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Provendier A, Migliorelli F, Loussert L, Boileau BG, Vayssiere C, Hamdi SM, Hanaire H, Dupuis N, Guerby P. The sFLT-1/PlGF Ratio for the Prediction of Preeclampsia-Related Adverse Fetal and Maternal Outcomes in Women with Preexisting Diabetes. Reprod Sci 2024:10.1007/s43032-024-01540-9. [PMID: 38605263 DOI: 10.1007/s43032-024-01540-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 04/02/2024] [Indexed: 04/13/2024]
Abstract
To evaluate the predictive value of the sFlt-1/PlGF ratio for the prediction of preeclampsia in women with preexisting diabetes mellitus. This is a monocentric retrospective observational study conducted between January 2018 and December 2020. All singleton pregnancies with preexisting diabetes mellitus, who had a dosage of the sFlt-1/PlGF ratio between 30 and 34 + 6 weeks of gestation were included. The principal outcome was preeclampsia. The secondary outcomes were preterm preeclampsia, gestational hypertension, placental abruption, intrauterine fetal death, IUGR, small for gestational age and a composite outcome named "hypertensive disorder of pregnancy" including gestational hypertension, preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count). Of 63 patients, 22% presented preeclampsia. The area under the curve of sFlt-1/PlGF ratio was 0.90 (95% CI: 0.79-0.96) for the prediction of preeclampsia. The receiver operator characteristic analysis suggested that the optimal sFlt-1/PlGF cutoff to predict preeclampsia was 29, with a sensitivity of 86% (95% CI: 60.1-96.0) and a specificity of 92% (95% CI: 80.8-96.8). A cut-off of 38 provided a sensitivity of 71% (95% CI: 45.4-88.3), a specificity of 92% (95% CI: 80.8-96.8). Further analysis using multivariable methods revealed nephropathy was significantly associated with PE (p = 0.014). The use of the sFlt-1/PlGF ratio during the third trimester of pregnancy seems to be of interest as a prognostic tool to improve multidisciplinary management of patients with preexisting diabetes mellitus.
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Affiliation(s)
- Anais Provendier
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France
| | - Federico Migliorelli
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France
| | - Lola Loussert
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France
| | - Béatrice Guyard Boileau
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France
| | - Christophe Vayssiere
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France
| | - Safouane M Hamdi
- Department of Biochemistry and Hormonology, University Paul Sabatier, Toulouse, France
| | - Hélène Hanaire
- Department of Endocrinology and Diabetology, University Paul Sabatier, Toulouse, France
| | - Ninon Dupuis
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France
| | - Paul Guerby
- Department of Obstetrics and Gynecology, Paule de Viguier maternity, CHU Toulouse, 330 avenue de Grande-Bretagne, 70034 31059, Toulouse, TSA, France.
- Toulouse Institute for Infectious and Inflammatory Diseases, Inserm UMR 1291 - CNRS UMR 5051- University Toulouse III, Toulouse, France.
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Yan A. Application value of serum S100B combined with glucose metabolism indexes in predicting adverse pregnancy outcomes of patients with severe preeclampsia. J Hum Hypertens 2024; 38:232-237. [PMID: 38160207 DOI: 10.1038/s41371-023-00887-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 12/06/2023] [Accepted: 12/14/2023] [Indexed: 01/03/2024]
Abstract
S100 calcium-binding protein B (S100B) and glucose control are reflective of maternal-fetal risks. We investigated the value of serum S100B combined with fasting blood glucose (FBG)/hemoglobin A1c (HbA1c) in evaluating the pregnancy outcomes of patients with severe preeclampsia (SPE). The clinical characteristics of SPE patients/controls were collected. FBG/HbA1c and serum S100B levels were measured, with their correlations analyzed. SPE patients were subdivided into adverse/non-adverse outcome groups based on follow-up results. The value of different indexes in predicting pregnancy outcomes was analyzed. SPE patients showed higher systolic blood pressure, diastolic blood pressure, urine protein, and body mass index and lower platelets, gestational age at delivery, and infant birth weight than healthy controls. FBG and HbA1c were positively correlated with serum S100B. SPE patients with adverse outcomes exhibited increased serum S100B and FBG/HbA1c levels. The area under the curve of serum S100B + FBG/HbA1c in evaluating adverse pregnancy outcomes of SPE patients was 0.8412 (77.05% sensitivity/84.21% specificity), higher than either alone. Serum S100B and FBG/HbA1c were independent risk factors for adverse outcomes of SPE patients. Overall, serum S100B positively-correlates with FBG/HbA1c in SPE patients. Serum S100B and FBG/HbA1c are independent risk factors, and their combination has high value on predicting adverse pregnancy outcomes of SPE patients.
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Affiliation(s)
- Aiqin Yan
- Department of Gynaecology and Obstetrics, Zhangye Second People's Hospital, Linsong West Street, Binhe New District, Ganzhou District, Zhangye City, 734000, Gansu Province, PR China.
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Lopian M, Kashani-Ligumsky L, Many A. A Balancing Act: Navigating Hypertensive Disorders of Pregnancy at Very Advanced Maternal Age, from Preconception to Postpartum. J Clin Med 2023; 12:4701. [PMID: 37510816 PMCID: PMC10380965 DOI: 10.3390/jcm12144701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The decision to postpone parenting has gained momentum in recent years, a shift driven by evolving social dynamics and improved access to fertility treatments. Despite their increasing prevalence, pregnancies at advanced maternal ages are associated with increased risks of adverse maternal and neonatal outcomes. This article addresses the association between advanced maternal age and hypertensive disorders of pregnancies (HDPs), which are more prevalent and a significant cause of maternal morbidity and mortality in this population. This review explores the biological mechanisms and age-related risk factors that underpin this increased susceptibility and offers practical management strategies that can be implemented prior to, as well as during, each stage of pregnancy to mitigate the incidence and severity of HDPs in this group. Lastly, this review acknowledges both the short-term and long-term postpartum implications of HDPs in women of advanced maternal age.
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Affiliation(s)
- Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Kashani-Ligumsky
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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Cypryk K, Wender-Ozegowska E, Cyganek K, Sieradzki J, Skoczylas K, Chen X, Cordero TL, Shin J, Cohen O. Insulin pump therapy with and without continuous glucose monitoring in pregnant women with type 1 diabetes: a prospective observational Orchestra Foundation study in Poland. Acta Diabetol 2023; 60:553-561. [PMID: 36653533 PMCID: PMC10033617 DOI: 10.1007/s00592-022-02020-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/14/2022] [Indexed: 01/20/2023]
Abstract
AIMS The effects of continuous subcutaneous insulin infusion (CSII) therapy with or without continuous glucose monitoring (CGM) on neonatal outcomes and glycemic outcomes of pregnant women with type 1 diabetes (T1D), living in Poland, were assessed. METHODS This prospective observational study enrolled women with T1D (N = 481, aged 18-45 years) who were pregnant or planned pregnancy. All used CSII therapy and a subset used CGM with CSII (CSII + CGM). Neonatal outcomes (e.g., rate of large for gestational age [LGA] delivery [birth weight > 90th percentile]) and maternal glycemia (e.g., HbA1c and percentage of time at sensor glucose ranges) were evaluated. RESULTS Overall HbA1c at trimesters 1, 2, and 3 was 6.8 ± 1.1% (50.9 ± 12.3 mmol/mol, N = 354), 5.8 ± 0.7% (40.1 ± 8.0 mmol/mol, N = 318), and 5.9 ± 0.7% (41.4 ± 8.0 mmol/mol, N = 255), respectively. A HbA1c target of < 6.0% (42 mmol/mol) at each trimester was achieved by 20.9% (74/354), 65.1% (207/318), and 58.0% (148/255), respectively. For women using CSII + CGM versus CSII only, HbA1c levels at trimesters 1, 2, and 3 were 6.5 ± 0.9% versus 7.1 ± 1.3% (47.8 ± 9.7 mmol/mol versus 54.3 ± 14.0 mmol/mol, p < 0.0001), 5.7 ± 0.6% versus 6.0 ± 0.9% (38.9 ± 6.5 mmol/mol versus 41.6 ± 9.3 mmol/mol, p = 0.0122), and 5.8 ± 0.6% versus 6.1 ± 0.8% (40.3 ± 6.9 mmol/mol versus 42.9 ± 9.1 mmol/mol, p = 0.0117), respectively. For the overall, CSII only, and CSII + CGM groups, rates of LGA delivery were 22.7% (74/326), 24.6% (34/138), and 21.3% (40/188), respectively. CONCLUSIONS Observational assessment of women with T1D using CSII therapy demonstrated low HbA1c throughout pregnancy and low rates of LGA. The addition of CGM to CSII therapy compared to CSII therapy alone was associated with some improved maternal glycemic and neonatal outcomes. GOV IDENTIFIER NCT01779141 (January 2013).
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Affiliation(s)
- Katarzyna Cypryk
- Department of Internal Diseases and Diabetology, Medical University of Lodz, Pomorska Str. 251, 92-213, Lodz, Poland.
| | - Ewa Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznań, Poland
| | - Katarzyna Cyganek
- Department of Metabolic Diseases, The University Hospital in Krakow, Krakow, Poland
- Collegium Medicum, Jagiellonian University of Krakow, Krakow, Poland
| | - Jacek Sieradzki
- Collegium Medicum, Jagiellonian University of Krakow, Krakow, Poland
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Lara-Barea A, Sánchez-Lechuga B, Aguilar-Diosdado M, López-Tinoco C. Higher daytime systolic BP, prepregnancy BMI and an elevated sFlt-1/PlGF ratio predict the development of hypertension in normotensive pregnant women. Reprod Biol Endocrinol 2022; 20:175. [PMID: 36564806 PMCID: PMC9783759 DOI: 10.1186/s12958-022-01050-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The risk of hypertensive disorders of pregnancy (HDP) varies in women with gestational diabetes mellitus (GDM), depending on the degree of insulin resistance and is also influenced by obesity. The aim of this study was to evaluate clinical features, blood pressure (BP) profiles and inflammatory markers, to identify patients with an elevated risk of developing HDP. METHODS A total of 146 normotensive pregnant women were studied. We analysed the relationships of BP profiles detected by ambulatory blood pressure monitoring (ABPM) with serum biomarkers and angiogenic factors and their association with the development of HDP. RESULTS Fourteen (9.6%) women developed HDP, of which 11 had GDM and 8 had obesity. Women with HDP had higher values of 24-h and daytime systolic/diastolic BP (113/69 vs. 104/64; 115/72 vs. 106/66 mmHg, respectively; p < 0.05). Higher levels of leptin (10.97 ± 0.82 vs. 10.2 ± 1.11; p = 0.018) andmonocyte chemoattractant protein-1 (MCP-1) (5.24 ± 0.60 vs. 4.9 ± 0.55; p = 0.044) and a higher soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PlGF) ratio (4.37 ± 2.2 vs. 2.2 ± 1.43; p = 0.003) were also observed in the HDP patients. Multivariate analysis showed that a higher sFlt-1/PlGF ratio was associated with an increased risk of developing HDP [OR = 2.02; IC 95%: 1.35-3.05]. Furthermore, higher daytime systolic BP [OR = 1.27; IC 95% 1.00-1.26] and prepregnancy body mass index (BMI) [OR = 1.14; IC 95%: 1.01-1.30] significantly increased the risk of developing HDP. CONCLUSIONS Higher daytime systolic BP values, prepregnancy BMI and the sFlt-1/PlGF ratio are useful for identifying normotensive pregnant women with an increased risk of developing HDP.
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Affiliation(s)
- Almudena Lara-Barea
- Department of Endocrinology and Nutrition, Puerta del Mar Hospital, 11009 Cádiz, Spain
- grid.512013.4Biomedical Research and Innovation Institute of Cádiz (INiBICA), Puerta del Mar Hospital, 11009 Cádiz, Spain
| | | | - Manuel Aguilar-Diosdado
- Department of Endocrinology and Nutrition, Puerta del Mar Hospital, 11009 Cádiz, Spain
- grid.512013.4Biomedical Research and Innovation Institute of Cádiz (INiBICA), Puerta del Mar Hospital, 11009 Cádiz, Spain
- grid.7759.c0000000103580096Department of Medicine, Cadiz University (UCA), 11003 Cádiz, Spain
| | - Cristina López-Tinoco
- Department of Endocrinology and Nutrition, Puerta del Mar Hospital, 11009 Cádiz, Spain
- grid.512013.4Biomedical Research and Innovation Institute of Cádiz (INiBICA), Puerta del Mar Hospital, 11009 Cádiz, Spain
- grid.7759.c0000000103580096Department of Medicine, Cadiz University (UCA), 11003 Cádiz, Spain
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Angiogenic Imbalance and Inflammatory Biomarkers in the Prediction of Hypertension as Well as Obstetric and Perinatal Complications in Women with Gestational Diabetes Mellitus. J Clin Med 2022; 11:jcm11061514. [PMID: 35329840 PMCID: PMC8953606 DOI: 10.3390/jcm11061514] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 02/07/2023] Open
Abstract
Gestational diabetes mellitus (GDM) increases the risk of hypertensive disorders of pregnancy (HDP). We aimed to analyze the altered inflammatory markers and angiogenic factors among women with GDM to identify pregnant women at higher risk of developing HDP. Methods: This was a prospective study of 149 women without hypertension diagnosed in the third trimester with GDM. Inflammatory markers and angiogenic factors were measured at 28−32 weeks of pregnancy. Obstetric and perinatal outcomes were evaluated. Results: More than eight percent of the women developed HDP. Higher levels of the soluble fms-like tyrosine kinase-1/placental growth factor (sFlt-1/PIGF) ratio (4.9 ± 2.6 versus 2.3 ± 1.3, respectively; p < 0.001) and leptin (10.9 ± 0.8 versus 10.08 ± 1.1, respectively; p = 0.038), as well as lower levels of adiponectin (10.5 ± 1.3 versus 12.9 ± 2.7, respectively; p = 0.031), were seen in women who developed HDP versus normotensive women with GDM. A multivariable logistic regression analysis showed that adiponectin had a protective effect with 0.45-fold odds (0.23−0.83; p = 0.012), and that the sFlt-1/PIGF ratio was associated with 2.70-fold odds of developing HDP (CI 95%: 1.24−5.86; p = 0.012). Conclusion: An increase in angiogenic imbalance in the sFlt-1/PIGF ratio in women with GDM was detected and may be an indicator of developing HDP in addition to any subsequent obstetric and perinatal complications.
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Tiselko AV, Kapustin RV, Milyutina YP, Borovik NV, Abashova EI, Yarmolinskaya MI. Glucose variability as the risk factor of preeclampsia in pregnant patients with type 1 diabetes mellitus. J Matern Fetal Neonatal Med 2022; 35:9639-9646. [PMID: 35264056 DOI: 10.1080/14767058.2022.2050361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To analyze glucose variability and investigate its role as a predictor for preeclampsia development in pregnant women with type 1 diabetes mellitus (T1DM) with various insulin therapy regimens. METHODS A total of 200 pregnant women with T1DM were included in the study. A hundred women used continuous subcutaneous insulin infusion (CSII), and the rest of the group was administered with multiple daily insulin injections (MDI). Continuous glucose monitoring (CGM), index calculation of glucose variability (MAGE, MODD, CONGA, and CV), assessment of preeclampsia frequency and severity were conducted. RESULTS The work results show the link between the severity rate of preeclampsia and the duration of T1DM as well as the level of HbA1c before and during pregnancy. The rate of preeclampsia in the group of women, using CSII comprises 26.8% of cases that appear less than in the group of those, administered with MDI that is 46.6% (χ2 = 5.45; р < .05). A negative correlation is defined between pathological glucose variability and gestational age when preeclampsia occurs. A negative correlation was also revealed between MODD, CV, and the time for the detection of preeclampsia: r = -0.30, r = -0.24, respectively. The study illustrates the correlation obtained between preeclampsia and glucose variability and the value of MAGE, MODD, CV, and SD. Preeclampsia development is affected by the duration of hyperglycemic conditions in the third trimester of pregnancy. The data in the group of women using MDI marks the early development of preeclampsia on the 33.0 [32-34] week of pregnancy compared to the group of women practicing CSII on 35.5 [33-36] week of pregnancy (Z = 5.4; p < .001). The increase of risk of preeclampsia development is proved in pregnant patients with T1DM when the hyperglycemic condition lasts more than 25% of a 24-h period according to the rate of CGM and measurements of glucose variability MODD > 1.07 and CONGA > 3.39. CONCLUSION Comprehensive evaluation of the glycemic profile while using CGM revealed a correlation between pathological glucose variability and the frequency and severity of preeclampsia thus proving the benefits of CSII in pregnant patients with T1DM to perform glycemic targets and decrease glucose variability, which eventually led to the decrease of preeclampsia frequency in this group of women.
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Affiliation(s)
- Alyona V Tiselko
- D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, Saint Petersburg, Russia
| | - Roman V Kapustin
- D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, Saint Petersburg, Russia.,Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, St. Petersburg State University, Saint Petersburg, Russia
| | - Yuliya P Milyutina
- D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, Saint Petersburg, Russia
| | - Natalia V Borovik
- D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, Saint Petersburg, Russia
| | - Elena I Abashova
- D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, Saint Petersburg, Russia
| | - Maria I Yarmolinskaya
- D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductive Medicine, Saint Petersburg, Russia.,I.I. Mechnikov North-Western State Medical University, Saint Petersburg, Russia
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Imbalances in circulating angiogenic factors in the pathophysiology of preeclampsia and related disorders. Am J Obstet Gynecol 2022; 226:S1019-S1034. [PMID: 33096092 PMCID: PMC8884164 DOI: 10.1016/j.ajog.2020.10.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/26/2020] [Accepted: 10/17/2020] [Indexed: 12/11/2022]
Abstract
Preeclampsia is a devastating medical complication of pregnancy that can lead to significant maternal and fetal morbidity and mortality. It is currently believed that there is abnormal placentation in as early as the first trimester in women destined to develop preeclampsia. Although the etiology of the abnormal placentation is being debated, numerous epidemiologic and experimental studies suggest that imbalances in circulating angiogenic factors released from the placenta are responsible for the maternal signs and symptoms of preeclampsia. In particular, circulating levels of soluble fms-like tyrosine kinase 1, an antiangiogenic factor, are markedly increased in women with preeclampsia, whereas free levels of its ligand, placental, growth factor are markedly diminished. Alterations in these angiogenic factors precede the onset of clinical signs of preeclampsia and correlate with disease severity. Recently, the availability of automated assays for the measurement of angiogenic biomarkers in the plasma, serum, and urine has helped investigators worldwide to demonstrate a key role for these factors in the clinical diagnosis and prediction of preeclampsia. Numerous studies have reported that circulating angiogenic biomarkers have a very high negative predictive value to rule out clinical disease among women with suspected preeclampsia. These blood-based biomarkers have provided a valuable tool to clinicians to accelerate the time to clinical diagnosis and minimize maternal adverse outcomes in women with preeclampsia. Angiogenic biomarkers have also been useful to elucidate the pathogenesis of related disorders of abnormal placentation such as intrauterine growth restriction, intrauterine fetal death, twin-to-twin transfusion syndrome, and fetal hydrops. In summary, the discovery and characterization of angiogenic proteins of placental origin have provided clinicians a noninvasive blood-based tool to monitor placental function and health and for early detection of disorders of placentation. Uncovering the mechanisms of altered angiogenic factors in preeclampsia and related disorders of placentation may provide insights into novel preventive and therapeutic options.
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Nergiz Avcıoğlu S, Demircan Sezer S, Altınkaya SÖ. Circulating s-Endoglin concentrations in non-obese patients with gestational diabetes mellitus. J OBSTET GYNAECOL 2022; 42:1126-1131. [PMID: 34994287 DOI: 10.1080/01443615.2021.2012436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim of this study was to compare maternal concentrations of soluble Endodlin (s-Endoglin) in women with gestational diabetes (GDM) and women with normal glucose tolerance (NGT) in pregnancy. Also, the association of insulin resistance markers and s-Endoglin was investigated. Forty patients complicated by GDM and forty gestational age-matched healthy pregnant women with NGT were included in the present study. s-Endoglin level was higher in patients with GDM compared with the control group (p .01). Besides a positive correlation was found between s-Endoglin and fasting glucose (r = 0.206, p = .057), insulin (r = 0.302, p = .005), HbA1c (r = 0.376, p < .01), HOMA-IR values (r = 0.283, p = .008) in pregnant women included in the study. s-Endoglin, as an anti-angiogenic marker seemed to have a role in pathogenesis and significantly associated with insulin resistance markers in non-obese GDM, thus may play important roles in the regulation of glucose hemostasis.Impact StatementWhat is already known on this subject? In women with GDM, hyperglycaemia induced glycosylation products might cause oxidative stress that may be subsequently involved in the release of inflammatory mediators, inducing angiogenesisWhat the results of this study add? s-Endoglin has an anti-angiogenic effect and is a useful marker of endothelial injury, activation of inflammation, senescence and oxidative stress, we speculate that it may be involved in the pathogenesis of GDM.What the implications are of these findings for clinical practice and/or further research? s-Endoglin seemed to have a role in the regulation of glucose hemostasis. Further exploration of novel factors like s-endoglin in the pathogenesis of GDM, is essential and valuable to develop new therapeutic strategies for this complex disease and its complications.
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Affiliation(s)
- Sümeyra Nergiz Avcıoğlu
- Department of Gynecology and Obstetrics, Adnan Menderes University, School of Medicine, Aydın, Türkiye
| | - Selda Demircan Sezer
- Department of Gynecology and Obstetrics, Adnan Menderes University, School of Medicine, Aydın, Türkiye
| | - Sündüz Özlem Altınkaya
- Department of Midwifery, Adnan Menderes University, Faculty of Health Sciences, Aydın, Türkiye
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Jaffar F, Laycock K, Huda MSB. Type 1 Diabetes in Pregnancy: A Review of Complications and Management. Curr Diabetes Rev 2022; 18:e051121197761. [PMID: 34749617 DOI: 10.2174/1573399818666211105124829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/15/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent's declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes. OBJECTIVES This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care. METHODS A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised. RESULTS One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised. CONCLUSION This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.
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Affiliation(s)
- Farah Jaffar
- Department of Diabetes & Metabolism, Barts Health NHS Trust, Royal London Hospital, Whitechapel, London, UK
| | - Kate Laycock
- Department of Diabetes & Metabolism, Barts Health NHS Trust, St Bartholomew's and Royal London Hospital, London, UK
| | - Mohammed S B Huda
- Department of Diabetes & Metabolism, Barts Health NHS Trust, Royal London Hospital, Whitechapel, London, UK
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Verlohren S, Brennecke SP, Galindo A, Karumanchi SA, Mirkovic LB, Schlembach D, Stepan H, Vatish M, Zeisler H, Rana S. Clinical interpretation and implementation of the sFlt-1/PlGF ratio in the prediction, diagnosis and management of preeclampsia. Pregnancy Hypertens 2021; 27:42-50. [PMID: 34915395 DOI: 10.1016/j.preghy.2021.12.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/12/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022]
Abstract
Preeclampsia is associated with significant morbidity and mortality for mother and baby. Although around 30% of all pregnancies are evaluated for preeclampsia, diagnosis is difficult, especially in patients who have overlying symptoms from other diseases. Discovery of circulating angiogenic factors in the pathogenesis of preeclampsia has been a major advance for both diagnosis and prognosis. The anti-angiogenic factor, soluble fms-like tyrosine kinase 1 (sFlt-1) and the pro-angiogenic factor, placental growth factor (PlGF), can be measured in plasma and serum and are usually reported as a ratio, which specifically relates to the onset and severity of preeclampsia. The sFlt-1/PlGF ratio has a very high negative predictive value in ruling out the development of preeclampsia within 7 days among women with suspected preeclampsia. Currently, there is no clear consensus on the practical use of angiogenic biomarkers in the detection and management of preeclampsia in routine clinical practice. While major international clinical guidelines exist, they do not define which specific parameters signal patient admission, or outpatient evaluation of suspected preeclampsia, and most clinicians follow local practices. Better guidance is needed on risk stratification among women with suspected preeclampsia, as well as among women at high risk for preeclampsia. Prediction of adverse outcomes in women, after the clinical diagnosis of preeclampsia, is also important. This report has been developed following a meeting of international experts and aims to guide clinicians in the management of pregnant women at risk of preeclampsia using the sFlt-1/PlGF ratio test.
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Affiliation(s)
| | - Shaun P Brennecke
- University of Melbourne/Royal Women's Hospital, Melbourne, Australia
| | - Alberto Galindo
- Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Research Institute (imas12), Complutense University, Madrid, Spain
| | | | | | - Dietmar Schlembach
- Vivantes Network of Health GmbH, Clinicum Berlin-Neukoelln, Clinic of Obstetric Medicine, Berlin, Germany
| | | | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA.
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12
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Buschur EO, Polsky S. Type 1 Diabetes: Management in Women From Preconception to Postpartum. J Clin Endocrinol Metab 2021; 106:952-967. [PMID: 33331893 DOI: 10.1210/clinem/dgaa931] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Indexed: 01/11/2023]
Abstract
CONTEXT This review presents an up-to-date summary on management of type 1 diabetes mellitus (T1DM) among women of reproductive age and covers the following time periods: preconception, gestation, and postpartum. EVIDENCE ACQUISITION A systematic search and review of the literature for randomized controlled trials and other studies evaluating management of T1DM before pregnancy, during pregnancy, and postpartum was performed. EVIDENCE SYNTHESIS Preconception planning should begin early in the reproductive years for young women with T1DM. Preconception and during pregnancy, it is recommended to have near-normal glucose values to prevent adverse maternal and neonatal outcomes, including fetal demise, congenital anomaly, pre-eclampsia, macrosomia, neonatal respiratory distress, neonatal hyperbilirubinemia, and neonatal hypoglycemia. CONCLUSION Women with T1DM can have healthy, safe pregnancies with preconception planning, optimal glycemic control, and multidisciplinary care.
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Affiliation(s)
| | - Sarit Polsky
- The University of Colorado Barbara Davis Center, Denver, CO, USA
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13
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Lah S, Cheung NW, Lee V, Athayde N, Inglis E, Padmanabhan S. Aspirin and pre-eclampsia prevention in women with pre-existing diabetes: a retrospective study. Intern Med J 2021; 51:1673-1680. [PMID: 33650231 DOI: 10.1111/imj.15257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 02/04/2021] [Accepted: 02/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Aspirin is routinely prescribed in high-risk pregnancies to prevent pre-eclampsia; however, there is a paucity of data in women with pre-existing diabetes. AIMS To assess the efficacy and safety of aspirin in women with pre-existing diabetes in preventing pre-eclampsia. METHODS A retrospective review of women with pre-existing diabetes who attended antenatal clinics in a tertiary referral hospital between 2013 and 2019 was conducted. Cases were those receiving aspirin prior to 16 weeks, with pre-eclampsia as the primary outcome. The relationship between early pregnancy glycaemic control and pre-eclampsia was also assessed. RESULTS Of the 164 women included in the study, 45 received aspirin. There were no differences in pre-eclampsia (odds ratio (OR) 0.9 (0.3-3.0), P = 0.924) or any other measure of placental insufficiency (OR 1.7 (0.7-4.3), P = 0.243) between the aspirin and control groups after adjusting for baseline differences. Aspirin therapy was associated with an increased risk of postpartum haemorrhage (PPH) (OR 3.1 (1.1-9.1), P = 0.041). The incidence of pre-eclampsia increased stepwise according to early pregnancy HbA1c subgroups of ≤6.0% (n = 47), 6.1-7.5% (n = 57) and > 7.5% (n = 39), with rates of 0, 12.3 and 20.5% (P = 0.007) respectively. CONCLUSIONS The aspirin group had a higher baseline risk of pre-eclampsia and placental insufficiency, therefore the absence of difference between the groups favoured the efficacy of aspirin. PPH was highlighted as a potential complication of therapy, and early pregnancy HbA1c as a novel risk stratification tool for pre-eclampsia in women with pre-existing diabetes.
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Affiliation(s)
- Siehoon Lah
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - N Wah Cheung
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Vincent Lee
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Neil Athayde
- Women's and Newborn Health, Westmead Hospital, Sydney, New South Wales, Australia
| | - Emma Inglis
- Women's and Newborn Health, Westmead Hospital, Sydney, New South Wales, Australia
| | - Suja Padmanabhan
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
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14
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Pereira MM, Torrado J, Sosa C, Zócalo Y, Bia D. Shedding light on the pathophysiology of preeclampsia-syndrome in the era of Cardio-Obstetrics: Role of inflammation and endothelial dysfunction. Curr Hypertens Rev 2021; 18:17-33. [DOI: 10.2174/1573402117666210218105951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/02/2021] [Accepted: 01/18/2021] [Indexed: 11/22/2022]
Abstract
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Preeclampsia (PE) is a worldwide pregnancy complication with serious maternal and neonatal consequences. Our understanding of PE pathophysiology has significantly evolved over the last decades by recognizing that endothelial dysfunction and systemic inflammation, with an associated angiogenic imbalance, are key pieces of this still incomplete puzzle. In the present era, where no single treatment to cure or treat this obstetric condition has been developed so far, PE prevention and early prediction poses the most useful clinical approach to reduce the PE burden. Although most PE episodes occur in healthy nulliparous women, the identification of specific clinical conditions that increase dramatically the risk of PE provides a critical opportunity to improve outcomes by acting on potential reversible factors, and also contribute to better understand this pathophysiologic enigma. In this review, we highlight major clinical contributors of PE and shed light about their potential link with endothelial dysfunction and inflammation.
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Affiliation(s)
- María M. Pereira
- Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA, United States
| | - Juan Torrado
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Claudio Sosa
- Department of Obstetrics and Gynecology “C”, Pereira-Rossell Hospital, School of Medicine, Republic University, Montevideo, Uruguay
| | - Yanina Zócalo
- Centro Universitario de Investigación, Innovación y Diagnóstico Arterial, Department of Physiology, School of Medicine, Republic University, Montevideo, Uruguay
| | - Daniel Bia
- Centro Universitario de Investigación, Innovación y Diagnóstico Arterial, Department of Physiology, School of Medicine, Republic University, Montevideo, Uruguay
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15
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Nuzzo AM, Giuffrida D, Moretti L, Re P, Grassi G, Menato G, Rolfo A. Placental and maternal sFlt1/PlGF expression in gestational diabetes mellitus. Sci Rep 2021; 11:2312. [PMID: 33504861 PMCID: PMC7840991 DOI: 10.1038/s41598-021-81785-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023] Open
Abstract
Gestational diabetes mellitus (GDM) and preeclampsia (PE) are both characterized by endothelial dysfunction and GDM women have higher incidence of PE. The placenta plays a key role in PE pathogenesis but its contribution to PE during GDM remains unclear. Herein, we compared placental and maternal blood anti-angiogenic soluble fms-like tyrosine kinase-1 (sFlt1) and pro-angiogenic Placental Growth Factor (PlGF) expressions in GDM and GDM-PE pregnancies compared to controls (CTRL) and PE cases. Electrochemiluminescence immunoassays showed a significantly higher maternal blood sFlt1/PlGF values in GDM-PE relative to CTRL and GDM pregnancies. We reported that placental PlGF gene expression was significantly decreased in GDM, PE and GDM-PE relative to CTRL. However, PlGF protein levels were significantly increased in GDM and GDM-PE relative to CTRL and PE placentae. Finally, sFlt1 gene expression was significantly increased in PE relative to CTRL, GDM and GDM-PE placentae. In contrast, sFlt1 protein expression was significantly decreased in GDM-PE relative to CTRL, GDM and PE placentae. Finally, higher sFlt1/PlGF ratio in GDM-PE maternal blood suggest that sFlt1 overproduction is related to PE onset also in GDM pregnancies even though characterized by a less severe endothelial dysfunction in terms of angiogenic biomarkers.
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Affiliation(s)
- Anna Maria Nuzzo
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy
| | - Domenica Giuffrida
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy
| | - Laura Moretti
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy
| | - Paola Re
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy
| | - Giorgio Grassi
- Department of Endocrinology, Diabetology, and Metabolism, Città della Salute e della Scienza University Hospital, Corso Bramante 88, 10126, Turin, Italy
| | - Guido Menato
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy
| | - Alessandro Rolfo
- Department of Surgical Sciences, University of Turin, Via Ventimiglia 3, 10126, Turin, Italy.
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16
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Zen M, Padmanabhan S, Zhang K, Kirby A, Cheung NW, Lee VW, Alahakoon TI. Urinary and Serum Angiogenic Markers in Women With Preexisting Diabetes During Pregnancy and Their Role in Preeclampsia Prediction. Diabetes Care 2020; 43:67-73. [PMID: 31601637 DOI: 10.2337/dc19-0967] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/26/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the correlation between urinary and serum placental growth factor (PlGF) and investigate the predictive value as pregnancy progresses of urinary PlGF compared with serum PlGF, soluble fms-like tyrosine kinase 1 (sFLT-1), and the sFLT-1-to-PlGF ratio for the outcome of preeclampsia in women with preexisting diabetes. RESEARCH DESIGN AND METHODS A multicenter prospective cohort study was conducted of 158 women with preexisting insulin-requiring diabetes (41 with type 1 and 117 with type 2). Urinary PlGF and serum PlGF, sFLT-1, and the sFLT-1-to-PlGF ratio were assessed four times (14, 24, 30, and 36 weeks' gestation), and the association with the outcome of preeclampsia was investigated. RESULTS A correlation between urinary and serum PlGF was demonstrated from 24 weeks' gestation onward (P < 0.001). At all time points, those who developed preeclampsia had lower serum PlGF levels (P < 0.05), and receiver operating characteristic curves demonstrated that serum PlGF in this cohort performed better than the serum sFLT-1-to-PlGF ratio as a predictive test for preeclampsia. Preconception HbA1c ≥6.5% (48 mmol/mol) was an important discriminative predictor for preeclampsia (P = 0.01). CONCLUSIONS This study prospectively describes the longitudinal changes in urinary PlGF alongside serum angiogenic markers throughout pregnancy in women with preexisting diabetes. We demonstrate correlation between urinary and serum PlGF and that in women with preexisting diabetes in pregnancy, serum PlGF is a better predictor of preeclampsia than the sFLT-1-to-PlGF ratio.
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Affiliation(s)
- Monica Zen
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Westmead, New South Wales, Australia .,The University of Sydney Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, Westmead, New South Wales, Australia
| | - Suja Padmanabhan
- The University of Sydney Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Kewei Zhang
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Adrienne Kirby
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - N Wah Cheung
- The University of Sydney Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Diabetes and Endocrinology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Vincent W Lee
- The University of Sydney Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Renal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Thushari I Alahakoon
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Westmead, New South Wales, Australia.,The University of Sydney Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, Westmead, New South Wales, Australia
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17
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Gorkem U, Togrul C, Arslan E. Relationship between elevated serum level of placental growth factor and status of gestational diabetes mellitus. J Matern Fetal Neonatal Med 2019; 33:4159-4163. [PMID: 30935303 DOI: 10.1080/14767058.2019.1598361] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: As only limited and confusing evidence about serum placental growth factor (PlGF) level in gestational diabetes mellitus (GDM) exist in the known literature, the aim of this study was to evaluate the association of maternal serum PlGF level with GDM status.Methods: The pregnant women attending the Obstetrics Outpatient Unit of Hitit University Hospital were screened at 24 and 28 weeks of gestation for GDM according to the suggestions of the American College of Obstetricians and Gynecologists (ACOG). Concisely, all of the low-risk pregnant women were evaluated with a 50 g glucose challenge test (GCT). Women with serum glucose ≥140 mg/dL at 1 h after GCT were subjected to a 100 g oral glucose tolerance test (OGTT). According to the criteria of Carpenter and Coustan, the GDM diagnosis was confirmed. Consequently, a total of 158 pregnant women eligible for inclusion criteria were categorized into two main groups; 76 of the GDM group, 82 of the control group. The demographic characteristic and biochemical parameters of the study population including age, body mass index (BMI), gestational age were recorded at the second trimester. The assays for glucose, insulin, and PlGF were carried out.Results: The mean maternal age of control and GDM groups were 27.9 and 30.5 years, respectively. The parameters such as age, BMI, and gestational age were statistically similar in both groups (p>.05, for all). As expected, serum insulin level and homeostasis model assessment-insulin resistance (HOMA-IR) value were significantly elevated in women with GDM (p<.001, for both). Moreover, maternal PlGF concentration was found to be higher in the GDM group compared to the control group (p=.029). Pearson's correlation analysis of PlGF with other study parameters revealed that there was a negative moderate and significant correlation in only control group (r= -0.416, p<.05). However, this correlation was not detected in the GDM group (r = 0.099, p>.05). None of the variables including maternal age, BMI, insulin, and HOMA-IR showed significant correlations in GDM and control groups.Conclusion: Our findings revealed that maternal serum PlGF level is increased in pregnant women complicated with GDM. Early identification of pregnant women who subsequently will pose GDM risk could improve the pregnancy outcomes.
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Affiliation(s)
- Umit Gorkem
- Department of Obstetrics and Gynecology, Hitit University Faculty of Medicine, Corum, Turkey
| | - Cihan Togrul
- Department of Obstetrics and Gynecology, Hitit University Faculty of Medicine, Corum, Turkey
| | - Emine Arslan
- Department of Obstetrics and Gynecology, Hitit University Faculty of Medicine, Corum, Turkey
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18
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Patti AM, Giglio RV, Pafili K, Rizzo M, Papanas N. Advances in pharmacological treatment of type 1 diabetes during pregnancy. Expert Opin Pharmacother 2019; 20:983-989. [PMID: 30924387 DOI: 10.1080/14656566.2019.1593372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION In women with type 1 diabetes mellitus (T1DM), pregnancy is associated with a potential risk of maternal, foetal and neonatal outcomes. Stringent metabolic control is required to improve these outcomes. AREAS COVERED In this review, the authors summarise the current evidence from studies on the pharmacological therapy and on monitoring of T1DM during pregnancy. The authors also discuss the use of new technologies to improve therapeutic management and patient compliance. EXPERT OPINION Pre-conception counselling is essential in T1DM to minimise pregnancy risks. Pregnancy in T1DM is always considered a high-risk pregnancy. During pregnancy, the target haemoglobin A1C (HbA1c) is near-normal at <6%, without excessive hypoglycaemia. Strict control of pre- and post-prandial glucose is also required. Human soluble insulin, neutral protamine Hagedorn and the quick-acting insulin analogues aspart and lispro are widely used. Insulin is administered either as a basal-bolus regimen or by continuous subcutaneous insulin infusion. Careful and strict glucose monitoring is also needed during labour and delivery, including caesarean section. Moreover, the control of retinopathy, hypertension, nephropathy, hyper- and hypothyroidism is required. Post-partum, insulin requirements decrease, and less stringent glycaemic control is pursued, to avoid hypoglycaemias. Finally, breastfeeding is recommended and should be encouraged.
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Affiliation(s)
- Angelo Maria Patti
- a Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Rosaria Vincenza Giglio
- a Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Kalliopi Pafili
- b Diabetes Centre, Second Department of Internal Medicine , Democritus University of Thrace, University Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Manfredi Rizzo
- a Department of Internal Medicine and Medical Specialties , University of Palermo , Palermo , Italy
| | - Nikolaos Papanas
- b Diabetes Centre, Second Department of Internal Medicine , Democritus University of Thrace, University Hospital of Alexandroupolis , Alexandroupolis , Greece
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19
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Microalbuminuria as an early predictor of preeclampsia in the pre-gestational diabetic population: A prospective cohort study. Pregnancy Hypertens 2019; 15:182-188. [PMID: 30825920 DOI: 10.1016/j.preghy.2019.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/25/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine if microalbuminuria can be used as a predictive marker of preeclampsia and adverse pregnancy and neonatal outcomes in women with pre-existing diabetes and to compare the prognostic utility of urinary albumin to creatinine ratio (uACR) and urinary protein to creatinine ratio (uPCR). STUDY DESIGN Multicentre prospective cohort study. Antenatal Diabetes in Pregnancy clinics at three tertiary referral hospitals in Western Sydney, Australia. 158 women with pre-existing diabetes requiring insulin in pregnancy. A spot uPCR and uACR was performed in each trimester. Pregnancy and fetal outcomes were investigated using linear models and receiver-operating characteristic (ROC) curves. MAIN OUTCOME MEASURES The primary outcome was preeclampsia (PE). Secondary outcomes investigated were other adverse pregnancy and neonatal outcomes. RESULTS Increased levels of both uPCR and uACR in trimester 3 were associated with the occurrence of PE (p = 0.007, 0.010 respectively). In the 113 patients with normal pregnancy uPCR (<30 mg/mmol) in trimester 1, microalbuminuria was found to be predictive of PE (p = 0.01) and need for operative delivery (p = 0.03). CONCLUSIONS In women with pre-existing diabetes, uPCR and uACR appear to have similar ability to diagnose PE, but microalbuminuria demonstrates prognostic ability at a much earlier gestation, prior to the onset of other signs or symptoms of PE. We therefore suggest that assessing microalbuminuria rather than overt proteinuria in trimester 1 provides prognostic information in women with pre-existing diabetes requiring insulin and should be used routinely to evaluate risk of PE in this high-risk cohort of women.
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20
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Abstract
OBJECTIVE To evaluate the pregnancy outcomes in mothers with controlled Type 1 diabetes mellitus (T1DM). MATERIALS AND METHODS Thirty seven pregnant patients with controlled T1DM were included in the study. RESULTS Twenty (54%) out of 37 patients had preterm delivery (<37 weeks of gestation). The type of delivery was induced vaginal delivery in 9 (24.3%) patients and cesarean section in 27 (72.9%) patients. Preeclampsia developed in 6 (16.2%) patients. Macrosomia was found in 9 (24%) patients. Two antenatal death occured. CONCLUSION Even in the most favorable conditions, the pregnant patients with T1DM would have a great risk for preterm delivery and cesarean section, moderate risk for macrosomia, preeclampsia, and an undefined risk for antenatal death.
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21
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Leon-Martinez D, Mulla MJ, Han CS, Chamley LW, Abrahams VM. Modulation of trophoblast function by concurrent hyperglycemia and antiphospholipid antibodies is in part TLR4-dependent. Am J Reprod Immunol 2018; 80:e13045. [PMID: 30194878 DOI: 10.1111/aji.13045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 08/09/2018] [Indexed: 12/21/2022] Open
Abstract
PROBLEM While diabetes and APS are individually associated with increased risk of poor perinatal outcomes, in particular preeclampsia, recent studies have demonstrated an association between concurrent aPL and diabetes leading to an increased risk of pregnancy morbidity. Hyperglycemia and aPL have independently been shown to alter human trophoblast function by inducing a pro-inflammatory, anti-angiogenic, and antimigratory response. However, little is known about the effects of concurrent hyperglycemia and aPL on trophoblast function. METHOD OF STUDY A human first-trimester extravillous trophoblast cell line was exposed to glucose at 5 mmol/L (normoglycemia) or 25 mmol/L (hyperglycemia), all in the presence or absence of low-dose aPL or control IgG. For some experiments, the TLR4 antagonist, LPS-RS, was included. Cell culture supernatants were measured for inflammatory IL-1β and IL-8, and angiogenic PlGF, sFlt-1, and sEndoglin by ELISA. Inflammasome-associated uric acid was measured using a bioassay; caspase-1 was measured using an activity assay. Trophoblast migration was quantified using a two-chamber colorimetric assay. RESULTS Compared to excess glucose alone, combination excess glucose and low-dose aPL (a) further augmented trophoblast inflammatory IL-1β, inflammasome-associated uric acid and caspase-1, and pro-angiogenic PlGF; (b) dampened trophoblast inflammatory IL-8, anti-angiogenic sEndoglin, and sFlt-1; and (c) further reduced trophoblast migration. CONCLUSION Our findings indicate that while concurrent aPL and hyperglycemia are overall detrimental to trophoblast function, the presence of two simultaneous insults triggers some protective effects.
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Affiliation(s)
- Daisy Leon-Martinez
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Melissa J Mulla
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Christina S Han
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lawrence W Chamley
- Department of Obstetrics and Gynecology, The University of Auckland, Auckland, New Zealand
| | - Vikki M Abrahams
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
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22
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Heim KR, Mulla MJ, Potter JA, Han CS, Guller S, Abrahams VM. Excess glucose induce trophoblast inflammation and limit cell migration through HMGB1 activation of Toll-Like receptor 4. Am J Reprod Immunol 2018; 80:e13044. [DOI: 10.1111/aji.13044] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/01/2018] [Accepted: 08/09/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Kathleen R. Heim
- Department of Obstetrics, Gynecology and Reproductive Sciences; Yale University; New Haven Connecticut
| | - Melissa J. Mulla
- Department of Obstetrics, Gynecology and Reproductive Sciences; Yale University; New Haven Connecticut
| | - Julie A. Potter
- Department of Obstetrics, Gynecology and Reproductive Sciences; Yale University; New Haven Connecticut
| | - Christina S. Han
- Department of Obstetrics & Gynecology; David Geffen School of Medicine at UCLA; Los Angeles California
| | - Seth Guller
- Department of Obstetrics, Gynecology and Reproductive Sciences; Yale University; New Haven Connecticut
| | - Vikki M. Abrahams
- Department of Obstetrics, Gynecology and Reproductive Sciences; Yale University; New Haven Connecticut
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23
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Abstract
Preeclampsia continues to afflict 5% to 8% of all pregnancies throughout the world and is associated with significant morbidity and mortality to the mother and the fetus. Although the pathogenesis of the disorder has not yet been fully elucidated, current evidence suggests that imbalance in angiogenic factors is responsible for the clinical manifestations of the disorder, and may explain why certain populations are risk. In this review, we begin by demonstrating the roles that angiogenic factors play in pathogenesis of preeclampsia and its complications in the mother and the fetus. We then continue to report on the use of angiogenic markers as biomarkers to predict and risk-stratify disease. Strategies to treat preeclampsia by correcting the angiogenic balance, either by promoting proangiogenic factors or by removing antiangiogenic factors in both animal and human studies, are discussed. We end the review by summarizing status of the current preventive strategies and the long-term cardiovascular outcomes of women afflicted with preeclampsia.
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Affiliation(s)
- Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - S Ananth Karumanchi
- Departments of Medicine, Obstetrics, and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Cavero-Redondo I, Martínez-Vizcaíno V, Soriano-Cano A, Martínez-Hortelano JA, Sanabria-Martínez G, Álvarez-Bueno C. Glycated haemoglobin A1c as a predictor of preeclampsia in type 1 diabetic pregnant women: A systematic review and meta-analysis. Pregnancy Hypertens 2018; 14:49-54. [PMID: 30527118 DOI: 10.1016/j.preghy.2018.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 03/20/2018] [Accepted: 04/06/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To examine the relationship between the increase of glycated haemoglobin A1c (HbA1c) levels and the risk of preeclampsia in pregnant with type 1 diabetes mellitus; and to determine from which trimester the increase of HbA1c levels better predicts the risk of suffering preeclampsia in type 1 diabetic pregnant women. METHODS We systematically searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews and Web of Science databases, from inception to May 2017, for observational studies addressing the association of HbA1c levels with preeclampsia. Fixed effects models were used to compute pooled estimates of odds ratio (OR) and respective 95% confidence intervals (95% CI) for preeclampsia in type 1 diabetic pregnant women. Additionally, subgroup analyses were performed based on pregnancy trimester. RESULTS Five published studies were included in the systematic review and meta-analysis. There was an increase in the risk of preeclampsia with a 1% increase of HbA1c during pregnancy (OR = 1.38; 95% CI 1.26-1.52, I2=0.0%). When analyses were performed based on pregnancy trimester to estimate the risk of preeclampsia with a 1% increase of HbA1c, pooled OR estimates were 1.37 (95% CI 1.24-1.51, I2=0.0%) for the first trimester and 1.67 (95% CI 1.44-1.93, I2=0.0%) for the second/third trimester. CONCLUSION HbA1c is a reliable predictor of preeclampsia in type 1 diabetic pregnant women. Our findings highlight the importance of including HbA1c measurements in the first antenatal visit to control the risk of preeclampsia in pregnant women. Systematic review registration: PROSPERO: CRD42017058394.
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Affiliation(s)
- I Cavero-Redondo
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain
| | - V Martínez-Vizcaíno
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain; Universidad Autónoma de Chile, Facultad de Ciencias de la Salud, Talca, Chile.
| | - A Soriano-Cano
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain
| | | | - G Sanabria-Martínez
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain; Virgen de la Luz Hospital, Cuenca, Spain
| | - C Álvarez-Bueno
- Universidad de Castilla-La Mancha, Health and Social Research Center, Cuenca, Spain
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Gray KJ, Saxena R, Karumanchi SA. Genetic predisposition to preeclampsia is conferred by fetal DNA variants near FLT1, a gene involved in the regulation of angiogenesis. Am J Obstet Gynecol 2018; 218:211-218. [PMID: 29138037 DOI: 10.1016/j.ajog.2017.11.562] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/06/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Abstract
Preeclampsia risk is influenced by both the mother's genetic background and the genetics of her fetus; however, the specific genes responsible for conferring preeclampsia risk have largely remained elusive. Evidence that preeclampsia has a genetic predisposition was first detailed in the early 1960s, and overall preeclampsia heritability is estimated at ∼55%. Many traditional gene discovery approaches have been used to investigate the specific genes that contribute to preeclampsia risk, but these have largely not been successful or reproducible. Over the past decade, genome-wide association studies have allowed for significant advances in the understanding of the genetic basis of many common diseases. Genome-wide association studies are predicated on the idea that the genetic basis of many common diseases are complex and polygenic with many variants, each with modest effects that contribute to disease risk. Using this approach in preeclampsia, a large genome-wide association study recently identified and replicated the first robust fetal genomic region associated with excess risk. A screen of >7 million genetic variants in 2658 offspring from preeclamptic women and 308,292 population controls identified a single association signal close to the Fms-like tyrosine kinase 1 gene, on chromosome 13. Fms-like tyrosine kinase 1 encodes soluble Fms-like tyrosine kinase 1, a splice variant of the vascular endothelial growth factor receptor that exerts antiangiogenic activity by inhibiting signaling of proangiogenic factors. The Fms-like tyrosine kinase 1 pathway is central in preeclampsia pathogenesis because excess circulating soluble Fms-like tyrosine kinase 1 in the maternal plasma leads to the hallmark clinical features of preeclampsia, including hypertension and proteinuria. The success of this landmark fetal preeclampsia genome-wide association study suggests that well-powered, larger maternal and fetal genome-wide association study will be fruitful in identifying additional common variants that implicate causal preeclampsia genes and pathways. Such efforts will rely on the continued development of large preeclampsia consortia focused on preeclampsia genetics to obtain adequate sample sizes, detailed clinical phenotyping, and matched maternal-fetal samples. In summary, the fetal preeclampsia genome-wide association study represents an exciting advance in preeclampsia biology, suggesting that dysregulation at the Fms-like tyrosine kinase 1 locus in the fetal genome (likely in the placenta) is a fundamental molecular defect in preeclampsia.
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Padmanabhan S, Lee VW, Mclean M, Athayde N, Lanzarone V, Khoshnow Q, Peek MJ, Cheung NW. The Association of Falling Insulin Requirements With Maternal Biomarkers and Placental Dysfunction: A Prospective Study of Women With Preexisting Diabetes in Pregnancy. Diabetes Care 2017; 40:1323-1330. [PMID: 28798085 DOI: 10.2337/dc17-0391] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/09/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association of falling insulin requirements (FIR) among women with preexisting diabetes with adverse obstetric outcomes and maternal biomarkers longitudinally in pregnancy. RESEARCH DESIGN AND METHODS A multicenter prospective cohort study of 158 women (41 with type 1 diabetes and 117 with type 2 diabetes) was conducted. Women with FIR of ≥15% from the peak total daily dose after 20 weeks' gestation were considered case subjects (n = 32). The primary outcome was a composite of clinical markers of placental dysfunction (preeclampsia, small for gestational age [≤5th centile], stillbirth, premature delivery [<30 weeks], and placental abruption). Maternal circulating angiogenic markers (placental growth factor [PlGF] and soluble fms-like tyrosine kinase 1 [sFlt-1]), placental hormones (human placental lactogen, progesterone, and tumor necrosis factor-α), HbA1c, and creatinine were studied serially during pregnancy. RESULTS FIR ≥15% were associated with an increased risk of the composite primary outcome (odds ratio [OR] 4.38 [95% CI 1.9-10.3]; P < 0.001), preeclampsia (OR 6.76 [95% CI 2.7-16.7]; P < 0.001), and was more common among women with type 1 diabetes (36.6 vs. 14.5%; P = 0.002). Creatinine was modestly elevated among women with FIR ≥15%; however, there was no difference in HbA1c. The ratio of sFlt-1 to PlGF was significantly higher among women with FIR at 25, 30, and 36 weeks, with differences maintained in the subgroup that developed preeclampsia. There was no difference in placental hormones between the groups. CONCLUSIONS This is the first prospective study to associate FIR with altered expression of placental antiangiogenic factors and preeclampsia. FIR are an important clinical sign, among women with preexisting diabetes, that should alert the clinician to investigate underlying placental dysfunction.
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Affiliation(s)
- Suja Padmanabhan
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia .,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vincent W Lee
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Mclean
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Diabetes and Endocrinology, Blacktown Hospital, Sydney, New South Wales, Australia.,Western Sydney University, Sydney, New South Wales, Australia
| | - Neil Athayde
- Obstetric Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Valeria Lanzarone
- Obstetric Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Qemer Khoshnow
- Obstetric Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Michael J Peek
- College of Medicine, Biology and Environment, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - N Wah Cheung
- Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Hoffmann J, Ossada V, Weber M, Stepan H. An intermediate sFlt-1/PlGF ratio indicates an increased risk for adverse pregnancy outcome. Pregnancy Hypertens 2017; 10:165-170. [PMID: 29153672 DOI: 10.1016/j.preghy.2017.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 08/07/2017] [Accepted: 08/10/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The sFlt-1/PlGF ratio is a valid marker in diagnosing or excluding preeclampsia. The currently used cut offs frame an intermediate zone of 33-85 (<340 weeks) or 33-110 (≥340 weeks), respectively. In this study we sought to evaluate the relevance of an intermediate sFlt-1/PlGF ratio for the clinical pregnancy course and outcome. MATERIAL AND METHODS We retrospectively analysed 533 consecutive patients with sFlt-1/PlGF ratio measurements for suspected preeclampsia. In patients with an intermediate sFlt-1/PlGF ratio, fetal and maternal characteristics and also pregnancy outcome were documented. Furthermore, we compared the patient groups with <340/340-366/≥370 gestational weeks at first visit. RESULTS 83/533 (15.6%) patients had an intermediate sFlt-1/PlGF ratio. Maternal or fetal diseases or twin pregnancies occurred in 87.9%. Preeclampsia/HELLP syndrome developed in 31.3% but were mostly mild or moderate (65.4%). However, severe adverse outcome was observed in 36.1% with severe preeclampsia in 10.8%. Even if further pregnancy duration and gestational week correlated negatively (r=-0.424; p<0.001), 92% of patients, tested with <340 weeks delivered prematurely. The overall preterm birth rate was 27.7%. CONCLUSIONS Patients with an intermediate sFlt-1/PlGF ratio are at risk for severe adverse outcome. An intermediate sFlt-1/PlGF ratio indicates a risk for preterm birth, independent from the occurrence of preeclampsia.
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Affiliation(s)
- Janine Hoffmann
- Department of Obstetrics, University Hospital Leipzig, Leipzig, Germany.
| | - Victoria Ossada
- Department of Obstetrics, University Hospital Leipzig, Leipzig, Germany
| | - Marie Weber
- Department of Obstetrics, University Hospital Leipzig, Leipzig, Germany
| | - Holger Stepan
- Department of Obstetrics, University Hospital Leipzig, Leipzig, Germany
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Wotherspoon AC, Young IS, McCance DR, Holmes VA. Exploring knowledge of pre-eclampsia and views on a potential screening test in women with type 1 diabetes. Midwifery 2017; 50:99-105. [PMID: 28399474 DOI: 10.1016/j.midw.2017.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 03/20/2017] [Accepted: 03/29/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE to explore knowledge of pre-eclampsia and opinions on potential screening tests for pre-eclampsia in women with type 1 diabetes. DESIGN a qualitative study using semi-structured interviews of women planning a pregnancy, currently pregnant or post-partum with experience of pre-eclampsia. SETTING, PARTICIPANTS AND METHODS: eleven women with type 1 diabetes were recruited from a pre-pregnancy planning clinic or antenatal clinic. Semi-structured interviews were conducted with the women, asking a series of open-ended questions about their current knowledge of pre-eclampsia and their views on screening for pre-eclampsia. Data analysis was conducted using inductive thematic analysis. FINDINGS four main themes were identified: Information, sources of stress, awareness and acceptability of screening. Generally, women's knowledge of pre-eclampsia was limited. Most did not appear to be aware of their increased risk of developing the disease. Similarly, the majority of women were unaware as to why their blood pressure and urine were checked regularly. The introduction of a screening test for pre-eclampsia was favoured, with only a small number of women raising concerns related to the screening tests. CONCLUSIONS health care professionals need to raise awareness of pre-eclampsia in this high risk group. The introduction of a screening test for pre-eclampsia appears to be acceptable in this population, however, further research is required to validate these findings and also to explore the views of women in other high risk groups.
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Affiliation(s)
- Amy C Wotherspoon
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Ian S Young
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - David R McCance
- Regional Centre for Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, UK
| | - Valerie A Holmes
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK.
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Spradley FT. Metabolic abnormalities and obesity's impact on the risk for developing preeclampsia. Am J Physiol Regul Integr Comp Physiol 2016; 312:R5-R12. [PMID: 27903516 DOI: 10.1152/ajpregu.00440.2016] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/11/2016] [Accepted: 11/29/2016] [Indexed: 02/07/2023]
Abstract
Preeclampsia (PE), a hypertensive disorder of pregnancy, is increasing as a major contributor to perinatal and long-term morbidity of mother and offspring. PE is thought to originate from ischemic insults in the placenta driving the release of prohypertensive anti-angiogenic [soluble fms-like tyrosine kinase-1 (sFlt-1)] and proinflammatory [tumor necrosis factor-α (TNF-α)] factors into the maternal circulation. Whereas the increased incidence of PE is hypothesized to be largely due to the obesity pandemic, the mechanisms whereby obesity increases this risk are unknown. The maternal endothelium is targeted by placental and adipose tissue-derived factors like sFlt-1 and TNF-α that promote hypertension during pregnancy, resulting in vascular dysfunction and hypertension. Interestingly, not all obese pregnant women develop PE. Data suggest that obese pregnant women with the greatest metabolic abnormalities have the highest incidence of PE. Identifying obesity-related mechanisms driving hypertension in some obese pregnant women and pathways that protect normotensive obese pregnant women, may uncover novel protocols to treat PE. Metabolic abnormalities, such as increased circulating leptin, glucose, insulin, and lipids, are likely to increase the risk for PE in obese women. It is not only important to understand whether each of these metabolic factors contribute to the increased risk for PE in obesity, but also their cumulative effects. This is particularly relevant to obese pregnant women with gestational diabetes mellitus (GDM) where all of these factors are increased and the risk for PE is highest. It is speculated that these factors potentiate the anti-angiogenic and proinflammatory mechanisms of placental ischemia-induced vascular dysfunction thereby contributing to the increasing incidence of PE.
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Affiliation(s)
- Frank T Spradley
- Department of Surgery, Department of Physiology and Biophysics, Cardiovascular-Renal Research Center, Women's Health Research Center, The University of Mississippi Medical Center, Jackson, Mississippi
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Abstract
Women with type 1 diabetes (T1DM) have unique needs during the preconception, pregnancy, and postpartum periods. Preconception counseling is essential for women with T1DM to minimize pregnancy risks. The goals of preconception care should be tight glycemic control with a hemoglobin A1c (A1C) < 7 % and as close to 6 % as possible, without significant hypoglycemia. This will lower risks of congenital malformations, preeclampsia, and perinatal mortality. The safety of medications should be assessed prior to conception. Optimal control of retinopathy, hypertension, and nephropathy should be achieved. During pregnancy, the goal A1C is near-normal at <6 %, without excessive hypoglycemia. There is no clear evidence that continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) is superior in achieving the desired tight glycemic control of T1DM during pregnancy. Data regarding continuous glucose monitoring (CGM) in pregnant women with T1DM is conflicting regarding improved glycemic control. However, a recent CGM study does provide some distinct patterns of glucose levels associated with large for gestational age infants. Frequent eye exams during pregnancy are essential due to risk of progression of retinopathy during pregnancy. Chronic hypertension treatment goals are systolic blood pressure 110-129 mmHg and diastolic blood pressure 65-79 mmHg. Labor and delivery target plasma glucose levels are 80-110 mg/dl, and an insulin drip is recommended to achieve these targets during active labor. Postpartum, insulin doses must be reduced and glucoses closely monitored in women with T1DM because of the enhanced insulin sensitivity after delivery. Breastfeeding is recommended and should be highly encouraged due to maternal benefits including increased insulin sensitivity and weight loss and infant and childhood benefits including reduced prevalence of overweight. In this article, we discuss the care of pregnant patients with T1DM.
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Affiliation(s)
- Anna Z Feldman
- Joslin Diabetes Center, 1 Joslin Place, Boston, MA, 02115, USA
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James-Todd T, Cohen A, Wenger J, Brown F. Time-specific placental growth factor (PlGF) across pregnancy and infant birth weight in women with preexisting diabetes. Hypertens Pregnancy 2016; 35:436-46. [PMID: 27336414 PMCID: PMC5065939 DOI: 10.3109/10641955.2016.1172085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Determine the independent association between time-specific placental growth factor (PIGF)-a marker of placental vasculature-and infant birth weight in offspring of mothers with preexisting type 1 and 2 diabetes. METHODS A total of 150 women were recruited from Joslin Diabetes Center's/Beth Israel Deaconess Medical Center's Diabetes in Pregnancy Program. PlGF was measured up to four times during pregnancy. Infant birth weight and covariate data were collected from medical records. Hemoglobin A1c was assessed from drawn blood samples. We used generalized linear and log-binomial models to calculate the change in continuous birth weight, as well as macrosomia for every unit change in time-specific ln-transformed PlGF, respectively. Models were adjusted for potential confounders. RESULTS Approximately 75% of women had type 1 diabetes. Third trimester PlGF levels were significantly associated with infant birth weight (r = 0.24, p = 0.02 at 27-34 weeks; r = 0.26, p < 0.009 for 36-40 weeks). After full adjustment, there was a 6.1% and 6.6% increase in birth weight for gestational age percentile for each unit increase in ln-transformed PlGF level at 27-34 weeks and 35-40 weeks, respectively (95% CI for 27-34 weeks gestation: 1.1, 11.0, and 95% CI for 35-40 weeks gestation: 0.7%, 12.5%). We found a statistically significant increased risk of macrosomia among women with higher ln-transformed PlGF levels (RR: 1.72; 95% CI: 1.09, 2.70). Associations were not mediated by hemoglobin A1c. CONCLUSIONS Third trimester PlGF levels were associated with higher birth weight in women with preexisting diabetes. These findings may provide insight to the pathophysiology of fetal overgrowth in women with diabetes.
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Affiliation(s)
- Tamarra James-Todd
- a Department of Environmental Health/Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | - Allison Cohen
- b Adult Diabetes Section , Joslin Diabetes Center and Harvard Medical School , Boston , MA , USA
| | - Julia Wenger
- c Division of Nephrology , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA
| | - Florence Brown
- b Adult Diabetes Section , Joslin Diabetes Center and Harvard Medical School , Boston , MA , USA
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Poorolajal J, Jenabi E. The association between body mass index and preeclampsia: a meta-analysis. J Matern Fetal Neonatal Med 2016; 29:3670-6. [PMID: 26762770 DOI: 10.3109/14767058.2016.1140738] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Several observational studies have reported a positive association between elevated body mass index (BMI) and preeclampsia, but no meta-analysis has been conducted yet. This meta-analysis was conducted to estimate the overall association between overweight or obesity and preeclampsia. METHODS Major electronic databases, including PubMed, Web of Science, and Scopus were searched until August 2015. The reference lists of included studies were screened as well. Epidemiological studies addressing the association between BMI and preeclampsia were enrolled. The heterogeneity across studies was explored by Q-test and I(2) statistic. The possibility of publication bias was assessed using Begg's and Egger's tests. The results were reported using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random-effects model. RESULTS We identified a total of 1298 references and included 23 studies with 1 387 599 participants. Preeclampsia was associated with overweight (OR = 1.73; 95% CI: 1.59, 1.87; 21 studies; I(2 )=( )62.3%) and obesity (OR = 3.15; 95% CI: 2.96, 3.35; 22 studies; I(2 )=( )36.0%). There was no evidence of publication bias. CONCLUSIONS There is sufficient evidence that excess body mass index is significantly associated with an increased risk of preeclampsia. Therefore, overweight and obesity can be considered as a predictor of preeclampsia.
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Affiliation(s)
- Jalal Poorolajal
- a Department of Epidemiology , Research Center for Health Sciences, School of Public Health, Hamadan University of Medical Sciences , Hamadan , Iran and.,b Department of Midwifery , Toyserkan Branch, Islamic Azad University , Toyserkan , Iran
| | - Ensiyeh Jenabi
- a Department of Epidemiology , Research Center for Health Sciences, School of Public Health, Hamadan University of Medical Sciences , Hamadan , Iran and.,b Department of Midwifery , Toyserkan Branch, Islamic Azad University , Toyserkan , Iran
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Mosimann B, Amylidi S, Risch L, Wiedemann U, Surbek D, Baumann M, Stettler C, Raio L. First-Trimester Placental Growth Factor in Screening for Gestational Diabetes. Fetal Diagn Ther 2015; 39:287-91. [PMID: 26421599 DOI: 10.1159/000441027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/07/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study was first to assess whether first-trimester serum concentrations of placental growth factor (PlGF) differ between patients with and without gestational diabetes (GDM) and second to test whether there is a correlation between glycosylated hemoglobin (HbA1c), a factor recently shown to be useful in predicting GDM, and PlGF. METHODS PlGF was measured at 8-14 weeks with the Kryptor Immunoassay Analyzer (Brahms, Berlin, Germany). Absolute values were converted to multiples of the median using the software provided by the Fetal Medicine Foundation London. GDM was diagnosed using internationally accepted criteria. HbA1c levels were quantified using the TOSOH G7 automated hemoglobin analyzer. RESULTS From January to December 2014, 328 women were included in the study, 51 (15.5%) of whom developed GDM. First-trimester PlGF quantification does not discriminate between women at risk to develop GDM and controls, while HbA1c is able to do so. No correlation was found between PlGF and HbA1c. CONCLUSION Our findings do not lend support to the hypothesis that early PlGF values are different in women who later develop GDM.
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Affiliation(s)
- Beatrice Mosimann
- Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
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Bautista Niño PK, Tielemans MJ, Schalekamp-Timmermans S, Steenweg-de Graaff J, Hofman A, Tiemeier H, Jaddoe VW, Steegers EAP, Felix JF, Franco OH. Maternal fish consumption, fatty acid levels and angiogenic factors: The Generation R Study. Placenta 2015; 36:1178-84. [PMID: 26278058 DOI: 10.1016/j.placenta.2015.07.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 07/15/2015] [Accepted: 07/20/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Angiogenic factors, such as placental growth factor (PlGF) and soluble Flt-1 (sFlt-1), are key regulators of placental vascular development. Evidence from in vitro studies indicates that fatty acids can affect angiogenesis. We investigated the associations of maternal fish consumption and fatty acids levels with angiogenic factors during pregnancy, and in cord blood in a large population-based prospective cohort. METHODS First trimester fish consumption was assessed among 3134 pregnant women using a food-frequency questionnaire. Plasma fatty acid levels were measured in second trimester. Plasma PlGF and sFlt-1 were measured in first and second trimester and in cord blood. Associations of fish consumption or fatty acid levels with angiogenic factors were assessed by multivariable linear regression analyses. RESULTS There were no consistent associations of total fish or lean fish consumption with levels of PlGF, sFlt-1, or sFlt-1/PlGF ratio. Neither fatty fish nor shellfish were associated with angiogenic factors. Plasma omega-3 polyunsaturated fatty acids, which are the main type of fatty acids in fish, were inconsistently associated with angiogenic factors in second trimester and cord blood. Yet, higher levels of arachidonic acid, an omega-6 polyunsaturated fatty acid, were associated with lower levels of PlGF and sFlt-1. DISCUSSION We found no consistent associations of fish consumption or fatty acids levels with angiogenic factors in a population with low fish consumption. Studies including populations with higher fish consumption are required to fully grasp the potential effects of maternal fish consumption on placental angiogenesis.
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Affiliation(s)
- Paula K Bautista Niño
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Myrte J Tielemans
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | | | - Jolien Steenweg-de Graaff
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Vincent W Jaddoe
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands; The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Paediatrics, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Janine F Felix
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands; The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Paediatrics, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, The Netherlands.
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Abstract
Hypertensive disease of pregnancy (HDP) has been associated with elevated lifetime cardiovascular risk, including stroke, myocardial disease, coronary artery disease, and peripheral arterial disease. These two entities share common risk factors such as obesity, insulin resistance, diabetes, and hypertension. This article will evaluate the current literature on the maternal and fetal cardiovascular risks posed by HDP. The landmark study by Barker et al. demonstrated increased cardiovascular risk in growth-restricted infants, which may also be associated with HDP. Research has demonstrated the effects that HDP may have on the vascular and nephron development in offspring, particularly with respect to endothelial and inflammatory markers. In order to control for confounding variables and better understand the relationship between HDP and lifetime cardiovascular risk, future research will require following blood pressure and metabolic profiles of the parturients and their offspring.
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Abstract
Preeclampsia is diagnosed in women presenting with new onset hypertension accompanied by proteinuria or other signs of severe organ dysfunction in the second half of pregnancy. Preeclampsia risk is increased 2- to 4-fold among women with type 1 or type 2 diabetes. The limited number of pregnant women with preexisting diabetes and the difficulties associated with diagnosing preeclampsia in women with proteinuria prior to pregnancy are significant barriers to research in this high-risk population. Gestational diabetes mellitus (GDM) also increases preeclampsia risk, although it is unclear whether these two conditions share a common pathophysiological pathway. Nondiabetic women who have had preeclampsia are more likely to develop type 2 diabetes later in life. Among women with type 1 diabetes, a history of preeclampsia is associated with an increased risk of retinopathy and nephropathy. More research examining the pathophysiology, treatment, and the long-term health implications of preeclampsia among women with preexisting and gestational diabetes is needed.
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Affiliation(s)
- Tracey L Weissgerber
- Division of Nephrology and Hypertension, Mayo Clinic, 200 1st St. SW, RO-HA-06-675B-5, Rochester, MN, 55905, USA,
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Sharp AN, Alfirevic Z. First trimester screening can predict adverse pregnancy outcomes. Prenat Diagn 2014; 34:660-7. [PMID: 24810468 DOI: 10.1002/pd.4406] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/04/2014] [Accepted: 05/05/2014] [Indexed: 11/09/2022]
Abstract
There has been an increasing drive over the last two decades to push the detection of women at risk of adverse pregnancy outcomes into the first trimester. This has led to a plethora of techniques, risk assessments and biomarkers, both fascinating and bewildering in its breadth. Despite the vast amount of knowledge available, it is often difficult to determine what is practicable and valuable for clinical practice. This is especially true as earlier diagnosis does not necessarily equate to improved outcomes for mother and child. We suggest that, at least for preeclampsia, fetal growth restriction, spontaneous preterm birth and gestational diabetes, there are effective first trimester tests available to identify the women at risk of subsequently developing complications. Unfortunately, there are no currently reliable first trimester tests available for identifying women at risk of stillbirth. It is likely that this field will continue to develop over time, and we hope that new and better strategies will continue to emerge to target these clinically important pathologies.
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Affiliation(s)
- Andrew N Sharp
- Department of Women and Children's Health Research, University Department, Liverpool Women's Hospital, Liverpool, UK
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