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Li T, Xu M, Wang Y, Wang Y, Tang H, Duan H, Zhao G, Zheng M, Hu Y. Prediction model of preeclampsia using machine learning based methods: a population based cohort study in China. Front Endocrinol (Lausanne) 2024; 15:1345573. [PMID: 38919479 PMCID: PMC11198873 DOI: 10.3389/fendo.2024.1345573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/27/2024] [Indexed: 06/27/2024] Open
Abstract
Introduction Preeclampsia is a disease with an unknown pathogenesis and is one of the leading causes of maternal and perinatal morbidity. At present, early identification of high-risk groups for preeclampsia and timely intervention with aspirin is an effective preventive method against preeclampsia. This study aims to develop a robust and effective preeclampsia prediction model with good performance by machine learning algorithms based on maternal characteristics, biophysical and biochemical markers at 11-13 + 6 weeks' gestation, providing an effective tool for early screening and prediction of preeclampsia. Methods This study included 5116 singleton pregnant women who underwent PE screening and fetal aneuploidy from a prospective cohort longitudinal study in China. Maternal characteristics (such as maternal age, height, pre-pregnancy weight), past medical history, mean arterial pressure, uterine artery pulsatility index, pregnancy-associated plasma protein A, and placental growth factor were collected as the covariates for the preeclampsia prediction model. Five classification algorithms including Logistic Regression, Extra Trees Classifier, Voting Classifier, Gaussian Process Classifier and Stacking Classifier were applied for the prediction model development. Five-fold cross-validation with an 8:2 train-test split was applied for model validation. Results We ultimately included 49 cases of preterm preeclampsia and 161 cases of term preeclampsia from the 4644 pregnant women data in the final analysis. Compared with other prediction algorithms, the AUC and detection rate at 10% FPR of the Voting Classifier algorithm showed better performance in the prediction of preterm preeclampsia (AUC=0.884, DR at 10%FPR=0.625) under all covariates included. However, its performance was similar to that of other model algorithms in all PE and term PE prediction. In the prediction of all preeclampsia, the contribution of PLGF was higher than PAPP-A (11.9% VS 8.7%), while the situation was opposite in the prediction of preterm preeclampsia (7.2% VS 16.5%). The performance for preeclampsia or preterm preeclampsia using machine learning algorithms was similar to that achieved by the fetal medicine foundation competing risk model under the same predictive factors (AUCs of 0.797 and 0.856 for PE and preterm PE, respectively). Conclusions Our models provide an accessible tool for large-scale population screening and prediction of preeclampsia, which helps reduce the disease burden and improve maternal and fetal outcomes.
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Affiliation(s)
- Taishun Li
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical Statistics and Analysis Center, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Mingyang Xu
- Information Management Division, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yuan Wang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Ya Wang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Huirong Tang
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Honglei Duan
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guangfeng Zhao
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Mingming Zheng
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yali Hu
- Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Saw KEE, Thann TSAM. Association Between Vascular Endothelial Growth Factor (VEGF) +936C/T Polymorphism (rs3025039) and Preeclampsia Among Myanmar Pregnant Women. J Pregnancy 2024; 2024:7608096. [PMID: 38919581 PMCID: PMC11199063 DOI: 10.1155/2024/7608096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/14/2024] [Accepted: 05/18/2024] [Indexed: 06/27/2024] Open
Abstract
Background: The vascular endothelial growth factor (VEGF) polymorphism is associated with preeclampsia since its abnormal expression plays an important role in vasculogenesis in placenta formation. Thus, this study is aimed at analyzing the association between VEGF +936C/T polymorphism and the risk of preeclampsia. Methods: To assess the causal relationship, a hospital-based cross-sectional analytical study was carried out among 204 Myanmar pregnant women during the period of January 2018-September 2020. For data collection, a pretested, structured questionnaire was used. Blood samples were collected after obtaining consent, and then we studied the extracted gene by using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The Statistical Package for Social Sciences version 18.0 was used for data management and analysis. Results: The genotype CT variant among preeclamptic women was more than that of non-preeclamptic women (26.5% vs. 18.6%), but not significant (p = 0.180). The risk of preeclampsia among women with CT genotypes was 1.57 times higher than that of women with CC genotypes (OR (95%CI) = 1.57 (0.81, 3.06), p = 0.180). The minor allele frequency of the T allele was 15.2% in preeclamptic women and 9.3% in normal pregnant women. The risk of preeclampsia among T allele carriers is 1.49 times (95%CI = 0.80, 2.77) more than that of C allele carriers (p = 0.211). Among the preeclamptic pregnant women, the frequency of the CT genotype was 26.3% in the severe preeclamptic group and 26.9% in the mild preeclamptic group, while the frequency of the T allele was 13.2% and 13.5%, respectively. The frequency of either CT genotype or T allele was more or less the same in both groups, and there was no association between VEGF C/T polymorphism and the severity of preeclampsia. After logistic regression analysis on VEGF genotype and clinical parameters such as age, maternal body mass index (BMI), and neonatal birth weight, the risk of preeclampsia was 2.1 times higher in pregnant women with CT genotype compared to CC genotype (adjusted OR, 2.1; 95% CI, 0.9-4.5, p value -0.057). Conclusion: There was no significant association between VEGF +936C/T polymorphism (rs3025039) and preeclampsia among Myanmar pregnant women. However, the findings of this study highlighted that individuals carrying either the CT genotype or the T allele are at a heightened risk of developing preeclampsia. Furthermore, it suggests a potential impact of the gene on the occurrence of preeclampsia, yet the data lacks sufficient evidence to establish statistical significance.
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Affiliation(s)
- Khin Ei Ei Saw
- Department of AnatomyUniversity of Medicine, Taunggyi, Shan 06017, Myanmar
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Espinoza J, Calsavara VF, Kilpatrick S, Rana S, Costantine MM, Boggess K, Wylie BJ, Moore Simas TA, Louis JM, Gaw SL, Murtha A, Wiegand S, Gollin Y, Singh D, Silver RM, Durie DE, Panda B, Norwitz ER, Burd I, Plunkett B, Scott RK, Lemoine E, Thadhani R, Karumanchi SA. Plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio of 11.5 multiples of median predicts preeclampsia with severe features within 2 weeks of testing. Am J Obstet Gynecol 2024:S0002-9378(24)00659-8. [PMID: 38825028 DOI: 10.1016/j.ajog.2024.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/28/2024] [Accepted: 05/28/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND Angiogenic imbalances, characterized by an excess of antiangiogenic factors (soluble fms-like tyrosine kinase 1) and reduced angiogenic factors (vascular endothelial growth factor and placental growth factor), contribute to the mechanisms of disease in preeclampsia. The ratio of soluble fms-like tyrosine kinase 1 to placental growth factor has been used as a biomarker for preeclampsia, but the cutoff values may vary with gestational age and assay platform. OBJECTIVE This study aimed to compare multiples of the median of the maternal plasma soluble fms-like tyrosine kinase 1 to placental growth factor ratio, soluble fms-like tyrosine kinase 1, placental growth factor, and conventional clinical and laboratory values in their ability to predict preeclampsia with severe features. STUDY DESIGN We conducted a cohort study across 18 United States centers involving hospitalized individuals with hypertension between 23 and 35 weeks' gestation. Receiver operating characteristic curve analyses of maternal plasma biomarkers, highest systolic or diastolic blood pressures, and laboratory values at enrollment were performed for the prediction of preeclampsia with severe features. The areas under the curve were compared, and quasi-Poisson regression models were fitted to estimate relative risks. The primary outcome was preeclampsia with severe features within 2 weeks of enrollment. Secondary outcomes were a composite of severe adverse maternal outcomes (elevated liver enzymes, low platelets count, placental abruption, eclampsia, disseminated intravascular coagulation, and pulmonary edema) and a composite of severe adverse perinatal outcomes (birth weight below the third percentile, very preterm birth [<32 weeks' gestation], and fetal or neonatal death). RESULTS Of the 543 individuals included in the study, preeclampsia with severe features within 2 weeks was observed in 33.1% (n=180) of them. A receiver operating characteristic curve-derived cutoff of 11.5 multiples of the median for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio provided good sensitivity (90.6%), specificity (76.9%), positive predictive value (66.0%), negative predictive value (94.3%), positive likelihood ratio (3.91), negative likelihood ratio (0.12), and accuracy (81.4%) for preeclampsia with severe features within 2 weeks. This cutoff was used to compare test positive cases (≥ cutoff) and test negative cases (< cutoff). Preeclampsia with severe features (66.0% vs 5.7%; P<.001) and composites of severe adverse maternal (8.11% vs 2.7%; P=.006) or perinatal (41.3% vs 10.14%; P=.001) outcomes within 2 weeks were more frequent in test positive cases than in test negative cases. A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the median was independently associated with preeclampsia with severe features (adjusted incidence rate ratio, 9.08; 95% confidence interval, 6.11-14.06; P<.001) and a composite of severe adverse perinatal outcomes (adjusted incidence rate ratio, 9.42; 95% confidence interval, 6.36-14.53; P<.001) but not with a composite of severe adverse maternal outcomes (adjusted incidence rate ratio, 2.20; 95% confidence interval, 0.95-5.54; P=.08). The area under the curve for the soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio in multiples of the median (0.91; 95% confidence interval, 0.89-0.94) for preeclampsia with severe features within 2 weeks was significantly higher (P<.001 for all comparisons) than either plasma biomarker alone or any other parameter with the exception of absolute soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio values. CONCLUSION A soluble fms-like tyrosine kinase 1 to placental growth factor plasma ratio ≥11.5 multiples of the mean among hospitalized patients with hypertension between 23 and 35 week's gestation predicts progression to preeclampsia with severe features and severe adverse perinatal outcomes within 2 weeks.
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Affiliation(s)
- Jimmy Espinoza
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX.
| | - Vinicius F Calsavara
- Department of Computational Biomedicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sarah Kilpatrick
- Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center, Santa Monica, CA
| | - Sarosh Rana
- Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medical Center, Chicago, IL
| | - Maged M Costantine
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kim Boggess
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Blair J Wylie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University, New York, NY
| | - Tiffany A Moore Simas
- Departments of Obstetrics and Gynecology, Pediatrics, Psychiatry, and Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA; Department of Obstetrics and Gynecology, UMass Memorial Health - UMass Memorial Medical Center, Worcester, MA
| | - Judette M Louis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL
| | - Stephanie L Gaw
- Division of Maternal-Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, CA
| | - Amy Murtha
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California at San Francisco, San Francisco, CA
| | - Samantha Wiegand
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miami Valley Hospital, Dayton, OH
| | - Yvonne Gollin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | - Deepjot Singh
- Department of Obstetrics and Gynecology, Torrance Memorial Medical Center, Torrance, CA
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Medical Center, Salt Lake City, UT
| | - Danielle E Durie
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA
| | - Britta Panda
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA
| | - Errol R Norwitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA; Department of Obstetrics and Gynecology, Newton-Wellesley Hospital, Newton, MA
| | - Irina Burd
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology & Reproductive Sciences, Johns Hopkins Medical Center, Baltimore, MD
| | - Beth Plunkett
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, NorthShore University Health System (Endeavor Health), Evanston, IL
| | - Rachel K Scott
- Department of Obstetrics and Gynecology, MedStar Health Research Institute, Washington, DC
| | - Elizabeth Lemoine
- Department of Obstetrics and Gynecology at University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - S Ananth Karumanchi
- Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center, Santa Monica, CA; Department of Medicine, Cedars-Sinai Medical Center, Santa Monica, CA
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Lindley KJ, Davila-Roman VG. Microvascular Dysfunction in Hypertensive Disorders of Pregnancy: Implications for Evaluation, Treatment, and Further Research. Circ Cardiovasc Imaging 2024; 17:e016816. [PMID: 38771900 DOI: 10.1161/circimaging.124.016816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Affiliation(s)
- Kathryn J Lindley
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (K.J.L.)
| | - Victor G Davila-Roman
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Department of Medicine and Global Health Center, Institute of Public Health, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.)
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Thadhani R, Cerdeira AS, Karumanchi SA. Translation of mechanistic advances in preeclampsia to the clinic: Long and winding road. FASEB J 2024; 38:e23441. [PMID: 38300220 DOI: 10.1096/fj.202301808r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/30/2023] [Accepted: 01/09/2024] [Indexed: 02/02/2024]
Abstract
As one of the leading causes of premature birth and maternal and infant mortality worldwide, preeclampsia remains a major unmet public health challenge. Preeclampsia and related hypertensive disorders of pregnancy are estimated to cause >75 000 maternal and 500 000 infant deaths globally each year. Because of rising rates of risk factors such as obesity, in vitro fertilization and advanced maternal age, the incidence of preeclampsia is going up with rates ranging from 5% to 10% of all pregnancies worldwide. A major discovery in the field was the realization that the clinical phenotypes related to preeclampsia, such as hypertension, proteinuria, and other adverse maternal/fetal events, are due to excess circulating soluble fms-like tyrosine kinase-1 (sFlt-1, also referred to as sVEGFR-1). sFlt-1 is an endogenous anti-angiogenic protein that is made by the placenta and acts by neutralizing the pro-angiogenic proteins vascular endothelial growth factor (VEGF) and placental growth factor (PlGF). During the last decade, this work has spawned a new era of molecular diagnostics for early detection of this condition. Antagonizing sFlt-1 either by reducing production or blocking its actions has shown salutary effects in animal models. Further, in early-stage human studies, the therapeutic removal of sFlt-1 from maternal circulation has shown promise in delaying disease progression and improving outcomes. Recently, the FDA approved the first molecular test for preterm preeclampsia (sFlt-1/PlGF ratio) for clinical use in the United States. Measuring serum sFlt-1/PlGF ratio in the acute hospital setting may aid short-term management, particularly regarding step-up or step-down of care, decision to transfer to settings better equipped to manage both the mother and the preterm neonate, appropriate timing of administration of steroids and magnesium sulfate, and in expectant management decisions. The test itself has the potential to save lives. Furthermore, the availability of a molecular test that correlates with adverse outcomes has set the stage for interventional clinical trials testing treatments for this disorder. In this review, we will discuss the role of circulating sFlt-1 and related factors in the pathogenesis of preeclampsia and specifically how this discovery is leading to concrete advances in the care of women with preeclampsia.
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Affiliation(s)
- Ravi Thadhani
- Woodruff Health Sciences Center, Emory University School of Medicine, Atlanta, Georgia, USA
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford, UK
- Fetal Maternal Medicine Unit, Queen Charlotte's and Chelsea Hospital, London, UK
| | - S Ananth Karumanchi
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Kitt J, Krasner S, Barr L, Frost A, Tucker K, Bateman PA, Suriano K, Kenworthy Y, Lapidaire W, Lacharie M, Mills R, Roman C, Mackillop L, Cairns A, Aye C, Ferreira V, Piechnik S, Lukaschuk E, Thilaganathan B, Chappell LC, Lewandowski AJ, McManus RJ, Leeson P. Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy. Circulation 2024; 149:529-541. [PMID: 37950907 DOI: 10.1161/circulationaha.123.067597] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 11/09/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling. METHODS In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed. RESULTS A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P<0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m2; 95% CI, -7.99 to -4.74; P<0.001), end-diastolic volume (-3.87 mL/m2; 95% CI, -6.77 to -0.98; P=0.009), and end-systolic volume (-3.25 mL/m2; 95% CI, 4.87 to -1.63; P<0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P<0.001) and 2.8% (95% CI, 1.4-4.1; P<0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P=0.024) and a reduction in left atrial volumes of -4.33 mL/m2 (95% CI, -5.52 to -3.21; P<0.001) between baseline and follow-up when adjusted for baseline differences in measures. CONCLUSIONS Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854.
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Affiliation(s)
- Jamie Kitt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Samuel Krasner
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Logan Barr
- Queen's University School of Medicine, Kingston, Canada (L.B.)
| | - Annabelle Frost
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Katherine Tucker
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Paul A Bateman
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Katie Suriano
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Yvonne Kenworthy
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Winok Lapidaire
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Miriam Lacharie
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Rebecca Mills
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Cristian Roman
- Institute of Biomedical Engineering, Department of Engineering Science (C.R.), University of Oxford, United Kingdom
| | - Lucy Mackillop
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Alexandra Cairns
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Christina Aye
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
- Fetal Medicine Unit, Oxford University Hospitals National Health Service Foundation Trust, United Kingdom (C.A.)
| | - Vanessa Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (V.F., E.L.), University of Oxford, United Kingdom
| | - Stefan Piechnik
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Elena Lukaschuk
- Oxford Centre for Clinical Magnetic Resonance Research (V.F., E.L.), University of Oxford, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (B.T.)
- Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Lucy C Chappell
- King's College London and Guy's and St Thomas' National Health Service Foundation Trust, United Kingdom (L.C.C.)
| | - Adam J Lewandowski
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
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Kilkenny K, Frishman W. Preeclampsia's Cardiovascular Aftermath: A Comprehensive Review of Consequences for Mother and Offspring. Cardiol Rev 2024:00045415-990000000-00188. [PMID: 38189425 DOI: 10.1097/crd.0000000000000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Preeclampsia (PE), a multisystem hypertensive disorder affecting 2-8% of pregnancies, has emerged as a novel risk factor for cardiovascular disease (CVD) in affected mothers and in their offspring. Between 10 and 15 years following gestation, women with a history of PE have double the risk of CVD, nearly 4 times the risk of hypertension, and increased all-cause mortality. Offspring exposed to PE in utero carry an increased risk of CVD and congenital heart defects. Due to the multifactorial nature of both PE and CVD, a clear dependency has been difficult to establish. The interplay between CVD and PE is an area of active investigation, likely involving placental, genetic, and epigenetic factors resulting in enduring endothelial, vascular, and immune dysfunction. Fetal developmental programming induced by adverse intrauterine environments, epigenetic changes triggered by oxidative stress, and underlying genetic predisposition play pivotal roles in the development of CVD in offspring exposed to PE. Though the literature has discussed the cardiovascular outcomes associated with PE for nearly a decade, patient risk perception and health care provider awareness remain low, representing a substantial missed opportunity for early intervention in this vulnerable population. This review article will discuss the pathophysiology of preeclampsia, its intersection with CVD, and the long-term cardiovascular consequences for affected mothers and their offspring. Our objective is to increase health care provider awareness and garner greater research interest in this important topic.
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Affiliation(s)
| | - William Frishman
- From the New York Medical College, School of Medicine, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
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Kumar M, Balyan K, Debnath E, Himtsoe B, Sapna S, Kumar A. Antenatal risk stratification for preeclampsia with sFlt-1/PlGF ratio: Which is the best time to test? Pregnancy Hypertens 2023; 34:39-46. [PMID: 37801800 DOI: 10.1016/j.preghy.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 07/15/2023] [Accepted: 09/21/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE To find out the predictive value of sFlt-1/PlGF ratio for antenatal risk stratification (ARS) of women at high risk of preeclampsia (PE). METHODS Antenatal women at high risk of PE underwent sFlt-1/PlGF ratio at 20-22, 28-30 and 34-36 weeks and were followed till delivery. Those who developed PE were cases those who had normal outcome were controls, the cases and controls were compared. RESULTS Hypertension in pregnancy was seen in 116/287 (40.4 %), 46/287(16.0 %) had PE and 21(7.3 %) had early onset PE. Mean arterial pressure at 20-22 weeks was the high in those who developed early onset PE (109.08 ± 9.74 mmHg). The sFlt-1/PlGF ratio of 38 or more at 20-22 weeks resulted in either PE or adverse fetal outcome in all cases. Whereas, the ratio of less than 38 ruled out PE in all cases up to 29 + 6 weeks. At 28-30 weeks, the ratio less than 38 predicted no PE up to 34 weeks and no complication up to 29+6 weeks. The sensitivity for the detection at later gestation further decreased as the gestation advanced however the specificity was above 98 % at all gestations. The positive predictive value of the test increased with the advancing gestation, the negative predictive value was 93 % or higher at all gestations. CONCLUSION The usefulness of sFlt-1/PlGF ratio ≥38 for risk stratification was validated in the study, the testing at 28-30 weeks appeared to be the best time to test for PE prediction in high risk women.
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Affiliation(s)
- Manisha Kumar
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India.
| | - Kirti Balyan
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Ekta Debnath
- Department of Biochemistry, LHMC, New Delhi, India
| | - Ben Himtsoe
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Surbhi Sapna
- Department of Obstetrics and Gynecology, LHMC, New Delhi, India
| | - Arunav Kumar
- Kasturba Medical College, Manipal, Karnataka, India
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9
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Kitt J, Fox R, Frost A, Shanyinde M, Tucker K, Bateman PA, Suriano K, Kenworthy Y, McCourt A, Woodward W, Lapidaire W, Lacharie M, Santos M, Roman C, Mackillop L, Delles C, Thilaganathan B, Chappell LC, Lewandowski AJ, McManus RJ, Leeson P. Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management: The POP-HT Randomized Clinical Trial. JAMA 2023; 330:1991-1999. [PMID: 37950919 PMCID: PMC10640702 DOI: 10.1001/jama.2023.21523] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/02/2023] [Indexed: 11/13/2023]
Abstract
Importance Pregnancy hypertension results in adverse cardiac remodeling and higher incidence of hypertension and cardiovascular diseases in later life. Objective To evaluate whether an intervention designed to achieve better blood pressure control in the postnatal period is associated with lower blood pressure than usual outpatient care during the first 9 months postpartum. Design, Setting, and Participants Randomized, open-label, blinded, end point trial set in a single hospital in the UK. Eligible participants were aged 18 years or older, following pregnancy complicated by preeclampsia or gestational hypertension, requiring antihypertensive medication postnatally when discharged. The first enrollment occurred on February 21, 2020, and the last follow-up, November 2, 2021. The follow-up period was approximately 9 months. Interventions Participants were randomly assigned 1:1 to self-monitoring along with physician-optimized antihypertensive titration or usual postnatal care. Main Outcomes and Measures The primary outcome was 24-hour mean diastolic blood pressure at 9 months postpartum, adjusted for baseline postnatal blood pressure. Results Two hundred twenty participants were randomly assigned to either the intervention group (n = 112) or the control group (n = 108). The mean (SD) age of participants was 32.6 (5.0) years, 40% had gestational hypertension, and 60% had preeclampsia. Two hundred participants (91%) were included in the primary analysis. The 24-hour mean (SD) diastolic blood pressure, measured at 249 (16) days postpartum, was 5.8 mm Hg lower in the intervention group (71.2 [5.6] mm Hg) than in the control group (76.6 [5.7] mm Hg). The between-group difference was -5.80 mm Hg (95% CI, -7.40 to -4.20; P < .001). Similarly, the 24-hour mean (SD) systolic blood pressure was 6.5 mm Hg lower in the intervention group (114.0 [7.7] mm Hg) than in the control group (120.3 [9.1] mm Hg). The between-group difference was -6.51 mm Hg (95% CI, -8.80 to -4.22; P < .001). Conclusions and Relevance In this single-center trial, self-monitoring and physician-guided titration of antihypertensive medications was associated with lower blood pressure during the first 9 months postpartum than usual postnatal outpatient care in the UK. Trial Registration ClinicalTrials.gov Identifier: NCT04273854.
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Affiliation(s)
- Jamie Kitt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rachael Fox
- Mercy Hospital for Women, Department of Obstetrics and Gynecology, Heidelberg, Australia
| | - Annabelle Frost
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Katherine Tucker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul A. Bateman
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Katie Suriano
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Yvonne Kenworthy
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Annabelle McCourt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - William Woodward
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Winok Lapidaire
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Miriam Lacharie
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Mauro Santos
- Institute for Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Cristian Roman
- Institute for Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Lucy Mackillop
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Molecular Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
| | - Lucy C. Chappell
- King’s College London, London, United Kingdom
- Guy’s St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Adam J. Lewandowski
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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10
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Lin LJ, Zhou HX, Ye ZY, Zhang Q, Chen S. Construction and validation of a personalized prediction model for postpartum anxiety in pregnant women with preeclampsia. World J Psychiatry 2023; 13:763-771. [PMID: 38058687 PMCID: PMC10696290 DOI: 10.5498/wjp.v13.i10.763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Preeclampsia is a pregnancy-specific multi-system disease with multi-factor and multi-mechanism characteristics. The cure for preeclampsia is to terminate the pregnancy and deliver the placenta. However, it will reduce the perinatal survival rate, prolong the pregnancy cycle, and increase the incidence of maternal complications. With relaxation of the birth policy, the number of elderly pregnant women has increased significantly, and the prevalence rate of preeclampsia has increased. Inappropriate treatment can seriously affect the normal postpartum life of pregnant women. Studies have shown that postpartum anxiety in women with preeclampsia can affect physical and mental health, as well as infant growth and development. AIM To analyze the factors influencing preeclampsia in pregnant women complicated with postpartum anxiety, and to construct a personalized predictive model. METHODS We retrospectively studied 528 pregnant women with preeclampsia who delivered in Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine between January 2018 and December 2021. Their basic data were collected, and various physiological and biochemical indicators were obtained by laboratory examination. The self-rating anxiety scale was used to determine whether the women had postpartum anxiety 42 d after delivery. The independent factors influencing postpartum anxiety in early pregnant women with eclampsia were analyzed with multifactor logistic regression and a predictive model was constructed. The Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve were used to evaluate the calibration and discrimination of the predictive model. Eighty pregnant women with preeclampsia admitted to our hospital from January 2022 to May 2022 were retrospectively selected to verify the prediction model. RESULTS We excluded 46 of the 528 pregnant women with preeclampsia because of loss to follow-up and adverse outcomes. A total of 482 cases completed the assessment of postpartum anxiety 42 d after delivery, and 126 (26.14%) had postpartum anxiety. Bad marital relationship, gender discrimination in family members, hematocrit (Hct), estradiol (E2) hormone and interleukin (IL)-6 were independent risk factors for postpartum anxiety in pregnant women with preeclampsia (P < 0.05). Prediction model: Logit (P) = 0.880 × marital relationship + 0.870 × gender discrimination of family members + 0.130 × Hct - 0.044 × E2 + 0.286 × IL-6 - 21.420. The area under the ROC curve of the model was 0.943 (95% confidence interval: 0.919-0.966). The threshold of the model was -1.507 according to the maximum Youden index (0.757), the corresponding sensitivity was 84.90%, and the specificity was 90.70%. Hosmer-Lemeshow χ2 = 5.900, P = 0.658. The sensitivity, specificity and accuracy of the model were 81.82%, 84.48% and 83.75%, respectively. CONCLUSION Poor marital relationship, family gender discrimination, Hct, IL-6 and E2 are the influencing factors of postpartum anxiety in preeclampsia women. The constructed prediction model has high sensitivity and specificity.
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Affiliation(s)
- Le-Jing Lin
- Department of Obstetrics and Gynecology, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou 325000, Zhejiang Province, China
| | - Hai-Xian Zhou
- Department of Obstetrics and Gynecology, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou 325000, Zhejiang Province, China
| | - Zhi-Yun Ye
- Department of Obstetrics and Gynecology, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou 325000, Zhejiang Province, China
| | - Qi Zhang
- Department of Obstetrics and Gynecology, Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou 325000, Zhejiang Province, China
| | - Shu Chen
- Department of Gynecology, Wenzhou Traditional Chinese Medicine Hospital, Wenzhou 325000, Zhejiang Province, China
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11
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Maselienė T, Struckutė E, Breivienė R, Ramašauskaitė D, Dženkevičiūtė V. The Importance of Inflammatory and Angiogenic Markers in the Evaluation of Early Cardiovascular Disease Risk in Women with Hypertensive Disorders of Pregnancy. J Cardiovasc Dev Dis 2023; 10:407. [PMID: 37887854 PMCID: PMC10607798 DOI: 10.3390/jcdd10100407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Women with hypertensive disorders of pregnancy (HDP) have a significantly higher risk of developing cardiovascular diseases later in life. The stratification of this risk using biomarkers during pregnancy can help to identify these women and apply early prevention. OBJECTIVE We aimed to determine proinflammatory cytokines and angiogenic markers, echocardiographic parameter changes after delivery and predict early cardiovascular disease risk in women with arterial hypertension and its complications during pregnancy. METHODS We conducted a literature search using the PubMed database for the last ten years. A total of 17 articles were included to our study and full text reviewed. RESULTS Four out of six studies found higher postpartum Interleukin-6 (IL-6) levels in women with HDP. IL-6 correlated positively with waist circumference, body mass index, and triglycerides, and negatively with high density lipoproteins (HDL). Two out of four studies found higher postpartum tumor necrosis factor alpha (TNF-α) levels in women with HDP but later concentration equalizes. One out of eight studies found higher placental growth factor (PlGF) and two out of eight found more elevated soluble fms-like tyrosine kinase-1 (sFlt-1) in women with HDP. With decreasing PlGF and increasing sFlt-1, common carotid artery intima and media thickness, aortic root diameter, left atrial diameter, left ventricle mass, systolic, diastolic, and mean blood pressure increased, whereas HDL decreased. One out of four studies found higher sFlt-1/PlGF. CONCLUSION IL-6 remains significantly higher after delivery. Few studies found higher TNF-α, sFlt-1, PlGF and their ratio postpartum. All studies found a correlation between angiogenic factors, IL-6, and cardiovascular disease risk factors.
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Affiliation(s)
- Tatjana Maselienė
- Clinics of Internal and Family Medicine, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania
| | - Emilija Struckutė
- Clinics of Obstetrics and Gyneacology, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (E.S.); (R.B.); (D.R.)
| | - Rūta Breivienė
- Clinics of Obstetrics and Gyneacology, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (E.S.); (R.B.); (D.R.)
| | - Diana Ramašauskaitė
- Clinics of Obstetrics and Gyneacology, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (E.S.); (R.B.); (D.R.)
| | - Vilma Dženkevičiūtė
- Clinics of Cardiology, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania;
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12
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Casey H, Dennehy N, Fraser A, Lees C, McEniery C, Scott K, Wilkinson I, Delles C. Placental syndromes and maternal cardiovascular health. Clin Sci (Lond) 2023; 137:1211-1224. [PMID: 37606085 PMCID: PMC10447226 DOI: 10.1042/cs20211130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 07/16/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023]
Abstract
The placental syndromes gestational hypertension, preeclampsia and intrauterine growth restriction are associated with an increased cardiovascular risk to the mother later in life. In this review, we argue that a woman's pre-conception cardiovascular health drives both the development of placental syndromes and long-term cardiovascular risk but acknowledge that placental syndromes can also contribute to future cardiovascular risk independent of pre-conception health. We describe how preclinical studies in models of preeclampsia inform our understanding of the links with later cardiovascular disease, and how current pre-pregnancy studies may explain relative contributions of both pre-conception factors and the occurrence of placental syndromes to long-term cardiovascular disease.
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Affiliation(s)
- Helen Casey
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
| | - Natalie Dennehy
- Chelsea and Westminster NHS Foundation Trust, London, England, U.K
| | - Abigail Fraser
- Department of Population Health Sciences, Bristol Medical School, and the MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, U.K
| | - Christoph Lees
- Chelsea and Westminster NHS Foundation Trust, London, England, U.K
| | - Carmel M. McEniery
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, U.K
| | - Kayley Scott
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
| | - Ian B. Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, U.K
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
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13
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Tabacco S, Ambrosii S, Polsinelli V, Fantasia I, D’Alfonso A, Ludovisi M, Cecconi S, Guido M. Pre-Eclampsia: From Etiology and Molecular Mechanisms to Clinical Tools-A Review of the Literature. Curr Issues Mol Biol 2023; 45:6202-6215. [PMID: 37623210 PMCID: PMC10453909 DOI: 10.3390/cimb45080391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
Pre-eclampsia is a severe pregnancy-related complication that manifests as a syndrome with multisystem involvement and damage. It has significantly grown in frequency during the past 30 years and could be considered as one of the major causes of maternal and fetal morbidity and mortality. However, the specific etiology and molecular mechanisms of pre-eclampsia are still poorly known and could have a variety of causes, such as altered angiogenesis, inflammations, maternal infections, obesity, metabolic disorders, gestational diabetes, and autoimmune diseases. Perhaps the most promising area under investigation is the imbalance of maternal angiogenic factors and its effects on vascular function, though studies in placental oxidative stress and maternal immune response have demonstrated intriguing findings. However, to determine the relative importance of each cause and the impact of actions aiming to significantly reduce the incidence of this illness, more research is needed. Moreover, it is necessary to better understand the etiologies of each subtype of pre-eclampsia as well as the pathophysiology of other major obstetrical syndromes to identify a clinical tool able to recognize patients at risk of pre-eclampsia early.
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Affiliation(s)
- Sara Tabacco
- Unit of Obstetrics and Gynecology, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Silvia Ambrosii
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Valentina Polsinelli
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Ilaria Fantasia
- Unit of Obstetrics and Gynecology, San Salvatore Hospital, 67100 L’Aquila, Italy
| | - Angela D’Alfonso
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Manuela Ludovisi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Sandra Cecconi
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
| | - Maurizio Guido
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy
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14
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Countouris ME, Koczo A, Reynolds HR, Hausvater A, Mann H, Wang Y, Sharbaugh D, Thoma FW, Mulukutla SR, Catov JM. Characteristics of Premature Myocardial Infarction Among Women With Prior Adverse Pregnancy Outcomes. JACC. ADVANCES 2023; 2:100411. [PMID: 37694271 PMCID: PMC10487279 DOI: 10.1016/j.jacadv.2023.100411] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/27/2023] [Accepted: 05/12/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Adverse pregnancy outcomes (APOs), hypertensive disorders of pregnancy, gestational diabetes mellitus, and preterm birth are associated with ischemic heart disease in later life. OBJECTIVES The authors aimed to study the features of premature myocardial infarction (MI) among women with and without prior APOs. METHODS We performed a retrospective analysis of women with premature MI (<65 years of age) referred for left heart catheterization matched with a database of abstracted pregnancy data. We compared MI characteristics and epicardial coronary anatomy between women with and without APOs during their index pregnancy and evaluated time from delivery to MI. RESULTS Of 391 women with premature MI and associated coronary angiography (age: 49 ± 8 years), 154 (39%) had a prior APO (hypertensive disorders of pregnancy n = 78, preeclampsia n = 35, gestational diabetes mellitus n = 28, and preterm birth n = 48). Women with APO history had a higher prevalence of diabetes (33% vs 16% without APO; P = 0.001) and presented earlier with MI following delivery (19.6 [IQR: 14.3-23.5] years vs those without APO 21.5 [IQR: 17.0-25.4] years; P = 0.012), driven by preeclampsia (17.1 [IQR: 12.7-22.4] years, P = 0.010). Women with and without APOs had similar MI features including rates of ST-segment elevation MI, obstructive and multi-vessel coronary artery disease, percutaneous coronary intervention, and shock. CONCLUSIONS Among women with premature MIs, 39% had a history of an APO. Women with APO history presented sooner after pregnancy but had similar MI characteristics vs those without APOs. Pregnancy history may identify women who warrant early, aggressive cardiovascular disease prevention.
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Affiliation(s)
- Malamo E. Countouris
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Agnes Koczo
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Harmony R. Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, Sarah Ross Soter Center for Women’s Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA
| | - Anais Hausvater
- Leon H. Charney Division of Cardiology, Department of Medicine, Sarah Ross Soter Center for Women’s Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA
| | - Harnoor Mann
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Danielle Sharbaugh
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd W. Thoma
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suresh R. Mulukutla
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Janet M. Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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15
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Weckman AM, Elphinstone RE, Ssenkusu JM, Tran V, Zhong K, Madanitsa M, Khairallah C, Kalilani-Phiri L, Mwapasa V, Conroy AL, Ter Kuile FO, McDonald CR, Kain KC. Sequential disruptions to inflammatory and angiogenic pathways and risk of spontaneous preterm birth in Malawian women. iScience 2023; 26:106912. [PMID: 37332611 PMCID: PMC10275952 DOI: 10.1016/j.isci.2023.106912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/11/2022] [Accepted: 05/12/2023] [Indexed: 06/20/2023] Open
Abstract
Preterm birth is a leading cause of death in children under five years of age. We hypothesized that sequential disruptions to inflammatory and angiogenic pathways during pregnancy increase the risk of placental insufficiency and spontaneous preterm labor and delivery. We conducted a secondary analysis of inflammatory and angiogenic analytes measured in plasma samples collected across pregnancy from 1462 Malawian women. Women with concentrations of the inflammatory markers sTNFR2, CHI3L1, and IL18BP in the highest quartile before 24 weeks gestation and women with anti-angiogenic factors sEndoglin and sFlt-1/PlGF ratio in the highest quartile at 28-33 weeks gestation had an increased relative risk of preterm birth. Mediation analysis further supported a potential causal link between early inflammation, subsequent angiogenic dysregulation detrimental to placental vascular development, and earlier gestational age at delivery. Interventions designed to reduce the burden of preterm birth may need to be implemented before 24 weeks of gestation.
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Affiliation(s)
- Andrea M. Weckman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Robyn E. Elphinstone
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Vanessa Tran
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Kathleen Zhong
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | | | - Carole Khairallah
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Victor Mwapasa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Andrea L. Conroy
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Feiko O. Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Chloe R. McDonald
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Kevin C. Kain
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- SAR Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, ON, Canada
- Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, ON, Canada
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16
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Sha M, Zhang S, Beejadhursing R, Sun Y, Qin Y, Chen S, Li W. Extracellular vesicles derived from hypoxic HTR-8/SVneo trophoblast inhibit endothelial cell functions through the miR-150-3p /CHPF pathway. Placenta 2023; 138:21-32. [PMID: 37156185 DOI: 10.1016/j.placenta.2023.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/21/2023] [Accepted: 04/25/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Endothelial dysfunction is one of the basic pathological changes in pre-eclampsia. Extracellular vesicles (EVs) can transport miRNAs expressed by placental trophoblast cells into endothelial cells. The aim of this study was to explore the differential effects of EVs induced by hypoxic trophoblasts (1%HTR-8-EV) and those derived from normoxic trophoblasts (20%HTR-8-EV) on the regulation of endothelial cell functions. METHODS Normoxia and hypoxia were preconditioned to induce trophoblast cells-derived EVs. The effect of EVs, miRNA, target gene, and their interactions on endothelial cell proliferation, migration, and angiogenesis were determined. Quantitative analysis of miR-150-3p and CHPF were verified by qRT-PCR and western blotting. The binding relationship among EVs pathway was demonstrated by luciferase reporter assay. RESULTS Compared with 20%HTR-8-EV, 1%HTR-8-EV had a suppressive effect on proliferation, migration, and angiogenesis of endothelial cells. The results of miRNA sequencing showed the vital role of miR-150-3p in trophoblast-to-endothelium communication. 1%HTR-8-EV carrying miR-150-3p could move into endothelial cells and target chondroitin polymerizing factor (CHPF) gene. MiR-150-3p inhibited endothelial cell functions by regulating CHPF. In patient-derived placental vascular tissues, there was a similar negative correlating between miR-150-3p and CHPF. DISCUSSION Our findings indicate that extracellular vesicles miR-150-3p derived from hypoxic trophoblasts inhibits endothelial cells proliferation, migration, and angiogenesis by modulating CHPF, illuminating a novel mechanism of hypoxic trophoblasts regulation of endothelial cells and their potential role in PE pathogenesis.
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Affiliation(s)
- Menghan Sha
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Shunran Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rajluxmee Beejadhursing
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yanan Sun
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yu Qin
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Suhua Chen
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Wei Li
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
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17
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Chaiworapongsa T, Romero R, Gotsch F, Suksai M, Gallo DM, Jung E, Krieger A, Chaemsaithong P, Erez O, Tarca AL. Preeclampsia at term can be classified into 2 clusters with different clinical characteristics and outcomes based on angiogenic biomarkers in maternal blood. Am J Obstet Gynecol 2023; 228:569.e1-569.e24. [PMID: 36336082 PMCID: PMC10149598 DOI: 10.1016/j.ajog.2022.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND An antiangiogenic state has emerged as a mechanism of disease in preeclampsia. Angiogenic biomarkers are used in the risk assessment of this syndrome, particularly of early disease. The role of an antiangiogenic state in late preeclampsia is unclear. OBJECTIVE This study aimed to determine the prevalence, characteristics, and clinical significance of angiogenic/antiangiogenic factor abnormalities in women with preeclampsia stratified according to gestational age at delivery. STUDY DESIGN Two studies were conducted: (1) a longitudinal nested case-control study comprising women with preeclampsia (n=151) and a control group (n=540); and (2) a case series of patients with preeclampsia (n=452). In patients with preeclampsia, blood was collected at the time of diagnosis. Plasma concentrations of placental growth factor and soluble fms-like tyrosine kinase-1 were determined by enzyme-linked immunosorbent assays. An abnormal angiogenic profile was defined as a plasma ratio of placental growth factor and soluble fms-like tyrosine kinase-1 expressed as a multiple of the median <10th percentile for gestational age based on values derived from the longitudinal study. The proportion of patients diagnosed with preeclampsia who had an abnormal angiogenic profile was determined in the case-series participants and stratified by gestational age at delivery into early (≤34 weeks), intermediate (34.1-36.9 weeks), and term (≥37 weeks) preeclampsia. The demographics, clinical characteristics, and pregnancy outcomes of women with preeclampsia with and without an abnormal angiogenic profile were compared. RESULTS The prevalence of an abnormal angiogenic profile was higher in preterm than in term preeclampsia (for early, intermediate, and term in the case-control study: 90%, 100%, and 39%; for the case series: 98%, 80%, and 55%, respectively). Women with preeclampsia at term who had an abnormal angiogenic profile were more frequently nulliparous (57% vs 35%), less likely to smoke (14% vs 26%), at greater risk for maternal (14% vs 5%) or neonatal (7% vs 1%) complications, and more often had placental lesions consistent with maternal vascular malperfusion (42% vs 23%; all, P<.05) than those without an abnormal profile. Women with preeclampsia at term who had a normal angiogenic profile had a higher frequency of chronic hypertension (36% vs 21%) and were more likely to have class ≥2 obesity (41% vs 23%) than those with an abnormal profile (both, P<.05). CONCLUSION Patients with early preeclampsia had an abnormal angiogenic profile in virtually all cases, whereas only 50% of women with preeclampsia at term had such abnormalities. The profile of angiogenic biomarkers can be used to classify patients with preeclampsia at term, on the basis of mechanisms of disease, into 2 clusters, which have different demographics, clinical characteristics, and risks of adverse maternal and neonatal outcomes. These findings provide a simple approach to classify preeclampsia at term and have implications for future clinical care and research.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI.
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI.
| | - Francesca Gotsch
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Manaphat Suksai
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dahiana M Gallo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eunjung Jung
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arthur Krieger
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, HaEmek Medical Center, Afula, Israel
| | - Adi L Tarca
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI
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18
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Biwer LA, Lu Q, Ibarrola J, Stepanian A, Man JJ, Carvajal BV, Camarda ND, Zsengeller Z, Skurnik G, Seely EW, Karumanchi SA, Jaffe IZ. Smooth Muscle Mineralocorticoid Receptor Promotes Hypertension After Preeclampsia. Circ Res 2023; 132:674-689. [PMID: 36815487 PMCID: PMC10119809 DOI: 10.1161/circresaha.122.321228] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Preeclampsia is a syndrome of high blood pressure (BP) with end organ damage in late pregnancy that is associated with high circulating soluble VEGF receptor (sFlt1 [soluble Fms-like tyrosine kinase 1]). Women exposed to preeclampsia have a substantially increased risk of hypertension after pregnancy, but the mechanism remains unknown, leaving a missed interventional opportunity. After preeclampsia, women have enhanced sensitivity to hypertensive stress. Since smooth muscle cell mineralocorticoid receptors (SMC-MR) are activated by hypertensive stimuli, we hypothesized that high sFlt1 exposure in pregnancy induces a postpartum state of enhanced SMC-MR responsiveness. METHODS Postpartum BP response to high salt intake was studied in women with prior preeclampsia. MR transcriptional activity was assessed in vitro in sFlt1-treated SMC by reporter assays and PCR. Preeclampsia was modeled by transient sFlt1 expression in pregnant mice. Two months post-partum, mice were exposed to high salt and then to AngII (angiotensin II) and BP and vasoconstriction were measured. RESULTS Women exposed to preeclampsia had significantly enhanced salt sensitivity of BP verses those with a normotensive pregnancy. sFlt1 overexpression during pregnancy in mice induced elevated BP and glomerular endotheliosis, which resolved post-partum. The sFlt1 exposed post-partum mice had significantly increased BP response to 4% salt diet and to AngII infusion. In vitro, SMC-MR transcriptional activity in response to aldosterone or AngII was significantly increased after transient exposure to sFlt1 as was aldosterone-induced expression of AngII type 1 receptor. Post-partum, SMC-MR-KO mice were protected from the enhanced response to hypertensive stimuli after preeclampsia. Mechanistically, preeclampsia mice exposed to postpartum hypertensive stimuli develop enhanced aortic stiffness, microvascular myogenic tone, AngII constriction, and AngII type 1 receptor expression, all of which were prevented in SMC-MR-KO littermates. CONCLUSIONS These data support that sFlt1-induced vascular injury during preeclampsia produces a persistent state of enhanced sensitivity of SMC-MR to activation. This contributes to postpartum hypertension in response to common stresses and supports testing of MR antagonism to mitigate the increased cardiovascular risk in women after PE.
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Affiliation(s)
- Lauren A. Biwer
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
| | - Qing Lu
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
| | - Jaime Ibarrola
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
| | - Alec Stepanian
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | - Joshua J. Man
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | - Brigett V. Carvajal
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | - Nicholas D. Camarda
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
| | | | | | - Ellen W. Seely
- Division of Endocrinology, Brigham and Women’s Hospital, Boston MA
| | - S. Ananth Karumanchi
- Department of Medicine, Beth Israel Deaconess Hospital, Boston MA
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles CA
| | - Iris Z. Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston MA
- Graduate School of Biomedical Sciences, Tufts University School of Medicine, Boston MA
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19
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Christenson E, Stout MJ, Williams D, Verma AK, Davila-Roman VG, Lindley KJ. Prenatal Low-Dose Aspirin Use Associated with Reduced Incidence of Postpartum Hypertension among Women with Preeclampsia. Am J Perinatol 2023; 40:394-399. [PMID: 33940641 DOI: 10.1055/s-0041-1728826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Postpartum hypertension (PP-HTN), defined as systolic/diastolic blood pressure (SBP/DBP) ≥140/90, on two occasions at least 4 hours apart after delivery occurs in up to 50% of preeclamptic pregnancies, and is associated with adverse maternal outcomes. Excessive production of antiangiogenic factors (i.e., soluble fms-like tyrosine kinase 1 [sFLT1]) and reduced levels of proangiogenic factors (i.e., placental growth factor [PlGF]) are associated with preeclamptic pregnancies. The aim of this study was to identify clinical risk factors and/or serum biomarkers associated with PP-HTN in preeclampsia. STUDY DESIGN Preeclamptic women (n = 82, aged ≥18 years) were prospectively enrolled in an observational study. Serial blood pressures were obtained through the labor course and until 48 hours postpartum, and serum was obtained within 24 hours postpartum. Statistical analysis was performed by using Student's two-tailed t-test and Fisher's exact test. RESULTS Baseline comorbidities and antihypertensive use were similar among those who developed PP-HTN and those who did not. Among preeclamptic patients, 33% developed PP-HTN; these had significantly more severe preeclampsia features versus no PP-HTN (96 vs. 78%, p = 0.05). PP-HTN was associated with higher re-hospitalization rates (26 vs. 6%, p = 0.01). Among those taking low-dose aspirin (ASA) for preeclampsia prophylaxis (n = 12), PP-HTN was significantly less frequent versus those not taking low-dose ASA (0 vs. 22%, p = 0.007). Low-dose ASA use was associated with significantly lower peripartum sFLT1 levels (4,650 ± 2,335 vs. 7,870 ± 6,282 pg/mL, p = 0.03) and sFLT1/PlGF ratio (397 ± 196 vs. 1,527 ± 2,668, p = 0.03). CONCLUSION One-third of women with preeclampsia develop PP-HTN; these patients have more severe preeclampsia and have higher re-hospitalization rates. Prenatal low-dose ASA use was associated with significantly lower incidence of PP-HTN, reduced levels of antiangiogenic factors, and lower 6-week re-hospitalization rates. These findings, if replicated, may have clinical implications on the use of low-dose ASA during pregnancy to reduce incidence of postpartum HTN. KEY POINTS · Postpartum hypertension is common in preeclampsia.. · Prenatal aspirin may reduce postpartum hypertension.. · Prenatal aspirin may reduce sFLT1 levels..
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Affiliation(s)
- Eleanor Christenson
- Internal Medicine Resident, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Molly J Stout
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Dominique Williams
- Division of Medicine, Cardiovascular, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Amanda K Verma
- Division of Medicine, Cardiovascular, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Victor G Davila-Roman
- Division of Medicine, Cardiovascular, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Kathryn J Lindley
- Division of Medicine, Obstetrics and Gynecology, Cardiovascular, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
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20
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Kumar A, Ravi R, Sivakumar RK, Chidambaram V, Majella MG, Sinha S, Adamo L, Lau ES, Al’Aref SJ, Asnani A, Sharma G, Mehta JL. Prolactin Inhibition in Peripartum Cardiomyopathy: Systematic Review and Meta-analysis. Curr Probl Cardiol 2023; 48:101461. [PMID: 36261102 PMCID: PMC9805509 DOI: 10.1016/j.cpcardiol.2022.101461] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/13/2022] [Indexed: 02/03/2023]
Abstract
Heart failure (HF) is one of the leading causes of maternal mortality and morbidity in the United States. Peripartum cardiomyopathy (PPCM) constitutes up to 70% of all HF in pregnancy. Cardiac angiogenic imbalance caused by cleaved 16kDa prolactin has been hypothesized to contribute to the development of PPCM, fueling investigation of prolactin inhibitors for the management of PPCM. We conducted a systematic review and meta-analysis to assess the impact of prolactin inhibition on left ventricular (LV) function and mortality in patients with PPCM. We included English language articles from PubMed and EMBASE published upto March 2022. We pooled the mean difference (MD) for left ventricular ejection fraction (LVEF) at follow-up, odds ratio (OR) for LV recovery and risk ratio (RR) for all-cause mortality using random-effects meta-analysis. Among 548 studies screened, 10 studies (3 randomized control trials (RCTs), 2 retrospective and 5 prospective cohorts) were included in the systematic review. Patients in the Bromocriptine + standard guideline directed medical therapy (GDMT) group had higher LVEF% (pMD 12.56 (95% CI 5.84-19.28, I2=0%) from two cohorts and pMD 14.25 (95% CI 0.61-27.89, I2=88%) from two RCTs) at follow-up compared to standard GDMT alone group. Bromocriptine group also had higher odds of LV recovery (pOR 3.55 (95% CI 1.39-9.1, I2=62)). We did not find any difference in all-cause mortality between the groups. Our analysis demonstrates that the addition of Bromocriptine to standard GDMT was associated with a significant improvement in LVEF% and greater odds of LV recovery, without significant reduction in all-cause mortality.
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Affiliation(s)
- Amudha Kumar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Ramya Ravi
- Department of Anesthesia and Intensive Care, Chinese university of Hong Kong, Prince of Wales hospital, Shatin, Hong Kong
| | - Ranjith K. Sivakumar
- Department of Anesthesia and Intensive Care, Chinese university of Hong Kong, Prince of Wales hospital, Shatin, Hong Kong
| | - Vignesh Chidambaram
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Marie G. Majella
- Department of Community Medicine, Sri Venkateshwaraa Medical College Hospital & Research Center, Pondicherry, India
| | - Shashank Sinha
- Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, VA
| | - Luigi Adamo
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Emily S. Lau
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Subhi J. Al’Aref
- Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Aarti Asnani
- Beth Israel Deaconess Medical Center, Harvard Medical School, Cardiovascular Institute, Boston, MA
| | - Garima Sharma
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jawahar L. Mehta
- Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
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21
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Utility of sFtl-1 and Placental Growth Factor Ratio for Adequate Preeclampsia Management. Healthcare (Basel) 2023; 11:healthcare11030381. [PMID: 36766955 PMCID: PMC9914058 DOI: 10.3390/healthcare11030381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
Introduction: The pathophysiology of preeclampsia is represented by placental ischemia and the release of angiogenic factors. Recent research suggests that using the value of the sFtl-1/PIGF ratio is more accurate for monitoring angiogenic activity. The aim of this study consists in assessing the clinical utility of the sFtl-1/PIGF ratio in determining the diagnosis and severity of preeclampsia. Material and Methods: In our study a descriptive and prospective plan was used for analyzing the specific value of the sFtl-1/PIGF ratio in women with preeclampsia and in women with gestational hypertension, depending on the gestational age and severity. Results: The study included 59 women with preeclampsia and 25 women with gestational hypertension. The mean value of the sFtl-1/PIGF ratio of pregnant women with preeclampsia was 209.2 pg/mL, while in the gestational hypertension group, the mean value of the sFtl-1/PIGF ratio was 46.08 pg/mL. The difference between the value of the sFtl-1/PIGF ratio of the group with preeclampsia and the gestational hypertension group was > 67 (pg/mL), with a sensitivity of 86.44% and a specificity of 92.00%. Significant differences were found between the median values of the sFtl-1/PIGF ratio in pregnant women with severe preeclampsia in the early-onset subgroup compared to those in the late-onset subgroup (307 pg/mL, and 98 pg/mL, respectively, p = 0.009 < α = 0.05). Conclusions: The sFtl-1/PIGF ratio may be an alternative method for diagnosing preeclampsia and it can provide data about this condition's severity.
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22
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Ntsethe A, Mackraj I. An Investigation of Exosome Concentration and Exosomal microRNA (miR-155 and miR-222) Expression in Pregnant Women with Gestational Hypertension and Preeclampsia. Int J Womens Health 2022; 14:1681-1689. [PMID: 36514348 PMCID: PMC9741850 DOI: 10.2147/ijwh.s382836] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Hypertensive disorders of pregnancy are characterized by widespread maternal endothelial dysfunction. Elevated secretion of exosomes has been associated with endothelial dysfunction. Exosomes play a role in cell-cell communication by transferring microRNAs. These microRNAs are associated with the pathogenesis of hypertensive disorders of pregnancy through the regulation of endothelial function. This study characterizes exosomes and determines exosomal miR-155 and miR-222 expression levels in women with gestational hypertension (GH) and preeclampsia (PE). Methods Exosomes were isolated and thereafter characterised using NTA, microscopy and ELISA. Results: Exosomes were elevated in the serum of pregnant women with GH and PE (P<0.05). The circulating exosomes and placental exosomes were increased in both GH and PE (P<0.0001). The exosomal miR-155 increased in PE but not in GH (P < 0.05). MiR-222 decreased in PE (P < 0.05). Discussion Elevated exosomes in pregnant women with GH and PE may be indicative of exosomes being potential biomarkers for both GH and PE. The difference in the exosomal miR-155 and miR-222 expression in PE and GH suggested that these two disorders have different pathological pathways.
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Affiliation(s)
- Aviwe Ntsethe
- Department of Human Physiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Irene Mackraj
- Department of Human Physiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa,Correspondence: Irene Mackraj; Aviwe Ntsethe, Department of Human Physiology, University of KwaZulu-Natal, Durban, South Africa, Tel +27 31-260-7770; +27 31-260-7192, Email ;
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23
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Persson LKG, Lihme FF, Basit S, Larsen M, Scheller NM, Andersen AS, Halse K, Thorsen‐Meyer A, Sørensen KM, Wohlfahrt J, Melbye M, Pihl KKØ, Lykke J, Boyd HA. Cohort profile: The PreEclampsia, Angiogenesis, Cardiac dysfunction and Hypertension (PEACH) Study. Paediatr Perinat Epidemiol 2022; 36:863-878. [PMID: 35951739 PMCID: PMC9804795 DOI: 10.1111/ppe.12917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/28/2022] [Accepted: 07/18/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) remain a leading cause of maternal morbidity and mortality worldwide, with implications for maternal and neonatal well-being in the short term and for long-term maternal cardiovascular health. Although the mechanisms behind HDP remain incompletely understood, evidence suggests that preeclampsia in particular is a syndrome with more than one distinct subtype. OBJECTIVES The PEACH (PreEclampsia, Angiogenesis, Cardiac dysfunction, Hypertension) Study was established to identify new HDP subtyping systems reflecting aetiology and prognosis and to find markers of later cardiovascular disease risk associated with preeclampsia. POPULATION The PEACH Study recruited pregnant women referred to two Copenhagen-area hospitals with suspected preeclampsia (mean gestational age at enrolment: 36.7 weeks) and a group of frequency-matched pregnant women planning delivery at the same hospitals and healthy when enrolled mid-pregnancy. DESIGN Prospective, longitudinal pregnancy cohort. METHODS Participants underwent repeated third-trimester blood sample collection, longitudinal cardiac function assessments using the USCOM-1A during the third trimester and at 1 year postpartum and collection of placental samples immediately after delivery. Medical information was abstracted from medical records and hospital databases. PRELIMINARY RESULTS During 2016-2018, we recruited 1149 pregnant women, of whom 1101 were followed to delivery. Among 691 women enrolled with suspected preeclampsia, 310 and 172 developed preeclampsia and gestational hypertension respectively. Among 410 women with healthy pregnancies when enrolled mid-pregnancy, 37 later developed hypertensive disorders of pregnancy. Of 1089 women still in the cohort 1 year postpartum, 578 (53.1%) participated in the follow-up assessment. CONCLUSIONS The PEACH Study's rich data from women with and without HDP will enable us to identify new, clinically useful HDP subtypes to aid in decision-making regarding monitoring and treatment. Continued postpartum follow-up will help us develop algorithms to identify women at risk of persistent postpartum cardiac dysfunction and later cardiovascular disease after pregnancies complicated by HDP.
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Affiliation(s)
- Lisa Kristine Grange Persson
- Department of Epidemiology ResearchStatens Serum InstitutCopenhagenDenmark,Department of ObstetricsCopenhagen University Hospital HerlevHerlevDenmark
| | | | - Saima Basit
- Department of Epidemiology ResearchStatens Serum InstitutCopenhagenDenmark
| | - Maria Oku Larsen
- Department of Epidemiology ResearchStatens Serum InstitutCopenhagenDenmark
| | | | - Anita Sylvest Andersen
- Department of ObstetricsCopenhagen University Hospital HerlevHerlevDenmark,Department of ObstetricsCopenhagen University Hospital HvidovreHvidovreDenmark
| | - Karen Green Halse
- Department of ObstetricsCopenhagen University Hospital HvidovreHvidovreDenmark
| | | | | | - Jan Wohlfahrt
- Department of Epidemiology ResearchStatens Serum InstitutCopenhagenDenmark
| | - Mads Melbye
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark,Department of MedicineStanford University School of MedicineStanfordCaliforniaUSA
| | - Kasper Kai Østrup Pihl
- Department of ObstetricsCopenhagen University Hospital HvidovreHvidovreDenmark,Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Jacob Alexander Lykke
- Department of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark,Department of ObstetricsCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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24
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Abstract
Pregnancy complications affect millions of women each year. Some of these diseases have high morbidity and mortality such as preeclampsia. At present, there is no safe and effective treatment for pregnancy complications, so it is still a difficult clinical problem. As many pregnancy complications are closely related to placental dysplasia, placenta-specific therapy, as an important method, is expected to be a safe, effective, and specific therapeutic strategy. This review explains in detail the placenta physiological structure, characteristics, and action mechanism of some biomolecules and signaling pathways that play roles in normal development and disorders of the development of the placenta, and how to use these biomolecules as therapeutic targets when the placenta disorder causes disease, combining the latest progress in the field of nanodelivery systems, so as to lay a foundation for the development of placenta-specific therapy of pregnancy complications.
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Affiliation(s)
- Yang Liu
- School of Pharmaceutical Sciences, Zhengzhou University, No. 100, Kexue Avenue, Zhengzhou, 450001, China
| | - Xingli Gao
- School of Pharmaceutical Sciences, Zhengzhou University, No. 100, Kexue Avenue, Zhengzhou, 450001, China
| | - Songwei Gao
- School of Pharmaceutical Sciences, Zhengzhou University, No. 100, Kexue Avenue, Zhengzhou, 450001, China.,Department of Pharmacy, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, China
| | - Yu Song
- School of Pharmacy, Xinxiang Medical University, Xinxiang, 453003, China
| | - Yongran Guo
- School of Pharmaceutical Sciences, Zhengzhou University, No. 100, Kexue Avenue, Zhengzhou, 450001, China
| | - Jing Cao
- Department of Pathology, The Third Affiliated Hospital of Zhenzhou University, Zhengzhou, 450001, China
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Tataru-Copos AF, Popescu MI, Murvai R, El Kharoubi A. Efficiency of sFlt-1/PlGF Ratio in Preeclampsia Diagnosis. Medicina (B Aires) 2022; 58:medicina58091196. [PMID: 36143873 PMCID: PMC9501471 DOI: 10.3390/medicina58091196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Preeclampsia is a health issue characterized by a new onset of hypertension after 20 weeks of gestation and proteinuria. This is a multiple organ disorder and is associated with significant maternal and fetal mortality. Material and Methods: The study is a prospective one and included 69 pregnant women (17 with hypertension without criteria for PE, 26 with severe PE and 26 with moderate PE) with an age of gestation between 24 and 40 weeks. Subjects were chosen from those who referred to the Oradea County Emergency Clinical Hospital, Department of Obstetrics-Gynecology between January 2020 and December 2022. We collected other characteristics from observation sheets and from patients and we measured the sFlt-1/PlGF ratio after 20 weeks of pregnancy if patients presented with suspected preeclampsia. All the results were collected in Excel analysis by SPSS. Results: In our study, 37.68% had severe preeclampsia, the same percentage had moderate PE and 24.63% presented only with hypertension. The mean of sFLT-1/PlGF for severe preeclampsia was 78.282 ng/mL, and for moderate, it was 50.154 ng/mL. For those who did not have criteria for preeclampsia, it was 29.076 ng/mL. When we compared the values of sFLT-1/PlGF in moderate PE and hypertension, we found that there was a statistically significant difference between this two, and the same conclusion was also obtained for severe PE and hypertension and for severe and moderate PE. Conclusions: This marker can be useful for improving the outcomes for pregnant women with preeclampsia. In addition, for newborns, sFlt-1/PlGF can be helpful because we can correctly and promptly manage a patient affected by this disease before 34 weeks of pregnancy. Our study demonstrates that the correlation between the values of sFlt-1/PlGF and the type of preeclampsia are positive; thus, if the values are high, the pregnant woman likely will develop severe preeclampsia with early onset. In addition, the sFlt-1/PlGF ratio has the highest accuracy for differentiating PE patients from pregnant women who did not develop sign and symptoms for preeclampsia. Our results are in line with the conclusions of other studies that researched the association between sFlt-1/PlGF and clinical diagnosis of preeclampsia.
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Affiliation(s)
- Anca-Florina Tataru-Copos
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
- Correspondence:
| | - Mircea Ioachim Popescu
- Cardiology Department, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
| | - Romina Murvai
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
| | - Amin El Kharoubi
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania
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Proteomics and Metabolomics Profiling of Platelets and Plasma Mediators of Thrombo-Inflammation in Gestational Hypertension and Preeclampsia. Cells 2022; 11:cells11081256. [PMID: 35455936 PMCID: PMC9027992 DOI: 10.3390/cells11081256] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/02/2022] [Accepted: 04/05/2022] [Indexed: 02/04/2023] Open
Abstract
Platelets may be pivotal mediators of the thrombotic and coagulopathic complications of preeclampsia (PE), linking inflammation and thrombosis with endothelial and vascular dysfunction. Both PE and gestational hypertension (GH) fall within the spectrum of hypertensive complications of pregnancy, with GH being a risk factor for preeclampsia. However, it is unclear what biomarkers distinguish PE from GH. Using a discovery size cohort, we aimed to characterize specific plasma and platelet thrombo-inflammatory drivers indicative of PE and differentiate PE from GH. We performed multiplex immunoassays, platelet and plasma quantitative proteomics and metabolomics of PE patients, comparing with non-pregnant (NP), healthy pregnant controls (PC) and GH participants. The expression pattern of plasma proteins and metabolites in PE/GH platelets was distinct from that of NP and PC. Whilst procoagulation in PC may be fibrinogen driven, inter-alpha-trypsin inhibitors ITIH2 and ITIH3 are likely mediators of thrombo-inflammation in GH and PE, and fibronectin and S100A8/9 may be major procoagulant agonists in PE only. Also enriched in PE were CCL1 and CCL27 plasma cytokines, and the platelet leucine-rich repeat-containing protein 27 and 42 (LRRC27/42), whose effects on platelets were explored using STRING analysis. Through protein-protein interactions analysis, we generated a new hypothesis for platelets’ contribution to the thrombo-inflammatory states of preeclampsia.
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Stanhewicz AE, Dillon GA, Serviente C, Alexander LM. Acute systemic inhibition of inflammation augments endothelium-dependent dilation in women with a history of preeclamptic pregnancy. Pregnancy Hypertens 2022; 27:81-86. [PMID: 34973597 PMCID: PMC8858855 DOI: 10.1016/j.preghy.2021.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/27/2022]
Abstract
Women who have had preeclampsia demonstrate microvascular endothelial-dysfunction, mediated in part by reduced nitric oxide (NO)-dependent dilation. Preeclamptic pregnancies are associated with elevated inflammation, and inhibition of inflammation attenuates endothelial damage in animal models of preeclampsia. However, it is unclear if inhibition of vascular inflammation improves endothelial function in women after a preeclamptic pregnancy. Using the cutaneous microcirculation as a model, we hypothesized that acute systemic inhibition of vascular inflammation (oral salsalate; 1500 mg/twice daily, 4 days) would improve endothelium- and NO-dependent vasodilation in women with a history of preeclampsia (PE) but not in women with a history of uncomplicated pregnancy (HC). Twelve HC (30 ± 1yrs, 10 ± 2 months postpartum) and 10 PE (30 ± 2yrs, 8 ± 2 months postpartum) participated in a double-blind placebo-controlled study. Following each treatment, 2 intradermal microdialysis fibers were placed in the skin of the ventral forearm for graded infusion of acetylcholine (Ach, 10-7-102mM) or Ach + 15 mM L-NAME (NO synthase antagonist). Red blood cell flux was measured over each site by laser-Doppler flowmetry (LDF). Cutaneous vascular conductance was calculated (CVC = LDF/mean arterial pressure) and normalized to maximum (%CVCmax; 28 mM SNP + local heat 43 °C). ACh-induced (77 ± 3 vs. 92 ± 3%CVCmax; p = 0.01) and NO-dependent (20 ± 6 vs. 33 ± 4%; p = 0.02) vasodilation were attenuated in PE compared to HC. Salsalate augmented ACh-induced (95 ± 2%CVCmax; p = 0.002) and NO-dependent (39 ± 3%; p = 0.009) dilation in PE compared to placebo but had no effect in HC (all p > 0.05). Salsalate treatment augmented endothelium-dependent vasodilation via NO-mediated pathways in women who have had preeclampsia, suggesting that inflammatory signaling mediates persistent endothelial dysfunction following preeclampsia.
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Affiliation(s)
- Anna E. Stanhewicz
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA,Department of Kinesiology, Pennsylvania State University, University Park, PA
| | - Gabrielle A. Dillon
- Department of Kinesiology, Pennsylvania State University, University Park, PA,Center for Healthy Aging, Pennsylvania State University, University Park, PA
| | - Corinna Serviente
- Center for Healthy Aging, Pennsylvania State University, University Park, PA,Institute for Applied Life Sciences, University of Massachusetts Amherst, Amherst, MA,Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA
| | - Lacy M. Alexander
- Department of Kinesiology, Pennsylvania State University, University Park, PA,Center for Healthy Aging, Pennsylvania State University, University Park, PA
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Gan B, Wu X, Lu L, Li X, Li J. The Value of Prenatal First Systolic Blood Pressure Can Predict Severe Preeclampsia and Birth Weight in Patients With Preeclampsia. Front Med (Lausanne) 2022; 8:771738. [PMID: 35186968 PMCID: PMC8850716 DOI: 10.3389/fmed.2021.771738] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
Background Preeclampsia is a serious complication of pregnancy that threatens the safety of the fetus and mother. We assessed the relationship between systolic blood pressure (SBP) in the early pregnancy stage (12 weeks) in patients with preeclampsia and the development of severe eclampsia and birth weight. Methods Patients were categorized based on the quartiles of the prenatal first SBP level. Logistic regression analysis was performed to assess whether prenatal first SBP was a risk factor for low birth weight and severe preeclampsia. The area under the receiver-operating characteristic curve (AUC) of sensitivity and specificity were used to predict the risk of low birth weight and severe preeclampsia. Results A total of 333 patients with preeclampsia were enrolled. There were 162 (48.6%) patients with severe preeclampsia and 270 (81.08%) cesareans. Group I patients with a prenatal first SBP ≤ 119 mmHg prenatal had a higher birth weight. Multiple logistic regression analysis showed that serum creatinine (p = 0.025), prenatal first SBP (p = 0.029), S-preeclampsia (p = 0.003), gestational age (p < 0.001), total cholesterol (TC) (p < 0.001), and low-density lipoprotein (LDL) (p < 0.001) were independent risk factors for low birth weight. Multiple logistic regression analysis showed that prenatal first SBP (p = 0.003), TC (p = 0.002), and B-type natriuretic peptide (BNP) (p < 0.001) were independent risk factors for severe preeclampsia. Compared with Group I (SBP ≤ 119 mmHg), the incidence of low birth weight for patients in groups III (131 ≤ SBP ≤ 138 mmHg) and IV (SBP ≥ 139 mmHg) was significantly higher. Even after correcting for age, gestational age, and biochemical indices, the difference remained statistically significant. The risk of diagnosed severe preeclampsia for patients in Groups IV (SBP ≥ 139 mmHg), III (131 ≤ SBP ≤ 138 mmHg), and II (120 ≤ SBP ≤ 130 mmHg) was significantly higher than that in Group I (SBP ≤ 119 mmHg). The AUC of the prenatal first SBP for predicting low birth weight and severe preeclampsia was 0.676 (95% CI 0.618–0.733, p < 0.001) and 0.727 (95% CI 0.673–0.781, p < 0.001), respectively, in patients with preeclampsia. Conclusions Prenatal first SBP was associated with birth weight and severe preeclampsia. Higher prenatal first SBP in patients with preeclampsia can predict low birth weight and severe preeclampsia.
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Preeclampsia has two phenotypes which require different treatment strategies. Am J Obstet Gynecol 2022; 226:S1006-S1018. [PMID: 34774281 DOI: 10.1016/j.ajog.2020.10.052] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 12/15/2022]
Abstract
The opinion on the mechanisms underlying the pathogenesis of preeclampsia still divides scientists and clinicians. This common complication of pregnancy has long been viewed as a disorder linked primarily to placental dysfunction, which is caused by abnormal trophoblast invasion, however, evidence from the previous two decades has triggered and supported a major shift in viewing preeclampsia as a condition that is caused by inherent maternal cardiovascular dysfunction, perhaps entirely independent of the placenta. In fact, abnormalities in the arterial and cardiac functions are evident from the early subclinical stages of preeclampsia and even before conception. Moving away from simply observing the peripheral blood pressure changes, studies on the central hemodynamics reveal two different mechanisms of cardiovascular dysfunction thought to be reflective of the early-onset and late-onset phenotypes of preeclampsia. More recent evidence identified that the underlying cardiovascular dysfunction in these phenotypes can be categorized according to the presence of coexisting fetal growth restriction instead of according to the gestational period at onset, the former being far more common at early gestational ages. The purpose of this review is to summarize the hemodynamic research observations for the two phenotypes of preeclampsia. We delineate the physiological hemodynamic changes that occur in normal pregnancy and those that are observed with the pathologic processes associated with preeclampsia. From this, we propose how the two phenotypes of preeclampsia could be managed to mitigate or redress the hemodynamic dysfunction, and we consider the implications for future research based on the current evidence. Maternal hemodynamic modifications throughout pregnancy can be recorded with simple-to-use, noninvasive devices in obstetrical settings, which require only basic training. This review includes a brief overview of the methodologies and techniques used to study hemodynamics and arterial function, specifically the noninvasive techniques that have been utilized in preeclampsia research.
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Pyevich M, Alexander LM, Stanhewicz AE. Women with a history of preeclampsia have preserved sensory nerve-mediated dilatation in the cutaneous microvasculature. Exp Physiol 2022; 107:175-182. [PMID: 34961978 PMCID: PMC8810741 DOI: 10.1113/ep090177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 12/20/2021] [Indexed: 02/03/2023]
Abstract
NEW FINDINGS What is the central question of this study? Are sensory nerve-mediated vasodilatation and the NO-dependent contribution to that response attenuated in the cutaneous microvasculature of women who have had preeclampsia? What is the main finding and its importance? Women who have had preeclampsia demonstrate attenuated microvascular endothelium-dependent dilatation compared to women with a history of uncomplicated pregnancy. However, there are no differences in sensory nerve-mediated vasodilatation between groups. This suggests that the neurogenic response is not altered following preeclampsia, and that the NO-dependent vasodilatation of the neurogenic response is not related to endothelium-dependent NO-mediated dilatation in these women. ABSTRACT Women who have had preeclampsia (PE) demonstrate microvascular endothelial dysfunction, mediated in part by reduced nitric oxide (NO)-dependent mechanisms. Localized heating of the skin induces a biphasic vasodilatation response: a sensory nerve-mediated initial peak, followed by a sustained endothelium-dependent plateau. We have previously shown that the endothelium-dependent plateau is attenuated in PE. However, it is unknown if the sensory nerve-mediated initial peak is similarly attenuated. Therefore, the purpose of this study was to examine the effect of PE history on sensory nerve-mediated vasodilatation and the NO-dependent contribution to that response. We hypothesized that PE would have an attenuated initial peak and a reduced NO-dependent contribution to that response compared to women with a history of normotensive pregnancy (healthy controls, HC). Nine HC (31 ± 4 years) and nine PE (28 ± 6 years) underwent a standard local heating protocol (42°C; 0.1°C s-1 ). Two intradermal microdialysis fibres were placed in the skin of the ventral forearm for the continuous local delivery of lactated Ringer solution alone (control) or 15-mM NG -nitro-l-arginine methyl ester for nitric oxide synthase (NOS) inhibition. Red blood cell flux was measured at each site by laser Doppler flowmetry (LDF). Cutaneous vascular conductance was calculated (CVC = LDF/mean arterial pressure) and normalized to maximum (%CVCmax ; 28-mM SNP + local heat 43°C). There were no differences in the initial peak between groups (HC: 79 ± 8 vs. PE: 80 ± 10%CVCmax ; P = 0.936). NOS inhibition attenuated the initial peak in both HC (57 ± 18% CVCmax ; P = 0.003) and PE (54 ± 10%CVCmax ; P = 0.002). However, there were no differences in the NO-dependent portion of the initial peak (HC: 23 ± 16 vs. PE: 24 ± 9%; P = 0.777). The local heating plateau (HC: 99 ± 4 vs. PE: 88 ± 7%CVCmax ; P = 0.001) and NO contribution to the plateau (HC: 31 ± 9 vs. PE: 17 ± 14%; P = 0.02) were attenuated in PE. There was no relation between NO-dependent dilatation in the initial peak and NO-dependent dilatation in the plateau across groups (R2 = 0.005; P = 0.943). Women who have had PE demonstrate attenuated microvascular endothelium-dependent dilatation. However, there are no differences in sensory nerve-mediated vasodilatation following PE, suggesting that the NO-dependent vasodilatation of the neurogenic response is not related to endothelium-dependent NO-mediated dilatation in these women.
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Affiliation(s)
- Michael Pyevich
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA
| | - Lacy M Alexander
- Department of Kinesiology, Pennsylvania State University, University Park, PA
| | - Anna E. Stanhewicz
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA
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Yagel S, Cohen SM, Goldman-Wohl D. An integrated model of preeclampsia: a multifaceted syndrome of the maternal cardiovascular-placental-fetal array. Am J Obstet Gynecol 2022; 226:S963-S972. [PMID: 33712272 DOI: 10.1016/j.ajog.2020.10.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/13/2020] [Accepted: 10/19/2020] [Indexed: 12/16/2022]
Abstract
Maternal tolerance of the semiallogenic fetus necessitates conciliation of competing interests. Viviparity evolved with a placenta to mediate the needs of the fetus and maternal adaptation to the demands of pregnancy and to ensure optimal survival for both entities. The maternal-fetal interface is imagined as a 2-dimensional porous barrier between the mother and fetus, when in fact it is an intricate multidimensional array of tissues and resident and circulating factors at play, encompassing the developing fetus, the growing placenta, the changing decidua, and the dynamic maternal cardiovascular system. Pregnancy triggers dramatic changes to maternal hemodynamics to meet the growing demands of the developing fetus. Nearly a century of extensive research into the development and function of the placenta has revealed the role of placental dysfunction in the great obstetrical syndromes, among them preeclampsia. Recently, a debate has arisen questioning the primacy of the placenta in the etiology of preeclampsia, asserting that the maternal cardiovascular system is the instigator of the disorder. It was the clinical observation of the high rate of preeclampsia in hydatidiform mole that initiated the focus on the placenta in the etiology of the disease. Over many years of research, shallow trophoblast invasion with deficient remodeling of the maternal spiral arteries into vessels of higher capacitance and lower resistance has been recognized as hallmarks of the preeclamptic milieu. The lack of the normal decrease in uterine artery resistance is likewise predictive of preeclampsia. In abdominal pregnancies, however, an extrauterine pregnancy develops without remodeling of the spiral arteries, yet there is reduced resistance in the uterine arteries and distant vessels, such as the maternal ophthalmic arteries. Proponents of the maternal cardiovascular model of preeclampsia point to the observed maternal hemodynamic adaptations to pregnancy and maladaptation in gestational hypertension and preeclampsia and how the latter resembles the changes associated with cardiac disease states. Recognition of the importance of the angiogenic-antiangiogenic balance between placental-derived growth factor and its receptor soluble fms-like tyrosine kinase-1 and disturbance in this balance by an excess of a circulating isoform, soluble fms-like tyrosine kinase-1, which competes for and disrupts the proangiogenic receptor binding of the vascular endothelial growth factor and placental-derived growth factor, opened new avenues of research into the pathways to normal adaptation of the maternal cardiovascular and other systems to pregnancy and maladaptation in preeclampsia. The significance of the "placenta vs heart" debate goes beyond the academic: understanding the mutuality of placental and maternal cardiac etiologies of preeclampsia has far-reaching clinical implications for designing prevention strategies, such as aspirin therapy, prediction and surveillance through maternal hemodynamic studies or serum placental-derived growth factor and soluble fms-like tyrosine kinase-1 testing, and possible treatments to attenuate the effects of insipient preeclampsia on women and their fetuses, such as RNAi therapy to counteract excess soluble fms-like tyrosine kinase-1 produced by the placenta. In this review, we will present an integrated model of the maternal-placental-fetal array that delineates the commensality among the constituent parts, showing how a disruption in any component or nexus may lead to the multifaceted syndrome of preeclampsia.
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Affiliation(s)
- Simcha Yagel
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Sarah M Cohen
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Debra Goldman-Wohl
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Imbalances in circulating angiogenic factors in the pathophysiology of preeclampsia and related disorders. Am J Obstet Gynecol 2022; 226:S1019-S1034. [PMID: 33096092 PMCID: PMC8884164 DOI: 10.1016/j.ajog.2020.10.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/26/2020] [Accepted: 10/17/2020] [Indexed: 12/11/2022]
Abstract
Preeclampsia is a devastating medical complication of pregnancy that can lead to significant maternal and fetal morbidity and mortality. It is currently believed that there is abnormal placentation in as early as the first trimester in women destined to develop preeclampsia. Although the etiology of the abnormal placentation is being debated, numerous epidemiologic and experimental studies suggest that imbalances in circulating angiogenic factors released from the placenta are responsible for the maternal signs and symptoms of preeclampsia. In particular, circulating levels of soluble fms-like tyrosine kinase 1, an antiangiogenic factor, are markedly increased in women with preeclampsia, whereas free levels of its ligand, placental, growth factor are markedly diminished. Alterations in these angiogenic factors precede the onset of clinical signs of preeclampsia and correlate with disease severity. Recently, the availability of automated assays for the measurement of angiogenic biomarkers in the plasma, serum, and urine has helped investigators worldwide to demonstrate a key role for these factors in the clinical diagnosis and prediction of preeclampsia. Numerous studies have reported that circulating angiogenic biomarkers have a very high negative predictive value to rule out clinical disease among women with suspected preeclampsia. These blood-based biomarkers have provided a valuable tool to clinicians to accelerate the time to clinical diagnosis and minimize maternal adverse outcomes in women with preeclampsia. Angiogenic biomarkers have also been useful to elucidate the pathogenesis of related disorders of abnormal placentation such as intrauterine growth restriction, intrauterine fetal death, twin-to-twin transfusion syndrome, and fetal hydrops. In summary, the discovery and characterization of angiogenic proteins of placental origin have provided clinicians a noninvasive blood-based tool to monitor placental function and health and for early detection of disorders of placentation. Uncovering the mechanisms of altered angiogenic factors in preeclampsia and related disorders of placentation may provide insights into novel preventive and therapeutic options.
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Oliver-Williams C, Stevens D, Payne RA, Wilkinson IB, Smith GCS, Wood A. Association between hypertensive disorders of pregnancy and later risk of cardiovascular outcomes. BMC Med 2022; 20:19. [PMID: 35073907 PMCID: PMC8787919 DOI: 10.1186/s12916-021-02218-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 12/14/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are common pregnancy complications that are associated with greater cardiovascular disease risk for mothers. However, risk of cardiovascular disease subtypes associated with gestational hypertension or pre-eclampsia is unclear. The present study aims to compare the risk of cardiovascular disease outcomes for women with and without a history of gestational hypertension and pre-eclampsia using national hospital admissions data. METHODS This was a retrospective cohort study of national medical records from all National Health Service hospitals in England. Women who had one or more singleton live births in England between 1997 and 2015 were included in the analysis. Risk of total cardiovascular disease and 19 pre-specified cardiovascular disease subtypes, including stroke, coronary heart disease, cardiomyopathy and peripheral arterial disease, was calculated separately for women with a history of gestational hypertension and pre-eclampsia compared to normotensive pregnancies. RESULTS Amongst 2,359,386 first live births, there were 85,277 and 74,542 hospital admissions with a diagnosis of gestational hypertension and pre-eclampsia, respectively. During 18 years (16,309,386 person-years) of follow-up, the number and incidence of total CVD for normotensive women, women with prior gestational hypertension and women with prior pre-eclampsia were n = 8668, 57.1 (95% CI: 55.9-58.3) per 100,000 person-years; n = 521, 85.8 (78.6-93.5) per 100,000 person-years; and n = 518, 99.3 (90.9-108.2) per 100,000 person-years, respectively. Adjusted HRs (aHR) for total CVD were aHR (95% CI) = 1.45 (1.33-1.59) for women with prior gestational hypertension and aHR = 1.62 (1.48-1.78) for women with prior pre-eclampsia. Gestational hypertension was strongly associated with dilated cardiomyopathy, aHR = 2.85 (1.67-4.86), and unstable angina, aHR = 1.92 (1.33-2.77). Pre-eclampsia was strongly associated with hypertrophic cardiomyopathy, aHR = 3.27 (1.49-7.19), and acute myocardial infarction, aHR = 2.46 (1.72-3.53). Associations were broadly homogenous across cardiovascular disease subtypes and increased with a greater number of affected pregnancies. CONCLUSIONS Women with either previous gestational hypertension or pre-eclampsia are at greater risk of a range of cardiovascular outcomes. These women may benefit from clinical risk assessment or early interventions to mitigate their greater risk of various cardiovascular outcomes.
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Affiliation(s)
- Clare Oliver-Williams
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, UK. .,Homerton College, Hills Road, Cambridge, UK. .,Department of Health Sciences, University of Leicester, George Davies Centre, University Road, Leicester, UK.
| | - David Stevens
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, UK
| | - Rupert A Payne
- Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, UK.,Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, England, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK.,NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Angela Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, England, UK.,British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, England, UK.,National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, University of Cambridge, Cambridge, England, UK.,National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, England, UK.,Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, England, UK
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OUP accepted manuscript. Clin Chem 2022; 68:771-781. [DOI: 10.1093/clinchem/hvab281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/23/2021] [Indexed: 11/13/2022]
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Oliver-Williams C, Johnson JD, Vladutiu CJ. Maternal Cardiovascular Disease After Pre-Eclampsia and Gestational Hypertension: A Narrative Review. Am J Lifestyle Med 2021; 17:8-17. [PMID: 36636385 PMCID: PMC9830232 DOI: 10.1177/15598276211037964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Previous literature has highlighted that women who have a pregnancy affected by gestational hypertension or preeclampsia are at higher risk of cardiovascular disease (CVD) in later life. However, CVD is a composite of multiple outcomes, including coronary heart disease, heart failure, and stroke, and the risk of both CVD and hypertensive disorders of pregnancy varies by the population studied. We conducted a narrative review of the risk of cardiovascular outcomes for women with prior gestational hypertension and pre-eclampsia. Previous literature is summarized by country and ethnicity, with a higher risk of CVD and coronary heart disease observed after gestational hypertension and a higher risk of CVD, coronary heart disease and heart failure observed after pre-eclampsia in most of the populations studied. Only one study was identified in a low- or middle-income country, and the majority of studies were conducted in white or mixed ethnicity populations. We discuss potential interventions to mitigate cardiovascular risk for these women in different settings and highlight the need for a greater understanding of the epidemiology of CVD risk after gestational hypertension and pre-eclampsia outside of high-income, white populations.
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Affiliation(s)
- Clare Oliver-Williams
- Clare Oliver-Williams, Strangeways Research
Laboratory, Department of Public Health and Primary Care, University of
Cambridge, Cambridge CB1 8RN, United Kingdom; e-mail:
| | - Jasmine D. Johnson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Catherine J. Vladutiu
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
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Zheng P, Chen D, Ye B, Yang X, Cheng W. Association between placental implantation abnormalities and hypertensive disorders of pregnancy. J Obstet Gynaecol Res 2021; 48:654-662. [PMID: 34939706 DOI: 10.1111/jog.15104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/24/2021] [Accepted: 11/09/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to investigate the association between placental implantation abnormalities (PIAs) and gestational hypertension-preeclampsia (GH-PE) in pregnant women. METHODS Patients were recruited from 2010 to 2019 into this retrospective study at the International Peace Maternity & Child Health Hospital. PIAs were classified as follows: placenta previa (PP), low-lying placenta (LP), placenta accreta, and placenta adherence (PA). Logistic regression models were constructed to analyze the associations between placental abnormalities and GH-PE. Propensity score matching (PSM) was conducted to reduce confounders. The relationship between PP with placenta accreta spectrum (PAS) and GH-PE were assessed. RESULTS In total, 5527 women were recruited, and 2614 women had an abnormal placenta (992 with LP; 749 with PP 839 and PA; and 34 with placenta accreta). There were 296 patients with GH-PE in those groups. After adjustments for confounding factors, women with PP had a lower risk of PE (odds ratio [OR]: 0.43; 95% confidence interval [CI]: 0.19-0.86, p = 0.025) than those in the control group. Women with PA had a higher risk of GH-PE (OR: 1.45; 95% CI: 1.05-1.99, p = 0.022). In addition, we categorized PP into marginal, complete, and partial PP and investigated these associations. We found a lower risk of PE in complete PP (OR: 0.09, 95% CI: 0.01-0.44, p = 0.020) than in marginal or partial PP. There was no significant difference regarding GH-PE in the PP with PAS group (OR = 0.67, 95% CI: 0.82-2.34, p = 0.525). CONCLUSION PP, especially complete PP, is associated with a lower risk of PE. PA is associated with higher risks of GH-PE.
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Affiliation(s)
- Panchan Zheng
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Dan Chen
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Baoying Ye
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Xingyu Yang
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.,Institute of Birth Defects and Rare Diseases, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weiwei Cheng
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China.,Institute of Birth Defects and Rare Diseases, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Ge G, Zhang Y, Zhang M. Pregnancy-induced hypertension and retinopathy of prematurity: a meta-analysis. Acta Ophthalmol 2021; 99:e1263-e1273. [PMID: 33611839 DOI: 10.1111/aos.14827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/08/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE Retinopathy of prematurity (ROP), one of the leading causes of childhood blindness, is a complex condition in which various antenatal and neonatal factors participate at different stages of the disease. This meta-analysis was conducted to investigate whether pregnancy-induced hypertension (PIH) was associated with ROP by summarizing all available evidence. METHODS PubMed, EMBASE, Web of Science, EBSCO and SCOPUS databases were searched for all relevant studies published from inception to April 2020. Studies investigating the association between PIH and ROP were included. RESULTS A total of 29 studies were finally included for the meta-analysis after study selection. The results showed there are both no significant association between PIH and the occurrence of ROP in case-control studies (OR 0.91, 95%CI 0.59 to 1.40, I2 = 81%, p = 0.67) and cohort studies (OR 1.32, 95%CI 0.89 to 1.98, I2 = 93%, p = 0.17). The conclusion was same between pre-eclampsia and ROP (OR 0.82, 95%CI: 0.50 to 1.35, I2 = 83%, p = 0.43 in case-control studies and OR 1.70, 95%CI: 0.82 to 3.50, I2 = 95%, p = 0.15 in cohort studies). CONCLUSION In summary, this meta-analysis did not reveal a consistent result, the conclusion remains inconclusive, and further studies will be needed to come to a conclusion for the effect of maternal PIH on ROP and foster a better understanding of the prevention of ROP.
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Affiliation(s)
- Ge Ge
- Macular Disease Research Laboratory Department of Ophthalmology West China Hospital of Sichuan University Chengdu China
| | - Yun Zhang
- Macular Disease Research Laboratory Department of Ophthalmology West China Hospital of Sichuan University Chengdu China
| | - Meixia Zhang
- Macular Disease Research Laboratory Department of Ophthalmology West China Hospital of Sichuan University Chengdu China
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Genest DS, Dal Soglio D, Girard S, Rey E. Association between proteinuria and placental pathology in preeclampsia: A retrospective study. SAGE Open Med 2021; 9:20503121211058053. [PMID: 34925835 PMCID: PMC8673865 DOI: 10.1177/20503121211058053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Preeclampsia develops due to placental insufficiency and systemic proinflammatory and antiangiogenic mediator release, with ensuing systemic endothelial dysfunction. Nephrotic-range proteinuria appears to be associated with worse pregnancy outcomes. The relationship between differing degrees of proteinuria and the severity of placental alterations has not been studied. Methods: This is a single-centre retrospective comparison of 150 singleton pregnancies complicated by preeclampsia and varying degrees of proteinuria. Maternal demographic, obstetrical and fetal outcome data were obtained from chart review. The placental histologic evaluations were performed by a placental pathologist blinded to all other clinical information. Results: Preeclamptic women with massive proteinuria had evidence of more severe maternal vascular malperfusion lesions. The severity of the lesions was progressive through mild, moderate and massive proteinuria. Women with massive proteinuria had a higher incidence of renal dysfunction and severe hypertension, and had earlier preterm deliveries compared to preeclamptic women with mild and moderate proteinuria (p < 0.05). Conclusion: Preeclampsia with more severe proteinuria is associated with a higher prevalence of placental maternal vascular malperfusion.
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Affiliation(s)
| | - Dorothée Dal Soglio
- Department of Pathology and Clinical Laboratory Medicine, CHU Sainte-Justine, Montreal, QC, Canada
| | - Sylvie Girard
- Department of Obstetrics and Gynecology, Université de Montréal, Centre de Recherche, CHU Sainte-Justine, Montreal, QC, Canada
| | - Evelyne Rey
- Department of Obstetrics and Gynecology, Université de Montréal, Centre de Recherche, CHU Sainte-Justine, Montreal, QC, Canada
- Division of Obstetric Medicine, Department of Medicine, University of Montreal, CHU Sainte-Justine, Montreal, QC, Canada
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Bovee EM, Gulati M, Maas AH. Novel Cardiovascular Biomarkers Associated with Increased Cardiovascular Risk in Women With Prior Preeclampsia/HELLP Syndrome: A Narrative Review. Eur Cardiol 2021; 16:e36. [PMID: 34721670 PMCID: PMC8546910 DOI: 10.15420/ecr.2021.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/11/2021] [Indexed: 12/11/2022] Open
Abstract
Evidence has shown that women with a history of preeclampsia or haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome have an increased risk of cardiovascular disease later in life. Recommendations for screening, prevention and management after such pregnancies are not yet defined. The identification of promising non-traditional cardiovascular biomarkers might be useful to predict which women are at greatest risk. Many studies are inconsistent and an overview of the most promising biomarkers is currently lacking. This narrative review provides an update of the current literature on circulating cardiovascular biomarkers that may be associated with an increased cardiovascular disease risk in women after previous preeclampsia/HELLP syndrome. Fifty-six studies on 53 biomarkers were included. From the summary of evidence, soluble fms-like tyrosine kinase-1, placental growth factor, interleukin (IL)-6, IL-6/IL-10 ratio, high-sensitivity cardiac troponin I, activin A, soluble human leukocyte antigen G, pregnancy-associated plasma protein A and norepinephrine show potential and are interesting candidate biomarkers to further explore. These biomarkers might be potentially eligible for cardiovascular risk stratification after preeclampsia/HELLP syndrome and may contribute to the development of adequate strategies for prevention of hypertension and adverse events in this population.
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Affiliation(s)
| | | | - Angela Hem Maas
- Department of Cardiology, Radboud University Medical Center Nijmegen, the Netherlands
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Nunes PR, Romao-Veiga M, Borges VTM, Matias ML, Ribeiro VR, Costa RAA, Peracoli MTS, Peracoli JC. Association between Adverse Maternal Clinical Outcomes and Imbalance of Cytokines and Angiogenic Factors in Preterm Preeclampsia. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:669-675. [PMID: 34670301 PMCID: PMC10183922 DOI: 10.1055/s-0041-1735157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE Preeclampsia (PE) is a pregnancy-specific syndrome characterized by abnormal levels of cytokines and angiogenic factors, playing a role in the disease development. The present study evaluated whether immunological markers are associated with the gestational age and with the disease severity in preeclamptic women. METHODS Ninety-five women who developed PE were stratified for gestational age as preterm PE (< 37 weeks) and term PE (≥ 37 weeks of gestation) and compared for disease severity as well as plasma concentration of angiogenic factors and cytokines. The concentrations of placental growth factor (PlGF), vascular endothelial growth factor (VEGF), Fms-like soluble tyrosine kinase (sFlt-1) and soluble endoglin (sEng), as well as the cytokines, tumor necrosis factor-α (TNF-α) and interleukin 10 (IL-10), were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS The comparison between preeclamptic groups showed a higher percentage of severe cases in preterm PE (82.1%) than in term PE (35.9%). Similarly, the concentrations of TNF-α, sFlt-1, and sEng, as well as TNF-α/IL-10 and sFlt-1/PlGF ratios were significantly higher in the preterm PE group. In contrast, concentrations of PlGF, VEGF, and IL-10 were significantly lower in women with preterm PE. Negative correlations between TNF-α and IL-10 (r = 0.5232) and between PlGF and sFlt1 (r = -0.4158) were detected in the preterm PE. CONCLUSION In pregnant women with preterm PE, there is an imbalance between immunological markers, with the predominance of anti-angiogenic factors and TNF-α, associated with adverse maternal clinical outcomes.
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Affiliation(s)
- Priscila Rezeck Nunes
- Faculdade de Medicina, Universidade Estadual Paulista Julio de Mesquita Filho, Botucatu, SP, Brazil
| | - Mariana Romao-Veiga
- Faculdade de Medicina, Universidade Estadual Paulista Julio de Mesquita Filho, Botucatu, SP, Brazil
| | | | - Mariana Leticia Matias
- Faculdade de Medicina, Universidade Estadual Paulista Julio de Mesquita Filho, Botucatu, SP, Brazil
| | - Vanessa Rocha Ribeiro
- Faculdade de Medicina, Universidade Estadual Paulista Julio de Mesquita Filho, Botucatu, SP, Brazil
| | | | | | - Jose Carlos Peracoli
- Faculdade de Medicina, Universidade Estadual Paulista Julio de Mesquita Filho, Botucatu, SP, Brazil
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Palei AC, Granger JP, Spradley FT. Placental Ischemia Says "NO" to Proper NOS-Mediated Control of Vascular Tone and Blood Pressure in Preeclampsia. Int J Mol Sci 2021; 22:ijms222011261. [PMID: 34681920 PMCID: PMC8541176 DOI: 10.3390/ijms222011261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Ana C. Palei
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Joey P. Granger
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Frank T. Spradley
- Department of Surgery, University of Mississippi Medical Center, Jackson, MS 39216, USA;
- Department of Physiology & Biophysics, University of Mississippi Medical Center, Jackson, MS 39216, USA;
- Department of Pharmacology & Toxicology, University of Mississippi Medical Center, Jackson, MS 39216, USA
- Correspondence:
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HIV Associated Preeclampsia: A Multifactorial Appraisal. Int J Mol Sci 2021; 22:ijms22179157. [PMID: 34502066 PMCID: PMC8431090 DOI: 10.3390/ijms22179157] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction: This review explores angiogenesis, vascular dysfunction, the complement system, RAAS, apoptosis and NETosis as potential pathways that are dysregulated during preeclampsia, HIV infection and ART usage. Results: HIV-1 accessory and matrix proteins are protagonists for the elevation of oxidative stress, apoptosis, angiogenesis, and elevation of adhesion markers. Despite the immunodeficiency during HIV-1 infection, HIV-1 exploits our cellular defence arsenal by escaping cell-mediated lysis, yet HIV-1 infectivity is enhanced via C5a release of TNF-α and IL-6. This review demonstrates that PE is an oxidatively stressed microenvironment associated with increased apoptosis and NETosis, but with a decline in angiogenesis. Immune reconstitution in the duality of HIV-1 and PE by protease inhibitors, HAART and nucleoside reverse transcriptase, affect similar cellular pathways that eventuate in loss of endothelial cell integrity and, hence, its dysfunction. Conclusions: HIV-1 infection, preeclampsia and ARTs differentially affect endothelial cell function. In the synergy of both conditions, endothelial dysfunction predominates. This knowledge will help us to understand the effect of HIV infection and ART on immune reconstitution in preeclampsia.
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Lindley KJ. Heart Failure and Pregnancy: Thinking Beyond Peripartum Cardiomyopathy. J Card Fail 2021; 27:153-156. [PMID: 33573757 DOI: 10.1016/j.cardfail.2020.09.475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Washington University in St. Louis, St. Louis, MO.
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44
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Neuman RI, Saleh L, Verdonk K, van den Meiracker AH, Russcher H, Metselaar HJ, Visser W, Danser AHJ. Accurate Prediction of Total PlGF (Placental Growth Factor) From Free PlGF and sFlt-1 (Soluble Fms-Like Tyrosine Kinase-1): Evidence for Markedly Elevated PlGF Levels in Women With Acute Fatty Liver of Pregnancy. Hypertension 2021; 78:489-498. [PMID: 34176292 PMCID: PMC8260338 DOI: 10.1161/hypertensionaha.121.17258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Acute fatty liver of pregnancy (AFLP) is characterized by elevated circulating sFlt-1 (soluble Fms-like tyrosine kinase-1), although the free circulating levels of its ligand, PlGF (placental growth factor) are not decreased. Here, we hypothesized that women with AFLP exhibit elevated PlGF production in comparison to women with preeclampsia or hemolysis elevated liver enzymes and low platelet count syndrome. Making use of the well-known mathematical formulas describing drug-receptor interactions, we established that serum total PlGF could be accurately predicted from sFlt-1 and free PlGF levels (n=42; mean calculated KD of 50 pmol/L), yielding similar values as the previously published method of thermal dissociation of the sFlt-1-PlGF complexes (r=0.94, P<0.0001). We found that median levels of free PlGF were significantly lower in women with preeclampsia (n=13; 117pg/mL) or hemolysis elevated liver enzymes and low platelet count syndrome (n=12; 59 pg/mL) compared with women without preeclampsia (n=11; 349pg/mL, P<0.0001). In contrast, median total PlGF did not differ between women with no preeclampsia, preeclampsia, and hemolysis elevated liver enzymes and low platelet count syndrome (354 versus 435 versus 344pg/mL), whereas it was markedly elevated in AFLP compared with all groups (2054 pg/mL, P<0.0001). Furthermore, in AFLP, both sFlt-1 and total PlGF declined rapidly postdelivery, with significantly higher predelivery total PlGF (n=12; median, 2054 pg/mL) than postpartum levels (n=14; median, 163pg/mL, P<0.0001), suggesting that in AFLP, PlGF is largely placenta-derived. Collectively, our findings indicate that like sFlt-1, PlGF production is significantly upregulated in AFLP, mainly originating from the placenta. Importantly, total PlGF can now be easily calculated from already available free PlGF and sFlt-1 levels, allowing subsequent evaluation of other groups in whom PlGF is altered.
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Affiliation(s)
- Rugina I Neuman
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (R.I.N., L.S., K.V., A.H.v.d.M., W.V., A.H.J.D.), Erasmus MC University Hospital, Rotterdam, the Netherlands.,Department of Gynecology and Obstetrics (R.I.N., W.V.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - Langeza Saleh
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (R.I.N., L.S., K.V., A.H.v.d.M., W.V., A.H.J.D.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - Koen Verdonk
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (R.I.N., L.S., K.V., A.H.v.d.M., W.V., A.H.J.D.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - Anton H van den Meiracker
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (R.I.N., L.S., K.V., A.H.v.d.M., W.V., A.H.J.D.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - Henk Russcher
- Department of Clinical Chemistry (H.R.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology & Hepatology (H.J.M.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - Willy Visser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (R.I.N., L.S., K.V., A.H.v.d.M., W.V., A.H.J.D.), Erasmus MC University Hospital, Rotterdam, the Netherlands.,Department of Gynecology and Obstetrics (R.I.N., W.V.), Erasmus MC University Hospital, Rotterdam, the Netherlands
| | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine (R.I.N., L.S., K.V., A.H.v.d.M., W.V., A.H.J.D.), Erasmus MC University Hospital, Rotterdam, the Netherlands
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Kitt JA, Fox RL, Cairns AE, Mollison J, Burchert HH, Kenworthy Y, McCourt A, Suriano K, Lewandowski AJ, Mackillop L, Tucker KL, McManus RJ, Leeson P. Short-Term Postpartum Blood Pressure Self-Management and Long-Term Blood Pressure Control: A Randomized Controlled Trial. Hypertension 2021; 78:469-479. [PMID: 34176288 PMCID: PMC8260340 DOI: 10.1161/hypertensionaha.120.17101] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Supplemental Digital Content is available in the text. Women with hypertensive pregnancies are 4× more likely to develop chronic hypertension. Previously, we showed a short period of blood pressure (BP) self-management following hypertensive pregnancy resulted in persistently lower BP after 6 months. We now report the impact on long-term BP control. Women who participated in the postpartum randomized controlled trial, SNAP-HT (Self-Management of Postnatal Hypertension; NCT02333240), were invited for 24-hour ambulatory and clinic BP measures. Height and weight were measured by calibrated scales and standardized tape measures, activity by 7-day wrist-worn accelerometer, and dietary factors assessed by questionnaire. Sixty-one of 70 eligible women were followed up 3.6±0.4 years after their original pregnancy. Twenty-four–hour diastolic BP was 7.0 mm Hg lower in those originally randomized to postpartum BP self-management instead of usual care. This difference remained significant after adjustment for either BP at the time of delivery (−7.4 mm Hg [95% CI, −10.7 to −4.2]; P<0.001) or pregnancy booking BP (−6.9 mm Hg [95% CI, −10.3 to −3.6]; P<0.001). Adjustment for current salt intake, age, body mass index, waist-to-hip ratio, arm circumference, parity, alcohol intake, and physical activity had no effect on this difference. Reductions in diastolic BP at 6 months, following self-management of BP postpartum, are maintained 3.6 years later as measured by lower 24-hour diastolic BP. Interventions to optimize BP control during the puerperium in women with hypertensive pregnancies improve BP in the longer term, in a cohort at increased risk of developing chronic hypertension and major adverse cardiovascular events.
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Affiliation(s)
- Jamie A Kitt
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Rachael L Fox
- University of Melbourne, Australia (R.F.).,Western Health, Melbourne, Australia (R.F.)
| | - Alexandra E Cairns
- Nuffield Department of Primary Care (A.C., J.M., K.T., R.M.), University of Oxford, United Kingdom.,Nuffield Department of Women's and Reproductive Health (A.C., L.M.), University of Oxford, United Kingdom
| | - Jill Mollison
- Nuffield Department of Primary Care (A.C., J.M., K.T., R.M.), University of Oxford, United Kingdom
| | - Holger H Burchert
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Yvonne Kenworthy
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Annabelle McCourt
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Katie Suriano
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Adam J Lewandowski
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Lucy Mackillop
- Nuffield Department of Women's and Reproductive Health (A.C., L.M.), University of Oxford, United Kingdom
| | - Katherine L Tucker
- Nuffield Department of Primary Care (A.C., J.M., K.T., R.M.), University of Oxford, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care (A.C., J.M., K.T., R.M.), University of Oxford, United Kingdom
| | - Paul Leeson
- Radcliffe Department of Medicine Division of Cardiovascular Medicine, Cardiovascular Clinical Research Facility (J.K., H.B., Y.K., A.M., K.S., A.J.L., P.L.), University of Oxford, United Kingdom
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46
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Maternal microvascular dysfunction during preeclamptic pregnancy. Clin Sci (Lond) 2021; 135:1083-1101. [PMID: 33960392 DOI: 10.1042/cs20200894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 12/15/2022]
Abstract
Preeclampsia is a hypertensive disorder of pregnancy effecting ∼5-8% of pregnancies in the United States, and ∼8 million pregnancies worldwide. Preeclampsia is clinically diagnosed after the 20th week of gestation and is characterized by new onset hypertension accompanied by proteinuria and/or thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. This broad definition emphasizes the heterogeneity of the clinical presentation of preeclampsia, but also underscores the role of the microvascular beds, specifically the renal, cerebral, and hepatic circulations, in the pathophysiology of the disease. While the diagnostic criteria for preeclampsia relies on the development of de novo hypertension and accompanying clinical symptoms after 20-week gestation, it is likely that subclinical dysfunction of the maternal microvascular beds occurs in parallel and may even precede the development of overt cardiovascular symptoms in these women. However, little is known about the physiology of the non-reproductive maternal microvascular beds during preeclampsia, and the mechanism(s) mediating microvascular dysfunction during preeclamptic pregnancy are largely unexplored in humans despite their integral role in the pathophysiology of the disease. Therefore, the purpose of this review is to provide a summary of the existing literature on maternal microvascular dysfunction during preeclamptic pregnancy by reviewing the functional evidence in humans, highlighting potential mechanisms, and providing recommendations for future work in this area.
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Milln J, Nakabuye B, Natamba B, Sekitoleko I, Mubiru M, Namara A, Tumwesigire S, Salome T, Mirembe M, Kakanda A, Agaba B, Nansubuga F, Zaake D, Ayiko B, Kalema H, Nakubulwa S, Sekikubo M, Nakimuli A, Webb EL, Nyirenda MJ. Adverse pregnancy outcomes associated with moderate elevations in blood pressure or blood glucose in Ugandan women; a prospective cohort study. AJOG GLOBAL REPORTS 2021; 1:100007. [PMID: 34095888 PMCID: PMC8164086 DOI: 10.1016/j.xagr.2021.100007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The association between overt hypertension and diabetes and adverse pregnancy outcomes is well documented. Recent evidence suggests that even moderate elevations in blood pressure or blood glucose may confer a significant risk in a dose-dependent manner. However, these studies have primarily been undertaken in white populations in high-income settings. Hypertension and diabetes are emerging as major public health issues in sub-Saharan Africa as the region undergoes rapid urbanization. It is therefore important to understand how such noncommunicable conditions contribute to pregnancy outcomes in these populations. OBJECTIVE This study aimed to determine the association between stage 1 hypertension or fasting blood glucose in the gestational diabetes mellitus-range and adverse pregnancy outcomes in Uganda, and to describe the effects of other contributing factors such as maternal obesity. STUDY DESIGN This was a prospective cohort study of 2857 women at 5 major hospitals in urban and semiurban central Uganda. Women were enrolled at 24 to 28 weeks' gestation. Data about the maternal demographics, anthropometrics, fasting venous blood glucose, blood pressure, and pregnancy outcomes were collected. Moderate elevations in blood pressure and blood glucose were defined using the latest American College of Cardiology and American Heart Association definition of stage 1 hypertension and the World Health Organization's criteria for fasting blood glucose in the gestational diabetes mellitus-range. The primary outcomes of interest were perinatal death and large birthweight for gestational age, and the secondary outcomes were preterm birth, cesarean delivery, and neonatal admission. A multivariable logistic regression analysis was used. RESULTS Stage 1 hypertension increased the odds of perinatal death by more than 2-fold (adjusted odds ratio, 2.68; 95% confidence interval, 1.36-5.29), with a positive but insignificant association with preterm birth. Hyperglycemia in the gestational diabetes mellitus-range was associated with cesarean delivery only (adjusted odds ratio, 1.65; 95% confidence interval, 1.20-2.27). Maternal obesity increased the risk of having large birthweight babies (adjusted odds ratio, 2.30; 95% confidence interval, 1.74-3.02), a cesarean delivery (adjusted odds ratio, 2.75; 95% confidence interval, 2.17-3.48), and neonatal admission (adjusted odds ratio, 1.63; 95% confidence interval, 1.16-2.30). CONCLUSION Moderate elevations in blood pressure and maternal obesity are stronger predictors of adverse maternal and neonatal outcomes than moderate elevations in blood glucose levels and should be the focus of intervention in these resource-poor settings. Further research is needed to determine the cost-effectiveness of identifying and managing moderate elevations in blood pressure and maternal obesity.
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Affiliation(s)
- Jack Milln
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
- Department of Endocrinology and Diabetes, Queen Mary University of London, London, United Kingdom (Dr Milln)
| | - Betty Nakabuye
- Department of Obstetrics and Gynaecology Uganda Martyrs Hospital, Lubaga, Kampala, Uganda (Drs Nakabuye and Agaba)
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda (Dr Nakabuye)
| | - Barnabas Natamba
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Isaac Sekitoleko
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Michael Mubiru
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Arthur Namara
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Samuel Tumwesigire
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Tino Salome
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Mandy Mirembe
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Ayoub Kakanda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
| | - Brian Agaba
- Department of Obstetrics and Gynaecology Uganda Martyrs Hospital, Lubaga, Kampala, Uganda (Drs Nakabuye and Agaba)
| | - Faridah Nansubuga
- Department of Obstetrics and Gynaecology, St. Francis Hospital, Nsambya, Kampala, Uganda (Drs Nansubuga and Zaake)
| | - Daniel Zaake
- Department of Obstetrics and Gynaecology, St. Francis Hospital, Nsambya, Kampala, Uganda (Drs Nansubuga and Zaake)
| | - Ben Ayiko
- Department of Obstetrics and Gynaecology, Entebbe Regional Referral Hospital, Entebbe, Uganda (Dr Ayiko)
| | - Herbert Kalema
- Department of Obstetrics and Gynaecology, Masaka Regional Referral Hospital, Masaka, Uganda (Dr Kalema)
| | - Sarah Nakubulwa
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
- Department of Obstetrics and Gynaecology, Kawempe National Referral Hospital, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
| | - Musa Sekikubo
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
- Department of Obstetrics and Gynaecology, Kawempe National Referral Hospital, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
| | - Annettee Nakimuli
- Department of Obstetrics and Gynaecology, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
- Department of Obstetrics and Gynaecology, Kawempe National Referral Hospital, Kampala, Uganda (Drs Nakubulwa, Sekikubo and Nakimuli)
| | - Emily L. Webb
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom (Drs Webb and Nyirenda)
| | - Moffat J. Nyirenda
- Non-Communicable Diseases Theme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI & LSHTM) Uganda Research Unit, Entebbe, Uganda (Drs Milln, Natamba, and Nyirenda and Mr Sekitoleko, Mubiru, Namara, Tumwesigire, Ms Salome, Mirembe, and Mr Kakanda)
- London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom (Drs Webb and Nyirenda)
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Zhang Y, Huang L, Wang D, Ren P, Hong Q, Kang D. The ROBINS-I and the NOS had similar reliability but differed in applicability: A random sampling observational studies of systematic reviews/meta-analysis. J Evid Based Med 2021; 14:112-122. [PMID: 34002466 DOI: 10.1111/jebm.12427] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 02/07/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE There is a lack of evidence on the usage of the quality assessment tool-the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I). This article aimed to measure the reliability, criterion validity, and feasibility of the ROBINS-I and the Newcastle-Ottawa Scale (NOS). METHODS A sample of systematic reviews or meta-analyses of observational studies were selected from Medline (2013-2017) and assessed by two reviewers using ROBINS-I and the NOS. We reported on reliability in terms of the first-order agreement coefficient (AC1) statistic. Correlation coefficient statistic was used to explore the criterion validity of the ROBINS-I. We compared the feasibility of the ROBINS-I and NOS by recording the time to complete an assessment and the instances where assessing was difficult. RESULTS Five systematic reviews containing 41 cohort studies were finally included. Interobserver agreement on the individual domain of the ROBINS-I as well as the NOS was substantial with a mean AC1 statistic of 0.67 (95% CI: 0.50-0.83) and 0.73 (95% CI: 0.65-0.81), respectively. The criterion validity of the ROBNS-I was moderate (K = 0.52) against NOS. The time in assessing a single study by ROBINS-I varied from 7 hours initially to 3 hours compared with 30 minutes for the NOS. Both reviewers rated "bias due to departure from the intended interventions" the most time-consuming domain in the ROBINS-I, items in the NOS were equal. CONCLUSIONS The ROBINS-I and the NOS seem to provide the same reliability but vary in applicability. The over-complicated feature of ROBINS-I may limit its usage and a simplified version is needed.
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Affiliation(s)
- Yuhui Zhang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Litao Huang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dandan Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Pengwei Ren
- Clinical Research Center for Respiratory Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Hong
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Deying Kang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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49
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Pereira MM, Torrado J, Sosa C, Zócalo Y, Bia D. Role of arterial impairment in preeclampsia: should the paradigm shift? Am J Physiol Heart Circ Physiol 2021; 320:H2011-H2030. [PMID: 33797272 DOI: 10.1152/ajpheart.01005.2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Preeclampsia is a worldwide pregnancy complication with serious short- and long-term maternal and neonatal consequences. Our understanding of preeclampsia pathophysiology has significantly evolved over the last decades with the recognition that impaired arterial function and structure may occur early in the course of pregnancy, preceding the clinic-humoral syndrome and driving long-term cardiovascular disease risk in the future of these patients. Although an early abnormal placentation may be the inciting event for a large proportion of cases, there is growing evidence that challenges the placental hypothesis in all affected women, since placental histopathology lesions thought to be characteristic are neither sensitive nor specific markers for the disorder. Recent hemodynamic investigations and studies on left ventricular function and structure in women with preeclampsia further challenge this universal paradigm and propose that placental dysfunction could be secondary to a maternal cardiovascular maladaptation to pregnancy in certain patients. Supporting this hypothesis, certain vascular features, which are characteristically enhanced in normal pregnancy allowing a healthy vascular adaptation, are absent in preeclampsia and comparable to the nonpregnant population. However, arterial biomechanics in preeclampsia may only not cope with hemodynamic demands of pregnancy but also impose additional detrimental loads to the maternal heart ("impaired left-ventricle-aorta coupling") and transmit pressure and flow disturbances into the fetoplacental circulation ("impaired large arteries-microcirculation coupling"). In this review, we analyze the major role of the arterial dysfunction in the cardiovascular maladaptation hypothesis of preeclampsia, shed light on its potential etiopathogenic link, and discuss the complementary nature of the placental and cardiovascular theories.
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Affiliation(s)
- María M Pereira
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, Virginia
| | - Juan Torrado
- Jacobi Medical Center, Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Claudio Sosa
- Department of Obstetrics and Gynecology "C", Pereira-Rossell Hospital, School of Medicine, Republic University, Montevideo, Uruguay
| | - Yanina Zócalo
- Centro Universitario de Investigación, Innovación y Diagnóstico Arterial, Department of Physiology, School of Medicine, Republic University, Montevideo, Uruguay
| | - Daniel Bia
- Centro Universitario de Investigación, Innovación y Diagnóstico Arterial, Department of Physiology, School of Medicine, Republic University, Montevideo, Uruguay
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50
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Stern-Ascher CN, North VS, Garg A, Ananth CV, Wapner RJ, Bearelly S. Subfoveal Choroidal Thickness and Associated Changes of Angiogenic Factors in Women with Severe Preeclampsia. Am J Perinatol 2021; 38:482-489. [PMID: 31683325 PMCID: PMC10895649 DOI: 10.1055/s-0039-1698832] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Severe preeclampsia complicates roughly 1% of all pregnancies. One defining feature of severe preeclampsia is new onset visual disturbance. The accessibility of the choroid to high-resolution, noninvasive imaging makes it a reasonable target of investigation for disease prediction, stratification, or monitoring in preeclampsia. This study aimed to compare subfoveal choroidal thickness between women with severe preeclampsia and those with normotensive pregnancies, and to investigate associations between such findings and other indicators of disease severity, including gestational age and serum angiogenic factors. STUDY DESIGN We designed a case-control study comprised of 36 women diagnosed with severe preeclampsia (cases) matched to 37 normotensive women (controls) by race/ethnicity and parity, all diagnosed in the postpartum period. All patients underwent enhanced depth imaging spectral-domain optical coherence tomography and serum analysis. RESULTS Cases showed no difference in subfoveal choroidal thickness compared with controls (p = 0.65). Amongst cases, subfoveal choroidal thickness and gestational age at delivery were inversely related (r = 0.86, p < .001). There was a positive association of placental growth factor with subfoveal choroidal thickness amongst cases (r = 0.54, p = 0.002). CONCLUSION This study suggests a relationship between the degree of disease severity and the magnitude of choroidal thickening. We also show an association between this index and placental growth factor level in the postpartum period.
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Affiliation(s)
- Conrad N Stern-Ascher
- Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York
- Department of Ophthalmology, Vagelos College of Physicians and Surgeons, Columbia University, New York
- Department of Ophthalmology, Duke University Medical Center, Durham, North Carolina
| | - Victoria S North
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Aakriti Garg
- Department of Ophthalmology, Vagelos College of Physicians and Surgeons, Columbia University, New York
| | - Cande V Ananth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Epidemiology and Biostatistics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Department of Health Policy and Management, Joseph L. Mailman School of Public Health, Columbia University, New York
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons, Columbia University, New York
| | - Srilaxmi Bearelly
- Department of Ophthalmology, Vagelos College of Physicians and Surgeons, Columbia University, New York
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