Uterine fibroids increase the risk of hypertensive disorders of pregnancy: a prospective cohort study

Association between urinary cotinine level and hypertensive disorders of pregnancy in women with uterine myoma: findings from the Japan Environment and Children's Study

The effect of smoking on hypertensive disorders of pregnancy is a public concern. Recent evidence suggests that the risk of hypertensive disorders of pregnancy is influenced by the presence of uterine fibroids. We explored the association between maternal smoking exposure and the risk of hypertensive disorders of pregnancy in relation to the presence of uterine fibroids using data from Japan's largest birth cohort study. This study focused on first-time mothers, and the study population comprised 2752 and 35,294 first-time mothers with and without uterine fibroids, respectively. Hypertensive disorders of pregnancy was categorized as early-onset (before 34 weeks) and late-onset (after 34 weeks). Maternal smoking exposure was assessed by measuring the urinary cotinine concentration during the mid-trimester. Participants were classified into four quartiles based on their urinary cotinine levels as follows: Q1 (low concentration) to Q4 (high concentration). Multivariate analysis adjusted for potential confounders revealed that in women without uterine fibroids, the Q3 urinary cotinine level was associated with a modified risk of early-onset hypertensive disorders of pregnancy (adjusted odds ratio: 0.63, 95% confidence interval: 0.44-0.89). Conversely, for women with uterine fibroids, Q4 urinary cotinine level was associated with an increased risk of hypertensive disorders of pregnancy (adjusted odds ratio: 1.68, 95% confidence interval: 1.05-2.72). In conclusion, this study indicated that the impact of maternal smoking exposure varied based on the presence of uterine fibroids, underscoring the importance of personalized preconception care.

First Australian estimates of incidence and prevalence of uterine fibroids: a data linkage cohort study 2000-2022

STUDY QUESTION

What is the estimated prevalence and incidence of uterine fibroids diagnosed in Australian women of reproductive age?

SUMMARY ANSWER

An estimated 7.3% of Australian women had a diagnosis of uterine fibroids by the age of 45-49 years, with age-specific incidence highest in women aged 40-44 years (5.0 cases per 1000 person-years).

WHAT IS KNOWN ALREADY

Uterine fibroids are associated with a high symptom burden and may affect overall health and quality of life. Studies in different countries show a wide variation in both the prevalence (4.5-68%) and incidence (2.2-37.5 per 1000 person-years) of uterine fibroids, which may be partly explained by the type of investigation, method of case ascertainment, or the age range of the study population, necessitating the reporting of country-specific estimates.

STUDY DESIGN, SIZE, DURATION

This observational prospective cohort study using self-report survey and linked administrative data (2000-2022) included 8066 women, born between 1973 and 1978, in the Australian Longitudinal Study on Women's Health.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A combination of self-report survey and linked administrative health data (hospital, emergency department, the Medicare Benefits Schedule, and the Pharmaceutical Benefits Scheme) were used to identify women with a report of a diagnosis of uterine fibroids between 2000 and 2022.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 8066 Australian women followed for 22 years, an estimated 7.3% of women (95% CI 6.9, 7.6) had a diagnosis of uterine fibroids by the age of 45-49 years. The incidence increased with age and was highest in women aged 40-44 years (5.0 cases per 1000 person-years, 95% CI 4.3, 5.7 cases per 1000 person-years). Women with uterine fibroids were more likely to experience heavy or painful periods. They were also more likely to report low iron levels, endometriosis, and poor self-rated health and to have two or more annual visits to their general practitioner.

LIMITATIONS, REASONS FOR CAUTION

Our estimates are based on self-report of doctor diagnosis or treatment for fibroids and/or data linked to treatment and procedure administrative records. This predominantly captures women with symptomatic fibroids, but has the potential for misclassification of asymptomatic women and an underestimate of overall prevalence and incidence. In addition, questions on fibroids were only asked in surveys when women were 37-42 years of age to 43-48 years of age, so cases at younger ages may have been underestimated (particularly in women with less severe symptoms) as these were only ascertained through data linkage.

WIDER IMPLICATIONS OF THE FINDINGS

These are the first population-based estimates of the prevalence and incidence of uterine fibroids in women of reproductive age in Australia. Establishing these first estimates will help inform health policy and health care provision in the Australian context.

STUDY FUNDING/COMPETING INTEREST(S)

The ALSWH is funded by the Australian Government Department of Health and Aged Care. L.FW. was supported by an Australian National Health and Medical Research Council (NHMRC) Centres for Research Excellence grant (APP1153420) and G.D.M. was supported by an NHMRC Leadership Fellowship (APP2009577). The funding bodies played no role in the design, the collection, analysis or interpretation of data, the writing of the manuscript, or the decision to submit the manuscript for publication. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Uterine leiomyoma causes an increase in systolic blood pressure: a two-sample Mendelian randomization study

Objectives

Hypertension and hypertensive disorders of pregnancy (HDP) are common diseases in women at different stages, which affect women's physical and mental health, and the impact of the latter on the offspring cannot not be ignored. Observational studies have investigated the correlation between uterine leiomyoma (UL) and the above conditions, but the relationship remains unclear. In this study, we employed two-sample Mendelian randomization (MR) analysis to assess the association between UL and hypertension, HDP, as well as blood pressure.

Methods

We collected genetic association data of UL (35,474 cases), hypertension (129,909 cases), HDP (gestational hypertension with 8,502 cases, pre-eclampsia with 6,663 cases and eclampsia with 452cases), systolic blood pressure (SBP) and diastolic blood pressure (DBP) (both 757,601 participants) from published available genome-wide association studies (GWAS). The single nucleotide polymorphisms (SNPs) associated with UL phenotype were used as instrumental variables, and hypertension, three sub-types of HDP, SBP and DBP were used as outcomes. The inverse-variance weighted (IVW) method was employed as the primary method of causal inference. Heterogeneity was assessed using Cochran's Q test, and sensitivity analyses were conducted using MR-Egger regression and MR pleiotropy residual sum and outlier (MR-PRESSO) tests to evaluate the pleiotropy of instrumental variables. PhenoScanner search was used to remove confounding SNP. Robustness and reliability of the results were assessed using methods such as the weighted median and weighted mode.

Results

The IVW analysis revealed a positive correlation between genetically predicted UL and SBP [odds ratio (OR)= 1.67, 95% confidence interval (CI):1.24~2.25, P = 0.0007], and no statistical association was found between UL and hypertension, HDP, or DBP. The MR-Egger regression suggested that the above causal relationships were not affected by horizontal pleiotropy. The weighted median method and weighted model produced similar results to the IVW.

Conclusion

Based on large-scale population GWAS data, our MR analysis suggested a causal relationship between UL and SBP. Therefore, women with UL, especially pregnant women, should pay attention to monitoring their blood pressure levels. For patients with hypertension who already have UL, interventions for UL may serve as potential therapeutic methods for managing blood pressure.

Advances in pathogenesis of preeclampsia

PURPOSE

Preeclampsia is a major cause of health problems for both pregnant women and unborn babies worldwide. However, the underlying causes of preeclampsia are not fully understood, leading to limited effective treatments. The goal of this study is to enhance our knowledge of its causes, devise prevention strategies, and develop treatments.

METHODS

We performed a systematic literature search. Six models regarding the pathogenesis of preeclampsia are discussed in this review.

RESULTS

This review focuses on the latest advancements in understanding preeclampsia's origins. Preeclampsia is a complex condition caused by various factors, processes, and pathways. Reduced blood flow and oxygen to the uterus and placenta, heightened inflammatory reactions, immune imbalances, altered genetic changes, imbalanced blood vessel growth factors, and disrupted gut bacteria may contribute to its development.

CONCLUSION

Preeclampsia is thought to result from the interplay of these factors.

Perimenopausal syndrome and hypertension during perimenopause in South China: prevalence, relationships and risk factors

BACKGROUND

More than 2 billion women are experiencing the menopausal transition in China, and some of these women have hypertension. Limited studies has focused on perimenopausal syndrome and hypertension in a specific population, so we aimed to investigate the prevalence of perimenopausal syndrome and hypertension and to analyse their relationships and risk factors in perimenopausal women in South China.

METHODS

This cross-sectional study included 3553 women aged 40 to 60 years from South China. We collected medical report, lifestyle, blood sample, general condition questionnaire, and modified Kupperman index (mKMI) data. Multivariate logistic regression analysis was performed to identify risk factors for perimenopausal syndrome and hypertension during perimenopause.

RESULTS

The prevalence of hypertension in perimenopause patients was 16.58%, and the prevalence of perimenopausal syndrome was 9.9%. Compared with women without hypertension during perimenopause, women with HTN during perimenopause had an increased risk of perimenopausal syndrome (26.4% vs. 8.7%, P < 0.001). Lipid levels and urinary tract infections were risk factors for hypertension and perimenopausal syndrome, in addition to the presence of breast nodules, the intake of snacks at night, high-salt diets, red meat and sugar-sweetened beverages, and a history of smoking and drinking for perimenopausal syndrome and the presence of gestational hypertension and diabetes for hypertension.

CONCLUSION

We concluded that perimenopausal syndrome and HTN are common in perimenopausal women in South China, and the associations between them are strong and positive. Perimenopausal syndrome shares some common risk factors with HTN during perimenopause, such as BMI and dyslipidaemia. Therefore, gynaecological endocrinologists in China should consider screening for perimenopausal syndrome in hypertensive perimenopausal women, and appropriate management of perimenopause is needed to alleviate these conditions.

Uterine Fibroids and Hypertensive Disorders in Pregnancy: A Systematic Review and Meta-Analysis

Capsule

In this study the presence of uterine fibroids was significantly associated with an increased risk of development of hypertensive disorders of pregnancy even when accounting for age and BMI in meta-regression. This finding has potential implications for risk stratification and monitoring for hypertension during pregnancy in this population.

Objective

To examine the association between uterine fibroids and the development of hypertensive disorders in pregnancy.

Data sources

Cochrane, Embase, PubMed, MEDLINE, Scopus, and Web of Science databases were searched from inception through April 2023.

Study Selection and Synthesis

Cohort, case-control, or case series studies including uterine fibroid status and hypertensive disorders of pregnancy status were included. The comparison group was pregnant women without uterine fibroids. Inverse-variance weighted random effects models were used to pool RR and OR estimates separately. Age and BMI were explored as potential sources of heterogeneity using inverse-variance weighted meta-regression.

Main Outcomes

Hypertensive disorders of pregnancy (HDP) defined as gestational hypertension, pre-eclampsia, eclampsia, superimposed preeclampsia, or hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome.

Results

A total of 17 studies were included (Total N=1,374,395 participants, N=64,968 with uterine fibroids). Thirteen studies were retrospective cohorts and four were case-control studies. Women with uterine fibroids had a significantly higher risk of hypertensive disorders in pregnancy compared to women without uterine fibroids with RR 1.74 (95% CI 1.33-2.27, p<0.01), and OR 2.87 (95% CI 1.38-5.97, p<0.01), in cohort studies and case-control studies, respectively. In meta-regression analyses, age did not significantly change the positive association between uterine fibroids and hypertensive disorders in pregnancy.

Conclusion

Uterine fibroids were associated with an increased risk of hypertensive disorders of pregnancy when all available literature was synthesized, including when shared risk factors are examined in meta-regression analyses.

Relevance

If confirmed in future studies, investigations into the mechanisms of this association are needed as this finding potentially has implications for risk stratification and monitoring for hypertensive disorders of pregnancy in this population.

Trial Registration

PROSPERO, ID # 331528.

Intrauterine Fetal Demise Associated with Vascular Malperfusion and Multiple Uterine Leiomyomata: A Report of Two Cases

BACKGROUND

Uterine leiomyomata have been loosely associated with intrauterine fetal demise (IUFD), largely attributed to fetal growth restriction from cavitary distortion. We present two cases of IUFD in patients with non-distorting leiomyomata and pathologic placental findings of maternal vascular malperfusion (MVM) and fetal vascular malperfusion (FVM).

CASE REPORT

Case 1 details a 28w3d IUFD associated with large leiomyomata (largest 11.9 × 7.6 × 9.7 cm), post-partum deep vein thrombosis, and severe pre-eclampsia histologic features. Case 2 details a 25w2d IUFD associated with smaller leiomyomata (largest 3.1 × 3.0 × 3.3 cm). Both placentas demonstrated MVM, including parenchymal thrombi and accelerated villous maturity, and FVM, including avascular stem villi.

DISCUSSION

As the placentas in both cases demonstrated findings consistent with altered placental perfusion, we posit that leiomyomata in these cases may have been associated with both maternal and fetal vascular malperfusion, ultimately contributing to fetal demise.

Uterine fibroids are associated with increased risk of pre-eclampsia: A case-control study

PURPOSE

Uterine fibroids are associated with hypertension in non-pregnant women. We aimed to evaluate the association between uterine fibroids and pre-eclampsia (PE).

PATIENTS AND METHODS

Participants were pregnant women who delivered in the Department of Obstetrics of the People's Hospital of Xinjiang Uygur Autonomous Region between January and December 2021. Patients with PE were identified as the case group, whereas those without PE were selected as the control group, using age-matching and a ratio of 1:5. Ultrasound examination during early pregnancy was used to detect uterine fibroids. Multivariable logistic regression was applied to evaluate the association between uterine fibroids and PE.

RESULTS

In total, 121 cases with PE and 578 controls without PE were included, with mean age of 32.9 years and gestational age of 37.7 weeks. Time of ultrasound examination was 12.0 ± 2.6 weeks. The case group had a significantly higher exposure rate of uterine fibroids than the control group (14.0 vs. 6.9%, P = 0.009). Multivariable Logistic regression models adjusted for potential confounding factors, including gestational age and blood pressure in early gestation, showed that pregnant women with uterine fibroids in early pregnancy exhibited three-fold higher odds for PE (OR, 3.02; 95% CI, 1.20-7.60; P = 0.019). Sensitivity analysis, which excluded those with gestational diabetes, further confirmed the robustness of the results. The association between uterine fibroids and PE was stronger in pregnant women aged ≥35 years and multiparas.

CONCLUSION

Uterine fibroids are significantly associated with an increased risk of PE in pregnant women. Uterine fibroids may serve as a new factor for identifying pregnant women at high risk of PE, and the effect of myomectomy before pregnancy on prevention of PE is worth further exploring.

The association between chronic endometritis and uterine fibroids

Background:

Some studies reported the association between fibroids with uterine inflammation. By considering this hypothesis, the formation and recurrence of uterine fibroids can be prevented by diagnosis and treatment of inflammation, and complications and costs can be reduced. This study aimed to evaluate the association between chronic endometritis and uterine fibroids in non-menopausal women.

Materials and Methods:

This prospective case-control study was performed on non-menopausal women referred to Al-Zahra Hospital in Rasht during April 2019-April 2020. Non- menopausal women of reproductive age (20-55 years old) with abnormal uterine bleeding who were candidates for hysteroscopy based on medical history and ultrasound reports were included in this study. The case group with fibroids were divided into two groups of intramural and subserosal myoma group and submucosal group based on the location of fibroids. The control group was patients with abnormal uterine bleeding complaints and no uterine fibroid. Endometrial specimens were examined by a pathologist for histological and immunochemistry assessments. In interpreting the results of endometrial biopsy, a positive result was indicated by the presence of one or more plasma cells per 10 high power field. Data were gathered by a form including age, parity, history of recurrent miscarriage, patient’s complaint (abnormal uterine bleeding), hysteroscopic results (submucosal myoma-polyp-normal), uterine histology (polyp, endometritis, and hyperplasia) and prevalence of chronic endometritis based on plasma cell in the biopsy. Data were analyzed by SPSS software version 21. Data were reported by descriptive statistics including number, percent, mean and standard deviation. The normality of quantitative data was assessed by the Kolmogorov- Smirnov test. Mann-Whitney U test, Chi-square and Fisher exact tests were used to compare groups and logistic regression was used to control the effect of confounders.

Results:

The incidence of chronic endometritis was 39% (38 out of 97) and a higher incidence of chronic endometritis was noted in the case group than the control group (46% vs. 31%), No significant difference was observed between the two groups (P > 0.05). However, the incidence of chronic endometritis in women with submucosal myoma was higher than the intramural and subserosal groups (64% vs. 37%) (P = 0.04). To control the effect of age on the rate of chronic endometritis in both groups, no significant effect was observed in logistic regression.

Conclusions:

The results showed the overall incidence of chronic endometritis was higher than previous studies and also the incidence was higher and more significant in women with submucosal myoma than in the intramural and subserosal group. As in this study, authors assessed the association between chronic endometritis and uterine fibroids, further studies assessing the cause and effect relationships are recommended.