Preeclampsia Among African American Pregnant Women: An Update on Prevalence, Complications, Etiology, and Biomarkers

Development and validation of a nomogram for predicting postpartum hemorrhage in women with preeclampsia: A retrospective case-control study

This retrospective case-control study aimed to develop a nomogram for predicting postpartum hemorrhage in women with preeclampsia. This study was carried out at the Fujian Maternity and Child Health Hospital, involving 542 preeclampsia patients who underwent vaginal deliveries. The participants were split into 2 groups: a training cohort (85%, n = 460) and a validation cohort (15%, n = 82). Least absolute shrinkage and selection operator regression was applied to pinpoint relevant risk factors by selecting appropriate candidate variables. Subsequently, multivariate logistic regression analysis was conducted on the training set, leading to the creation of a nomogram as a visual risk prediction tool. The model's performance was tested and verified internally and externally by examining receiver operating characteristic curves and calibration curves. The correlation heatmap revealed collinearity among variables, necessitating the use of least absolute shrinkage and selection operator regression to select 4 candidate variables. Multivariate logistic regression analysis identified significant associations with the following outcomes: white blood cell count (odds ratio [OR]: 2.485, 95% confidence interval [CI]: 1.483-4.166), third stage of labor (OR: 1.382, 95% CI: 1.182-1.616), anemia (OR: 9.588, 95% CI: 4.022-22.854), and labor analgesia (OR: 0.187, 95% CI: 0.073-0.477). These variables were utilized to construct the nomogram. The receiver operating characteristic curves demonstrated good predictive performance (area under the curve train = 0.867, area under the curve test = 0.882), and the calibration curve yielded a C-index of 0.867. The nomogram created in this study has good sensitivity and specificity to assess risk and support clinical decision-making for postpartum hemorrhage in women with preeclampsia.

Trends in the Incidence of Hypertensive Disorders of Pregnancy Among the Medicaid Population before and During COVID-19

Importance

Hypertensive disorders of pregnancy (HDP) are a group of high blood pressure disorders during pregnancy that are a leading cause of maternal and infant morbidity and mortality. Data on the trend in the incidence of HDP among the Medicaid population during coronavirus disease of 2019 (COVID-19) are lacking.

Objective

To determine the trends in the annual incidence of HDP among pregnant Medicaid-insured women in Louisiana before and during the COVID-19 pandemic (2016-2021).

Methods

A total of 113,776 pregnant women aged 15-50 years were included in this study. For multiparous individuals, only the first pregnancy was used in the analyses. Women with a diagnosis of each type-specific HDP were identified by using the International Classification of Diseases, 10th revision (ICD-10) codes. The annual incidence of HDP was calculated for each race and age subgroup. For each type-specific HDP, the annual age-specific incidence was calculated.

Results

The incidence of HDP increased from 10.5% in 2016 to 17.7% in 2021. The highest race/ethnicity-specific incidence of HDP was seen in African American women (19.2%), then White women (13.1%), followed by other women (10.7%).

Conclusion and Relevance

HDP remains a very prevalent and significant global health issue, especially in African American women and during the COVID-19 pandemic. Severe HDP substantially increases the risk of mortality in offspring and poses long-term issues for both mother and infant. HDP prevention holds particular relevance for the Medicaid population, given the health care disparities and barriers that impact quality of care, leading to an increased risk for HDP.

Prevalence of Preeclampsia and Eclampsia in Iran: An Updated Systematic Review and Meta-Analysis

Background

Preeclampsia is a major contributor to maternal morbidity and mortality. A previous systematic review was carried out in Iran in 2014. Due to the importance of this issue, a current evaluation is necessary after ten years. This research was performed to determine the prevalence of preeclampsia and eclampsia in Iran.

Materials and Methods

Adhering to the PRISMA guideline, we searched English databases including Web of Science, PubMed, Scopus, and Persian databases including SID, Magiran, and IranMedex on August 20, 2023, to identify studies reporting the prevalence of preeclampsia or eclampsia in Iran. Employing a focused term strategy and eligibility criteria, we ultimately included 55 studies in this review. After conducting a thorough evaluation, the CMAV3 software was utilized to analyze the data using the random effects model and calculate pooled results.

Results

The overall prevalence of preeclampsia among Iranian mothers was 5.3%, while eclampsia accounted for 0.1% of live births. Notably, preeclampsia rates have risen since 2015, whereas eclampsia rates have declined over time. Single-variable meta-regression results indicated a negative correlation between age and preeclampsia.

Conclusions

Preeclampsia is increasing among Iranian mothers, requiring an investigation into its risk factors, including maternal age, and consequently, high-risk pregnancies. Conversely, the decreasing occurrence of eclampsia indicates an enhancement in the quality of care following a preeclampsia diagnosis.

"There is nothing to protect us from dying": Black women's perceived sense of safety accessing pregnancy and intrapartum care

Pregnancy and childbirth have become a dangerous journey for Black women as harrowing stories of death and near-death experiences resonate within Black communities. While the causes of pregnancy-related morbidity and mortality are well documented, little is known about how Black Canadian women feel protected from undesirable maternal health outcomes when accessing and receiving pregnancy and intrapartum care. This critical qualitative inquiry sheds light on Black women's perceived sense of safety in accessing pregnancy and intrapartum care. Twenty-four in-depth interviews were conducted with Black women who were pregnant or had given birth. Five interconnected themes were generated through thematic analysis: (1) There is a lot of prejudice towards us, (2) We are treated as sick bodies, (3) There is a lot of stereotypes towards us, (4) Our care is lacking in quality, and (5) We feel unsafe in the healthcare system. These themes highlight the perils faced by Black women accessing pregnancy and intrapartum care. The right to safe motherhood and equitable care for Black women should be a national priority in Canada to avert a looming crisis.

Understanding Health Disparities in Preeclampsia: A Literature Review

Preeclampsia is a multifactorial pathology with negative outcomes in affected patients in both the peripartum and postpartum period. Black patients in the United States, when compared to their White and Hispanic counterparts, have higher rates of preeclampsia. This article aims to review the current literature to investigate how race, social determinants of health, and genetic profiles influence the prevalence and outcomes of patients with preeclampsia. Published studies utilized in this review were identified through PubMed using authors' topic knowledge and a focused search through a Medline search strategy. These articles were thoroughly reviewed to explore the contributing biosocial factors, genes/biomarkers, as well as negative outcomes associated with disparate rates of preeclampsia. Increased rates of contributing comorbidities, including hypertension and obesity, which are largely associated with low access to care in Black patient populations lead to disparate rates of preeclampsia in this population. Limited research shows an association between increased rate of preeclampsia in Black patients and specific APOL1, HLA-G, and PP13 gene polymorphisms as well as factor V Leiden mutations. Further research is required to understand the use of certain biomarkers in predicting preeclampsia within racial populations. Understanding contributing biosocial factors and identifying genes that may predispose high-risk populations may help to address the disparate rates of preeclampsia in Black patients as described in this review. Further research is required to understand if serum, placental, or urine biomarkers may be used to predict individuals at risk of developing preeclampsia in pregnancy. KEY POINTS: · Prevalence of preeclampsia in the U.S. is higher in Black patients compared to other racial groups.. · Patients with preeclampsia are at risk for poorer health outcomes both during and after delivery.. · Limited research suggests specific biomarkers or gene polymorphisms contribute to this difference; however, explanations for this disparity are multifactorial and further investigation is necessary..

Black Pregnancy-Related Mortality in the United States

The maternal mortality rate for non-Hispanic Black birthing people is 69.9 deaths per 100,000 live births compared with 26.6 deaths per 100,000 live births for non-Hispanic White birthing people. Black pregnancy-related mortality has been underrepresented in research and the media; however, there is growing literature on the role of racism in health disparities. Those who provide care to Black patients should increase their understanding of racism's impact and take steps to center the experiences and needs of Black birthing people.

Racial Disparities in Outcomes of Delivery and Cardiac Complications Among Pregnant Women with Congenital Heart Disease

Advances in cardiology have led to improved survival among patients with congenital heart disease (CHD). Racial disparities in cardiovascular and maternal outcomes are well known and are likely to be more profound among pregnant women with CHD. Using the 2001 to 2018 National Inpatient Sample, we identified all hospitalizations for delivery among women ≥ 18 years of age with CHD. Unadjusted and adjusted between-race differences in adverse maternal cardiovascular, obstetric, and fetal events were assessed using logistic regression models. During the study period, we identified 52,711 hospitalizations for delivery among women with concomitant CHD. Of these, 66%, 11%, and 16% were White, Black, and Hispanic, respectively. Obstetric complications and fetal adverse events were higher among Blacks compared to Whites and Hispanics (44% vs. 33% vs. 37%, p < .001; 36% vs. 28% vs. 30%, p < .001), respectively. No between-race differences were observed in overall cardiovascular adverse events (27% vs. 24% vs. 23%, p < .21). However, heart failure was significantly higher among Black women (3.6% vs. 1.7% vs. 2.2%, p = 0.001). While a lower income quartile was associated with higher rates of adverse outcomes, adjustment for income did not attenuate the adverse impact of race. Black females with CHD diagnoses were more likely to experience adverse obstetric, fetal events, and heart failure compared to White and Hispanic women irrespective of their income status. Further research is needed to identify causes and devise interventions to mitigate racial disparities in the care of pregnant women with CHD.

Pathophysiology of Pre-Eclampsia-Two Theories of the Development of the Disease

Pre-eclampsia (PE) continues to be a leading cause of maternal and fetal mortality and morbidity. While substantial progress has been made in understanding the pathomechanisms of PE, the pathophysiology of the disease is still not fully understood. While the "two-stage model" of the development of PE is the most widely accepted theory, stating that the placenta is the main source of the disease, there are some other pathophysiological models of PE. Among these other theories, the one considering heart dysfunction as serving as the primary cause of PE seems to be gaining increasing prominence. In this review, we aim to elucidate these two divergent concepts concerning the development of PE. Despite some differences in their proposed pathomechanisms, both theories share vital pathophysiological elements in common. A central and critical component in both models is impaired placental perfusion, which appears to be a crucial phenomenon in PE. A comprehensive understanding of the different pathomechanisms involved in PE may be helpful in clinical practice, prompting a more individual approach to care of patients with PE.

The role of genetics in maternal susceptibility to preeclampsia in women of African ancestry

Racial disparities exist in the prevalence of preeclampsia (PE), with women of African ancestry suffering the highest rates of morbidity and mortality. Genetic changes may play a role in the preponderance of PE among women of African ancestry. This review discusses 30 genes with variants that have been studied in PE in women of African ancestry. These studies found that a single gene is not responsible for PE susceptibility as 13 genes have been implicated. These genes subserve endothelial, immune, hemodynamic, homeostatic, thrombophilic, oxidative stress, and lipid metabolic pathways. Notably, maternal-fetal gene interactions also contribute to the susceptibility of the disease. For instance, the maternal KIR AA genotype and paternally inherited fetal HLA-C2 genotype confer risk for developing PE. Additionally, genetic changes such as epigenetic modulation of expression of the MTHFR gene through DNA methylation is also associated with the occurrence of PE. In contrast, some genes such as the KIR B centromeric region protect against development of PE in some women. The soluble fms-like tyrosine kinase 1 (sFlt-1) contributes to the development of PE and is a potential novel therapeutic option for targeted gene silencing of anti-angiogenic sFLT-1 gene. Additionally, NOS3 gene is an important target for pharmacogenomics because it is responsible for the production of endothelial nitric oxide. In conclusion, maternal genetic and epigenetic variants confer susceptibility to PE, indicating the need for further studies to develop a screening tool incorporating maternal genetic variants to identify women at high risk for PE and offer them a preventive therapy.

High placental expression of FLT1, LEP, PHYHIP and IL3RA - In persons of African ancestry with severe preeclampsia

INTRODUCTION

Mortality from preeclampsia (PE) and PE-associated morbidities are 3-to 5-fold higher in persons of African ancestry than in those of Asian and European ancestries.

METHODS

To elucidate placental contribution to worse PE outcomes in African ancestry pregnancies, we performed bulk RNA sequencing on 50 placentas from persons with severe PE (sPE) of African (n = 9), Asian (n = 18) and European (n = 23) ancestries and 73 normotensive controls of African (n = 10), Asian (n = 15) and European (n = 48) ancestries.

RESULTS

Previously described canonical preeclampsia genes, involved in metabolism and hypoxia/angiogenesis including: LEP, HK2, FSTL3, FLT1, ENG, TMEM45A, ARHGEF4 and HTRA1 were upregulated sPE versus normotensive placentas across ancestries. LTF, NPR3 and PHYHIP were higher in African vs. Asian ancestry sPE placentas. Allograft rejection/adaptive immune response genes were upregulated in placentas from African but not in Asian or European ancestry sPE patients; IL3RA was of particular interest because the patient with the highest placental IL3RA expression, a person of African ancestry with sPE, developed postpartum cardiomyopathy, and was the only patient out of 123, that developed this condition. Interestingly, the sPE patients with the highest IL3RA expression among persons of Asian and European ancestries developed unexplained tachycardia peripartum, necessitating echocardiography in the European ancestry patient. The association between elevated placental IL3RA levels and unexplained tachycardia or peripartum cardiomyopathy was found to be significant in the 50 sPE patients (p = .0005).

DISCUSSION

High placental upregulation of both canonical preeclampsia and allograft rejection/adaptive immune response genes may contribute to worse PE outcomes in African ancestry sPE patients.

Pregnancy in Living Kidney Donors: An Evidence-Based Review

Purpose of review

To review the current studies and guidelines on the risk of adverse pregnancy outcomes in female kidney donors.

Recent findings

Living kidney donors include a significant amount of young women of child-bearing age. Safety and possible risks of pregnancy after donation are a concern for female kidney donor candidates. Many current studies indicate a higher risk of preeclampsia in women after kidney donation. Considering the increasing number of living kidney donors, the maternal outcomes of living kidney donation is an active area of research.

Summary

Guidelines and consensus statements on the risk of pregnancy in living kidney donors recommend close monitoring of blood pressure, weight gain, and proteinuria during pregnancy. Current studies indicate an increased risk of hypertensive disorders of pregnancy in living kidney donors. Counseling and informing donor candidates about the possible risks is important.

Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study

OBJECTIVES

To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms.

STUDY DESIGN

This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control).

MAIN OUTCOME MEASURES

Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms).

RESULTS

Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%).

CONCLUSIONS

Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.

Ethnic disparities in pregnancy-related acute kidney injury in a United Kingdom population

BACKGROUND

The incidence of acute kidney injury in pregnancy (P-AKI) is rising and is associated with detrimental maternal and foetal outcomes. Ethnic disparities in pregnancy outcomes are well recognized, with females who identify as Black or Asian being more likely to die during pregnancy compared to females who identify as White ethnicity.

METHODS

This study reports rates of P-AKI and associated risk factors in pregnant females of different ethnicities. All pregnancies were recorded between 2016 and 2020. AKI episodes were identified using electronic alerts. Ethnicity, AKI stage (1-3), obstetric outcomes and risk factors for P-AKI (chronic hypertension, pregnancy-induced hypertension and pre-eclampsia, and haemorrhage) were assessed.

RESULTS

There were 649 P-AKI episodes from 16,943 deliveries (3.8%). Black females were more likely to have P-AKI (5.72%) compared to those who were White (3.12%), Asian (3.74%), mixed ethnicity (2.89%) and Other/Not Stated (3.10%). Black females, compared to White females, were at greater risk of developing P-AKI if they had haemorrhage requiring blood transfusion (OR 2.44, 95% CI 1.31,4.54; p < 0.001) or pregnancy-induced hypertension (OR 1.79, 95% CI 1.12, 2.86; p < 0.001). After adjusting for risk factors, Black females had increased risk of developing P-AKI (OR 1.52, 95% CI 1.22, 1.80; p < 0.001) compared to White females. Black females were at increased risk of developing P-AKI compared to White females. Mode of delivery, pregnancy-induced hypertension and haemorrhage are likely to have contributed. The increased risk persists despite accounting for these variables, suggesting that other factors such as socioeconomic disparities need to be considered.

CONCLUSIONS

The incidence of P-AKI is likely higher than previously stated in the literature. However, caution must be exercised, particularly with AKI stage 1, as the KDIGO system is not validated in pregnancy and gestational changes in renal physiology need to be considered. Pregnancy-specific AKI definitions are needed.

Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition

Preeclampsia accounts for one of the most common documented gestational complications, with a prevalence of approximately 2 to 15% of all pregnancies. Defined as gestational hypertension after 20 weeks of pregnancy and coexisting proteinuria or generalized edema, and certain forms of organ damage, it is life-threatening for both the mother and the fetus, in terms of increasing the rate of mortality and morbidity. Preeclamptic pregnancies are strongly associated with significantly higher medical costs. The maternal costs are related to the extra utility of the healthcare system, more resources used during hospitalization, and likely more surgical spending due to an elevated rate of cesarean deliveries. The infant costs also contribute to a large percentage of the expenses as the babies are prone to preterm deliveries and relevant or causative adverse events. Preeclampsia imposes a considerable financial burden on our societies. It is important for healthcare providers and policy-makers to recognize this phenomenon and allocate enough economic budgets and medical and social resources accordingly. The true cellular and molecular mechanisms underlying preeclampsia remain largely unexplained, which is assumed to be a two-stage process of impaired uteroplacental perfusion with or without prior defective trophoblast invasion (stage 1), followed by general endothelial dysfunction and vascular inflammation that lead to systemic organ damages (stage 2). Risk factors for preeclampsia including race, advanced maternal age, obesity, nulliparity, multi-fetal pregnancy, and co-existing medical disorders, can serve as warnings or markers that call for enhanced surveillance of maternal and fetal well-being. Doppler ultrasonography and biomarkers including the mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), and serum pregnancy-associated plasma protein A (PAPP-A) can be used for the prediction of preeclampsia. For women perceived as high-risk individuals for developing preeclampsia, the administration of low-dose aspirin on a daily basis since early pregnancy has proven to be the most effective way to prevent preeclampsia. For preeclamptic females, relevant information, counseling, and suggestions should be provided to facilitate timely intervention or specialty referral. In pregnancies complicated with preeclampsia, closer monitoring and antepartum surveillance including the Doppler ultrasound blood flow study, biophysical profile, non-stress test, and oxytocin challenge test can be arranged. If the results are unfavorable, early intervention and aggressive therapy should be considered. Affected females should have access to higher levels of obstetric units and neonatal institutes. Before, during, and after delivery, monitoring and preparation should be intensified for affected gravidas to avoid serious complications of preeclampsia. In severe cases, delivery of the fetus and the placenta is the ultimate solution to treat preeclampsia. The current review is a summary of recent advances regarding the knowledge of preeclampsia. However, the detailed etiology, pathophysiology, and effect of preeclampsia seem complicated, and further research to address the primary etiology and pathophysiology underlying the clinical manifestations and outcomes is warranted.

Pravastatin in preeclampsia: A meta-analysis and systematic review

Objective

To review of the efficacy and safety of pravastatin use for prophylaxis and treatment of preeclampsia.

Design

Systematic review and meta-analysis of clinical studies evaluating pravastatin for treatment and/or prophylaxis of preeclampsia.

Data collection

Two independent reviewers systematically searched data from PubMed, Scopus, Web of Science, Cochrane, Embase, and clinicaltrials.gov databases, for studies evaluating pravastatin for prevention of pre-eclampsia.

Results

Fourteen studies were identified, including 1,570 pregnant women who received either pravastatin or placebo, published between 2003 and 2022. From these studies, 5 studies were identified for inclusion in the meta-analysis to evaluate the role of pravastatin use prior to 20 weeks of gestation, to prevent pre-eclampsia, Pravastatin treatment reduced the incidence of preeclampsia by 61% and premature birth by 45%. Among the newborns, there was a 45% reduction in intrauterine growth retardation (IUGR) in the treated group, as well as a 77% reduction in those receiving neonatal intensive care unit (NICU) admissions.

Conclusion

Prophylactic treatment with pravastatin appears to reduce risk of developing pre-eclampsia as well as potentially lowering risk of IUGR, preterm birth, and NICU admission in neonates.

Black mothers' birthing experiences: in search of birthing justice

OBJECTIVES

Previous studies have suggested that often, Black mothers' birthing experiences are not what they expected because of how they were treated by healthcare providers during labor and birth. Our goal in this study was to ask Black mothers who had recently given birth about the quality of their birthing experiences as well as their level of respect from, trust in, and satisfaction with their maternity healthcare providers.

DESIGN

This study gathered data from Black mothers (N = 209) who had given birth within the past two years, using a cross-sectional online survey measuring several variables about the birthing experience including types of healthcare provider communication, provider respect for the mother, trust, birth satisfaction, and emotional responses to birth.

RESULTS

Provider-centered communication, although preferred by some mothers, was associated with lower birth satisfaction and stronger negative emotions whereas positive birth satisfaction was linked to patient-centered communication which resulted in positive emotions. While most mothers reported overall satisfaction with their birth experience, nearly half reported experiencing some degree of disrespect from their healthcare providers during labor and birth. Moreover, trust and respect mediated the relationship for patient-centered communication with positive emotion and birth satisfaction. Over one-third of participants gave birth with a certified nurse midwife attending. There were no differences in perception of being respected or the quality of birth given the professional identity of the provider as an Obstetrician/Gynecologist or as a midwife. The advice suggested by Black mothers for their healthcare providers was instructive in identifying ways those providers could better serve their patients during birth.

CONCLUSION

This study showed that there is still additional work that needs to be done for racial equity and respect during birth. Practical implications for addressing health inequities are discussed.

Pregnancy after living kidney donation, a systematic review of the available evidence, and a review of the current guidance

Understanding and communicating the risk of pregnancy complications post-living kidney donation is imperative as the majority of living kidney donors (LKD) are women of childbearing age. We aimed to identify all original research articles examining complications in post-donation pregnancies and compared the quality and consistency of related guidelines. We searched Embase, MEDLINE, PubMed, society webpages, and guideline registries for English-language publications published up until December 18, 2020. Ninety-three articles were screened from which 16 studies were identified, with a total of 1399 post-donation pregnancies. The outcome of interest, post-donation pregnancy complications, was not calculable, and only a narrative synthesis of the evidence was possible. The absolute risk of pre-eclampsia increased from ~1%-3% pre-donation (lower than the general population) to ~4%-10% post-donation (comparable to the general population). The risks of adverse fetal and neonatal outcomes were no different between post-donation and pre-donation pregnancies. Guidelines and consensus statements were consistent in stating the need to inform LKDs of their post-donation pregnancy risk, however, the depth and scope of this guidance were variable. While the absolute risk of pregnancy complications remains low post-donation, a concerted effort is required to better identify and individualize risk in these women, such that consent to donation is truly informed.

Diagnostic value of miR-101 levels in blood and urine of patients with hypertensive disorder complicating pregnancy

OBJECTIVES

This study explored the miR-101 clinical significance in hypertensive disorder complicating pregnancy (HDCP).

METHODS

Pregnant women with gestational hypertension (GH)/mild preeclampsia (mPE)/severe preeclampsia (sPE) were included. The miR-101 levels were measured. Correlation between miR-101 and soluble fmslike tyrosine kinase-1 (sFlt-1), miR-101 predictive value, and factors influencing HDCP grade were evaluated.

RESULTS

Serum miR-101 was down-regulated and negatively correlated with sFlt-1. miR-101 was an independent risk factor for HDCP and decreased with HDCP severity. The area under the curve of miR-101 in differentiating GH from mPE and mPE from sPE was 0.7764 and 0.8529.

CONCLUSION

Serum miR-101 level may be a biomarker for grading HDCP.

Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching

Background

This evaluation of doula care emerges at a time when maternal mortality in the U.S. outranks every country in the developed world. Study objectives were to: 1) examine when over the maternity care continuum and with whom (i.e., clinical providers) doula care provides the greatest benefits to clinical health outcomes and health care utilization; and 2) evaluate whether women gain differential benefits from doulas depending upon race/ethnicity and health status.

Methods

We conducted a retrospective cohort study using Medicaid medical claims from California, Florida, and a northeastern state (USA) to compare maternal health outcomes between women who did and did not receive doula care between January 1, 2014 and December 31, 2020. We used propensity score matching and logistic regression models to calculate associations between selected health outcomes and doula care. Our analysis included 298 pairs of women matched on age, race/ethnicity, state, socioeconomic status, and hospital type (teaching or non-teaching).

Findings

Women who received doula care had 52.9% lower odds of cesarean delivery (OR: 0.471 95% CI: 0.29-0.79) and 57.5% lower odds of postpartum depression/postpartum anxiety (PPD/PPA) (OR: 0.425 95% CI: 0.22-0.82). Doulas who provided care with a clinical team that included a midwife most consistently showed a reduction in odds of cesarean delivery, regardless of the trimester when doula care was received. Women who received doula care during labor and birth, but not necessarily during pregnancy, showed a 64.7% reduction in odds of PPA/PPD (OR: 0.353 95% CI: 0.16-0.78) of PPA/PPD.

Interpretation

The use of doulas appears an effective strategy for improving maternal health, especially among socioeconomically vulnerable and marginalized minority populations. Future studies could address research gaps through focusing on the relationship between doula care received in the postpartum period and postpartum health.

Funding

No sources of funding were used to assist in the preparation of this manuscript. Research was completed as part of the usual employment obligations to Anthem, Inc.

RAR-Related Orphan Receptor: An Accelerated Preeclampsia Progression by Activating the JAK/STAT3 Pathway

PURPOSE

To investigate the effect and underlying mechanism of RAR related orphan receptor A (RORA) on preeclampsia (PE).

MATERIALS AND METHODS

Differentially expressed genes (DEGs) in four datasets were obtained by using the Venn diagram method. RORA mRNA and protein expressions were detected by qRT-PCR, western blot, and immunohistochemistry. HTR-8/SVneo cell viability, proliferation, invasion, migration, and angiogenesis were detected by CCK-8 assay, EdU assay, Transwell, wound healing assay, and tube formation assay, respectively. The concentration of Ang-1 in cells was assessed using available ELISA kit. Epithelial-mesenchymal transition, proliferation, and angiogenesis-related proteins were detected by western blot. GSEA analysis were performed for common DEGs, and the expression of enriched pathway-related proteins was also detected.

RESULTS

The expression of RORA was increased in PE tissue and HTR-8/SVneo cells. Silencing RORA could promote the migration, invasion, epithelial-mesenchymal transition, proliferation, and angiogenesis of hypoxia-treated HTR-8/SVneo cells. Mechanistically, RORA contributed to the deterioration of PE by activating the JAK2/STAT3 signaling pathway to promote cell proliferation, migration, invasion, and angiogenesis.

CONCLUSION

RORA was up-regulated in PE and affected HTR-8/SVneo cell proliferation, invasion, migration, apoptosis, and angiogenesis via the JAK2/STAT3 signaling pathway. This provided a novel strategy for the prevention and treatment of PE.

Pre-eclampsia: a Scoping Review of Risk Factors and Suggestions for Future Research Direction

Abstract

Most of maternal deaths are preventable, and one-quarter of maternal deaths are due to pre-eclampsia and eclampsia. Prenatal screening is essential for detecting and managing pre-eclampsia. However, pre-eclampsia screening is solely based on maternal risk factors and has low (< 5% in the USA) detection rates. This review looks at pre-eclampsia from engineering, public health, and medical points of view. First, pre-eclampsia is defined clinically, and the biological basis of established risk factors is described. The multiple theories behind pre-eclampsia etiology should serve as the scientific basis behind established risk factors for pre-eclampsia; however, African American race does not have sufficient evidence as a risk factor. We then briefly describe predictive statistical models that have been created to improve screening detection rates, which use a combination of biophysical and biochemical biomarkers, as well as aspects of patient medical history as inputs. Lastly, technologies that aid in advancing pre-eclampsia screening worldwide are explored. The review concludes with suggestions for more robust pre-eclampsia research, which includes diversifying study sites, improving biomarker analytical tools, and for researchers to consider studying patients before they become pregnant to improve pre-eclampsia detection rates. Additionally, researchers must acknowledge the systemic racism involved in using race as a risk factor and include qualitative measures in study designs to capture the effects of racism on patients.

Lay Summary

Pre-eclampsia is a pregnancy-specific hypertensive disorder that can affect almost every organ system and complicates 2-8% of pregnancies globally. Here, we focus on the biological basis of the risk factors that have been identified for the condition. African American race currently does not have sufficient evidence as a risk factor and has been poorly studied. Current clinical methods poorly predict a patient's likelihood of developing pre-eclampsia; thus, researchers have made statistical models that are briefly described in this review. Then, low-cost technologies that aid in advancing pre-eclampsia screening are discussed. The review ends with suggestions for research direction to improve pre-eclampsia screening in all settings.Overall, we suggest that the future of pre-eclampsia screening should aim to identify those at risk before they become pregnant. We also suggest that the clinical standard of assessing patient risk solely on patient characteristics needs to be reevaluated, that study locations of pre-eclampsia research need to be expanded beyond a few high-income countries, and that low-cost technologies should be developed to increase access to prenatal screening.

An imbalance-aware deep neural network for early prediction of preeclampsia

Preeclampsia (PE) is a hypertensive complication affecting 8-10% of US pregnancies annually. While there is no cure for PE, aspirin may reduce complications for those at high risk for PE. Furthermore, PE disproportionately affects racial minorities, with a higher burden of morbidity and mortality. Previous studies have shown early prediction of PE would allow for prevention. We approached the prediction of PE using a new method based on a cost-sensitive deep neural network (CSDNN) by considering the severe imbalance and sparse nature of the data, as well as racial disparities. We validated our model using large extant rich data sources that represent a diverse cohort of minority populations in the US. These include Texas Public Use Data Files (PUDF), Oklahoma PUDF, and the Magee Obstetric Medical and Infant (MOMI) databases. We identified the most influential clinical and demographic features (predictor variables) relevant to PE for both general populations and smaller racial groups. We also investigated the effectiveness of multiple network architectures using three hyperparameter optimization algorithms: Bayesian optimization, Hyperband, and random search. Our proposed models equipped with focal loss function yield superior and reliable prediction performance compared with the state-of-the-art techniques with an average area under the curve (AUC) of 66.3% and 63.5% for the Texas and Oklahoma PUDF respectively, while the CSDNN model with weighted cross-entropy loss function outperforms with an AUC of 76.5% for the MOMI data. Furthermore, our CSDNN model equipped with focal loss function leads to an AUC of 66.7% for Texas African American and 57.1% for Native American. The best results are obtained with 62.3% AUC with CSDNN with weighted cross-entropy loss function for Oklahoma African American, 58% AUC with DNN and balanced batch for Oklahoma Native American, and 72.4% AUC using either CSDNN with weighted cross-entropy loss function or CSDNN with focal loss with balanced batch method for MOMI African American dataset. Our results provide the first evidence of the predictive power of clinical databases for PE prediction among minority populations.

Vascular Dysfunction in Preeclampsia

Preeclampsia is a life-threatening pregnancy-associated cardiovascular disorder characterized by hypertension and proteinuria at 20 weeks of gestation. Though its exact underlying cause is not precisely defined and likely heterogenous, a plethora of research indicates that in some women with preeclampsia, both maternal and placental vascular dysfunction plays a role in the pathogenesis and can persist into the postpartum period. Potential abnormalities include impaired placentation, incomplete spiral artery remodeling, and endothelial damage, which are further propagated by immune factors, mitochondrial stress, and an imbalance of pro- and antiangiogenic substances. While the field has progressed, current gaps in knowledge include detailed initial molecular mechanisms and effective treatment options. Newfound evidence indicates that vasopressin is an early mediator and biomarker of the disorder, and promising future therapeutic avenues include mitigating mitochondrial dysfunction, excess oxidative stress, and the resulting inflammatory state. In this review, we provide a detailed overview of vascular defects present during preeclampsia and connect well-established notions to newer discoveries at the molecular, cellular, and whole-organism levels.

Could Vitamin D Be Effective in Prevention of Preeclampsia?

Prevention of preeclampsia (PE) remains one of the most significant problems in perinatal medicine. Due to the possible unpredictable course of hypertension in pregnancy, primarily PE and the high complication rate for the mother and fetus/newborn, it is urgent to offer pregnant women in high-risk groups effective methods of preventing the PE development or delaying its appearance. In addition, due to the association of PE with an increased risk of developing cardiovascular diseases (CVD) in later life, effective preeclampsia prevention could also be important in reducing their incidence. Ideal PE prophylaxis should target the pathogenetic changes leading to the development of PE and be safe for the mother and fetus, inexpensive and freely available. Currently, the only recognized method of PE prevention recommended by many institutions around the world is the use of a small dose of acetylsalicylic acid in pregnant women with risk factors. Unfortunately, some cases of PE are diagnosed in women without recognized risk factors and in those in whom prophylaxis with acetylsalicylic acid is not adequate. Hence, new drugs which would target pathogenetic elements in the development of preeclampsia are studied. Vitamin D (Vit D) seems to be a promising agent due to its beneficial effect on placental implantation, the immune system, and angiogenic factors. Studies published so far emphasize the relationship of its deficiency with the development of PE, but the data on the benefits of its supplementation to reduce the risk of PE are inconclusive. In the light of current research, the key issue is determining the protective concentration of Vit D in a pregnant woman. The study aims to present the possibility of using Vit D to prevent PE, emphasizing its impact on the pathogenetic elements of preeclampsia development.

Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension

Patients with a history of hypertensive disorders of pregnancy (HDP) suffer higher rates of long-term cardiovascular events including heart failure, coronary artery disease, and stroke. Cardiovascular changes during pregnancy can act as a natural stress test, subsequently unmasking latent cardiovascular disease in the form of HDP. Because HDP now affect 10% of pregnancies in the United States, the American Heart Association has called for physicians who provide peripartum care to promote early identification and cardiovascular risk reduction. In this review, we discuss the epidemiology, pathophysiology, and outcomes of HDP-associated cardiovascular disease. In addition, we propose a multi-pronged approach to support cardiovascular risk reduction for women with a history of HDP. Additional research is warranted to define appropriate blood pressure targets in the postpartum period, optimize the use of pregnancy history in risk stratification tools, and clarify the effectiveness of preventive interventions. The highest rates of HDP are in populations with poor access to resources and quality health care, making it a major risk for inequity of care. Interventions to decrease long-term cardiovascular disease risk in women following HDP must also target disparity reduction.

Preeclampsia beyond pregnancy: long-term consequences for mother and child

Preeclampsia is defined as new-onset hypertension after the 20th wk of gestation along with evidence of maternal organ failure. Rates of preeclampsia have steadily increased over the past 30 yr, affecting ∼4% of pregnancies in the United States and causing a high economic burden (22, 69). The pathogenesis is multifactorial, with acknowledged contributions by placental, vascular, renal, and immunological dysfunction. Treatment is limited, commonly using symptomatic management and/or early delivery of the fetus (6). Along with significant peripartum morbidity and mortality, current research continues to demonstrate that the consequences of preeclampsia extend far beyond preterm delivery. It has lasting effects for both mother and child, resulting in increased susceptibility to hypertension and chronic kidney disease (45, 54, 115, 116), yielding lifelong risk to both individuals. This review discusses recent guideline updates and recommendations along with current research on these long-term consequences of preeclampsia.