Contemporary prediction of preeclampsia

Predictive Performance of Machine Learning-Based Methods for the Prediction of Preeclampsia-A Prospective Study

(1) Background: Preeclampsia (PE) prediction in the first trimester of pregnancy is a challenge for clinicians. The aim of this study was to evaluate and compare the predictive performances of machine learning-based models for the prediction of preeclampsia and its subtypes. (2) Methods: This prospective case-control study evaluated pregnancies that occurred in women who attended a tertiary maternity hospital in Romania between November 2019 and September 2022. The patients' clinical and paraclinical characteristics were evaluated in the first trimester and were included in four machine learning-based models: decision tree (DT), naïve Bayes (NB), support vector machine (SVM), and random forest (RF), and their predictive performance was assessed. (3) Results: Early-onset PE was best predicted by DT (accuracy: 94.1%) and SVM (accuracy: 91.2%) models, while NB (accuracy: 98.6%) and RF (accuracy: 92.8%) models had the highest performance when used to predict all types of PE. The predictive performance of these models was modest for moderate and severe types of PE, with accuracies ranging from 70.6% and 82.4%. (4) Conclusions: The machine learning-based models could be useful tools for EO-PE prediction and could differentiate patients who will develop PE as early as the first trimester of pregnancy.

Evaluation of Angiogenic Factors (PlGF and sFlt-1) in Pre-eclampsia Diagnosis

OBJECTIVE

 Recent observations support the hypothesis that an imbalance between angiogenic factors has a fundamental role in the pathogenesis of pre-eclampsia and is responsible for the clinical manifestations of the disease. The goal of the present study was to evaluate the sensitivity, specificity, and the best accuracy level of Soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and sFlt-1/PlGF ratio in maternal serum and protein/creatinine ratio in urine sample to define the best cutoff point of these tests to discriminate between the patients with gestational hypertension and the patients with pre-eclampsia, to evaluate the possibility of using them as diagnostic methods.

METHODS

 A prospective longitudinal study was performed, and blood samples were collected from 95 pregnant patients with hypertension to measure serum concentrations of biomarkers sFlt-1 and PlGF. Urine samples were collected for protein screening. Significance was set as p < 0.05.

RESULTS

 The sFlt-1/PlGF ratio demonstrated a sensitivity of 57.5% and a specificity of 60% using 50.4 as a cutoff point. The test that showed the best accuracy in the diagnosis of pre-eclampsia was protein/creatinine ratio, with a sensitivity of 78.9% and a specificity of 70% using 0.4 as a cutoff point and showing an area under the receiver operating characteristic curve of 0.80 (p < 0.001).

CONCLUSION

 No studied laboratory test proved to be fairly accurate for the diagnosis of pre-eclampsia, except for the protein/creatinine ratio. The evidence is insufficient to recommend biomarkers sFlt-1 and PlGF to be used for the diagnosis of pre-eclampsia.

Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world

Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.

Cell-Free Fetal DNA: A Novel Biomarker for Early Prediction of Pre-eclampsia and Other Obstetric Complications

Hypertensive disorder of pregnancy, especially Pre-eclampsia is one of the major causes of increased maternal and perinatal morbidity and mortality all over the world. Early prediction of pre-eclampsia is the need of modern obstetrics, as this can timely prevent the progress of disease as well as related fetal and maternal morbidity and mortality. In addition to the screening of fetal aneuploidies, Rhesus-D status, fetal sex, single gene disorders, the cell-free fetal Deoxyribonucleic acid (DNA) quantification has emerged as a promising biomarker for the prediction of pre-eclampsia. Hence, its use can help in the early prediction of hypertensive disorders of pregnancy, especially pre-eclampsia even before the appearance of symptoms. Furthermore, in future, it can also help in the determination of the complete DNA sequence of every gene of the fetus. The present review focuses on recent literature concerning the use of cell-free fetal DNA in early prediction of preeclampsia as well as for non-invasive prenatal genetic screening of fetus for various disorders. Methods: The recent literature related to cell-free fetal DNA was searched from numerous English language journals and published peer-reviewed articles on Pubmed, Google Scholar, MEDLINE and various government agencies till 2016.

Neuropathological complications associated with hypertensive disorders of pregnancy

Objective: Hypertensive disorders in pregnancy particularly severe preeclampsia and eclampsia result in significant maternal and neonatal morbidity and mortality. Many of these misfunctions can aggravate some of the neuropathological complications of hypertensive disorders during pregnancy. Method: In this review article, we described some of the neuropathological complications associated with hypertensive disorders of pregnancy. Results and conclusion: It is explained how the possible mechanism of neuropathological events triggers some of the complications associated with hypertensive disorders of pregnancy. Conclusion: A strong plea is made for the early detection of high blood pressure, its immediate control with rapid acting anti-hypertensive agents if necessary and timeous delivery of fetus as the exact pathogenesis of preeclampsia remains unknown.

An analysis of the risk factors of preeclampsia and prediction based on combined biochemical indexes

This study aims to investigate the risk factors and the joint biochemical indicators predictive value for preeclampsia. Related factors and biochemical indicators were investigated in 558 patients with preeclampsia and 435 normal pregnant women. Multiplicity analysis was performed by logistic regression. The predictive value of the biochemical index and joint biochemical indicators for predicting the incidence of pregnant women preeclampsia were analyzed by ROC curve. A progestation BMI of >24 kg/m² (OR = 5.412, 95% CI: 1.169-9.447), hypertension history (OR = 7.487, 95% CI: 2.541-11.247) and advanced age (>35 years old, OR = 6.321, 95% CI: 3.142-20.342) are risk factors for preeclampsia. Tumor necrosis factor-α and plasma protein-A are valuable for preeclampsia prediction. The predictive success of preeclampsia could be improved by clinical risk factors associated with biochemical indicators detection.

Influence of the sFlt-1/PlGF ratio on clinical decision-making in women with suspected preeclampsia--the PreOS study protocol

OBJECTIVE

To assess how routine clinical use of the Roche fully automated Elecsys® sFlt-1/PlGF test changes decision-making of physicians to hospitalize pregnant women with suspected preeclampsia.

METHODS

The Preeclampsia Open Study (PreOS) study is a multicenter, prospective, open-label, non-interventional study in 150 women showing signs and symptoms of preeclampsia (suspected preeclampsia). Physicians record their intended procedures before and after knowledge of participants' sFlt-1/PlGF ratio. The study is conducted at five investigational sites in Germany and Austria.

CONCLUSION

The PreOS study will provide evidence on how sFlt-1/PlGF ratio testing influences clinical decision-making in women with suspected preeclampsia in real-world clinical practice.

Normal Pregnancy Is Associated with Changes in Central Hemodynamics and Enhanced Recruitable, but Not Resting, Endothelial Function

Introduction. Flow-mediated dilation (FMD), low flow-mediated constriction (L-FMC), and reactive hyperemia-related changes in carotid-to-radial pulse wave velocity (ΔPWVcr%) could offer complementary information about both “recruitability” and “resting” endothelial function (EF). Carotid-to-femoral pulse wave velocity (PWVcf) and pulse wave analysis-derived parameters (i.e., AIx@75) are the gold standard methods for noninvasive evaluation of aortic stiffness and central hemodynamics. If healthy pregnancy is associated with both changes in resting and recruitable EF, as well as in several arterial parameters, it remains unknown and/or controversial. Objectives. To simultaneously and noninvasively assess in healthy pregnant (HP) and nonpregnant (NP) women central parameters in conjunction with “basal and recruitable” EF, employing new complementary approaches. Methods. HP (n = 11, 34.2 ± 3.3 weeks of gestation) and age- and cardiovascular risk factors-matched NP (n = 22) were included. Aortic blood pressure (BP), AIx@75, PWVcf, common carotid stiffness, and intima-media thickness, as well as FMD, L-FMC, and ΔPWVcr %, were measured. Results. Aortic BP, stiffness, and AIx@75 were reduced in HP. ΔPWVcr% and FMD were enhanced in HP in comparison to NP. No differences were found in L-FMC between groups. Conclusion. HP is associated with reduced aortic stiffness, central BP, wave reflections, and enhanced recruitable, but not resting, EF.

Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.

Massive ascites in a patient with preeclampsia

Preeclampsia is a systemic endothelial disorder triggered by many factors originated by the human placenta. The presence of massive ascites (more than 2 L of serous liquid in peritoneal cavity) signifies rare and severe complication of preeclampsia. We present a case of 25-year-old primigravida admitted to hospital due to preeclampsia who immediately after delivery developed a clinical condition similar to hemorrhagic shock, but the explorative laparotomy revealed only massive ascites of 4.5 L serous liquid. We suggest that appearance of massive ascites in women with preeclampsia is the underestimated fact that surprises us frequently. Sometimes, its sudden onset can mimic life-threatening conditions, as happened with our patient. Cautious evaluation of peritoneal fluid quantity in women with preeclampsia could warn the obstetrician about the potential risks that demand more intensive and more frequent maternal and fetal surveillance.

Combined Screening for Early Detection of Pre-Eclampsia

Although the precise pathophysiology of pre-eclampsia remains unknown, this condition continues to be a major cause of maternal and fetal mortality. Early prediction of pre-eclampsia would allow for timely initiation of preventive therapy. A combination of biophysical and biochemical markers are superior to other tests for early prediction of the development of pre-eclampsia. Apart from the use of parameters in first-trimester aneuploidy screening, cell-free fetal DNA quantification is emerging as a promising marker for prediction of pre-eclampsia. This article reviews the current research of the most important strategies for prediction of pre-eclampsia, including the use of maternal risk factors, mean maternal arterial pressure, ultrasound parameters, and biomarkers.

Preeclampsia Is Associated with Increased Central Aortic Pressure, Elastic Arteries Stiffness and Wave Reflections, and Resting and Recruitable Endothelial Dysfunction

Introduction. An altered endothelial function (EF) could be associated with preeclampsia (PE). However, more specific and complementary analyses are required to confirm this topic. Flow-mediated dilation (FMD), low-flow-mediated constriction (L-FMC), and hyperemic-related changes in carotid-radial pulse wave velocity (PWVcr) offer complementary information about “recruitability” of EF. Objectives. To evaluate, in healthy and hypertensive pregnant women (with and without PE), central arterial parameters in conjunction with “basal and recruitable” EF. Methods. Nonhypertensive (HP) and hypertensive pregnant women (gestational hypertension, GH; preeclampsia, PE) were included. Aortic blood pressure (BP), wave reflection parameters (AIx@75), aortic pulse wave velocity (PWVcf) and PWVcr, and brachial and common carotid stiffness and intima-media thickness were measured. Brachial FMD and L-FMC and hyperemic-related change in PWVcr were measured. Results. Aortic BP and AIx@75 were elevated in PE. PE showed stiffer elastic but not muscular arteries. After cuff deflation, PWVcr decreased in HP, while GH showed a blunted PWVcr response and PE showed a tendency to increase. Maximal FMD and L-FMC were observed in HP followed by GH; PE did not reach significant arterial constriction. Conclusion. Aortic BP and wave reflections as well as elastic arteries stiffness are increased in PE. PE showed both “resting and recruitable” endothelial dysfunctions.

Involvement of T lymphocytes in the placentae with villitis of unknown etiology from pregnancies complicated with preeclampsia

OBJECTIVE

The aim of the study was to compare immunohistochemical expression of different T type lymphocytes in foci of villitis of placentae with villitis of unknown etiology (VUE) without and with preeclampsia (PE).

METHODS

Fifty-four placentae were collected from women who had VUE with (N = 27) and without (N = 27) PE. Immunohistochemistry for types of T lymphocytes was performed on formalin fixed and paraffin-embedded sections by use of the CD3, CD4, FOXP3, CD25, CD8 and CD68 antibodies. All data analyses were done by R Development Core Team.

RESULTS

There was higher immunohistochemical CD4 positive T lymphocyte count and CD4 positive/CD8 positive ratio in placentae with VUE complicated with PE compared to control group.

CONCLUSION

The higher immunohistochemical CD4 positive T lymphocyte count and CD4 positive/CD8 positive ratio in placentae with VUE complicated with PE could point to their role in ethiopathogenesis of PE.

Preeclampsia is associated with lower production of vascular endothelial growth factor by peripheral blood mononuclear cells

BACKGROUND

Recent studies show that vascular endothelial growth factor (VEGF) downregulation is implicated in preeclampsia (PE) pathophysiology. This study assessed the relationship between PE and VEGF levels produced by peripheral blood mononuclear cells (PBMCs) and their serum levels.

METHODS

A cross-sectional design was performed in 36 patients who had hypertensive disorders during pregnancy. We also used a longitudinal design with 12 pregnant women with risk factors for PE development and/or abnormal uterine arteries by Doppler study. VEGF and soluble fms-like tyrosine kinase-1 (sFlt-1) levels were measured for all patients in both designs.

RESULTS

sFlt-1 serum was higher in preeclamptic patients (n = 26), whereas VEGF produced by stimulated PBMCs was lower than in healthy pregnant women and VEGF levels produced by stimulated PBMCs were even lower (p <0.003) in severe PE (n = 16). The receiver-operating characteristic curve analysis allowed establishing a cut-off value to identify patients with PE. VEGF production by PBMCs was 339.87 pg/mL. In addition, a robust linear regression model was performed to adjust the variance in VEGF levels. The patients' age decreased VEGF levels and was adjusted by weeks of gestation (WG) in our model. In the longitudinal study, 7/12 patients developed PE. VEGF produced by PBMCs cells was significantly lower in PE at 24-26 WG.

CONCLUSIONS

VEGF production by PBMCs is inhibited during PE, creating a downregulation of the microenvironment; this deficiency may contribute to the pathogenesis of disease.

Psychological impact of first-trimester prevention for preeclampsia on anxiety

OBJECTIVE

This study aims to examine whether a first-trimester strategy of secondary prevention for preeclampsia increases anxiety in pregnant women.

METHODS

The anxiety levels of a cohort of women screened for preeclampsia at first trimester were measured by the Spielberg State-Trait Anxiety Inventory (STAI-S) and compared between women screened as low and high risk. In a subgroup of women, the anxiety levels were additionally measured at second and third trimester. A General Linear Model (GLM) for repeated measurements was performed to adjust for potential confounders (age, nulliparity and socio-economic level).

RESULTS

A total of 255 women (135 low-risk and 120 high-risk) were evaluated. No differences were found in the mean STAI-S scores between low-risk and high-risk women: 35 (SD 9.9) and 34.6 (SD 10.1); p = 0.77. The proportion of women with high anxiety was not significantly different between groups (28/134 [20.7%] vs 24/120 [20%]; p = 0.88). No differences were found in the subgroups (51 low-risk and 50 high-risk) in which the anxiety levels were also measured at second and third trimester: 35.8 (SD 8.8) vs 35.2 (SD 9.7), p = 0.74, and 37.2 (SD 9.4) vs 35.3 (SD 8.6), p = 0.3. These differences remained non-significant after adjustment for potential confounders.

CONCLUSION

A strategy of first-trimester screening for preeclampsia does not increase maternal anxiety.

Multicenter prospective clinical study to evaluate the prediction of short-term outcome in pregnant women with suspected preeclampsia (PROGNOSIS): study protocol

BACKGROUND

Preeclampsia is defined as new onset of hypertension and proteinuria at gestational week 20 or after. However, use of these measures to predict preeclampsia before its clinical onset is unreliable, and evidence suggests that preeclampsia, eclampsia, or hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome may develop without hypertension or proteinuria being evident. Because of its unpredictability, varying clinical presentation and potential adverse outcomes, pregnant women with suspected preeclampsia require intensive monitoring or hospitalization. Beyond preeclampsia diagnosis, there is a high unmet medical need for more reliable predictive markers for preeclampsia to improve maternal and fetal outcomes and reduce unnecessary hospital admissions. An imbalance of circulating angiogenic and antiangiogenic factors, including raised soluble fms-like tyrosine kinase-1 (sFlt-1) and decreased placental growth factor (PlGF), has been found in women diagnosed with preeclampsia and before clinical onset of the disease. The PRediction of short-term Outcome in preGNant wOmen with Suspected preeclampsIa Study (PROGNOSIS) was designed to investigate the use of the sFlt-1/PlGF ratio in the short-term prediction of preeclampsia.

METHODS/DESIGN

This global, multicenter, prospective, double-blind, non-interventional study aims to derive and validate cutoffs for the sFlt-1/PlGF ratio, to rule out (for 1 week) or rule in (within 4 weeks) the occurrence of preeclampsia/eclampsia/HELLP syndrome. Eligible participants are women presenting at 24 to <37 weeks' gestation with clinical suspicion of, but not manifest preeclampsia/eclampsia/HELLP syndrome. Clinical assessments, maternal serum sFlt-1/PlGF sampling and documentation of maternal/neonatal outcomes are performed at regular intervals, using strict diagnostic criteria for preeclampsia-related conditions and outcomes. Serum sFlt-1 and PlGF analysis will be performed using fully automated Elecsys® immunoassays. Investigators and participants will remain blinded to the results. Target recruitment is 1000 participants. Health economic analysis is also planned.

DISCUSSION

The results of PROGNOSIS will provide the most comprehensive evidence to date on the accuracy of the sFlt-1/PlGF ratio for short-term prediction of preeclampsia/eclampsia/HELLP syndrome. Adoption of the sFlt-1/PlGF test in clinical practice has the potential to reduce the frequency of adverse pregnancy outcomes for both mother and fetus, and decrease healthcare costs associated with unnecessary hospitalization of women with suspected preeclampsia.

First-trimester prediction of pre-eclampsia: external validity of algorithms in a prospectively enrolled cohort

OBJECTIVE

To evaluate the performance of published first-trimester prediction algorithms for pre-eclampsia (PE) in a prospectively enrolled cohort of women.

METHOD

A MEDLINE search identified first-trimester screening-prediction algorithms for early-onset (requiring delivery < 34 weeks) and late-onset (requiring delivery ≥ 34 weeks) PE. Maternal variables, ultrasound parameters and biomarkers were determined prospectively in singleton pregnancies enrolled between 9 and 14 weeks. Prediction algorithms were applied to this population to calculate predicted probabilities for PE. The performance of the prediction algorithms was compared with that in the original publication and evaluated for factors explaining differences in prediction.

RESULTS

Six early and two late PE prediction algorithms were applicable to 871-2962 women, depending on the variables required. The prevalence of early PE was 1.0-1.2% and of late PE was 4.1-5.0% in these patient subsets. One early PE prediction algorithm performed better than in the original publication (80% detection rate (DR) of early PE for 10% false-positive rate (FPR)); the remaining five prediction algorithms underperformed (29-53% DR). Prediction algorithms for late PE also underperformed (18-31% DR, 10% FPR). Applying the screening cut-offs based on the highest Youden index probability scores correctly detected 40-80% of women developing early PE and 71-82% who developed late PE. Exclusion of patients on first-trimester aspirin resulted in DRs of 40-83% and 65-82% for early and late PE, respectively.

CONCLUSION

First-trimester prediction algorithms for PE share a high negative predictive value if applied to an external population but underperform in their ability to correctly identify women who develop PE. Further research is required to determine the factors responsible for the suboptimal external validity.

External validity of first-trimester algorithms in the prediction of pre-eclampsia disease severity

OBJECTIVE

To compare disease features in women with pre-eclampsia between those who are correctly identified (true positive) and those who are missed (false negative) when applying first-trimester prediction algorithms for pre-eclampsia to a prospectively enrolled population.

METHOD

Six first-trimester early (requiring delivery < 34 weeks' gestation) pre-eclampsia algorithms were applied to a prospective cohort of singleton pregnancies enrolled at first-trimester screening. Maternal outcomes, neonatal outcomes and severity parameters for pre-eclampsia were compared between true-positive and false-negative predictions.

RESULTS

Twenty of 2446 (0.8%) women developed early pre-eclampsia, with 65% of these developing severe features and 20% HELLP syndrome. At enrollment, true-positive cases were more likely to be African-American and chronically hypertensive, while false-negative cases were more likely to be Caucasian. At delivery, true-positive cases were more likely to have pre-eclampsia superimposed on hypertension, severely elevated blood pressure and creatinine level > 1.1 mg/dL. False-negative cases were more likely to have HELLP syndrome (all P < 0.05).

CONCLUSION

In an urban population with a high prevalence of chronic hypertension, patients who are correctly identified by first-trimester screening models are more likely to develop pre-eclampsia superimposed on chronic hypertension with severely elevated blood pressure and evidence of renal failure. In contrast, patients who are missed by these algorithms are more likely to have HELLP syndrome. Further research is needed to confirm these findings and the algorithm adjustments that may be necessary to better predict pre-eclampsia phenotypes.

Contemporary clinical management of the cerebral complications of preeclampsia

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

miR-210 inhibits trophoblast invasion and is a serum biomarker for preeclampsia

Preeclampsia is characterized by hypertension and proteinuria in pregnant women. Its exact cause is unknown. Preeclampsia increases the risk of maternal and fetal morbidity and mortality. Although delivery, often premature, is the only known cure, early targeted interventions may improve maternal and fetal outcomes. Successful intervention requires a better understanding of the molecular etiology of preeclampsia and the development of accurate methods to predict women at risk. To this end, we tested the role of miR-210, a miRNA up-regulated in preeclamptic placentas, in first-trimester extravillous trophoblasts. miR-210 overexpression reduced trophoblast invasion, a process necessary for uteroplacental perfusion, in an extracellular signal-regulated kinase/mitogen-activated protein kinase-dependent manner. Conversely, miR-210 inhibition promoted invasion. Furthermore, given that the placenta secretes miRNAs into the maternal circulation, we tested if serum expression of miR-210 was associated with the disease. We measured miR-210 expression in two clinical studies: a case-control study and a prospective cohort study. Serum miR-210 expression was significantly associated with a diagnosis of preeclampsia (P = 0.007, area under the receiver operator curves = 0.81) and was predictive of the disease, even months before clinical diagnosis (P < 0.0001, area under the receiver operator curve = 0.89). Hence, we conclude that aberrant expression of miR-210 may contribute to trophoblast function and that miR-210 is a novel predictive serum biomarker for preeclampsia that can help in identifying at-risk women for monitoring and treatment.

Prevention of preeclampsia

Preeclampsia (PE) affects around 2–5% of pregnant women. It is a major cause of maternal and perinatal morbidity and mortality. In an attempt to prevent preeclampsia, many strategies based on antenatal care, change in lifestyle, nutritional supplementation, and drugs have been studied. The aim of this paper is to review recent evidence about primary and secondary prevention of preeclampsia.

Abnormal second-trimester serum analytes are more predictive of preterm preeclampsia

OBJECTIVE

We sought to determine the association of abnormal second-trimester serum analytes with early preterm preeclampsia.

STUDY DESIGN

We conducted a retrospective study of 7767 subjects undergoing second-trimester serum aneuploidy screening. Values of maternal serum α-fetoprotein (AFP), β-human chorionic gonadotropin (hCG), and inhibin (INH) were calculated as multiples of the median (MoM) and evaluated by gestational age at delivery and occurrence of preeclampsia.

RESULTS

Of 459 (6.5%) cases of preeclampsia, 65 (14%) delivered <34 weeks and 394 (86%) delivered >34 weeks. Elevated AFP, hCG, and INH >2 MoM were associated with preeclampsia, and the odds ratio was higher for the development of preeclampsia <34 weeks than >34 weeks (odds ratio, 8.04 vs 2.91 for AFP, 3.6 vs 2 for hCG, and 4.17 vs 3.08 for INH, P < .001 for all). The higher the MoM for each analyte the greater the likelihood of preeclampsia.

CONCLUSION

Elevated AFP, hCG, and INH levels >2 MoM are associated with developing early preeclampsia, and the more elevated they are, the higher the likelihood.

Cell free expression of hif1α and p21 in maternal peripheral blood as a marker for preeclampsia and fetal growth restriction

Preeclampsia, a severe unpredictable complication of pregnancy, occurs in 6% of pregnancies, usually in the second or third trimester. The specific etiology of preeclampsia remains unclear, although the pathophysiological hallmark of this condition appears to be an inadequate blood supply to the placenta. As a result of the impaired placental blood flow, intrauterine growth restriction (IUGR) and consequential fetal oxidative stress may occur. Consistent with this view, pregnancies complicated by preeclampsia and IUGR are characterized by up-regulation of key transcriptional regulators of the hypoxic response including, hif1α and as well as p53 and its target genes. Recently, the presence of circulating cell-free fetal RNA has been documented in maternal plasma. We speculated that pregnancies complicated by preeclampsia and IUGR, will be associated with an abnormal expression of p53 and/or hif1α related genes in the maternal plasma. Maternal plasma from 113 singleton pregnancies (72 normal and 41 complicated pregnancies) and 19 twins (9 normal and 10 complicated pregnancies) were collected and cell free RNA was extracted. The expression of 18 genes was measured by one step real-time RT-PCR and was analyzed for prevalence of positive/negative expression levels. Results indicate that, among the genes examined, cell free plasma expressions of p21 and hif1α were more prevalent in pregnancies complicated by hypoxia and/or IUGR (p<0.001). To conclude, we present in this manuscript data to support the association between two possible surrogate markers of hypoxia and common complications of pregnancy. More work is needed in order to implement these findings in clinical practice.

Preeclampsia: multiple approaches for a multifactorial disease

Preeclampsia is a pregnancy-specific disorder characterized by hypertension and excess protein excretion in the urine. It is an important cause of maternal and fetal morbidity and mortality worldwide. The disease is almost exclusive to humans and delivery of the pregnancy continues to be the only effective treatment. The disorder is probably multifactorial, although most cases of preeclampsia are characterized by abnormal maternal uterine vascular remodeling by fetally derived placental trophoblast cells. Numerous in vitro and animal models have been used to study aspects of preeclampsia, the most common being models of placental oxygen dysregulation, abnormal trophoblast invasion, inappropriate maternal vascular damage and anomalous maternal-fetal immune interactions. Investigations into the pathophysiology and treatment of preeclampsia continue to move the field forward, albeit at a frustratingly slow pace. There remains a pressing need for novel approaches, new disease models and innovative investigators to effectively tackle this complex and devastating disorder.

Preeclampsia, hypoxia, thrombosis, and inflammation

Reductions in uteroplacental flow initiate a cascade of molecular effects leading to hypoxia, thrombosis, inflammation, and endothelial cell dysfunction resulting in untoward pregnancy outcomes. In this review, we detail these effects and their relationship to preeclampsia (PE) and intrauterine growth restriction (IUGR).