Uterine Artery Doppler and Prediction of Preeclampsia

INOVASIA Study: A Multicenter Randomized Clinical Trial of Pravastatin to Prevent Preeclampsia in High-Risk Patients

OBJECTIVE

Our objective was to determine if treatment with pravastatin prevents preeclampsia in pregnant patients at risk of preeclampsia.

MATERIALS AND METHODS

The study was performed in four major tertiary hospitals in Surabaya, Bandung, and Makassar between 2017 and 2021. Pregnant women at high risk of developing preeclampsia were recruited and randomized into an intervention group and control group. The control group received low-dose aspirin (80 mg) and calcium (1 g) daily, while the intervention group received additional pravastatin (20 mg twice daily) starting from 14 to 20 weeks' gestation until delivery. The pregnancy was followed until delivery, and the clinical data were collected. The primary outcome was the occurrence of preeclampsia.

RESULT

A total of 173 people participated in this study, including 86 in the control group and 87 in the pravastatin group. The pravastatin group had a significantly lower rate of preterm preeclampsia (13.8 vs. 26.7%; p = 0.034; odds ratio [OR] = 0.034, 95% confidence interval [CI] = 0.202-0.905) and preterm birth (16.1 vs. 36%; p = 0.003; OR = 0.340, 95% CI = 0.165-0.7), mostly indicated preterm birth. Preeclampsia occurred later in the pravastatin group than in the control group (36.39 + 2.32 vs. 34.89 + 3.38 weeks, p = 0.048). Overall, the pravastatin group showed better perinatal outcomes. Neonates with low Apgar scores (<7) at 1 minute (5.7 vs. 25.6%, p = 0.000) and 5 minutes (2.3 vs. 25.6%, p = 0.028) were significantly less common in the pravastatin group. Additionally, the rate of low birthweight babies (<2,500 g) was lower in the pravastatin group (27.6 vs. 40.7%; p = 0.069).

CONCLUSION

Pravastatin (20 mg bid) significantly reduces the risk of preterm preeclampsia and preterm birth in women at a high risk of developing preeclampsia.

KEY POINTS

· This is an open-label multicenter RCT to evaluate pravastatin effect to prevent preeclampsia.. · Pravastatin significantly reduces the risk of preterm preeclampsia (PE) and preterm birth in high risk PE women.. · Pravastatin had a beneficial effect on perinatal outcomes, including Apgar scores and birth weight..

Hypertensive disorders and maternal hemodynamic changes in pregnancy: monitoring by USCOM® device

Hypertensive disorders are quite common, complicating about 10% of pregnancies, while preeclampsia occurs in 2-8% of cases. The most recognized etiopathogenetic factor for the development of preeclampsia is deficient remodeling of the spiral arteries during trophoblastic invasion. Recently, some authors speculated about the "cardiovascular origin of preeclampsia"; in particular, they postulate that placental dysfunction is not the primum movens of preeclampsia, but it could be caused by a failure of the maternal cardiovascular system to adapt to the pregnancy itself. Moreover, several studies have also shown that developing preeclampsia in pregnancy is associated with an increased risk of cardiovascular disease later in life. Due to the importance of this pathology, it would be crucial to have an effective screening in order to implement a prophylaxis; for this purpose, it could be useful to have an accurate and noninvasive device for the assessment of maternal hemodynamic variables. USCOM^® (Ultrasonic Cardiac Output Monitor) is a noninvasive Doppler ultrasonic technology which combines accuracy, reproducibility, noninvasiveness, and a fast learning curve. Maternal hemodynamic evaluation is important in order to monitor the changes that the maternal organism encounters, in particular a reduction in blood pressure, a decrease in total peripheral resistances, and an increase in cardiac output, resulting in a hyperdynamic circle. These hemodynamic modifications are lacking in pregnancies complicated by preeclampsia. For these reasons, it is crucial to have a tool that allows these parameters to be easily evaluated in order to identify those women at higher risk of hypertensive complications and more severe outcomes.

Maternal hemodynamic assessment by USCOM® device in the first trimester of pregnancy

BACKGROUND

Preeclampsia is a main obstetric disease and could be caused by the inability of the woman hemodynamic system to face the cardiovascular effort required by gestation.

OBJECTIVE

The aim of the present study is to evaluate the correlation between maternal hemodynamic parameters detected by UltraSonic Cardiac Output Monitor (USCOM^®) and ultrasound or biochemical parameters in women during the first-trimester screening of chromosomal abnormalities.

METHODS

This was a prospective observational study with 162 women enrolled during the first-trimester ultrasound, recording demographic, biochemical and ultrasound data, including the pulsatility index of uterine arteries (UTPI). Hemodynamic indices were obtained using the USCOM^® system. We also analyzed the outcomes of pregnancy of those women who delivered in our clinic.

RESULTS

As for the correlation between biochemical and ultrasound parameters, pregnancy-associated plasma protein A (PAPP-A) relates inversely with the mean UTPI (r _s -0.298, p < .001). We also reported a statistically significant correlation between the mean UTPI and the maternal haemodynamic parameters detected by USCOM^® (higher values of mean UTPI are associated with lower values of indexed cardiac output, CO, and higher indexed peripheral resistances, TVR). When comparing women with higher UTPI and TVR or lower CO to patients who had regular values of these parameters, we noticed that between these groups there were significant differences in all the remaining hemodynamic parameters, including inotropy index and stroke volume, as well as in the biochemical values of PAPP-A. Analyzing postpartum data, if we combine the onset of hypertensive disorders and fetal growth restriction, the most predictive parameter is indexed TVR.

CONCLUSION

Our study confirmed the correlation between PAPP-A and placental function, expressed through the determination of the pulsatility index of the uterine arteries. Moreover, we found a clear correlation between biochemical markers, placental function and maternal hemodynamics, since the first trimester of pregnancy. The inclusion of maternal hemodynamic evaluation could be useful in the screening protocols of preeclampsia. If we combine the onset of hypertensive disorders and of fetal growth restriction, the most predictive parameter is indexed total vascular resistances.

Pravastatin suppresses inflammatory cytokines and endothelial activation in patients at risk of developing preeclampsia: INOVASIA study

INTRODUCTION

The Indonesian INOVASIA study is an ongoing multicentre randomized, open controlled trial of pravastatin for the prevention of preeclampsia in patients deemed to be high risk. Here we evaluate the effects of pravastatin on circulating inflammatory and endothelial markers, i.e. Vascular Endothelial Growth Factor (VEGF), Interleukin-6 (IL-6), Endothelin-1 (ET-1), and Nitric Oxide (NO).

METHODS

Pregnant women deemed to be at a high risk of developing preeclampsia women were recruited based on the Fetal Medicine Foundation preeclampsia screening test or a history of preterm preeclampsia, or clinical risk factors in combination with an abnormal uterine artery Doppler flow pattern at 11-20 week's gestation. This is a nested cohort study within the larger trial (INOVASIA); 38 patients were consecutively recruited and assigned to the pravastatin group and the control group. Participants in the pravastatin group received pravastatin (2 × 20 mg p.o) in addition to a standard regimen of aspirin (80 mg p.o) and calcium (1 g p.o), from 14 to 20 weeks until delivery. Blood samples to measure the various biomarkers were obtained in consecutive patients before starting the research medication and just before delivery (pre and post-test examination).

RESULT

The number of samples on the 2 time points for the various biomarkers was: VEGF: 38, IL-6: 30, ET-1: 38, and NO: 35. IL-6 levels decreased significantly in the pravastatin group (mean ± SD): (191.87 ± 82.99 vs. 151.85 + 48.46, p = .013), while levels in the control group did not change significantly (median (interquartile range)) (144.17 (53.91) vs. 140.82 (16.18), p = .177). ET-1 levels decreased significantly in the pravastatin group (3.64 ± 0.85 vs. 3.01 ± 0.74, p = .006) while the control group had more or less stable levels (3.57 ± 1.12 vs. 3.78 ± 0.73 p = .594). NO was the only serum marker that showed significant changes in both groups. NO levels increased in pravastatin group (11.30 (17.43) vs. 41.90 (53.18), p = .044) and decreased in control group (38.70 (34.80) vs. 10.03 (26.96), p = .002). VEGF levels appeared to follow opposite trends in the 2 groups (NS) (Pravastatin: 3.22 (0.62) vs. 3.28 (0.75), p = .402. Control: 3.38 (0.83) vs. 3.06 (0.74), p = .287).

CONCLUSION

Administration of 40 mg pravastatin resulted in an improvement in NO levels, and a decrease in IL-6 and endothelin (ET-1) levels. The direction of the effect of pravastatin on these biomarkers appears to underpin the potential for a beneficial effect of pravastatin in the prevention of preeclampsia.

Effect of previous cesarean sections on second-trimester uterine artery Doppler

AIM

In this study, we investigated the effects of previous cesarean sections on uterine artery Doppler indices.

METHODS

This prospective cohort study included 153 healthy pregnant women between 18 and 24 weeks of gestation. Seventy-three pregnant women without previous cesarean sections (control group) and 80 pregnant women with previous cesarean sections (study group) were compared in terms of uterine artery Doppler indices.

RESULTS

The mean uterine artery pulsatility index (PI) MoM value was 1.18 ± 0.40 in the study group and 1.07 ± 0.35 in the control group (P = 0.046). The number of patients with uterine artery PI values above 95 percentile was 18 (22.5%) in the study group and 5(6.8%) in the control group (P = 0.007). The mean gestational age at birth was significantly lower in the study group (38.2 ± 1.3 vs. 39 ± 1.0, P < 0.001). There was no significant difference between the mean PI, resistance index (RI) and systolic/diastolic (S/D) ratio values of the uterine artery (P = 0.16, 0.11, 0.08, respectively). When the comparison was made with the number of previous cesarean sections, all three index values of the patients who had had more than two cesarean sections were found to be significantly higher.

CONCLUSION

The Doppler flow indices of the uterine artery significantly increased in patients with more than two previous cesarean sections. When evaluating uterine artery Doppler indices in pregnant women with a history of previous cesarean sections, these factors should be considered.

The first trimester uterine artery Doppler: comparison between sagittal and transverse techniques

CONTEXT

Preeclampsia is a major cause of maternal and perinatal morbidity and mortality worldwide, affecting about 2-3% of all pregnancies. There is consistent evidence today that starting to take aspirin before the 16th week of gestation manages to halve the prevalence of PE and also reduces the incidence of fetal growth restriction, hence the importance of being able to identify early high-risk pregnant women regarding those outcomes and thus finding candidates for the use of that medication. Therefore, interest in methods of PE screening and prediction has increased in recent years.

MATERIALS AND METHODS

A retrospective study was carried out by means of a review of the medical records of pregnant women submitted to the first trimester morphological examination at Mater Dei Healthcare Network from August 2017 to January 2018, which included the Doppler study of the uterine arteries performed using longitudinal and transverse insonation techniques, for calculating PE risk in the way recommended by the Fetal Medicine Foundation. Then, a comparative analysis of uterine artery mean pulsatility index (PI) measured transversally and longitudinally was performed.

RESULTS

The value for the PI in the sagittal plane (1.634 ± 0.52) was highly correlated (ICC = 0.85) and similar to the value found for the cross-section (1.633 ± 0.54), with no statistically significant differences between them (p = .93). Bland Altman's analysis highlighted the existence of a very tight agreement between both methods of measuring PI.

CONCLUSION

The pulsatility index of uterine arteries can be measured in a reliable and easily reproducible way using both the sagittal and transverse techniques, with no change in the final outcome of preeclampsia screening through the Fetal Medicine Foundation (FMF) algorithm.

Reference centile charts of first-trimester aneuploidy screening & Doppler parameters for Indian population

Background & objectives:

The risk estimation for foetal aneuploidies in the first trimester of pregnancy uses reference curves based on western data. The objective of this study was to construct the reference curves of first-trimester foetal aneuploidy screening parameters for the Indian women.

Methods:

Cross-sectional data were obtained from 1204 singleton pregnancies between the crown-rump length (CRL) of 40-84 mm. Linear regression models were constructed; the mean, median and standard deviation were derived as a function of CRL.

Results:

The mean value of CRL was 61.3 mm. The regression analysis showed a significant correlation between all variables and CRL (P<0.001). There was a positive correlation of CRL with nuchal translucency (NT) (y=0.010x+0.629, R²=0.116) and pregnancy-associated plasma protein-A (PAPP-A) (y=0.107x−1.079, R²=0.173), whereas inverse correlation was seen with free β-human chorionic gonadotropin (β-hCG) (y=−0.409x+75.025, R²=0.018) and Doppler parameters pulsatility index (PI) (y=−0.008x+1.924 R²=0.053). The centile charts of NT, PAPP-A, free β-hCG and uterine artery (Ut A) Doppler PI were constructed.

Interpretation & conclusions:

The reference centile charts of first trimester aneuploidy screening along with Doppler parameters were derived in Indian pregnant women. These centile charts may be used as a reference for clinical use in Indian population.

New Predictive Model at 11+0 to 13+6 Gestational Weeks for Early-Onset Preeclampsia With Fetal Growth Restriction

The aim of the present study was to determine a predictive model for early-onset preeclampsia with fetal growth restriction (FGR) to be used at 11⁺⁰ to 13⁺⁶ gestational weeks, by combining the maternal serum level of pregnancy-associated plasma protein-A (PAPP-A), placental growth factor (PLGF), placental protein 13 (PP13), soluble endoglin (sEng), mean arterial pressure (MAP), and uterine artery Doppler. This was a retrospective cohort study of 4453 pregnant women. Uterine artery Doppler examination was conducted in the first trimester. Maternal serum PAPP-A, PLGF, PP13, and sEng were measured. Mean arterial pressure was obtained. Women were classified as with/without early-onset preeclampsia, and women with preeclampsia were classified as with/without FGR. Receiver operating characteristic analysis was performed to determine the value of the model. There were 30 and 32 pregnant women with early-onset preeclampsia with and without FGR. The diagnosis rate of early-onset preeclampsia with FGR was 67.4% using the predictive model when the false positive rate was set at 5% and 73.2% when the false positive rate was 10%. The predictive model (MAP, uterine artery Doppler measurements, and serum biomarkers) had some predictive value for the early diagnosis (11⁺⁰ to 13⁺⁶ gestational weeks) of early-onset preeclampsia with FGR.

Adverse fetal outcome: is first trimester ultrasound and Doppler better predictor than biomarkers?

AIMS AND OBJECTIVES

To evaluate the predictive value of first trimester biomarkers and ultrasound in determining adverse fetal outcomes in a low risk Asian population.

MATERIAL AND METHOD

All low risk, singleton pregnancies between 11 and 14 weeks gestation underwent ultrasound with uterine artery Doppler along with PAPP-A and free β-hCG estimation, and were followed till delivery to observe the outcome. The adverse fetal outcomes detected were structural anomaly, aneuploidy, intrauterine growth restriction, preterm birth and stillbirth (SB).

RESULTS

Out of 3500 women screened, 417 cases had adverse fetal outcome in the absence of maternal complication, 2151 had normal outcome. Major structural anomaly was detected in first trimester in 17/28 (60.7%) cases. The most important markers for adverse fetal outcome were increased uterine artery pulsatility index (UPI) (p = 0.028, OR 1.5, 95% CI: 1.05-2.38, AUC 0.56) for IUGR, nuchal translucency (p = 0.001, OR 1.7, 95% CI: 1.11-2.77, AUC 0.60) for major anomaly and low PAPP-A (p = 0.017, OR -0.075, 95% CI: 0.87-0.98, AUC 0.621) for SB.

CONCLUSION

UPI, NT and PAPP-A in the first trimester are significant markers of adverse fetal outcome, although the sensitivity and specificity are not high they have a high negative predictive value.

Serum C3 and uterine artery Doppler indices at 14-20 weeks gestation for preeclampsia screening in low-risk primigravidas: A prospective observational study

PROBLEM

Preeclampsia affects 2-10% of human pregnancies with poor screening tests. In order to intervene preventively, high risk population should be identified before the 20th week of pregnancy and by a method not subjected to operator efficiency.

METHODOLOGY

Prospective observational study recruiting 825 low risk primigravidas. Serum C3 and uterine artery Doppler indices were measured at 14-20 weeks.

RESULTS

Serum C3 levels at 14-20 weeks of gestation had a sensitivity 83.3%, specificity 100%, PPV 100% and NPV 98.3% when the cut-off value was 53.1mg/. For the mean RI, the best cut off value found was 0.72 with 100% sensitivity, 99.1% specificity, 92.3% PPV and 100% NPV. For the mean PI the best cut off value was 1.35 with 100% sensitivity, 94.1% specificity, 63.2% PPV and 100% NPV. The combination of serum C3 level and mean uterine artery PI showed 100% sensitivity, 97.4% specificity, 80% PPV and 100% NPV in prediction of PE.

CONCLUSION

Serum C3 levels at 14-20 weeks can be used for prediction of PE with comparable results to uterine artery Doppler indices but has the superiority of being operator independent.

Combination of serum angiopoietin-2 and uterine artery Doppler for prediction of preeclampsia

The aim of this study was to determine the predictive value of the combination of serum angiopoietin-2 (Ang-2) levels and uterine artery Doppler for the detection of preeclampsia in women at 16-18 weeks of gestation and to identify other pregnancy complications that could be predicted with these combined tests. Maternal serum Ang-2 levels were measured, and uterine artery Doppler was performed in 400 pregnant women. The main outcome was preeclampsia. The predictive values of this combination were calculated. Twenty-five women (6.3%) developed preeclampsia. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of uterine artery Doppler combined with serum Ang-2 levels for the prediction of preeclampsia were 24.0%, 94.4%, 22.2% and 94.9%, respectively. For the prediction of early-onset preeclampsia, the sensitivity, specificity, PPV and NPV were 57.1%, 94.1%, 14.8% and 99.2%, respectively. Patients with abnormal uterine artery Doppler and abnormal serum Ang-2 levels (above 19.5 ng ml(-1)) were at higher risk for preterm delivery (relative risk=2.7, 95% confidence interval 1.2-5.8). Our findings revealed that the combination of uterine artery Doppler and serum Ang-2 levels at 16-18 weeks of gestation can be used to predict early-onset preeclampsia but not overall preeclampsia. Thus, this combination may be a useful early second trimester screening test for the prediction of early-onset preeclampsia.

Predictive accuracy of the first trimester Doppler scan: a meta-study

AIM

To determine sensitivity and cut-off indices of the uterine artery Doppler (UAD) in prediction of preeclampsia and fetal growth restriction (FGR).

METHODS

Seventy-six studies published in 1995-2014, present 298,329 prenatal Doppler screenings performed in nullipara in the first and early second trimesters of singleton pregnancies. The sample is stratified into four groups based on the Doppler sensitivity and specificity indices pertaining to the major clinical endpoints of the cohort.

RESULTS

The FGR diagnostic specificity (r = 0.728) and bilateral notching index (r = 0.803) correlations indicate that the UAD accuracy depends on the placental bed and the screening mode.

CONCLUSIONS

Predictive sensitivity of the UAD increases after 16 weeks + 3 days (115 days) of gestation. The best predictive parameter of preeclampsia and FGR is the placental side uterine artery resistance index which confers to the highest means when the placenta is on the midline (OR 0.9).

[Placental 3D Doppler angiography: current and upcoming applications]

The placental dysfunction, which seems to be caused by a defect of trophoblastic invasion and impaired uterine vascular remodeling since the first trimester, is responsible in a non-exclusive way for the chronic placental hypoxia, resulting secondarily in the intra-uterine growth restriction (IUGR) and/or pre-eclampsia (PE). The quality of utero-placental vasculature is essential for a proper fetal development and a successful progress of pregnancy. However, the in vivo assessment of placental vascularization with non-invasive methods is complicated by the small size of placental terminal vessel and its complex architecture. Moreover, imaging with contrast agent is not recommended to pregnant women. Until recently, the fetal and maternal vascularization could only be evaluated through pulse Doppler of uterine arteries during pregnancy, which has little clinical value for utero-placental vascularization defects assessment. Recently, a non-invasive study, without use of contrast agent for vasculature evaluation of an organ of interest has become possible by the development of 3D Doppler angiography technique. The objective of this review was to make an inventory of its current and future applications for utero-placental vasculature quantification. The main findings of the literature on the assessment of utero-placental vascularization in physiological situation and major placental vascular dysfunction pathologies such as PE and IUGR were widely discussed.

First-trimester prediction of small-for-gestational age neonates incorporating fetal Doppler parameters and maternal characteristics

OBJECTIVE

First-trimester screening for subsequent delivery of a small-for-gestational-age (SGA) infant typically focuses on maternal risk factors and uterine artery (UtA) Doppler. Our aim is to test if incorporation of fetal umbilical artery (UA) and ductus venosus (DV) Doppler improves SGA prediction.

STUDY DESIGN

Prospective screening study of singletons at 11-14 weeks. Maternal characteristics, serum concentrations of pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin are ascertained and UtA Doppler, UA, and DV Doppler studies are performed. These parameters are tested for their ability to predict subsequent delivery of a SGA infant.

RESULTS

Among 2267 enrolled women, 191 (8.4%) deliver an SGA infant. At univariate analysis women with SGA neonates are younger, more frequently African-American (AA), nulliparous, more likely to smoke, have lower PAPP-A and free β-human chorionic gonadotropin levels. They have a higher incidence of UtA Doppler bilateral notching, higher mean UtA Doppler-pulsatility index z-scores (P < .001) and UA pulsatility index z-scores (P = .03), but no significant difference in DV-pulsatility index z-scores or in the incidence of abnormal qualitative UA and DV patterns. Multivariate logistic regression analysis identifies nulliparity and AA ethnicity (P < .001), PAPP-A multiple of the median and bilateral notching (P < .05) as determinants of SGA infant. Predictive sensitivity was low; receiver operating characteristic curve analysis yields areas under the curve of 0.592 (95% confidence interval, 0.548-0.635) for the combination of UtA Doppler and UA pulsatility index z-scores.

CONCLUSION

Delivery of a SGA infant is most frequent in nulliparous women of AA ethnicity. Despite the statistical association with UtA Doppler first-trimester SGA prediction is poor and not improved by the incorporation of fetal Doppler.

Combination of plasma-soluble fms-like tyrosine kinase 1 and uterine artery Doppler for the prediction of preeclampsia in cases of elderly gravida

The aim of this study was to determine the predictive value of the combination of plasma-soluble fms-like tyrosine kinase 1 (sFlt-1) and uterine artery Doppler for the detection of preeclampsia in women of advanced age at 16-18 weeks of gestation and to identify associations between other pregnancy complications and abnormalities of these combined tests. The maternal plasma sFlt-1 level was measured, and uterine artery Doppler was performed at 16-18 weeks of gestation in 314 cases of elderly gravida. The main outcome was preeclampsia. Fourteen women (4.46%) developed preeclampsia. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of uterine artery Doppler combined with plasma sFlt-1 for preeclampsia prediction were 28.6, 95.7, 23.5 and 96.6%, respectively. For the prediction of early-onset preeclampsia, the sensitivity, specificity, PPV and NPV were 80, 95.8, 23.5 and 99.7%, respectively. Patients with abnormal uterine artery Doppler findings and an abnormal plasma s Flt-1 level (greater than 1724.5 pg ml(-1)) had a higher risk of preterm delivery (relative risk (RR)=3.38, 95% confidence interval (CI) 1.47-7.59), neonatal respiratory distress syndrome (RR=52.06, 95% CI 5.71-474.45) and perinatal death (RR=17.35, 95% CI 1.13-265.64). Our findings indicate that the combination of uterine artery Doppler and sFlt-1 level at 16-18 weeks of gestation in cases of elderly gravida has a high predictive value for early-onset preeclampsia, but not for overall preeclampsia. This combination test may be a useful early second trimester screening test for the prediction of early-onset preeclampsia in cases of elderly gravida.

First-trimester hyperglycosylated human chorionic gonadotropin and development of hypertension

OBJECTIVE

This study aimed to determine whether urine levels of hyperglycosylated human chorionic gonadotropin (HhCG) in the first trimester are predictive of subsequent development of hypertension during pregnancy

METHOD

This prospective cohort study consisted of women seeking care before 12 weeks gestation. A clean catch urine was obtained at the first prenatal visit and tested for HhCG and creatinine levels. The median HhCG levels and multiples of the median (MoM) by gestational age were compared between the groups that either developed hypertension or did not.

RESULTS

Urine HhCG were determined for 204 women between 4 weeks 4 days to 11 weeks 6 days. The median HhCG of those who developed gestational hypertension (n = 7) or preeclampsia (n = 15) did not differ from the group that did not (median: 284 ng/mg creatinine vs 365 ng/mg; p = 0.55). If the MoM of HhCG for the no hypertension group was 1.00, the MoM of HhCG for the hypertension group was 0.93 (p = 0.93). A possible association was observed after 10 weeks between low HhCG levels and the development of late-onset hypertension (≥34 weeks).

CONCLUSIONS

Prenatal screening for subsequent hypertension is unreliable with a single measurement of maternal urine HhCG at 10 weeks or less.

Second- and third-trimester placental hemodynamics and the risks of pregnancy complications: the Generation R Study

Characteristics of the uterine and umbilical artery blood flow patterns are indirect measures of uteroplacental circulation. We examined whether uterine and umbilical artery resistance indices are influenced by maternal demographic and lifestyle characteristics, track from the second trimester to the third, and are associated with the risk of pregnancy complications. This analysis was embedded among 7,660 pregnant women in the Generation R Study (Rotterdam, the Netherlands, 2001-2005). Placental resistance indices were assessed in the second and third trimesters. Information about pregnancy outcomes was obtained from medical records. Maternal characteristics affected second- and third-trimester placental resistance indices. Correlation coefficients for correlation between the second and third trimesters were 0.50 and 0.32 for uterine artery resistance index and umbilical artery pulsatility index, respectively. Higher placental resistance indices in the second and third trimesters and persistence in the highest tertile of uterine artery resistance index from the second trimester to the third were associated with the risks of preeclampsia, preterm birth, and small size for gestational age at birth (all P's < 0.05). Our study shows that placental resistance indices are influenced by maternal demographic and lifestyle characteristics and track moderately from the second trimester to the third. Increased placental resistance indices in the second and third trimesters are associated with increased risks of adverse pregnancy outcomes.

Early detection of maternal risk for preeclampsia

Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality. New molecular insights offer new possibilities of early diagnosis of elevated maternal risk. Maternal risk factors, biophysical parameters like Doppler examination of the uterine arteries and biochemical parameters allow early risk calculation. Preventive and effective therapeutic agents like acetylsalicylacid can be started in the early second trimester. This article reviews the diagnostic possibilities of early risk calculation to detect women having high risk for preeclampsia and the potential benefits for them, the offspring and health care systems. We provide risk calculation for preeclampsia as an important and sensible part of first trimester screening.

Postpartum evaluation and long term implications

Hypertension, proteinuria and biochemical changes caused by pre-eclampsia may persist for several weeks and even months postpartum. Hypertension and pre-eclampsia may even develop for the first time postpartum. Care in the six weeks postpartum should include management of hypertension and screening for secondary causes of hypertension including renal disease if abnormalities persist beyond six weeks. Optimal postpartum monitoring for patients with preeclampsia has not been determined, and care needs to be individualized. The postpartum period also provides a window of opportunity for planning for the next pregnancy in addition to discussing long term implications of pre-eclampsia. Increased risk for the development of premature cardiovascular disease is the most significant long term implication of pre-eclampsia. Pre-eclampsia and cardiovascular disease share a common disease pathophysiology. Women who develop pre-eclampsia have pre-existing metabolic abnormalities or may develop them later in life. Women with early onset pre-eclampsia are at the highest risk of ischemic heart disease. Women with a history of pre-eclampsia should adopt a heart healthy lifestyle and should be screened and treated for traditional cardiovascular risk factors according to locally accepted guidelines.