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Ngene NC, Moodley J. Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102473. [PMID: 38513504 DOI: 10.1016/j.bpobgyn.2024.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 03/23/2024]
Abstract
Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, Rahima Moosa Mother and Child Hospital, Johannesburg, Gauteng, South Africa; Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Gauteng, South Africa.
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, Department of Obstetrics and Gynecology, School of Clinical Medicine, Faculty of Health Sciences, University of Kwa Zulu-Natal, Durban, South Africa.
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2
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Brownfoot F, Rolnik DL. Prevention of preeclampsia. Best Pract Res Clin Obstet Gynaecol 2024; 93:102481. [PMID: 38373378 DOI: 10.1016/j.bpobgyn.2024.102481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/19/2023] [Accepted: 02/05/2024] [Indexed: 02/21/2024]
Abstract
Preeclampsia is a relatively common pregnancy complication and constitutes a major cause of morbidity and mortality for mothers and children worldwide. It disproportionally affects low-resource countries. Appropriate identification of individuals at increased risk and prevention of the disease and its complications remain healthcare and research priorities, and the investigation of potential interventions to prevent preeclampsia has driven much of the obstetric research in recent decades. In this article, we review the scientific literature on the topic, highlighting established benefits and remaining questions regarding different non-pharmacological and pharmacological strategies, including exercise, the timing of birth, aspirin and calcium use, among others, as well as potential novel therapies under investigation.
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Affiliation(s)
- Fiona Brownfoot
- Mercy Hospital for Women, Heidelberg, Victoria, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel Lorber Rolnik
- Women's and Newborn, Monash Health, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.
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3
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Tocci V, Mirabelli M, Salatino A, Sicilia L, Giuliano S, Brunetti FS, Chiefari E, De Sarro G, Foti DP, Brunetti A. Metformin in Gestational Diabetes Mellitus: To Use or Not to Use, That Is the Question. Pharmaceuticals (Basel) 2023; 16:1318. [PMID: 37765126 PMCID: PMC10537239 DOI: 10.3390/ph16091318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
In recent years, there has been a dramatic increase in the number of pregnancies complicated by gestational diabetes mellitus (GDM). GDM occurs when maternal insulin resistance develops and/or progresses during gestation, and it is not compensated by a rise in maternal insulin secretion. If not properly managed, this condition can cause serious short-term and long-term problems for both mother and child. Lifestyle changes are the first line of treatment for GDM, but if ineffective, insulin injections are the recommended pharmacological treatment choice. Some guidance authorities and scientific societies have proposed the use of metformin as an alternative pharmacological option for treating GDM, but there is not yet a unanimous consensus on this. Although the use of metformin appears to be safe for the mother, concerns remain about its long-term metabolic effects on the child that is exposed in utero to the drug, given that metformin, contrary to insulin, crosses the placenta. This review article describes the existing lines of evidence about the use of metformin in pregnancies complicated by GDM, in order to clarify its potential benefits and limits, and to help clinicians make decisions about who could benefit most from this drug treatment.
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Affiliation(s)
- Vera Tocci
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Maria Mirabelli
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Alessandro Salatino
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Luciana Sicilia
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Stefania Giuliano
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Francesco S. Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Eusebio Chiefari
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Giovambattista De Sarro
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Daniela P. Foti
- Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Antonio Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
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4
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Sakowicz A, Bralewska M, Rybak-Krzyszkowska M, Grzesiak M, Pietrucha T. New Ideas for the Prevention and Treatment of Preeclampsia and Their Molecular Inspirations. Int J Mol Sci 2023; 24:12100. [PMID: 37569476 PMCID: PMC10418829 DOI: 10.3390/ijms241512100] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Preeclampsia (PE) is a pregnancy-specific disorder affecting 4-10% of all expectant women. It greatly increases the risk of maternal and foetal death. Although the main symptoms generally appear after week 20 of gestation, scientific studies indicate that the mechanism underpinning PE is initiated at the beginning of gestation. It is known that the pathomechanism of preeclampsia is strongly related to inflammation and oxidative stress, which influence placentation and provoke endothelial dysfunction in the mother. However, as of yet, no "key players" regulating all these processes have been discovered. This might be why current therapeutic strategies intended for prevention or treatment are not fully effective, and the only effective method to stop the disease is the premature induction of delivery, mostly by caesarean section. Therefore, there is a need for further research into new pharmacological strategies for the treatment and prevention of preeclampsia. This review presents new preventive methods and therapies for PE not yet recommended by obstetrical and gynaecological societies. As many of these therapies are in preclinical studies or under evaluation in clinical trials, this paper reports the molecular targets of the tested agents or methods.
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Affiliation(s)
- Agata Sakowicz
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
| | - Michalina Bralewska
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
| | - Magda Rybak-Krzyszkowska
- Department of Obstetrics and Perinatology, University Hospital in Krakow, 31-501 Krakow, Poland;
| | - Mariusz Grzesiak
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute in Lodz, 93-338 Lodz, Poland;
- Department of Gynecology and Obstetrics, Medical University of Lodz, 93-338 Lodz, Poland
| | - Tadeusz Pietrucha
- Department of Medical Biotechnology, Medical University of Lodz, Zeligowskiego 7/9, 90-752 Lodz, Poland; (M.B.); (T.P.)
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5
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Tabacco S, Ambrosii S, Polsinelli V, Fantasia I, D’Alfonso A, Ludovisi M, Cecconi S, Guido M. Pre-Eclampsia: From Etiology and Molecular Mechanisms to Clinical Tools-A Review of the Literature. Curr Issues Mol Biol 2023; 45:6202-6215. [PMID: 37623210 PMCID: PMC10453909 DOI: 10.3390/cimb45080391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
Pre-eclampsia is a severe pregnancy-related complication that manifests as a syndrome with multisystem involvement and damage. It has significantly grown in frequency during the past 30 years and could be considered as one of the major causes of maternal and fetal morbidity and mortality. However, the specific etiology and molecular mechanisms of pre-eclampsia are still poorly known and could have a variety of causes, such as altered angiogenesis, inflammations, maternal infections, obesity, metabolic disorders, gestational diabetes, and autoimmune diseases. Perhaps the most promising area under investigation is the imbalance of maternal angiogenic factors and its effects on vascular function, though studies in placental oxidative stress and maternal immune response have demonstrated intriguing findings. However, to determine the relative importance of each cause and the impact of actions aiming to significantly reduce the incidence of this illness, more research is needed. Moreover, it is necessary to better understand the etiologies of each subtype of pre-eclampsia as well as the pathophysiology of other major obstetrical syndromes to identify a clinical tool able to recognize patients at risk of pre-eclampsia early.
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Affiliation(s)
- Sara Tabacco
- Unit of Obstetrics and Gynecology, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Silvia Ambrosii
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Valentina Polsinelli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Ilaria Fantasia
- Unit of Obstetrics and Gynecology, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Angela D’Alfonso
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Manuela Ludovisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Sandra Cecconi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Maurizio Guido
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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6
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Lopian M, Kashani-Ligumsky L, Many A. A Balancing Act: Navigating Hypertensive Disorders of Pregnancy at Very Advanced Maternal Age, from Preconception to Postpartum. J Clin Med 2023; 12:4701. [PMID: 37510816 PMCID: PMC10380965 DOI: 10.3390/jcm12144701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The decision to postpone parenting has gained momentum in recent years, a shift driven by evolving social dynamics and improved access to fertility treatments. Despite their increasing prevalence, pregnancies at advanced maternal ages are associated with increased risks of adverse maternal and neonatal outcomes. This article addresses the association between advanced maternal age and hypertensive disorders of pregnancies (HDPs), which are more prevalent and a significant cause of maternal morbidity and mortality in this population. This review explores the biological mechanisms and age-related risk factors that underpin this increased susceptibility and offers practical management strategies that can be implemented prior to, as well as during, each stage of pregnancy to mitigate the incidence and severity of HDPs in this group. Lastly, this review acknowledges both the short-term and long-term postpartum implications of HDPs in women of advanced maternal age.
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Affiliation(s)
- Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Kashani-Ligumsky
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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7
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Semertzidou A, Grout-Smith H, Kalliala I, Garg A, Terzidou V, Marchesi J, MacIntyre D, Bennett P, Tsilidis K, Kyrgiou M. Diabetes and anti-diabetic interventions and the risk of gynaecological and obstetric morbidity: an umbrella review of the literature. BMC Med 2023; 21:152. [PMID: 37072764 PMCID: PMC10114404 DOI: 10.1186/s12916-023-02758-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/27/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Diabetes has reached epidemic proportions in recent years with serious health ramifications. The aim of this study was to evaluate the strength and validity of associations between diabetes and anti-diabetic interventions and the risk of any type of gynaecological or obstetric conditions. METHODS Design: Umbrella review of systematic reviews and meta-analyses. DATA SOURCES PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, manual screening of references. ELIGIBILITY CRITERIA Systematic reviews and meta-analyses of observational and interventional studies investigating the relationship between diabetes and anti-diabetic interventions with gynaecological or obstetric outcomes. Meta-analyses that did not include complete data from individual studies, such as relative risk, 95% confidence intervals, number of cases/controls, or total population were excluded. DATA ANALYSIS The evidence from meta-analyses of observational studies was graded as strong, highly suggestive, suggestive or weak according to criteria comprising the random effects estimate of meta-analyses and their largest study, the number of cases, 95% prediction intervals, I2 heterogeneity index between studies, excess significance bias, small study effect and sensitivity analysis using credibility ceilings. Interventional meta-analyses of randomised controlled trials were assessed separately based on the statistical significance of reported associations, the risk of bias and quality of evidence (GRADE) of included meta-analyses. RESULTS A total of 117 meta-analyses of observational cohort studies and 200 meta-analyses of randomised clinical trials that evaluated 317 outcomes were included. Strong or highly suggestive evidence only supported a positive association between gestational diabetes and caesarean section, large for gestational age babies, major congenital malformations and heart defects and an inverse relationship between metformin use and ovarian cancer incidence. Only a fifth of the randomised controlled trials investigating the effect of anti-diabetic interventions on women's health reached statistical significance and highlighted metformin as a more effective agent than insulin on risk reduction of adverse obstetric outcomes in both gestational and pre-gestational diabetes. CONCLUSIONS Gestational diabetes appears to be strongly associated with a high risk of caesarean section and large for gestational age babies. Weaker associations were demonstrated between diabetes and anti-diabetic interventions with other obstetric and gynaecological outcomes. TRIAL REGISTRATION Open Science Framework (OSF) (Registration https://doi.org/10.17605/OSF.IO/9G6AB ).
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Affiliation(s)
- Anita Semertzidou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Harriet Grout-Smith
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Ilkka Kalliala
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Akanksha Garg
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Vasso Terzidou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Julian Marchesi
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- School of Biosciences, Cardiff University, Cardiff, UK
| | - David MacIntyre
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Phillip Bennett
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Konstantinos Tsilidis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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8
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Paschou SA, Bletsa E, Papazisi M, Mili N, Kanouta F, Kassi GN, Psaltopoulou T, Goulis DG, Lambrinoudaki I. Screening and management of major endocrinopathies during pregnancy: an update. Endocrine 2023; 80:10-19. [PMID: 36327019 PMCID: PMC10060311 DOI: 10.1007/s12020-022-03237-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022]
Abstract
Endocrinopathies during pregnancy constitute a challenging issue, being prevalent and requiring appropriate management to avoid maternal and fetal complications. This review aims to summarize and present major endocrine problems during pregnancy, the appropriate screening, maternal monitoring and management, fetal monitoring, and follow-up. Glucose metabolism, thyroid function, as well as calcium and vitamin D metabolism are the main endocrine domains that should be screened and monitored during pregnancy. Gestational diabetes mellitus (GDM) is the most prevalent endocrine disease during pregnancy, followed by thyroid disorders. Specific recommendations are provided for the optimal clinical care of pregnant women and their offspring for GDM, thyroid disorders, and calcium and vitamin D disorders.
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Affiliation(s)
- Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Evanthia Bletsa
- Third Department of Cardiology, Sotiria Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Papazisi
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikoletta Mili
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Fotini Kanouta
- Department of Endocrinology, Alexandra Hospital, Athens, Greece
| | - Georgia N Kassi
- Department of Endocrinology, Alexandra Hospital, Athens, Greece
| | - Theodora Psaltopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios G Goulis
- 1st Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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9
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Vatish M, Powys VR, Cerdeira AS. Novel therapeutic and diagnostic approaches for preeclampsia. Curr Opin Nephrol Hypertens 2023; 32:124-133. [PMID: 36683536 DOI: 10.1097/mnh.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW This review will summarize recent findings relating to the diagnostic approach to preeclampsia and current avenues of research aimed at modifying the underlying disease process. RECENT FINDINGS Growing international consensus supports a broad preeclampsia definition that incorporates maternal end-organ and uteroplacental dysfunction. Recent evidence demonstrates that this definition better identifies women and babies at risk of adverse outcomes compared to the traditional definition of hypertension and proteinuria. Multiple studies have demonstrated the usefulness and cost-effectiveness of angiogenic biomarkers such as soluble fms-like tyrosine kinase-1 and placental growth factor as a clinical adjunct to diagnose and predict severity of preeclampsia associated outcomes. Current novel therapeutic approaches to preeclampsia target pathogenic pathways (e.g. antiangiogenesis) or downstream effects such as oxidative stress and nitric oxide. Recent findings relating to these promising candidates are discussed. Multicenter clinical trials are needed to evaluate their effectiveness and ability to improve fetal and maternal outcomes. SUMMARY We provide an updated framework of the current approaches to define and diagnose preeclampsia. Disease modifying therapies (in particular, targeting the angiogenic pathway) are being developed for the first time and promise to revolutionize the way we manage preeclampsia.
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Affiliation(s)
- Manu Vatish
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
| | | | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
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10
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Preeclampsia: Narrative review for clinical use. Heliyon 2023; 9:e14187. [PMID: 36923871 PMCID: PMC10009735 DOI: 10.1016/j.heliyon.2023.e14187] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/05/2023] Open
Abstract
Aim Preeclampsia is a very complex multisystem disorder characterized by mild to severe hypertension. Methods PubMed and the Cochrane Library were searched from January 1, 2002 to March 31, 2022, with the search terms "pre-eclampsia" and "hypertensive disorders in pregnancy". We also look for guidelines from international societies and clinical specialty colleges and we focused on publications made after 2015. Results The primary issue associated with this physiopathology is a reduction in utero-placental perfusion and ischemia. Preeclampsia has a multifactorial genesis, its focus in prevention consists of the identification of high and moderate-risk clinical factors. The clinical manifestations of preeclampsia vary from asymptomatic to fatal complications for both the fetus and the mother. In severe cases, the mother may present renal, neurological, hepatic, or vascular disease. The main prevention strategy is the use of aspirin at low doses, started from the beginning to the end of the second trimester and maintained until the end of pregnancy. Conclusion Preeclampsia is a multisystem disorder; we do not know how to predict it accurately. Acetylsalicylic acid at low doses to prevent a low percentage, especially in patients with far from term preeclampsia. There is evidence that exercising for at least 140 min per week reduces gestational hypertension and preeclampsia. Currently, the safest approach is the termination of pregnancy. It is necessary to improve the prediction and prevention of preeclampsia, in addition, better research is needed in the long-term postpartum follow-up.
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11
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Placental Mitochondrial Function and Dysfunction in Preeclampsia. Int J Mol Sci 2023; 24:ijms24044177. [PMID: 36835587 PMCID: PMC9963167 DOI: 10.3390/ijms24044177] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
The placenta is a vital organ of pregnancy, regulating adaptation to pregnancy, gestational parent/fetal exchange, and ultimately, fetal development and growth. Not surprisingly, in cases of placental dysfunction-where aspects of placental development or function become compromised-adverse pregnancy outcomes can result. One common placenta-mediated disorder of pregnancy is preeclampsia (PE), a hypertensive disorder of pregnancy with a highly heterogeneous clinical presentation. The wide array of clinical characteristics observed in pregnant individuals and neonates of a PE pregnancy are likely the result of distinct forms of placental pathology underlying the PE diagnosis, explaining why no one common intervention has proven effective in the prevention or treatment of PE. The historical paradigm of placental pathology in PE highlights an important role for utero-placental malperfusion, placental hypoxia and oxidative stress, and a critical role for placental mitochondrial dysfunction in the pathogenesis and progression of the disease. In the current review, the evidence of placental mitochondrial dysfunction in the context of PE will be summarized, highlighting how altered mitochondrial function may be a common feature across distinct PE subtypes. Further, advances in this field of study and therapeutic targeting of mitochondria as a promising intervention for PE will be discussed.
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12
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Ghorbanpour SM, Richards C, Pienaar D, Sesperez K, Aboulkheyr Es H, Nikolic VN, Karadzov Orlic N, Mikovic Z, Stefanovic M, Cakic Z, Alqudah A, Cole L, Gorrie C, McGrath K, Kavurma MM, Ebrahimi Warkiani M, McClements L. A placenta-on-a-chip model to determine the regulation of FKBPL and galectin-3 in preeclampsia. Cell Mol Life Sci 2023; 80:44. [PMID: 36652019 PMCID: PMC9849194 DOI: 10.1007/s00018-022-04648-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 11/03/2022] [Accepted: 11/24/2022] [Indexed: 01/19/2023]
Abstract
Preeclampsia is a pregnancy-specific cardiovascular disorder, involving significant maternal endothelial dysfunction. Although inappropriate placentation due to aberrant angiogenesis, inflammation and shallow trophoblast invasion are the root causes of preeclampsia, pathogenic mechanisms are poorly understood, particularly in early pregnancy. Here, we first confirm the abnormal expression of important vascular and inflammatory proteins, FK506-binding protein-like (FKBPL) and galectin-3 (Gal-3), in human plasma and placental tissues from women with preeclampsia and normotensive controls. We then employ a three-dimensional microfluidic placental model incorporating human umbilical vein endothelial cells (HUVECs) and a first trimester trophoblast cell line (ACH-3P) to investigate FKBPL and Gal-3 signaling in inflammatory conditions. In human samples, both circulating (n = 17 controls; n = 30 preeclampsia) and placental (n ≥ 6) FKBPL and Gal-3 levels were increased in preeclampsia compared to controls (plasma: FKBPL, p < 0.0001; Gal-3, p < 0.01; placenta: FKBPL, p < 0.05; Gal-3, p < 0.01), indicative of vascular dysfunction in preeclampsia. In our placenta-on-a-chip model, we show that endothelial cells are critical for trophoblast-mediated migration and that trophoblasts effectively remodel endothelial vascular networks. Inflammatory cytokine tumour necrosis factor-α (10 ng/mL) modulates both FKBPL and Gal-3 signaling in conjunction with trophoblast migration and impairs vascular network formation (p < 0.005). Our placenta-on-a-chip recapitulates aspects of inappropriate placental development and vascular dysfunction in preeclampsia.
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Affiliation(s)
- Sahar Masoumeh Ghorbanpour
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
- Institute for Biomedical Materials and Devices, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
- Heart Research Institute, Sydney, NSW, Australia
| | - Claire Richards
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
- Institute for Biomedical Materials and Devices, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Dillan Pienaar
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Kimberly Sesperez
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Hamidreza Aboulkheyr Es
- School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Sydney, NSW, Australia
| | - Valentina N Nikolic
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Nis, Niš, Serbia
| | - Natasa Karadzov Orlic
- Department of Gynaecology and Obstetrics, Narodni Front, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Zeljko Mikovic
- Department of Gynaecology and Obstetrics, Narodni Front, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milan Stefanovic
- Department of Internal Medicine-Gynaecology, Faculty of Medicine, University of Nis, Niš, Serbia
- Department of Gynaecology and Obstetrics, Clinical Centre Nis, Niš, Serbia
| | - Zoran Cakic
- Department of Gynaecology and Obstetrics, General Hospital of Leskovac, Leskovac, Serbia
| | - Abdelrahim Alqudah
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmaceutical Sciences, The Hashemite University, Zarqa, Jordan
| | - Louise Cole
- Australian Institute of Microbiology and Infection, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Catherine Gorrie
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Kristine McGrath
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
| | - Mary M Kavurma
- Heart Research Institute,The University of Sydney, Sydney, NSW, Australia
| | - Majid Ebrahimi Warkiani
- Institute for Biomedical Materials and Devices, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
- School of Biomedical Engineering, Faculty of Engineering and Information Technology, University of Technology Sydney, Sydney, NSW, Australia
| | - Lana McClements
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia.
- Institute for Biomedical Materials and Devices, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia.
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13
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Jiang L, Tang K, Magee LA, von Dadelszen P, Ekeroma A, Li X, Zhang E, Bhutta ZA. A global view of hypertensive disorders and diabetes mellitus during pregnancy. Nat Rev Endocrinol 2022; 18:760-775. [PMID: 36109676 PMCID: PMC9483536 DOI: 10.1038/s41574-022-00734-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 11/23/2022]
Abstract
Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis.
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Affiliation(s)
- Li Jiang
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Kun Tang
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Alec Ekeroma
- Department of Obstetrics and Gynecology, Wellington School of Medicine, University of Otago, Wellington, New Zealand
- National University of Samoa, Apia, Samoa
| | - Xuan Li
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Enyao Zhang
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan.
- Institute for Global Health & Development, the Aga Khan University, Karachi, Pakistan.
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14
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Bramante CT, Johnson SG, Garcia V, Evans MD, Harper J, Wilkins KJ, Huling JD, Mehta H, Alexander C, Tronieri J, Hong S, Kahkoska A, Alamgir J, Koraishy F, Hartman K, Yang K, Abrahamsen T, Stürmer T, Buse JB. Diabetes medications and associations with Covid-19 outcomes in the N3C database: A national retrospective cohort study. PLoS One 2022; 17:e0271574. [PMID: 36395143 PMCID: PMC9671347 DOI: 10.1371/journal.pone.0271574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 07/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While vaccination is the most important way to combat the SARS-CoV-2 pandemic, there may still be a need for early outpatient treatment that is safe, inexpensive, and currently widely available in parts of the world that do not have access to the vaccine. There are in-silico, in-vitro, and in-tissue data suggesting that metformin inhibits the viral life cycle, as well as observational data suggesting that metformin use before infection with SARS-CoV2 is associated with less severe COVID-19. Previous observational analyses from single-center cohorts have been limited by size. METHODS Conducted a retrospective cohort analysis in adults with type 2 diabetes (T2DM) for associations between metformin use and COVID-19 outcomes with an active comparator design of prevalent users of therapeutically equivalent diabetes monotherapy: metformin versus dipeptidyl-peptidase-4-inhibitors (DPP4i) and sulfonylureas (SU). This took place in the National COVID Cohort Collaborative (N3C) longitudinal U.S. cohort of adults with +SARS-CoV-2 result between January 1 2020 to June 1 2021. Findings included hospitalization or ventilation or mortality from COVID-19. Back pain was assessed as a negative control outcome. RESULTS 6,626 adults with T2DM and +SARS-CoV-2 from 36 sites. Mean age was 60.7 +/- 12.0 years; 48.7% male; 56.7% White, 21.9% Black, 3.5% Asian, and 16.7% Latinx. Mean BMI was 34.1 +/- 7.8kg/m2. Overall 14.5% of the sample was hospitalized; 1.5% received mechanical ventilation; and 1.8% died. In adjusted outcomes, compared to DPP4i, metformin had non-significant associations with reduced need for ventilation (RR 0.68, 0.32-1.44), and mortality (RR 0.82, 0.41-1.64). Compared to SU, metformin was associated with a lower risk of ventilation (RR 0.5, 95% CI 0.28-0.98, p = 0.044) and mortality (RR 0.56, 95%CI 0.33-0.97, p = 0.037). There was no difference in unadjusted or adjusted results of the negative control. CONCLUSIONS There were clinically significant associations between metformin use and less severe COVID-19 compared to SU, but not compared to DPP4i. New-user studies and randomized trials are needed to assess early outpatient treatment and post-exposure prophylaxis with therapeutics that are safe in adults, children, pregnancy and available worldwide.
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Affiliation(s)
- Carolyn T. Bramante
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Steven G. Johnson
- Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Victor Garcia
- Department of Biomedical Informatics, Stony Brook University Hospital, Stony Brook, New York, United States of America
| | - Michael D. Evans
- Biostatistical Design and Analysis Center, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Jeremy Harper
- Owl HealthWorks, Indianapolis, IN, United States of America
| | - Kenneth J. Wilkins
- Biostatistics Program, Office of the Director, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, United States of America
| | - Jared D. Huling
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America
| | - Hemalkumar Mehta
- Division of Epidemiology and Methodology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Caleb Alexander
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jena Tronieri
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Stephenie Hong
- Division of Epidemiology and Methodology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Anna Kahkoska
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joy Alamgir
- ARIScience, Boston, Massachusetts, United States of America
| | - Farrukh Koraishy
- Division of Nephrology, Stony Brook University Hospital, Stony Brook, New York, United States of America
| | - Katrina Hartman
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Kaifeng Yang
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America
| | | | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina Medical School, Chapel Hill, North Carolina, United States of America
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15
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McDougall ARA, Hastie R, Goldstein M, Tuttle A, Tong S, Ammerdorffer A, Gülmezoglu AM, Vogel JP. Systematic evaluation of the pre-eclampsia drugs, dietary supplements and biologicals pipeline using target product profiles. BMC Med 2022; 20:393. [PMID: 36329468 PMCID: PMC9635102 DOI: 10.1186/s12916-022-02582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The Accelerating Innovation for Mothers (AIM) project established a database of candidate medicines in research and development (R&D) between 2000 and 2021 for five pregnancy-related conditions, including pre-eclampsia. In parallel, we published target product profiles (TPPs) that describe optimal characteristics of medicines for use in preventing/treating pre-eclampsia. The study objective was to use systematic double screening and extraction to identify all candidate medicines being investigated for pre-eclampsia prevention/treatment and rank their potential based on the TPPs. METHODS Adis Insight, Pharmaprojects, WHO international clinical trials registry platform (ICTRP), PubMed and grant databases were searched (Jan-May 2021). The AIM database was screened for all candidates being investigated for pre-eclampsia. Candidates in clinical development were evaluated against nine prespecified criteria from TPPs identified as key for wide-scale implementation, and classified as high, medium or low potential based on matching to the TPPs. Preclinical candidates were categorised by product type, archetype and medicine subclass. RESULTS The AIM database identified 153 candidates for pre-eclampsia. Of the 87 candidates in clinical development, seven were classified as high potential (prevention: esomeprazole, L-arginine, chloroquine, vitamin D and metformin; treatment: sulfasalazine and metformin) and eight as medium potential (prevention: probiotic lactobacilli, dalteparin, selenium and omega-3 fatty acid; treatment: sulforaphane, pravastatin, rosuvastatin and vitamin B3). Sixty-six candidates were in preclinical development, the most common being amino acid/peptides, siRNA-based medicines and polyphenols. CONCLUSIONS This is a novel, evidence-informed approach to identifying promising candidates for pre-eclampsia prevention and treatment - a vital step in stimulating R&D of new medicines for pre-eclampsia suitable for real-world implementation.
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Affiliation(s)
- Annie R A McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Roxanne Hastie
- Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Australia
| | | | | | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Australia
| | | | | | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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16
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Louis JM, Parchem J, Vaught A, Tesfalul M, Kendle A, Tsigas E. Preeclampsia: a report and recommendations of the workshop of the Society for Maternal-Fetal Medicine and the Preeclampsia Foundation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2022.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Fornes R, Simin J, Nguyen MH, Cruz G, Crisosto N, van der Schaaf M, Engstrand L, Brusselaers N. Pregnancy, perinatal and childhood outcomes in women with and without polycystic ovary syndrome and metformin during pregnancy: a nationwide population-based study. Reprod Biol Endocrinol 2022; 20:30. [PMID: 35130922 PMCID: PMC8819934 DOI: 10.1186/s12958-022-00905-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/30/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Polycystic Ovary Syndrome (PCOS) is an endocrine disorder that affects women in reproductive age and represents an unfavourable risk factor for several pregnancy and perinatal outcomes. Despite, no guidelines or pharmaceutical strategies for treating PCOS during pregnancy are available. The aim of this study is to determine the association between polycystic ovary syndrome with or without metformin and the pregnancy, perinatal outcomes as well as the risk of obesity in children born to these mothers. METHODS In this nationwide population-based cohort study based in Swedish population, all singleton births (n = 1,016,805) from 686,847 women since 2006 up to 2016 were included. Multivariable logistic and Cox regression modelling with odds ratios (OR) and hazard ratios (HR) and 95% confidence intervals were used to study the association between the exposure of maternal PCOS, metformin during pregnancy (or the combination of both) and: 1) Pregnancy outcomes: preeclampsia, gestational diabetes, caesarean section, and acute caesarean section, 2) Perinatal outcomes: preterm birth, stillbirth, low birth weight, macrosomia, Apgar < 7 at 5 min, small for gestational age and large for gestational age, and 3) Childhood Obesity. RESULTS PCOS in women without metformin use during pregnancy was associated with higher risks of preeclampsia (OR = 1.09, 1.02-1.17), gestational diabetes (OR = 1.71, 1.53-1.91) and caesarean section (OR = 1.08, 1.04-1.12), preterm birth (OR = 1.30, 1.23-1.38), low birth weight (OR = 1.29, 1.20-1.38), low Apgar scores (OR = 1.17, 1.05-1.31) and large for gestational age (OR = 1.11, 1.03-1.20). Metformin use during pregnancy (in women without PCOS) was associated with a 29% lower risks of preeclampsia (OR = 0.71, 0.51-0.97), macrosomia and large for gestational age. Obesity was more common among children born to mothers with PCOS without metformin (HR = 1.61, 1.44-1.81); and those with metformin without PCOS (HR = 1.67, 1.05-2.65). PCOS with metformin was not associated with any adverse outcome. CONCLUSION PCOS was associated with increased risks of adverse pregnancy and perinatal outcomes and childhood obesity. Metformin appears to reduce these risks in mothers with polycystic ovary syndrome and their children; but may increase the risk of childhood-obesity in children form women without PCOS.
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Affiliation(s)
- Romina Fornes
- Centre for Translational Microbiome Research (CTMR), Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum kvarter 8A, Tomtebodavägen 16, SE-171 65, Stockholm, Sweden
| | - Johanna Simin
- Centre for Translational Microbiome Research (CTMR), Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum kvarter 8A, Tomtebodavägen 16, SE-171 65, Stockholm, Sweden
| | - Minh Hanh Nguyen
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Gonzalo Cruz
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile
| | - Nicolás Crisosto
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Facultad de Ciencias, Universidad de Valparaíso, Valparaíso, Chile
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
- Endocrinology Unit, Clínica Las Condes, Las Condes, Chile
| | | | - Lars Engstrand
- Centre for Translational Microbiome Research (CTMR), Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum kvarter 8A, Tomtebodavägen 16, SE-171 65, Stockholm, Sweden
| | - Nele Brusselaers
- Centre for Translational Microbiome Research (CTMR), Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Biomedicum kvarter 8A, Tomtebodavägen 16, SE-171 65, Stockholm, Sweden.
- Global Health Institute, Antwerp University, Antwerpen, Belgium.
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18
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Tong S, Kaitu’u-Lino TJ, Hastie R, Brownfoot F, Cluver C, Hannan N. Pravastatin, proton-pump inhibitors, metformin, micronutrients, and biologics: new horizons for the prevention or treatment of preeclampsia. Am J Obstet Gynecol 2022; 226:S1157-S1170. [PMID: 32946849 DOI: 10.1016/j.ajog.2020.09.014] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/25/2020] [Accepted: 09/10/2020] [Indexed: 12/14/2022]
Abstract
There has been increasing research momentum to identify new therapeutic agents for the prevention or treatment of preeclampsia, drugs that can affect the underlying disease pathophysiology. Molecular targets of candidate treatments include oxidative stress, antiangiogenic factors, and the angiotensin, nitric oxide, and proinflammatory pathways. The proposed treatments undergoing preclinical and clinical trial evaluation are thought to act on placental or endothelial disease or both. Most have adopted the pragmatic strategy of repurposing drugs. Of all the therapeutic agents proposed, pravastatin has received the most interest. There are preclinical studies showing that it has pleiotropic actions that favorably impact on multiple molecular targets and can resolve a preeclampsia phenotype in many animal models. An early phase clinical trial suggests that it may have therapeutic activity. Several large prevention trials are planned or ongoing and, when completed, could definitively address whether pravastatin can prevent preeclampsia. Proton-pump inhibitors, metformin, and sulfasalazine are other drugs with preclinical evidence of multiple molecular actions that could resolve the pathophysiology of preeclampsia. These agents are also currently being evaluated in clinical trials. There have been many recent preclinical studies identifying the potential of numerous natural compounds to treat preeclampsia, such as plant extracts and micronutrients that have potent anti-inflammatory or antioxidant activity. Recent preclinical studies have also proposed novel molecular-targeted strategies, such as monoclonal antibodies targeting tumor necrosis factor alpha, placental growth factor, and short interfering RNA technology, to silence the gene expression of soluble fms-like tyrosine kinase-1 or angiotensinogen. Other treatment approaches that have transitioned to human trials (ranging from single-arm to phase III trials that have been completed or are ongoing) include folic acid, nitric oxide donors (such as L-arginine), recombinant antithrombin III, digoxin immune antigen-binding fragment, and melatonin. There have been case series showing the removal of circulating soluble fms-like tyrosine kinase-1 may help stabilize the disease and prolong pregnancy. Interestingly, there are case reports suggesting that monoclonal antibody eculizumab (complement inhibitor) may have therapeutic potential. If new agents are discovered that are proven to be effective in preventing or treating preeclampsia, the potential to improve global maternal and perinatal health will be significant.
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19
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The etiology of preeclampsia. Am J Obstet Gynecol 2022; 226:S844-S866. [PMID: 35177222 PMCID: PMC8988238 DOI: 10.1016/j.ajog.2021.11.1356] [Citation(s) in RCA: 151] [Impact Index Per Article: 75.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023]
Abstract
Preeclampsia is one of the "great obstetrical syndromes" in which multiple and sometimes overlapping pathologic processes activate a common pathway consisting of endothelial cell activation, intravascular inflammation, and syncytiotrophoblast stress. This article reviews the potential etiologies of preeclampsia. The role of uteroplacental ischemia is well-established on the basis of a solid body of clinical and experimental evidence. A causal role for microorganisms has gained recognition through the realization that periodontal disease and maternal gut dysbiosis are linked to atherosclerosis, thus possibly to a subset of patients with preeclampsia. The recent reports indicating that SARS-CoV-2 infection might be causally linked to preeclampsia are reviewed along with the potential mechanisms involved. Particular etiologic factors, such as the breakdown of maternal-fetal immune tolerance (thought to account for the excess of preeclampsia in primipaternity and egg donation), may operate, in part, through uteroplacental ischemia, whereas other factors such as placental aging may operate largely through syncytiotrophoblast stress. This article also examines the association between gestational diabetes mellitus and maternal obesity with preeclampsia. The role of autoimmunity, fetal diseases, and endocrine disorders is discussed. A greater understanding of the etiologic factors of preeclampsia is essential to improve treatment and prevention.
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20
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Ala M, Ala M. Metformin for Cardiovascular Protection, Inflammatory Bowel Disease, Osteoporosis, Periodontitis, Polycystic Ovarian Syndrome, Neurodegeneration, Cancer, Inflammation and Senescence: What Is Next? ACS Pharmacol Transl Sci 2021; 4:1747-1770. [PMID: 34927008 DOI: 10.1021/acsptsci.1c00167] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Indexed: 12/15/2022]
Abstract
Diabetes is accompanied by several complications. Higher prevalence of cancers, cardiovascular diseases, chronic kidney disease (CKD), obesity, osteoporosis, and neurodegenerative diseases has been reported among patients with diabetes. Metformin is the oldest oral antidiabetic drug and can improve coexisting complications of diabetes. Clinical trials and observational studies uncovered that metformin can remarkably prevent or alleviate cardiovascular diseases, obesity, polycystic ovarian syndrome (PCOS), osteoporosis, cancer, periodontitis, neuronal damage and neurodegenerative diseases, inflammation, inflammatory bowel disease (IBD), tuberculosis, and COVID-19. In addition, metformin has been proposed as an antiaging agent. Numerous mechanisms were shown to be involved in the protective effects of metformin. Metformin activates the LKB1/AMPK pathway to interact with several intracellular signaling pathways and molecular mechanisms. The drug modifies the biologic function of NF-κB, PI3K/AKT/mTOR, SIRT1/PGC-1α, NLRP3, ERK, P38 MAPK, Wnt/β-catenin, Nrf2, JNK, and other major molecules in the intracellular signaling network. It also regulates the expression of noncoding RNAs. Thereby, metformin can regulate metabolism, growth, proliferation, inflammation, tumorigenesis, and senescence. Additionally, metformin modulates immune response, autophagy, mitophagy, endoplasmic reticulum (ER) stress, and apoptosis and exerts epigenetic effects. Furthermore, metformin protects against oxidative stress and genomic instability, preserves telomere length, and prevents stem cell exhaustion. In this review, the protective effects of metformin on each disease will be discussed using the results of recent meta-analyses, clinical trials, and observational studies. Thereafter, it will be meticulously explained how metformin reprograms intracellular signaling pathways and alters molecular and cellular interactions to modify the clinical presentations of several diseases.
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Affiliation(s)
- Moein Ala
- School of Medicine, Tehran University of Medical Sciences (TUMS), 1416753955 Tehran, Iran
| | - Mahan Ala
- School of Dentistry, Golestan University of Medical Sciences (GUMS), 4814565589 Golestan, Iran
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21
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Quadir H. Current Therapeutic Use of Metformin During Pregnancy: Maternal Changes, Postnatal Effects and Safety. Cureus 2021; 13:e18818. [PMID: 34804675 PMCID: PMC8592788 DOI: 10.7759/cureus.18818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022] Open
Abstract
Metformin is one of the most easily available medications for diabetes and has a relatively low cost. It is not only used in diabetes but is also effective in polycystic ovarian syndrome (PCOS) and obesity. Although insulin is the first choice when it comes to treating pregnant women with gestational diabetes mellitus (GDM), metformin has also been debated as a good choice after modification of diet. As metformin passes through the placenta, it is essential to know its consequence of leading to insulin resistance in the fetus as well as the impact on postnatal development. The use of metformin during GDM has raised many trials demonstrating that outcomes from the use of metformin are similar to those achieved with insulin. Follow-up studies were also conducted that assessed the impact on children exposed to metformin in utero. This review highlights the experimental evidence relating to the use of metformin during pregnancy for different conditions, and its impact on the growth and development of offspring.
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Affiliation(s)
- Huma Quadir
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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22
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Anthoulakis C, Mamopoulos A, Rousso D, Karagiannis A, Athanasiadis A, Grimbizis G, Athyros V. Arterial Stiffness as a Cardiovascular Risk Factor for the Development of Preeclampsia and Pharmacopreventive Options. Curr Vasc Pharmacol 2021; 20:52-61. [PMID: 34615450 DOI: 10.2174/1570161119666211006114258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 11/22/2022]
Abstract
Arterial stiffness (AS) describes the rigidity of the arterial walls. Epidemiological studies have shown that increased AS is an independent predictive marker of cardiovascular (CV) morbidity and mortality in both pregnant and non-pregnant women. Preeclampsia (PE), a form of pregnancy-induced hypertension, affects approximately 5% of pregnancies worldwide. Preeclamptic women have a higher risk of CV disease (CVD), mainly because PE damages the heart's ability to relax between contractions. Different pharmacological approaches for the prevention of PE have been tested in clinical trials (e.g. aspirin, enoxaparin, metformin, pravastatin, and sildenafil citrate). In current clinical practice, only low-dose aspirin is used for PE pharmacoprevention. However, low-dose aspirin does not prevent term PE, which is the most common form of PE. Compromised vascular integrity precedes the onset of PE and therefore, AS assessment may constitute a promising predictive marker of PE. Several non-invasive techniques have been developed to assess AS. Compared with normotensive pregnancies, both carotid-femoral pulse wave velocity (cfPWV) and augmentation index (AIx) are increased in PE. In view of simplicity, reliability, and reproducibility, there is an interest in oscillometric AS measurements in pregnancies complicated by PE.
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Affiliation(s)
- Christos Anthoulakis
- First Department of Obstetrics & Gynecology, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - David Rousso
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Asterios Karagiannis
- Second Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Grigoris Grimbizis
- First Department of Obstetrics & Gynecology, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Vasilios Athyros
- Second Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
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23
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Cluver CA, Hiscock R, Decloedt EH, Hall DR, Schell S, Mol BW, Brownfoot F, Kaitu'u-Lino TJ, Walker SP, Tong S. Use of metformin to prolong gestation in preterm pre-eclampsia: randomised, double blind, placebo controlled trial. BMJ 2021; 374:n2103. [PMID: 34551918 PMCID: PMC8457042 DOI: 10.1136/bmj.n2103] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate whether extended release metformin could be used to prolong gestation in women being expectantly managed for preterm pre-eclampsia. DESIGN Randomised, double blind, placebo controlled trial. SETTING Referral hospital in Cape Town, South Africa. PARTICIPANTS 180 women with preterm pre-eclampsia between 26+0 to 31+6 weeks' gestation undergoing expectant management: 90 were randomised to extended release metformin and 90 to placebo. INTERVENTION 3 g of oral extended release metformin or placebo daily, in divided doses, until delivery. MAIN OUTCOME MEASURE The primary outcome was prolongation of gestation. RESULTS Of 180 participants, one woman delivered before taking any trial drug. The median time from randomisation to delivery was 17.7 days (interquartile range 5.4-29.4 days; n=89) in the metformin arm and 10.1 (3.7-24.1; n=90) days in the placebo arm, a median difference of 7.6 days (geometric mean ratio 1.39, 95% confidence interval 0.99 to 1.95; P=0.057). Among those who continued to take the trial drug at any dose, the median prolongation of gestation in the metformin arm was 17.5 (interquartile range 5.4-28.7; n=76) days compared with 7.9 (3.0-22.2; n=74) days in the placebo arm, a median difference of 9.6 days (geometric mean ratio 1.67, 95% confidence interval 1.16 to 2.42). Among those who took the full dosage, the median prolongation of gestation in the metformin arm was 16.3 (interquartile range 4.8-28.8; n=40) days compared with 4.8 (2.5-15.4; n=61) days in the placebo arm, a median difference of 11.5 days (geometric mean ratio 1.85, 95% confidence interval 1.14 to 2.88). Composite maternal, fetal, and neonatal outcomes and circulating concentrations of soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin did not differ. In the metformin arm, birth weight increased non-significantly and length of stay decreased in the neonatal nursery. No serious adverse events related to trial drugs were observed, although diarrhoea was more common in the metformin arm. CONCLUSIONS This trial suggests that extended release metformin can prolong gestation in women with preterm pre-eclampsia, although further trials are needed. It provides proof of concept that treatment of preterm pre-eclampsia is possible. TRIAL REGISTRATION Pan African Clinical Trial Registry PACTR201608001752102 https://pactr.samrc.ac.za/.
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Affiliation(s)
- Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Richard Hiscock
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
| | - Eric H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - David R Hall
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
| | - Sonja Schell
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Susan P Walker
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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24
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Racine JL, Adams JH, Antony KM, Hoppe KK, Iruretagoyena JI, Stewart KS, Eddy A, Rhoades JS. Metformin Exposure and Risk of Hypertensive Disorders of Pregnancy in Patients with Type 2 Diabetes. Am J Perinatol 2021; 38:1103-1108. [PMID: 33940652 DOI: 10.1055/s-0041-1728821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Metformin has been found to have a role in promoting vascular remodeling and angiogenesis which may reduce the risk of developing preeclampsia. Prior studies have shown a decrease in the incidence of hypertensive disorders of pregnancy in patients with type 2 and gestational diabetes taking metformin. We hypothesize metformin exposure decreases the risk of developing hypertension in patients with type 2 diabetes. STUDY DESIGN Retrospective cohort study from 2009 to 2019 of singleton pregnancies was complicated by type 2 diabetes. We compared patients who received metformin throughout pregnancy to those with no metformin exposure. The primary outcome was a hypertension composite defined as gestational hypertension, preeclampsia with or without severe features, HELLP syndrome, or eclampsia. Individual hypertensive outcomes and neonatal outcomes were secondarily evaluated. Logistic regression was used to adjust for confounding variables. RESULTS A total of 254 pregnancies were included. Women exposed to metformin were significantly less likely to develop hypertension composite compared with nonexposed women (22.7 vs. 33.1%, aOR 0.53, 95% CI 0.29-0.96). The incidence of preeclampsia with severe features was also significantly lower in those who received metformin compared with those who did not (12.1 vs. 20.7%, aOR 0.38, 95% CI 0.18-0.81). There were no differences in preterm birth prior to 34 or 37 weeks, fetal growth restriction, or birth weight between the study groups. A subgroup analysis of women without chronic hypertension also had a significantly lower risk of developing preeclampsia with severe features (7.6 vs. 17.8%, aOR 0.35, 95% CI 0.13-0.94). CONCLUSION Metformin exposure was associated with a decreased risk of composite hypertensive disorders of pregnancy in patients with pregestational type 2 diabetes. These data suggest that there may be benefit to metformin administration beyond glycemic control in this patient population. KEY POINTS · Metformin use showed a decreased risk of a hypertension composite.. · Results were consistent in patients without chronic hypertension.. · Metformin may show benefit beyond glycemic control in women with type 2 diabetes..
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Affiliation(s)
- Jenna L Racine
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jacquelyn H Adams
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kathleen M Antony
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Kara K Hoppe
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jesus I Iruretagoyena
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Katharina S Stewart
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - April Eddy
- Department of Perinatal Services, UnityPoint Health-Meriter, Madison, Wisconsin
| | - Janine S Rhoades
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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25
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Olmos-Ortiz A, Flores-Espinosa P, Díaz L, Velázquez P, Ramírez-Isarraraz C, Zaga-Clavellina V. Immunoendocrine Dysregulation during Gestational Diabetes Mellitus: The Central Role of the Placenta. Int J Mol Sci 2021; 22:8087. [PMID: 34360849 PMCID: PMC8348825 DOI: 10.3390/ijms22158087] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023] Open
Abstract
Gestational Diabetes Mellitus (GDM) is a transitory metabolic condition caused by dysregulation triggered by intolerance to carbohydrates, dysfunction of beta-pancreatic and endothelial cells, and insulin resistance during pregnancy. However, this disease includes not only changes related to metabolic distress but also placental immunoendocrine adaptations, resulting in harmful effects to the mother and fetus. In this review, we focus on the placenta as an immuno-endocrine organ that can recognize and respond to the hyperglycemic environment. It synthesizes diverse chemicals that play a role in inflammation, innate defense, endocrine response, oxidative stress, and angiogenesis, all associated with different perinatal outcomes.
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Affiliation(s)
- Andrea Olmos-Ortiz
- Departamento de Inmunobioquímica, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INPer), Ciudad de México 11000, Mexico; (A.O.-O.); (P.F.-E.)
| | - Pilar Flores-Espinosa
- Departamento de Inmunobioquímica, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INPer), Ciudad de México 11000, Mexico; (A.O.-O.); (P.F.-E.)
| | - Lorenza Díaz
- Departamento de Biología de la Reproducción, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México 14080, Mexico;
| | - Pilar Velázquez
- Departamento de Ginecología y Obstetricia, Hospital Ángeles México, Ciudad de México 11800, Mexico;
| | - Carlos Ramírez-Isarraraz
- Clínica de Urología Ginecológica, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INPer), Ciudad de México 11000, Mexico;
| | - Verónica Zaga-Clavellina
- Departamento de Fisiología y Desarrollo Celular, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INPer), Ciudad de México 11000, Mexico
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26
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Chappell LC, Cluver CA, Kingdom J, Tong S. Pre-eclampsia. Lancet 2021; 398:341-354. [PMID: 34051884 DOI: 10.1016/s0140-6736(20)32335-7] [Citation(s) in RCA: 364] [Impact Index Per Article: 121.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Abstract
Pre-eclampsia is a multisystem pregnancy disorder characterised by variable degrees of placental malperfusion, with release of soluble factors into the circulation. These factors cause maternal vascular endothelial injury, which leads to hypertension and multi-organ injury. The placental disease can cause fetal growth restriction and stillbirth. Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity, especially in low-income and middle-income countries. Prophylactic low-dose aspirin can reduce the risk of preterm pre-eclampsia, but once pre-eclampsia has been diagnosed there are no curative treatments except for delivery, and no drugs have been shown to influence disease progression. Timing of delivery is planned to optimise fetal and maternal outcomes. Clinical trials have reported diagnostic and prognostic strategies that could improve fetal and maternal outcomes and have evaluated the optimal timing of birth in women with late preterm pre-eclampsia. Ongoing studies are evaluating the efficacy, dose, and timing of aspirin and calcium to prevent pre-eclampsia and are evaluating other drugs to control hypertension or ameliorate disease progression.
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Affiliation(s)
- Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Kings' College London, London, UK.
| | - Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa; Tygerberg Hospital, Cape Town, South Africa
| | - John Kingdom
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Mercy Hospital for Women, Heidelberg, VIC, Australia
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27
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Insulin-mediated immune dysfunction in the development of preeclampsia. J Mol Med (Berl) 2021; 99:889-897. [PMID: 33768298 DOI: 10.1007/s00109-021-02068-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 03/08/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Epidemiological observations implicate insulin resistance as a predisposing factor in the development of preeclampsia (PE). It is also well established that PE manifests in the context of a dysregulated immune response at the maternal-foetal interface, though all the underlying drivers of such immune dysregulation remains to be accounted for. Although it has long been known that various immune cells express insulin receptors following immune activation, it is only recently that insulin signalling has been shown to play a key role in immune cell differentiation, survival and effector function through its canonical activation of the PI3K/Akt/mTOR pathway. Here we argue that hyperinsulinemia, manifesting either from insulin resistance or from intensive insulin therapy, likely plays a direct role in driving immune cell dysfunction which plays a central role in the development of PE. This line of reasoning also explains the superior results of insulin-sparing interventions compared to intensive insulin therapy as monotherapy.
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28
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The Role of Metformin in Treating Preeclampsia. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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29
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Bedell S, Hutson J, de Vrijer B, Eastabrook G. Effects of Maternal Obesity and Gestational Diabetes Mellitus on the Placenta: Current Knowledge and Targets for Therapeutic Interventions. Curr Vasc Pharmacol 2021; 19:176-192. [PMID: 32543363 DOI: 10.2174/1570161118666200616144512] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/16/2020] [Accepted: 05/17/2020] [Indexed: 02/08/2023]
Abstract
Obesity and gestational diabetes mellitus (GDM) are becoming more common among pregnant women worldwide and are individually associated with a number of placenta-mediated obstetric complications, including preeclampsia, macrosomia, intrauterine growth restriction and stillbirth. The placenta serves several functions throughout pregnancy and is the main exchange site for the transfer of nutrients and gas from mother to fetus. In pregnancies complicated by maternal obesity or GDM, the placenta is exposed to environmental changes, such as increased inflammation and oxidative stress, dyslipidemia, and altered hormone levels. These changes can affect placental development and function and lead to abnormal fetal growth and development as well as metabolic and cardiovascular abnormalities in the offspring. This review aims to summarize current knowledge on the effects of obesity and GDM on placental development and function. Understanding these processes is key in developing therapeutic interventions with the goal of mitigating these effects and preventing future cardiovascular and metabolic pathology in subsequent generations.
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Affiliation(s)
- Samantha Bedell
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
| | - Janine Hutson
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
| | - Barbra de Vrijer
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
| | - Genevieve Eastabrook
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
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30
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Alimoradi N, Firouzabadi N, Fatehi R. Metformin and insulin-resistant related diseases: Emphasis on the role of microRNAs. Biomed Pharmacother 2021; 139:111662. [PMID: 34243629 DOI: 10.1016/j.biopha.2021.111662] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/16/2021] [Accepted: 04/22/2021] [Indexed: 12/14/2022] Open
Abstract
Metformin is one of the most prescribed drugs in type II diabetes (T2DM) which has recently found new applications in the prevention and treatment of various illnesses, from metabolic disorders to cardiovascular and age-related diseases. Metformin improves insulin resistance (IR) by modulating metabolic mechanisms and mitochondrial biogenesis. Alternation of microRNAs (miRs) in the treatment of IR-related illnesses has been observed by metformin therapy. MiRs are small non-coding RNAs that play important roles in RNA silencing, targeting the 3'untranslated region (3'UTR) of most mRNAs and inhibiting the translation of related proteins. As a result, their dysregulation is associated with many diseases. Metformin may alter miRs levels in the treatment of various diseases by AMPK-dependent or AMPK-independent mechanisms. Here, we summarized the therapeutic role of metformin by modifying the aberrant expression of miRs as potential biomarkers or therapeutic targets in diseases in which IR plays a key role.
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Affiliation(s)
- Nahid Alimoradi
- Department of Pharmacology & Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negar Firouzabadi
- Department of Pharmacology & Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Reihaneh Fatehi
- Department of Pharmacology & Toxicology, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
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31
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Tarry-Adkins JL, Ozanne SE, Aiken CE. Impact of metformin treatment during pregnancy on maternal outcomes: a systematic review/meta-analysis. Sci Rep 2021; 11:9240. [PMID: 33927270 PMCID: PMC8085032 DOI: 10.1038/s41598-021-88650-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/09/2021] [Indexed: 02/02/2023] Open
Abstract
We systematically assessed the impact of metformin treatment on maternal pregnancy outcomes. PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov and Cochrane databases were systematically searched (inception-1st February 2021). Randomised controlled trials reporting pregnancy outcomes in women randomised to metformin versus any other treatment for any indication were included. Outcomes included gestational weight gain (GWG), pre-eclampsia, gestational hypertension, preterm birth, gestational age at delivery, caesarean section, gestational diabetes, glycaemic control, and gastrointestinal side-effects. Two independent reviewers conducted screening, with a third available to evaluate disagreements. Risk-of-bias and GRADE assessments were conducted using Cochrane Risk-of-Bias and GRADE-pro software. Thirty-five studies (n = 8033 pregnancies) met eligibility criteria. GWG was lower in pregnancies randomised to metformin versus other treatments (1.57 kg ± 0.60 kg; I2 = 86%, p < 0.0001), as was likelihood of pre-eclampsia (OR 0.69, 95% CI 0.50-0.95; I2 = 55%, p = 0.02). The risk of gastrointestinal side-effects was greater in metformin-exposed versus other treatment groups (OR 2.43, 95% CI 1.53-3.84; I2 = 76%, p = 0.0002). The risk of other maternal outcomes assessed was not significantly different between metformin-exposed versus other treatment groups. Metformin for any indication during pregnancy is associated with lower GWG and a modest reduced risk of pre-eclampsia, but increased gastrointestinal side-effects compared to other treatments.
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Affiliation(s)
- Jane L. Tarry-Adkins
- grid.5335.00000000121885934Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Obstetrics and Gynaecology, The Rosie Hospital and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Susan E. Ozanne
- grid.5335.00000000121885934Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Catherine E. Aiken
- grid.5335.00000000121885934Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Obstetrics and Gynaecology, The Rosie Hospital and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
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32
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Carris NW, Nwabuobi C, He W, Bullers K, Wilson RE, Louis JM, Magness RR. Review of Prediabetes and Hypertensive Disorders of Pregnancy. Am J Perinatol 2021; 38:428-435. [PMID: 31707724 PMCID: PMC7227138 DOI: 10.1055/s-0039-1698831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Obesity and diabetes increase hypertensive disorders of pregnancy (HDP) risk, thus preventive interventions are heavily studied. How pregestational prediabetes and related interventions impact HDP risk is less characterized. Therefore, we searched and reviewed the literature to assess the impact on HDP risk of prediabetes and varied interventions. We identified 297 citations related to pregnancy, prediabetes, and early pregnancy interventions. We also reviewed the references and citations of included articles. We included five studies assessing HDP outcomes in women with first trimester hemoglobin A1c in the prediabetes range (5.7-6.4%). One prospective observational study demonstrated first trimester hemoglobin A1c (5.9-6.4%) is associated with increased HDP risk, while another prospective observational study and one retrospective observational study had similar trends without statistical significance. A small and underpowered randomized controlled trial demonstrated initiating gestational diabetes mellitus treatment (i.e., diet, monitoring, ± insulin) in response to first trimester hemoglobin A1c (5.7-6.4%) did not statistically reduce HDP compared with standard care. One retrospective observational study suggested metformin, when started early, may reduce HDP risk in patients with prediabetes. Pregestational prediabetes appears to increase HDP risk. Interventions (i.e., metformin, diet/glucose monitoring, and/or exercise) to reduce HDP risk require additional study with long-term follow-up.
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Affiliation(s)
- Nicholas W. Carris
- University of South Florida; College of Pharmacy, Department of Pharmacotherapeutics and Clinical Research; Morsani College of Medicine, Department of Family Medicine
| | - Chinedu Nwabuobi
- University of South Florida; Morsani College of Medicine, Department of Obstetrics and Gynecology
| | - Weiwei He
- University of South Florida; College of Public Health, Department of Epidemiology & Biostatistics
| | - Krystal Bullers
- University of South Florida; Shimberg Health Sciences Library
| | - Roneé E. Wilson
- University of South Florida; College of Public Health, Department of Epidemiology & Biostatistics
| | - Judette M. Louis
- University of South Florida; Morsani College of Medicine, Department of Obstetrics and Gynecology
| | - Ronald R. Magness
- University of South Florida; Morsani College of Medicine, Department of Obstetrics and Gynecology
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Anness AR, Baldo A, Webb DR, Khalil A, Robinson TG, Mousa HA. Effect of metformin on biomarkers of placental- mediated disease: A systematic review and meta-analysis. Placenta 2021; 107:51-58. [PMID: 33798839 DOI: 10.1016/j.placenta.2021.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
Metformin reduces the incidence of placental-mediated disease (PMD) in pregnancies with and without diabetes, but the mechanism through which it exerts these effects is not yet fully understood. We performed a systematic review and meta-analysis to examine the effect of metformin on biomarkers implicated in the pathogenesis of PMD. We searched Medline, Embase and the Cochrane Library for studies of metformin and biomarkers of PMD in pregnancy. Meta-analysis was undertaken where comparable data were obtained from two or more studies. 12 studies were included in the final review. Meta-analysis of 2 studies including 323 pregnant women showed significantly reduced CRP levels following treatment with metformin compared to placebo [mean difference = -1.72, 95% CI (-2.97; -0.48); p = 0.007]. Metformin exposure was also associated with decreased levels of the inflammatory cytokines TNFα, IL-1a, IL-1b and IL-6 in serum, placenta and omental tissue taken from pregnant women. Metformin significantly decreased the release of anti-angiogenic factors sFlt-1 and sEng from ex-vivo placental and umbilical vein tissue, and increased maternal serum levels of non-phosphorylated IGFBP-1. Overall, our findings show that metformin mediates several molecular pathways implicated in the pathogenesis of pre-eclampsia and intrauterine growth retardation. Metformin therefore has exciting potential as a therapeutic, as well as preventative, agent in the treatment of PMD, which warrants further investigation.
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Affiliation(s)
| | | | - David R Webb
- Diabetes Research Centre, University of Leicester, UK
| | - Asma Khalil
- St. George's University Hospital (University of London), UK
| | | | - Hatem A Mousa
- University Hospitals of Leicester NHS Trust, Leicester, UK
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34
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Raperport C, Chronopoulou E, Homburg R. Effects of metformin treatment on pregnancy outcomes in patients with polycystic ovary syndrome. Expert Rev Endocrinol Metab 2021; 16:37-47. [PMID: 33634727 DOI: 10.1080/17446651.2021.1889366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/09/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This review covers the current evidence regarding the use of metformin as a therapeutic intervention for optimizing pregnancy outcomes in women with polycystic ovary syndrome (PCOS). AREAS COVERED After searching Medline, Embase and CINAHL, all important large clinical trials and observational studies plus systematic reviews, meta-analyses and Cochrane reviews have been summarized here. The results have been compared to culminate in a thorough review and discussion on the use of metformin in relation to reproductive outcomes for women with PCOS. The role of metformin in PCOS is explored both in terms of achieving conception and during pregnancy. The existing evidence around metformin use is summarized both during the preconceptual period and during pregnancy, in relation to reproductive outcomes. EXPERT OPINION Metformin is a widely used medication, often prescribed to improve reproductive outcomes for women with PCOS. However, the evidence remains equivocal regarding its efficacy both in optimizing fertility and pregnancy outcomes. More research is required with special emphasis on metformin use within different populations, including ethnic groups and women with varying BMI ranges.
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Affiliation(s)
- Claudia Raperport
- Fertility Unit, Homerton University Hospital, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Roy Homburg
- Fertility Unit, Homerton University Hospital, London, UK
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35
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Maggio L. Medications for Pregnant Women With Obesity: Special Considerations. Clin Obstet Gynecol 2021; 64:214-225. [PMID: 33306496 DOI: 10.1097/grf.0000000000000584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pregnant women with obesity are at increased risk of a multitude of complications of pregnancy and adverse perinatal outcomes. The risk of some of these complications, such as neural tube defects or preeclampsia, may be mitigated by some medications. Other complications, such as diabetes, venous thromboembolism, and infections, require treatment with medications. Given the changes in pharmacokinetics and pharmacodynamics during pregnancy, which is further enhanced by obesity, the optimal medication and its dose is often researched. This chapter further explores the different complications and common medications that women with obesity are likely to require.
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Affiliation(s)
- Lindsay Maggio
- Division of Maternal Fetal Medicine, Nemours Children's Hospital, Orlando, Florida
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Godhamgaonkar AA, Sundrani DP, Joshi SR. Role of maternal nutrition and oxidative stress in placental telomere attrition in women with preeclampsia. Hypertens Pregnancy 2021; 40:63-74. [PMID: 33406938 DOI: 10.1080/10641955.2020.1869248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background:Maternal nutrition influences the growth and development of the fetus and influences pregnancy outcome. We have earlier demonstrated altered maternal nutrition and increased oxidative stress in women with preeclampsia. Oxidative stress is known to be associated with reduced telomere length and short telomere aggregates. Increased telomere attrition leads to increased cellular senescence and tissue ageing. Methods:The present review focuses on the role of maternal nutrition and oxidative stress in telomere attrition in preeclampsia. Results and Conclusion:Future studies need to examine the association between maternal nutritional status in early pregnancy, oxidative stress and telomere attrition in preeclampsia.
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Affiliation(s)
- Aditi A Godhamgaonkar
- Mother and Child Health, Interactive Research School of Health Affairs (IRSHA), Bharati Vidyapeeth (Deemed to Be University) , Pune, India
| | - Deepali P Sundrani
- Mother and Child Health, Interactive Research School of Health Affairs (IRSHA), Bharati Vidyapeeth (Deemed to Be University) , Pune, India
| | - Sadhana R Joshi
- Mother and Child Health, Interactive Research School of Health Affairs (IRSHA), Bharati Vidyapeeth (Deemed to Be University) , Pune, India
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Ibrahim S, Lowe JR, Bramante CT, Shah S, Klatt NR, Sherwood N, Aronne L, Puskarich M, Tamariz L, Palacio A, Bomberg E, Usher M, King S, Benson B, Vojta D, Tignanelli C, Ingraham N. Metformin and Covid-19: Focused Review of Mechanisms and Current Literature Suggesting Benefit. Front Endocrinol (Lausanne) 2021; 12:587801. [PMID: 34367059 PMCID: PMC8342037 DOI: 10.3389/fendo.2021.587801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 05/11/2021] [Indexed: 01/08/2023] Open
Abstract
Metformin is the first-line medication for type 2 diabetes, but it also has a long history of improved outcomes in infectious diseases, such as influenza, hepatitis C, and in-vitro assays of zika. In the current Covid-19 pandemic, which has rapidly spread throughout the world, 4 observational studies have been published showing reduced mortality among individuals with home metformin use. There are several potential overlapping mechanisms by which metformin may reduce mortality from Covid-19. Metformin's past anti-infectious benefits have been both against the infectious agent directly, as well as by improving the underlying health of the human host. It is unknown if the lower mortality suggested by observational studies in patients infected with Covid-19 who are on home metformin is due to direct activity against the virus itself, improved host substrate, or both.
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Affiliation(s)
- Sherehan Ibrahim
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jamie R. Lowe
- MPH Program, Dartmouth College, Hanover, NH, United States
| | - Carolyn T. Bramante
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
- *Correspondence: Carolyn T. Bramante,
| | - Surbhi Shah
- Department of Medicine, Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN, United States
| | - Nichole R. Klatt
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Nancy Sherwood
- Department of Epidemiology, University of Minnesota, Minneapolis, MN, United States
| | - Louis Aronne
- Division of Endocrinology, Cornell Weill College of Medicine, New York, NY, United States
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Leonardo Tamariz
- Division of Cardiology and Miami VA Healthcare Administration, University of Miami, Miami, FL, United States
| | - Ana Palacio
- Division of Cardiology and Miami VA Healthcare Administration, University of Miami, Miami, FL, United States
| | - Eric Bomberg
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota, Minneapolis, MN, United States
| | - Michael Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Samantha King
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Brad Benson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Deneen Vojta
- UnitedHealth Group, Research and Development, Plymouth, MN, United States
| | - Chris Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Nicholas Ingraham
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, United States
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Todd N, McNally R, Alqudah A, Jerotic D, Suvakov S, Obradovic D, Hoch D, Hombrebueno JR, Campos GL, Watson CJ, Gojnic-Dugalic M, Simic TP, Krasnodembskaya A, Desoye G, Eastwood KA, Hunter AJ, Holmes VA, McCance DR, Young IS, Grieve DJ, Kenny LC, Garovic VD, Robson T, McClements L. Role of A Novel Angiogenesis FKBPL-CD44 Pathway in Preeclampsia Risk Stratification and Mesenchymal Stem Cell Treatment. J Clin Endocrinol Metab 2021; 106:26-41. [PMID: 32617576 PMCID: PMC7765643 DOI: 10.1210/clinem/dgaa403] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Preeclampsia is a leading cardiovascular complication in pregnancy lacking effective diagnostic and treatment strategies. OBJECTIVE To investigate the diagnostic and therapeutic target potential of the angiogenesis proteins, FK506-binding protein like (FKBPL) and CD44. DESIGN AND INTERVENTION FKBPL and CD44 plasma concentration or placental expression were determined in women pre- or postdiagnosis of preeclampsia. Trophoblast and endothelial cell function was assessed following mesenchymal stem cell (MSC) treatment and in the context of FKBPL signaling. SETTINGS AND PARTICIPANTS Human samples prediagnosis (15 and 20 weeks of gestation; n ≥ 57), or postdiagnosis (n = 18 for plasma; n = 4 for placenta) of preeclampsia were used to determine FKBPL and CD44 levels, compared to healthy controls. Trophoblast or endothelial cells were exposed to low/high oxygen, and treated with MSC-conditioned media (MSC-CM) or a FKBPL overexpression plasmid. MAIN OUTCOME MEASURES Preeclampsia risk stratification and diagnostic potential of FKBPL and CD44 were investigated. MSC treatment effects and FKBPL-CD44 signaling in trophoblast and endothelial cells were assessed. RESULTS The CD44/FKBPL ratio was reduced in placenta and plasma following clinical diagnosis of preeclampsia. At 20 weeks of gestation, a high plasma CD44/FKBPL ratio was independently associated with the 2.3-fold increased risk of preeclampsia (odds ratio = 2.3, 95% confidence interval [CI] 1.03-5.23, P = 0.04). In combination with high mean arterial blood pressure (>82.5 mmHg), the risk further increased to 3.9-fold (95% CI 1.30-11.84, P = 0.016). Both hypoxia and MSC-based therapy inhibited FKBPL-CD44 signaling, enhancing cell angiogenesis. CONCLUSIONS The FKBPL-CD44 pathway appears to have a central role in the pathogenesis of preeclampsia, showing promising utilities for early diagnostic and therapeutic purposes.
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Affiliation(s)
- Naomi Todd
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - Ross McNally
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - Abdelrahim Alqudah
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
- The School of Pharmacy, The Hashemite University, Amman, Jordan
| | | | - Sonja Suvakov
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, US
| | | | - Denise Hoch
- Department of Gynaecology and Obstetrics, Medical University Graz, Graz, Austria
| | - Jose R Hombrebueno
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - Guillermo Lopez Campos
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - Chris J Watson
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | | | | | - Anna Krasnodembskaya
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - Gernot Desoye
- Department of Gynaecology and Obstetrics, Medical University Graz, Graz, Austria
| | - Kelly-Ann Eastwood
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
- Royal Jubilee Maternity Hospital, Belfast Health and Social Care Trust, Northern Ireland, UK
| | - Alyson J Hunter
- Royal Jubilee Maternity Hospital, Belfast Health and Social Care Trust, Northern Ireland, UK
| | - Valerie A Holmes
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - David R McCance
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
- Royal Victoria Hospital, Belfast Health and Social Care Trust, Northern Ireland, UK
| | - Ian S Young
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
- Royal Victoria Hospital, Belfast Health and Social Care Trust, Northern Ireland, UK
| | - David J Grieve
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
| | - Louise C Kenny
- The Irish Centre for Foetal and Neonatal Translational Research (INFANT) and Department of Obstetrics and Gynaecology, University College Cork, Cork, Republic of Ireland
- Department of Women’s and Children’s Health, Institute of Translational Research, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Vesna D Garovic
- Department of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, US
| | - Tracy Robson
- School of Pharmacy and Biomolecular Sciences, Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland (RCSI), Dublin, Republic of Ireland
| | - Lana McClements
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Northern Ireland, UK
- School of Life Sciences, Faculty of Science, University of Technology Sydney, NSW, Australia
- Correspondence and Reprint Requests: Lana McClements, School of Life Sciences, Faculty of Science, University of Technology Sydney, PO Box 123 Broadway, NSW, 2007, Australia. E-mail:
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Abstract
Preeclampsia is an obstetric disorder that affects 3-8% of pregnant women and remains a leading cause of short- and long-term neonatal and maternal morbidity and mortality. Professional societies recommend the use of low dose aspirin to prevent preeclampsia in high-risk women. However, interest in prevention of this disease and better understanding of its pathophysiology have led to growing research on other agents. This review focuses on the main therapeutic agents evaluated or in use for preeclampsia prevention.
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Novel approaches to combat preeclampsia: from new drugs to innovative delivery. Placenta 2020; 102:10-16. [PMID: 32980138 DOI: 10.1016/j.placenta.2020.08.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
Preeclampsia is a complex disease affecting 2-8% of pregnancies worldwide. It poses significant risk of maternal and perinatal morbidity and mortality. Despite the rising research interest to discover new therapeutic approaches to prevent and treat preeclampsia, options remain limited. Identifying the important pathological stages in the progression of this disease allows us to evaluate effective candidate therapeutics. Three important stages in the pathophysiology are: 1) placental hypoxia and oxidative stress, 2) excess release of anti-angiogenic and pro-inflammatory factors, and 3) widespread systemic endothelial dysfunction and vasoconstriction. Repurposing drugs already safe for use in pregnancy is an attractive option for discovery of novel therapeutics. There are many drugs currently being assessed to treat preeclampsia, including proton pump inhibitors (PPIs), metformin, statins, sulfasalazine, sofalcone, resveratrol, melatonin, and sildenafil citrate. These drugs show positive effects in preclinical studies, targeting placental and endothelial dysfunction. However, using novel therapeutics can raise safety concerns for the developing fetus. Therefore, innovative targeted delivery systems are being developed to safely administer these therapeutics directly to the placenta and/or endothelium. These include nanoparticle delivery systems, developed and used by the oncology field, now being adapted for obstetrics. This technology is currently being assessed in animal models and shows promise for treating preeclampsia. Combining effective therapeutics with targeted drug delivery could be the future of preeclampsia treatment.
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Aneman I, Pienaar D, Suvakov S, Simic TP, Garovic VD, McClements L. Mechanisms of Key Innate Immune Cells in Early- and Late-Onset Preeclampsia. Front Immunol 2020; 11:1864. [PMID: 33013837 PMCID: PMC7462000 DOI: 10.3389/fimmu.2020.01864] [Citation(s) in RCA: 101] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/10/2020] [Indexed: 12/23/2022] Open
Abstract
Preeclampsia is a complex cardiovascular disorder of pregnancy with underlying multifactorial pathogeneses; however, its etiology is not fully understood. It is characterized by the new onset of maternal hypertension after 20 weeks of gestation, accompanied by proteinuria, maternal organ damage, and/or uteroplacental dysfunction. Preeclampsia can be subdivided into early- and late-onset phenotypes (EOPE and LOPE), diagnosed before 34 weeks or from 34 weeks of gestation, respectively. Impaired placental development in early pregnancy and subsequent growth restriction is often associated with EOPE, while LOPE is associated with maternal endothelial dysfunction. The innate immune system plays an essential role in normal progression of physiological pregnancy and fetal development. However, inappropriate or excessive activation of this system can lead to placental dysfunction or poor maternal vascular adaptation and contribute to the development of preeclampsia. This review aims to comprehensively outline the mechanisms of key innate immune cells including macrophages, neutrophils, natural killer (NK) cells, and innate B1 cells, in normal physiological pregnancy, EOPE and LOPE. The roles of the complement system, syncytiotrophoblast extracellular vesicles and mesenchymal stem cells (MSCs) are also discussed in the context of innate immune system regulation and preeclampsia. The outlined molecular mechanisms, which represent potential therapeutic targets, and associated emerging treatments, are evaluated as treatments for preeclampsia. Therefore, by addressing the current understanding of innate immunity in the pathogenesis of EOPE and LOPE, this review will contribute to the body of research that could lead to the development of better diagnosis, prevention, and treatment strategies. Importantly, it will delineate the differences in the mechanisms of the innate immune system in two different types of preeclampsia, which is necessary for a more personalized approach to the monitoring and treatment of affected women.
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Affiliation(s)
- Ingrid Aneman
- Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - Dillan Pienaar
- Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
| | - Sonja Suvakov
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Tatjana P. Simic
- Faculty of Medicine, Institute of Medical and Clinical Biochemistry, University of Belgrade, Belgrade, Serbia
- Department of Medical Sciences, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Lana McClements
- Faculty of Science, School of Life Sciences, University of Technology Sydney, Sydney, NSW, Australia
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Virtanen A, Huttala O, Tihtonen K, Toimela T, Heinonen T, Laivuori H, Uotila J. Therapeutic doses of metformin do not have impact on angiogenesis in presence of sera from pre-eclamptic, IUGR and healthy pregnancies. Pregnancy Hypertens 2020; 22:7-13. [PMID: 32682321 DOI: 10.1016/j.preghy.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023]
Abstract
Recent evidence suggests that metformin may prevent pre-eclampsia by reverting the angiogenic imbalance in maternal sera. In this study, we investigated effect of metformin on angiogenesis by quantifying tubule formation in a human-based in vitro test with co-culture of human adipose stromal cell (hASC) and human umbilical vein endothelial cell (HUVEC). A total of 20 pregnant women were recruited in the study. Serum samples were obtained from women with early- and late-onset pre-eclampsia and from women with pregnancies complicated by intrauterine growth restriction (IUGR) without pre-eclampsia (N = 5 in each of the three groups). Serum samples from women with healthy pregnancies served as controls (N = 5). The direct effect of metformin on angiogenesis was first assessed without maternal sera. Secondly, we investigated the impact of metformin on angiogenesis in the present of maternal sera. Metformin was used at 5, 50 and 600 µg/ml concentrations. Angiogenic and inflammatory biomarkers in maternal sera were analyzed by immunoassays. When the direct effect of metformin was studied, the two lowest concentrations of metformin did not affect tubule formation (angiogenesis), but the highest concentration inhibited angiogenesis. When metformin was supplemented at therapeutic concentrations of 5 and 50 µg/ml along with serum samples, there was no change in tubule formation in comparison to maternal sera alone. However, strong inhibitory effect on tubule formation was observed in all groups with the highest, non-therapeutic (600 µg/ml), concentration of metformin.
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Affiliation(s)
- Anita Virtanen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland.
| | - Outi Huttala
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Tarja Toimela
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuula Heinonen
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hannele Laivuori
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
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Jorquera G, Echiburú B, Crisosto N, Sotomayor-Zárate R, Maliqueo M, Cruz G. Metformin during Pregnancy: Effects on Offspring Development and Metabolic Function. Front Pharmacol 2020; 11:653. [PMID: 32625081 PMCID: PMC7311748 DOI: 10.3389/fphar.2020.00653] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
Maternal obesity during pregnancy and gestational diabetes mellitus (GDM) are both associated with of several postnatal diseases in the offspring, including obesity, early onset hypertension, diabetes mellitus, and reproductive alterations. Metformin is an oral drug that is being evaluated to treat GDM, obesity-associated insulin resistance, and polycystic ovary syndrome (PCOS) during pregnancy. The beneficial effects of metformin on glycemia and pregnancy outcomes place it as a good alternative for its use during pregnancy. In this line of thought, improving the metabolic status of the pregnant mother by using metformin should avoid the consequences of insulin resistance on the offspring's fetal and postnatal development. However, some human and animal studies have shown that metformin during pregnancy could amplify these alterations and be associated with excessive postnatal weight gain and obesity. In this minireview, we discuss not only the clinical and experimental evidence that supports the benefits of using metformin during pregnancy but also the evidence showing a possible negative impact of this drug on the offspring's development.
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Affiliation(s)
- Gonzalo Jorquera
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
| | - Bárbara Echiburú
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Nicolás Crisosto
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile.,Unit of Endocrinology, Clínica Las Condes, Santiago, Chile
| | - Ramón Sotomayor-Zárate
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
| | - Manuel Maliqueo
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Gonzalo Cruz
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
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Mate A, Blanca AJ, Salsoso R, Toledo F, Stiefel P, Sobrevia L, Vázquez CM. Insulin Therapy in Pregnancy Hypertensive Diseases and its Effect on the Offspring and Mother Later in Life. Curr Vasc Pharmacol 2020; 17:455-464. [PMID: 30426902 DOI: 10.2174/1570161117666181114125109] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 10/07/2018] [Accepted: 10/10/2018] [Indexed: 01/24/2023]
Abstract
Pregnancy hypertensive disorders such as Preeclampsia (PE) are strongly correlated with insulin resistance, a condition in which the metabolic handling of D-glucose is deficient. In addition, the impact of preeclampsia is enhanced by other insulin-resistant disorders, including polycystic ovary syndrome and obesity. For this reason, there is a clear association between maternal insulin resistance, polycystic ovary syndrome, obesity and the development of PE. However, whether PE is a consequence or the cause of these disorders is still unclear. Insulin therapy is usually recommended to pregnant women with diabetes mellitus when dietary and lifestyle measures have failed. The advantage of insulin therapy for Gestational Diabetes Mellitus (GDM) patients with hypertension is still controversial; surprisingly, there are no studies in which insulin therapy has been used in patients with hypertension in pregnancy without or with an established GDM. This review is focused on the use of insulin therapy in hypertensive disorders in the pregnancy and its effect on offspring and mother later in life. PubMed and relevant medical databases have been screened for literature covering research in the field especially in the last 5-10 years.
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Affiliation(s)
- Alfonso Mate
- Departamento de Fisiologia, Facultad de Farmacia, Universidad de Sevilla, E-41012 Sevilla, Spain.,Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/ Universidad de Sevilla, E- 41013 Sevilla, Spain
| | - Antonio J Blanca
- Departamento de Fisiologia, Facultad de Farmacia, Universidad de Sevilla, E-41012 Sevilla, Spain
| | - Rocío Salsoso
- Departamento de Fisiologia, Facultad de Farmacia, Universidad de Sevilla, E-41012 Sevilla, Spain.,Unidad de Enfermedades Coronarias Agudas, Instituto del Corazón, Escuela de Medicina, Universidad de Sao Paulo, Sao Paulo 05403-000 Brazil
| | - Fernando Toledo
- Department of Basic Sciences, Faculty of Sciences, Universidad del Bío-Bío, Chillan 3780000, Chile.,Cellular and Molecular Physiology Laboratory (CMPL), Department of Obstetrics, Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
| | - Pablo Stiefel
- Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/ Universidad de Sevilla, E- 41013 Sevilla, Spain
| | - Luis Sobrevia
- Departamento de Fisiologia, Facultad de Farmacia, Universidad de Sevilla, E-41012 Sevilla, Spain.,Cellular and Molecular Physiology Laboratory (CMPL), Department of Obstetrics, Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile.,University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine and Biomedical Sciences, University of Queensland, Herston, QLD 4029, Queensland, Australia
| | - Carmen M Vázquez
- Departamento de Fisiologia, Facultad de Farmacia, Universidad de Sevilla, E-41012 Sevilla, Spain.,Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocío/Consejo Superior de Investigaciones Científicas/ Universidad de Sevilla, E- 41013 Sevilla, Spain
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Abstract
PURPOSE OF REVIEW To review the rationale and biological plausibility and discuss the current research on novel interventions for the prevention of preeclampsia. RECENT FINDINGS Preeclampsia affects up to 8% of pregnancies worldwide and remains a major cause of maternal and neonatal morbidity and mortality. Multiple medications have been investigated or repurposed as potential effective interventions for preeclampsia prevention. Aspirin is currently the only drug for which there is some evidence of benefit for preeclampsia prevention, and its use is recommended by professional societies for pregnancies at risk. Statins have shown promise for prevention of preeclampsia in animal models and human pilot studies, without any trend or concerns for safety signals or teratogenicity. The use of metformin has also gained popularity in experimental studies, but observations from randomized clinical trials were not consistent on its utility as a possible intervention for preeclampsia prevention. While initial studies evaluating esomeprazole were promising, randomized trials failed to show benefit. Contemporary research shows exciting new opportunities for prophylactic treatment for preeclampsia, to prevent this debilitating and life-threatening disease.
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Affiliation(s)
- Marwan Ma'ayeh
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA. Marwan.Ma'
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Douglas Kniss
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA
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Ding Y, Yuan X, Gu W, Lu L. Treatment with metformin prevents pre-eclampsia by suppressing migration of trophoblast cells via modulating the signaling pathway of UCA1/miR-204/MMP-9. Biochem Biophys Res Commun 2019; 520:115-121. [DOI: 10.1016/j.bbrc.2019.09.099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 09/23/2019] [Indexed: 12/27/2022]
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Abstract
Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.
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Maple-Brown LJ, Lindenmayer G, Barzi F, Whitbread C, Connors C, Moore E, Boyle J, Kirkwood M, Lee IL, Longmore D, van Dokkum P, Wicks M, Dowden M, Inglis C, Cotter M, Kirkham R, Corpus S, Chitturi S, Thomas S, O'Dea K, Zimmet P, Oats J, McIntyre HD, Brown A, Shaw JE. Real-world experience of metformin use in pregnancy: Observational data from the Northern Territory Diabetes in Pregnancy Clinical Register. J Diabetes 2019; 11:761-770. [PMID: 30680949 DOI: 10.1111/1753-0407.12905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 12/11/2018] [Accepted: 01/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND In Australia's Northern Territory, Indigenous mothers account for 33% of births and have high rates of hyperglycemia in pregnancy. The prevalence of type 2 diabetes (T2D) in pregnancy is up to 10-fold higher in Indigenous than non-Indigenous Australian mothers, and the use of metformin is common. We assessed birth outcomes in relation to metformin use during pregnancy from a clinical register. METHODS The study included women with gestational diabetes (GDM), newly diagnosed diabetes in pregnancy (DIP), or pre-existing T2D from 2012 to 2016. Data were analyzed for metformin use in the third trimester. Regression models were adjusted for maternal age, body mass index, parity, and insulin use. RESULTS Of 1649 pregnancies, 814 (49.4%) were to Indigenous women, of whom 234 (28.7%) had T2D (vs 4.6% non-Indigenous women; P < 0.001). Metformin use was high in Indigenous women (84%-90% T2D, 42%-48% GDM/DIP) and increased over time in non-Indigenous women (43%-100% T2D, 14%-35% GDM/DIP). Among Indigenous women with GDM/DIP, there were no significant differences between groups with and without metformin in cesarean section (51% vs 39%; adjusted odds ratio [aOR] 1.25, 95% confidence interval [CI] 0.87-1.81), large for gestational age (24% vs 13%; aOR 1.5, 95% CI 0.9-2.5), or serious neonatal adverse events (9.4% vs 5.9%; aOR 1.32, 95% CI 0.68-2.57). Metformin use was independently associated with earlier gestational age (37.7 vs 38.5 weeks), but the risk did not remain independently higher after exclusion of women managed with medical nutrition therapy alone, and the increase in births <37 weeks was not significant on multivariate analysis. CONCLUSIONS We found no clear evidence of any adverse outcomes related to the use of metformin for the treatment of hyperglycemia in pregnancy.
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Affiliation(s)
- Louise J Maple-Brown
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Greta Lindenmayer
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Federica Barzi
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Cherie Whitbread
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Christine Connors
- Northern Territory Department of Health, Darwin, Northern Territory, Australia
| | - Elizabeth Moore
- Aboriginal Medical Services Alliance Northern Territory, Darwin, Northern Territory, Australia
| | - Jacqueline Boyle
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Marie Kirkwood
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - I-Lynn Lee
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Danielle Longmore
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Paula van Dokkum
- Department of Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- Population Health Research, Baker Heart and Diabetes Institute, Alice Springs, Northern Territory, Australia
| | - Mary Wicks
- Department of Medicine, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | | | | | - Margaret Cotter
- Aboriginal Medical Services Alliance Northern Territory, Darwin, Northern Territory, Australia
| | - Renae Kirkham
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Sumaria Corpus
- Danila Dilba Health Service, Darwin, Northern Territory, Australia
| | - Sridhar Chitturi
- Division of Medicine, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Sujatha Thomas
- Obstetrics and Gynaecology Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Kerin O'Dea
- Population Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Paul Zimmet
- Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Oats
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Harold D McIntyre
- Mater Medical Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Alex Brown
- Obstetrics and Gynaecology Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jonathan E Shaw
- Population Health Research, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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Abstract
Diabetes is a common complication of pregnancy associated with both short- and long-term adverse maternal and offspring effects. All types of diabetes in pregnancy are increasing in prevalence. Treatment of diabetes in pregnancy, targeting glycemic control, improves both maternal and offspring outcomes, albeit imperfectly for many women. Pharmacologic treatment recommendations differ between pregestational and gestational diabetes. Improved treatment of diabetes in pregnancy will need to consider maternal disease heterogeneity and comorbidities as well as long-term offspring outcomes. In this review, the authors summarize recent clinical studies to highlight established pharmacologic treatments for diabetes in pregnancy and provide suggestions for further research.
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Affiliation(s)
- Maisa N Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Women's Research Institute, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA.
| | - Jason G Umans
- Department of Medicine, Georgetown-Howard Universities Center for Clinical and Translational Science, Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007, USA; Department of Obstetrics and Gynecology, Georgetown-Howard Universities Center for Clinical and Translational Science, Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007, USA
| | - Patrick M Catalano
- Maternal Infant Research Institute, Obstetrics and Gynecology Research, Tufts University School of Medicine, Friedman School of Nutrition Science and Policy, 800 Washington Street, Box 394, Boston, MA 02111, USA
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