Acute maternal infection and risk of pre-eclampsia: a population-based case-control study

Intrauterine Shaping of Fetal Microbiota

Mechanisms resulting from the physiological immaturity of the digestive system in children delivered before 32 weeks of gestation and, in particular, different interactions between the microbiome and the body have not been fully elucidated yet. Next-generation sequencing methods demonstrated the presence of bacterial DNA in the placenta and amniotic fluid, which may reflect bacterial populations that initiate intestinal colonization in utero. Numerous studies confirmed the hypothesis stating that intestinal bacteria played an important role in the pathogenesis of necrotizing enterocolitis (NEC) early- and late-onset neonatal sepsis (EONS and LONS). The model and scale of disorders within the intestinal microbiome are the subject of active research in premature infants. Neonatal meconium was primarily used as an indicator defining the environment in utero, as it is formed before birth. Metagenomic results and previous data from microbiological bacterial cultures showed a correlation between the time from birth to sample collection and the detection of bacteria in the neonatal meconium. Therefore, it may be determined that the colonization of the newborn's intestines is influenced by numerous factors, which may be divided into prenatal, perinatal, and postnatal, with particular emphasis put on the mode of delivery and contact with the parent immediately after birth. Background: The aim of this review was to collect available data on the intrauterine shaping of the fetal microbiota. Methods: On 13 March 2024, the available literature in the PubMed National Library of Medicine search engine was reviewed using the following selected keywords: "placental microbiome", "intestinal bacteria in newborns and premature infants", and "intrauterine microbiota". Results: After reviewing the available articles and abstracts and an in-depth analysis of their content, over 100 articles were selected for detailed elaboration. We focused on the origin of microorganisms shaping the microbiota of newborns. We also described the types of bacteria that made up the intrauterine microbiota and the intestinal microbiota of newborns. Conclusions: The data presented in the review on the microbiome of both term newborns and those with a body weight below 1200 g indicate a possible intrauterine colonization of the fetus depending on the duration of pregnancy. The colonization occurs both via the vaginal and intestinal route (hematogenous route). However, there are differences in the demonstrated representatives of various types of bacteria, phyla Firmicutes and Actinobacteria in particular, taking account of the distribution in their abundance in the individual groups of pregnancy duration. Simultaneously, the distribution of the phyla Actinobacteria and Proteobacteria is consistent. Considering the duration of pregnancy, it may also be concluded that the bacterial flora of vaginal origin dominates in preterm newborns, while the flora of intestinal origin dominates in term newborns. This might explain the role of bacterial and infectious factors in inducing premature birth with the rupture of fetal membranes.

Are Antiphospholipid Antibodies a Surrogate Risk Factor for Thrombosis in Sepsis?

Antiphospholipid syndrome (APS) is a hypercoagulable state caused by antiphospholipid antibodies (aPL). APS clinically manifests with arterial or venous or microvascular thrombi and/or pregnancy complications. It is well-known that the development of aPL can be a transient phenomenon and thus the current diagnostic criterion for APS requires repeat laboratory testing several weeks apart before a definitive diagnosis is made. However, transient presence of aPL may also be pathogenic. In this article, we attempt to give historical and clinical evidence for the importance of these antibodies, even when transient, and call for further research into mechanisms by which these antibodies may promote thrombosis and pregnancy morbidities.

Maternal Prenatal Infections and Biliary Atresia in Offspring

Importance

Investigations into the association of antepartum maternal infections with the pathogenesis of biliary atresia (BA) in human offspring are insufficient.

Objective

To examine the association between prenatal infections in mothers and the development of BA in their offspring.

Design, Setting, and Participants

This population-based case-control study obtained administrative data from the Taiwan National Health Insurance Research Database with linkage to the Taiwan Maternal and Child Health Database, capturing demographic and medical information on nearly all 23 million of the Taiwan population. The cohort comprised 2 905 978 singleton live births among mother-infant dyads between January 1, 2004, and December 31, 2020, in Taiwan. The case group of infants with BA was identified from use of International Classification of Diseases diagnostic codes for BA and subsequent Kasai procedure or liver transplant. The control group was randomly selected from infants without BA, representing approximately 1 in 1000 study population. Data analyses were performed from May 1 to October 31, 2023.

Exposure

Prenatal maternal infections, including intestinal infection, influenza, upper airway infection, pneumonia, soft-tissue infection, and genitourinary tract infection.

Main Outcomes and Measures

The main outcome was exposure to prenatal maternal infections. Inverse probability weighting analysis was performed by building a logistic regression model to estimate the probability of the exposure observed for a particular infant and using the estimated probability as a weight in subsequent analyses. The weighted odds ratio (OR) estimated by logistic regressions was then used to assess the risk of BA in offspring after prenatal maternal infections.

Results

Among the mother-infant dyads included, 447 infants with BA were cases (232 females [51.9%]) and 2912 infants without BA were controls (1514 males [52.0%]). The mean (SD) maternal age at childbirth was 30.7 (4.9) years. Offspring exposed to prenatal intestinal infection (weighted OR, 1.46; 95% CI, 1.17-1.82) and genitourinary tract infection (weighted OR, 1.22; 95% CI, 1.05-1.41) in mothers exhibited a significantly higher risk of BA. Furthermore, maternal intestinal infection (weighted OR, 6.05; 95% CI, 3.80-9.63) and genitourinary tract infection (weighted OR, 1.55; 95% CI, 1.13-2.11) that occurred during the third trimester were associated with an increased risk of BA in offspring.

Conclusions and Relevance

Results of this case-control study indicate an association between prenatal intestinal infection and genitourinary tract infection in mothers and BA occurrence in their offspring. Further studies are warranted to explore the underlying mechanisms of this association.

Global prevalence of urinary tract infection in pregnant mothers: a systematic review and meta-analysis

OBJECTIVE

Urinary tract infection (UTI) is a prevalent infection during pregnancy that can lead to complications for both the mother and the foetus. The objective of this systematic review and meta-analysis is to determine the global prevalence of UTIs (both symptomatic and asymptomatic) during pregnancy, based on previous studies in this area. Furthermore, this study aims to identify any factors that contribute to heterogeneity in the prevalence of UTIs during pregnancy.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines on August 8, 2022. To conduct the systematic review and meta-analysis, a search was performed using the keywords "urinary tract system", "UTI", "pregnancy", and "gestation" was performed in several databases, including Web of Science (WoS), PubMed, Scopus, ScienceDirect, Embase, and Google Scholar, without a time limit until September 18, 2022. The analysis was performed using a random-effects model, and the heterogeneity of the studies was assessed using the I2 index. The Comprehensive Meta-Analysis software (Version 2) was used for data analysis.

RESULTS

The systematic review and meta-analysis of 27 studies, which included a total of 30,641 pregnant women, showed an overall prevalence of UTI (both symptomatic and asymptomatic) to be 23.9% (95% confidence interval: 16.2-33.8). Meta-regression analysis was conducted to examine the impact of two factors, namely study sample size and study year, on the heterogeneity of the meta-analysis. The results revealed that an increase in sample size, and the study year was associated with a decrease in the prevalence of UTI in pregnant women (P < 0.05).

CONCLUSION

The results of our study indicate a global prevalence of UTI in pregnant women to be 23.9%. Therefore, it is recommended that all pregnant women undergo regular UTI screening tests and receive prompt treatment if diagnosed with UTI. Early detection and treatment of UTI during pregnancy are crucial to prevent complications that may affect the health of both the mother and the foetus.

Infection and disruption of placental multidrug resistance (MDR) transporters: Implications for fetal drug exposure

P-glycoprotein (P-gp, encoded by the ABCB1 gene) and breast cancer resistance protein (BCRP/ABCG2) are efflux multidrug resistance (MDR) transporters localized at the syncytiotrophoblast barrier of the placenta and protect the conceptus from drug and toxin exposure throughout pregnancy. Infection is an important modulator of MDR expression and function. This review comprehensively examines the effect of infection on the MDR transporters, P-gp and BCRP in the placenta. Infection PAMPs such as bacterial lipopolysaccharide (LPS) and viral polyinosinic-polycytidylic acid (poly I:C) and single-stranded (ss)RNA, as well as infection with Zika virus (ZIKV), Plasmodium berghei ANKA (modeling malaria in pregnancy - MiP) and polymicrobial infection of intrauterine tissues (chorioamnionitis) all modulate placental P-gp and BCRP at the levels of mRNA, protein and or function; with specific responses varying according to gestational age, trophoblast type and species (human vs. mice). Furthermore, we describe the expression and localization profile of Toll-like receptor (TLR) proteins of the innate immune system at the maternal-fetal interface, aiming to better understand how infective agents modulate placental MDR. We also highlight important gaps in the field and propose future research directions. We conclude that alterations in placental MDR expression and function induced by infective agents may not only alter the intrauterine biodistribution of important MDR substrates such as drugs, toxins, hormones, cytokines, chemokines and waste metabolites, but also impact normal placentation and adversely affect pregnancy outcome and maternal/neonatal health.

Time-related biases in perinatal pharmacoepidemiology: A systematic review of observational studies

BACKGROUND

Time-related biases, such as immortal time and time-window bias, frequently occur in pharmacoepidemiologic research. However, the prevalence of these biases in perinatal pharmacoepidemiology is not well understood.

OBJECTIVE

To describe the frequency of time-related biases in observational studies of medications commonly used during pregnancy (antibiotic, antifungal, and antiemetic drugs) via systematic review.

METHOD

We searched Medline and EMBASE for observational studies published between January 2013 and September 2020 and examining the association between antibiotic, antifungal, or antiemetic drugs and adverse pregnancy outcomes, including spontaneous abortion, stillbirth, preterm delivery, small-for-gestational age, pre-eclampsia, and gestational diabetes. The proportion of studies with time-related biases was estimated overall and by type (immortal time bias, time-window bias).

RESULTS

Our systematic review included 20 studies (16 cohort studies, 3 nested case-control studies, and 1 case-control study), of which 12 examined antibiotic, 6 antiemetic, and 2 anti-fungal drugs. Eleven studies (55%) had immortal time bias due to the misclassification of unexposed, event-free person-time between cohort entry and exposure initiation as exposed. No included study had time-window bias. The direction of effect varied for both studies with and without time-related bias, with many studies reporting very wide confidence intervals around the effect estimates, thus making the direction of effect less interpretable. However, studies with time-related bias were more likely to show protective or null associations compared with studies without time-related bias.

CONCLUSION

Time-related biases occur frequently in observational studies of drug effects during pregnancy. The use of appropriate study design and analytical approaches is needed to prevent time-related biases and ensure study validity.

New insights into smoking and urinary tract infections during pregnancy using pregnancy-pair design: A population-based register study

INTRODUCTION

Pregnancy itself predisposes to urinary tract infections (UTI). There appears to be a higher prevalence of infections and genitourinary diseases among pregnant smokers than among non-smokers. The present study is a retrospective observational register study aiming to investigate whether maternal smoking is associated with the prevalence of UTIs during pregnancy by utilizing a pregnancy-pair analysis.

MATERIAL AND METHODS

Information about pregnancies and maternal smoking was obtained from the Finnish Medical Birth Register. The study sample consisted of all singleton pregnancies (n = 723 433) of women giving birth between January 2006 and December 2018 in Finland. Information on maternal smoking was collected in three categories: (1) non-smoking; (2) quit smoking during the first trimester; and (3) continued smoking throughout the pregnancy. Information about maternal UTI diagnoses during pregnancy was received from the Hospital Discharge Register and the Medical Birth Register. UTIs were categorized as lower and upper UTIs according to the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 diagnosis codes. Risks were calculated as odds ratios (OR) by logistic regression with 95% confidence intervals (CI) further adjusted for maternal characteristics (aOR). Finally, pregnancy-pair analyses were performed: mothers who had changed smoking status (no smoking/any smoking) between consecutive pregnancies (n = 27 246 pregnancy-pairs) were analyzed as one cluster and compared with non-smokers.

RESULTS

Smokers had UTIs more often compared with the non-smokers. The association was even stronger among those who continued to smoke (aOR 1.60, 95% CI 1.51-1.70) than among those who smoked only during the first trimester (aOR 1.27, 95% CI 1.18-1.37) compared with non-smokers. In pregnancy-pair analysis, smoking was associated with upper UTIs during pregnancy (OR 1.49, 95% CI 1.05-2.12) compared with non-smokers, but after the adjustments this association was attenuated (aOR 1.27, 95% CI 0.88-1.82). No association in lower UTIs was observed in the pregnancy-pair design.

CONCLUSIONS

Maternal smoking was associated with a higher prevalence of UTIs during pregnancy in the standard comparison. The observed association was fully attenuated in the pregnancy-pair analysis, in which smoking was dichotomized. This study suggests that the association between maternal smoking during pregnancy and adverse maternal health effects might be more complex than previously thought.

Animal Models of Preeclampsia: Mechanistic Insights and Promising Therapeutics

Preeclampsia (PE) is a common pregnancy-specific disorder that is a major cause of both maternal and fetal morbidity and mortality. Central to the pathogenesis of PE is the production of antiangiogenic and inflammatory factors by the hypoxic placenta, leading to the downstream manifestations of the disease, including hypertension and end-organ damage. Currently, effective treatments are limited for PE; however, the development of preclinical animal models has helped in the development and evaluation of new therapeutics. In this review, we will summarize some of the more commonly used models of PE and highlight their similarities to the human syndrome, as well as the therapeutics tested in each model.

Seasonal variations in the occurrence of preeclampsia and potential implication of upper respiratory infections in South Korea

The aim of this study was to examine the effect of seasonal changes on the incidence of preeclampsia (PE) in South Korea and East Asian populations, and to evaluate the relationship between upper respiratory infection (URI) during pregnancy and the development of PE. This cohort study included women who had singleton births between 2012 and 2018 in South Korea. A total of 548,080 first singleton births were analyzed, and 9311 patients (1.70%) were diagnosed with PE. Multivariate analysis showed that older age (≥ 30 years old), low income, residing in the southern part of South Korea, history of cigarette smoking, heavy drinking, higher body mass index, hypertension, or diabetes mellitus were risk factors for PE. Univariate analysis showed that URI was associated with the incidence of PE (P = 0.0294). However, this association was not statistically significant in the multivariate analysis (aOR 1.01; 95% CI 0.95-1.07). After adjusting for confounding variables, the occurrence of PE was the highest in December (aOR 1.21; 95% CI 1.10-1.34) and lowest in July and August. This study demonstrated that there are seasonal variations in the occurrence of PE in South Korea. Moreover, URI may be associated with the development of PE.

Salicornia herbacea Aqueous Extracts Regulate NLRP3 Inflammasome Activation in Macrophages and Trophoblasts

Salicornia herbacea L. (Chenopodiaceae), an edible salt marsh plant with anti-inflammatory effects, was examined in macrophages and trophoblasts whether it modulates NLRP3 inflammasome activity. Pretreatment and delayed treatment of S. herbacea extract (SHE) in bone marrow-derived macrophages (BMDMs) reduced the activity of NLRP3 inflammasome induced by lipopolysaccharide (LPS) and adenosine triphosphate stimulation and downregulated interleukin (IL)-1β production. SHE also inhibited pyroptotic cell death, the adaptor molecule apoptosis-associated speck-like protein containing a CARD (ASC), oligomerization, and speck by NLRP3 inflammasome activity in BMDM. Similarly, SHE decreased the mRNA expression of NLRP3, ASC, IL-1β, and IL-6 in the LPS-stimulated human trophoblast cell line, Swan 71 cells. In addition, SHE inhibited the production of IL-6 and IL-1β and decreased the expression of cyclooxygenase-2 and prostaglandin E2 in stimulated Swan 71 cells. Finally, 3,5-dicaffeoylquinic acid (3,5-DCQA), one of the components of S. herbacea, inhibited IL-1β produced by NLRP3 inflammasome activity. In conclusion, SHE downregulated the activity of the NLRP3 inflammasome in macrophages and trophoblasts.

Are the Diagnosis and Treatment of Acute Cystitis in the Premenopausal, Pregnant, and Postmenopausal Women the Same? A Review of the Literature

Importance

Acute cystitis is a common condition diagnosed in women. The diagnosis and treatment of this condition change throughout a woman's life. Understanding the differences in diagnosis and treatment in premenopausal, pregnant, and postmenopausal woman increases the likelihood of treatment success and decreases risk of complications from untreated or suboptimally treated infections.

Objective

The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of acute cystitis and the similarities and differences of these aspects of the condition in the premenopausal, pregnant, and postmenopausal woman.

Evidence Acquisition

A PubMed, Web of Science, and CINAHL search was undertaken with the years 1990 to 2020 searched.

Results

There were 393 articles identified, with 103 being the basis of review. Multiple risk factors for acute cystitis have been identified and are largely consistent throughout a woman's lifetime with few exceptions. The diagnoses by group with common diagnostic tools, such as urinalysis, vary in specificity and sensitivity between these groups. Management also varies between groups, with pregnancy having specific limitations related to drug safety in regard to possible fetal effects posed by certain medications commonly used to treat acute cystitis.

Conclusions

Acute cystitis not only varies in presentation throughout a woman's lifespan, but also in appropriate diagnosis and treatment. Treatment of acute cystitis does have some commonalities between the groups; however, there are contraindications unique to each group. These differences are paramount to not only ensuring appropriate treatment but also treatment success.

Relevance

Acute cystitis is a common condition with different diagnostic and management recommendations throughout a woman's lifespan.

Maternal HPV Infection: Effects on Pregnancy Outcome

The human papilloma virus (HPV) infection, caused by a ubiquitous virus typically transmitted through the direct contact of infected organs, either through the skin or mucosa, is the most common sexually transmitted infection, placing young women at a high risk of contracting it. Although the vast majority of cases spontaneously clear within 1-2 years, persistent HPV infection remains a serious concern, as it has repeatedly been linked to the development of multiple malignancies, including cervical, anogenital, and oropharyngeal cancers. Additionally, more recent data suggest a harmful effect of HPV infection on pregnancy. As the maternal hormonal environment and immune system undergo significant changes during pregnancy, the persistence of HPV is arguably favored. Various studies have reported an increased risk of adverse pregnancy outcomes among HPV-positive women, with the clinical impact encompassing a range of conditions, including preterm birth, miscarriage, pregnancy-induced hypertensive disorders (PIHD), intrauterine growth restriction (IUGR), low birth weight, the premature rupture of membranes (PROM), and fetal death. Therefore, understanding the mechanisms employed by HPV that negatively impact pregnancy and assessing potential approaches to counteract them would be of interest in the quest to optimize pregnancy outcomes and improve child survival and health.

Assessing the involvement of the placental microbiome and virome in preeclampsia using non coding RNA sequencing

OBJECTIVES

Preeclampsia is a dangerous pregnancy complication. The source of preeclampsia is unknown, though the placenta is believed to have a central role in its pathogenesis. An association between maternal infection and preeclampsia has been demonstrated, yet the involvement of the placental microbiome in the etiology of preeclampsia has not been determined. In this study, we examined whether preeclampsia is associated with an imbalanced microorganism composition in the placenta.

METHODS

To this end, we developed a novel method for the identification of bacteria/viruses based on sequencing of small non-coding RNA, which increases the microorganism-to-host ratio, this being a major challenge in microbiome methods. We validated the method on various infected tissues and demonstrated its efficiency in detecting microorganisms in samples with extremely low bacterial/viral biomass. We then applied the method to placenta specimens from preeclamptic and healthy pregnancies. Since the placenta is a remarkably large and heterogeneous organ, we explored the bacterial and viral RNA at each of 15 distinct locations.

RESULTS

Bacterial RNA was detected at all locations and was consistent with previous studies of the placental microbiome, though without significant differences between the preeclampsia and control groups. Nevertheless, the bacterial RNA composition differed significantly between various areas of the placenta. Viral RNA was detected in extremely low quantities, below the threshold of significance, thus viral abundance could not be determined.

CONCLUSIONS

Our results suggest that the bacterial and viral abundance in the placenta may have only limited involvement in the pathogenesis of preeclampsia. The evidence of a heterogenic bacterial RNA composition in the various placental locations warrants further investigation to capture the true nature of the placental microbiome.

Antibiotic Intervention Affects Maternal Immunity During Gestation in Mice

Background

Pregnancy is a portentous stage in life, during which countless events are precisely orchestrated to ensure a healthy offspring. Maternal microbial communities are thought to have a profound impact on development. Although antibiotic drugs may interfere in these processes, they constitute the most frequently prescribed medication during pregnancy to prohibit detrimental consequences of infections. Gestational antibiotic intervention is linked to preeclampsia and negative effects on neonatal immunity. Even though perturbations in the immune system of the mother can affect reproductive health, the impact of microbial manipulation on maternal immunity is still unknown.

Aim

To assess whether antibiotic treatment influences maternal immunity during pregnancy.

Methods

Pregnant mice were treated with broad-spectrum antibiotics. The maternal gut microbiome was assessed. Numerous immune parameters throughout the maternal body, including placenta and amniotic fluid were investigated and a novel machine-learning ensemble strategy was used to identify immunological parameters that allow distinction between the control and antibiotic-treated group.

Results

Antibiotic treatment reduced diversity of maternal microbiota, but litter sizes remained unaffected. Effects of antibiotic treatment on immunity reached as far as the placenta. Four immunological features were identified by recursive feature selection to contribute to the most robust classification (splenic T helper 17 cells and CD5⁺ B cells, CD4⁺ T cells in mesenteric lymph nodes and RORγT mRNA expression in placenta).

Conclusion

In the present study, antibiotic treatment was able to affect the carefully coordinated immunity during pregnancy. These findings highlight the importance of inclusion of immunological parameters when studying the effects of medication used during gestation.

Maternal Neutrophil Depletion Fails to Avert Systemic Lipopolysaccharide-Induced Early Pregnancy Defects in Mice

Maternal infection-induced early pregnancy complications arise from perturbation of the immune environment at the uterine early blastocyst implantation site (EBIS), yet the underlying mechanisms remain unclear. Here, we demonstrated in a mouse model that the progression of normal pregnancy from days 4 to 6 induced steady migration of leukocytes away from the uterine decidual stromal zone (DSZ) that surrounds the implanted blastocyst. Uterine macrophages were found to be CD206⁺ M2-polarized. While monocytes were nearly absent in the DSZ, DSZ cells were found to express monocyte marker protein Ly6C. Systemic endotoxic lipopolysaccharide (LPS) exposure on day 5 of pregnancy led to: (1) rapid (at 2 h) induction of neutrophil chemoattractants that promoted huge neutrophil infiltrations at the EBISs by 24 h; (2) rapid (at 2 h) elevation of mRNA levels of MyD88, but not Trif, modulated cytokines at the EBISs; and (3) dose-dependent EBIS defects by day 7 of pregnancy. Yet, elimination of maternal neutrophils using anti-Ly6G antibody prior to LPS exposure failed to avert LPS-induced EBIS defects allowing us to suggest that activation of Tlr4-MyD88 dependent inflammatory pathway is involved in LPS-induced defects at EBISs. Thus, blocking the activation of the Tlr4-MyD88 signaling pathway may be an interesting approach to prevent infection-induced pathology at EBISs.

Peripartum infectious morbidity in women with preeclampsia

BACKGROUND

Dysregulated maternal systemic inflammatory response is a commonly accepted component in the pathogenesis of preeclampsia. Chronic inflammation then occurs characterized by oxidative stress, proinflammatory cytokine production, and abnormal T-cell function. Infection results in similar physiologic changes.

OBJECTIVE

The objective of this study was to examine the association between the diagnosis of preeclampsia and the development of chorioamnionitis, postpartum fever, endometritis and wound infection. We hypothesize that the heightened chronic inflammatory state of preeclampsia increases the risk for maternal peripartum infection.

STUDY DESIGN

This was a retrospective cohort study from the Consortium on Safe Labor (CSL). In the present analysis, we included all women from the CSL database and compared their characteristics and pregnancy outcomes between those with and without a diagnosis of preeclampsia prior to labor. Women presenting with preterm prelabor rupture of membranes or were diagnosed with preeclampsia during labor or postpartum were excluded. The primary outcome was a composite of maternal peripartum infections including intrapartum chorioamnionitis, postpartum fever, endometritis, and wound infection. This outcome was compared between women with and without a diagnosis of preeclampsia prior to labor using univariable and multivariable analyses.

RESULTS

A total of 227,052 women were eligible for the analysis, of these 14,268 (6.3%) were diagnosed with preeclampsia. In univariable analysis, the rate of composite maternal peripartum infection was higher among women with preeclampsia (4.2 versus 3.8%, p = .026). When looking at each individual component, that rates of wound infection (1.0 versus 0.5%, p < .001) and postpartum fever (8.2 versus 4.4%, p < .001) were higher among women with diagnosis of preeclampsia, whereas the rate of intrapartum chorioamnionitis was lower among women with preeclampsia (1.3 versus 1.7% p = .004). Endometritis rates did not differ between the two groups. In multivariable logistic regression, adjusted for confounding variables, including maternal race, insurance status, prepregnancy BMI, maternal age, number of fetuses, number of vaginal exams, intrauterine pressure catheter and fetal scalp electrode placement, mode of delivery, group B streptococcus positivity, maternal education level, induction of labor, prelabor rupture of membranes, tobacco use, presence of diabetes (pregestational and gestational), gestational age at delivery, and chronic hypertension, the association between preeclampsia and composite maternal peripartum infection did not persist. In fact, after controlling for these influences, women with preeclampsia showed lower rates of intrapartum chorioamnionitis (aOR 0.83, 95% CI 0.70-0.99). The rest of the individual component of the primary composite outcome, postpartum fever, endometritis, and wound infection, were not associated with the diagnosis of preeclampsia.

CONCLUSIONS

In this large cohort of women diagnosed with preeclampsia prior to labor, the rate of intrapartum chorioamnionitis was decreased and the rate of postpartum infectious morbidity was not higher compared to women without a diagnosis of preeclampsia.

Association Between Urinary Tract Infection in the First Trimester and Risk of Preeclampsia: A Case-Control Study

Background

Urinary tract infection (UTI) is a common clinical problem during pregnancy that can have serious consequences for the mother and fetus. Some studies have suggested that UTI can trigger or aggravate preeclampsia. The present study aimed to investigate the association between urinary tract infection in the first trimester and the risk of preeclampsia in pregnant women referring to Bahar hospital of Shahroud.

Patients and Methods

In this case–control study, 92 pregnant women with a diagnosis of preeclampsia were selected as cases, and for comparison 92 pregnant women were selected as control. History of previous UTI in the first trimester was assessed as a risk factor. Data were analyzed using SPSS 16 software and related statistical tests such as mean and standard deviation, chi-square, and independent t-test.

Results

In this study, the mean age of the patients was 28.6 ± 6.9 years that no significant differences were found between the two groups. It was also found that 37 (40.2%) patients in the case group and 29 (31.5%) patients in the control group had a UTI which was significantly (p<0.043) higher in the case group. Also, in the multivariate regression model, UTI was significantly associated with preeclampsia (p<0.048), so that UTI increases the risk of preeclampsia (OR=1.86).

Conclusion

The results of this study showed UTI during the first trimester of pregnancy is associated with the risk of preeclampsia. Therefore, controlling and treatment of urinary infections can reduce the risk of preeclampsia in the later months.

Multi-drug resistant and extended-spectrum β-lactamases producing bacterial uropathogens among pregnant women in Northwest Ethiopia

INTRODUCTION

Above 80% of urinary tract infections are caused by enteric bacteria, which are known for years by their drug-resistant ability. Though the prevalence of drug-resistant strains is increasing in the world, it is not well known in low-income countries. The aim of this study was to assess the prevalence of Multi-drug resistance, Extended-spectrum β-lactamases production, and associated risk factors among pregnant women in Northwest Ethiopia.

METHODS

A hospital-based cross-sectional study was conducted among pregnant women from March to May 2017. A total of 384 clean-catch midstream urine sample was collected from study participants. Bacterial identification and drug susceptibility testing were done following standard microbiological techniques; Extended-spectrum β-lactamase production was screened using a disc diffusion test and confirmed by a combination disc test. The data were entered and analyzed by using SPSS version 20, and a p-value of less than 0.05 was considered as statistically significant.

RESULT

The overall prevalence of urinary tract infection was 15.9% (95% CI 12.8-20.1%). E. coli (49.2%), CoNS (27.9%), and S. aureus (18%) were the main uropathogens. The prevalence of MDR uropathogens was 60.65%. The prevalence of ESBLs production among cases caused by Enterobacteriaceae was 18.2%. The drug resistance rate of Gram-negative isolates was higher for ampicillin (90.9%), cephalothin (84.8%), and augmentin (57.6%). The drug nitrofurantoin showed the highest activity (100%) against Gram-negative isolates. Gram-positive isolates were showed low susceptibility to penicillin (89.3%) and cotrimoxazole (75%); however highest susceptibility rate for gentamicin (100%), amikacin (100%), and nitrofurantoin (98.36%) was recorded. Prior antibiotic therapy (AOR = 5.46, 95% CI 1.38-21.65) was a risk factor for the presence of multi-drug resistant bacteria.

CONCLUSION AND RECOMMENDATION

The multi-drug resistance prevalence was high among uropathogen, thus treatment of urinary tract infection during pregnancy; should be based on the antibacterial susceptibility testing result. The isolation of drug-resistant strains like Extended-spectrum β-lactamases in this study calls for the need of periodic and continuous follow-up of antibiotic usage among pregnant women. Nitrofurantoin, gentamicin, amikacin, and ciprofloxacin/norfloxacin showed higher activity against bacterial uropathogen.

Pre-Eclampsia: Microbiota possibly playing a role

Pre-eclampsia (PE) is a complication of pregnancy that is associated with mortality and morbidity in mothers and fetuses worldwide. Oxygen dysregulation in the placenta, abnormal remodeling of the spiral artery, defective placentation, oxidative stress at the fetal-maternal border, inflammation and angiogenic impairment in the maternal circulation are the main causes of this syndrome. These events result in a systemic and diffuse endothelial cell dysfunction, an essential pathophysiological feature of PE. The impact of bacteria on the multifactorial pathway of PE is the recent focus of scientific inquiry since microbes may cause each of the aforementioned features. Microbes and their derivatives by producing antigens and other inflammatory factors may trigger infection and inflammatory responses. A mother's bacterial communities in the oral cavity, gut, vagina, cervix and uterine along with the placenta and amniotic fluid microbiota may be involved in the development of PE. Here, we review the mechanistic and pathogenic role of bacteria in the development of PE. Then, we highlight the impact of alterations in a set of maternal microbiota (dysbiosis) on the pathogenesis of PE.

Immunological Role of the Maternal Uterine Microbiome in Pregnancy: Pregnancies Pathologies and Alterated Microbiota

Understanding what happens at the time of embryo implantation has been the subject of significant research. Investigators from many differing fields including maternal fetal medicine, microbiology, genetics, reproductive endocrinology and immunology have all been studying the moment the embryo interacts with the maternal endometrium. A perfect relationship between the uterus and the embryo, mediated by a tightly controlled interaction between the embryo and the endometrium, is required for successful implantation. Any factors affecting this communication, such as altered microbiome may lead to poor reproductive outcomes. Current theories suggest that altered microbiota may trigger an inflammatory response in the endometrium that affects the success of embryo implantation, as inflammatory mediators are tightly regulated during the adhesion of the blastocyst to the epithelial endometrial wall. In this review, we will highlight the various microbiome found during the periconceptual period, the microbiomes interaction with immunological responses surrounding the time of implantation, its effect on implantation, placentation and ultimately maternal and neonatal outcomes.

Bioinformatics identification of potential genes and pathways in preeclampsia based on functional gene set enrichment analyses

Preeclampsia is a complication of pregnancy characterized by new-onset hypertension and proteinuria of gestation, with serious consequences for mother and infant. Although a vast amount of research has been performed on the pathogenesis of preeclampsia, the underlying mechanisms of this multisystemic disease have remained to be fully elucidated. Data were retrieved from Gene Expression Omnibus database GSE40182 dataset. After data preprocessing, differentially expressed genes of placental cells cultured in vitro from preeclampsia and normal pregnancy were determined and subjected to Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis to identify the associated pathways. Furthermore, functional principal component analysis (FPCA) was used to calculate the corresponding F-value of each gene. In order to further study the key signaling pathways of preeclampsia, an elastic-net regression model and the Mann-Whitney U (MWU) test were used to estimate the weight of the signaling pathways. Finally, a co-expression network was generated and hub genes were identified based on the topological features. A total of 134 pathways with a role in preeclampsia were identified. The gene expression data of placenta cells cultured in vitro for different durations were determined and F-values of genes were estimated using the FPCA model. The top 1,000 genes were identified as the differentially expressed genes and subjected to further analysis by elastic-net regression and MWU test. Two key signaling pathways were different between the preeclampsia and control groups, namely hsa05142 Chagas disease and hsa05204 Chemical carcinogenesis. Among the genes involved in these two key pathways, 13 hub genes were identified from the co-expression network. Clustering analysis demonstrated that depending on these hub genes, it was possible to divide the sample into four distinct groups based on different incubation time. The top 3 candidates were Toll-like receptor 2 (TLR2), glutathione S-transferase omega 1 (GSTO1) and mitogen-activated protein kinase 13 (MAPK13). TLR2 and associated pathways are known to be closely associated with preeclampsia, indirectly demonstrating the applicability of the analytic process applied. However, the role of GSTO1 and MAPK13 in preeclampsia has remained poorly investigated, and elucidation thereof may be a worthwhile endeavor. The present study may provide a basis for exploring potential novel genes and pathways as therapeutic targets for preeclampsia.

Methods to generate and validate a Pregnancy Register in the UK Clinical Practice Research Datalink primary care database

PURPOSE

Primary care databases are increasingly used for researching pregnancy, eg, the effects of maternal drug exposures. However, ascertaining pregnancies, their timing, and outcomes in these data is challenging. While individual studies have adopted different methods, no systematic approach to characterise all pregnancies in a primary care database has yet been published. Therefore, we developed a new algorithm to establish a Pregnancy Register in the UK Clinical Practice Research Datalink (CPRD) GOLD primary care database.

METHODS

We compiled over 4000 read and entity codes to identify pregnancy-related records among women aged 11 to 49 years in CPRD GOLD. Codes were categorised by the stage or outcome of pregnancy to facilitate delineation of pregnancy episodes. We constructed hierarchical rule systems to handle information from multiple sources. We assessed the validity of the Register to identify pregnancy outcomes by comparing our results to linked hospitalisation records and Office for National Statistics population rates.

RESULTS

Our algorithm identified 5.8 million pregnancies among 2.4 million women (January 1987-February 2018). We observed close agreement with hospitalisation data regarding completeness of pregnancy outcomes (91% sensitivity for deliveries and 77% for pregnancy losses) and their timing (median 0 days difference, interquartile range 0-2 days). Miscarriage and prematurity rates were consistent with population figures, although termination and, to a lesser extent, live birth rates were underestimated in the Register.

CONCLUSIONS

The Pregnancy Register offers huge research potential because of its large size, high completeness, and availability. Further validation work is underway to enhance this data resource and identify optimal approaches for its use.

Urinary Tract Infections and Preeclampsia among Pregnant Women Attending Two Hospitals in Mwanza City, Tanzania: A 1:2 Matched Case-Control Study

Urinary tract infection (UTI) and preeclampsia are common among pregnant women and are associated with adverse maternal-fetal and neonatal outcomes. Despite this, limited information exists on the association between UTIs and preeclampsia in Tanzania to guide specific management and thereby averting the adverse outcomes. A 1:2 matched case-control study (by age and gravidity) involving 131 pregnant women with preeclampsia (cases) and 262 without preeclampsia (controls) was conducted. Sociodemographic and clinical information was collected using a questionnaire. Midstream urine samples were collected during admission for culture and antimicrobial susceptibility testing (AST). Out of 393 pregnant women enrolled, 110 (28.0%), 95% CI: 23.8%-32.7%, had significant bacteriuria [cases: 50.4% (66/131) and control: 16.8% (44/262)]. Pregnant women with preeclampsia had 7.7 odds of having significant bacteriuria than those without preeclampsia [OR=7.7, 95% CI (4.11-14.49); p-value <0.001]. Escherichia coli, 50 (45.5%), and Klebsiella spp., 25 (23.6%), predominated, and resistance to gentamicin, ceftriaxone, and piperacillin-tazobactam ranged from 9.0% to 29.0% in these dominant species. Extended spectrum beta lactamases (ESBL) production in Escherichia coli and Klebsiella spp. was 18.0% (9/50) and 15.4% (4/26), respectively. Routine urine culture and AST among pregnant women with preeclampsia should be introduced in the antenatal clinics to ensure prompt management. Delineation of maternal-fetal and neonatal outcomes among pregnant women with preeclampsia and UTIs would be of interest in future studies.

Through the Microbial Looking Glass: Premature Labor, Preeclampsia, and Gestational Diabetes: A Scoping Review

The influence of microbial factors on adverse perinatal outcomes has become the focal point of recent investigations, with particular interest in the role of the microbiome and probiotic interventions. The purpose of this scoping review was to identify and critique the most recent evidence about these factors as they relate to pregnancies complicated by preeclampsia (PEC), preterm birth (PTB), and gestational diabetes mellitus (GDM). Four databases (PubMed, EMBASE, Web of Science, and Cochrane) were searched for articles published in English in the last 10 years with the concepts of the microbiome, probiotics, and PEC, PTB, or GDM. Forty-nine articles were eligible for full-text review. Five articles were excluded, leaving 44 articles that met all the eligibility criteria. The relationships between the microbiome and the risk for PEC, PTB, and GDM are not fully elucidated, although probiotic interventions seem beneficial in decreasing PEC and GDM risk. Probiotic interventions targeting bacterial vaginosis and elimination of infection in women at risk for PTB appear to be beneficial. More research is needed to understand the contributions of the microbiome to adverse perinatal outcomes. Probiotic interventions appear to be effective in reducing risk for select outcomes.

The association between urinary tract infection during pregnancy and preeclampsia: A meta-analysis

OBJECTIVE

The association between urinary tract infection (UTI) during pregnancy and preeclampsia (PE) continues to be the subject of debate. This meta-analysis aimed to examine the relationship between UTI during pregnancy and PE.

STUDY DESIGN

Observational studies up to October 2017, extracted from Medline, PubMed, Cochrane Library, and Embase databases, were included in the analysis. Data were extracted to 4-fold table, and the pooled odds ratio (OR) and 95% confidence intervals (CIs) of respective studies were calculated. Then meta-analysis was performed.

RESULTS

Nineteen studies qualified the inclusion criteria. Urinary tract infection during pregnancy was found to be a risk factor for the development of PE (OR: 1.31, 95% CI: 1.22-1.40).

CONCLUSION

Occurrence of UTI during pregnancy increases the risk of PE in pregnant women. Screening for, and treatment of UTI should be part of routine antenatal care, especially in developing countries.

Antigen Analysis of Pre-Eclamptic Plasma Antibodies Using Escherichia Coli Proteome Chips

Pre-eclampsia is one of the main causes of perinatal mortality and morbidity. Many biomarkers for diagnosing pre-eclampsia have been found but most have low accuracy. Therefore, a potential marker that can detect pre-eclampsia with high accuracy is required. Infection has been reported as a cause of pre-eclampsia. In recent years, protein microarray chips have been recognized as a strong and robust tool for profiling antibodies for infection diagnoses. The purpose of the present study was to profile antibodies in the human plasma of healthy and pre-eclamptic pregnancies to identify suitable biomarkers. In this study, an Escherichia coli chip was probed with samples from 29 individuals (16 pre-eclamptic women and 13 healthy pregnant women) to profile plasma antibodies. Bioinformatics tools were used to analyze the results, discover conserved motifs, compare against the entire human proteome, and perform protein functional analysis. An antibody classifier was identified using k-top scoring pairs and additional samples for a blinded test were collected. The findings indicated that compared with the healthy women, the pre-eclamptic women exhibited 108 and 130 differentially immunogenic proteins against human immunoglobulins G and M, respectively. In addition, pre-eclamptic women developed more immunoglobulin G but less immunoglobulin M against bacterial surface proteins compared with healthy women. The k-top scoring pairs identified five pairs of immunogenic proteins as classifiers with a high accuracy of 90% in the blind test. [AG] [ISV] GV [AE] L [LF] and [IV] [IV] RI [AG] [AD] E were the consensus motifs observed in immunogenic proteins in the immunoglobulin G and immunoglobulin M of pre-eclamptic women, respectively, whereas GA [AG] [AL] L [LF] and [SRY] [IQML] [ILV] [ILV] [ACG] GI [GH] [AEF] [AK] [ATY] [RG] N [IV] were observed in the immunoglobulins G and immunoglobulin M of healthy women, respectively.

Infections and Risk of Peripartum Stroke During Delivery Admissions

BACKGROUND AND PURPOSE

Peripartum strokes during delivery admissions are rare but have high maternal morbidity. Infections have been proposed as a possible stroke trigger. We hypothesized that women who had infections diagnosed at the time of delivery admission would have higher risk of stroke during their delivery hospitalization.

METHODS

We conducted a case-control study using state inpatient administrative databases for California (2007-2011), Florida (2009-2011), and New York (2009-2011). Women whose admission included a vaginal or cesarean delivery, with a new diagnosis of stroke during the admission, were considered cases and were randomly matched to 3 in-state controls by age/admission year and presence and severity of hypertensive disorders of pregnancy. The primary exposure of interest was infection of any type present on admission. Secondary exposures included race/ethnicity, payer status, delivery method, and known vascular risk factors such as chronic hypertension, diabetes mellitus, smoking, alcohol abuse, hypercoagulable states, coagulopathies, and renal disease. We used multivariable conditional logistic regression to estimate the odds ratios and 95% confidence intervals for the association of infections and known vascular risk factors with stroke risk.

RESULTS

A total of 455 cases (mean age, 29.8), of whom 195 (42.9%) had hypertensive disorders of pregnancy, were matched with 1365 controls. Infection of any type present on admission increased the odds of stroke diagnosis during the admission (adjusted odds ratio, 1.74; 95% confidence interval, 1.29-2.35). Risk was higher for genitourinary infections (adjusted odds ratio, 2.56; 95% confidence interval, 1.25-5.24) and sepsis (adjusted odds ratio, 10.4; 95% confidence interval, 2.15-20.0). The association between infection and stroke during delivery admission did not differ by the presence of hypertensive disorders of pregnancy.

CONCLUSIONS

Infections present on admission increased stroke risk during delivery admissions in women with and without hypertensive disorders of pregnancy. The results were driven by genitourinary infections and sepsis. Infections may be an underrecognized precipitant of peripartum stroke.

Maternal allergy as an isolated risk factor for early-onset preeclampsia: An epidemiological study

Immunological mechanisms underlying the development of preeclampsia are well known, but no association to allergy has yet been demonstrated. The aim of this study was to assess the correlation between maternal pre-gestational allergy, and early-onset and late-onset preeclampsia, respectively. It was a retrospective cohort study including all women giving birth in the Norwegian cities of Stavanger (1996-2014) and Bergen (2009-2014). Pre-gestational asthma, allergy, other known risk factors for preeclampsia, maternal age and parity were obtained from the electronic medical record system. The main outcome variables were early-onset and late-onset preeclampsia (before and after 34 completed weeks of gestation, respectively). We used multinomial logistic regression to estimate odds ratios (OR) with 95% confidence intervals (95% CI) for early and late-onset preeclampsia in women with pre-gestational allergy when compared to women without allergy, adjusting for covariates. Predicted probabilities for the outcomes were also calculated. Of the 110 064 included pregnancies, 2 799 developed late-onset preeclampsia (2.5%) and 348 developed early-onset preeclampsia (0.3%). Pre-gestational allergy increased the risk of early-onset preeclampsia (OR 1.7, 95% CI 1.3-2.4), and reduced the risk of late-onset preeclampsia (OR 0.8, 95% CI 0.7-0.9). These findings add valuable information on preeclampsia as an immunological complication of pregnancy and corroborate the understanding of early- and late-onset preeclampsia as two different entities.

HSV infection is associated with gestational hypertension: results from the US National inpatient sample

The purpose of this study was to determine if there is an association between maternal herpes simplex virus (HSV) infection and pre-eclampsia/eclampsia or gestational hypertension. The US Nationwide Inpatient Sample database was searched for women aged 15–44 years who delivered in a hospital between 2005 and 2014. The patients were categorized into those with and without HSV and pre-eclampsia/eclampsia and gestational hypertension were compared between the groups. The analytic sample size (n=8 264 076) was equivalent to a population-based sample size of 40 653 030 patients. After adjusting for significant variables including age, race, income, insurance status, diabetes mellitus (DM), gestational DM, obesity, and multiple gestations, multivariate regression analysis indicated that HSV was associated with a higher OR for gestational hypertension (adjusted OR 1.038; 95% CI 1.004 to 1.072). However, HSV was not associated with pre-eclampsia/eclampsia (OR 1.001; 95% CI 0.968 to 1.035) in univariate regression analysis. The results of the current study suggest that HSV infection is associated with gestational hypertension but not pre-eclampsia. Given the prevalence of HSV infection and its potential association with hypertensive disorders of pregnancy, further study of HSV and hypertension in pregnancy is warranted.

Immunological Tolerance, Pregnancy, and Preeclampsia: The Roles of Semen Microbes and the Father

Although it is widely considered, in many cases, to involve two separable stages (poor placentation followed by oxidative stress/inflammation), the precise originating causes of preeclampsia (PE) remain elusive. We have previously brought together some of the considerable evidence that a (dormant) microbial component is commonly a significant part of its etiology. However, apart from recognizing, consistent with this view, that the many inflammatory markers of PE are also increased in infection, we had little to say about immunity, whether innate or adaptive. In addition, we focused on the gut, oral and female urinary tract microbiomes as the main sources of the infection. We here marshall further evidence for an infectious component in PE, focusing on the immunological tolerance characteristic of pregnancy, and the well-established fact that increased exposure to the father's semen assists this immunological tolerance. As well as these benefits, however, semen is not sterile, microbial tolerance mechanisms may exist, and we also review the evidence that semen may be responsible for inoculating the developing conceptus (and maybe the placenta) with microbes, not all of which are benign. It is suggested that when they are not, this may be a significant cause of PE. A variety of epidemiological and other evidence is entirely consistent with this, not least correlations between semen infection, infertility and PE. Our view also leads to a series of other, testable predictions. Overall, we argue for a significant paternal role in the development of PE through microbial infection of the mother via insemination.

Role of angiopoietin-2, endoglin, and placental growth factor in HIV-associated preeclampsia

OBJECTIVE

The factors angiopoeitin-2 (Ang-2), endoglin (Eng), and placental growth factor (PlGF) have been implicated in the pathophysiology of preeclampsia (PE). This study assessed their serum levels in HIV-negative and HIV-positive pregnant normotensive and pre-eclamptic women.

METHODS

Participants were recruited at the antenatal clinic, serum samples were evaluated using the Bioplex Human Cancer Biomarker (panel 2).

RESULTS

Ang-2 and Eng levels were higher, whilst PlGF levels were lower in the PE compared with the normotensive group. Pregnancy type had no significant effect on Ang-2 and showed a significant interaction with Eng (p < 0.0001) and PlGF (p = 0.0033). HIV status had no significant effect on angiopoeitin-2 (p = 0.4), Eng (p = 0.4), and PlGF (p = 0.7) but the levels were slightly higher in the HIV-negative cohort.

CONCLUSIONS

This study demonstrates an elevation of Ang-2 and Eng in pre-eclamptic compared with normotensive pregnant women implicating their role in its pathogenesis.

Human infectious diseases and risk of preeclampsia: an updated review of the literature

BACKGROUND

Preeclampsia (PE) is one of the major causes of maternal and perinatal morbidity and mortality, especially in low- and middle-income countries. In recent years, a growing body of literatures suggests that infections by bacteria, viruses, and parasites and their related inflammations play an important role in the pathogenesis of PE.

METHODS

We searched PubMed, Google scholar, and Cochrane databases using the following search words: "infection and preeclampsia," "bacterial infection and preeclampsia," "viral infection and preeclampsia" and "parasitic infection and preeclampsia."

RESULTS

The literature review revealed that many bacteria including Helicobacter pylori, Chlamydia pneumonia, and those are involved in periodontal disease or urinary tract infections (UTIs) and some viral agents such as Cytomegalovirus, herpes simplex virus type-2, human immunodeficiency virus, and some parasites especially Plasmodium spp. and Toxoplasma gondii can be effective in development of PE. Inflammation responses against infections has major role in the inducement of PE. The shift of immunological cytokine profile of Th2 toward Th1 and high levels of pro-inflammatory cytokines (TNF-ɑ, IL-12, IFN-γ, etc.), increase of oxidative stress, increase of anti-angiogenic proteins, increase of vascular endothelial growth factor receptor 1 (sVEGFR1), and complement C5a are the main potential mechanisms related to infections and enhanced development of PE.

CONCLUSION

Thus, early diagnosis and treatment of bacterial, viral, and parasitic infections could be an effective strategy to reduce the incidence of PE.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Urinary tract infection during pregnancy, angiogenic factor profiles, and risk of preeclampsia

BACKGROUND

Despite decades of research, and much progress in discernment of biomarkers in the maternal circulation, the pathogenesis of preeclampsia (PE) remains elusive. The pathophysiology of PE is believed to involve aberrant placentation and an associated increase in systemic inflammation. In this conceptualization, PE becomes more likely when the level of systemic inflammatory burden inherent in pregnancy itself exceeds the maternal capacity to compensate for this additional stress. If this is the case, then it is possible to hypothesize that conditions, such as infectious disease, that increase systemic inflammatory burden should also increase the risk of PE. As urinary tract infection (UTI) represents a common source of inflammation during pregnancy, we tested whether presence of UTI during pregnancy increased the odds of developing PE. Prior work has documented this association. However many of these studies were limited by small cohort sizes and insufficient control for covariates.

OBJECTIVE

The present study is a secondary analysis of a robust contemporary obstetrical cohort recruited to examine the ability of longitudinally sampled maternal angiogenic concentrations to predict PE. We hypothesize that the occurrence of UTI during a pregnancy is associated with the later occurrence of PE in that pregnancy. As PE is believed to be associated with aberrations in systemic angiogenic levels (placental growth factor and soluble isoform of VEGF receptor), we further hypothesize that there will be significant interactions between maternal angiogenic protein levels and the occurrence of UTI.

STUDY DESIGN

Women aged ≥18 years (n = 2607) were recruited and followed up prospectively from the initiation of prenatal care through delivery at 3 regional academic centers. PE was defined by American Congress of Obstetricians and Gynecologists criteria and was independently validated by a panel of physicians. UTI was defined by the presence of clinical symptoms necessitating treatment in addition to supportive laboratory evidence. Multivariate logistic regression models were used and controlled for maternal age, race, parity, body mass index, hypertension, diabetes, in vitro fertilization, and smoking status.

RESULTS

There were 129 women with diagnosed UTIs and 235 with PE. Patients with UTI in pregnancy had higher rates of PE (31.1% vs 7.8%, P < .001) compared to those without reported UTI. The mean gestational age (SD) for UTI diagnosis in PE cases and controls was 25.6 (10.4) and 21.9 (10.9) weeks, respectively (P = .08). The unadjusted odds ratio for PE in the setting of UTI was 5.29 (95% confidence interval, 3.54-7.89). After controlling for confounders, UTI was associated with an odds ratio for PE of 3.2 (95% confidence interval, 2.0-5.1).

CONCLUSION

Presence of UTI in pregnancy, particularly in the third trimester, is strongly associated with PE. This association supports the hypothesis that the risk of PE is enhanced by an increased maternal inflammatory burden. Prophylaxis against UTI represents a potentially low-cost global intervention to slow or halt the development of PE.

A Dormant Microbial Component in the Development of Preeclampsia

Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.

Association between Asymptomatic Bacteriuria and Pre-Eclampsia

Asymptomatic bacteriuria is one of the most common and important bacterial infections during pregnancy and can result in progressive infections and endanger maternal as well as fetal health. In this study, we assessed the relationship between asymptomatic bacteriuria and pre-eclampsia. In this case-control study, pregnant women who presented to Imam Reza Hospital in Kermanshah in 2013-14 were studied. The minimum sample size was calculated as 125 pregnant women in each group with a total of 250 subjects. There were 125 women with pre-eclampsia and 125 women without pre-eclampsia (control group). Matching was done for age, gestational age, and parity between case and control groups. Matching was verified by a P value of 0.061 for maternal age and gestational age and 0.77 for parity. The statistical analyses were done by applying the chi-squared test and determining odds ratio (OR) for having bacteriuria in univariate logistic regression as well as multivariate regression with adjusting the effect of maternal age, gestational age, and parity. Pyuria and bacteriuria were significantly more common in pre-eclampsia group than in control group. The results showed that a significant association existed between asymptomatic bacteriuria and pre-eclampsia. The rate of asymptomatic bacteriuria was 6.8 times higher in women with pre-eclampsia compared to those without pre-eclampsia. Further studies are required for better clarification of association between asymptomatic bacteriuria and pre-eclampsia.

Helicobacter pylori, Chlamydiae pneumoniae and trachomatis as probable etiological agents of preeclampsia

OBJECTIVES

The aim of this study was to evaluate the evidence for Helicobacter pylori, Chlamydiae pneumoniae and trachomatis to act as a probable etiology for preeclampsia (PE), together with estimating the prevalence of such infections in pregnant women with PE.

METHODS

We performed a prospective study in Mansoura University Hospitals, Egypt, for detecting H. pylori infection by estimating H. pylori IgG and IgM, in addition to detection of Chlamydiae infections by PCR in 90 pregnant women with PE and 90 normotensive pregnant women of the same age and body mass index who were studied as control.

RESULTS

The prevalence of H. pylori infection in preeclamptic pregnant women was 54.4% with a statistically significant association to PE. The prevalence of C. pneumonia was 27.8% whereas that of C. trachomatis was 4.44%. The infected preeclamptic cases showed high levels of leucocytes besides elevated C-reactive protein concentrations.

CONCLUSION

Helicobacter pylori was found to act as a cofactor in the development of PE. Occurrence of C. trachomatis was low in pregnant women in our community; however, it showed that it may act as a cofactor in PE, whereas C. pneumoniae was attributed to have no role in PE pathogenesis until supported by further studies.

Getting the basic rights - the role of water, sanitation and hygiene in maternal and reproductive health: a conceptual framework

OBJECTIVE

To explore linkages between water, sanitation and hygiene (WASH) and maternal and perinatal health via a conceptual approach and a scoping review.

METHODS

We developed a conceptual framework iteratively, amalgamating three literature-based lenses. We then searched literature and identified risk factors potentially linked to maternal and perinatal health. We conducted a systematic scoping review for all chemical and biological WASH risk factors identified using text and MeSH terms, limiting results to systematic reviews or meta-analyses. The remaining 10 complex behavioural associations were not reviewed systematically.

RESULTS

The main ways poor WASH could lead to adverse outcomes are via two non-exclusive categories: 1. 'In-water' associations: (a) Inorganic contaminants, and (b) 'water-system' related infections, (c) 'water-based' infections, and (d) 'water borne' infections. 2. 'Behaviour' associations: (e) Behaviours leading to water-washed infections, (f) Water-related insect-vector infections, and (g-i) Behaviours leading to non-infectious diseases/conditions. We added a gender inequality and a life course lens to the above framework to identify whether WASH affected health of mothers in particular, and acted beyond the immediate effects. This framework led us to identifying 77 risk mechanisms (67 chemical or biological factors and 10 complex behavioural factors) linking WASH to maternal and perinatal health outcomes.

CONCLUSION

WASH affects the risk of adverse maternal and perinatal health outcomes; these exposures are multiple and overlapping and may be distant from the immediate health outcome. Much of the evidence is weak, based on observational studies and anecdotal evidence, with relatively few systematic reviews. New systematic reviews are required to assess the quality of existing evidence more rigorously, and primary research is required to investigate the magnitude of effects of particular WASH exposures on specific maternal and perinatal outcomes. Whilst major gaps exist, the evidence strongly suggests that poor WASH influences maternal and reproductive health outcomes to the extent that it should be considered in global and national strategies.

Pre-eclampsia, eclampsia and adverse maternal and perinatal outcomes: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health

OBJECTIVE

To assess the incidence of hypertensive disorders of pregnancy and related severe complications, identify other associated factors and compare maternal and perinatal outcomes in women with and without these conditions.

DESIGN

Secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health (WHOMCS) database.

SETTING

Cross-sectional study implemented at 357 health facilities conducting 1000 or more deliveries annually in 29 countries from Africa, Asia, Latin America and the Middle East.

POPULATION

All women suffering from any hypertensive disorder during pregnancy, the intrapartum or early postpartum period in the participating hospitals during the study period.

METHODS

We calculated the proportion of the pre-specified outcomes in the study population and their distribution according to hypertensive disorders' severity. We estimated the association between them and maternal deaths, near-miss cases, and severe maternal complications using a multilevel logit model.

MAIN OUTCOME MEASURES

Hypertensive disorders of pregnancy. Potentially life-threatening conditions among maternal near-miss cases, maternal deaths and cases without severe maternal outcomes.

RESULTS

Overall, 8542 (2.73%) women suffered from hypertensive disorders. Incidences of pre-eclampsia, eclampsia and chronic hypertension were 2.16%, 0.28% and 0.29%, respectively. Maternal near-miss cases were eight times more frequent in women with pre-eclampsia, and increased to up to 60 times more frequent in women with eclampsia, when compared with women without these conditions.

CONCLUSIONS

The analysis of this large database provides estimates of the global distribution of the incidence of hypertensive disorders of pregnancy. The information on the most frequent complications related to pre-eclampsia and eclampsia could be of interest to inform policies for health systems organisation.

Lack of association between Toxoplasma gondii infection and hypertensive disorders in pregnancy: a case-control study in a Northern Mexican population

Background

The outcome of pregnancy is often threatened by hypertension disorders, i.e. eclampsia. Rate of infection with the protozoan parasite Toxoplasma gondii can be as high as 80% in pregnant women, and infection acquired during pregnancy can lead to fetal death. Very little is known about a potential association between infections, i.e. those with Toxoplasma gondii, and hypertensive disorders during pregnancy.

Methods

Through a case–control study design, we investigated the presence of anti-Toxoplasma IgG and anti-Toxoplasma IgM antibodies in 146 pregnant women suffering from hypertensive disorders (cases) and 146 age-matched normotensive pregnant women (controls) attending a public hospital in Durango City, Mexico. Obstetric and blood pressure characteristics from cases and controls were also obtained.

Results

Seroprevalence of anti-Toxoplasma IgG antibodies and IgG titers did not differ significantly in controls (8/146; 5.5%) and cases (9/146; 6.2%). Anti-Toxoplasma IgM antibodies were found in 2 (1.2%) controls and none of the cases. Seroprevalence of T. gondii in controls (5.5%) was similar to seroprevalences found in patients with mild preeclampsia (4/27: 14.8%), severe preeclampsia (5/95: 5.3%), eclampsia (0/16: 0%) and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) (0/8: 0%) (P = 0.23).

Conclusions

Our results suggest that latent infection with T. gondii is not associated with hypertensive disorders in pregnant women in Northern Mexico. Further studies with larger sample sizes are needed to elucidate the association of infection with T. gondii with hypertensive disorders in pregnancy.

Fibrinogen, an endogenous ligand of Toll-like receptor 4, activates monocytes in pre-eclamptic patients

Pre-eclampsia (PE) remains the leading cause of pregnancy-associated mortality and morbidity, urging the need for a better understanding of its aetiology and pathophysiological progression. A key characteristic of PE is a systemic, exaggerated, inflammatory condition involving abnormal cytokine levels in serum, altered immune cell phenotype and Th1/Th2-type immunological imbalance. However, it is unknown how this heightened inflammatory condition manifests. We previously reported increased expression of the lipopolysaccharide receptor, Toll-like receptor 4 (TLR4), on monocytes from PE patients compared with normotensive, pregnant patients (NP). This upregulation of TLR4 on PE monocytes was accompanied by a hyper-responsiveness to bacterial TLR4 ligands. To determine whether non-microbial, endogenous TLR4 ligands also activate monocytes from PE patients, we investigated the expression of host-derived TLR4 ligands and the response of monocytes to these endogenous ligands. Plasma levels of fibrinogen - but not fibronectin or heparan sulphate - were higher in PE patients than in NP. Exposure to fibrinogen was associated with significantly increased production of inflammatory cytokines by monocytes from PE patients. Interestingly, this effect was not observed with NP monocytes. Our findings suggest that the fibrinogen-TLR4 axis might play an important role in the atypical activation of monocytes observed in PE patients that may contribute to the exaggerated inflammatory condition.