Super-obesity and risk for early and late pre-eclampsia

The maternal body mass index and first-trimester placental (vascular) development

BACKGROUND

Maternal obesity is associated with maternal complications, including hypertensive disorders of pregnancy (HDP), and related fetal complications, such as fetal growth restriction. During pregnancy, the placenta is one of the key regulators of embryonic and fetal growth. Previous studies mainly investigated placental growth by measuring postpartum placental weight. However, the effects of obesity on aberrant placental and fetal growth might occur already in the first trimester.

OBJECTIVES

Investigate associations between maternal BMI and first-trimester features of placental size and vascular development.

STUDY DESIGN

870 women were included from a prospective cohort study. BMI was measured <10 weeks of gestation. Transvaginal 3D Power Doppler ultrasounds were obtained at 7, 9, and 11 weeks of gestation to measure placental volume (PV) and utero-placental vascular volume (uPVV). Associations between BMI and utero-placental (vascular) volume trajectories were assessed using mixed models, adjusted for covariates.

RESULTS

Associations were found between maternal BMI and PV (non-linear model; p = 0.022). A BMI ≥34 kg/m2 showed decreased first-trimester PV compared to normal weight (Δ∛PV=-0.070, 95%CI -0.136 to -0.004, p=0.039). Negative associations were found between maternal BMI and uPVV (β=-0.027, 95%CI -0.041 to -0.014, p<0.001). Exclusion of women developing HDP, attenuated the association with PV (non-linear model; p=0.152), whilst the association between uPVV remained (β=-0.031, 95%CI -0.046 to -0.016, p=0.001).

CONCLUSION

Increased maternal BMI is associated with decreasing first-trimester uPVV, moreover, in women with a BMI ≥34 kg/m2 the PV is decreased. These findings suggest tissue-specific changes in the placental development of women with obesity.

Gestational weight gain and obstetric outcomes in women with obesity in an inner-city population

OBJECTIVES

To describe maternal and perinatal outcomes in patients with BMI ≥30 kg/m2 by BMI class and gestational weight gain.

METHODS

Retrospective review of singleton pregnancies with pre-pregnancy BMI ≥30 kg/m2 who received care at our institution between January 1, 2016 and December 31, 2021. Patients were divided into three categories based on BMI (kg/m2): Class I (BMI 30.0-34.9), Class II (BMI 35-39.9), and Class III (BMI≥40) obesity. For gestational weight gain analysis, pregnancies were stratified into three groups: <11 pounds, 11-20 pounds, and >20 pounds. Maternal demographics and outcomes were compared using chi-square analysis, analysis of variance, nonparametric tests, and multivariable regression analysis.

RESULTS

Of 641 patients included, 299 (46.6 %) were in Class I, 209 (32.6 %) in Class II, and 133 (20.7 %) in Class III. Readmission within 6 weeks postpartum, the only outcome found to have a significant difference between BMI categories, was higher in the Class III group (p=0.01). One hundred sixty-two (25.3 %) patients gained <11 pounds, 164 (25.6 %) gained 11-20 pounds, and 313 (48.8 %) gained ≥20 pounds. Greater gestational weight gain was associated with increased rates of cesarean delivery (p<0.001), higher quantitative blood loss (p=0.006), longer length of hospitalization (p=0.03), and higher birthweights (p<0.001).

CONCLUSIONS

This represents a unique and actionable opportunity for clinicians to counsel and support their patients in adhering to optimal weight gain targets throughout their pregnancy. Future studies are needed to determine the optimal gestational weight gain recommendations for obese patients.

Mid-late gestation leptin infusion induces placental mitochondrial and endoplasmic reticulum unfolded protein responses in a mouse model of preeclampsia

INTRODUCTION

Preeclamptic patients, both lean and obese, present with elevated leptin levels which are associated with the development of maternal endothelial dysfunction and adverse fetal outcomes, such as growth restriction, leading to low birth weight. Recent studies in pregnant mice demonstrate that mid-late gestation leptin infusion induces clinical characteristics of preeclampsia, including elevated maternal blood pressure, maternal endothelial dysfunction and fetal growth restriction. However, whether leptin triggers placental stress responses that contribute to adverse fetal outcomes as in preeclampsia is unknown.

METHODS

In the current study we measured the expression of proteins involved in the endoplasmic reticulum (UPRer) and mitochondrial (UPRmt) unfolded protein responses in placentas of wild-type sham normal pregnant and leptin-infused preeclamptic mice.

RESULTS

The data show that mid-late gestation leptin infusion induced activation of indices of placental UPRer and UPRmt, while reducing placental repair mechanisms to UPRmt in preeclamptic mice. Mid-late gestation infusion with leptin upregulated markers of placental oxidative stress, reduced the placental expression levels of mitochondrial electron transport chain complexes I and II and increased the expression of placental endothelin-1 (ET-1) in preeclamptic mice. The leptin-induced activation of several placental UPRmt markers as well as ET-1 levels correlated with fetal growth restriction and impaired maternal endothelial function in preeclamptic mice.

DISCUSSION

Collectively, these data indicate that elevated levels of leptin in mid-late pregnancy in mice promote placental stress responses, akin to those in pregnant women with preeclampsia.

Temporal Trend in Maternal Morbidity and Comorbidity

OBJECTIVE

 This study aimed to examine the temporal trends of severe maternal morbidity (SMM) in the U.S. population in relation to trends in maternal comorbidity.

STUDY DESIGN

 We performed a repeated cross-sectional analysis of data from individuals at 20 weeks' gestation or greater using U.S. birth certificate data from 2011 to 2021. Our primary outcome was SMM defined as the occurrence of intensive care unit admission, eclampsia, hysterectomy, uterine rupture, and blood product transfusion. We also examined the proportions of maternal comorbidity. Outcomes of the adjusted incidence rate ratio (IRR) with 99% confidence intervals (99% CIs) for 2021 m12 compared with 2011 m1 were calculated using negative binomial regression, controlling for predefined confounders.

RESULTS

 There were 42,504,125 births included in the analysis. From 2011 m1 to 2021 m12, there was a significant increase in the prevalence of advanced maternal age (35-39 [45%], 40-44 [29%], and ≥45 [43%] years), morbid obesity (body mass index 40-49.9 [66%], 50-59.9 [91%], and 60-69.9 [98%]), previous cesarean delivery (14%), chronic hypertension (104%), pregestational diabetes (64%), pregnancy-associated hypertension (240%), gestational diabetes (74%), and preterm delivery at 34 to 36 weeks (12%). There was a significant decrease in the incidence of multiple gestation (9%), preterm delivery at 22 to 27 weeks (9%), and preterm delivery at 20 to 21 weeks (22%). From 2011 m1 to 2021 m12, the incidence of SMM increased from 0.7 to 1.0% (crude IRR 1.60 [99% CI 1.54-1.66]). However, the trend was no longer statistically significant after controlling for confounders (adjusted IRR 1.01 [95% CI 0.81-1.27]). The main comorbidity that was associated with the increase in SMM was pregnancy-associated hypertension.

CONCLUSION

 The rise in the prevalence of comorbidity in pregnancy seems to fuel the rise in SMM. Interventions to prevent SMM should include the management and prevention of pregnancy-associated hypertension.

KEY POINTS

· The rise in maternal mortality is related to morbidity.. · Pregnancy-associated hypertension increases morbidity.. · There were increasing trends in age, body mass index, and medical conditions..

Implications of pregnancy on cardiometabolic disease risk: preeclampsia and gestational diabetes

Cardiometabolic disorders, such as obesity, insulin resistance, and hypertension, prior to and within pregnancy are increasing in prevalence worldwide. Pregnancy-associated cardiometabolic disease poses a great risk to the short- and long-term well-being of the mother and offspring. Hypertensive pregnancy, notably preeclampsia, as well as gestational diabetes are the major diseases of pregnancy growing in prevalence as a result of growing cardiometabolic disease prevalence. The mechanisms whereby obesity, diabetes, and other comorbidities lead to preeclampsia and gestational diabetes are incompletely understood and continually evolving in the literature. In addition, novel therapeutic avenues are currently being explored in these patients to offset cardiometabolic-induced adverse pregnancy outcomes in preeclamptic and gestational diabetes pregnancies. In this review, we discuss the emerging pathophysiological mechanisms of preeclampsia and gestational diabetes in the context of cardiometabolic risk as well as the most recent preclinical and clinical updates in the pathogenesis and treatment of these conditions.

The Roles of Obesity and ASB4 in Preeclampsia Pathogenesis

Preeclampsia is a complex pregnancy-related hypertensive disorder which poses significant risks for both maternal and fetal health. Preeclampsia affects 5-8% of pregnancies in the United States, causing a significant public health and economic burden. Despite extensive research, the etiology and pathogenesis of preeclampsia remain elusive, but have been correlated with maternal conditions such as obesity. In recent decades, the incidence of preeclampsia increased along with the prevalence of obesity among women of reproductive age. Maternal obesity has been shown to negatively affect pregnancy in almost all aspects. However, the precise mechanisms by which obesity influences preeclampsia are unclear. Ankyrin repeat and SOCS Box Containing protein 4 (ASB4) is an E3 ubiquitin ligase that can promote the degradation of a wide range of target proteins. ASB4-null mice display a full spectrum of preeclampsia-like phenotypes during pregnancy including hypertension, proteinuria, and decreased litter size. Furthermore, maternal obesity induced by a high-fat diet aggravates preeclampsia-like phenotypes in pregnant mice lacking ASB4. Variants in the ASB4 gene have been associated with obesity in humans, and a functional connection between the ASB4 gene and obesity has been established in mice. This review discusses the connections between preeclampsia, obesity, and ASB4.

Both endothelial mineralocorticoid receptor expression and hyperleptinemia are required for clinical characteristics of placental ischemia in mice

One of the initiating events in preeclampsia (PE) is placental ischemia. Rodent models of placental ischemia do not present with vascular endothelial dysfunction, a hallmark of PE. We previously demonstrated a role for leptin in endothelial dysfunction in pregnancy in the absence of placental ischemia. We hypothesized that placental ischemia requires hyperleptinemia and endothelial mineralocorticoid receptor (ECMR) expression to induce PE-associated endothelial dysfunction in pregnant mice. We induced placental ischemia via the reduced uterine perfusion pressure (RUPP) procedure in pregnant ECMR-intact (ECMR+/+) and ECMR deletion (ECMR-/-) mice at gestational day (GD) 13. ECMR+/+ RUPP pregnant mice also received concurrent leptin infusion via miniosmotic pump (0.9 mg/kg/day). RUPP increased blood pressure via radiotelemetry and decreased fetal growth in ECMR+/+ pregnant mice. Both increases in blood pressure and reduced fetal growth were abolished in RUPP ECMR-/- mice. Placental ischemia did not decrease endothelial-dependent relaxation to acetylcholine (ACh) but increased phenylephrine (Phe) contraction in mesenteric arteries of pregnant mice, which was ablated by ECMR deletion. Addition of leptin to RUPP mice significantly reduced ACh relaxation in ECMR+/+ pregnant mice, accompanied by an increase in soluble FMS-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PLGF) ratio. In conclusion, our data indicate that high leptin levels drive endothelial dysfunction in PE and that ECMR is required for clinical characteristics of hypertension and fetal growth restriction in placental ischemia PE. Collectively, we show that both ECMR and leptin play a role to mediate PE.NEW & NOTEWORTHY Leptin is a key feature of preeclampsia that initiates vascular endothelial dysfunction in preeclampsia characterized by placental ischemia. Endothelial mineralocorticoid receptor (ECMR) deletion in placental ischemia protects pregnant mice from elevations in blood pressure and fetal growth restriction in pregnancy. Increases in leptin production mediate the key pathological feature of endothelial dysfunction in preeclampsia in rodents. ECMR activation contributes to the increase in blood pressure and fetal growth restriction in preeclampsia.

Maternal cardiovascular adaptation to pregnancy in obese pregnant women

INTRODUCTION

Obesity is known to be associated with cardiovascular compromise and a major risk factor for the development of hypertensive disorders in pregnancy. However, little is known about the effect of obesity on maternal cardiac function. The aim of this study was to investigate the effect of obesity on the maternal cardiovascular system.

MATERIAL AND METHODS

This was a prospective, observational, longitudinal study. Pregnant women with booking body mass index (BMI) ≥30 kg/m2 were compared with pregnant women with normal booking BMI 20-24.9 kg/m2. Participants were seen at three time points during pregnancy; 12-14, 20-24 and 30-32 weeks. At all visits, maternal blood pressure (BP) was measured, and cardiac geometry and function were assessed using two-dimensional trans-thoracic echocardiography. Multilevel linear mixed-effects models were used for all the comparisons.

RESULTS

Fifty-nine pregnant women with obesity were compared with 14 pregnant women with normal BMI. In women with obesity, the maternal BP, heart rate and cardiac output were higher and peripheral vascular resistance was lower (p < 0.01 for all comparisons) compared with normal BMI women. Women with obesity had altered cardiac geometry with higher left ventricular end diastolic diameter, intraventricular septal thickness, posterior wall diameter, relative wall thickness and left ventricular mass (p < 0.001 for all comparisons). There was also evidence of impaired diastolic indices in the obese group with a lower E/A ratio, tissue Doppler imaging E' lateral and medial and higher left atrial volume (p < 0.01 for all comparisons). Finally, women with obesity had reduced longitudinal function, as assessed by mitral plane annular systolic excursion, between the second and third trimester of pregnancy, indicating possible early cardiac dysfunction in this group.

CONCLUSIONS

Obesity is associated with maternal hyperdynamic circulation, altered cardiac geometry and suboptimal diastolic function, compared with normal BMI pregnant women, and these factors may contribute to the increased risk of complications in obese pregnant women.

Preconception maternal retinal venular widening and steeper resistance increments in the utero-fetoplacental circulation in pregnancy

We investigated the relationship of preconception maternal retinal vasculature and utero-fetoplacental circulation in ensuing pregnancy. Embedded in a hospital-based, prospective preconception cohort, 396 women with a singleton live birth were included for analysis. We assessed retinal vascular caliber during preconception phase and retrieved ultrasonogram results documenting utero-fetoplacental circulatory indices using Doppler ultrasonography and documented them at 18-21 weeks, 24-28 weeks, and 32-34 weeks where available. We performed a modified Poisson regression to estimate the relative risk of utero-fetoplacental abnormalities, adjusting for major confounders including pre-pregnancy and blood pressure. Per 10 μm increment in maternal preconception retinal venules was associated with over two-fold risks in developing notching (Relative risk [RR]: 2.84; 95% confidence interval [CI]: 1.79, 4.81) and ≥95th percentile umbilical artery pulsatility index (2.36; 1.72, 3.23) during mid-to-late pregnancy, respectively. Women with preconception retinal venular widening tended to demonstrate steeper resistance increments in both maternal uterine arteries and fetal umbilical arteries during mid-to-late pregnancy.

Preterm preeclampsia screening using biomarkers: combining phenotypic classifiers into robust prediction models

BACKGROUND

Preeclampsia screening is a critical component of antenatal care worldwide. Currently, the most developed screening test for preeclampsia at 11 to 13 weeks' gestation integrates maternal demographic characteristics and medical history with 3 biomarkers-serum placental growth factor, mean arterial pressure, and uterine artery pulsatility index-to identify approximately 75% of women who develop preterm preeclampsia with delivery before 37 weeks of gestation. It is generally accepted that further improvements to preeclampsia screening require the use of additional biomarkers. We recently reported that the levels of specific metabolites and metabolite ratios are associated with preterm preeclampsia. Notably, for several of these markers, preterm preeclampsia prediction varied according to maternal body mass index class. These findings motivated us to study whether patient classification allowed for combining metabolites with the current biomarkers more effectively to improve prediction of preterm preeclampsia.

OBJECTIVE

This study aimed to investigate whether metabolite biomarkers can improve biomarker-based preterm preeclampsia prediction in 3 screening resource scenarios according to the availability of: (1) placental growth factor, (2) placental growth factor+mean arterial pressure, and (3) placental growth factor+mean arterial pressure+uterine artery pulsatility index.

STUDY DESIGN

This was an observational case-control study, drawn from a large prospective screening study at 11 to 13 weeks' gestation on the prediction of pregnancy complications, conducted at King's College Hospital, London, United Kingdom. Maternal blood samples were also collected for subsequent research studies. We used liquid chromatography-mass spectrometry to quantify levels of 50 metabolites previously associated with pregnancy complications in plasma samples from singleton pregnancies. Biomarker data, normalized using multiples of medians, on 1635 control and 106 preterm preeclampsia pregnancies were available for model development. Modeling was performed using a methodology that generated a prediction model for preterm preeclampsia in 4 consecutive steps: (1) z-normalization of predictors, (2) combinatorial modeling of so-called (weak) classifiers in the unstratified patient set and in discrete patient strata based on body mass index and/or race, (3) selection of classifiers, and (4) aggregation of the selected classifiers (ie, bagging) into the final prediction model. The prediction performance of models was evaluated using the area under the receiver operating characteristic curve, and detection rate at 10% false-positive rate.

RESULTS

First, the predictor development methodology itself was evaluated. The patient set was split into a training set (2/3) and a test set (1/3) for predictor model development and internal validation. A prediction model was developed for each of the 3 different predictor panels, that is, placental growth factor+metabolites, placental growth factor+mean arterial pressure+metabolites, and placental growth factor+mean arterial pressure+uterine artery pulsatility index+metabolites. For all 3 models, the area under the receiver operating characteristic curve in the test set did not differ significantly from that of the training set. Next, a prediction model was developed using the complete data set for the 3 predictor panels. Among the 50 metabolites available for modeling, 26 were selected across the 3 prediction models; 21 contributed to at least 2 out of the 3 prediction models developed. Each time, area under the receiver operating characteristic curve and detection rate were significantly higher with the new prediction model than with the reference model. Markedly, the estimated detection rate with the placental growth factor+mean arterial pressure+metabolites prediction model in all patients was 0.58 (95% confidence interval, 0.49-0.70), a 15% increase (P<.001) over the detection rate of 0.43 (95% confidence interval, 0.33-0.55) estimated for the reference placental growth factor+mean arterial pressure. The same prediction model significantly improved detection in Black (14%) and White (19%) patients, and in the normal-weight group (18.5≤body mass index<25) and the obese group (body mass index≥30), with respectively 19% and 20% more cases detected, but not in the overweight group, when compared with the reference model. Similar improvement patterns in detection rates were found in the other 2 scenarios, but with smaller improvement amplitudes.

CONCLUSION

Metabolite biomarkers can be combined with the established biomarkers of placental growth factor, mean arterial pressure, and uterine artery pulsatility index to improve the biomarker component of early-pregnancy preterm preeclampsia prediction tests. Classification of the pregnant women according to the maternal characteristics of body mass index and/or race proved instrumental in achieving improved prediction. This suggests that maternal phenotyping can have a role in improving the prediction of obstetrical syndromes such as preeclampsia.

Sexually dimorphic pubertal development and adipose tissue kisspeptin dysregulation in the obese and preeclamptic-like BPH/5 mouse model offspring

Preeclampsia (PE) is a devastating hypertensive disorder of pregnancy closely linked to obesity. Long-term adverse outcomes may occur in offspring from preeclamptic pregnancies. Accordingly, sex-specific changes in pubertal development have been described in children from preeclamptic women, but the underlying mechanisms remain vastly unexplored. Features of PE are spontaneously recapitulated by the blood pressure high subline 5 (BPH/5) mouse model, including obesity and dyslipidemia in females before and throughout pregnancy, superimposed hypertension from late gestation to parturition and fetal growth restriction. A sexually dimorphic cardiometabolic phenotype has been described in BPH/5 offspring: while females are hyperphagic, hyperleptinemic, and overweight, with increased reproductive white adipose tissue (rWAT), males have similar food intake, serum leptin concentration, body weight and rWAT mass as controls. Herein, pubertal development and adiposity were further investigated in BPH/5 progeny. Precocious onset of puberty occurs in BPH/5 females, but not in male offspring. When reaching adulthood, the obese BPH/5 females display hypoestrogenism and hyperandrogenism. Kisspeptins, a family of peptides closely linked to reproduction and metabolism, have been previously shown to induce lipolysis and inhibit adipogenesis. Interestingly, expression of kisspeptins (Kiss1) and their cognate receptor (Kiss1r) in the adipose tissue seem to be modulated by the sex steroid hormone milieu. To further understand the metabolic-reproductive crosstalk in the BPH/5 offspring, Kiss1/Kiss1r expression in male and female rWAT were investigated. Downregulation of Kiss1/Kiss1r occurs in BPH/5 females when compared to males. Interestingly, dietary weight loss attenuated circulating testosterone concentration and rWAT Kiss1 downregulation in BPH/5 females. Altogether, the studies demonstrate reproductive abnormalities in offspring gestated in a PE-like uterus, which appear to be closely associated to the sexually dimorphic metabolic phenotype of the BPH/5 mouse model.

First-trimester preterm preeclampsia prediction with metabolite biomarkers: differential prediction according to maternal body mass index

BACKGROUND

Prediction of preeclampsia risk is key to informing effective maternal care. Current screening for preeclampsia at 11 to 13 weeks of gestation using maternal demographic characteristics and medical history with measurements of mean arterial pressure, uterine artery pulsatility index, and serum placental growth factor can identify approximately 75% of women who develop preterm preeclampsia with delivery at <37 weeks of gestation. Further improvements to preeclampsia screening tests will likely require integrating additional biomarkers. Recent research suggests the existence of distinct maternal risk profiles. Therefore, biomarker evaluation should account for the possibility that a biomarker only predicts preeclampsia in a specific maternal phenotype.

OBJECTIVE

This study aimed to verify metabolite biomarkers as preterm preeclampsia predictors early in pregnancy in all women and across body mass index groups.

STUDY DESIGN

Observational case-control study drawn from a large prospective study on the early prediction of pregnancy complications in women attending their routine first hospital visit at King's College Hospital, London, United Kingdom, in 2010 to 2015. Pregnant women underwent a complete first-trimester assessment, including the collection of blood samples for biobanking. In 11- to 13-week plasma samples of 2501 singleton pregnancies, the levels of preselected metabolites implicated in the prediction of pregnancy complications were analyzed using a targeted liquid chromatography-mass spectrometry method, yielding high-quality quantification data on 50 metabolites. The ratios of amino acid levels involved in arginine biosynthesis and nitric oxide synthase pathways were added to the list of biomarkers. Placental growth factor and pregnancy-associated plasma protein A were also available for all study subjects, serving as comparator risk predictors. Data on 1635 control and 106 pregnancies complicated by preterm preeclampsia were considered for this analysis, normalized using multiples of medians. Prediction analyses were performed across the following patient strata: all subjects and the body mass index classes of <25, 25 to <30, and ≥30 kg/m². Adjusted median levels were compared between cases and controls and between each body mass index class group. Odds ratios and 95% confidence intervals were calculated at the mean ±1 standard deviation to gauge clinical prediction merits.

RESULTS

The levels of 13 metabolites were associated with preterm preeclampsia in the entire study population (P<.05) with particularly significant (P<.01) associations found for 6 of them, namely, 2-hydroxy-(2/3)-methylbutyric acid, 25-hydroxyvitamin D3, 2-hydroxybutyric acid, alanine, dodecanoylcarnitine, and 1-(1Z-octadecenyl)-2-oleoyl-sn-glycero-3-phosphocholine. Fold changes in 7 amino acid ratios, all involving glutamine or ornithine, were also significantly different between cases and controls (P<.01). The predictive performance of some metabolites and ratios differed according to body mass index classification; for example, ornithine (P<.001) and several ornithine-related ratios (P<.0001 to P<.01) were only strongly associated with preterm preeclampsia in the body mass index of <25 kg/m² group, whereas dodecanoylcarnitine and 3 glutamine ratios were particularly predictive in the body mass index of ≥30 kg/m² group (P<.01).

CONCLUSION

Single metabolites and ratios of amino acids related to arginine bioavailability and nitric oxide synthase pathways were associated with preterm preeclampsia risk at 11 to 13 weeks of gestation. Differential prediction was observed according to body mass index classes, supporting the existence of distinct maternal risk profiles. Future studies in preeclampsia prediction should account for the possibility of different maternal risk profiles to improve etiologic and prognostic understanding and, ultimately, clinical utility of screening tests.

Pregnancy outcomes and risk factors for preeclampsia in dichorionic twin pregnancies after in vitro fertilization: a five-year retrospective study

Background

Both in vitro fertilization (IVF) and preeclampsia (PE) were associated with placental dysfunction. Although IVF can increase the incidence of PE, the pregnancy outcomes and risk factors for preeclampsia in dichorionic twin pregnancies conceived via IVF remain unclear. This study aimed to investigate the pregnancy outcomes and the risk factors for preeclampsia in dichorionic twin pregnancies conceived through IVF compared to those conceived after natural conception (NC).

Methods

This retrospective observational study enrolled 181 dichorionic twin pregnancy women with preeclampsia from 2016 to 2020. According to the mode of conception, they were allocated into IVF (n = 117) and NC groups (n = 64). The clinical characteristics of preeclampsia and pregnancy outcomes between the two groups were compared by using Student’s t test, chi-square test, and Fisher’s exact test, and logistic regression models were used to obtain adjusted odds ratios (aOR) with 95% confidence intervals (CI) for risk factors of early-onset preeclampsia.

Results

The incidence of early-onset PE and growth discordance in dichorionic twin pregnancies with PE is significantly higher in IVF-PE group than in NC group (78.60% vs 43.80%, P < 0.001, 11.10% vs 25.00%, P = 0.015). We found that IVF (aOR = 4.635, 95% CI: 2.130–10.084, P < 0.001) and growth discordance (aOR = 3.288; 95% CI: 1.090–9.749, P < 0.05) increased the incidence of early-onset PE.

Conclusions

In preeclamptic dichorionic twin pregnancies, IVF and growth discordance were associated with the increased incidence of early-onset PE. The underlying mechanism for the relationship between IVF and early-onset PE or growth discordance may be placental dysfunction.

Analysis of serum placental growth factor levels in preeclamptic and normotensive pregnant women in Lagos, Nigeria: a worthwhile screening tool?

The clinical usefulness of serum placental growth factor (PlGF) as a predictive biomarker of preeclampsia is currently being examined. However, there are still conflicting results in the literature. We assessed the association between maternal low PlGF levels and the occurrence and severity of preeclampsia. This was an analytical cross-sectional study conducted among 60 women with preeclampsia, and an equal number of matched normotensive pregnant women. PlGF concentrations were analysed using the ELISA method. Bivariate and multivariate analysis was used to test for the association between low maternal PlGF levels and the occurrence of preeclampsia and its severity. Statistical significance was reported at p < .05. The study showed that having a low maternal PlGF level (Adjusted OR 14.23; 95%CI 8.06, 29.71) together with being primigravid (Adjusted OR 3.97; 95%CI 1.03, 6.18) and having an unbooked pregnancy (Adjusted OR 8.07; 95%CI 2.06, 19.40) were independently associated with preeclampsia. We established an association between low maternal PlGF levels and preeclampsia, but no similar association with severe preeclampsia. The use of PlGF as a potential predictive marker and a reliable screening tool may have a profound implication on the prevention of preeclampsia and the subsequent reduction in its associated morbidity and mortality.Impact statementWhat is already known on this subject? The utility of serum placental growth factor (PlGF) as a predictive biomarker of preeclampsia is currently being examined, however, there are conflicting results of its clinical usefulness in the literature.What do the results of this study add? This study that assessed the association between maternal low PlGF levels and the occurrence and severity of preeclampsia showed that having a low maternal PlGF level together with being primigravid and having an unbooked pregnancy were independently associated with the occurrence of preeclampsia. However, we were unable to establish any significant relationship between maternal PlGF and the severity of preeclampsia.What are the implications of these findings for clinical practice and/or further research? We opined that the use of PlGF as a potential predictive marker and a reliable screening tool may have a profound clinical implication on the prevention and reduction in the associated morbidity and mortality of preeclampsia. However, there is an urgent need for more robust longitudinal studies to define the regulation of placental vascular development and the clinical usefulness of maternal serum PlGF and other placental biomarkers as potential screening tools for preeclampsia among black African women.

Midgestation Leptin Infusion Induces Characteristics of Clinical Preeclampsia in Mice, Which Is Ablated by Endothelial Mineralocorticoid Receptor Deletion

BACKGROUND

Patients with preeclampsia demonstrate increases in placental leptin production in midgestation, and an associated increase in late gestation plasma leptin levels. The consequences of mid-late gestation increases in leptin production in pregnancy is unknown. Our previous work indicates that leptin infusion induces endothelial dysfunction in nonpregnant female mice via leptin-mediated aldosterone production and endothelial mineralocorticoid receptor (ECMR) activation, which is ablated by ECMR deletion. Therefore, we hypothesized that leptin infusion in mid-gestation of pregnancy induces endothelial dysfunction and hypertension, hallmarks of clinical preeclampsia, which are prevented by ECMR deletion.

METHODS

Leptin was infused via miniosmotic pump (0.9 mg/kg per day) into timed-pregnant ECMR-intact (WT) and littermate-mice with ECMR deletion (KO) on gestation day (GD)11-18.

RESULTS

Leptin infusion decreased fetal weight and placental efficiency in WT mice compared with WT+vehicle. Radiotelemetry recording demonstrated that blood pressure increased in leptin-infused WT mice during infusion. Leptin infusion reduced endothelial-dependent relaxation responses to acetylcholine (ACh) in both resistance (second-order mesenteric) and conduit (aorta) vessels in WT pregnant mice. Leptin infusion increased placental ET-1 (endothelin-1) production evidenced by increased PPET-1 (preproendothelin-1) and ECE-1 (endothelin-converting enzyme-1) expressions in WT mice. Adrenal aldosterone synthase (CYP11B2) and angiotensin II type 1 receptor b (AT1Rb) expression increased with leptin infusion in pregnant WT mice. KO pregnant mice demonstrated protection from leptin-induced reductions in pup weight, placental efficiency, increased BP, and endothelial dysfunction.

CONCLUSIONS

Collectively, these data indicate that leptin infusion in midgestation induces endothelial dysfunction, hypertension, and fetal growth restriction in pregnant mice, which is ablated by ECMR deletion.

Dietary factors that affect the risk of pre-eclampsia

Pre-eclampsia affects 3%-5% of pregnant women worldwide and is associated with a range of adverse maternal and fetal outcomes, including maternal and/or fetal death. It particularly affects those with chronic hypertension, pregestational diabetes mellitus or a family history of pre-eclampsia. Other than early delivery of the fetus, there is no cure for pre-eclampsia. Since diet or dietary supplements may affect the risk, we have carried out an up-to-date, narrative literature review to assess the relationship between nutrition and pre-eclampsia. Several nutrients and dietary factors previously believed to be implicated in the risk of pre-eclampsia have now been shown to have no effect on risk; these include vitamins C and E, magnesium, salt, ω-3 long-chain polyunsaturated fatty acids (fish oils) and zinc. Body mass index is proportionally correlated with pre-eclampsia risk, therefore women should aim for a healthy pre-pregnancy body weight and avoid excessive gestational and interpregnancy weight gain. The association between the risk and progression of the pathophysiology of pre-eclampsia may explain the apparent benefit of dietary modifications resulting from increased consumption of fruits and vegetables (≥400 g/day), plant-based foods and vegetable oils and a limited intake of foods high in fat, sugar and salt. Consuming a high-fibre diet (25-30 g/day) may attenuate dyslipidaemia and reduce blood pressure and inflammation. Other key nutrients that may mitigate the risk include increased calcium intake, a daily multivitamin/mineral supplement and an adequate vitamin D status. For those with a low selenium intake (such as those living in Europe), fish/seafood intake could be increased to improve selenium intake or selenium could be supplemented in the recommended multivitamin/mineral supplement. Milk-based probiotics have also been found to be beneficial in pregnant women at risk. Our recommendations are summarised in a table of guidance for women at particular risk of developing pre-eclampsia.

Performance of sFlt-1/PIGF Ratio for the Prediction of Perinatal Outcome in Obese Pre-Eclamptic Women

Obese women are at high risk of developing pre-eclampsia (PE). As an altered angiogenic profile is characteristic for PE, measurement of soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PIGF) ratio in the maternal serum can be helpful for PE diagnosis, as well as for adverse perinatal outcome (APO) prediction. There is growing evidence that obesity might influence the level of sFlt-1/PIGF and, therefore, the aim of the study was the evaluation of sFlt-1/PIGF as an APO predictor in obese women with PE. Pre-eclamptic women who had an sFlt-1/PIGF measurement at the time of diagnosis were retrospectively included. Women were classified according to their pre-pregnancy body mass index (BMI) as normal weight (BMI < 25 kg/m2), overweight (BMI > 25−29.9 kg/m2) or obese (BMI ≥ 30 kg/m2). APO was defined as the occurrence of one of the following outcomes: Small for gestational age, defined as a birthweight < 3rd centile, neonatal mortality, neonatal seizures, admission to neonatal unit required (NICU) or respiratory support. A total of 141 women were included. Of them, 28 (20%) patients were obese. ROC (receiver operating characteristic) analysis revealed a high predictive value for sFlt-1/PIGF and APO across the whole study cohort (AUC = 0.880, 95% CI: 0.826−0.936; p < 0.001). However, the subgroup of obese women showed a significantly lower level of sFlt-1 and, therefore, the performance of sFlt-1/PIGF as APO predictor was poorer compared to normal or overweight PE women (AUC = 0.754, 95% CI: 0.552−0.956, p = 0.025). In contrast to normal or overweight women, a ratio of sFlt-1/PIGF < 38 could not rule out APO in women with obesity.

The Relationship between Obesity and Pre-Eclampsia: Incidental Risks and Identification of Potential Biomarkers for Pre-Eclampsia

Obesity has been steadily increasing over the past decade in the US and worldwide. Since 1975, the prevalence of obesity has increased by 2% per decade, unabated despite new and more stringent guidelines set by WHO, CDC, and other public health organizations. Likewise, maternal obesity has also increased worldwide over the past several years. In the United States, pre-pregnancy rates have increased proportionally across all racial groups. Obesity during pregnancy has been directly linked to obstetric complications including gestational diabetes, HTN, hematomas, pre-eclampsia, and congenital defects. In the particular case of pre-eclampsia, the incidence rate across the globe is 2.16%, but the condition accounts for 30% of maternal deaths, and a robust body of evidence underscored the relationship between obesity and pre-eclampsia. More recently, attention has focused on the identification of reliable biomarkers predictive of an elevated risk for pre-eclampsia. The aim of this literature review is to elucidate the relationship between obesity and these predictive biomarkers for future prediction and prevention of pre-eclampsia condition in women at risk.

Evaluation of the PLAC8 Gene in Mexican Women With and Without Preeclampsia and Obesity

Preeclampsia (PE) is a leading cause of maternal-fetal mortality worldwide, and obesity is an important risk factor. Genes associated with pathophysiological events common to preeclampsia and obesity, such as PLAC8, remain to be studied; therefore, the aim of the present study was to evaluate this gene in the placentas of women affected with preeclampsia and healthy pregnant women. This case-controlled study included 71 healthy and 64 preeclampsia pregnancies. Gene expression was evaluated in primary human cytotrophoblasts (PHCT) from six normal and six preeclampsia pregnancies, and protein expression was verified in placentas from five healthy and six preeclampsia pregnancies. The whole coding and 5′ regions of the PLAC8 gene were sequenced from healthy (n = 10) and preeclamptic (n = 10) pregnancies. The presence of the observed nucleotide variations was analyzed by RT-PCR in the total population. Statistical analyses were performed accordingly. Obesity was associated with severe preeclampsia (SPE) (OR = 3.34; CI 95% 1.3–8.2, p < 0.01). Significantly higher mRNA and protein expression was observed in preeclamptic vs. healthy placentas (p < 0.05). After sequencing, a single nucleotide variation was identified in 10 cases and one control (p < 0.01), which was then evaluated in the total population showing no association with preeclampsia. This preliminary study confirms the association of SPE with obesity and suggests higher expression of PLAC8 mRNA and protein in placentas from preeclampsia. No differences in nucleotide variations between cases and controls of the whole population were observed. Further research is required to evaluate the implications of higher gene/protein expression in preeclampsia and the causes of such variation.

Pregnancy Care for Patients With Super Morbid Obesity

The patient with obesity represents unique challenges to the medical community and, in the setting of pregnancy, additional risks to both mother and fetus. This document will focus on the risks and considerations needed to care for the women with obesity and her fetus during the antepartum, intrapartum, and immediate postpartum stages of pregnancy. Specific attention will be given to pregnancy in the setting of class III and super morbid obesity.

Bariatric surgery and its impact on fertility, pregnancy and its outcome: A narrative review

Bariatric procedures are on the rise as a surgical treatment for morbid obesity. In reproductive age of women, bariatric surgeries will improve factors related to anovulation and lead to spontaneous fertility. Spontaneous pregnancy can happen within a year after bariatric surgery due to higher level of sex hormone binding globulin and follicular stimulating hormone and reduction in androgens level. Reduction of length of follicular phase of menstrual cycle was reported and contribute to improved ovulatory status.

The major impact to pregnant women is development of small for gestational age babies due to persistent weight loss but this can be minimized by avoiding pregnancies too soon after bariatric surgery and good nutrition supplement. Risk of developing gestational diabetes mellitus and preeclampsia reduced among post bariatric surgery compared to no surgery. Another benefit observed are reduction in the risk of caesarean section and admission to neonatal intensive care unit. There are no significant changes in composition of breast milk in postpartum women without bariatric surgery and with women whom undergone surgery although more study needed to evaluate this effect.

Good prenatal care, micronutrient supplement during antenatal follow up and close supervision from expert managing this pregnancy are essential component to ensure good outcome to mothers and their newborn.

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Bariatric surgery in obese women will lead to improvement in ovulation.

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Bariatric surgery will improve the BMI and reduce risk associated with Gestational Diabetes Mellitus and Preeclampsia.

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Bariatric surgery will improve BMI and reduce miscarriages.

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Bariatric surgery in obese women will improve perinatal outcome.

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Mode of delivery and role of breastfeeding after bariatric surgery in obese women.

Placental Ischemia Says "NO" to Proper NOS-Mediated Control of Vascular Tone and Blood Pressure in Preeclampsia

In this review, we first provide a brief overview of the nitric oxide synthase (NOS) isoforms and biochemistry. This is followed by describing what is known about NOS-mediated blood pressure control during normal pregnancy. Circulating nitric oxide (NO) bioavailability has been assessed by measuring its metabolites, nitrite (NO₂) and/or nitrate (NO₃), and shown to rise throughout normal pregnancy in humans and rats and decline postpartum. In contrast, placental malperfusion/ischemia leads to systemic reductions in NO bioavailability leading to maternal endothelial and vascular dysfunction with subsequent development of hypertension in PE. We end this article by describing emergent risk factors for placental malperfusion and ischemic disease and discussing strategies to target the NOS system therapeutically to increase NO bioavailability in preeclamptic patients. Throughout this discussion, we highlight the critical importance that experimental animal studies have played in our current understanding of NOS biology in normal pregnancy and their use in finding novel ways to preserve this signaling pathway to prevent the development, treat symptoms, or reduce the severity of PE.

Obesity-associated cardiovascular risk in women: hypertension and heart failure

The pathogenesis of obesity-associated cardiovascular diseases begins long prior to the presentation of a cardiovascular event. In both men and women, cardiovascular events, and their associated hospitalizations and mortality, are often clinically predisposed by the presentation of a chronic cardiovascular risk factor. Obesity increases the risk of cardiovascular diseases in both sexes, however, the clinical prevalence of obesity, as well as its contribution to crucial cardiovascular risk factors is dependent on sex. The mechanisms via which obesity leads to cardiovascular risk is also discrepant in women between their premenopausal, pregnancy and postmenopausal phases of life. Emerging data indicate that at all reproductive statuses and ages, the presentation of a cardiovascular event in obese women is strongly associated with hypertension and its subsequent chronic risk factor, heart failure with preserved ejection fraction (HFpEF). In addition, emerging evidence indicates that obesity increases the risk of both hypertension and heart failure in pregnancy. This review will summarize clinical and experimental data on the female-specific prevalence and mechanisms of hypertension and heart failure in women across reproductive stages and highlight the particular risks in pregnancy as well as emerging data in a high-risk ethnicity in women of African ancestry (AA).

Severe maternal morbidity and mortality during delivery hospitalization of class I, II, III, and super obese women

BACKGROUND

Previous studies show that obesity predisposes patients to higher risks of adverse pregnancy outcomes. Data on the relationship between increasing degrees of obesity and risks of severe maternal morbidity, including mortality, are limited.

OBJECTIVE

We examined the association of increasing classes of obesity, especially super obesity, with the risk of severe maternal morbidity and mortality at the time of delivery hospitalization.

STUDY DESIGN

Using New York City linked birth certificates and hospital discharge data, we conducted a retrospective cohort study. This study identified delivery hospitalizations for singleton, live births in 2008-2012. Women were classified as having obesity (class I, II, III, or super obesity), as opposed to normal weight or overweight, based on prepregnancy body mass index. Cases of severe maternal morbidity were identified based on International Classification of Diseases, Ninth Revision diagnosis and procedure codes according to Centers for Disease Control and Prevention criteria. Multivariable logistic regression was used to evaluate the association between obesity classes and severe maternal morbidity, adjusting for maternal sociodemographic characteristics.

RESULTS

During 2008-2012, there were 570,997 live singleton births with available information on prepregnancy body mass index that met all inclusion criteria. After adjusting for maternal characteristics, women with class II (adjusted odds ratio, 1.14; 95% confidence interval, 1.05-1.23), class III (adjusted odds ratio, 1.34; 95% confidence interval, 1.21-1.49), and super obesity (adjusted odds ratio, 1.99; 95% confidence interval, 1.57-2.54) were all significantly more likely to have severe maternal morbidity than normal and overweight women. Super obesity was associated with specific severe maternal morbidity indicators, including renal failure, air and thrombotic embolism, blood transfusion, heart failure, and the need for mechanical ventilation.

CONCLUSION

There is a significant dose-response relationship between increasing obesity class and the risk of severe maternal morbidity at delivery hospitalization. The risks of severe maternal morbidity are highest for women with super obesity. Given that this is a modifiable risk factor, women with prepregnancy obesity should be counseled on the specific risks associated with pregnancy before conception to optimize their pregnancy outcomes.

Impact of hyperleptinemia during placental ischemia-induced hypertension in pregnant rats

The prevalence of preeclampsia and obesity have increased. Although obesity is a major risk factor for preeclampsia, the mechanisms linking these morbidities are poorly understood. Circulating leptin levels increase in proportion to fat mass. Infusion of this adipokine elicits hypertension in nonpregnant rats, but less is known about how hyperleptinemia impacts blood pressure during placental ischemia, an initiating event in the pathophysiology of hypertension in preeclampsia. We tested the hypothesis that hyperleptinemia during reduced uterine perfusion pressure (RUPP) exaggerates placental ischemia-induced hypertension. On gestational day (GD) 14, Sprague-Dawley rats were implanted with osmotic mini-pumps delivering recombinant rat leptin (1 µg/kg/min iv) or vehicle concurrently with the RUPP procedure to induce placental ischemia or Sham. On GD 19, plasma leptin was elevated in Sham + Leptin and RUPP + Leptin. Leptin infusion did not significantly impact mean arterial pressure (MAP) in Sham. MAP was increased in RUPP + Vehicle vs. Sham + Vehicle. In contrast to our hypothesis, placental ischemia-induced hypertension was attenuated by leptin infusion. To examine potential mechanisms for attenuation of RUPP-induced hypertension during hyperleptinemia, endothelial-dependent vasorelaxation to acetylcholine was similar between Sham and RUPP; however, endothelial-independent vasorelaxation to the nitric oxide (NO)-donor, sodium nitroprusside, was increased in Sham and RUPP. These findings suggest that NO/cyclic guanosine monophosphate (cGMP) signaling was increased in the presence of hyperleptinemia. Plasma cGMP was elevated in Sham and RUPP hyperleptinemic groups compared with vehicle groups but plasma and vascular NO metabolites were reduced. These data suggest that hyperleptinemia during placental ischemia attenuates hypertension by compensatory increases in NO/cGMP signaling.NEW & NOTEWORTHY Ours is the first study to examine the impact of hyperleptinemia on the development of placental ischemia-induced hypertension using an experimental animal model.

Preeclampsia: Linking Placental Ischemia with Maternal Endothelial and Vascular Dysfunction

Preeclampsia (PE), a hypertensive disorder, occurs in 3% to 8% of pregnancies in the United States and affects over 200,000 women and newborns per year. The United States has seen a 25% increase in the incidence of PE, largely owing to increases in risk factors, including obesity and cardiovascular disease. Although the etiology of PE is not clear, it is believed that impaired spiral artery remodeling of the placenta reduces perfusion, leading to placental ischemia. Subsequently, the ischemic placenta releases antiangiogenic and pro-inflammatory factors, such as cytokines, reactive oxygen species, and the angiotensin II type 1 receptor autoantibody (AT1-AA), among others, into the maternal circulation. These factors cause widespread endothelial activation, upregulation of the endothelin system, and vasoconstriction. In turn, these changes affect the function of multiple organ systems including the kidneys, brain, liver, and heart. Despite extensive research into the pathophysiology of PE, the only treatment option remains early delivery of the baby and importantly, the placenta. While premature delivery is effective in ameliorating immediate risk to the mother, mounting evidence suggests that PE increases risk of cardiovascular disease later in life for both mother and baby. Notably, these women are at increased risk of hypertension, heart disease, and stroke, while offspring are at risk of obesity, hypertension, and neurological disease, among other complications, later in life. This article aims to discuss the current understanding of the diagnosis and pathophysiology of PE, as well as associated organ damage, maternal and fetal outcomes, and potential therapeutic avenues. © 2021 American Physiological Society. Compr Physiol 11:1315-1349, 2021.

Maternal Obesity and the Risk of Early-Onset and Late-Onset Hypertensive Disorders of Pregnancy

OBJECTIVE

To evaluate the relationship between maternal body mass index (BMI) at delivery and rates of early-onset and late-onset hypertensive disorders of pregnancy.

METHODS

We performed a population-based, retrospective cohort study using U.S. Vital Statistics period-linked birth and infant death certificates from 2014 to 2017. Women who delivered a nonanomalous singleton live neonate from 24 to 41 completed weeks of gestation were included. We excluded women with chronic hypertension and those with BMIs less than 18.5. The primary exposure was maternal BMI, defined as nonobese (BMI 18.5-29.9; referent group), class 1 obesity (BMI 30.0-34.9), class 2 obesity (BMI 35.0-39.9), and class 3 obesity (BMI 40.0 or greater). The primary outcome was delivery with hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, or eclampsia) at less than 34 weeks of gestation or at 34 weeks or more. Multivariable Poisson regression was used to estimate relate risk and adjust for confounding variables. Results are presented as adjusted relative risk (aRR) and 95% CIs.

RESULTS

Of the 15.8 million women with live births during the study period, 14.0 million (88.6%) met inclusion criteria, and 825,722 (5.9%) had hypertensive disorders of pregnancy. The risk of early-onset hypertensive disorders of pregnancy was significantly higher in women with class 1 obesity (aRR 1.13; 95% CI 1.10-1.16), class 2 obesity (aRR 1.57; 95% CI 1.53-1.62), and class 3 obesity (aRR 2.18; 95% CI 2.12-2.24), compared with nonobese women. The risk of late-onset hypertensive disorders of pregnancy was also significantly increased in women with class 1 obesity (aRR 1.71; 95% CI 1.70-1.73), class 2 obesity (aRR 2.60; 95% CI 2.58-2.62), and class 3 obesity (aRR 3.93; 95% CI 3.91-3.96) compared with nonobese women.

CONCLUSION

Compared with nonobese women, the risk of early-onset and late-onset hypertensive disorders of pregnancy is significantly and progressively increased among women with increased class of obesity.

The non-traditional and familial risk factors for preeclampsia in the FINNPEC cohort

OBJECTIVES

Considering the burden of preeclampsia (PE), it is important to understand better the underlying risk factors involved in its etiology. We studied the association of background factors with PE with an emphasis on socioeconomic factors, reproductive factors and health history enclosing the parents of pregnant women.

STUDY DESIGN

The Finnish Genetics of Pre-eclampsia Consortium (FINNPEC) cohort participants filled in a questionnaire on background information. The questionnaire data was available from 708 women with PE and 724 control women. Two different control groups, healthy controls with uncomplicated pregnancies (n = 498) and all controls (n = 724, including controls with uncomplicated pregnancies and pregnancy complications other than PE), were established.

RESULTS

PE women had similar socioeconomic status and more often non-communicable diseases including type 1 diabetes, chronic hypertension and hyperlipidemia than the two control groups (p < 0.05 for all). Depression and subfertility were more common among PE women and they had earlier menarche (p < 0.05 for all). Hypertension was more common in both parents of PE women, stroke in fathers and diabetes in mothers (p < 0.05 for all). Mental disorders including depression were more common in mothers of PE women compared to controls (PE women 7.2%, healthy controls 3.7% (p = 0.013) and all controls 3.9% (p = 0.007)).

CONCLUSIONS

In the FINNPEC cohort, PE women had similar socioeconomic status, more non-communicable diseases and depression, earlier menarche, more subfertility and more parental non-communicable diseases compared to controls. As a novel finding we found more mental disorders including depression in mothers of PE women.

High-fat diet from parental generation exaggerates body and adipose tissue weights in pregnant offspring

Parental high-fat diet (HFD) programs for obesity and hypertension in female offspring in rats, but it is unknown how the pregnancies of these offspring are impacted. Therefore, the hypothesis was tested that parental HFD exaggerates obesity and hypertension during pregnancy of the offspring. Wistar Hannover rat dams (the parental, P generation) were maintained on normal-fat diet (NFD) or HFD from weaning and were kept on respective diets through pregnancy and lactation. Their offspring (the first filial, F1 generation) were weaned onto the same diet as the P generation, or they were changed to the other diet to determine if combined HFD in the P and F1 generations exaggerates body weight and blood pressure levels during pregnancy in these offspring. This diet paradigm resulted in the following groups of pregnant F1 offspring: P-NFD/F1-NFD, P-HFD/F1-NFD, P-NFD/F1-HFD, and P-HFD/F1-HFD. Maternal body and adipose tissue weights were greatest in the P-HFD/F1-HFD group compared to the other 3 groups by the end of pregnancy. Plasma leptin and conscious mean arterial blood pressure were not significantly different between any group, although there was a main effect for increased blood pressure in the F1-HFD groups. Circulating levels of the antihypertensive pregnancy factor, placental growth factor (PlGF), were assessed. Although average PlGF levels were similar among all groups, correlative studies revealed that lower levels of PlGF were associated with higher blood pressure only in the P-HFD/F1-HFD group. In summary, HFD feeding from the P generation exaggerated HFD-induced body and adipose tissue weights in the pregnant offspring.

Neonatal outcomes in obese pregnant women who develop preeclampsia

OBJECTIVE

Obesity and preeclampsia in pregnant women are each independently associated with poorer neonatal outcomes. We study obesity and preeclampsia alone and also in combination in pregnant women to determine their association with neonatal outcomes.

STUDY DESIGN

This retrospective study (n = 664) compared four groups: 1) no preeclampsia/no obesity, 2) no preeclampsia/yes obesity, 3) yes preeclampsia/no obesity, and 4) yes preeclampsia/yes obesity. The primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes were low birth weight, low Apgar 1 score, and low Apgar 5 score.

RESULTS

Those with yes preeclampsia/yes obesity (OR:3.06, 95% CI:1.76, 5.32, p < 0.001) and those with yes preeclampsia/no obesity (OR:1.98, 95% CI:1.03, 3.80, p < 0.05) each had significantly higher odds for NICU admission. Those with no preeclampsia/yes obesity were not associated with NICU admission. Yes preeclampsia/yes obesity did not have any significant association with low birth weight, low Apgar 1 score, and low Apgar 5 score.

CONCLUSION

Patients with preeclampsia alone or preeclampsia/obesity combined are associated with higher odds for NICU admission. However, obesity alone without preeclampsia is not associated with NICU admission. This knowledge can allow the Pediatric service prior to delivery to prepare and mitigate potential poor neonatal complications.

What are the Predictive Factors for Preeclampsia in Oocyte Recipients?

Objectives:

Oocyte donation pregnancies are more frequently complicated by preeclampsia (PE), which cause significant fetal-maternal morbidity and mortality. Our objective was to determine risk factors for PE in oocyte recipients (OR). Our secondary objective was to describe the course of pregnancy and the neonatal outcome in this group.

Methods:

This was a historical-prospective study. One hundred and fifty OR who gave birth to children at over 22 weeks of amenorrhea between January 2010 and June 2018 were included in the study.

Results:

Risk factors for PE in OR found in univariate analysis were as follows: primiparity, primipaternity, body mass index (BMI), and anti-Müllerian hormone (AMH) of the OR and age and AMH of the oocyte donors (OD). In multivariate analysis, the BMI of the OR (odds ratio [OR]: 1.2, 95% confidence interval [CI]: [1.1–1.4], P = 0.0474) and the AMH of the OD (OR: 1.2, 95% CI: [1.2–1.4], P = 0.0481) were found to be statistically significant risk factors for PE. In addition, we observed an increase in the rate of prematurity in the OR that were not associated with fetal growth retardation, despite the occurrence of PE.

Conclusion:

In OR, the allogeneic nature of pregnancy induces an increased risk of PE, the pathophysiology of which seems different from that in other methods of conception. Thus, risk factors for PE should be reconsidered to take into account the impact of certain characteristics of OD such as age and AMH.

Melanocortin-4 Receptor Deficiency Attenuates Placental Ischemia-Induced Hypertension in Pregnant Rats

Preeclampsia is a pregnancy-specific disorder of new-onset hypertension linked to placental ischemia. While obesity is a major risk factor for preeclampsia, not all obese pregnant women develop pregnancy-induced hypertension or preeclampsia. Previously, we reported that placental ischemia-induced hypertension is dependent upon intact signaling of the sympathetic nervous system. Moreover, in various models of obesity, blockade of MC4R (melanocortin-4 receptor) signaling protects against the development of hypertension via suppression of the sympathetic nervous system. Less is known about this pathway during obese pregnancy. Although blockade of MC4R may lead to increased body weight during pregnancy, we tested the hypothesis that placental ischemia-induced hypertension is attenuated in obese MC4R-deficient pregnant rats. On gestational day 14, MC4R wild-type or heterozygous-deficient (MC4R-def) rats were subjected to chronic placental ischemia via the reduced uterine perfusion pressure procedure or Sham surgery then examined on gestational day 19. In Sham MC4R-def versus Sham wild-type pregnant rats, there was increased body weight, fat mass, and circulating leptin levels but they had similar fetus weights. Reduced uterine perfusion pressure reduced fetus weights in both strains. Reduced uterine perfusion pressure increased blood pressure in wild-type rats but this response was significantly attenuated in MC4R-def rats, although blood pressure was elevated in Sham MC4R-def over Sham wild-type. These data indicate that while obese MC4R-def pregnant rats have higher blood pressure during pregnancy, placental ischemia-induced hypertension is attenuated in obese MC4R-def pregnant rats. Thus, obese women with abnormal MC4R signaling may be less susceptible to the development of placental ischemia-induced hypertension.

Increased BMI has a linear association with late-onset preeclampsia: A population-based study

Background

To investigate the ongoing controversy on the effect of BMI (body mass index) on EOP (early onset preeclampsia) vs LOP (late onset), especially focusing on diabetes and maternal booking/pre-pregnancy BMI as possible independent variables.

Methods

18 year-observational cohort study (2001–2018). The study population consisted of all consecutive births delivered at the Centre Hospitalier Universitaire Hospitalier Sud Reunion’s maternity (ap. 4,300 birth per year, only level 3 maternity in the south of Reunion Island, sole allowed to follow and deliver all preeclampsia cases of the area). History of pregnancies, deliveries and neonatal outcomes have been collected in standardized fashion into an epidemiological perinatal data base.

Results

Chronic hypertension and, history of preeclampsia in multigravidas, were the strongest risk factors for EOP. Primiparity, age over 35 years and BMI ≥ 35 kg/m² were rather associated with LOP. In a multivariate analysis with EOP or LOP as outcome variables compared with controls (normotensive), maternal age and pre-pregnancy BMI were independent risk factors for both EOP and LOP (p < 0.001). However, analyzing by increment of 5 (years of age, kg/m² for BMI) rising maternal ages and incidence of preeclampsia were strictly parallel for EOP and LOP, while increment of BMI was only associated with LOP. Controlling for maternal ages and booking/pre-pregnancy BMI, diabetes was not an independent risk factor neither for EOP or LOP.

Conclusions

Metabolic factors, other than diabetes, associated with pre-pregnancy maternal corpulence are specifically associated with LOP. This may be a direction for future researches on the maternal preeclamptic syndrome. This may explain the discrepancy we are facing nowadays where high-income countries report 90% of their preeclampsia being LOP, while it is only 60–70% in medium-low income countries.

Adipokines and Endothelium Dysfunction Markers in Pregnant Women with Gestational Hypertension

Objective

The aim of the study was to evaluate the levels of adipokines such as adiponectin and leptin as well as soluble intercellular adhesion molecule-1 (sICAM-1) and endogenous NOS inhibitor-asymmetric dimethylarginine (ADMA), as the endothelium dysfunction markers in pregnant women with gestational hypertension (GH).

Patients and Methods

Adiponectin, leptin, sICAM-1, and ADMA concentrations were measured in a group of 34 patients with GH and in 32 healthy pregnant women between the 24^th and 34^th week of gestation with ELISA tests.

Results

The patients with GH compared with healthy ones were characterized by significantly higher BMI (28.09 ± 7.90 vs. 22.34 ± 4.21 kg/m², p=0.016) and higher concentrations of leptin (45.89 ± 35.91 vs. 24.09 ± 24.40 ng/mL, p=0.006). sICAM-1 levels were also higher in the GH group but without the statistical significance (264.51 ± 50.99 vs. 232.56 ± 43.3 ng/ml, p=0.057). There were no significant differences between groups in adiponectin (8.79 ± 8.67 vs. 7.90 ± 3.71 μg/mL, p=0.46, NS) and ADMA (0.57 ± 0.26 vs. 0.60 ± 0.24 μmol/L, p=0.68, NS) levels. The significant correlation between leptin levels and BMI value was observed only in patients with GH (R = 0.56, p=0.02).

Conclusions

The higher levels of leptin in pregnant women with gestational hypertension may be suggestive of the role of leptin in GH development. As the patients in the GH group had higher BMI, hyperleptinemia may link obesity with gestational hypertension. The significance of leptin as the predictive marker of GH development could be implied. It could be postulated that the higher levels of sICAM-1 in the GH patients, although not statistically significant, could reflect some impairment of the endothelium function occurring in GH regardless of BMI. The comparable adiponectin levels in GH and healthy pregnant patients and the lack of its correlation with BMI may indicate the occurrence of a protective mechanism in pregnancy maintaining its concentration and preserving from the consequences of the decrease in its levels in overweight and obese patients. Since ADMA levels were similar in GH and healthy pregnant women, ADMA seems not to be involved in GH pathogenesis, suggesting that NO synthesis is not impaired in this pregnancy complication. As the data on the gestational hypertension pathogenesis and its correlations with adipokines and markers of the endothelium dysfunction are limited, further studies on this issue are warranted.

The role of neutrophil activation in determining the outcome of pregnancy and modulation by hormones and/or cytokines

Neutrophils are often exclusively considered as a first-line innate immune defence, able to rapidly kill or trap pathogens and causing in case of over-activation tissue damage. In the female reproductive tract, however, the presence and activity of neutrophils seems to be tightly regulated. Major players in orchestrating this regulation are cyclical steroid sex hormones present during the menstrual cycle and pregnancy. This review describes the role of sex hormones in regulating directly or indirectly the functionality of neutrophils, the role of neutrophils during fertilization and pregnancy and in controlling viral, fungal and bacterial infection. This review also discusses the consequence of overt neutrophil activation in pregnancy pathologies.

Pregnancy after bariatric surgery: a narrative literature review and discussion of impact on pregnancy management and outcome

Bariatric surgery (BS) is regarded to be the most effective treatment of obesity with long lasting beneficial effects including weight loss and improvement of metabolic disorders. A considerable number of women undergoing BS are at childbearing age.Although the surgery mediated weight loss has a positive effect on pregnancy outcome, the procedures might be associated with adverse outcomes as well, for example micronutrient deficiencies, iron or B12 deficiency anemia, dumping syndrome, surgical complications such as internal hernias, and small for gestational age (SGA) offspring, possibly due to maternal undernutrition. Also, there is no international consensus concerning the ideal time to conception after BS. Hence, the present narrative review intents to summarize the available literature concerning the most common challenges which arise before and during pregnancy after BS, such as fertility related considerations, vitamin and nutritional deficiencies and their adequate compensation through supplementation, altered glucose metabolism and its implications for gestational diabetes screening, the symptoms and treatment of dumping syndrome, surgical complications and the impact of BS on pregnancy outcome. The impact of different bariatric procedures on pregnancy and fetal outcome will also be discussed, as well as general considerations concerning the monitoring and management of pregnancies after BS.Whereas BS leads to the mitigation of many obesity-related pregnancy complications, such as gestational diabetes mellitus (GDM), pregnancy induced hypertension and fetal macrosomia; those procedures pose new risks which might lead to adverse outcomes for mothers and offspring, for example nutritional deficiencies, anemia, altered maternal glucose metabolism and small for gestational age children.

Fertility, Pregnancy and Lactation After Bariatric Surgery - a Consensus Statement from the OEGGG

Bariatric surgery is recommended when other weight loss interventions, such as lifestyle modification or medications, have failed. A considerable number of women undergoing bariatric surgery are of childbearing age; hence, it is necessary to be aware of the effects of bariatric surgery on pregnancy for managing these patients. Although bariatric surgery is associated with positive effects on cardiovascular and metabolic parameters, side effects such as anaemia, the risk of developing internal hernia, altered glucose metabolism and the risk of small for gestational age offspring have to be considered. Pregnant women with a history of gastric bypass should not undergo the oral glucose tolerance test (OGTT) due to the high risk of hypoglycaemia. There are no contraindications for vaginal delivery and breastfeeding. This paper has been published as a consensus statement by the Austrian Society of Gynaecology and Obstetrics (OEGGG).

Leptin and Adiponectin as markers for preeclampsia in obese pregnant women, a cohort study

OBJECTIVE

Preeclampsia (PE) is a serious complication of pregnancy, the pathogenesis of which is largely unknown. We hypothesize that adipocytokines may play a role in the pathogenesis of PE, particularly in obese women, and evaluate leptin and adiponectin as potential first trimester markers for predicting PE.

STUDY DESIGN

A cohort of 2503 pregnancies, containing 93 PE pregnancies, was divided into women with normal weight, moderate, or severe obesity. All pregnancies had serum adiponectin and leptin measured in first trimester. Logistic regression was used to model PE with maternal characteristics and concentrations of the biomarkers.

RESULTS

In obese women a lower concentration of adiponectin was found in PE pregnancies; the concentration was lowest in the severely obese (p = 0.005). No association was found in normal weight women (p = 0.72). Leptin concentration had no association with PE in normal weight and moderately obese (p = 0.175-0.072), however in women with severe obesity a lower level of leptin was found (p = 0.049). The AUC was 0.73 for the ROC curve of combined maternal characteristics and adiponectin. Using adiponectin in women with moderate to severe obesity the sensitivity was 72.9% and the specificity was 49%.

CONCLUSIONS

In severely obese women, PE is associated with low serum adiponectin and leptin concentrations in first trimester. This indicates that the inability of adipokine regulation to adapt to severe obesity may play a role in the pathogenesis of PE. Adipocytokines may contribute in identification of risk pregnancies among severe obese.

Early-pregnancy weight gain and the risk of preeclampsia: A case-cohort study

OBJECTIVE

To investigate the association between early-pregnancy weight gain and risk of preeclampsia to inform pregnancy weight gain recommendations.

STUDY DESIGN

We performed a case-cohort study using a hospital database including 80,812 singleton deliveries from Magee-Womens Hospital, Pittsburgh, Pennsylvania (1998-2011). In each of 6 prepregnancy body mass index (BMI) groups, we abstracted serial antenatal weight measurements from the records of up to 339 preeclampsia cases and 1254 randomly selected pregnancies. Early gestational weight gain (16-19 weeks' gestation) was standardized for gestational duration using BMI-specific z-score charts. Multivariable log-binomial regression was used to assess the association between weight gain z-score and risk of preeclampsia. We determined the impact of preeclampsia misclassification using probabilistic bias analysis.

MAIN OUTCOME MEASURE

Risk of preeclampsia.

RESULTS

For normal weight women, there was a steady increase in preeclampsia risk with increasing early gestational weight gain z-score. For example, compared with a weight gain of 1.2 kg (z-score = -1 SD), a 7.2-kg weight gain (z-score = +1 SD) at 16 weeks was associated with 1.3 (0.50, 2.2) excess preeclampsia cases per 100 deliveries. Weight loss at 16-19 weeks among grade 2 or 3 obese women was associated with a reduced risk of preeclampsia. Associations were null among overweight and grade 1 obese women. The bias analysis supported the validity of the conventional analysis.

CONCLUSIONS

Early-pregnancy weight gain may be associated with preeclampsia in some BMI groups. Future revisions of pregnancy weight gain recommendations should account for preeclampsia risks from this and additional studies.

Binational cohort study comparing the management and outcomes of pregnant women with a BMI >50-59.9 kg/m2 and those with a BMI ≥60 kg/m2

OBJECTIVES

To compare the management, maternal and perinatal outcomes of women with a body mass index (BMI) ≥60 kg/m² with women with a BMI >50-59.9 kg/m².

DESIGN

International collaborative cohort study.

SETTING

Binational study in the UK and Australia.

PARTICIPANTS

UK: all pregnant women, and Australia: women who gave birth (birth weight ≥400 g or gestation ≥20 weeks) METHODS: Data from the Australasian Maternity Outcomes Surveillance System and UK Obstetric Surveillance System. Management, maternal and infant outcomes were compared between women with a BMI ≥60 kg/m² and women with a BMI >50-59.9 kg/m², using unconditional logistic regression.

RESULTS

The sociodemographic characteristics and previous medical histories were similar between the 111 women with a BMI ≥60 kg/m² and the 821 women with a BMI >50-59.9 kg/m². Women with a BMI ≥60 kg/m² had higher odds of thromboprophylaxis usage in both the antenatal (24% vs. 12%; OR 2.25, 95% CI 1.39 to 3.64) and postpartum periods (78% vs. 66%; OR 1.68, 95% CI 1.04 to 2.70). Women with BMI ≥60 kg/m² had nearly double the odds of pre-eclampsia/eclampsia (adjusted OR 1.83 (95% CI 1.01 to 3.30)). No other maternal or perinatal outcomes were statistically significantly different. Severe adverse outcomes such as perinatal death were uncommon in both groups thus limiting the power of these comparisons. The rate of perinatal deaths was 18 per 1000 births for those with BMI ≥60 kg/m²; 12 per 1000 births for those with BMI >50-59.9 kg/m²; those with BMI ≥60 kg/m² had a non-significant increased odds of perinatal death (unadjusted OR 1.46, 95% CI 0.31 to 6.74).

CONCLUSIONS

Women are managed differently on the basis of BMI even at this extreme as shown by thromboprophylaxis. The pre-eclampsia result suggests that future research should examine whether weight reduction of any amount prior to pregnancy could reduce poor outcomes even if women remain extremely obese.

Endothelial dysfunction as a long-term effect of late onset hypertensive pregnancy disorders: High BMI is key

OBJECTIVE

Hypertensive disorders during pregnancy increase cardiovascular risk later in life by 2 to 9-fold. Endothelial activation is one of the underlying mechanisms of cardiovascular risk. Therefore, we decided to investigate endothelial activation in primiparous women, 2.5 years after a hypertensive pregnancy disorder.

STUDY DESIGN

Plasma samples were taken from women 2.5 years after gestational hypertension (GH) or late onset preeclampsia (cases) and from women 2.5 years after a normotensive pregnancy (controls). We studied the effects of patient plasma on the endothelial barrier function of primary human umbilical vein endothelial cells (HUVECs) using Electric Cell-Substrate Impedance Sensing (ECIS) and we measured levels of endothelial activation markers soluble intercellular adhesion molecule 1 (sICAM-1) and soluble endothelial selectin (sE-selectin) in the plasma samples of patients.

RESULTS

Plasma from primiparous women with a history of late onset preeclampsia disrupted the endothelial barrier more than plasma from women with a history of GH. Endothelial resistance was reduced by 22% in samples taken after preeclampsia, 16% after normotensive pregnancy and 3% after GH (p ≤ 0.0001 GH versus preeclampsia and p = 0.0003 versus normotensive pregnancy). We did not find differences in the levels of soluble endothelial activation markers (sICAM-1 p = 0.326 and sE-selectin p = 0.978). However, the BMI ≥25 showed a strong correlation with increased levels of sICAM-1 (p = 0.046) and sE-selectin (p = 0.002).

CONCLUSION

Our results indicate that GH and late onset preeclampsia are distinct disease entities with a different pathogenic mechanism underlying their cardiovascular risk. Furthermore, this study supports the hypothesis that these two diseases are early manifestations of cardiovascular vulnerability due to an unfavorable risk profile, and that obesity plays a main role. Our results suggest that this high-risk female population would be eligible for preventive care.

Excessive Neutrophil Activity in Gestational Diabetes Mellitus: Could It Contribute to the Development of Preeclampsia?

Gestational diabetes mellitus is a transient form of glucose intolerance occurring during pregnancy. Pregnancies affected by gestational diabetes mellitus are at risk for the development of preeclampsia, a severe life threatening condition, associated with significant feto-maternal morbidity and mortality. It is a risk factor for long-term health in women and their offspring. Pregnancy has been shown to be associated with a subliminal degree of neutrophil activation and tightly regulated generation of neutrophil extracellular traps (NETs). This response is excessive in cases with preeclampsia, leading to the presence of large numbers of NETs in affected placentae. We have recently observed that circulatory neutrophils in cases with gestational diabetes mellitus similarly exhibit an excessive pro-NETotic phenotype, and pronounced placental presence, as detected by expression of neutrophil elastase. Furthermore, exogenous neutrophil elastase liberated by degranulating neutrophils was demonstrated to alter trophoblast physiology and glucose metabolism by interfering with key signal transduction components. In this review we examine whether additional evidence exists suggesting that altered neutrophil activity in gestational diabetes mellitus may contribute to the development of preeclampsia.

Pre-pregnancy BMI, gestational weight gain and risk of preeclampsia: a birth cohort study in Lanzhou, China

BACKGROUND

To evaluate the independent and joint effects of maternal pre-pregnancy BMI and gestational weight gain (GWG) on the risk of preeclampsia and its subtypes.

METHODS

A birth cohort study was conducted from 2010 to 2012 in Lanzhou, China. Three hundred fourty seven pregnant women with preeclampsia and 9516 normotensive women at Gansu Provincial Maternity and Child Care Hospital were included in the present study. Unconditional logistic regression models were used to evaluate the associations between pre-pregnancy BMI, GWG, and risk of preeclampsia and its subtypes.

RESULTS

Compared to women with normal pre-pregnancy BMI, those who were overweight/obese had an increased risk of preeclampsia (OR = 1.81; 95%CI: 1.37-2.39). Women with excessive GWG had an increased risk of preeclampsia (OR = 2.28; 95%CI: 1.70-3.05) compared to women with adequate GWG. The observed increased risk was similar for mild-, severe- and late-onset preeclampsia. No association was found for early-onset preeclampsia. Overweight/obese women with excessive GWG had the highest risk of developing preeclampsia compared to normal weight women with no excessive weight gain (OR = 3.78; 95%CI: 2.65-5.41).

CONCLUSIONS

Our results suggested that pre-pregnancy BMI and GWG are independent risk factors for preeclampsia and that the risk might vary by preeclampsia subtypes. Our study also proposed a potential synergistic effect of pre-pregnancy BMI and GWG that warrants further investigation.

Differential body weight, blood pressure and placental inflammatory responses to normal versus high-fat diet in melanocortin-4 receptor-deficient pregnant rats

OBJECTIVES

Although obesity increases the risk for hypertensive disorders of pregnancy, the mechanisms remain unclear. Neural melanocortin-4 receptor (MC4R) deficiency causes hyperphagia and obesity. Effects of MC4R deficiency on body weight, blood pressure (BP) and placental inflammatory responses to high-fat diet (HFD) are unknown. We tested two hypotheses: MC4R deficiency results in higher body weight, BP and placental inflammation under normal-fat diet (NFD) conditions and HFD exaggerates these responses in MC4R-deficient pregnant rats.

METHODS

MC4R and MC4R rats were maintained on NFD (13% kcal fat) or HFD (40% kcal fat) for ∼15 weeks, then measurements made on gestational day 19.

RESULTS

MC4R pregnant rats had greater body mass and total body fat and visceral adipose tissue weights along with greater circulating total cholesterol (TC) and leptin levels than MC4R rats regardless of diet. On NFD, circulating adiponectin levels were lower and placental TNFα levels and BP (conscious with carotid catheter) were higher in these heavier rats. Circulating adiponectin levels were lower and placental TNFα levels and BP were higher in MC4R rats compared with NFD controls. These parameters were not affected by HFD in the already heavier and hypertensive MC4R pregnant rats.

CONCLUSION

Obesity in MC4R deficiency and HFD in MC4R rats result in higher BP and placental inflammation during pregnancy. However, HFD did not exaggerate these responses in already obese MC4R pregnant rats. These data suggest that obesity and HFD are independently related to hypertension and placental inflammation in pregnancy.

What are the metabolic precursors which increase the risk of pre-eclampsia and how could these be investigated further

Several maternal and pregnancy characteristics have been associated with an increased risk of preeclampsia in epidemiological studies. This review discusses metabolic risk factors in particular and their interaction with other maternal and/or pregnancy characteristics. Examples of research studies that have used data from women with specific characteristics or explored the interaction between risk factors are discussed. Suggestions for future research using large data sets and incorporating knowledge of cardiovascular disease and other metabolic diseases are also highlighted.

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Obesity and nulliparity account for the largest population risk of preeclampsia.

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Low PlGF in early pregnancy is more strongly associated with preeclampsia in obese women.

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There are interactions between obesity and other characteristics which amplify the risk of preeclampsia e.g. ART, ethnicity.

The prediction of late-onset preeclampsia: Results from a longitudinal proteomics study

BACKGROUND

Late-onset preeclampsia is the most prevalent phenotype of this syndrome; nevertheless, only a few biomarkers for its early diagnosis have been reported. We sought to correct this deficiency using a high through-put proteomic platform.

METHODS

A case-control longitudinal study was conducted, including 90 patients with normal pregnancies and 76 patients with late-onset preeclampsia (diagnosed at ≥34 weeks of gestation). Maternal plasma samples were collected throughout gestation (normal pregnancy: 2-6 samples per patient, median of 2; late-onset preeclampsia: 2-6, median of 5). The abundance of 1,125 proteins was measured using an aptamers-based proteomics technique. Protein abundance in normal pregnancies was modeled using linear mixed-effects models to estimate mean abundance as a function of gestational age. Data was then expressed as multiples of-the-mean (MoM) values in normal pregnancies. Multi-marker prediction models were built using data from one of five gestational age intervals (8-16, 16.1-22, 22.1-28, 28.1-32, 32.1-36 weeks of gestation). The predictive performance of the best combination of proteins was compared to placental growth factor (PIGF) using bootstrap.

RESULTS

1) At 8-16 weeks of gestation, the best prediction model included only one protein, matrix metalloproteinase 7 (MMP-7), that had a sensitivity of 69% at a false positive rate (FPR) of 20% (AUC = 0.76); 2) at 16.1-22 weeks of gestation, MMP-7 was the single best predictor of late-onset preeclampsia with a sensitivity of 70% at a FPR of 20% (AUC = 0.82); 3) after 22 weeks of gestation, PlGF was the best predictor of late-onset preeclampsia, identifying 1/3 to 1/2 of the patients destined to develop this syndrome (FPR = 20%); 4) 36 proteins were associated with late-onset preeclampsia in at least one interval of gestation (after adjustment for covariates); 5) several biological processes, such as positive regulation of vascular endothelial growth factor receptor signaling pathway, were perturbed; and 6) from 22.1 weeks of gestation onward, the set of proteins most predictive of severe preeclampsia was different from the set most predictive of the mild form of this syndrome.

CONCLUSIONS

Elevated MMP-7 early in gestation (8-22 weeks) and low PlGF later in gestation (after 22 weeks) are the strongest predictors for the subsequent development of late-onset preeclampsia, suggesting that the optimal identification of patients at risk may involve a two-step diagnostic process.

Obstetric and Neonatal Risks Among Obese Women Without Chronic Disease

OBJECTIVE

To investigate whether prepregnancy obesity is associated with adverse pregnancy outcomes among women without chronic disease.

METHODS

Singleton deliveries (N=112,309) among mothers without chronic diseases in the Consortium on Safe Labor, a retrospective U.S. cohort, were analyzed using Poisson regression with robust variance estimation. Relative risks and 95% confidence intervals (CIs) estimated perinatal risks in relation to prepregnancy obesity status adjusted for age, race-ethnicity, parity, insurance, smoking and alcohol use during pregnancy, and study site.

RESULTS

Obstetric risks were variably (and mostly marginally) increased as body mass index (BMI) category and obesity class increased. In particular, the risk of gestational hypertensive disorders, gestational diabetes, cesarean delivery, and induction increased in a dose-response fashion. For example, the percentage of gestational diabetes among obese class III women was 14.6% in contrast to 2.8% among women with normal BMIs (corresponding relative risks [95% CI] 1.99 [1.86-2.13], 2.94 [2.73-3.18], 3.97 [3.61-4.36], and 5.47 [4.96-6.04] for overweight, obese class I, obese class II, and obese class III women, respectively) compared with women with normal BMIs. Similarly, neonatal risks increased in a dose-response fashion with maternal BMI status including preterm birth at less than 32 weeks of gestation, large for gestational age (LGA), transient tachypnea, sepsis, and intensive care unit admission. The percentage of LGA neonates increased from 7.9% among women with normal BMIs to 17.3% among obese class III women and relative risks increased to 1.52 (1.45-1.58), 1.74 (1.65-1.83), 1.93 (1.79-2.07), and 2.32 (2.14-2.52) as BMI category increased.

CONCLUSION

Prepregnancy obesity is associated with increased risks of a wide range of adverse pregnancy and neonatal outcomes among women without chronic diseases.

Spontaneous and indicated preterm delivery risk is increased among overweight and obese women without prepregnancy chronic disease

OBJECTIVE

To investigate the independent impact of prepregnancy obesity on preterm delivery among women without chronic diseases by gestational age, preterm category and parity.

DESIGN

A retrospective cohort study.

SETTING

Data from the Consortium on Safe Labor (CSL) in the USA (2002-08).

POPULATION

Singleton deliveries at ≥23 weeks of gestation in the CSL (43 200 nulliparas and 63 129 multiparas) with a prepregnancy body mass index (BMI) ≥18.5 kg/m² and without chronic diseases.

METHODS

Association of prepregnancy BMI and the risk of preterm delivery was examined using Poisson regression with normal weight as reference.

MAIN OUTCOME MEASURES

Preterm deliveries were categorised by gestational age (extremely, very, moderate to late) and category (spontaneous, indicated, no recorded indication).

RESULTS

Relative risk of spontaneous preterm delivery was increased for extremely preterm among obese nulliparas (1.26, 95% CI: 0.94-1.70 for overweight; 1.88, 95% CI: 1.30-2.71 for obese class I; 1.99, 95% CI: 1.32-3.01 for obese class II/III) and decreased for moderate to late preterm delivery among overweight and obese multiparas (0.90, 95% CI: 0.83-0.97 for overweight; 0.87, 95% CI: 0.78-0.97 for obese class I; 0.79, 95% CI: 0.69-0.90 for obese class II/III). Indicated preterm delivery risk was increased with prepregnancy BMI in a dose-response manner for extremely preterm and moderate to late preterm among nulliparas, as it was for moderate to late preterm delivery among multiparas.

CONCLUSIONS

Prepregnancy BMI was associated with increased risk of preterm delivery even in the absence of chronic diseases, but the association was heterogeneous by preterm categories, gestational age and parity.

TWEETABLE ABSTRACT

Obese nulliparas without chronic disease had higher risk for spontaneous delivery <28 weeks of gestation.

Placental Growth Factor, Soluble fms-Like Tyrosine Kinase 1, Soluble Endoglin, IL-6, and IL-16 as Biomarkers in Preeclampsia

Preeclampsia (PE), an important cause of maternal and perinatal morbidity and mortality worldwide, is a pregnancy-related disease characterized by hypertension and proteinuria after 20 weeks of gestation. The aim of our study was to find a practical panel of biomarkers useful in early diagnosis of PE. This study was carried out at the Obstetrics and Gynecology Department in Tîrgu Mureș University Hospital, Romania, between January 2014 and July 2015 and included 68 pregnant women (47 preeclamptic women and 21 controls) with gestational age between 16 and 20 weeks at enrollment. The biomarkers PlGF, sFlt-1, sEng, IL-6, and IL-16 were determined by ELISA test. We compared the serum levels of soluble markers analysed in preeclamptic women and controls during the second and third trimesters of pregnancy and we found that the best predictor for PE was PlGF with a sensitivity of 100% at a concentration threshold of 120.16 pg/mL, a diagnosis accuracy of 70.8%, and AUC of 0.684 (p = 0.005). We also estimated the risk for PE according to BMI and we found that pregnant women with weight >90 kg had 7 times higher risk for PE. Second-trimester PlGF serum level may serve as an early biomarker for the diagnosis of PE.