First trimester inflammatory mediators in women with chronic hypertension

Association of LEPTIN and other inflammatory markers with preeclampsia: A systematic review

Background: Preeclampsia is a serious pregnancy complication that affects 5%–10% of the obstetric population.

Objective: To study inflammatory markers associated with preeclampsia.

Search Strategy: Searches of articles on the topic published over a 10-year period (2009–2019) were performed in three databases (PubMed, Cochrane, and Embase) using the keywords preeclampsia and inflammatory markers. The PubMed search using 10 years and humans as filters retrieved 124 articles. Using an advanced search strategy, 0 articles were identified in Embase and 10 articles in Cochrane. After screening and eligibility assessment, 13 articles were included in the systematic review and meta-analysis. Meta-analysis and quality assessment of the studies were performed using the Review Manager 5.3 program.

Results: For meta-analysis, women with preeclampsia were compared to control women, i.e., pregnancies without arterial hypertension. Leptin levels were significantly higher (p < 0.0002) in women with preeclampsia compared to controls. Total cholesterol was also significantly elevated in women with preeclampsia (p < 0.0001). There was no significant difference in HDL between groups, but women with preeclampsia had significantly increased LDL (p < 0.01). The same was observed for triglycerides, which were significantly increased in women with preeclampsia (p < 0.04) compared to controls. Analysis of TNF-alpha, an important inflammatory marker, showed higher levels in women with preeclampsia (p < 0.03) compared to controls. The same was observed for another important inflammatory marker, interleukin 6, which was significantly increased in women with preeclampsia (p < 0.0002). There was a significant increase of C-reactive protein in women with preeclampsia (p < 0.003) compared to controls.

Conclusion: Women with preeclampsia have increased levels of inflammatory markers compared to control women.

Chronic hypertension and superimposed preeclampsia: screening and diagnosis

Superimposed preeclampsia complicates about 20% of pregnancies in women with chronic hypertension and is associated with increased maternal and perinatal morbidity compared with preeclampsia alone. Distinguishing superimposed preeclampsia from chronic hypertension can be challenging because, in chronic hypertension, the traditional criteria for the diagnosis of preeclampsia, hypertension, and significant proteinuria can often predate the pregnancy. Furthermore, the prevalence of superimposed preeclampsia is unlikely to be uniformly distributed across this high-risk group but is related to the severity of preexisting endothelial dysfunction. This has led to interest in identifying biomarkers that could help in screening and diagnosis of superimposed preeclampsia and in the stratification of risk in women with chronic hypertension. Elevated levels of uric acid and suppression of other renal biomarkers, such as the renin-angiotensin aldosterone system, have been demonstrated in women with superimposed preeclampsia but perform only modestly in its prediction. In addition, central to the pathogenesis of preeclampsia is a tendency toward an antiangiogenic state thought to be triggered by an impaired placenta and, ultimately, contributing to the endothelial dysfunction pathognomonic of the disease. In the general obstetrical population, angiogenic factors, such as soluble fms-like tyrosine kinase-1 and placental growth factor, have shown promise in the prediction of preeclampsia. However, soluble fms-like tyrosine kinase-1 and placental growth factor are impaired in women with chronic hypertension irrespective of whether they develop superimposed preeclampsia. Therefore, the differences in levels are less discriminatory in the prediction of superimposed preeclampsia compared with the general obstetrical population. Alternative biomarkers to the angiogenic and renal factors include those of endothelial dysfunction. A characteristic of both preeclampsia and chronic hypertension is an exaggerated systemic inflammatory response causing or augmenting endothelial dysfunction. Thus, proinflammatory mediators, such as tumor necrosis factor-α, interleukin-6, cell adhesion molecules, and endothelin, have been investigated for their role in the screening and diagnosis of superimposed preeclampsia in women with chronic hypertension. To date, the existing limited evidence suggests that the differences between those who develop superimposed preeclampsia and those who do not are, as with angiogenic factors, also modest and not clinically useful for the stratification of women with chronic hypertension. Finally, pro-B-type natriuretic peptide is regarded as a sensitive marker of early cardiac dysfunction that, in women with chronic hypertension, may predate the pregnancy. Thus, it has been proposed that pro-B-type natriuretic peptide could give insight as to the ability of women with chronic hypertension to adapt to the hemodynamic requirements of pregnancy and, subsequently, their risk of developing superimposed preeclampsia. Although higher levels of pro-B-type natriuretic peptide have been demonstrated in women with superimposed preeclampsia compared with those without, current evidence suggests that pro-B-type natriuretic peptide is not a predictor for the disease. The objectives of this review are to, first, discuss the current criteria for the diagnosis of superimposed preeclampsia and, second, to summarize the evidence for these potential biomarkers that may assist in the diagnosis of superimposed preeclampsia.