Relationships of risk factors for pre-eclampsia with patterns of occurrence of isolated gestational proteinuria during normal term pregnancy

Twenty-four-hour urinary protein excretion in uncomplicated singleton pregnancy

BACKGROUND

Twenty-four-hour urinary total protein excretion is an essential parameter used for evaluation of renal function and early detection of gestational complications. However, data on reference ranges of 24-hour urinary total protein excretion in normal pregnancy are scarce.

OBJECTIVE

This study aimed to determine reference ranges for 24-hour urinary total protein excretion in a population with uncomplicated singleton pregnancies using a standard method for urinary total protein. In addition, the values of 24-hour urinary total protein were stratified by maternal age and prepregnancy body mass index.

STUDY DESIGN

This study was based on a prospective cohort study in Shenzhen, China. The pregnant women were enrolled at their first prenatal clinical visit. All the participants were instructed to collect 24-hour urine samples during the following successive gestational periods: 6+0 to 13+6, 14+0 to 27+6, and 28+0 to 41+6 weeks. Total urinary protein excretion was analyzed by a colorimetric method. Ultimately, the study encompassed a total of 4844 pregnant women with uncomplicated pregnancies. The nonparametric percentile method was used to determine reference ranges for 24-hour urinary total protein excretion during different trimesters in women with uncomplicated pregnancies (excluding those with previous kidney disorders, gestational or chronic hypertension, preeclampsia, and pregestational diabetes mellitus, among others).

RESULTS

The 24-hour urinary total protein levels expressed as medians and percentiles (5th, 95th) for each trimester were as follows: 72.0 (28.4, 165.0), 88.0 (34.0, 185.0), and 108.0 (37.5, 258.0) mg in the first, second, and third trimesters, respectively. A significant increase in 24-hour urinary total protein excretion was observed throughout pregnancy (all P values <.001). Moreover, 24-hour urinary total protein levels were higher in the older (≥35 years) than in the younger (<35 years) group from mid-gestation. Specifically, the median (interquartile range) 24-hour urinary total protein levels by age were 72.2 (50.6-100.0) vs 70.5 (50.5-100.0) mg, 85.8 (62.0-117.0) vs 96.0 (68.0-127.8) mg, and 106.6 (76.0-146.2) vs 114.7 (81.5-153.6) mg in the first, second, and third trimesters, respectively. In addition, 24-hour proteinuria was significantly increased in higher-weight (overweight or obese) subgroups compared with lower-weight (underweight or normal-weight) subgroups (all P values <.05).

CONCLUSION

Our study provides reference values for 24-hour urinary total protein excretion with apparently uncomplicated pregnancies. Understanding these changes in low-risk pregnancies is essential for optimizing maternal management.

Proteinuria among Pregnant Women Admitted to the Department of Obstetrics and Gynaecology of a Tertiary Care Centre

Introduction

Proteinuria is usually related with preeclampsia during pregnancy, although it can also be caused by other conditions such as renal disease or isolated proteinuria. Proteinuria during pregnancy can result in adverse fetomaternal outcomes. The study aimed to find the prevalence of proteinuria among pregnant women admitted to the Department of Obstetrics and Gynaecology of a tertiary care centre.

Methods

A descriptive cross-sectional study was carried out among pregnant women in the Department of Obstetrics and Gynaecology after obtaining ethical approval from the Institutional Review Committee. Data of 14 April 2022 to 13 April 2023 was collected from 9 June 2023 to 9 September 2023 from medical records. The study included pregnant women aged 18-45 years, who were past 28 weeks of gestation and had a 24-hour urine protein measurement. Pregnant women who had insufficient medical records were excluded from the study. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 3,914 pregnant women, proteinuria was seen in 61 (1.56%) (1.17-1.95, 95% Confidence Interval). The mean proteinuria in the study group was 1.5±2.75 gm/24 hr. In pregnant women with proteinuria, maternal complications were seen in 51 (83.60%) and foetal complications in 34 (55.73%) cases. A total of 47 (77.05%) underwent emergency lower-section caesarean section.

Conclusions

The prevalence of proteinuria among pregnant women was found to be similar as compared to studies done in similar settings.

Keywords

preeclampsia; pregnancy complications; proteinuria.

Fabry Disease in Women: Genetic Basis, Available Biomarkers, and Clinical Manifestations

Fabry Disease (FD) is a rare lysosomal storage disorder caused by mutations in the GLA gene on the X chromosome, leading to a deficiency in α-galactosidase A (AGAL) enzyme activity. This leads to the accumulation of glycosphingolipids, primarily globotriaosylceramide (Gb3), in vital organs such as the kidneys, heart, and nervous system. While FD was initially considered predominantly affecting males, recent studies have uncovered that heterozygous Fabry women, carrying a single mutated GLA gene, can manifest a wide array of clinical symptoms, challenging the notion of asymptomatic carriers. The mechanisms underlying the diverse clinical manifestations in females remain not fully understood due to X-chromosome inactivation (XCI). XCI also known as "lyonization", involves the random inactivation of one of the two X chromosomes. This process is considered a potential factor influencing phenotypic variation. This review delves into the complex landscape of FD in women, discussing its genetic basis, the available biomarkers, clinical manifestations, and the potential impact of XCI on disease severity. Additionally, it highlights the challenges faced by heterozygous Fabry women, both in terms of their disease burden and interactions with healthcare professionals. Current treatment options, including enzyme replacement therapy, are discussed, along with the need for healthcare providers to be well-informed about FD in women, ultimately contributing to improved patient care and quality of life.

Twenty-four-hour proteinuria levels are associated with adverse pregnancy outcomes among women with CKD

Background

Proteinuria is commonly measured to assess the renal status of chronic kidney disease (CKD) patients before the 20th week of gestation during pregnancy. High levels of proteiuria have been associated with adverse pregnancy outcomes. However, researchers have not clearly determined what baseline proteinuria levels would be associated with adverse pregnancy outcomes. This study aimed to analyse associations between proteinuria levels and adverse pregnancy outcomes among CKD patients treated with or without steroids/immunosuppressive therapy in early pregnancy.

Methods

This retrospective study included the clinical information of 557 pregnant patients with CKD from 1 January 2009 to 31 December 2021. A multivariable logistic regression analysis was conducted to evaluate the risk of adverse pregnancy outcomes across various proteinuria ranges, which were further stratified by whether the patients were receiving steroids/immunosuppressive therapy.

Results

(i) Proteinuria was assessed on 24-h urine collection. The median (quartile) baseline proteinuria levels were 0.83 g (0.20, 1.92) and 0.25 g (0.06, 0.80) in the steroids/immunosuppressive therapy and therapy-free groups, respectively. (ii) CKD patients with adverse pregnancy outcomes had significantly higher proteinuria levels in the first trimester than patients without adverse pregnancy outcomes. (iii) The risk of adverse pregnancy outcomes increased with increasing baseline proteinuria levels (P < .001). (iv) In the early-pregnancy steroids/immunosuppressive therapy group, the risk of severe preeclampsia was higher in patients with higher baseline proteinuria levels (P < .007) [odds ratio (OR) 30.86 for proteinuria ≥5.00 g/24 h]; in the therapy-free group, the risks of severe preeclampsia, very-low-birth-weight infants, early preterm birth and foetal-neonatal death were higher in patients with higher baseline proteinuria levels (OR 53.16 for proteinuria ≥5.00 g/24 h; OR 37.83 for proteinuria ≥5.00 g/24 h; OR 15.30 for proteinuria ≥5.00 g/24 h; and OR 18.83 for proteinuria ≥5.00 g/24 h, respectively; P < .001, P < .001, P < .001 and P = .006, respectively).

Conclusions

As shown in the present study, a baseline 24-h proteinuria level >1.00 g was associated with adverse maternal outcomes. Furthermore, a 24-h proteinuria level >2.00 g increased the incidence of adverse foetal events among CKD patients.

Regulatory mechanism and research progress of ferroptosis in obstetrical and gynecological diseases

Ferroptosis is a novel type of regulated cell death driven by iron-dependent lipid peroxidation, which is distinguished from traditional types of programmed cell death, such as apoptosis, proptosis and necrosis et al. Impaired iron homeostasis, lipid peroxidation and antioxidants depletion are three hallmarks of ferroptosis. Over the past years, emerging studies support the notion that ferroptosis might be involved in the pathology of obstetrical and gynecological diseases, including preeclampsia (PE), endometriosis (EMs) and polycystic ovarian syndrome (PCOS). In the PE condition, the high sensitivity of trophoblasts towards ferroptosis has been found to potentially link to inflammation, suboptimal vascular remodeling and aberrant hemodynamics, which are three prominent pathophysiological features of PE. As for EMs, compromised ferroptosis of endometrial cells was associated with the formation ectopic lesions, whereas in the nearby lesions, the presence of ferroptosis was suggested to promote the progression of EMs, contributing to the relative clinical manifestations. Ferroptosis has been implicated a crucial role in the initiation of ovarian follicular atresia, which might help to manage ovulation in PCOS patients. Taken together, this review explored the basis of ferroptosis mechanisms and comprehensively summarized the latest discovery of roles of ferroptosis on PE, EMs and PCOS, gaining a deeper insight into the pathogenesis of these obstetrical and gynecological diseases and investigation of novel therapeutic interventions.

A case of preeclampsia developing massive ascites after delivery

We experienced a case of preeclampsia in which massive ascites became apparent in the postpartum period. The patient had isolated proteinuria without hypertension before delivery. The infant had fatal growth restriction and neonatal distress. Massive ascites and isolated proteinuria are important symptoms for predicting the aggravation of PE.

Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance

Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.

Maternal and neonatal complications in women with medical comorbidities and preeclampsia

OBJECTIVES

To evaluate how medical comorbidities - chronic hypertension, pre-gestational or gestational diabetes and obesity - influence maternal and neonatal complications from preeclampsia.

STUDY DESIGN

We undertook a retrospective cohort study of women delivering in Victoria, Australia, between 2009 and 2017. We compared the likelihood of having a maternal complication before delivery or neonatal complication after birth between women with and without comorbidities. We used causal mediation analysis for neonatal outcomes to separate the effects of comorbidities and of prematurity on morbidity.

MAIN OUTCOME MEASURES

Pregnancy complications (eclampsia; haemolysis, elevated liver enzymes, low platelets syndrome; placental abruption; stillbirth) and neonatal complications (respiratory distress syndrome; neonatal sepsis; a 5-minute APGAR < 5; neonatal intensive care unit admission).

RESULTS

Women with comorbidities delivered at a median (interquartile range) of 37.0 (36.0-39.0) weeks gestation, earlier than women without comorbidities (38.0 (36.0-39.0) weeks, p < 0.001). Women with comorbidities were less likely than those without to suffer any pregnancy complication prior to delivery (adjusted relative risk 0.78, 95% confidence interval 0.72-0.86); however, their neonates suffered more respiratory distress syndrome (aRR 1.43, 95% CI 1.31-1.57), neonatal sepsis (aRR 1.42, 95% CI 1.17-1.72) and NICU admission (aRR 1.37, 95% CI 1.23-1.53). Earlier delivery was a major contributor to worse neonatal outcomes.

CONCLUSIONS

Medical comorbidities are associated with earlier delivery among women with preeclampsia. This is associated with fewer maternal complications, but worse neonatal outcomes.

Implementing placental-growth-factor (PLGF) measurements in suspected pre-eclampsia----Challenges in clinical practice

OBJECTIVES

As a part of NHS' Innovation and Technology Payment programme (ITP), pregnant women were offered Placental Growth Factor (PLGF)-based testing to help rule out pre-eclampsia (PET) - a serious condition that affects approximately 2.3% of the female population. The study was aimed to evaluate the implementation of PLGF-based testing at United Lincolnshire Trust Hospitals (ULHT).

STUDY DESIGN

The soluble FMS like Tyrosine kinase 1/placental growth factor (sFlt-1/PLGF) ratio test was launched at ULHT on 8th October 2020. The project involved a review of an electronic maternity database (MEDWAY) for all women who had sFLT-1/PLGF ratio test performed at ULHT over a 5-month period (October 2020-February 2021). The sFlt-1/PLGF ratio was recorded alongside clinical outcome. Women were classified as low, moderate, and high risk for development of PET if the sFlt-1/PLGF ratio was ≤ 38, 39-84 and ≥ 85 respectively. Reasons for admission were further investigated and adherence to the sFLT-1/PLGF protocol was monitored to evaluate staff performance. Data was then statistically analysed with χ2 and T-test for categorical and continuous variables respectively. Finally, sensitivity and specificity of the sFLT-1/PLGF was assessed with an ROC curve.

RESULTS

A total of 236 women had sFlt-1/PLGF ratio test performed in a five-month period. A two-time point analysis (a "during implementation" and "post implementation phase") showed a significant decrease in the admission rates in the post-implementation phase in low-risk group (28.5% during implementation vs 11.3% post-implementation, P < 0.05). Further analysis showed greater staff adherence to the sFLT-1/PLGF protocol in the post-implementation period. The high-risk group demonstrated shorter time from test to delivery, earlier gestational age at delivery and lower birth weight (P < 0.05).

CONCLUSIONS

The study outcomes resulted in a successful submission of a business case. Successful triage of low-risk women at the point where historically admissions were considered reduced clinical workload and enabled better utilisation of resources by allowing focussed care on high-risk women for an optimal maternal and perinatal outcome.

Routinely collected antenatal data for longitudinal prediction of preeclampsia in nulliparous women: a population-based study

The objective was to evaluate the sequentially updated predictive capacity for preeclampsia during pregnancy, using multivariable longitudinal models including data from antenatal care. This population-based cohort study in the Stockholm-Gotland Counties, Sweden, included 58,899 pregnancies of nulliparous women 2008-2013. Prospectively collected data from each antenatal care visit was used, including maternal characteristics, reproductive and medical history, and repeated measurements of blood pressure, weight, symphysis-fundal height, proteinuria, hemoglobin and blood glucose levels. We used a shared-effects joint longitudinal model including all available information up until a given gestational length (week 24, 28, 32, 34 and 36), to update preeclampsia prediction sequentially. Outcome measures were prediction of preeclampsia, preeclampsia with delivery < 37, and preeclampsia with delivery ≥ 37 weeks' gestation. The area under the curve (AUC) increased with gestational length. AUC for preeclampsia with delivery < 37 weeks' gestation was 0.73 (95% CI 0.68-0.79) at week 24, and increased to 0.87 (95% CI 0.84-0.90) in week 34. For preeclampsia with delivery ≥ 37 weeks' gestation, the AUC in week 24 was 0.65 (95% CI 0.63-0.68), but increased to 0.79 (95% CI 0.78-0.80) in week 36. The addition of routinely collected clinical measurements throughout pregnancy improve preeclampsia prediction and may be useful to individualize antenatal care.

Preeclampsia: The Need for a Biological Definition and Diagnosis

The centuries-old approach to the prevention of eclampsia and its associated maternal morbidity and mortality is based on the recognition of the presence of premonitory signs and symptoms such as hypertension and proteinuria. The spectrum of preceding signs and symptoms came to be known as preeclampsia, which is debatably considered to be an early stage on a clinical continuum possibly leading to eclampsia. The premonitory signs and symptoms were then construed as diagnostic criteria for the poorly understood syndrome of preeclampsia, and this led to a perpetual debate that remains subject to wide disagreement and periodic updates. In this commentary, we will draw attention to the fact that the criteria for preeclampsia should be viewed from the prism of a screening test rather than as diagnostic of a condition in itself. Focusing research on developing better diagnostic and screening methods for what is clinically important, namely maternal and perinatal morbidity and mortality from hypertensive disorders of pregnancy, a long overdue upgrade from what was possible centuries ago, will ultimately lead to better management approaches to what really matters.

Progression from isolated gestational proteinuria to preeclampsia with severe features

INTRODUCTION

The association between the degree of isolated gestational proteinuria and preeclampsia with severe features and other placental-mediated complications is controversial. The aim of this study was to evaluate whether a higher isolated proteinuria level is associated with an increased frequency of preeclampsia with severe features.

MATERIAL AND METHODS

This retrospective cohort study included pregnant women who were past 24 weeks of gestation and were diagnosed as having new-onset proteinuria ≥300 mg in a 24-h urine collection. Exclusion criteria included diagnosis of preeclampsia within 72 h from admission, chronic renal disease or chronic hypertension. The study population was divided into tertiles by proteinuria level and the association with preeclampsia with severe features was assessed in both bivariable and multivariable analysis. The main outcome measures was the development of preeclampsia with severe features.

RESULTS

Overall, 165 women were diagnosed with isolated gestational proteinuria, and 38 (23.0%) of them developed preeclampsia with severe features. Women in the increasing proteinuria tertile were more likely to develop preeclampsia with severe features (5.5%, 21.8%, 41.8%, respectively; p = 0.004). A multivariable logistic regression model controlling for background characteristics as well as gestational age at diagnosis, blood pressure, and kidney and liver function tests showed an increased risk of 14% to develop preeclampsia with severe features for every 500-mg rise in proteinuria level (adjusted odds ratio = 1.14, 95% confidence interval 1.03-1.27).

CONCLUSIONS

A higher isolated gestational proteinuria level was associated with an increased risk to develop preeclampsia with severe features among pregnant women past 24 weeks of gestation.

Population-level data on antenatal screening for proteinuria; India, Mozambique, Nigeria, Pakistan

Objective

To estimate the prevalence and prognosis of proteinuria at enrolment in the 27 intervention clusters of the Community-Level Interventions for Pre-eclampsia cluster randomized trials.

Methods

We identified pregnant women eligible for inclusion in the trials in their communities in four countries (2013–2017). We included women who delivered by trial end and received an intervention antenatal care visit. The intervention was a community health worker providing supplementary hypertension-oriented care, including proteinuria assessment by visual assessment of urinary dipstick at the first visit and all subsequent visits when hypertension was detected. In a multilevel regression model, we compared baseline prevalence of proteinuria (≥ 1+ or ≥ 2+) across countries. We compared the incidence of subsequent complications by baseline proteinuria.

Findings

Baseline proteinuria was detected in less than 5% of eligible pregnancies in each country (India: 234/6120; Mozambique: 94/4234; Nigeria: 286/7004; Pakistan: 315/10 885), almost always with normotension (India: 225/234; Mozambique: 93/94; Nigeria: 241/286; Pakistan: 264/315). There was no consistent relationship between baseline proteinuria (either ≥ 1+ or ≥ 2+) and progression to hypertension, maternal mortality or morbidity, birth at < 37 weeks, caesarean section delivery or perinatal mortality or morbidity. If proteinuria testing were restricted to women with hypertension, we projected annual cost savings of 153 223 981 United States dollars (US$) in India, US$ 9 055 286 in Mozambique, US$ 53 181 933 in Nigeria and US$ 38 828 746 in Pakistan.

Conclusion

Our findings question the recommendations to routinely evaluate proteinuria at first assessment in pregnancy. Restricting proteinuria testing to pregnant women with hypertension has the potential to save resources.

Cytological and Pathological Evaluation of Hashimoto's Thyroiditis

Background and objectives:Hashimoto's thyroiditis is one of the most prevalent autoimmune thyroid disease (AITD) and the most common cause of acquired hypothyroidism among children and adults. Regarding diagnostic problems and various patterns of autoimmune diseases, this study aimed to investigate the cytology and pathology of Hashimoto's thyroiditis. Materials and methods:The present descriptive study was conducted on patients with Hashimoto's thyroiditis referred to the Department of Pathology at Shahid Sadoughi Hospital from 2011 to 2015, whose information recorded in medical archives was extracted and noted in a pre-prepared checklist, including gender, age, thyroid nodule size, clinical findings and radiology findings along with the results of fine needle aspiration (FNA). Subsequently, by extraction of thyroid surgery cases, the cases of surgical specimens were studied and the thyroid nodule size was entered into a checklist based on the involvement of the right lobe or left lobe. Data were analyzed using SPSS v 23 software. Results:This study was performed on 243 patients, of which 32 (13.2%) were males. The mean age was 39.3±11.61 years. The most frequent thyroid nodule size was 1-3 cm (33.7%), the most common clinical symptom was hypothyroidism (17.7%), and the most prevalent pathology was chronic lymphocytic thyroiditis (14%). There was a significant relationship between pathology findings and age (p value 0.049). Conclusion:Findings of radiology, cytology and pathology had no significant relationship with each other, and the gender and age showed no effect on the type of cytology, pathology, and radiology. Only the relationship between pathology and age was significant.

Biomarkers for diagnosis of pre-eclampsia and endometriosis

Gynecological disorders are leading public health problems in developing countries with substantial impact on women's quality of life. Significant proportion of maternal mortality and reproductive morbidity is attributed to misdiagnosis and mismanagement of pregnancy related lethal pathological conditions and affect women's health. Timely diagnosis is necessary to prevent maternal deaths and to manage complications. Biomarker development will create a wide window of opportunity for early diagnosis. This review discusses the current status of biomarkers and recent advances in 'omics' technology for early screening of endometriosis and pre-eclampsia because of significant global bioburden associated with these disorders. This review will also give baseline data for future biomarker development strategies.

Effects of mitochondrial disease/dysfunction on pregnancy: A retrospective study

A retrospective survey assessed the gynecologic, obstetric and fertility history of 103 women with mitochondrial disease (MD)/dysfunction (Md) aged 16 to 75 who had previously been pregnant. Most participants (34%) had a mitochondrial myopathy and there were 248 combined pregnancies with live deliveries (average 3.6 pregnancies/woman). In general, pregnancy in those with MD/Md appears to exacerbate some constitutional and neurological symptoms and may be more frequently associated with common obstetric complications, but this did not appear to result in worse pregnancy outcomes. Most women carried their pregnancy to term, but their neonates tended to have more congenital anomalies than expected.

Nitric Oxide and Pre-Eclampsia: A Comparative Study in Ghana

BACKGROUND

Preeclampsia is one of the commonest aetiologies of foetal and maternal mortality and morbidity. Though common, the aetiology of preeclampsia has remained unknown with several inconclusive theories surrounding the disease. Recent studies have implicated vascular endothelial dysfunction and possibly nitric oxide in preeclampsia.

AIM

To compare plasma nitric oxide levels in pre-eclampsia and healthy pregnant women in a large tertiary hospital in Ghana.

METHODS

This was a case-control study conducted among pre-eclampsia and healthy pregnant women in Korle-Bu Teaching Hospital over a four-month period. Thirty (30) pre-eclamptic and 30 healthy pregnant women aged 18-35 years with over 30 weeks' gestation were consecutively recruited into the study after obtaining informed consent. Plasma nitric oxide levels were determined using the Griess Reagent system. Data were analysed using Statistical Package for the Social Sciences (SPSS) software version 20.0 and results were compared using the independent t-test. A P-value of ≤ 0.05 was considered statistically significant.

RESULTS

The parity and body mass index (BMI) of the participants were similar. There was a significant difference in the blood pressure of the pre-eclamptic compared to healthy pregnant women. There was no statistically significant difference (P-value = 0.160) in the plasma levels of nitric oxide in pre-eclamptic (Mean = 1178.78; SD = 89.70 nM) compared to healthy pregnant women (Mean = 1365.43; SD = 95.46 nM).

CONCLUSION

Plasma nitric oxide levels may not play a significant role in the aetiology of pre-eclampsia.

Incidence of and risk factors for severe maternal complications associated with hypertensive disorders after 36 weeks' gestation in uncomplicated twin pregnancies: A prospective cohort study

AIM

To elucidate the incidence of and risk factors for severe hypertensive disorders (HD) and related maternal complications in uncomplicated twin pregnancies that reached 36 weeks' gestation.

METHODS

We conducted a prospective cohort study of twin pregnancies delivered after 36 weeks' gestation. Cases of twin-twin transfusion syndrome, twin anemia-polycythemia sequence, malformed fetuses, monoamniotic twins, selective reduction, fetal therapy and HD or fetal death before 35 weeks' gestation were excluded. The study's primary outcome was the incidence of severe maternal complications, including severe HD, eclampsia, placental abruption, HELLP (hemolysis, elevated liver enzyme and low platelet) syndrome, pulmonary edema and cerebrovascular disease. Perinatal factors associated with the primary outcome were identified using a multivariate logistic regression model.

RESULTS

In 330 enrolled women, the number of cases with the primary outcome was 28 (8.5%; 95% confidence interval 5.9-12.0), including 25 cases of severe HD and each one case of placental abruption, HELLP syndrome and eclampsia. The rate of severe maternal complications significantly increased with gestational age, demonstrating 1.2% at 36 weeks, 3.9% at 37 weeks and 6.4% at 38 weeks. Only gestational proteinuria was identified as the independent risk factor for severe maternal complications (adjusted odds ratio 17.1 [95% confidence interval 6.71-45.4]).

CONCLUSION

Severe maternal HD and related complications increased from late preterm to early term; particularly, patients with gestational proteinuria were at high risk.

Outcome of pregnancy with new onset proteinuria and progression to pre-eclampsia: A retrospective analysis

OBJECTIVE

To examine maternal and neonatal outcomes of gestational proteinuria, and to identify maternal characteristics for progression to pre-eclampsia.

STUDY DESIGN

Retrospective cohort. Included all pregnant women who delivered between Jan 2014-Feb 2017 with new onset proteinuria in a single obstetric unit. Demographic, maternal and neonatal outcomes were compared.

RESULTS

Eighteen (25%) out of 73 women with new onset gestational proteinuria developed pre-eclampsia. The incidence of gestational proteinuria was 0.54%. Compared with women that remained normotensive, those that developed hypertension had delivery at earlier gestation (p = .02), increased risk of fetal growth restriction (p = .01) and lower newborn birthweight (p = .002). Maximal proteinuria and fetal growth restriction were independent factors associated with development of pre-eclampsia. In particular, high proteinuria level ≥ 2 g/d constitute a major predictor for progression (p = .03).

CONCLUSION

Increased vigilance for antenatal surveillance is important in women with gestational proteinuria as a substantial portion progress to pre-eclampsia. Serial growth scan and proteinuria assay are suggested to predict possible pre-eclampsia development.

Serum magnesium and calcium in preeclampsia: a comparative study at the Korle-Bu Teaching Hospital, Ghana

Background

A large percentage (16% of maternal mortality in developed countries, compared to 9% in developing countries), is due to hypertensive disorders in pregnancy. The etiology of preeclampsia remains unknown, with poorly understood pathophysiology. Magnesium and calcium play an important role in vascular smooth muscle function and therefore a possible role in the development of preeclampsia.

Aim

We aimed to compare serum magnesium and total calcium levels of preeclamptic and normal pregnant women at the Korle-Bu Teaching Hospital in Ghana.

Patients and methods

A comparative cross-sectional study involving 30 normal pregnant and 30 preeclamptic women with >30 weeks gestation and aged 18–35 years, was conducted at the Korle-Bu Teaching Hospital. Magnesium and calcium were determined using a flame atomic absorption spectrometer.

Results

Mean serum magnesium and total calcium levels in preeclamptic women were 0.70±0.15 and 2.13±0.30 mmol/L, respectively. Mean serum magnesium and total calcium levels in normal pregnant women were 0.76±0.14 and 2.13±0.35 mmol/L, respectively. There was a statistically nonsignificant difference in serum magnesium and total calcium in preeclamptic women compared to normal pregnant women, with p-values of 0.092 and 0.972, respectively.

Conclusion

Serum magnesium and total calcium, therefore, seem not to differ in preeclamptic women compared to normal pregnant women in Ghana.

Serum copper and zinc levels in preeclamptic Nigerian women

Background:

The exact etiology of preeclampsia remains unknown even though several studies have been done. Some studies have shown that supplementation of zinc (Zn) and copper could ameliorate the effects of preeclampsia while other studies did not establish the beneficial role of these elements in preeclampsia. The objective of this study was to compare the Zn and copper levels in the serum of Nigerian women with or without preeclampsia.

Materials and Methods:

In this study, serum Zn and copper levels were determined using atomic absorption spectrometry in 54 patients and 48 healthy normotensive pregnant women. The mean, standard deviation, Student's t-test, and Pearson correlation were employed.

Results:

Serum Zn was significantly lower in patients than controls (8.27 ± 0.60 vs. 12.16 ± 1.83 μmol/l. P <0.001) (t-test). Serum copper was also significantly lower in patients than controls (8.14 ± 1.80 vs. 16.62 ± 3.17 μmol/l, P < 0.001).

Conclusion:

There was a significant reduction in the levels of Zn and copper in patients with preeclampsia. Dietary supplementation of these trace elements may help to prevent preeclampsia.

The outcome of pregnancy with new onset proteinuria without hypertension: retrospective observational study

OBJECTIVE

The aim of this study was to evaluate preeclampsia progression of isolated proteinuria and associations with pregnancy outcome.

METHOD

We performed a retrospective analysis in patients who were hospitalized for evaluation of new onset proteinuria without hypertension after 20 weeks of gestation between January 2012 and January 2014. One hundred fifty-seven patients who met the inclusion criteria were enrolled the study.

RESULTS

After detection of new onset proteinuria, 53 of 157 (33.7%) patients developed preeclampsia and the incidence of gestational proteinuria was found to be 0.33%. Twenty-four hours urine proteinuria testing results were significantly higher in preeclampsia (PE) group compared with the gestational proteinuria (GP) group (p < 0.01). Patients who developed preeclampsia delivered significantly earlier than the GP group (p < 0.01). The weights of the infants born to mothers in the PE group were significantly lower than the other group (p < 0.01).

CONCLUSION

The incidence of gestational proteinuria was lower than the previous studies. Preeclampsia developed in 33% of patients with new onset proteinuria in pregnancy. In patients who developed PE had significantly higher proteinuria, lower delivery time and birth weight in their infants. Therefore, patients with new onset proteinuria should be followed-up for preeclampsia development and associated morbidities.

Pregnancy outcome in proteinuria-onset and hypertension-onset preeclampsia

OBJECTIVE

To evaluate pregnancy outcome in preeclampsia (PE), according to the timing of onset of proteinuria and hypertension.

METHODS

Preeclamptic women were retrospectively divided into proteinuria-onset and hypertension-onset PE according to the first symptom. Maternal and perinatal outcome were assessed in both the groups.

RESULTS

One hundred and ninety five single pregnancies complicated by PE were included. According to the first symptom, they were divided into two groups: proteinuria-onset PE (n = 49, 25.1%) and hypertension-onset PE (n = 146, 74.9%). Pregnancy and neonatal outcome was significantly worse in proteinuria-onset PE.

CONCLUSION

Proteinuria-onset PE is associated with an increased risk of adverse pregnancy outcome than hypertension-onset PE.

A Retrospective Survey Studying the Impact of Fabry Disease on Pregnancy

Fabry disease (FD) is a lysosomal storage disorder resulting from a deficiency of lysosomal enzyme α-galactosidase A (α-gal A). Reduced or missing α-gal A enzyme results in the storage of globotriaosylceramide (GL3) and related glycosphingolipids in the cellular lysosomes throughout the body. The majority of GL3 buildup occurs in the body's vasculature resulting in narrowed blood vessels and an increased risk for strokes, transient ischemic attacks, and deep vein thrombosis. Theoretical concerns have been raised about increased pregnancy complications in women affected by FD as glycosphingolipid storage has been found in both maternal- and fetal-derived placental tissues. This retrospective study was conducted to better understand risks for women with FD during pregnancy. Survey questions included queries about prenatal medications, teratogenic exposures, prenatal testing, common pregnancy complications, Fabry symptoms during pregnancy, obstetrical history, and immediate neonatal history. In total, 41 affected women completed the survey. Results indicate several Fabry-related symptoms and features may worsen during pregnancy, including gastrointestinal symptoms, acroparesthesias, proteinuria, headaches, and postpartum depression. Although no life-threatening complications were reported, a statistically significant increased frequency of hypertension was observed when comparing data from this study to the general population (p < 0.05) and previous publications (p < 0.001). Limitations include sample size and recall bias. Though this survey sampling of women was small and required women to recall their past pregnancy experiences, the findings suggest that when pregnant, women with FD should be aware of potential worsening of FD symptoms and may benefit from consulting with a maternal-fetal medicine specialist.

Clinical features of isolated gestational proteinuria progressing to pre-eclampsia: retrospective observational study

OBJECTIVES

Some women with isolated gestational proteinuria (IGP) later develop hypertension and are diagnosed with pre-eclampsia (PE). This study was performed to determine whether clinical features of such proteinuria preceding PE (P-PE) differ from those of other PE (O-PE).

DESIGN

Retrospective observational study after approval of the institutional review board of ethics.

SETTING

A single university hospital. Proteinuria was defined as a protein-to-creatinine ratio (mg/mg; P/Cr) of ≥0.27 in the spot urine specimen. IGP was defined as proteinuria in the absence of hypertension. P-PE was defined as PE in which proteinuria preceded hypertension by more than 2 days.

PARTICIPANTS

All of 10 and 18 consecutive women with P-PE and O-PE, respectively, who gave birth between January 2008 and August 2013.

RESULTS

Proteinuria appeared earlier (at 30.2±3.0 vs 35.3±4.3 weeks, p=0.001), the P/Cr level was greater at birth (7.28±2.14 vs 3.19±2.49, p<0.001), net maternal weight gain during the last antenatal 1 week was greater (3.1±1.8 vs 1.3±1.7 kg, p=0.023) and length of pregnancy was shorter (32.5±1.9 vs 36.1±3.6 weeks, p=0.001) in women with P-PE than in O-PE. The duration of IGP was 10.0±5.9 days (range 3-20), and the time interval until delivery after diagnosis of PE was 6.1±8.2 days (range 0-23) in 10 women with P-PE. The P/Cr levels at birth were significantly inversely correlated with the antenatal lowest antithrombin activity and fibrinogen levels among the 28 women with PE.

CONCLUSIONS

Women with P-PE were likely to exhibit greater proteinuria in the urine, greater water retention in the interstitial space and more enhanced coagulation-fibrinolysis, thus suggesting that they may constitute a more severe form of PE than women with O-PE do.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictive factors for preeclampsia in pregnant women: a Receiver Operation Character approach

INTRODUCTION

Preeclampsia is a major cause of maternal and prenatal mortality and morbidity worldwide. There are some risk factors that are of great value for prediction of preeclampsia by which the practitioners can counsel women regarding this disease. The aim of this study was to analyze the role of such risk factors as the predictors associated with preeclampsia among Iranian women using logistic regression.

MATERIAL AND METHODS

The role of some risk factors such as demographic, anthropometric, medical and obstetrics variables in preeclampsia among 610 women attending the obstetric ward of Mustafa hospital in Ilam in the west of Iran was analyzed from May to September 2010. All the pregnant women referred to this hospital participated in the study except those cases that had abortion. Unvaried and Multiple logistic regression analyses were used to find the predictive factors behind preeclampsia. Standard errors of area compute using nonparametric methods. A p-value of 0.05 was considered statistically significant.

RESULTS

Prevalence of preeclampsia was 9.5% (95% CI 7.4-11.6%). Predictive model build using history of preeclampsia, history of hypertension, and history of infertility. Area Under the Receiver Operation Character (AUROC) was estimated 0.67 (95% CI 0.59-0.67, p < 0.01) that showed that using the model is much better than having a guess.

CONCLUSIONS

The odd of preeclampsia increased in women with a history of preeclampsia, hypertension and infertility. Recognition of these predictor factors would improve the ability to diagnose and monitor women likely to develop preeclampsia before the onset of disease for timely interventions.

Is teenage pregnancy an obstetric risk in a welfare society? A population-based study in Finland, from 2006 to 2011

OBJECTIVE

To assess obstetric outcomes in teenage pregnancies in a country with a low teenage delivery rate and comprehensive high-quality prenatal care.

DESIGN

Retrospective population-based register study.

SETTING

Finland.

PARTICIPANTS

All nulliparous teenagers (13-15 years (n=84), 16-17 years (n=1234), 18-19 years (n=5987)) and controls (25-year-old to 29-year-old women (n=51 142)) with singleton deliveries in 2006-2011.

MAIN OUTCOME MEASURES

Risk of adverse obstetric outcomes adjusted for demographic factors and clinically relevant pregnancy complications, with main focus on maternal pregnancy complications.

RESULTS

Teenage mothers were more likely than controls to live in rural areas (16% (n=1168) vs 11.8% (n=6035)), smoke (36.4% (n=2661) vs 7% (n=3580)) and misuse alcohol or drugs (1.1% (n=82) vs 0.2% (n=96); p<0.001 for all). Teenagers made a good mean number of antenatal clinic visits (16.4 vs 16.5), but were more likely to have attended fewer than half of the recommended visits (3% (n=210) vs 1.4% (n=716)). Teenagers faced increased risks of several obstetric complications, for example, anaemia (adjusted OR 1.8, 95% CI 1.6 to 2.1), proteinuria (1.8, 1.2 to 2.6), urinary tract infection (UTI; 2.9, 1.8 to 4.8), pyelonephritis (6.3, 3.8 to 10.4) and eclampsia (3.2, 1.4 to 7.3), the risks increasing with descending age for most outcomes. Elevated risks of pre-eclampsia (3.7, 1.5 to 9.0) and preterm delivery (2.5, 1.2 to 5.3) were also found among 13-year-olds to 15-year-olds. However, teenage mothers were more likely to have vaginal delivery (1.9, 1.7 to 2.0) without complications. Inadequate prenatal care among teenagers was a risk factor of eclampsia (12.6, 2.6 to 62.6), UTI (5.8, 1.7 to 19.7) and adverse neonatal outcomes.

CONCLUSIONS

Pregnant teenagers tended to be socioeconomically disadvantaged versus controls and faced higher risks of various pregnancy complications. Special attention should be paid to enrolling teenagers into adequate prenatal care in early pregnancy.

Plasma concentrations of angiogenic/anti-angiogenic factors have prognostic value in women presenting with suspected preeclampsia to the obstetrical triage area: a prospective study

OBJECTIVE

To prospectively determine the prognostic value of maternal plasma concentrations of placental growth factor (PlGF), soluble endoglin (sEng) and soluble vascular endothelial growth factor receptors-1 and -2 (sVEGFR-1 and -2) in identifying patients with suspected preeclampsia (PE), who require preterm delivery (PTD) or develop adverse outcomes.

STUDY DESIGN

This prospective cohort study included 85 consecutive patients who presented to the obstetrical triage area at 20-36 weeks with a diagnosis of "rule out PE." Patients were classified as: 1) those who remained stable until term (n = 37); and 2) those who developed severe PE and required PTD (n = 48). Plasma concentrations of PlGF, sEng and sVEGFR-1 and -2 were determined by ELISA.

RESULTS

Patients with PlGF/sVEGFR-1 ≤0.05 multiples of the median (MoM) or PlGF/sEng ≤0.07 MoM were more likely to deliver preterm due to PE [adjusted odd ratio (aOR) 7.4 and 8.8], and to develop maternal (aOR 3.7 and 2.4) or neonatal complications (aOR 10.0 and 10.1). Among patients who presented <34 weeks of gestation, PlGF/sVEGFR-1 ≤ 0.035 MoM or PlGF/sEng ≤0.05 MoM had a sensitivity of 89% (16/18), specificity of 96% (24/25) and likelihood ratio for a positive test of 22 to identify patients who delivered within 2 weeks. The addition of the PlGF/sVEGFR-1 ratio to standard clinical tests improved the sensitivity at a fixed false-positive rate of 3% (p = 0.004) for the identification of patients who were delivered due to PE within 2 weeks. Among patients who had a plasma concentration of PlGF/sVEGFR-1 ratio ≤0.035 MoM, 0.036-0.34 MoM and ≥0.35 MoM, the rates of PTD <34 weeks were 94%, 27% and 7%, respectively.

CONCLUSIONS

The determination of angiogenic/anti-angiogenic factors has prognostic value in patients presenting to the obstetrical triage area with suspected PE for the identification of those requiring preterm delivery and at risk for adverse maternal/neonatal outcomes.

Mixing nulliparous and multiparous women in randomised controlled trials of preeclampsia prevention is debatable: evidence from a systematic review

BACKGROUND

Nulliparity is a major risk factor of preeclampsia investigated in numerous trials of its prevention.

OBJECTIVE

We aimed to assess whether these trials considered nulliparity in subject selection or analysis of results.

SEARCH STRATEGY

01 April 2013 search of MEDLINE via PubMed, EMBASE and the Cochrane Library. 01 April 2013 search of trials registered in Clinicaltrials.gov.

SELECTION CRITERIA

Randomised controlled trials and metaanalyses of preeclampsia prevention with no restriction to period of publication or language. Metaanalyses were selected to fully identify relevant trials.

DATA COLLECTION AND ANALYSIS

One reader appraised each selected article/registered protocol using a pretested, standardized data abstraction form developed in a pilot test. For each article, he recorded whether both nulliparous and multiparous were included and, in case of mixed populations, whether randomisation was stratified, and whether subgroup analyses had been reported. For registered protocols, he only assessed whether it was planned to include mixed populations.

MAIN RESULTS

88 randomised controlled trials were identified, representing 83,396 included women. In 58 of the 88 articles identified (65.9%), preeclampsia was the primary outcome. In 31 of these (53.4%), the investigation combined nulliparous and multiparous women; only two reports in 31 (6.5%) stated that randomisation was stratified on parity and only four (12.9%) described a subgroup analysis by parity. Of the 30 registered trials, 20 (66.6%) planned to include both nulliparous and multiparous women.

CONCLUSION

Parity is largely ignored in randomised controlled trials of preeclampsia prevention, which raises difficulties in interpreting the results.

Cohort Profile: the Avon Longitudinal Study of Parents and Children: ALSPAC mothers cohort

Summary The Avon Longitudinal Study of Children and Parents (ALSPAC) was established to understand how genetic and environmental characteristics influence health and development in parents and children. All pregnant women resident in a defined area in the South West of England, with an expected date of delivery between 1st April 1991 and 31st December 1992, were eligible and 13761 women (contributing 13867 pregnancies) were recruited. These women have been followed over the last 19-22 years and have completed up to 20 questionnaires, have had detailed data abstracted from their medical records and have information on any cancer diagnoses and deaths through record linkage. A follow-up assessment was completed 17-18 years postnatal at which anthropometry, blood pressure, fat, lean and bone mass and carotid intima media thickness were assessed, and a fasting blood sample taken. The second follow-up clinic, which additionally measures cognitive function, physical capability, physical activity (with accelerometer) and wrist bone architecture, is underway and two further assessments with similar measurements will take place over the next 5 years. There is a detailed biobank that includes DNA, with genome-wide data available on >10000, stored serum and plasma taken repeatedly since pregnancy and other samples; a wide range of data on completed biospecimen assays are available. Details of how to access these data are provided in this cohort profile.

Offspring's blood pressure and metabolic phenotype after exposure to gestational hypertension in utero

The aim of the study was to investigate the impact of de novo hypertension in pregnancy, i.e. gestational (non-proteinuric) hypertension (GH) and preeclampsia (PE), on the long-term metabolic outcome of the offspring. Data was obtained from the Northern Finland Birth Cohort 1986 (NFBC 1986), including 9,362 pregnancies and subsequent births between 1985 and 1986. Pregnancies were categorised into three groups: (1) GH with blood pressure (BP) ≥ 140/90 mmHg, (2) PE with BP ≥ 140/90 mmHg and proteinuria, and (3) reference group with normal BP. The final study population included 331 offspring of mothers with GH, 197 with PE and 5,045 offspring of normotensive mothers. The main outcome measures were systolic and diastolic blood pressure (SBP, DBP), mean arterial pressure (MAP), body mass index (BMI), and serum lipid, glucose and insulin levels of the 16 year-old offspring. The children of mothers with GH had higher BP compared to the reference group (SBP percentage difference 2.7 (95% CI 1.6, 3.8); DBP 3.4 (2.1, 4.6); MAP 3.1 (2.0, 4.1), P < 0.001 for all) and a tendency towards higher cholesterol and apolipoprotein B values. The offspring of mothers with PE had higher DBP and MAP, however after the adjustments this difference disappeared. Maternal de novo hypertension during pregnancy is associated with offspring's elevated blood pressure level already in adolescence. GH may also be associated with unfavourable lipid profile of the offspring.