Prevention of Preeclampsia and Intrauterine Growth Restriction With Aspirin Started in Early Pregnancy: A Meta-Analysis

Pregnancy-associated plasma protein A (PAPP-A) as a first trimester serum biomarker for preeclampsia screening: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to systematically examine the role of the pregnancy-associated plasma protein A (PAPP-A) serum biomarker in the first trimester screening of preeclampsia (PE).

MATERIALS AND METHODS

A systematic search of the literature was conducted on PubMed via Medline, and Cochrane Library up to 8 November 2022, for prospective studies evaluating PAPP-A serum levels in first trimester pregnant women as a screening biomarker for PE. Eligible were all prospectively designed case-control or cohort studies, published in English. Two investigators independently examined the studies and the studies' characteristics were extracted. Newcastle-Ottawa Scale (NOS) for case-control and cohort studies were applied to assess the risk of bias. For the quantitative analysis of the studies, a meta-analysis was also performed.

RESULTS

A total of 22 studies including 33,651 pregnant women were assessed, of whom, 2001 were diagnosed with PE. A meta-analysis was performed, showing that PAPP-A levels in the first trimester were significantly lower in early onset preeclamptic women (MD: -0.24, 95% CI: -0.37, -0.11, p = .0002), late onset (MD: -0.15, 95% CI: -0.25, -0.05, p = .03), and total preeclamptic cases (MD = -0.17, 95% CI = -0.23, -0.11, p < .00001) when compared with controls.

CONCLUSIONS

Our results suggest that PAPP-A can be a promising predictor in early screening for PE; hence, women at risk can be diagnosed early in their pregnancy stage and benefit from individualized PE treatment before it progresses.

Targeting oxidative stress in preeclampsia

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

Pregnancy in Women Receiving Maintenance Dialysis

Women with kidney failure experience pathophysiological changes that frequently result in disruption of the hypothalamic-pituitary-ovarian axis. Because of these hormonal disturbances, women with kidney disease often experience oligomenorrhea, amenorrhea, sexual dysfunction, and infertility. Preconception counseling, partnered with the early identification and optimal management of risk factors, such as hypertension and discontinuation of teratogenic medications, should be pursued for females contemplating conception. Pregnancy in women receiving maintenance dialysis is associated with a high risk of adverse maternal and fetal outcomes and should be managed by a multidisciplinary team of providers. In this review article, we discuss pregnancy incidence, pregnancy outcomes, and management of pregnancy among women receiving maintenance dialysis.

Maternal Thyroid Function and Biochemical Markers of Placental Function in Early Pregnancy

OBJECTIVE

A link between maternal thyroid function and the placental biomarkers, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF), has been brought forward. This study aimed to describe their association in early pregnancy.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Eight hundred and fifty-eight pregnant women from the North Denmark Region, 2013, with blood samples drawn in early pregnancy.

MEASUREMENTS

Thyroid-stimulating hormone (TSH), free thyroxine (fT4), thyroid-peroxidase antibodies (TPO-Ab), thyroglobulin antibodies (Tg-Ab) (ADVIA Centaur XPT, Siemens Healthineers), sFlt-1 and PlGF (Kryptor Compact, ThermoFisher Scientific) were measured. The association between maternal TSH and fT4 and percentile (pc) levels of sFlt-1 and PlGF (< 25th pc, 25-75th pc, > 75th pc) was evaluated using regression analysis and reported as adjusted beta coefficient (aβ). The frequency of maternal thyroid autoantibodies (TPO-Ab > 60 U/mL or Tg-Ab > 33 U/mL) by pc levels of sFlt-1 and PlGF was compared using chi-squared test.

RESULTS

Higher levels (> 75th pc) of sFlt-1 associated with lower TSH (aβ 0.62, 95% CI: 0.51-0.76) and higher fT4 (aβ 1.03, 95% CI: 1.01-1.05). Higher levels of PlGF associated with lower TSH (aβ 0.82, 95% CI: 0.69-0.98), but not with levels of fT4 (aβ 1.00, 95% CI: 0.97-1.02). No association with maternal thyroid autoantibodies was found (TPO-Ab: sFlt-1: p-value 0.5 and PlGF: p-value 0.1; Tg-Ab: sFlt-1: p-value 0.7 and PlGF: p-value 0.1).

CONCLUSIONS

In a large cohort of Danish pregnant women, higher levels of sFlt-1 and PlGF associated with maternal thyroid function in early pregnancy, while there was no association with maternal thyroid autoantibodies.

First-Trimester PlGF and PAPP-A and the Risk of Placenta-Mediated Complications: PREDICTION Prospective Study

OBJECTIVES

This study aimed to estimate the association between low first-trimester maternal serum PlGF (placental growth factor) and PAPP-A (pregnancy-associated plasma protein A) and the risk of placenta-mediated complications.

METHODS

We performed a secondary analysis of the PREDICTION study, including nulliparous participants recruited at 11 to 14 weeks of pregnancy. First-trimester PlGF and PAPP-A levels were reported in multiples of the median (MoM) adjusted for maternal characteristics and gestational age. Participants were stratified into 4 groups based on absence/presence of low (<0.4 MoM) PlGF and PAPP-A values. A composite of adverse pregnancy outcomes (including preeclampsia, fetal growth restriction, fetal death, and placental abruption) was calculated for deliveries occurring before 34 weeks, before 37 weeks, and at or after 37 weeks.

RESULTS

Out of the 7262 participants, 86 (1.2%) experienced the composite outcome before 37 weeks of gestation, including 35 (0.4%) before 34 weeks. The combination of low PAPP-A and low PlGF levels was associated with the greatest risk of adverse outcomes before 37 weeks (21%) and before 34 weeks (12%) compared with low PlGF alone (7% and 3%), low PAPP-A alone (2% and 1%), or neither marker (1% and 0.4%, respectively; P < 0.001). For preterm preeclampsia specifically, the combination of low PAPP-A and low PlGF was also associated with a greater risk (12%) compared with low PlGF alone (6%), low PAPP-A alone (0.5%), or neither marker (0.7%; P < 0.001).

CONCLUSIONS

The combination of low PAPP-A and low PlGF levels is associated with a very high risk for adverse outcomes before 34 and 37 weeks. An isolated low PAPP-A should not be considered a risk factor for adverse pregnancy outcomes.

Combined first-trimester screening for preterm small-for-gestational-age infants: Australian multicenter clinical feasibility study

OBJECTIVE

To assess the performance of the Fetal Medicine Foundation (FMF) first-trimester competing-risks screening model for small-for-gestational-age (SGA) fetuses requiring delivery at < 37 weeks' gestation, in a large cohort of women receiving maternity care in Australia.

METHODS

This was a retrospective analysis of prospectively collected data from a cohort of women attending one of two private multicenter fetal medicine practices for first-trimester screening for preterm pre-eclampsia (PE), defined as PE requiring delivery before 37 weeks' gestation. Risk for preterm SGA, defined as SGA requiring delivery before 37 weeks, was calculated but was not disclosed to the patient or referring physician. Screening data were matched to obstetric outcomes. The primary outcome was the efficacy of the FMF screening model in assessing the risk of preterm SGA. The potential effect on identifying other adverse pregnancy outcomes was also assessed.

RESULTS

During the study period, 22 841 women with a singleton pregnancy underwent combined first-trimester screening for preterm PE. These data were compared with those of 301 721 women in the state of Victoria with a singleton pregnancy who did not undergo screening during the study period. Calculation of the risk for preterm SGA identified 3030 (13.3%) pregnancies as high risk. The sensitivity of the model was 48.6% (95% CI, 41.0-56.2%), specificity was 87.0% (95% CI, 86.6-87.5%) and positive and negative predictive values were 2.9% (95% CI, 2.7-3.1%) and 99.5% (95% CI, 99.4-99.6%), respectively. Pregnancies at high risk for preterm SGA were also more likely to have preterm PE (risk ratio (RR), 2.28 (95% CI, 1.72-3.03)) and preterm birth (RR, 1.46 (95% CI, 1.32-1.63)), compared with unscreened pregnancies. Pregnancies at low risk for preterm SGA were less likely to result in a stillbirth (RR, 0.64 (95% CI, 0.47-0.86)) compared with unscreened pregnancies.

CONCLUSION

Combined first-trimester screening for preterm SGA shows moderate screening efficacy and therefore could help to inform pregnancy management and improve antenatal resource allocation. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

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

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

Preterm preeclampsia screening and prevention: a comprehensive approach to implementation in a real-world setting

BACKGROUND

Preeclampsia significantly impacts maternal and perinatal health. Early screening using advanced models and primary prevention with low-dose acetylsalicylic acid for high-risk populations is crucial to reduce the disease's incidence. This study assesses the feasibility of implementing preterm preeclampsia screening and prevention by leveraging information from our current aneuploidy screening program in a real-world setting with geographic separation clinical site and laboratory analysis site.

METHODS

A prospective cohort study involved pregnant individuals undergoing nuchal translucency scans between 11 and 14 weeks. Risk for preterm preeclampsia was assessed using the Fetal Medicine Foundation algorithm, which includes maternal risk factors, uterine artery Doppler, mean arterial pressure and serum markers (Placental growth factor, PlGF and Pregnancy-associated plasma protein-A, PAPP-A). High-risk patients were offered low-dose acetylsalicylic acid prophylaxis. Feasibility outcomes, such as recruitment rates, protocol adherence, operational impact, integration with existing workflows, screening performance and pregnancy outcomes, were evaluated.

RESULTS

Out of 974 participants, 15.6% were deemed high-risk for preterm preeclampsia. The study achieved high recruitment (82.1%) and adherence rates, with 95.4% of high-risk patients prescribed low-dose acetylsalicylic acid. Screening performance, adjusted for low-dose acetylsalicylic acid use, showed a detection rate of 88.9-90% (FPR 13.0% and 12.7%) for preterm preeclampsia. High-risk group for preeclampsia had higher incidences of adverse outcomes, including preterm preeclampsia (7.5 vs 0.4%; p < 0.001), preterm delivery (21.2 vs 6.2%; p < 0.001), low birth weight (23.3 vs 5.6%; p < 0.001) and birthweight < 10th percentile (11% vs 5.6%; p = 0.015) compared to low-risk group. The integration of preeclampsia screening had a minimal effect on the time required for aneuploidy screening, with results obtained within a rapid turnaround time.

CONCLUSIONS

The study confirms the feasibility of integrating comprehensive preeclampsia screening into clinical practice, notwithstanding geographic separation between laboratory and clinical settings. It underscores the need for broader adoption and enhanced infrastructure to optimize patient care and outcomes across diverse healthcare settings.

TRIAL REGISTRATION

Clinical trial: NCT04412681 (2020-06-02).

Comparison of two aspirin doses for the prophylaxis of pre-eclampsia in twin pregnancy: a multicentre retrospective study with propensity score matching

BACKGROUND

Aspirin has proved its efficacy in reducing the rate of preeclampsia in singleton pregnancy; however, there is discrepancy about the efficient dosage that should be used. While some societies recommend daily 75 to 81 mg, others recommend higher dosage (160 mg). This discrepancy is due to the lack of randomized controlled studies that compare these 2 dosages. Moreover, there remains a considerable gap in our knowledge concerning the appropriate prophylactic aspirin dosage for twin pregnancies.

OBJECTIVE

This study aimed to assess the efficacy of various aspirin prophylaxis dosages in the prevention of preeclampsia and hypertensive disorders of pregnancy (HDP) in twin pregnancies.

STUDY DESIGN

This was an international multicentre retrospective cohort study that was conducted in 3 European centers. We included all twin pregnancies with 2 live fetuses at 13 weeks of gestation (WG). We excluded fetal malformations, twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, twin pregnancies at onset but continued as singletons (vanishing twin/arrest before 13 WG), and loss of follow-up. Patients were categorized into 3 groups: no aspirin, daily 80 to 100 mg aspirin, and daily 160 mg aspirin. Primary outcomes were the incidence of preeclampsia and HDP, whereas secondary outcomes were small-for-gestational age, postpartum hemorrhage >1000 mL, antenatal bleeding of obstetrical origin, thrombocytopenia, miscarriage, intrauterine fetal demise, neonatal death, and gastritis. Propensity score matching and multivariate analyses were conducted to assess outcomes including pre-eclampsia, gestational hypertension, maternal complications, and gastritis. Propensity score matching was used to balance the 3 groups of study. Cox regression models were done for each outcome after matching to compare the 3 groups. A P-value<.05 was considered statistically significant.

RESULTS

A total of 1907 twin pregnancies were included: 1423 (74.62%) received no aspirin, 212 (11.12%) received 80 to 100 mg, and 272 (14.26%) received 160 mg. After using propensity score matching for maternal age, body mass index, race, parity, history of preeclampsia, chronic hypertension, diabetes mellitus, thrombophilia, spontaneous conception, and type of twin pregnancy, the 3 groups were adequately balanced (absolute standardized difference [ASD] <15%), except for age and thrombophilia (ASD 22.1% and 16.4%, respectively). The administration of aspirin 160 mg decreased the hazard ratio (HR) for preeclampsia to 0.63 and for HDP to 0.56, whereas the administration of aspirin 80 to 100 mg failed to decrease both HR below 1. In addition, aspirin 160 mg decreased the risk for preeclampsia <34 WG. No significant increase for aspirin-related complications, such as bleeding or thrombocytopenia, or other obstetrical outcomes was observed with the higher dose of aspirin.

CONCLUSION

The use of 160 mg aspirin for the prevention of hypertensive disorders of pregnancy may offer superior outcomes in twin pregnancies, with no discernible rise in complications when compared to aspirin doses ranging from 80 to 100 mg. Further research should explore long-term impacts and refine dosage strategies for optimal outcomes in twin pregnancies.

Al-Dahwi R, Georgieva E, Karamalakova Y, Nikolova G. Preeclampsia Treatment Aspirin/Clampsilin: Oxidative Stress, sFlt-1/PIGF Soluble Tyrosine Kinase 1, and Placental Growth Factor Monitoring

The present study aimed to investigate and compare oxidative stress biomarkers and antioxidant enzyme activity in the serum of women at risk of developing preeclampsia (PE) to prevent adverse pregnancy outcomes through early intervention. Changes in soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) levels were measured between 11 and 13 gestational weeks (gw.) before the onset of preeclampsia and its associated complications. This study evaluated the feasibility of the sFlt-1/PlGF biomarker ratio in predicting preeclampsia and adverse pregnancy outcomes, with the goal of preventive therapy with acetylsalicylic acid (150 mg daily), with acetylsalicylic acid (75 mg daily) and Clampsilin. For this purpose, the following were evaluated: (1) the levels of reactive oxygen species (ROS) and reactive nitrogen species (RNS) as parameters of oxidative stress; (2) lipid oxidation; (3) antioxidant enzyme activity; and (4) cytokine production. Analysis of the results showed that pregnant women at risk of preeclampsia had significantly higher levels of ROS, lipid oxidation, and superoxide anion radical (•O2-) levels compared to normal pregnancies. In PE, depleted levels of nitric oxide (NO), impaired NO synthase system (NOS), and reduced antioxidant enzyme activity (p < 0.03) suggest that PE patients cannot compensate for oxidative stress (OS). In conclusion, oxidative stress in PE plays a key role, which arises from placental problems and affects both mother and baby. The groups with acetylsalicylic acid therapy (150 mg and 75 mg) were better affected compared to those on Clampsillin.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT05287321.

Chronic Inflammation Offers Hints About Viable Therapeutic Targets for Preeclampsia and Potentially Related Offspring Sequelae

The combination of hypertension with systemic inflammation during pregnancy is a hallmark of preeclampsia, but both processes also convey dynamic information about its antecedents and correlates (e.g., fetal growth restriction) and potentially related offspring sequelae. Causal inferences are further complicated by the increasingly frequent overlap of preeclampsia, fetal growth restriction, and multiple indicators of acute and chronic inflammation, with decreased gestational length and its correlates (e.g., social vulnerability). This complexity prompted our group to summarize information from mechanistic studies, integrated with key clinical evidence, to discuss the possibility that sustained or intermittent systemic inflammation-related phenomena offer hints about viable therapeutic targets, not only for the prevention of preeclampsia, but also the neurobehavioral and other developmental deficits that appear to be overrepresented in surviving offspring. Importantly, we feel that carefully designed hypothesis-driven observational studies are necessary if we are to translate the mechanistic evidence into child health benefits, namely because multiple pregnancy disorders might contribute to heightened risks of neuroinflammation, arrested brain development, or dysconnectivity in survivors who exhibit developmental problems later in life.

Impact of Sonographer Experience, Insonation Angle, and Bladder Filling on Uterine Artery Doppler Measurements in the First Trimester of Pregnancy

OBJECTIVE

To investigate the influence of different measurement conditions and ultrasound training level on uterine artery pulsatility index (UtA-PI) measurements as required for combined first trimester preeclampsia (PE) screening.

METHODS

This was a prospective study of consecutive patients with singleton pregnancies presenting for an ultrasound examination between 11 and 14 weeks' gestation. UtA-PI measurements were conducted by residents in training and repeated by experienced sonographers thereafter. UtA-PI measurements were conducted under different examination conditions. First, the trainee sonographers performed transabdominal sagittal and transverse UtA-PI measurements without bladder filling. These measurements were then repeated by the expert sonographers. Additionally, the expert sonographers also performed transvaginal UtA-PI measurements and transabdominal measurements with bladder filling. Statistical analysis was conducted with the statistical software R and included descriptive statistics as well as 2-sided paired t tests.

RESULTS

A total of 100 women were included in the study. Mean age was 31.7 ± 4.92 years and mean gestational week was 12.5 ± 0.53 weeks. A total of 56% were nulliparous and 44% were parous. UtA-PI was significantly lower if performed by a sonographer in training versus an experienced sonographer (P = .031). No significant difference was observed in comparing transverse and sagittal techniques (P = .241). There was also no significant difference in transabominal versus transvaginal measurements (P = .806) and with an empty versus full bladder (P = .444).

CONCLUSION

Experience of sonographer has a significant impact on UtA-PI. Supervised onsite training is necessary to improve reliability and consistency of UtA-PI measurements and make PE screening reliable for implementation in a universal screening setting.

The effectiveness of low-dose aspirin for the prevention of hypertensive disorders of pregnancy in a sub-Saharan Africa Country: A randomized clinical trial

OBJECTIVE

To evaluate whether a daily dose of low-dose aspirin (LDA) can prevent hypertensive disorders of pregnancy (HDP), including preeclampsia, among pregnant women in a South African cohort, and to assess its impact on related maternal and fetal outcomes, such as preterm birth and neonatal complications.

STUDY DESIGN

This single-center, open-label, parallel-group randomized controlled trial (RCT) was conducted at a regional hospital in Durban, KwaZulu-Natal, South Africa, from May 2021 to March 2024. A total of 423 pregnant women, aged 18 years or older with singleton pregnancies between 12 and 20 weeks of gestation, were randomized to receive either 162 mg of LDA daily or standard care. The primary outcome was the incidence of HDP, while secondary outcomes included early-onset preeclampsia (EOPE), preterm birth, low birth weight (LBW), and neonatal death. Data analysis used relative risk (RR) and 95 % confidence intervals (CIs).

RESULTS

Of the 423 women, 209 were in the LDA group and 214 in the control group. The incidence of HDP was significantly lower in the LDA group (6.2 % vs. 25.2 %; RR = 0.25, 95 % CI [0.14-0.44], p < 0.001), corresponding to a 75 % reduction in HDP risk, with an absolute risk reduction (ARR) of 19 % and a number needed to treat (NNT) of 5.3. EOPE was reduced (2.4 % vs. 14.0 %; RR = 0.17, 95 % CI [0.07-0.41], p < 0.001), as was preterm birth (6.7 % vs. 26.2 %; RR = 0.26, 95 % CI [0.15-0.45], p < 0.001). There were no significant differences for LBW or neonatal death. Sensitivity analysis confirmed the importance of initiating LDA before 16 weeks, showing continued reductions in HDP incidence with early initiation.

CONCLUSION

LDA significantly reduces the risk of HDP, EOPE, and preterm birth, particularly when initiated before 16 weeks of gestation. These findings support the use of LDA for preventing hypertensive disorders of pregnancy in low-resource settings and underscore the value of early intervention for improved maternal and fetal outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The value of a mobile educative Application additional to Standard counselling on aspirin Adherence in Pregnancy: the ASAP study, a randomised controlled trial

Objective

To assess the added value of a novel, mobile educative application to standard counselling on aspirin adherence during pregnancy versus standard counselling alone.

Methods

Participants were randomly assigned for additional use of a mobile educative application or standard counselling alone. Main outcome measures were adherence to aspirin measured by two validated questionnaires: Simplified Medication Adherence Questionnaire (SMAQ), Believes and Behaviour Questionnaire (BBQ), and patients reported tablet intake >90%.

Results

A total of 174 women with an indication for aspirin during pregnancy were included. The questionnaires were filled in by 126 out of the 174 participants (72.4%). Similar results were found in the app group and the standard counselling groups for both validated questionnaires. Tablet intake >90% was seen in 88.7% and 87.5% (p = 0.834) of the app group and standard counselling group respectively. Subgroup analyses demonstrated a negative effect of BMI and a positive effect of educational level on adherence.

Conclusions

Our study revealed no added effect of a novel, mobile educative application to standard counselling on aspirin adherence during pregnancy. Tablet intake was equally high in both groups probably explained by our high educated population.

Innovation

Future studies should focus on tailored counselling on medication to pregnant women's needs including medication reminders, addressing concerns, adequate health literacy and side effects, offering rewards to further stimulate aspirin adherence in pregnancy with optimal outcome for mother and their neonate.

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

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

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Contributions Regarding the Study of Pulsatility and Resistivity Indices of Uterine Arteries in Term Pregnancies-A Prospective Study in Bucharest, Romania

Pregnancy is a complex stage in a woman's life, considering the physical and psychological changes that occur. The introduction of Doppler studies of the pregnant woman's vessels and those of the fetus has proven to be a useful tool in evaluating the maternal-fetal relationship. Objective: The study aims to assess the correlations of PI and RI values in term pregnancies. Methods: This analysis is based on the prospective evaluation of medical data from 60 patients who were admitted to the Obstetrics and Gynecology department of Saint Pantelimon Hospital in Bucharest, Romania, from May to August 2024. Among the examined parameters are patient age, blood pressure, amniotic fluid quantity, placenta location, and pulsatility and resistivity indices of uterine arteries. Results: A higher diastolic blood pressure is associated with higher mean PI and RI values, indicating that diastolic blood pressure has a significant correlation to these values. The mean RI shows a moderately negative and significant correlation, suggesting that a lower level of amniotic fluid is associated with a higher mean RI. Regarding the PI value of the uterine arteries, the p-value suggests that the difference between the groups with and without associated diseases is statistically significant. Placental insertion on the anterior or posterior uterine wall does not have a significant impact on the PI and RI values of the uterine arteries, but the values are higher in the contralateral part of the placental insertion. Conclusions: These results strengthen the evidence previously demonstrated. Uterine artery Doppler ultrasonography is an extremely useful tool in monitoring and managing high-risk pregnancies.

Clinical and sonographic risk factors for developing pre-eclampsia refractory to aspirin prophylaxis

OBJECTIVE

Identify risk factors for development of preeclampsia refractory to aspirin prophylaxis in women at high-risk of preeclampsia.

MATERIAL AND METHODS

A retrospective cohort study analyzed 206 women identified as high-risk for preeclampsia through first-trimester screening and prescribed aspirin prophylaxis. We compared maternal characteristics, medical history, biochemical markers, and uterine artery Doppler indices between those with and without preeclampsia.

RESULTS

Women with preeclampsia had significantly higher rates of chronic hypertension (54.3% vs. 8.2%), higher first-trimester mean arterial pressure (MAP, 109.6 vs. 95.4 mmHg), and higher body mass index (BMI, 27.6 vs. 24.9) compared to controls. Second-trimester MAP and mean uterine artery pulsatility index (UtA-PI) were also significantly elevated in the preeclampsia group (103.3 mmHg and 1.39, respectively) compared to controls (89.7 mmHg and 1.05). ROC curve analysis identified an optimal second trimester UtA-PI cut-off of 1.36 for predicting preeclampsia, with sensitivity of 49% and specificity of 87.1%. When using a cut-off value of 0.77 for the second-to-first trimester UtA-PI ratio, the sensitivity and specificity were 60% and 90.6%, respectively.

CONCLUSION

Chronic hypertension, high first and second trimester MAP, higher BMI, and elevated second trimester UtA-PI are associated with preeclampsia despite aspirin prophylaxis. Evaluating second trimester UtA-PI or the ratio of second to first trimester UtA-PI may be a promising tool for identifying women who do not respond to aspirin.

Effect of low-dose aspirin intervention on pre-eclampsia prevention in high-risk pregnant women and its impact on postpartum hemorrhage

Background

Pre-eclampsia, characterized by hypertension and organ dysfunction during pregnancy, poses significant risks to both maternal and fetal health. Aspirin, known for its antiplatelet properties, has been extensively utilized to mitigate pregnancy-related complications. However, the efficacy of low-dose aspirin in managing pre-eclampsia among high-risk pregnant women and its potential impact on postpartum hemorrhage remain contentious topics.

Methods

A retrospective analysis was conducted on 344 pregnant women diagnosed with high-risk factors for pre-eclampsia. Among them, 152 received intervention with low-dose aspirin, while the rest did not receive it. The incidence of pre-eclampsia, as well as related complications and outcomes associated with bleeding, were compared and evaluated between the two groups.

Results

The study findings indicate a significant reduction in the incidence of pre-eclampsia among pregnant women receiving low-dose aspirin intervention, along with a significantly reduced risk of complications. Additionally, there was no significant statistical difference in postpartum hemorrhage between the two groups (p > 0.05). The safety profile of aspirin usage was found to be favorable.

Conclusion

Low-dose aspirin demonstrates promising efficacy as an intervention strategy for high-risk preeclamptic women. It does not increase the risk of postpartum hemorrhage and reduces the occurrence of complications associated with preeclampsia. Therefore, low-dose aspirin presents a potential preventive measure against adverse outcomes associated with high-risk pregnancies related to preeclampsia. Further research is necessary to validate and elucidate the optimal dosage and timing of administration for maximal benefits.

Association Between Maternal Cytomegalovirus Seropositivity, Preterm Birth, and Preeclampsia in Two Cohorts From Quebec, Canada: A Mediation Analysis

PROBLEM

Preterm birth and preeclampsia significantly contribute to infant morbidity and mortality, posing critical public health concerns. Viral infections, particularly Cytomegalovirus (CMV), associated with chronic inflammation, may play a role in these adverse pregnancy outcomes. The contribution of CMV to preterm birth and preeclampsia requires further investigation.

METHOD OF STUDY

Data from 6048 pregnant women from two prospective Quebec cohorts, recruited between May 2005 and August 2012, were analyzed. First-trimester CMV serology was the exposure variable. Associations were assessed using multivariable logistic regression adjusted by inverse probability treatment weighting (IPTW) of propensity scores. Mediation analyses estimated the direct effect of maternal CMV serostatus on preterm birth, excluding mediation by preeclampsia.

RESULTS

Preterm birth and preeclampsia proportions were 5.1% (95% CI: 4.6-5.7) and 1.9% (95% CI: 1.6-2.3), respectively. Multivariable logistic regression adjusted by IPTW showed associations between CMV seropositivity and preterm birth (OR 1.20, 95% CI: 1.02-1.41) and CMV seropositivity and preeclampsia (OR 1.41, 95% CI: 1.08-1.84). Mediation analysis indicated that 97% of the total effect of CMV seropositivity on preterm birth is direct, with the remaining 3% mediated by preeclampsia.

CONCLUSIONS

CMV seropositivity appears to be a risk factor for both preterm birth and preeclampsia. The effect of maternal CMV seropositivity on preterm birth is primarily direct, not mediated by preeclampsia. Future studies should explore the impact of preventive measures against CMV infection on the incidence of preterm delivery and preeclampsia.

Can maternal inflammatory and nutritional status, evaluated by the hemoglobin, albumin, lymphocyte, and platelet (HALP) score and the prognostic nutritional index (PNI) in the first trimester, predict late-onset fetal growth restriction?

OBJECTIVE

The aim of this study was to evaluate the potential of immunonutritional markers, specifically the hemoglobin, albumin, lymphocyte, and platelet (HALP) score and the prognostic nutritional index (PNI), in predicting late-onset fetal growth restriction (LO-FGR) during the first trimester.

MATERIALS AND METHODS

This retrospective study was conducted at a tertiary care center between October 2022 and August 2023. The study included a total of 213 singleton pregnancies, with 99 women in the LO-FGR group and 114 in the healthy control group, matched by maternal age and gestational age at delivery. All blood samples were collected between 11 and 14 weeks of gestation (during the first-trimester screening test). We analyzed first-trimester laboratory parameters, specifically focusing on hemoglobin levels, white blood cells (WBCs), lymphocytes, platelets, and albumin levels. Afterwards, we calculated the HALP score and PNI, and then compared the values of both groups.

RESULTS

Both HALP score (3.58 ± 1.31 vs. 4.19 ± 1.8, p = 0.012) and PNI (36.75 ± 2.9 vs. 39.37 ± 3.96, p < 0.001) were significantly lower in the FGR group than in the control group. The HALP score cut-off value of < 3.43 in predicting FGR had a sensitivity of 62.3% and specificity of 54.5% (AUC = 0.600, 95% CI: 0.528-0.672, p = 0.012). The PNI cut-off value of < 37.9 in predicting FGR had a sensitivity of 65.8% and specificity of 62.9% (AUC = 0.707, 95% CI: 0.632-0.778, p < 0.001). While the HALP score was not a significant predictor of composite adverse neonatal outcomes in the FGR group, PNI showed a cut-off value of < 37.7 with a sensitivity of 60.9% and specificity of 59.7% (AUC = 0.657, 95% CI: 0.581-0.733, p < 0.001).

CONCLUSION

The HALP score and PNI are valuable prognostic tools for predicting the risk of FGR in the first trimester. Low PNI values are also associated with composite adverse neonatal outcomes in pregnancies complicated by FGR.

Systemic lupus erythematosus is associated with an increased frequency of spontaneous preterm births: systematic review and meta-analysis

OBJECTIVE

Preterm birth is one of the most frequent complications of pregnancy in women with systemic lupus erythematosus. The high indicated preterm birth proportion due to hypertensive disorders of pregnancy and/or fetal growth restriction is well known, and preventive measures and screening for early detection are performed. The risk of spontaneous preterm birth is less well recognized. This study aimed to determine the proportions of spontaneous and indicated preterm birth in pregnancies of women with systemic lupus erythematosus.

DATA SOURCES

A systematic literature search using Pubmed, Embase, Web of Science, and Google Scholar was performed in June 2021.

STUDY ELIGIBILITY CRITERIA

Studies in pregnant women with systemic lupus erythematosus reporting spontaneous and indicated preterm birth rates were selected. Original research articles published from 1995 to June 2021 were included.

METHODS

Quality and risk of bias of the included studies were assessed using the Newcastle-Ottawa quality assessment scale. To estimate the pooled event rates and 95% confidence intervals, meta-analysis of single proportions with a random-effects model was performed.

RESULTS

We included 21 articles, containing data of 8157 pregnancies in women with systemic lupus erythematosus. On average, 31% (95% prediction interval, 0.14-0.50) of the pregnancies resulted in preterm birth, including 14% (95% prediction interval, 0.04-0.27) spontaneous and 16% (95% prediction interval, 0.03-0.35) indicated preterm birth.

CONCLUSION

In pregnant women with systemic lupus erythematosus, spontaneous and indicated preterm birth proportions are high. This information should be applied in (prepregnancy) counseling and management in pregnancy. The knowledge obtained by this meta-analysis paves the way for further research of associated risk factors and development of interventions to reduce spontaneous preterm birth in systemic lupus erythematosus pregnancies.

Comparison of National Factor-Based Models for Preeclampsia Screening

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

The sFlt-1/PlGF-ratio and the risk of preeclampsia-related adverse outcomes in subsequent pregnancies with signs and symptoms of a preeclampsia

OBJECTIVES

This study characterizes the outcome of two subsequent pregnancies with suspected preeclampsia (PE). We investigated the diagnostic accuracy of clinical signs, Doppler examinations, and the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF)-ratio to predict PE-related adverse outcomes (AO). The sFlt-1/PlGF-ratio of the first pregnancy was compared to the outcome of the subsequent pregnancy.

STUDY DESIGN

A total of 1928 patients at risk for preeclampsia were screened, of them 1117 were eligible for inclusion. Of these, 84 women presented with suspected PE in two subsequent pregnancies.

OUTCOME MEASURES

Diagnostic accuracy of clinical markers was assessed. Associations between the sFlt-1/PlGF-ratio in the first and the odds of an AO in the subsequent pregnancy were investigated with logistic regression.

RESULTS

The prevalence of AOs decreased from 27.4 % in the first to 17.9 % in the second pregnancy. Comparison of the accuracy of the different clinical markers for an AO showed a high specificity for an sFlt-1/PlGF-ratio at the cut-off of ≥ 85 in both pregnancies (81.3 %, 95 % CI 63.6-92.8 vs 92.6 %,95 % CI 83.7-97.6), but a lower sensitivity in the second pregnancy (92.9 %, 95 % CI 66.1-99.8 vs 33.3%, 95 % CI 11.8-61.6). An elevated sFlt-1/PlGF-ratio in the first did not increase the odds of an AO in the subsequent pregnancy.

CONCLUSIONS

The prevalence of AOs decreases in subsequent pregnancies. Our finding that the sFlt-1/PlGF-ratio of the first was not related to the outcome of the subsequent pregnancy suggests that angiogenic markers are only a within-pregnancy short-term tool to assess AOs.

Pre-eclampsia challenges and care in low and middle-income countries: Understanding diagnosis, management, and health impacts in remote and developing regions

As an example of a low- and middle-income country (LMIC), India ranks pre-eclampsia among the top three causes of maternal mortality, following haemorrhage and infections. It is one of the primary concerns for maternal and perinatal health in LMICs. Many LMICs lack clear consensus and guidelines for the prevention, diagnosis, and management of hypertensive disorders in pregnancy, including pre-eclampsia. The International Society for the Study of Hypertension in Pregnancy 2021 guidelines address LMIC applications, offering customisable solutions. Atypical presentations of pre-eclampsia contribute to diagnostic delays, resulting in additional adverse maternal and perinatal outcomes. Implementing management strategies faces challenges in both urban and rural settings. Adapting global research involving local populations is imperative, with the potential for cost-effective adoption of international guidelines. Prevention, early diagnosis, and education dissemination are essential, involving healthcare providers and advocacy initiatives. Encouraging government investment in pre-eclampsia management as a public health initiative is important. This article explores socio-economic, cultural, and legislative factors influencing the management of pre-eclampsia in LMICs, addressing emerging challenges and potential partnerships for healthcare provision.

Cardiovascular complications during delivery hospitalizations in patients with nonalcoholic fatty liver disease in pregnancy

OBJECTIVE

While the association between metabolic dysfunction-associated steatotic liver disease (MASLD) and long-term cardiovascular risks has been studied, the impact of MASLD on cardiovascular events during delivery hospitalizations remains relatively unexplored. This study aims to examine the prevalence of cardiovascular diseases (CVDs) and cardiac arrhythmias in pregnant patients with MASLD and identify potential risk factors.

METHODS

A retrospective analysis of hospital discharge records from the National Inpatient Sample database between 2009 and 2019 was conducted to assess maternal cardiovascular outcomes. Multivariable logistic regression models were employed, and adjusted odds ratios (AOR) were calculated to evaluate the association between MASLD and cardiovascular outcomes during pregnancy.

RESULTS

The study sample included 17 593 pregnancies with MASLD and 41 171 211 pregnancies without this condition. Women with MASLD exhibited an increased risk of congestive heart failure [AOR 3.45, 95% confidence interval (CI) 1.04-11.43], cardiac arrhythmia (AOR 2.60, 95% CI 1.94-3.49), and gestational hypertensive complications (AOR 3.30, 95% CI 2.93-3.72). Pregnancies with MASLD were also associated with a higher rate of pulmonary edema (AOR 3.30, 95% CI 1.60-6.81).

CONCLUSION

MASLD is an independent risk factor for cardiovascular complications during delivery hospitalizations, emphasizing the necessity for prepregnancy screening and targeted prevention strategies to manage CVD risks in expectant patients with MASLD.

Pregnancy Disorders: A Potential Role for Mitochondrial Altered Homeostasis

Pregnancy is a complex and challenging process associated with physiological changes whose objective is to adapt the maternal organism to the increasing energetic requirements due to embryo and fetal development. A failed adaptation to these demands may lead to pregnancy complications that threaten the health of both mothers and their offspring. Since mitochondria are the main organelle responsible for energy generation in the form of ATP, the adequate state of these organelles seems crucial for proper pregnancy development and healthy pregnancy outcomes. The homeostasis of these organelles depends on several aspects, including their content, biogenesis, energy production, oxidative stress, dynamics, and signaling functions, such as apoptosis, which can be modified in relation to diseases during pregnancy. The etiology of pregnancy disorders like preeclampsia, fetal growth restriction, and gestational diabetes mellitus is not yet well understood. Nevertheless, insufficient placental perfusion and oxygen transfer are characteristic of many of them, being associated with alterations in the previously cited different aspects of mitochondrial homeostasis. Therefore, and due to the capacity of these multifactorial organelles to respond to physiological and pathophysiological stimuli, it is of great importance to gather the currently available scientific information regarding the relationship between main pregnancy complications and mitochondrial alterations. According to this, the present review is intended to show clear insight into the possible implications of mitochondria in these disorders, thus providing relevant information for further investigation in relation to the investigation and management of pregnancy diseases.

Maternal hypothyroidism and the risk of preeclampsia: a Danish national and regional study

BACKGROUND

Maternal hypothyroidism in pregnancy has been proposed to increase the risk of preeclampsia, but uncertainties persist regarding the underlying causal mechanisms. Thus, it remains unclear if an increased risk of preeclampsia in hypothyroid pregnant women is caused by the lack of thyroid hormones or by the autoimmunity per se.

METHODS

We conducted a retrospective study of two pregnancy cohorts in the Danish population. The nationwide cohort (n = 1,014,775) was register-based and included all singleton pregnancies in Denmark from 1999-2015. The regional cohort (n = 14,573) included the biochemical measurement of thyroid stimulating hormone (TSH), thyroid peroxidase antibodies (TPO-Ab), and thyroglobulin antibodies (Tg-Ab) (ADVIA Centaur XPT, Siemens Healthineers) among pregnant women in The North Denmark Region from 2011-2015 who had a blood sample drawn in early pregnancy as part of routine prenatal screening for chromosomal anomalies. The associations between diagnosed and biochemically assessed hypothyroidism and a diagnosis of preeclampsia were evaluated using logistic regression (adjusted odds ratio (aOR) with 95% confidence interval (CI)) adjusting for potential confounders, such as maternal age, diabetes, and parity.

RESULTS

In the nationwide cohort, 2.2% of pregnant women with no history of hypothyroidism (reference group (ref.)) were diagnosed with preeclampsia, whereas the prevalence was 3.0% among pregnant women with hypothyroidism (aOR 1.3 (95% CI: 1.2-1.4)) and 4.2% among women with newly diagnosed hypothyroidism in the pregnancy (aOR 1.6 (95% CI: 1.3-2.0)). In the regional cohort, 2.3% of women with early pregnancy TSH < 2.5 mIU/L (ref.) were diagnosed with preeclampsia. Among women with TSH ≥ 6 mIU/L, the prevalence was 6.2% (aOR 2.4 (95% CI: 1.1-5.3)). Considering thyroid autoimmunity, preeclampsia was diagnosed in 2.2% of women positive for TPO-Ab (> 60 U/mL) or Tg-Ab (> 33 U/mL) in early pregnancy (aOR 0.86 (95% CI: 0.6-1.2)).

CONCLUSIONS

In two large cohorts of Danish pregnant women, maternal hypothyroidism was consistently associated with a higher risk of preeclampsia. Biochemical assessment of maternal thyroid function revealed that the severity of hypothyroidism was important. Furthermore, results did not support an association between thyroid autoimmunity per se and preeclampsia.

Implementation of aspirin use during pregnancy in community midwifery-led care in the Netherlands: A pilot survey

INTRODUCTION

Aspirin nowadays is widely used in pregnancy, but implementation among gynecologists took nearly four decades. For a complete insight in the implementation of aspirin, community midwives are to be involved. Community midwives do not have authority to prescribe aspirin and have to refer to a general practitioner or consultant obstetrician for a prescription.

METHODS

The study was an online, national pilot survey about the implementation of aspirin use during pregnancy among independently practicing community midwives consisting of 29 items with five categories: background, advising, prescribing, possible indications, and clinical practice.

RESULTS

Forty-seven community midwives completed the survey between April and May 2021. All respondents had experience on advising aspirin use in pregnancy. History of preterm pre-eclampsia or HELLP syndrome was identified as a risk factor for developing utero-placental complications by 97.9% of the community midwives. Moderate risk factors in women with otherwise low-risk pregnancy were identified by >75% of the participants. Practical issues in prescribing aspirin were experienced by one-third of the respondents. Suggestions were made to obtain authority for community midwives to prescribe aspirin and improve collaboration with consultant obstetricians and general practitioners.

CONCLUSIONS

Community midwives seem to be adequate in identifying risk factors for developing utero-placental complications in women with otherwise low-risk pregnancy. Practical issues for prescribing aspirin occur often. Obtaining authority for community midwives to prescribe aspirin after education should be considered and consulting a consultant obstetrician should become more accessible to overcome the practical issues. Further educating community midwives and general practitioners might improve implementation rates and perinatal outcomes.

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

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

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

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

Cardiovascular complications during delivery hospitalizations in inflammatory bowel disease patients

BACKGROUND

The relationship between inflammatory bowel disease (IBD) and cardiovascular outcomes among pregnant women has yet to be thoroughly investigated. Our aim is to assess the odds of cardiovascular disease and cardiac arrhythmias during hospital admissions for delivery and identify contributing factors associated with cardiovascular complications in pregnant women with IBD.

METHODS

We performed a retrospective analysis of data from the National Inpatient Sample, obtained from delivery admissions of pregnant women with and without IBD, identified via International Classification of Diseases codes, from 2009 to 2019. Using a regression model, we compared the odds of cardiovascular complications between these two groups, adjusting for traditional cardiovascular risk factors as confounding variables.

RESULTS

Our study included 71,361 pregnancies with IBD and 41,117,443 pregnancies without this condition. The incidence of IBD in pregnancy rose near three-fold increase over the decade. In comparison to pregnancies without IBD, those involving pregnant patients with IBD exhibited an increased likelihood of encountering cardiovascular complications, with an adjusted odds ratio (AOR) of 1.37 (95% CI, 1.29-1.46). This heightened risk encompasses a range of conditions, including peripartum cardiomyopathy (AOR, 9.45; 95% CI, 3.86-23.15), cardiac arrhythmias (AOR, 2.03; 95% CI, 1.59-2.60), and hypertensive disorders of pregnancy (AOR, 1.51; 95% CI, 1.37-1.66), notably preeclampsia, eclampsia, and the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome). Pregnancies with IBD were also associated with three-fold higher odds of venous thromboembolism (AOR, 3.91; 95% CI, 1.45-10.48).

CONCLUSIONS

Pregnant patients with IBD had an increased odds of cardiovascular complications during delivery admissions, independent of traditional cardiovascular risk factors. Further research is needed to elucidate the underlying mechanisms and develop targeted prevention strategies for this high-risk population.

Placental Senescence and the Two-Stage Model of Preeclampsia

In this review, we summarize how an increasingly stressed and aging placenta contributes to the maternal clinical signs of preeclampsia, a potentially lethal pregnancy complication. The pathophysiology of preeclampsia has been conceptualized in the two-stage model. Originally, highlighting the importance of poor placentation for early-onset preeclampsia, the revised two-stage model explains late-onset preeclampsia as well, which is often preceded by normal placentation. We discuss how cellular senescence in the placenta may fit with the framework of the revised two-stage model of preeclampsia pathophysiology and summarize potential cellular and molecular mechanisms, including effects on placental and maternal endothelial function. Cellular senescence may occur in response to inflammatory processes and oxidative, mitochondrial, or endoplasmic reticulum stress and chronic stress induce accelerated, premature placental senescence. In preeclampsia, both circulating and tissue-based senescence markers are present. We suggest that aspirin prophylaxis, commonly recommended from the first trimester onward for women at risk of preeclampsia, may affect placentation and possibly mechanisms of placental senescence, thus attenuating the risk of preeclampsia developing clinically. We propose that biomarkers of placental dysfunction and senescence may contribute to altered preventive strategies, including discontinuation of aspirin at week 24-28 depending on placenta-associated biomarker risk stratification.

Hypertensive Disorders of Pregnancy and the Cardiovascular System: Causes, Consequences, Therapy, and Prevention

Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..

Prospective Validation of First-Trimester Screening for Preterm Preeclampsia in Nulliparous Women (PREDICTION Study)

BACKGROUND

Fetal Medicine Foundation (FMF) studies suggest that preterm preeclampsia can be predicted in the first trimester by combining biophysical, biochemical, and ultrasound markers and prevented using aspirin. We aimed to evaluate the FMF preterm preeclampsia screening test in nulliparous women.

METHODS

We conducted a prospective multicenter cohort study of nulliparous women recruited at 11 to 14 weeks. Maternal characteristics, mean arterial blood pressure, PAPP-A (pregnancy-associated plasma protein A), PlGF (placental growth factor) in maternal blood, and uterine artery pulsatility index were collected at recruitment. The risk of preterm preeclampsia was calculated by a third party blinded to pregnancy outcomes. Receiver operating characteristic curves were used to estimate the detection rate (sensitivity) and the false-positive rate (1-specificity) for preterm (<37 weeks) and for early-onset (<34 weeks) preeclampsia according to the FMF screening test and according to the American College of Obstetricians and Gynecologists criteria.

RESULTS

We recruited 7554 participants including 7325 (97%) who remained eligible after 20 weeks of which 65 (0.9%) developed preterm preeclampsia, and 22 (0.3%) developed early-onset preeclampsia. Using the FMF algorithm (cutoff of ≥1 in 110 for preterm preeclampsia), the detection rate was 63.1% for preterm preeclampsia and 77.3% for early-onset preeclampsia at a false-positive rate of 15.8%. Using the American College of Obstetricians and Gynecologists criteria, the equivalent detection rates would have been 61.5% and 59.1%, respectively, for a false-positive rate of 34.3%.

CONCLUSIONS

The first-trimester FMF preeclampsia screening test predicts two-thirds of preterm preeclampsia and three-quarters of early-onset preeclampsia in nulliparous women, with a false-positive rate of ≈16%.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02189148.

Decidual macrophages and Hofbauer cells in fetal growth restriction

Placental macrophages, which include maternal decidual macrophages and fetal Hofbauer cells, display a high degree of phenotypical and functional plasticity. This provides these macrophages with a key role in immunologically driven events in pregnancy like host defense, establishing and maintaining maternal-fetal tolerance. Moreover, placental macrophages have an important role in placental development, including implantation of the conceptus and remodeling of the intrauterine vasculature. To facilitate these processes, it is crucial that placental macrophages adapt accordingly to the needs of each phase of pregnancy. Dysregulated functionalities of placental macrophages are related to placental malfunctioning and have been associated with several adverse pregnancy outcomes. Although fetal growth restriction is specifically associated with placental insufficiency, knowledge on the role of macrophages in fetal growth restriction remains limited. This review provides an overview of the distinct functionalities of decidual macrophages and Hofbauer cells in each trimester of a healthy pregnancy and aims to elucidate the mechanisms by which placental macrophages could be involved in the pathogenesis of fetal growth restriction. Additionally, potential immune targeted therapies for fetal growth restriction are discussed.

Cohort profile: Improved Pregnancy Outcomes via Early Detection (IMPROvED), an International Multicentre Prospective Cohort

Background

Improved Pregnancy Outcomes via Early Detection (IMPROvED) is a multi-centre, European phase IIa clinical study. The primary aim of IMPROvED is to enable the assessment and refinement of innovative prototype preeclampsia risk assessment tests based on emerging biomarker technologies. Here we describe IMPROvED's profile and invite researchers to collaborate.

Methods

A total of 4,038 low-risk nulliparous singleton pregnancies were recruited from maternity units in Ireland (N=1,501), United Kingdom (N=1,108), The Netherlands (N=810), and Sweden (N=619) between November 2013 to August 2017. Participants were interviewed by a research midwife at ~11 weeks (optional visit), ~15 weeks, ~20 weeks, ~34 weeks' gestation (optional visit), and postpartum (within 72-hours following delivery).

Findings to date

Clinical data included information on maternal sociodemographic, medical history, and lifestyle factors collected at ~15 weeks' gestation, and maternal measurements, collected at each study visit. Biobank samples included blood, urine, and hair collected at each study visit throughout pregnancy in all units plus umbilical cord/blood samples collected at birth in Ireland and Sweden. A total of 74.0% (N=2,922) had an uncomplicated pregnancy, 3.1% (N=122) developed preeclampsia, 3.6% (N=143) had a spontaneous preterm birth, and 10.5% (N=416) had a small for gestational age baby. We evaluated a panel of metabolite biomarkers and a panel of protein biomarkers at 15 weeks and 20 weeks' gestation for preeclampsia risk assessment. Their translation into tests with clinical application, as conducted by commercial entities, was hampered by technical issues and changes in test requirements. Work on the panel of proteins was abandoned, while work on the use of metabolite biomarkers for preeclampsia risk assessment is ongoing.

Future plans

In accordance with the original goals of the IMPROvED study, the data and biobank are now available for international collaboration to conduct high quality research into the cause and prevention of adverse pregnancy outcomes.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

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

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

Maternal-Fetal Compatibility in Recurrent Pregnancy Loss

Nowadays, recurrent pregnancy loss (RPL) is an undesirable condition suffered by many patients of reproductive age. In this scenario, certain immune cell populations and molecules, involved in maternal-fetal compatibility, have emerged as factors related with the pathogenesis of RPL. Among them, uterine Natural Killer cells (uNKs) appear to be of great relevance. These cells are involved in numerous processes during pregnancy, such as the remodeling of uterine spiral arteries or the control of trophoblast invasion. These functions are regulated by the interactions that these cells establish with the extravillous trophoblast, mainly through their Killer Immunoglobulin-like Receptors (KIRs) and the Human Leukocyte Antigen-C (HLA-C) molecules expressed by the embryo. A high level of polymorphism has been reported for both molecules involved in this interaction, with some of the possible KIR-HLA-C combinations being associated with an increased risk of RPL. However, the complexity of the maternal-fetal interface goes beyond this, as other HLA molecules also appear to be related to this reproductive pathology. In this review, we will discuss the role of uNKs in pregnancy, as well as the polymorphisms and clinical implications of KIR-HLA-C binding. We will also address the involvement of other, different HLA molecules in RPL, and the current advice on the appropriate management of patients with 'immunological mismatch', thus covering the main aspects regarding the involvement of maternal-fetal compatibility in RPL.

The IRELAnD study-investigating the role of early low-dose aspirin in diabetes mellitus: a double-blinded, placebo-controlled, randomized trial

BACKGROUND

Although aspirin therapy is being increasingly advocated with the intention of risk modification for a wide range of pregnancy complications, women with prepregnancy diabetes mellitus are commonly excluded from clinical trials.

OBJECTIVE

The primary aim of this study was to examine the effect of aspirin therapy on a composite measure of adverse perinatal outcome in pregnancies complicated by pregestational diabetes mellitus.

STUDY DESIGN

A double-blinded, placebo-controlled randomized trial was conducted at 6 university-affiliated perinatology centers. Women with type 1 diabetes mellitus or type 2 diabetes mellitus of at least 6 months' duration were randomly allocated to 150-mg daily aspirin or placebo from 11 to 14 weeks' gestation until 36 weeks. Established vascular complications of diabetes mellitus, including chronic hypertension or nephropathy, led to exclusion from the trial. The primary outcome was a composite measure of placental dysfunction (preeclampsia, fetal growth restriction, preterm birth <34 weeks' gestation, or perinatal mortality). The planned sample size was 566 participants to achieve a 35% reduction in the primary outcome, assuming 80% statistical power. Secondary end points included maternal and neonatal outcomes and determination of insulin requirements across gestation. Data were centrally managed using ClinInfo and analyzed using SAS 9.4. The 2 treatment groups were compared using t tests or chi-square tests, as required, and longitudinal data were compared using a repeated-measures analysis.

RESULTS

From February 2020 to September 2022, 191 patients were deemed eligible, 134 of whom were enrolled (67 randomized to aspirin and 67 to placebo) with a retrospective power of 64%. A total of 101 (80%) women had type 1 diabetes mellitus and 25 (20%) had type 2 diabetes mellitus. Reaching the target sample size was limited by the impact of the COVID-19 pandemic. Baseline characteristics were similar between the aspirin and placebo groups. Treatment compliance was very high and similar between groups (97% for aspirin, 94% for placebo). The risk of the composite measure of placental dysfunction did not differ between groups (25% aspirin vs 21% placebo; P=.796). Women in the aspirin group had significantly lower insulin requirements throughout pregnancy compared with the placebo group. Insulin requirements in the aspirin group increased on average from 0.7 units/kg at baseline to 1.1 units/kg by 36 weeks' gestation (an average 83% within-patient increase), and increased from 0.7 units/kg to 1.3 units/kg (a 181% within-patient increase) in the placebo group, over the same gestational period (P=.002). Serial hemoglobin A1c levels were lower in the aspirin group than in the placebo group, although this trend did not reach statistical significance.

CONCLUSION

In this multicenter, double-blinded, placebo-controlled randomized trial, aspirin did not reduce the risk of adverse perinatal outcome in pregnancies complicated by prepregnancy diabetes mellitus. Compared with the placebo group, aspirin-treated patients required significantly less insulin throughout pregnancy, indicating a beneficial effect of aspirin on glycemic control. Aspirin may exert a plausible placenta-mediated effect on pregestational diabetes mellitus that is not limited to its antithrombotic properties.

Hypertensive states of pregnancy

Hypertensive disorders in pregnancy (HDP) remain a leading cause of pregnancy-related maternal and foetal morbidity and mortality worldwide, including chronic hypertension, gestational hypertension, and pre-eclampsia. Affected women and newborns also have an increased risk of cardiovascular disease later in life, independent of traditional cardiovascular disease risks. Despite these risks, recommendations for optimal diagnosis and treatment have changed little in recent decades, probably due to fear of the foetal repercussions of decreased blood pressure and possible drug toxicity. In this document we review the diagnostic criteria and classification of (HDP), as well as important aspects regarding pathophysiology and early detection that allows early identification of women at risk, with the aim of preventing both immediate and long-term consequences. Prophylactic treatment with aspirin is also reviewed early and a therapeutic approach is carried out that involves close maternal and foetal monitoring, and if necessary, the use of safe drugs in each situation. This review aims to provide an updated vision for the prevention, diagnosis, and treatment of HDP that is useful in our usual clinical practice.

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

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

Immunologic aspects of preeclampsia

Preeclampsia is a syndrome with multiple etiologies. The diagnosis can be made without proteinuria in the presence of dysfunction of at least 1 organ associated with hypertension. The common pathophysiological pathway includes endothelial cell activation, intravascular inflammation, and syncytiotrophoblast stress. There is evidence to support, among others, immunologic causes of preeclampsia. Unlike defense immunology, reproductive immunology is not based on immunologic recognition systems of self/non-self and missing-self but on immunotolerance and maternal-fetal cellular interactions. The main mechanisms of immune escape from fetal to maternal immunity at the maternal-fetal interface are a reduction in the expression of major histocompatibility complex molecules by trophoblast cells, the presence of complement regulators, increased production of indoleamine 2,3-dioxygenase, activation of regulatory T cells, and an increase in immune checkpoints. These immune protections are more similar to the immune responses observed in tumor biology than in allograft biology. The role of immune and nonimmune decidual cells is critical for the regulation of trophoblast invasion and vascular remodeling of the uterine spiral arteries. Regulatory T cells have been found to play an important role in suppressing the effectiveness of other T cells and contributing to local immunotolerance. Decidual natural killer cells have a cytokine profile that is favored by the presence of HLA-G and HLA-E and contributes to vascular remodeling. Studies on the evolution of mammals show that HLA-E, HLA-G, and HLA-C1/C2, which are expressed by trophoblasts and their cognate receptors on decidual natural killer cells, are necessary for the development of a hemochorial placenta with vascular remodeling. The activation or inhibition of decidual natural killer cells depends on the different possible combinations between killer cell immunoglobulin-like receptors, expressed by uterine natural killer cells, and the HLA-C1/C2 antigens, expressed by trophoblasts. Polarization of decidual macrophages in phenotype 2 and decidualization of stromal cells are also essential for high-quality vascular remodeling. Knowledge of the various immunologic mechanisms required for adequate vascular remodeling and their dysfunction in case of preeclampsia opens new avenues of research to identify novel biological markers or therapeutic targets to predict or prevent the onset of preeclampsia.