Can we predict recurrence of pre-eclampsia or gestational hypertension?

The sFlt-1/PlGF-ratio and the risk of preeclampsia-related adverse outcomes in subsequent pregnancies with signs and symptoms of a preeclampsia

OBJECTIVES

This study characterizes the outcome of two subsequent pregnancies with suspected preeclampsia (PE). We investigated the diagnostic accuracy of clinical signs, Doppler examinations, and the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF)-ratio to predict PE-related adverse outcomes (AO). The sFlt-1/PlGF-ratio of the first pregnancy was compared to the outcome of the subsequent pregnancy.

STUDY DESIGN

A total of 1928 patients at risk for preeclampsia were screened, of them 1117 were eligible for inclusion. Of these, 84 women presented with suspected PE in two subsequent pregnancies.

OUTCOME MEASURES

Diagnostic accuracy of clinical markers was assessed. Associations between the sFlt-1/PlGF-ratio in the first and the odds of an AO in the subsequent pregnancy were investigated with logistic regression.

RESULTS

The prevalence of AOs decreased from 27.4 % in the first to 17.9 % in the second pregnancy. Comparison of the accuracy of the different clinical markers for an AO showed a high specificity for an sFlt-1/PlGF-ratio at the cut-off of ≥ 85 in both pregnancies (81.3 %, 95 % CI 63.6-92.8 vs 92.6 %,95 % CI 83.7-97.6), but a lower sensitivity in the second pregnancy (92.9 %, 95 % CI 66.1-99.8 vs 33.3%, 95 % CI 11.8-61.6). An elevated sFlt-1/PlGF-ratio in the first did not increase the odds of an AO in the subsequent pregnancy.

CONCLUSIONS

The prevalence of AOs decreases in subsequent pregnancies. Our finding that the sFlt-1/PlGF-ratio of the first was not related to the outcome of the subsequent pregnancy suggests that angiogenic markers are only a within-pregnancy short-term tool to assess AOs.

Development and validation of prediction models for fetal growth restriction and birthweight: an individual participant data meta-analysis

Background

Fetal growth restriction is associated with perinatal morbidity and mortality. Early identification of women having at-risk fetuses can reduce perinatal adverse outcomes.

Objectives

To assess the predictive performance of existing models predicting fetal growth restriction and birthweight, and if needed, to develop and validate new multivariable models using individual participant data.

Design

Individual participant data meta-analyses of cohorts in International Prediction of Pregnancy Complications network, decision curve analysis and health economics analysis.

Participants

Pregnant women at booking. External validation of existing models (9 cohorts, 441,415 pregnancies); International Prediction of Pregnancy Complications model development and validation (4 cohorts, 237,228 pregnancies).

Predictors

Maternal clinical characteristics, biochemical and ultrasound markers.

Primary outcomes

fetal growth restriction defined as birthweight <10th centile adjusted for gestational age and with stillbirth, neonatal death or delivery before 32 weeks' gestation birthweight.

Analysis

First, we externally validated existing models using individual participant data meta-analysis. If needed, we developed and validated new International Prediction of Pregnancy Complications models using random-intercept regression models with backward elimination for variable selection and undertook internal-external cross-validation. We estimated the study-specific performance (c-statistic, calibration slope, calibration-in-the-large) for each model and pooled using random-effects meta-analysis. Heterogeneity was quantified using τ2 and 95% prediction intervals. We assessed the clinical utility of the fetal growth restriction model using decision curve analysis, and health economics analysis based on National Institute for Health and Care Excellence 2008 model.

Results

Of the 119 published models, one birthweight model (Poon) could be validated. None reported fetal growth restriction using our definition. Across all cohorts, the Poon model had good summary calibration slope of 0.93 (95% confidence interval 0.90 to 0.96) with slight overfitting, and underpredicted birthweight by 90.4 g on average (95% confidence interval 37.9 g to 142.9 g). The newly developed International Prediction of Pregnancy Complications-fetal growth restriction model included maternal age, height, parity, smoking status, ethnicity, and any history of hypertension, pre-eclampsia, previous stillbirth or small for gestational age baby and gestational age at delivery. This allowed predictions conditional on a range of assumed gestational ages at delivery. The pooled apparent c-statistic and calibration were 0.96 (95% confidence interval 0.51 to 1.0), and 0.95 (95% confidence interval 0.67 to 1.23), respectively. The model showed positive net benefit for predicted probability thresholds between 1% and 90%. In addition to the predictors in the International Prediction of Pregnancy Complications-fetal growth restriction model, the International Prediction of Pregnancy Complications-birthweight model included maternal weight, history of diabetes and mode of conception. Average calibration slope across cohorts in the internal-external cross-validation was 1.00 (95% confidence interval 0.78 to 1.23) with no evidence of overfitting. Birthweight was underestimated by 9.7 g on average (95% confidence interval -154.3 g to 173.8 g).

Limitations

We could not externally validate most of the published models due to variations in the definitions of outcomes. Internal-external cross-validation of our International Prediction of Pregnancy Complications-fetal growth restriction model was limited by the paucity of events in the included cohorts. The economic evaluation using the published National Institute for Health and Care Excellence 2008 model may not reflect current practice, and full economic evaluation was not possible due to paucity of data.

Future work

International Prediction of Pregnancy Complications models' performance needs to be assessed in routine practice, and their impact on decision-making and clinical outcomes needs evaluation.

Conclusion

The International Prediction of Pregnancy Complications-fetal growth restriction and International Prediction of Pregnancy Complications-birthweight models accurately predict fetal growth restriction and birthweight for various assumed gestational ages at delivery. These can be used to stratify the risk status at booking, plan monitoring and management.

Study registration

This study is registered as PROSPERO CRD42019135045.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/148/07) and is published in full in Health Technology Assessment; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.

Recurrence Risk of Pregnancy Complications in Twin and Singleton Deliveries

OBJECTIVE

 This study aimed to estimate and compare the recurrence risk of preterm birth (PTB), gestational diabetes mellitus (GDM), gestational hypertension (GH), and preeclampsia and eclampsia (PE and E) in subsequent pregnancy groups (index-subsequent) of singleton-singleton (n = 49,868), twin-singleton (n = 448), and singleton-twin (n = 723) pregnancies.

STUDY DESIGN

 Birthing individuals from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Consecutive Pregnancy Study (2002-2010) with ≥ 2 singleton or twin deliveries were examined. Adjusted relative risks (aRR) and 95% confidence intervals (CI) for recurrent PTB, GDM, GH, and PE and E were estimated using Poisson regression models with robust variance estimators.

RESULTS

 The aRR of PTB and GDM ranged from 1.4 to 5.1 and 5.2 to 22.7, respectively, with the greatest recurrence relative risk for both conditions in singleton-singleton subsequent pregnancies (PTB: aRR = 5.1 [95% CI: 4.8-5.5], GDM: aRR = 22.7 [95% CI: 20.8-24.8]). The aRR of GH and PE and E ranged from 2.8 to 7.6 and 3.2 to 9.2, respectively, with the greatest recurrence relative risk for both conditions in twin-singleton subsequent pregnancies (GH: aRR = 7.6 [95% CI: 2.8-20.5], PE and E: aRR = 9.2 [95% CI: 2.9-28.6]).

CONCLUSION

 Recurrence relative risk was increased for PTB, GDM, GH, and PE and E in all subsequent pregnancy groups, which varied in magnitude based on the birth number of the index and subsequent pregnancy. This information provides insight into risk management for subsequent pregnancies including multiples.

KEY POINTS

· Recurrence risk for all conditions is persistent in all subsequent pregnancy groups.. · The magnitude of risk varies by the presence of multiples in the index or subsequent pregnancy.. · Singleton-singleton pregnancies are at the greatest risk of PTB.. · Singleton-singleton pregnancies are at the greatest risk of GDM.. · Twin-singleton pregnancies are at the greatest risk of hypertensive disorders..

Hypertensive states of pregnancy

Hypertensive disorders in pregnancy (HDP) remain a leading cause of pregnancy-related maternal and foetal morbidity and mortality worldwide, including chronic hypertension, gestational hypertension, and pre-eclampsia. Affected women and newborns also have an increased risk of cardiovascular disease later in life, independent of traditional cardiovascular disease risks. Despite these risks, recommendations for optimal diagnosis and treatment have changed little in recent decades, probably due to fear of the foetal repercussions of decreased blood pressure and possible drug toxicity. In this document we review the diagnostic criteria and classification of (HDP), as well as important aspects regarding pathophysiology and early detection that allows early identification of women at risk, with the aim of preventing both immediate and long-term consequences. Prophylactic treatment with aspirin is also reviewed early and a therapeutic approach is carried out that involves close maternal and foetal monitoring, and if necessary, the use of safe drugs in each situation. This review aims to provide an updated vision for the prevention, diagnosis, and treatment of HDP that is useful in our usual clinical practice.

Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations

OBJECTIVE

Aspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice.

METHODS

We implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race.

RESULTS

Pre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80-100% of the time.

CONCLUSION

It is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.

The Role of Endothelial Dysfunction in the Pathogenesis of Pregnancy-Related Pathological Conditions: A Review

In the recent decades, endothelial dysfunction (ED) has been recognized as a significant contributing factor in the pathogenesis of many pathological conditions. In interaction with atherosclerosis, hypercholesterolemia, and hypertension, ED plays a crucial role in the pathogenesis of coronary artery disease, chronic renal disease, and microvascular complications in diabetes mellitus. Although ED plays a significant role in the pathogenesis of several pregnancy-related disorders such as preeclampsia, HELLP syndrome, fetal growth restriction, and gestational diabetes mellitus, the exact pathogenetic mechanisms are still a matter of debate. The increased prevalence of these entities in patients with preexisting vascular diseases highlights the essential pathological role of the preexisting ED in these patients. The abnormal uteroplacental circulation and the release of soluble factors from the ischemic placenta into the maternal bloodstream are the main causes of the maternal ED underlying the characteristic preeclamptic phenotype. Besides the increased risk for maternal and fetal poor outcomes, the preexisting ED also increases the risk of development of future cardiovascular diseases in these patients. This study aimed to look deeper into the role of ED in the pathogenesis of several pregnancy-related hypertensive and liver diseases. Hopefully, it could contribute to improvement of the awareness, knowledge, and management of these conditions and also to the reduction of the adverse outcomes and additional long-term cardiovascular complications.

Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.

Racial and ethnic differences in the relationship between infant loss after prior live birth and hypertensive disorders in pregnancy

BACKGROUND

Race and ethnicity influence the distribution and severity of hypertensive disorders of pregnancy (HDP) in the U.S. population, although the impact of prior infant loss on this relationship requires further investigation.

OBJECTIVES

The aim of this study was to assess the relationship between history of infant loss and the risk of HDP by maternal race and ethnicity.

METHODS

For this large cross-sectional study, data were analyzed from the National Center for Health Statistics Vital Statistics Natality Birth Data, 2014-2017. The primary outcome was HDP, and the primary predictor was infant loss after prior live birth. Maternal race/ethnicity was the secondary predictor categorized as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Asian, or Other. Multiple logistic regression was used to assess the association between history of infant loss and HDP by race and ethnicity.

RESULTS

The 9,439,520 women included in this sample were 51% NHW, 15% NHB, 25% Hispanic, 6% Asian, and 3% Other with a mean age of 29.8 ± 5.3 years. In adjusted analyses, infant loss after prior live birth was significantly associated with an 11% odds of HDP (OR 1.11, 95% CI 1.08, 1.13). Stratified by race, NHB (OR 1.28; 95% CI 1.21, 1.36) women had significantly higher odds of HDP, and Hispanic (OR 0.84, 95% CI 0.79, 0.90) and Asian (OR 0.85, 95% CI 0.75, 0.97) women had significantly lower odds compared to NHW women. Within races, all women with infant loss after prior live birth had significantly higher odds of HDP (p < .001), except Other women (p = .632).

CONCLUSIONS

Infant loss after prior live birth was significantly associated with higher odds of HDP among NHB women after adjusting for covariates. Further research is warranted to assess underlying mechanisms associated with higher odds of HDP in NHB women.

Interconception Preventive Care and Recurrence of Pregnancy Complications for Medicaid-Insured Women

Background: Pregnancy complications may recur and are associated with potentially modifiable risks. The role of interconception preventive care in reducing repeat pregnancy complications is understudied. Materials and Methods: This retrospective cohort used 2007-2012 Medicaid claims from 12 states. Included women who had an index birth complicated by prematurity, hypertension, or diabetes, a subsequent birth within 36 months, and Medicaid eligibility for ≥11 of 12 months after index birth. Logistic regression assessed for an association between the exposure of preventive visits in the year after index birth and primary outcomes of prematurity, hypertension, or diabetes in the subsequent pregnancy. Regression adjusted for confounders including demographics (age, race and ethnicity, rural residence, state), index pregnancy features (complications, prenatal visits, multiple gestation, maternal and infant length of stay, year), visits to address complications in the index birth, and interpregnancy interval. Results: Of 17,372 women, mean age was 24.3 ± 5.3 years, and race/ethnicity was 50.3% non-Hispanic White, 27.2% non-Hispanic Black, and 11.9% Hispanic. In the index pregnancy 43.3% experienced prematurity, 39.2% experienced hypertension, and 34.2% experienced diabetes. In the year after the index pregnancy, 54.7% had at least one preventive visit. In the second pregnancy, 47.7% experienced prematurity, hypertension, or diabetes. Recurrence rates were 28.1% for preterm birth, 38.0% for hypertension, and 48.3% for diabetes. Preventive visits were associated with reduced hypertension in the subsequent pregnancy (OR 0.88, 95% CI 0.82-0.97) but not reduced preterm birth or diabetes. Conclusions: Preventive visits after an index birth complicated by prematurity, hypertension, or diabetes were associated with 10% lower odds of hypertension in a subsequent pregnancy, but not with reductions in diabetes or prematurity. Some complications may be more amenable to interconception preventive services than others.

Proteomics and Metabolomics Profiling of Platelets and Plasma Mediators of Thrombo-Inflammation in Gestational Hypertension and Preeclampsia

Platelets may be pivotal mediators of the thrombotic and coagulopathic complications of preeclampsia (PE), linking inflammation and thrombosis with endothelial and vascular dysfunction. Both PE and gestational hypertension (GH) fall within the spectrum of hypertensive complications of pregnancy, with GH being a risk factor for preeclampsia. However, it is unclear what biomarkers distinguish PE from GH. Using a discovery size cohort, we aimed to characterize specific plasma and platelet thrombo-inflammatory drivers indicative of PE and differentiate PE from GH. We performed multiplex immunoassays, platelet and plasma quantitative proteomics and metabolomics of PE patients, comparing with non-pregnant (NP), healthy pregnant controls (PC) and GH participants. The expression pattern of plasma proteins and metabolites in PE/GH platelets was distinct from that of NP and PC. Whilst procoagulation in PC may be fibrinogen driven, inter-alpha-trypsin inhibitors ITIH2 and ITIH3 are likely mediators of thrombo-inflammation in GH and PE, and fibronectin and S100A8/9 may be major procoagulant agonists in PE only. Also enriched in PE were CCL1 and CCL27 plasma cytokines, and the platelet leucine-rich repeat-containing protein 27 and 42 (LRRC27/42), whose effects on platelets were explored using STRING analysis. Through protein-protein interactions analysis, we generated a new hypothesis for platelets’ contribution to the thrombo-inflammatory states of preeclampsia.

Annual body mass index gain and risk of hypertensive disorders of pregnancy in a subsequent pregnancy

Weight gain during interpregnancy period is related to hypertensive disorders of pregnancy (HDP). However, in interpregnancy care/counseling, the unpredictability of the timing of the next conception and the difficulties in preventing age-related body weight gain must be considered while setting weight management goals. Therefore, we suggest considering the annual change in the body mass index (BMI). This study aimed to clarify the association between annual BMI changes during the interpregnancy period and HDP risk in subsequent pregnancies. A multicenter retrospective study of data from 2009 to 2019 examined the adjusted odds ratio (aOR) of HDP in subsequent pregnancies. The aORs in several annual BMI change categories were also calculated in the subgroups classified by HDP occurrence in the index pregnancy. This study included 1,746 pregnant women. A history of HDP (aOR, 16.76; 95% confidence interval [CI], 9.62 - 29.22), and annual BMI gain (aOR, 2.30; 95% CI, 1.76 - 3.01) were independent risk factors for HDP in subsequent pregnancies. An annual BMI increase of ≥ 1.0 kg/m2/year was related to HDP development in subsequent pregnancies for women without a history of HDP. This study provides data as a basis for interpregnancy care/counseling, but further research is necessary to validate our findings and confirm this relationship.

Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis

BACKGROUND

Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management.

OBJECTIVES

To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers.

DESIGN

This was an individual participant data meta-analysis of cohort studies.

SETTING

Source data from secondary and tertiary care.

PREDICTORS

We identified predictors from systematic reviews, and prioritised for importance in an international survey.

PRIMARY OUTCOMES

Early-onset (delivery at < 34 weeks' gestation), late-onset (delivery at ≥ 34 weeks' gestation) and any-onset pre-eclampsia.

ANALYSIS

We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I ² and τ². A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals.

RESULTS

The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia.

LIMITATIONS

Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data.

CONCLUSION

For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings.

FUTURE WORK

Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015029349.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 72. See the NIHR Journals Library website for further project information.

Preeclampsia before 26 weeks of gestation: Obstetrical prognosis for the subsequent pregnancy

INTRODUCTION

Gestational age at delivery seems to be a risk factor of recurrence of preeclampsia. The objective of this study was to analyze adverse pregnancy outcomes and recurrence of preeclampsia during the subsequent pregnancy in women with a history of pre-eclampsia delivered before 26 weeks of gestation.

MATERIAL AND METHOD

We performed a retrospective study in two French tertiary care hospitals between 2000 and 2018. Patients with a history of pre-eclampsia delivered before 26 weeks of gestation were analyzed. Information on the immediate subsequent pregnancy was collected. Adverse composite outcome was defined as recurrent preeclampsia, HELLP syndrome, placental abruption, fetal growth restriction <3rd percentile or <10^e percentile with Doppler abnormalities, maternal death and fetal death.

RESULTS

Among the 107 patients who met the criteria, 48 were analyzed for a subsequent pregnancy. Seventeen women (35.4 %) developed an adverse composite outcome, occurring for 15 women (31.2 %) before 34 weeks. Ten women (20.8 %) developed a recurrent preeclampsia occurring for 5 women (10.4 %) before 34 weeks. We related 3 HELLP syndromes, 1 placental abruption, 9 fetal growth restrictions, 3 fetal deaths and no maternal death. Compared to baseline normotensive women, chronic hypertension was significantly associated with an increased risk of adverse composite outcome (19.3 vs 58.8 %, p-value 0.014).

CONCLUSION

In our population, preeclampsia with delivery before 26 weeks is associated with 35.4 % of adverse composite outcomes and 20.8 % of recurrent preeclampsia during the immediate subsequent pregnancy. These results justify the importance of an ongoing monitoring of these patients during subsequent pregnancy.

Perinatal outcome in gestational hypertension: Which role for developing preeclampsia. A population-based cohort study

OBJECTIVE

To analyze perinatal outcome in singleton pregnancies complicated by gestational hypertension (GH), to investigate the rate of women developing preeclampsia (PE) and to describe maternal features associated with progression to PE.

STUDY DESIGN

This is a population-based retrospective cohort-study involving 514 singleton pregnancies with a diagnosis of GH at admission.

RESULTS

In pregnancies with GH, a poorer pregnancy outcome in comparison to healthy controls was observed in terms of gestational age at delivery, birthweight and birthweight percentile. The observed overall rate of developing PE was 11.7 %. Of all pregnancies with GH at admission, two different groups were identified based on the diagnosis at delivery: GHPE, i.e. women who developed PE (60/514; 11.7 %), and GHnoPE, i.e. women who did not develop PE (454/514; 88.3 %). In the GHPE group it was observed that the 62 % of the women with diagnosis of GH earlier than 28 weeks developed PE while only 2% developed PE if the diagnosis of GH was performed later than 36 weeks. The observed rate of developing PE was 14.7 % in pharmacologically treated hypertensive women, whereas the diagnosis of PE has been made in only 3% of non-treated women.

CONCLUSION

Pregnant women with raised blood pressure are at risk of having a less favourable perinatal outcome. The risk is mainly associated with the progression to PE. Major determinants of the risk of developing PE are the earlier gestational age at diagnosis of GH, the necessity of treatment and the number of anti-hypertensive drugs needed for controlling blood pressure.

Low antithrombin activity before delivery predicts subsequent hypertensive disorders in pregnancy

OBJECTIVE

To examine whether laboratory parameters can predict the onset of recurrent hypertensive disorders of pregnancy (HDP).

METHODS

A retrospective study of 257 women with consecutive deliveries at a hospital in Sapporo, Japan, between 2009 and 2017. Women were divided into four groups according to whether or not they had HDP in the first and second peripartum periods (HDP-HPD, HDP-Non, Non-HDP, Non-Non). HDP was defined as gestational hypertension and/or proteinuria. Laboratory parameters measured on the day of or 1 day before delivery were compared between peripartum-1 and peripartum-2.

RESULTS

Frequency of HDP in peripartum-2 was higher among the 24 (9.3%) women with HPD in peripartum-1 (6/24, 25.0%) than among the 233 (90.7%) women without (3/233, 1.3%) (P<0.001). In peripartum-1, women with HDP had lower median antithrombin activity than those without (74% vs 89%, P=0.021). Antithrombin activity in peripartum-1 was also lower in the HDP-HDP (67%) than in the HDP-Non (79%) group (P=0.021). Antithrombin activities of 77% or less at the first delivery predicted HDP in peripartum-1 (P<0.001) and 70% or less predicted HDP in peripartum-2 (P=0.018).

CONCLUSION

Women with HDP in peripartum-1 had a higher incidence of HDP recurrence. Low antithrombin before a first delivery might predict recurrent HDP in a second pregnancy.

[Hypertension and pregnancy: Post-partum period]

Post-partum period is associated with specific characteristics in women with gestational disorders or preeclampsia. For breastfeeding women, the choice of antihypertensive treatment should take into account the impact on child health. The impact of breastfeeding on health mother must be also discussed. Moreover, for lactation inhibition, bromocriptine should not be used, especially in the context of gestational disorders. In post-partum period, the best contraceptive strategy is only-progestin contraception or non-hormonal contraceptives use. However, this choice will depend on the stabilization or normalization of blood pressure in early post-partum period. Finally, several consultations should be suggested: an information and announcement to explain the consequences of these gestational disorders and organize their multidisciplinary management and follow-up. A preconceptional consultation takes its place to anticipate potential recurrent preeclampsia or gestational hypertension and to schedule a future pregnancy in optimal conditions.

Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies

OBJECTIVE

To develop a practical evidence based list of clinical risk factors that can be assessed by a clinician at ≤ 16 weeks' gestation to estimate a woman's risk of pre-eclampsia.

DESIGN

Systematic review and meta-analysis of cohort studies.

DATA SOURCES

PubMed and Embase databases, 2000-15.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Cohort studies with ≥ 1000 participants that evaluated the risk of pre-eclampsia in relation to a common and generally accepted clinical risk factor assessed at ≤ 16 weeks' gestation.

DATA EXTRACTION

Two independent reviewers extracted data from included studies. A pooled event rate and pooled relative risk for pre-eclampsia were calculated for each of 14 risk factors.

RESULTS

There were 25,356,688 pregnancies among 92 studies. The pooled relative risk for each risk factor significantly exceeded 1.0, except for prior intrauterine growth restriction. Women with antiphospholipid antibody syndrome had the highest pooled rate of pre-eclampsia (17.3%, 95% confidence interval 6.8% to 31.4%). Those with prior pre-eclampsia had the greatest pooled relative risk (8.4, 7.1 to 9.9). Chronic hypertension ranked second, both in terms of its pooled rate (16.0%, 12.6% to 19.7%) and pooled relative risk (5.1, 4.0 to 6.5) of pre-eclampsia. Pregestational diabetes (pooled rate 11.0%, 8.4% to 13.8%; pooled relative risk 3.7, 3.1 to 4.3), prepregnancy body mass index (BMI) >30 (7.1%, 6.1% to 8.2%; 2.8, 2.6 to 3.1), and use of assisted reproductive technology (6.2%, 4.7% to 7.9%; 1.8, 1.6 to 2.1) were other prominent risk factors.

CONCLUSIONS

There are several practical clinical risk factors that, either alone or in combination, might identify women in early pregnancy who are at "high risk" of pre-eclampsia. These data can inform the generation of a clinical prediction model for pre-eclampsia and the use of aspirin prophylaxis in pregnancy.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013)

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.

Delivery Blood Pressure and Other First Pregnancy Risk Factors in Relation to Hypertensive Disorders in Second Pregnancies

BACKGROUND

First pregnancy characteristics and blood pressure (BP) measures may be associated with second pregnancy hypertensive disorder risk. We examined the association between first pregnancy risk factors and second pregnancy hypertensive disorders.

METHODS

Electronic medical records of nulliparas (n = 26,787) delivering at least twice in Utah (2002-2010) were used. Polychotomous logistic regression models estimated the association of first pregnancy risk factors with second pregnancy hypertensive disorders (gestational hypertension, preeclampsia, or chronic hypertension) stratified by first pregnancy hypertensive status and adjusted for second characteristics.

RESULTS

Among normotensive women in their first pregnancy, preterm birth (<34 weeks) and elevated BP at delivery admission in the first pregnancy increased odds of all incident hypertensive disorders in the second. Even borderline admission BP (either systolic or diastolic BP: 130-139 or 85-89 mm Hg, respectively) was associated with a doubling of hypertensive disorder risk in a subsequent pregnancy. First pregnancy BP was also associated with recurrence risks for hypertensive disorders, but the relation was stronger for women with gestational hypertension in their first pregnancy with more than 2-fold elevated risk across all BP categories (odds ratios range: 2.32-12.6). However, the majority of women (75%) with a hypertensive disorder in the first pregnancy do not repeat this outcome in the second pregnancy.

CONCLUSION

Delivery admission BP of a first pregnancy was strongly related to hypertensive disorder incidence and recurrence in the subsequent pregnancy. Although crude, these measures may prove useful as a predictor of long-term maternal health and future pregnancy risk.

Long-term methionine-diet induced mild hyperhomocysteinemia associated cardiac metabolic dysfunction in multiparous rats

Mild hyperhomocysteinemia (HHcy, clinically defined as less than 30 μmol/L) is an independent cardiovascular disease (CVD) risk factor, and is associated with many complications during pregnancy, such as preeclampsia (PE). The aim of this study was to assess the effect of long-term mild HHcy on cardiac metabolic function of multiparous rats. Female rats were mated 3 to 4 times and were fed with methionine in drinking water to increase plasma Hcy (2.9 ± 0.3 to 10.5 ± 2.3 μmol/L) until termination. This caused significant increase of heart weight/body weight (0.24 ± 0.01 to 0.27 ± 0.01 g/100 g) and left ventricle weight (0.69 ± 0.03 to 0.78 ± 0.01 g). Superoxide production was increased by 2.5-fold in HHcy hearts using lucigenin chemiluminescence. The ability of bradykinin and carbachol to regulate myocardial oxygen consumption (MVO₂) in vitro was impaired by 59% and 66% in HHcy heart, and it was restored by ascorbic acid (AA), tempol, or apocynin (Apo). Protein expression of p22^phox subunit of NAD(P)H oxidase was increased by 2.6-fold, but there were no changes in other NAD(P)H oxidase subunits, NOSs or SODs. Microarray revealed 1518 genes to be differentially regulated (P < 0.05). The mRNA level of NAD(P)H oxidase subunits, NOSs or SODs remained unchanged. In conclusion, long-term mild HHcy increases cardiac superoxide mainly through regulation of p22^phox component of the NAD(P)H oxidase and impairs the ability of NO to regulate MVO₂ in heart of multiparous mothers.

Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis

OBJECTIVE

We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes.

STUDY DESIGN

We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI.

RESULTS

Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1).

CONCLUSION

Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Risk factors differ between recurrent and incident preeclampsia: a hospital-based cohort study

PURPOSE

To examine whether risk factors, including prepregnancy body mass index (BMI), differ between recurrent and incident preeclampsia.

METHODS

Data included electronic medical records of nulliparas (n = 26,613) delivering 2 times or more in Utah (2002-2010). Modified Poisson regression models were used to examine (1) adjusted relative risks (RR) of preeclampsia and 95% confidence intervals (CI) associated with prepregnancy BMI; (2) maternal risk factor differences between incident and recurrent preeclampsia among primiparous women.

RESULTS

In the first pregnancy, compared with normal weight women (BMI: 18.5-24.9), preeclampsia risks for overweight (BMI: 25-29.9), obese class I (BMI: 30-34.9), and obese class II/III (BMI: ≥ 35) women were 1.82 (95% CI = 1.60-2.06), 2.10 (95% CI = 1.76-2.50), and 2.84 (95% CI = 2.32-3.47), respectively, whereas second pregnancy-incident preeclampsia risks were 1.66 (95% CI = 1.27-2.16), 2.31 (95% CI = 1.67-3.20), and 4.29 (95% CI = 3.16-5.82), respectively. Recurrent preeclampsia risks associated with BMI were highest among obese class I women (RR = 1.60; 95% CI = 1.06-2.42) without increasing in a dose-response manner. Nonwhite women had higher recurrence risk than white women (RR = 1.70; 95% CI = 1.16-2.50), whereas second pregnancy-incident preeclampsia risk did not differ by race.

CONCLUSION

Prepregnancy BMI appeared to have stronger associations with risk of incident preeclampsia either in the first or second pregnancy, than with recurrence risk. Nonwhite women had higher recurrence risk.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Risk for Recurrence of Pre-eclampsia in the Subsequent Pregnancy

BACKGROUND

Pre-eclampsia (PE) is the commonest type of pregnancy induced hypertension and it affects nearly 5% of pregnant women. Besides short term morbidity and mortality that are associated with pregnancy, PE is associated with long term morbidity in women. There is a lack of information on the risk of recurrence of PE in pregnant Asian Indian women.

AIM

To determine the rates and risk factors which were associated with recurrence of PE in the subsequent pregnancies of women with PE in index pregnancies.

SETTINGS AND DESIGN

A retrospective, observational study done at a single tertiary care centre in southern India.

MATERIAL AND METHODS

The study included pregnant women with PE, who delivered at the study institute in 2008 and received care for their subsequent pregnancies at the study institute. Hypertension in pregnancy was categorized, based on the criteria of the International Society for the Study of Hypertension in Pregnancy. Point estimates and the 95% confidence intervals around point estimates of rates of recurrence of PE and associations of potential clinical and laboratory parameters with recurrence were determined by using bivariate analysis, logistic regression models and area under Receiver Operator Characteristic (ROC) curves.

RESULTS

The study included 82 pregnant women with PE in their index pregnancies. Twenty two (26.83%, 95% CI: 17.03, 36.62) of these 82 women developed recurrence of PE in their subsequent pregnancies. Recurrence of PE was significantly higher (OR 3.94, 95% CI: 1.05, 14.80, p=0.04) among women who were nulliparous in their index pregnancies. Recurrence of PE was not significantly associated with clinical factors or laboratory parameters in the index pregnancies.

CONCLUSION

Nearly one in four of pregnant women with PE developed recurrences in their subsequent pregnancies, although a large proportion of pregnant women with PE (63.38% to 82.97%) in their index pregnancies were normotensive in their subsequent pregnancies.

Pregnancy outcomes following recovery from acquired thrombotic thrombocytopenic purpura

Pregnancy may precipitate acute episodes of thrombotic thrombocytopenic purpura (TTP), but pregnancy outcomes in women who have recovered from acquired TTP are not well documented. We analyzed pregnancy outcomes following recovery from TTP associated with acquired, severe ADAMTS13 deficiency (ADAMTS13 activity <10%) in women enrolled in the Oklahoma TTP-HUS Registry from 1995 to 2012. We also systematically searched for published reports on outcomes of pregnancies following recovery from TTP associated with acquired, severe ADAMTS13 deficiency. Ten women in the Oklahoma Registry had 16 subsequent pregnancies from 1999 to 2013. Two women had recurrent TTP, which occurred 9 and 29 days postpartum. Five of 16 pregnancies (31%, 95% confidence interval, 11%-59%) in 3 women were complicated by preeclampsia, a frequency greater than US population estimates (2.1%-3.2%). Thirteen (81%) pregnancies resulted in normal children. The literature search identified 382 articles. Only 6 articles reported pregnancies in women who had recovered from TTP associated with acquired, severe ADAMTS13 deficiency, describing 10 pregnancies in 8 women. TTP recurred in 6 pregnancies.

CONCLUSIONS

With prospective complete follow-up, recurrent TTP complicating subsequent pregnancies in Oklahoma patients is uncommon, but the occurrence of preeclampsia may be increased. Most pregnancies following recovery from TTP in Oklahoma patients result in normal children.

Recurrence of preeclampsia in northern Tanzania: a registry-based cohort study

OBJECTIVE

Preeclampsia occurs in about 4 per cent of pregnancies worldwide, and may have particularly serious consequences for women in Africa. Studies in western countries have shown that women with preeclampsia in one pregnancy have a substantially increased risk of preeclampsia in subsequent pregnancies. We estimate the recurrence risks of preeclampsia in data from Northern Tanzania.

METHODS

A prospective cohort study was designed using 19,811 women who delivered singleton infants at a hospital in Northern Tanzania between 2000 and 2008. A total of 3,909 women were recorded with subsequent deliveries in the hospital with follow up through 2010. Adjusted recurrence risks of preeclampsia were computed using regression models.

RESULTS

The absolute recurrence risk of preeclampsia was 25%, which was 9.2-fold (95% CI: 6.4 - 13.2) compared with the risk for women without prior preeclampsia. When there were signs that the preeclampsia in a previous pregnancy had been serious either because the baby was delivered preterm or had died in the perinatal period, the recurrence risk of preeclampsia was even higher. Women who had preeclampsia had increased risk of a series of adverse pregnancy outcomes in future pregnancies. These include perinatal death (RR= 4.3), a baby with low birth weight (RR= 3.5), or a preterm birth (RR= 2.5). These risks were only partly explained by recurrence of preeclampsia.

CONCLUSIONS

Preeclampsia in one pregnancy is a strong predictor for preeclampsia and other adverse pregnancy outcomes in subsequent pregnancies in Tanzania. Women with previous preeclampsia may benefit from close follow-up during their pregnancies.

A complicated role for the renin-angiotensin system during pregnancy: highlighting the importance of drug discovery

INTRODUCTION

Blood pressure management is recommended to avoid maternal cerebrovascular or cardiovascular compromise during pregnancy. Current antihypertensive treatment during pregnancy with positive safety profiles includes labetalol, hydralazine, methyldopa and nifedipine.

AREAS COVERED

Many earlier animal and human studies indicate that angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are associated with fetopathy; therefore, these drugs are contraindicated during pregnancy, especially if these medications were taken during the second and third trimesters. The role of the RAS is quite complex, with fetal development heavily dependent on its appropriate expression and function. New findings indicate that the placental unit expresses its own RAS in order to regulate angiogenesis. Multiple studies have shown that women with abnormal uterine doppler sonography produce an agonistic autoantibody to the angiotensin I receptor, implicating a role for RAS function and regulation in abnormal pregnancies. Importantly, interruption of a normal RAS compromises fetal development.

EXPERT OPINION

Traditional medications that inhibit components of RAS for long-term hypertension control are not appropriate for use before or during pregnancy. Further study and drug discovery are needed to find alternative pathways for treatment of hypertensive disorders when pregnancy is present or a possibility.

Short-term outcome of patients with preeclampsia

Introduction

Preeclampsia constitutes a cause of increased mortality in mothers and fetuses. Screening for promoting factors is essential for adequate prevention in the event of any subsequent pregnancy, and for the adequate follow-up of concerned patients. The aim of the present study was to evaluate the short-term outcome of patients with preeclampsia and to identify possible new factors predisposing them to the disease.

Methods

One hundred fifty-five patients having experienced preeclampsia between 2005 and 2010 from the Gynecology and Obstetrics Department of the Foch Hospital (Suresnes, France) were included in the study. All patients had undergone close clinical and standard biological follow-up immediately postpartum and then 3 months later with a reference practitioner. In severe cases, further investigation was carried out by full etiological examination with an assessment of both autoimmune and thrombophilic status.

Results

Obesity and gestational diabetes were observed to be major risk factors for preeclampsia, which were found in 46% and 15% of the cases, respectively. The etiological assessment showed abnormalities in 11% of the patients. Impaired thrombophilia was found in 3% of the patients, impaired autoimmune status in 4%, a combination of both abnormalities in only 1% of the patients, and detection of renal abnormalities in 3% of the patients were observed. In the immediate postpartum period, 66% of patients had maintained elevated blood pressure levels, and 66% had proteinuria > 0.3 g/24 hours. At the 3-month postpartum assessment, persisting arterial hypertension was found in 16% of the patients, requiring continuation of antihypertensive therapy, and 22% of the patients had proteinuria over the accepted threshold (0.15 g/24 hours).

Conclusion

Patients with preeclampsia have increased cardiovascular risk, necessitating lifestyle measures and long-term follow-up. Etiological assessment must be carried out, systematically aiming at the detection of promoting underlying diseases and adaptation of the management of subsequent pregnancies.

Massive respiratory dysfunction as sign of fulminant peripartum cardiomyopathy (PPCM)

OBJECTIVE

Case report of a 35-year-old gravida 3, para 2, at 40 + 6 weeks with massive respiratory dysfunction with need of oxygenation, requiring cesarean section.

CASE REPORT

Postpartum investigations revealed pathological cardiomegaly with left ventricular failure (NYHAIV). Cardiac biopsy diagnosed postpartum dilatative cardiomyopathy. Despite medication with bromocriptine and levosimendan, cardiac function continued to decrease, requiring surgical intervention and implantation of an intracorporal, left ventricular assist device. Following surgery, cardiac function progressively improved and stabilized.

OBJECTIVE

Peripartum cardiomyopathy (PPCM) is a rare, pregnancy-induced disease and requires an interdisciplinary approach for diagnostics and therapeutical treatment.

Risk for recurrence of preeclampsia and outcome of subsequent pregnancy in women with preeclampsia in their first pregnancy

OBJECTIVE

To assess subsequent pregnancy outcome and to identify risk factors for recurrence of preeclampsia (PET) in women with PET in their first pregnancy.

METHODS

A retrospective cohort study of all nulliparous women diagnosed with PET during the years 1996-2008 (PET group, N = 600). Outcome of subsequent pregnancy was compared with a control group of nulliparous women without PET matched by maternal age in a 3:1 ratio (N = 1800).

RESULTS

Subsequent pregnancies in the PET group were characterized by a higher rate of preterm delivery at less than 37 and 34 weeks (15.2% vs. 5.7%, p < 0.001 and 3.8% vs. 0.8%, p < 0.001, respectively), placental abruption (1.7% vs. 0.2%, p = 0.004), IUGR (2.8% vs. 0.9%, p = 0.016), and PET (5.9% vs. 0.8%, p < 0.001). Risk factors for PET and adverse outcome in the subsequent pregnancy included: PET complicated by placental abruption in the index pregnancy (OR = 10.8, 95%-CI = 1.8-34.6), PET requiring delivery prior to 34 weeks in the index pregnancy (OR = 6.5, 95%-CI = 1.6-22.5), chronic hypertension (OR = 5.3, 95%-CI = 1.9-12.7), and maternal age > 35 (OR = 4.3, 95%-CI = 1.2-20.5).

CONCLUSION

PET in the first pregnancy is independently associated with an increased risk for adverse pregnancy outcome and recurrence of PET in the subsequent pregnancy in a manner that is related to the severity of PET in the first pregnancy.

Recurrence risks of hypertensive diseases in pregnancy after HELLP syndrome

AIM

To determine the recurrence risk for hypertensive diseases in pregnancy after HELLP (Hemolysis Elevated Liver enzymes and Low Platelets) syndrome in a first pregnancy.

METHODS

The study was designed as a cohort study investigating 148 Caucasian primiparae with a diagnosis of HELLP syndrome in a first pregnancy and at least one subsequent pregnancy conducted beyond the 24th gestational week. Diagnoses were verified by reviewing medical records and classified according to ISSHP (International Society for the Study of Hypertension in Pregnancy) criteria. The recurrence risk of HELLP syndrome or other hypertensive disorders in the subsequent pregnancy was calculated with regard to disease severity in the index pregnancy.

RESULTS

Among 148 pregnancies subsequent to HELLP syndrome, 56.1% of the women were normotensive. The recurrence rate was 12.8% for HELLP syndrome, 16.2% for pre-eclampsia, and 14.2% for gestational hypertension only. Women with HELLP syndrome ≤32 gestational weeks tended to show a greater risk of complicated subsequent pregnancies compared to women presenting with HELLP after 32 gestational weeks.

CONCLUSIONS

Women with a diagnosis of HELLP syndrome are at a strongly increased risk of recurrent HELLP syndrome, pre-eclampsia or gestational hypertension, however, currently no clinical or laboratory parameters allow the prediction of recurrence risk in any individual case.

Adverse maternal and perinatal outcomes in women with previous preeclampsia: a prospective study

OBJECTIVE

The purpose of this study was to assess recurrence rates of preeclampsia and neonatal outcomes in women with a history of preeclampsia that required preterm delivery.

STUDY DESIGN

Five hundred women with previous preeclampsia that required delivery at <37 weeks' gestation were followed prospectively.

RESULTS

Preeclampsia reoccurred in 117 women (23%). Predictive factors included black (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.16-4.53) or Asian (OR, 2.98; 95% CI, 1.33-6.59) ethnicity, enrollment systolic blood pressure of >130 mm Hg (OR, 2.89; 95% CI, 1.52-5.50), current antihypertensive use (OR, 6.39; 95% CI, 2.38-17.16), and proteinuria of ≥2+ on enrollment urinalysis (OR, 12.35; 95% CI, 3.45-44.21). Women who previously delivered at <34 weeks' gestation were more likely to deliver preterm again (29% vs 17%; relative risk, 1.69; 95% CI, 1.19-2.40) than were those women with previous delivery between 34 and 37 weeks' gestation.

CONCLUSION

Although this study confirms that women with previous preeclampsia that required early delivery are at high risk of the development of preeclampsia, the study identifies risk factors for recurrence and illustrates that women with previous preeclampsia are at greater risk of adverse neonatal outcome.

STOX2 but not STOX1 is differentially expressed in decidua from pre-eclamptic women: data from the Second Nord-Trondelag Health Study

Variation in the Storkhead box-1 (STOX1) gene has previously been associated with pre-eclampsia. In this study, we assess candidate single nucleotide polymorphisms (SNPs) in STOX1 in an independent population cohort of pre-eclamptic (n = 1.139) and non-pre-eclamptic (n = 2.269) women (the HUNT2 study). We also compare gene expression levels of STOX1 and its paralogue, Storkhead box-2 (STOX2) in decidual tissue from pregnancies complicated by pre-eclampsia and/or fetal growth restriction (FGR) (n = 40) to expression levels in decidual tissue from uncomplicated pregnancies (n = 59). We cannot confirm association of the candidate SNPs to pre-eclampsia (P > 0.05). For STOX1, no differential gene expression was observed in any of the case groups, whereas STOX2 showed significantly lower expression in deciduas from pregnancies complicated by both pre-eclampsia and FGR as compared with controls (P = 0.01). We further report a strong correlation between transcriptional alterations reported previously in choriocarcinoma cells over expressing STOX1A and alterations observed in decidual tissue of pre-eclamptic women with FGR.