Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri Lanka

ST2 and galectin-3 as novel biomarkers for the prediction of future cardiovascular disease risk in preeclampsia

The aim of this study was to investigate known cardiovascular disease (CVD) risk biomarkers galectin-3 (Gal-3) and human stromelysin-2 (ST2) levels in preeclampsia (PE) and normotensive pregnancies. A case-control study was conducted in a teaching and research hospital. We performed data analysis involving 45 pregnant women with PE and gestational week (GW) matched 35 normotensive pregnant women. The Gal-3 and ST2 levels were determined by using ELISA kit. Gal-3 values did not differ statistically between PE and control groups (535.1 ng/mL vs. 615.2 ng/mL) (p> .05). ST2 value in the PE group was statistically significantly lower than the control group (33.3 pg/mL vs. PE, 54.5 pg/mL, p ˂ .05). >34 GW patients (late-onset PE) had statistically significantly lower Gal-3 values than the ≤34 GW patients (early-onset PE) (507.1 ng/mL vs. 769.6 ng/mL, p ˂ .05). Late-onset PE patients had significantly lower ST2 values than early-onset patients (26.4 pg/mL vs. 57.9 pg/mL, p ˂ .05). We assume that low Gal-3 values in early-onset PE show a higher risk of cardiac fibrosis although both early and late-onset PE patients had an increased CVD risk later in life. We found the superiority of ST2 levels to Gal-3 levels in PE pregnancies for CVD risk assessment.Impact StatementWhat is already known about this subject? Preeclampsia (PE) in pregnancy is a known risk factor for future cardiovascular disease (CVD) and is also associated with increased mortality from ischaemic heart disease later in life. Studies that investigate patients with a higher risk for CVD in PE pregnancies are lacking.What do the results of this study add? We found different levels of two novel cardiac markers with PE and normotensive pregnancies, and also with early and late-onset PE pregnancies.What are the implications of these findings for clinical practice and/or further research? Different adaptive responses from patients during PE pregnancies via altered levels of cardiac markers could help clinicians to identify women with a higher risk of CVD.

Telomere Homeostasis and Senescence Markers Are Differently Expressed in Placentas From Pregnancies With Early- Versus Late-Onset Preeclampsia

BACKGROUND

Early-onset preeclampsia (EOPE; <34 weeks' gestation) usually has more severe morbidity for the mother and fetus compared to late-onset preeclampsia (LOPE). Telomere homeostasis is disrupted in preeclampsia (PE) and senescence markers are increased. The pathophysiologic differences between early and LOPE are not fully unraveled yet.

METHODS

We studied placental biopsies from 7 pregnancies with EOPE, 6 pregnancies with LOPE, and 13 healthy gestational age-matched controls. Telomere length and aggregate formation were assessed using qualitative fluorescence in situ hybridization and electronic quantitative methods. Senescence markers were evaluated including senescence-associated heterochromatin foci, β-galactosidase (SAβ-Gal), and P16 staining, as was the expression of P16 complementary DNA (cDNA) using real-time quantitative polymerase chain reaction (RT-qPCR).

RESULTS

There were no differences in maternal age, gravidity, parity, body mass index, and mode of conception between the study and the control groups. The percentage of trophoblasts with short telomeres was higher in placental samples from EOPE (52.61% [12.27%]) versus LOPE (28.72% [10.14%]); both were higher compared to controls (7.53% [5.14%], P = .03). Aggregate formation was enhanced in EOPE (8.72% [2.49%]) compared to LOPE (4.54% [1.45%]); both were higher than in healthy controls (2.72% [1.08%], P = .03). Trophoblasts from EOPE versus LOPE were more likely to stain positive for SAβ-Gal and P16 compared to controls (P < .001). P16 cDNA expression assayed by RT-qPCR was 7.51 times higher in EOPE compared to controls and 5.86 times higher than in LOPE.

CONCLUSIONS

Impaired telomere homeostasis and senescence markers are more prominent in EOPE versus LOPE. These findings may contribute to our understanding of the pathophysiology and explain their different clinical presentations and outcomes.

Maternal serum copeptin concentrations in early- and late-onset pre-eclampsia

OBJECTIVE

Early-onset pre-eclampsia is primarily associated with placental dysfunction, whereas late-onset pre-eclampsia is defined as a maternal constitutional disorder. As a protein cosynthesized with vasopressin, copeptin is a potential marker of metabolic syndrome and insulin resistance, which shares similar risk factors with pre-eclampsia. The aim of this study was to investigate the copeptin levels in patients with early-onset and late-onset pre-eclampsia.

MATERIALS AND METHODS

A total of 80 pregnant women receiving antenatal and obstetric care were recruited. The patients were subdivided into four groups: Early-onset pre-eclampsia (n = 20), late-onset pre-eclampsia (n = 20), and two control groups of similar gestational ages for both pre-eclamptic groups (n = 20 in each group). The maternal serum copeptin levels were measured using an enzyme-linked immunosorbent assay.

RESULTS

The mean copeptin levels were 0.92 ± 0.57 ng/mL and 1.65 ± 0.95 ng/mL in the early-onset and late-onset pre-eclampsia groups, respectively. These values were higher compared with the control groups (0.54 ± 0.25 ng/mL and 1.15 ± 0.94 ng/mL, respectively). However, the difference was only statistically significant in the early-onset pre-eclampsia group (p = 0.011). Copeptin levels were associated only with gestational age and systolic-diastolic blood pressure.

CONCLUSION

Our results suggest that copeptin levels might be useful in the evaluation of the severity of pre-eclampsia. However, copeptin might be involved in early- rather than late-onset pre-eclampsia.

Perinatal Outcome in Women with Hypertensive Disorders of Pregnancy: A Retrospective Cohort Study

Background. Hypertensive disorders of pregnancy (HDP) are multisystem diseases known to increase the risk of perinatal mortality worldwide, with a significant proportion of these deaths occurring in low income countries. However, little is known about the obstetric and treatment predictors of perinatal mortality in women with HDP. Methods. A retrospective cohort study design was used to include 1015 hypertensive pregnant women who gave birth to 1110 babies between 2008 and 2013 in three university teaching hospitals. Bivariate and multivariate regression models were used to estimate the associations between selected predictor variables and perinatal mortality taking the onset of HDP illness to death or discharge from the hospital as the time period. Results. There were 322 perinatal deaths resulting in a perinatal mortality rate (PMR) of 290/1000 total births. The proportion of stillbirths was more than 4-fold higher than early neonatal deaths (81% versus 19%). The multivariate analysis demonstrated that multiparity (OR, 1.6; 95% CI, 1.12–228), grand multiparity (OR, 2.8; 95% CI, 1.55–4.92), preterm (OR, 1.5; 95% CI, 1.02–2.35) and very preterm gestational age (OR, 7.7; 95% CI, 5.26–11.20), lack of antenatal care (OR, 2.0; 95% CI, 1.43–2.67), having eclampsia (OR, 4.1; 95% CI, 2.85–6.04), antepartum or before (OR, 6.6; 95% CI, 3.40–12.75) and intrapartum onset of HDP (OR, 4.0; 95% CI, 1.99–8.04), raised SGOT level (OR, 2.3; 95% CI, 1.30–3.91), vaginal delivery (OR, 5.3; 95% CI, 2.93–9.54), low fetal birth weight (OR, 4.3; 95% CI, 2.56–7.23), and maternal death (OR, 12.8; 95% CI, 2.99–54.49) were independent predictors of perinatal mortality. Conclusion. This study showed that the PMR of HDP was among the highest in the world. Parity, gestational age, type and onset of HDP, mode of delivery, birthweight, and maternal outcome were strong predictors of perinatal mortality.

Screening models using multiple markers for early detection of late-onset preeclampsia in low-risk pregnancy

BACKGROUND

Our primary objective was to establish a cutoff value for the soluble fms-like tyrosine kinase 1(sFlt-1)/placental growth factor (PlGF) ratio measured using the Elecsys assay to predict late-onset preeclampsia in low-risk pregnancies. Our secondary objective was to evaluate the ability of combination models using Elecsys data, second trimester uterine artery (UtA) Doppler ultrasonography measurements, and the serum fetoplacental protein levels used for Down's syndrome screening, to predict preeclampsia.

METHODS

This prospective cohort study included 262 pregnant women with a low risk of preeclampsia. Plasma levels of pregnancy-associated plasma protein-A (PAPP-A) and serum levels of alpha-fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin-A were measured, and sFlt-1/PlGF ratios were calculated. All women underwent UtA Doppler ultrasonography at 20 to 24 weeks of gestation.

RESULTS

Eight of the 262 women (3.0%) developed late-onset preeclampsia. Receiver operating characteristic curve analysis showed that the third trimester sFlt-1/PlGF ratio yielded the best detection rate (DR) for preeclampsia at a fixed false-positive rate (FPR) of 10%, followed by the second trimester sFlt-1/PlGF ratio, sFlt-1 level, and PlGF level. Binary logistic regression analysis was used to determine the five best combination models for early detection of late-onset preeclampsia. The combination of the PAPP-A level and the second trimester sFlt-1/PlGF ratio yielded a DR of 87.5% at a fixed FPR of 5%, the combination of second and third trimester sFlt-1/PlGF ratios yielded a DR of 87.5% at a fixed FPR of 10%, the combination of body mass index and the second trimester sFlt-1 level yielded a DR of 87.5% at a fixed FPR of 10%, the combination of the PAPP-A and inhibin-A levels yielded a DR of 50% at a fixed FPR of 10%, and the combination of the PAPP-A level and the third trimester sFlt-1/PlGF ratio yielded a DR of 62.5% at a fixed FPR of 10%.

CONCLUSIONS

The combination of the PAPP-A level and the second trimester sFlt-1/PlGF ratio, and the combination of the second trimester sFlt-1 level with body mass index, were better predictors of late-onset preeclampsia than any individual marker.

Vascular endothelial growth factor family gene polymorphisms in preeclampsia in Sinhalese women in Sri-Lanka

OBJECTIVE

To investigate the association of polymorphisms in the vascular endothelial growth factor (VEGF) family genes (VEGFA rs699947, VEGFA rs3025039, PGF rs1042886, KDR rs2071559 and KDR rs2305948) with preeclampsia in Sinhalese women in Sri-Lanka.

METHODS

We conducted a case-control study where 175 nulliparous Sinhalese women with preeclampsia and 171 normotensive women matched for age, ethnicity, parity and BMI were recruited in tertiary care maternity hospitals in Sri-Lanka. Preeclampsia was diagnosed using international guidelines. DNA extracted from peripheral venous blood and was genotyped using the Sequenom MassARRAY system. χ(2)-test was used to compare the distribution of allele and genotype frequencies between the cases and the control subjects.

RESULTS

The frequency of PGF rs1042886 variant allele (odds ratio (OR) 1.5, 95% confidence interval (CI) 1.1-2.1) and dominant genotype model (aOR 1.6, 95% CI 1.0-2.4) were increased in preeclamptic women compared to controls. VEGFA rs699947, VEGFA rs3025039, KDR rs2071559, and KDR rs2305948 polymorphisms were not associated with preeclampsia.

CONCLUSION

Maternal PGF rs1042886 polymorphism is associated with preeclampsia in Sinhalese women in Sri-Lanka.

Is expectant management of early-onset severe preeclampsia worthwhile in low-resource settings?

OBJECTIVE

To evaluate the maternal and perinatal outcome following expectant management of early-onset severe preeclampsia (PE) at a tertiary hospital in Mansoura, Egypt.

METHODS

This prospective, observational study included 211 patients with severe PE, occurring between 24 and 34 weeks of gestation. They were classified according to gestational age on admission into three groups. Group 1 included 61 patients with gestational ages between 24 and 28 weeks. Group 2 (28 to <32 weeks) included 66 patients and group 3 (32-34 weeks) included 84 patients. Outcome measures included prolongation of gestation, and maternal and perinatal complications.

RESULTS

The median overall prolongation of gestation was 12 +/- 6 days. The rate of neonatal survival significantly increased (P < 0.001) from 12/61 (19.7%) in group 1 to 30/66 (45.5%) in group 2 and 67/84 (79.8%) in group 3. There were no maternal mortalities; however, 43 (20.4%) women developed significant morbidities. HELLP syndrome, renal impairment and placental abruption were the main complications.

CONCLUSION

In low-resource settings, expectant management of early-onset severe PE is associated with relatively higher rates of perinatal mortality and maternal morbidity and should be limited to gestational ages between 28 and 34 weeks of gestation.

Maternal deaths due to eclampsia and HELLP syndrome

OBJECTIVE

To evaluate maternal deaths associated with eclampsia, HELLP syndrome, and the concurrence of these conditions.

METHOD

A review of Medline studies reporting maternal deaths associated with eclampsia or HELLP syndrome published in English, Spanish, and Portuguese between 1995 and June 2008.

RESULTS

A total of 304 deaths were identified: 100 due to eclampsia, 117 due to eclampsia/HELLP, and 87 associated with HELLP syndrome. Of the total deaths, 71.3% of women had seizures and 67.1% developed HELLP syndrome. In high-income countries 3.9% of deaths were due to eclampsia without HELLP syndrome, while in low-income countries this figure was 42.5% (P<0.0001). The presence of HELLP syndrome in the women who died of eclampsia was 90.6% (29/32) in high-income countries compared with 47.6% (88/185) in low-income countries (P<0.001).

CONCLUSION

Concurrent eclampsia and HELLP syndrome was diagnosed in 5-6 out of 10 deaths associated with eclampsia or HELLP syndrome in this review.