest. Mean estimated score for preeclampsia was 9.4 for control subjects and 72.5 for subjects who experienced preeclampsia. A receiver operating characteristic curve that was obtained with the estimated score for preeclampsia as a test variable yielded a detection rate of 84% (95% CI, 71.8-91.5) at a 5% false-positive rate with an area under the curve of 0.927 (P < .001). Again, detection rate and score for each patient for classification as preeclamptic correlated with severity.

CONCLUSION

A panel of messenger RNA is able to detect subjects who will experience preeclampsia.

Mean arterial pressure and prediction of pre-eclampsia

Is better than diastolic or systolic pressures in low risk women, but is still only moderately effective

Decreased ovarian reserve relates to pre-eclampsia in IVF/ICSI pregnancies

BACKGROUND

Pre-eclampsia affects 2-10% of all pregnancies and is a major cause of maternal and fetal morbidity and mortality. As compared with the general population, IVF pregnancies are associated with a 2.7-fold risk of pre-eclampsia. An advanced age and associated subfertility in the IVF group reflects a general decrease in ovarian reserve, which itself has been linked to cardiovascular disease. We tested the hypothesis that decreased ovarian reserve is associated with pre-eclampsia as a vascular complication in IVF/ICSI pregnancies.

METHODS

In this retrospective case-control study, 41 cases with a history of pre-eclampsia were compared to 82 matched controls without hypertension or (pre)eclampsia. All pregnancies were established after IVF or ICSI. Several indicators of ovarian reserve such as variables related to basal ovarian function and response to hyperstimulation were compared in both the groups by multivariate analysis. The condition of the neonates was evaluated as well.

RESULTS

A higher amount of total administered FSH and FSH per day, together with a lower number of obtained oocytes during IVF treatment, were associated with an increased risk to pre-eclampsia in a subsequent pregnancy. The administered FSH per follicle and per obtained oocyte showed even stronger relationships, the latter having the best predictive value. Neonatal outcome was comparable between the groups.

CONCLUSION

Diminished responsiveness of the ovaries to FSH stimulation in an IVF cycle, reflecting decreased ovarian reserve, is associated with an increased risk of developing pre-eclampsia in a subsequent pregnancy.

Clinical Proteomics: A Novel Diagnostic Tool for the New Biology of Preterm Labor, Part I: Proteomics Tools

The molecular mechanisms regulating myometrial contractility and preterm premature rupture of the membranes leading to preterm birth are poorly understood. The completion of the human genome sequence led to the development of functional genomics and gene array technology to simultaneously identify candidate genes potentially involved in regulation of human parturition. However, the study of living systems can now be expanded past genomics based on the rationale that it is the protein products of the genes, not simply gene expression, that have effects and cause disturbances at the cellular level. Therefore, identification of disease biomarkers, followed by a description of their functional networks, has the potential to significantly aid the development of new strategies for the prediction, diagnosis, and prevention of preterm birth. Interest in mass spectrometry and its use as a new clinical diagnostic tool has grown rapidly and is poised to become an important medical field for the next century.

Prediction and prevention of preeclampsia and IUGR

Preeclampsia, being one of the leading causes of maternal and perinatal morbidity and mortality, has been the subject of extensive research since its description. Preeclampsia has been called the disease of theories due to the enigma surrounding its exact pathophysiology. Despite the absence of treatment that reverses the disease process once started, screening for preeclampsia and intrauterine growth restriction (IUGR) has been a major clinical and research issue since the disease was first reported. This review evaluates the current evidence for prediction and prevention of preeclampsia and IUGR using clinical tests, maternal serum markers, and uterine artery Doppler screening. In addition, we critically evaluate the evidence regarding the different therapeutic strategies for the prevention of preeclampsia and IUGR and the latest clinical recommendations for their use.