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Buralli RJ, da Silva ZP, Alencar GP, Figueiredo GM, Hoshida MS, Luna EJA, Pastro LDM, Santos OAD, Marques LJP, Zerbinati RM, Galisteo Junior AJ, Andrade Junior HD, Machado CM, Meireles LR, Schultz R, Rodrigues LC, Francisco RPV, Novaes HMD, Almeida MFD, Gouveia N. Assessing the risks for stillbirth in São Paulo, Brazil: protocol for a multidisciplinary case-control study - FetRisks. BMJ Open 2024; 14:e079261. [PMID: 38866578 PMCID: PMC11177680 DOI: 10.1136/bmjopen-2023-079261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 05/27/2024] [Indexed: 06/14/2024] Open
Abstract
Stillbirth is a fundamental component of childhood mortality, but its causes are still insufficiently understood. This study aims to explore stillbirth risk factors by using a multidisciplinary approach to stimulate public policies and protocols to prevent stillbirth, improve maternal care and support bereaved families. METHODS AND ANALYSIS: In this case-control study with stillbirths and live births in 14 public hospitals in São Paulo, mothers are interviewed at hospitals after delivery, and hospital records and prenatal care registries are reviewed. Maternal and umbilical cord blood samples and placentas are collected to analyse angiogenesis and infection biomarkers, and the placenta's anatomopathological exam. Air pollutant exposure is estimated through the participant's residence and work addresses. Traditional and non-invasive autopsies by image-guided histopathology are conducted in a subset of stillbirths. Subsample mothers of cases are interviewed at home 2 months after delivery on how they were dealing with grief. Information contained in the official prenatal care registries of cases and controls is being compiled. Hospital managers are interviewed about the care offered to stillbirth mothers. Data analysis will identify the main risk factors for stillbirth, investigate their interrelations, and evaluate health services care and support for bereaved families. We hope this project will contribute to the understanding of stillbirth's risk factors and related health services in Brazil, providing new knowledge about this central public health problem, contributing to the improvement of public policies and prenatal and puerperal care, helping to prevent stillbirths and improve the healthcare and support for bereaved families. ETHICS AND DISSEMINATION: This study protocol was approved by the Ethics Committee of the Municipal Health Secretary (process no 16509319.0.3012.5551) and of the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (process no 16509319.0.0000.0068). Results will be communicated to the study participants, policy-makers and the scientific community.
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Affiliation(s)
- Rafael Junqueira Buralli
- Departamento de Medicina Preventiva, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Brazil
| | - Zilda Pereira da Silva
- Departamento de Epidemiologia, Universidade de Sao Paulo Faculdade de Saude Publica, São Paulo, Brazil
| | - Gizelton Pereira Alencar
- Departamento de Epidemiologia, Universidade de Sao Paulo Faculdade de Saude Publica, São Paulo, Brazil
| | - Gerusa Maria Figueiredo
- Universidade de São Paulo Instituto de Medicina Tropical de São Paulo, Sao Paulo, Brazil
- Departamento de Medicina Preventiva, Universidade de São Paulo Faculdade de Medicina, São Paulo, Brazil
| | - Mara Sandra Hoshida
- Laboratorio de Investigaçao Medica em Fisiologia Obstetrica (LIM 57), Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
| | - Expedito J A Luna
- Departamento de Medicina Preventiva, Universidade de São Paulo Faculdade de Medicina, São Paulo, Brazil
- Universidade de São Paulo Instituto de Medicina Tropical de São Paulo, São Paulo, Brazil
| | | | - Osmara Alves Dos Santos
- Departamento de Medicina Preventiva, Universidade de São Paulo Faculdade de Medicina, São Paulo, Brazil
| | | | - Rodrigo Melim Zerbinati
- Laboratorio de Virologia (LIM 52), Universidade de São Paulo Instituto de Medicina Tropical de São Paulo, São Paulo, Brazil
| | - Andrés Jimenez Galisteo Junior
- Laboratorio de Investigaçao Medica em Protozoologia, Bacteriologia e Resistencia Antimicrobiana (LIM 49), Universidade de Sao Paulo Hospital das Clinicas, São Paulo, Brazil
| | - Heitor de Andrade Junior
- Universidade de São Paulo Instituto de Medicina Tropical de São Paulo, São Paulo, Brazil
- Laboratorio de Anatomia Patologica, Universidade de Sao Paulo Hospital das Clinicas, São Paulo, Brazil
| | - Clarisse M Machado
- Universidade de São Paulo Instituto de Medicina Tropical de São Paulo, São Paulo, Brazil
- Laboratorio de Virologia (LIM 52), Universidade de São Paulo Instituto de Medicina Tropical de São Paulo, São Paulo, Brazil
| | | | - Regina Schultz
- Laboratorio de Anatomia Patologica, Universidade de Sao Paulo Hospital das Clinicas, São Paulo, Brazil
| | | | - Rossana Pulcineli Vieira Francisco
- Laboratorio de Investigaçao Medica em Fisiologia Obstetrica (LIM 57), Universidade de São Paulo Hospital das Clínicas, São Paulo, Brazil
- Departamento de Obstetricia e Ginecologia, Universidade de Sao Paulo Faculdade de Medicina, São Paulo, Brazil
| | | | - Marcia Furquim de Almeida
- Departamento de Epidemiologia, Universidade de Sao Paulo Faculdade de Saude Publica, São Paulo, Brazil
| | - Nelson Gouveia
- Departamento de Medicina Preventiva, Universidade de Sao Paulo Faculdade de Medicina, Sao Paulo, Brazil
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Gannoun MBA, Mehdi M, Zitouni H, Boussabah M, Zouari I, Jlali A, Almawi WY. Evaluation of the angiogenic factors sFlt-1, PlGF, and the sFlt-1/PlGF ratio in preeclampsia and associated features. Am J Reprod Immunol 2023; 90:e13715. [PMID: 37382174 DOI: 10.1111/aji.13715] [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: 02/08/2023] [Revised: 04/18/2023] [Accepted: 05/12/2023] [Indexed: 06/30/2023] Open
Abstract
PROBLEM Soluble Fms-like tyrosine kinase-1 (sFLT-1) and placental growth factor (PlGF) were previously reported to play a key role in the pathogenesis of preeclampsia (PE). We tested the link between altered PlGF and sFLT-1 levels, and their ratio (sFlt-1/PlGF) with PE and PE-associated featured in Tunisian PE cases and age- and BMI-matched normotensive women. METHOD OF STUDY Peripheral blood specimens from 88 women with PE, and 60 control women were tested for PlGF and sFLT by commercially available ELISA. RESULTS Significant increases in sFlt-1 levels and in the sFlt-1/PlGF ratio, more than changes in PlGF levels were noted in PE subjects when compared to control women. Elevation in sFlt-1 and sFlt-1/PlGF ratio was observed at different percentile values in PE cases. The receiver operating characteristic (ROC) area under the curve (AUC) for sFlt-1, PlGF, and sFlt-1/PlGF ratio were 0.869 ± 0.031, 0.463 ± 0.048, and 0.759 ± 0.039, respectively. A systematic shift in sFlt-1, but not in PlGF, distributions for higher values occurred in PE subjects. A progressive increase in the adjusted OR paralleled increased sFlt-1 and the sFlt-1/PlGF ratio percentile values; no similar trend was noted for the PlGF percentiles. Increased sFlt-1 levels and sFlt-1/PlGF ratio were significantly correlated with dysmenorrhea, hypertension, baby weight, and C-section. In contrast, no correlation was found between PlGF and the PE-associated features tested. CONCLUSIONS Increased sFlt-1 levels and corresponding sFlt-1/PlGF ratio, but not circulating PlGF levels, constitute an independent risk factor for PE.
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Affiliation(s)
- Marwa Ben Ali Gannoun
- Faculty of Medicine, University of Monastir, Monastir, Tunisia
- Department of Gynecology & Obstetrics, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Meriem Mehdi
- Faculty of Medicine, University of Monastir, Monastir, Tunisia
- Department of Gynecology & Obstetrics, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Hedia Zitouni
- Faculty of Pharmacy, University of Monastir, Monastir, Tunisia
| | - Manel Boussabah
- Department of Gynecology & Obstetrics, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Ines Zouari
- Department of Gynecology & Obstetrics, CHU Fattouma Bourguiba, Monastir, Tunisia
| | - Ali Jlali
- Department of Anaesthesia, Fattouma Bourguiba University Teaching Hospital, Monastir, Tunisia
| | - Wassim Y Almawi
- Department of Biological Sciences, Brock University, St. Catharines, Canada
- Faculte des Sciences, El-Manar University, Tunis, Tunisia
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Hesson AM, Langen ES, Plazyo O, Gudjonsson JE, Ganesh SK. Placental transcriptome analysis of hypertensive pregnancies identifies distinct gene expression profiles of preeclampsia superimposed on chronic hypertension. BMC Med Genomics 2023; 16:91. [PMID: 37131171 PMCID: PMC10152005 DOI: 10.1186/s12920-023-01522-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 04/20/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The pathogenesis of preeclampsia superimposed on chronic hypertension (SI) is poorly understood relative to preeclampsia (PreE) occurring in pregnant people without chronic hypertension. Placental transcriptomes in pregnancies complicated by PreE and SI have not been previously compared. METHODS We identified pregnant people in the University of Michigan Biorepository for Understanding Maternal and Pediatric Health with hypertensive disorders affecting singleton, euploid gestations (N = 36) along with non-hypertensive control subjects (N = 12). Subjects were grouped as: (1) normotensive (N = 12), (2) chronic hypertensive (N = 13), (3) preterm PreE with severe features (N = 5), (4) term PreE with severe features (N = 11), (5) preterm SI (N = 3), or (6) term SI (N = 4). Bulk RNA sequencing of paraffin-embedded placental tissue was performed. The primary analysis assessed differential gene expression relative to normotensive and chronic hypertensive placentas, where Wald adjusted P values < 0.05 were considered significant. Unsupervised clustering analyses and correlation analyses were performed between conditions of interest, and a gene ontology was constructed. RESULTS Comparing samples from pregnant people with hypertensive diseases to non-hypertensive controls, there were 2290 differentially expressed genes. The log2-fold changes in genes differentially expressed in chronic hypertension correlated better with term (R = 0.59) and preterm (R = 0.63) PreE with severe features than with term (R = 0.21) and preterm (R = 0.22) SI. A relatively poor correlation was observed between preterm SI and preterm PreE with severe features (0.20) as well as term SI and term PreE with severe features (0.31). The majority of significant genes were downregulated in term and preterm SI versus normotensive controls (92.1%, N = 128). Conversely, most term and preterm PreE with severe features genes were upregulated compared to the normotensive group (91.8%, N = 97). Many of the upregulated genes in PreE with the lowest adjusted P values are known markers of abnormal placentation (e.g., PAAPA, KISS1, CLIC3), while the downregulated genes with the greatest adjusted P values in SI have fewer known pregnancy-specific functions. CONCLUSIONS We identified unique placental transcriptional profiles in clinically relevant subgroups of individuals with hypertension in pregnancy. Preeclampsia superimposed on chronic hypertension was molecularly distinct from preeclampsia in individuals without chronic hypertension, and chronic hypertension without preeclampsia, suggesting that preeclampsia superimposed on hypertension may represent a distinct entity.
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Affiliation(s)
- Ashley M Hesson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, 1500 East Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Elizabeth S Langen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, 1500 East Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Olesya Plazyo
- Departments of Dermatology and Immunology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Johann E Gudjonsson
- Departments of Dermatology and Immunology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Santhi K Ganesh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Department of Human Genetics, University of Michigan, MSRB III / Room 7220A, 1150 West Medical Center Dr., Ann Arbor, MI, 48109, USA.
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Karpova NS, Dmitrenko OP, Budykina TS. Literature Review: The sFlt1/PlGF Ratio and Pregestational Maternal Comorbidities: New Risk Factors to Predict Pre-Eclampsia. Int J Mol Sci 2023; 24:ijms24076744. [PMID: 37047717 PMCID: PMC10095124 DOI: 10.3390/ijms24076744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023] Open
Abstract
One of the main causes of maternal and neonatal morbidity and mortality is pre-eclampsia. It is characterized by a high sFlt1/PlGF ratio, according to prior research. Pregestational diseases in mothers may increase the risk of developing pre-eclampsia. Only a few studies have looked at the connection between maternal comorbidities before conception and the sFlt1/PlGF ratio. The most recent information regarding the association between maternal pregestational diseases and the ratio of sFlt1/PlGF is described in this review. The paper also examines current research suggesting that changes in pregnancy hormones and metabolites are related to a high sFlt1/PlGF ratio. Certain maternal disorders have been found to dramatically raise sFlt-1 and sFlt1/PlGF levels, according to an analysis of the literature. There is still debate about the data on the association between the sFlt1/PlGF ratio and maternal disorders such as HIV, acute coronary syndromes, cardiovascular function in the mother between 19 and 23 weeks of pregnancy, thyroid hormones, diabetes, and cancer. Additional research is needed to confirm these findings.
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Affiliation(s)
- Nataliia Sergeevna Karpova
- Federal State Budgetary Institution “Research Institute of Pathology and Pathophysiology”, St. Baltiyskaya, House 8, Moscow 125315, Russia
| | - Olga Pavlovna Dmitrenko
- Federal State Budgetary Institution “Research Institute of Pathology and Pathophysiology”, St. Baltiyskaya, House 8, Moscow 125315, Russia
| | - Tatyana Sergeevna Budykina
- State Budgetary Health Institution of the Moscow Region “Moscow Regional Research Institute of Obstetrics and Gynecology”, St. Pokrovka, d.22a, Moscow 101000, Russia
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Dela Justina V, Dos Passos Júnior RR, Lima VV, Giachini FR. Evidence of Nitric Oxide Impairment During Hypertensive Pregnancies. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1428:99-125. [PMID: 37466771 DOI: 10.1007/978-3-031-32554-0_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, and they can be classified into (1) gestational hypertension, (2) preeclampsia, (3) chronic hypertension and (4) chronic hypertension with preeclampsia. Nitric oxide (NO) plays an essential role in the haemodynamic adaptations observed during pregnancy. It has been shown that the nitric oxide pathway's dysfunction during pregnancy is associated with placental- and vascular-related diseases such as hypertensive disorders of pregnancy. This review aims to present a brief definition of hypertensive disorders of pregnancy and physiological maternal cardiovascular adaptations during pregnancy. We also detail how NO signalling is altered in the (a) systemic vasculature, (b) uterine artery/spiral arteries, (c) implantation and (d) placenta of hypertensive disorders during pregnancy. We conclude by summarizing the anti-hypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy.
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Affiliation(s)
- Vanessa Dela Justina
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
| | - Rinaldo Rodrigues Dos Passos Júnior
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
- Institute of Health Sciences and Health, Universidad Federal De Mato Grosso, Barra do Garcas, Brazil
| | - Victor Vitorino Lima
- Institute of Health Sciences and Health, Universidad Federal De Mato Grosso, Barra do Garcas, Brazil
| | - Fernanda Regina Giachini
- Graduate Program in Biological Sciences, Federal University of Goiás, Goiânia, Brazil
- Institute of Health Sciences and Health, Universidad Federal De Mato Grosso, Barra do Garcas, Brazil
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Ohseto H, Ishikuro M, Obara T, Murakami K, Onuma T, Noda A, Ueno F, Iwama N, Kikuya M, Metoki H, Sugawara J, Kuriyama S. Preeclampsia prediction model using the dipstick test for proteinuria during early gestation. HYPERTENSION RESEARCH IN PREGNANCY 2022. [DOI: 10.14390/jsshp.hrp2022-002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Taku Obara
- Tohoku University Graduate School of Medicine,
| | | | - Tomomi Onuma
- Tohoku Medical Megabank Organization, Tohoku University,
| | - Aoi Noda
- Tohoku Medical Megabank Organization, Tohoku University,
| | - Fumihiko Ueno
- Tohoku Medical Megabank Organization, Tohoku University,
| | | | | | - Hirohito Metoki
- Faculty of Medicine, Tohoku Medical and Pharmaceutical University,
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Fishel Bartal M, Lindheimer MD, Sibai BM. Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance. Am J Obstet Gynecol 2022; 226:S819-S834. [PMID: 32882208 DOI: 10.1016/j.ajog.2020.08.108] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.
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Binder J, Kalafat E, Palmrich P, Pateisky P, Khalil A. Should angiogenic markers be included in diagnostic criteria of superimposed pre-eclampsia in women with chronic hypertension? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:192-201. [PMID: 34165863 DOI: 10.1002/uog.23711] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Although the most recent guidance from the International Society for the Study of Hypertension in Pregnancy (ISSHP) has highlighted the role of angiogenic marker assessment in the diagnosis of pre-eclampsia (PE) in women with chronic hypertension, the ISSHP has withheld recommending its implementation due to the limited available evidence in this group of women. Therefore, we aimed to investigate the value of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) assessment in women with chronic hypertension and suspected superimposed PE. METHODS This was a retrospective analysis of prospectively collected data recorded in an electronic database between January 2013 and October 2019. Women with chronic hypertension and singleton pregnancy who had suspected superimposed PE were included. Superimposed PE was suspected in women presenting with worsening hypertension, epigastric pain, new-onset edema, dyspnea or neurological symptoms. The exclusion criteria were delivery within 1 week after assessment for reasons other than PE, chronic kidney disease, history of cardiac disease, fetal aneuploidy, genetic syndrome or major structural anomaly and missing pregnancy outcome. Maternal serum angiogenic markers (sFlt-1, PlGF and sFlt-1/PlGF ratio) were measured. The primary outcome was the utility of angiogenic markers in the prediction of superimposed PE. Predictive accuracy was assessed for superimposed PE diagnosed at different timepoints, including within 1 week after assessment and any time before birth. The secondary outcome was comparison of adverse maternal and perinatal outcomes between women with superimposed PE diagnosed according to the traditional ISSHP criteria and those diagnosed according to extended criteria including angiogenic markers. The predictive accuracy of each angiogenic marker was assessed using receiver-operating-characteristics-curve analysis. Area under the curve (AUC) values were compared using De Long's test. A sensitivity analysis was planned for gestational age at assessment. The association of various variables with composite adverse maternal and perinatal outcomes was assessed using binomial regression. RESULTS The study included 142 pregnant women with chronic hypertension and suspected superimposed PE, of whom 25 (17.6%) developed PE within 1 week after assessment, 52 (36.6%) developed PE at any timepoint before birth and 90 (63.4%) delivered without PE. Maternal serum angiogenic imbalance was associated significantly with superimposed PE diagnosed according to the ISSHP criteria within 1 week or at any time after assessment (P < 0.001 for both). The predictive accuracy of maternal serum sFlt-1/PlGF ratio for superimposed PE diagnosed within 1 week after assessment was superior to that of maternal serum PlGF level (AUC, 0.91 vs 0.86; P = 0.032). The addition of angiogenic imbalance to the traditional ISSHP diagnostic criteria was associated with an increase in the detection rate (35.1% increase; 95% credible interval (CrI), 16.6-53.6%) and positive (9.6% increase; 95% CrI, 0.0-20.6%) and negative (3.1% increase; 95% CrI, 1.3-4.9%) predictive values for composite adverse maternal outcome, with high posterior probabilities of an increase in each predictive accuracy parameter (> 99.9%, 95.6% and > 99.9%, respectively), without a meaningful decrease in specificity. The addition of angiogenic imbalance improved the detection rate for composite adverse perinatal outcome (20.6% increase; 95% CrI, 0.0-42.2%), with a high posterior probability (96.9%). There was a corresponding drop in specificity (5.7% decrease; 95% CrI, -2.3% to 13.6%), with a posterior probability of 91.8%. CONCLUSIONS In women with chronic hypertension and suspected superimposed PE, addition of maternal serum angiogenic markers to the traditional diagnostic criteria for superimposed PE improved significantly the sensitivity for the prediction of both maternal and perinatal adverse outcomes. Implementation of angiogenic marker assessment in the evaluation of pregnant women with chronic hypertension should therefore be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
- Department of Obstetrics and Gynecology, Faculty of Medicine, Koc University, Istanbul, Turkey
| | - P Palmrich
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Pateisky
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Kametas NA, Nzelu D, Nicolaides KH. Chronic hypertension and superimposed preeclampsia: screening and diagnosis. Am J Obstet Gynecol 2022; 226:S1182-S1195. [PMID: 35177217 DOI: 10.1016/j.ajog.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 01/23/2023]
Abstract
Superimposed preeclampsia complicates about 20% of pregnancies in women with chronic hypertension and is associated with increased maternal and perinatal morbidity compared with preeclampsia alone. Distinguishing superimposed preeclampsia from chronic hypertension can be challenging because, in chronic hypertension, the traditional criteria for the diagnosis of preeclampsia, hypertension, and significant proteinuria can often predate the pregnancy. Furthermore, the prevalence of superimposed preeclampsia is unlikely to be uniformly distributed across this high-risk group but is related to the severity of preexisting endothelial dysfunction. This has led to interest in identifying biomarkers that could help in screening and diagnosis of superimposed preeclampsia and in the stratification of risk in women with chronic hypertension. Elevated levels of uric acid and suppression of other renal biomarkers, such as the renin-angiotensin aldosterone system, have been demonstrated in women with superimposed preeclampsia but perform only modestly in its prediction. In addition, central to the pathogenesis of preeclampsia is a tendency toward an antiangiogenic state thought to be triggered by an impaired placenta and, ultimately, contributing to the endothelial dysfunction pathognomonic of the disease. In the general obstetrical population, angiogenic factors, such as soluble fms-like tyrosine kinase-1 and placental growth factor, have shown promise in the prediction of preeclampsia. However, soluble fms-like tyrosine kinase-1 and placental growth factor are impaired in women with chronic hypertension irrespective of whether they develop superimposed preeclampsia. Therefore, the differences in levels are less discriminatory in the prediction of superimposed preeclampsia compared with the general obstetrical population. Alternative biomarkers to the angiogenic and renal factors include those of endothelial dysfunction. A characteristic of both preeclampsia and chronic hypertension is an exaggerated systemic inflammatory response causing or augmenting endothelial dysfunction. Thus, proinflammatory mediators, such as tumor necrosis factor-α, interleukin-6, cell adhesion molecules, and endothelin, have been investigated for their role in the screening and diagnosis of superimposed preeclampsia in women with chronic hypertension. To date, the existing limited evidence suggests that the differences between those who develop superimposed preeclampsia and those who do not are, as with angiogenic factors, also modest and not clinically useful for the stratification of women with chronic hypertension. Finally, pro-B-type natriuretic peptide is regarded as a sensitive marker of early cardiac dysfunction that, in women with chronic hypertension, may predate the pregnancy. Thus, it has been proposed that pro-B-type natriuretic peptide could give insight as to the ability of women with chronic hypertension to adapt to the hemodynamic requirements of pregnancy and, subsequently, their risk of developing superimposed preeclampsia. Although higher levels of pro-B-type natriuretic peptide have been demonstrated in women with superimposed preeclampsia compared with those without, current evidence suggests that pro-B-type natriuretic peptide is not a predictor for the disease. The objectives of this review are to, first, discuss the current criteria for the diagnosis of superimposed preeclampsia and, second, to summarize the evidence for these potential biomarkers that may assist in the diagnosis of superimposed preeclampsia.
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Affiliation(s)
- Nikos A Kametas
- Antenatal Hypertension Clinic, Division of Women's Health, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom; Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom.
| | - Diane Nzelu
- Antenatal Hypertension Clinic, Division of Women's Health, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Kypros H Nicolaides
- Antenatal Hypertension Clinic, Division of Women's Health, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom; Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
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Cabiddu G, Longhitano E, Cataldo E, Lepori N, Chatrenet A, Torreggiani M, Attini R, Masturzo B, Rossini M, Versino E, Moroni G, Pani A, Gesualdo L, Santoro D, Piccoli GB. History of Preeclampsia in Patients Undergoing a Kidney Biopsy: A Biphasic, Multiple-Hit Pathogenic Hypothesis. Kidney Int Rep 2021; 7:547-557. [PMID: 35257067 PMCID: PMC8897305 DOI: 10.1016/j.ekir.2021.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Gianfranca Cabiddu
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| | - Elisa Longhitano
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino,” University of Messina, Messina, Italy
| | | | - Nicola Lepori
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| | | | | | - Rossella Attini
- Department of Surgery, Obstetrics, University of Torino, Torino, Italy
| | - Bianca Masturzo
- Department of Surgery, Obstetrics, University of Torino, Torino, Italy
| | | | - Elisabetta Versino
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Gabriella Moroni
- Division of Nephrology and Dialysis, Humanitas Research Hospital, Milan, Italy
| | - Antonello Pani
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| | | | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino,” University of Messina, Messina, Italy
| | - Giorgina Barbara Piccoli
- Néphrologie et Dialyse, Centre Hospitalier, Le Mans, France
- Correspondence: Giorgina Barbara Piccoli, Nephrology and Dialysis Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72037 Le Mans, France.
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11
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Binder J, Palmrich P, Kalafat E, Pateisky P, Öztürk E, Mittelberger J, Khalil A. Prognostic Value of Angiogenic Markers in Pregnant Women With Chronic Hypertension. J Am Heart Assoc 2021; 10:e020631. [PMID: 34459247 PMCID: PMC8649241 DOI: 10.1161/jaha.120.020631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Women with chronic hypertension face a 5‐ to 6‐fold increased risk of developing preeclampsia compared with normotensive women. Angiogenic markers, especially soluble fms‐like kinase 1 (sFlt‐1) and placental growth factor (PlGF), were identified as clinically useful markers predicting the development of preeclampsia, but data on the prediction of superimposed preeclampsia are scarce. Therefore, we aimed to evaluate the predictive value of the sFlt‐1/PlGF ratio for delivery because of superimposed preeclampsia in women with chronic hypertension. Methods and Results This retrospective study included 142 women with chronic hypertension and suspected superimposed preeclampsia. Twenty‐seven women (19.0%) delivered because of maternal indications only, 17 women (12.0%) because of fetal indications primarily, and 98 women (69.0%) for other reasons. Women who both delivered because of maternal indications and for fetal indications had a significantly higher sFlt‐1/PlGF ratio (median 99.9 and 120.2 versus 7.3, respectively, P<0.001 for both) and lower PlGF levels (median 73.6 and 53.3 versus 320.0 pg/mL, respectively, P<0.001 for both) compared with women who delivered for other reasons. SFlt‐1/PlGF ratio and PlGF were strong predictors for delivery because of superimposed preeclampsia, whether for maternal or fetal indications (P<0.05). Half of women with angiogenic imbalance (sFlt‐1/PlGF ratio ≥85 or PlGF levels <100 pg/mL) delivered because of maternal or fetal indications within 1.6 weeks (95% CI, 1.0–2.4 weeks). Conclusions Angiogenic marker imbalance in women with suspected superimposed preeclampsia can predict delivery because of maternal and fetal indications related to superimposed preeclampsia and is associated with a significantly shorter time to delivery interval.
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Affiliation(s)
- Julia Binder
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Pilar Palmrich
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Erkan Kalafat
- Department of Statistics Faculty of Arts and Sciences Middle East Technical University Ankara Turkey.,Department of Obstetrics and Gynecology Faculty of Medicine Koc University Istanbul Turkey
| | - Petra Pateisky
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Ebru Öztürk
- Department of Biostatistics Faculty of Medicine Hacettepe University Ankara Turkey
| | - Johanna Mittelberger
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Asma Khalil
- Fetal Medicine Unit St George's Hospital St George's University of London London United Kingdom.,Vascular Biology Research Centre Molecular and Clinical Sciences Research Institute St George's University of London London United Kingdom
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12
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Binder J, Kalafat E, Palmrich P, Pateisky P, Khalil A. Angiogenic markers and their longitudinal change for predicting adverse outcomes in pregnant women with chronic hypertension. Am J Obstet Gynecol 2021; 225:305.e1-305.e14. [PMID: 33812812 DOI: 10.1016/j.ajog.2021.03.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/19/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Women with chronic hypertension are at increased risk for adverse maternal and perinatal outcomes. Maternal serum angiogenic markers, such as soluble fms-like tyrosine kinase 1 and placental growth factor, can be used to triage women with suspected preeclampsia. However, data about these markers in pregnant women with chronic hypertension are scarce. OBJECTIVE We aimed to evaluate the predictive accuracy of maternal serum levels of soluble fms-like tyrosine kinase 1, placental growth factor, and their ratio for predicting adverse maternal and perinatal outcomes in women with chronic hypertension. STUDY DESIGN This was a retrospective analysis of prospectively collected data from January 2013 to October 2019 at the University of Vienna Hospital, Vienna, Austria. The inclusion criteria were pregnant women with chronic hypertension and suspected preeclampsia. The primary outcome of this study was the prognostic performance of angiogenic markers for the prediction of adverse maternal and perinatal outcomes in pregnant women with chronic hypertension. The accuracy of angiogenic markers for predicting adverse composite outcomes was assessed with a binomial logistic regression. The accuracy of each marker was assessed using receiver operating characteristics curves and area under the curve values. Area under the curve values were compared using De Long's test. RESULTS Of the 145 included women with chronic hypertension and suspected superimposed preeclampsia, 26 (17.9%) women developed complications (ie, composite adverse maternal or fetal outcomes) within 1 week of assessment (average gestational age at assessment, 29.9 weeks) and 35 (24.1%) developed complications at any time (average gestational age at assessment, 30.1 weeks). In women who developed complications at any time, the median maternal serum soluble fms-like tyrosine kinase-1 to placental growth factor ratio was 149.4 (interquartile range, 64.6-457.4) compared with 8.0 (interquartile range, 3.37-41.2) for women who did not develop complications (P<.001). The area under the curve values for the maternal serum soluble fms-like tyrosine kinase-1 to placental growth factor ratio Z-score (0.95; 95% confidence interval, 0.90-0.99) and placental growth factor level Z-score (0.94; 95% confidence interval, 0.88-0.99) for predicting complications within 1 week of assessment were very high. The area under the curve values for new-onset edema (0.61; 95% confidence interval, 0.52-0.70), proteinuria (0.62; 95% confidence interval, 0.52-0.71), high mean arterial pressure (0.52; 95% confidence interval, 0.50-0.54), and other symptoms of preeclampsia (0.57; 95% confidence interval, 0.49-0.65) were all significantly lower than for the angiogenic markers (P<.001 for all). Women who had an angiogenic imbalance and/or proteinuria had the highest rate of complications (28/57, 49.1%). The rate of complications in women with an angiogenic imbalance and/or proteinuria was significantly higher than in women with either proteinuria, other symptoms, or intrauterine growth restriction in the absence of an angiogenic imbalance (49.1% vs 16.7%; P=.039). The highest positive and negative predictive values for predicting adverse outcomes were demonstrated by an angiogenic imbalance and/or proteinuria criteria with a positive predictive value of 49.1% (95% confidence interval, 50.4%-57.9%) and a negative predictive value of 92% (95% confidence interval, 85.5%-95.8%). Longitudinal changes in measurements of the gestational age-corrected ratio of soluble fms-like tyrosine kinase-1 to placental growth factor up to the last measurement had a significantly higher area under the curve value than the last measurement alone (area under the curve, 0.95; 95% confidence interval, 0.92-0.99 vs 0.87; 95% confidence interval, 0.79-0.95; P=.024) CONCLUSION: Maternal serum angiogenic markers are superior to clinical assessment in predicting adverse maternal and perinatal outcomes in pregnant women with chronic hypertension. Repeated measurements of the ratio of soluble fms-like tyrosine kinase-1 to placental growth factor seems beneficial given the better predictive accuracy compared with a single measurement alone. The use of angiogenic makers should be implemented in clinical management guidelines for pregnant women with chronic hypertension.
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13
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Hettfleisch K, Carvalho MA, Hoshida MS, Pastro LDM, Saldiva SRDM, Vieira SE, Francisco RPV, Saldiva PHN, Bernardes LS. Individual exposure to urban air pollution and its correlation with placental angiogenic markers in the first trimester of pregnancy, in São Paulo, Brazil. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:28658-28665. [PMID: 33544347 DOI: 10.1007/s11356-021-12353-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/02/2021] [Indexed: 06/12/2023]
Abstract
Pollution of the atmosphere is known that may lead to adverse obstetric outcomes, including fetal growth restriction, gestational hypertension, and preeclampsia. Such disorders are correlated with imbalances in angiogenic factors, which may also be involved in the pathological mechanism as the pollutants impact placental and maternal physiology. In the first trimester of gestation, this study assessed the outcomes of personal maternal short period exposure to air pollution on soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PLGF) of pregnant women blood concentrations. This was a cross-sectional study, held in the city of São Paulo, Brazil, and conducted with low-risk pregnant women, who carried personal passive nitrogen dioxide (NO2) and ozone (O3) monitors for about a few days preceding the ultrasound evaluation, and on this day, the venous blood sample was collected to measure the angiogenic factors sFlt1 and PLGF and their ratio (sFlt1/PLGF) by enzyme-linked immunosorbent assay (ELISA). By means of multiple regression models, the effect of the studied pollutants on the log-transformed concentrations of the angiogenic factors was evaluated. One hundred thirty-one patients were included. The log of the sFlt1/PLGF ratio increased with rising NO2 levels (p = 0.021 and beta = 0.206), and the log of the PLGF concentration showed a negative correlation with NO2 (p = 0.008 and beta = - 0.234). NO2, an indicator of the levels of primary air pollutants, presented significant positive correlation with an increased sFlt1/PLGF ratio and diminished PLGF levels, which may reflect an antiangiogenic state generated by air pollution exposure.
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Affiliation(s)
- Karen Hettfleisch
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mariana Azevedo Carvalho
- Divisao de Clinica Obstetrica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mara Sandra Hoshida
- LIM 57 Laboratorio de Fisiologia Obstetrica, Hospital das Clinicas HCFMUSP, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Luciana Duzolina Manfré Pastro
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Sandra Elisabete Vieira
- Departamento de Pediatria, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, São Paulo, Brazil
| | - Rossana Pulcineli Vieira Francisco
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Lisandra Stein Bernardes
- Disciplina de Obstetricia, Departamento de Obstetricia e Ginecologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil.
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14
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Zhang Y, Huang L, Wang D, Ren P, Hong Q, Kang D. The ROBINS-I and the NOS had similar reliability but differed in applicability: A random sampling observational studies of systematic reviews/meta-analysis. J Evid Based Med 2021; 14:112-122. [PMID: 34002466 DOI: 10.1111/jebm.12427] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 02/07/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE There is a lack of evidence on the usage of the quality assessment tool-the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I). This article aimed to measure the reliability, criterion validity, and feasibility of the ROBINS-I and the Newcastle-Ottawa Scale (NOS). METHODS A sample of systematic reviews or meta-analyses of observational studies were selected from Medline (2013-2017) and assessed by two reviewers using ROBINS-I and the NOS. We reported on reliability in terms of the first-order agreement coefficient (AC1) statistic. Correlation coefficient statistic was used to explore the criterion validity of the ROBINS-I. We compared the feasibility of the ROBINS-I and NOS by recording the time to complete an assessment and the instances where assessing was difficult. RESULTS Five systematic reviews containing 41 cohort studies were finally included. Interobserver agreement on the individual domain of the ROBINS-I as well as the NOS was substantial with a mean AC1 statistic of 0.67 (95% CI: 0.50-0.83) and 0.73 (95% CI: 0.65-0.81), respectively. The criterion validity of the ROBNS-I was moderate (K = 0.52) against NOS. The time in assessing a single study by ROBINS-I varied from 7 hours initially to 3 hours compared with 30 minutes for the NOS. Both reviewers rated "bias due to departure from the intended interventions" the most time-consuming domain in the ROBINS-I, items in the NOS were equal. CONCLUSIONS The ROBINS-I and the NOS seem to provide the same reliability but vary in applicability. The over-complicated feature of ROBINS-I may limit its usage and a simplified version is needed.
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Affiliation(s)
- Yuhui Zhang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Litao Huang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dandan Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, Gansu, China
| | - Pengwei Ren
- Clinical Research Center for Respiratory Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi Hong
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Deying Kang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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15
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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
:
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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16
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Shin YY, An SM, Jeong JS, Yang SY, Lee GS, Hong EJ, Jeung EB, Kim SC, An BS. Comparison of steroid hormones in three different preeclamptic models. Mol Med Rep 2021; 23:252. [PMID: 33537808 PMCID: PMC7893799 DOI: 10.3892/mmr.2021.11891] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/06/2020] [Indexed: 12/17/2022] Open
Abstract
Preeclampsia (PE) is a complication of pregnancy and is characterized by hypertension and proteinuria, threatening both the mother and the fetus. However, the etiology of PE has not yet been fully understood. Since the imbalance of steroid hormones is associated with the pathogenesis of PE, investigating steroidogenic mechanisms under various PE conditions is essential to understand the entire spectrum of pregnancy disorders. Therefore, the current study established three PE in vitro and in vivo models, and compared the levels of steroid hormones and steroidogenic enzymes within them. In cellular PE models induced by hypoxia, N‑nitro‑L‑arginine methyl ester hydrocholride (L‑NAME) and catechol‑o‑methyltransferase inhibitor, the levels of steroid hormones, including pregnenolone (P5), progesterone (P4), dehydroepiandrosterone (DHEA) and testosterone tended to decrease during steroidogenesis. Injection of L‑NAME in pregnant rats led to a reduction in the levels of estradiol and P4 through regulation of cholesterol side‑chain cleavage enzyme (CYP11A1) and 3β‑hydroxysteroid dehydrogenase/δ5 4‑isomerase type 1 (HSD3B1), whereas rats treated with COMT‑I exhibited elevated levels of P5 and DHEA by regulation of the CYP11A1 and aromatase cytochrome P450 (CYP19A1) in the placenta and plasma. The reduced uterine perfusion pressure operation decreased CYP11A1 and increased CYP19A1 expression in placental tissues, whereas steroid hormone levels were not altered. In conclusion, the results of the present study suggest that the induction of PE conditions dysregulates the steroid hormones via regulation of steroidogenic enzymes, depending on specific PE symptoms. These findings can contribute to the development of novel diagnostic and therapeutic modalities for PE, by monitoring and supplying appropriate levels of steroid hormones.
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Affiliation(s)
- Ye Young Shin
- Department of Biomaterials Science (BK21 FOUR Program), College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang, Gyeongsangnam 50463, Republic of Korea
| | - Sung-Min An
- Department of Biomaterials Science (BK21 FOUR Program), College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang, Gyeongsangnam 50463, Republic of Korea
| | - Jea Sic Jeong
- Department of Biomaterials Science (BK21 FOUR Program), College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang, Gyeongsangnam 50463, Republic of Korea
| | - Seung Yun Yang
- Department of Biomaterials Science (BK21 FOUR Program), College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang, Gyeongsangnam 50463, Republic of Korea
| | - Geun-Shik Lee
- College of Veterinary Medicine, Kangwon National University, Chuncheon, Gangwon 24341, Republic of Korea
| | - Eui-Ju Hong
- College of Veterinary Medicine, Chungnam National University, Daejeon 34134, Republic of Korea
| | - Eui-Bae Jeung
- College of Veterinary Medicine, Chungbuk National University, Cheongju, Chungbuk 28644, Republic of Korea
| | - Seung Chul Kim
- Department of Obstetrics and Gynecology, Biomedical Research Institute, Pusan National University School of Medicine, Busan 49241, Republic of Korea
| | - Beum-Soo An
- Department of Biomaterials Science (BK21 FOUR Program), College of Natural Resources and Life Science/Life and Industry Convergence Research Institute, Pusan National University, Miryang, Gyeongsangnam 50463, Republic of Korea
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Varagic J, Desvigne-Nickens P, Gamble-George J, Hollier L, Maric-Bilkan C, Mitchell M, Pemberton VL, Redmond N. Maternal Morbidity and Mortality: Are We Getting to the "Heart" of the Matter? J Womens Health (Larchmt) 2020; 30:178-186. [PMID: 33259740 PMCID: PMC8020498 DOI: 10.1089/jwh.2020.8852] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Cardiovascular disease (CVD), including hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy, is a leading cause of pregnancy-related death in the United States. Women who are African American or American Indian/Alaskan Native, have HDP, are medically underserved, are older, or are obese have a major risk for the onset and/or progression of CVD during and after pregnancy. Paradoxically, women with no preexisting chronic conditions or risk factors also experience significant pregnancy-related cardiovascular (CV) complications. The question remains whether substantial physiologic stress on the CV system during pregnancy reflected in hemodynamic, hematological, and metabolic changes uncovers subclinical prepregnancy CVD in these otherwise healthy women. Equally important and similarly understudied is the concept that women's long-term CV health could be detrimentally affected by adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, and diabetes, and preterm birth. Thus, a critical life span perspective in the assessment of women's CV risk factors is needed to help women and health care providers recognize and appreciate not only optimal CV health but also risk factors present before, during, and after pregnancy. In this review article, we highlight new advancements in understanding adverse, pregnancy-related CV conditions and will discuss promising strategies or interventions for their prevention, diagnosis, and treatment.
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Affiliation(s)
- Jasmina Varagic
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Joyonna Gamble-George
- Center for Translational Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Christine Maric-Bilkan
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Megan Mitchell
- Division of Extramural Research Activities, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Victoria L Pemberton
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Nicole Redmond
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
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18
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Nzelu D, Biris D, Karampitsakos T, Nicolaides KK, Kametas NA. First trimester serum angiogenic and anti-angiogenic factors in women with chronic hypertension for the prediction of preeclampsia. Am J Obstet Gynecol 2020; 222:374.e1-374.e9. [PMID: 31705883 DOI: 10.1016/j.ajog.2019.10.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/10/2019] [Accepted: 10/30/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND An imbalance between angiogenic and antiangiogenic factors is thought to be a central pathogenetic mechanism in preeclampsia. In pregnancies that subsequently experience preeclampsia, the maternal serum concentration of the angiogenic placental growth factor is decreased from as early as the first trimester of pregnancy, and the concentration of the antiangiogenic soluble fms-like tyrosine kinase-1 is increased in the last few weeks before the clinical presentation of the disease. Chronic hypertension, which complicates 1-2% of pregnancies, is the highest risk factor for the development of preeclampsia among all other factors in maternal demographic characteristics and medical history. Two previous studies in women with chronic hypertension reported that first-trimester serum placental growth factor and soluble fms-like tyrosine kinase-1 levels were not significantly different between those who experienced superimposed preeclampsia and those who did not, whereas a third study reported that concentrations of placental growth factor were decreased. OBJECTIVE The purpose of this study was to investigate whether, in women with chronic hypertension, serum concentrations of placental growth factor and soluble fms-like tyrosine kinase-1 and soluble fms-like tyrosine kinase-1/placental growth factor ratio at 11+0-13+6 weeks gestation are different between those women who experienced superimposed preeclampsia and those who did not and to compare these values with those in normotensive control subjects. STUDY DESIGN The study population comprised 650 women with chronic hypertension, which included 202 women who experienced superimposed preeclampsia and 448 women who did not experience preeclampsia, and 142 normotensive control subjects. Maternal serum concentration of placental growth factor and soluble fms-like tyrosine kinase-1 were measured by an automated biochemical analyzer and converted into multiples of the expected median with the use of multivariate regression analysis in the control group. Comparisons of placental growth factor and soluble fms-like tyrosine kinase-1 levels and soluble fms-like tyrosine kinase-1/placental growth factor ratio in multiples of the expected median values between the 2 groups of chronic hypertension and the control subjects were made with the analysis of variance or the Kruskal-Wallis test. RESULTS In the group of women with chronic hypertension who experienced preeclampsia compared with those women who did not experience preeclampsia, there were significantly lower median concentrations of serum placental growth factor multiples of the expected median (0.904 [interquartile range, 0.771-1.052] vs 0.948 [interquartile range, 0.814-1.093]; P=.014) and soluble fms-like tyrosine kinase-1 multiples of the expected median (0.895 [interquartile range, 0.760-1.033] vs 0.938 [interquartile range, 0.807-1.095]; P=.013); they were both lower than in the normotensive control subjects (1.009 [interquartile range, 0.901-1.111] and 0.991 [interquartile range, 0.861-1.159], respectively; P<.01 for both). There were no significant differences among the 3 groups in soluble fms-like tyrosine kinase-1/placental growth factor ratios. In women with chronic hypertension, serum placental growth factor and soluble fms-like tyrosine kinase-1 levels provided poor prediction of superimposed preeclampsia (area under the curve, 0.567 [95% confidence interval, 0.537-0.615] and 0.546 [95% confidence interval, 0.507-0.585], respectively). CONCLUSION Women with chronic hypertension, and particularly those who subsequently experienced preeclampsia, have reduced first-trimester concentrations of both placental growth factor and soluble fms-like tyrosine kinase-1.
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19
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Park YS, Kim Y, Kim HY, Ahn KH, Cho GJ, Hong SC, Oh MJ, Kim HJ. Serum sFlt-1, cystatin C and cathepsin B are potential severity markers in preeclampsia: a pilot study. Arch Gynecol Obstet 2020; 301:955-962. [PMID: 32140809 DOI: 10.1007/s00404-020-05478-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/25/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Preeclampsia is associated with abnormal invasion of the trophoblast through decidua and subsequently altered remodeling of the maternal spiral arteries and endothelial dysfunction. This phenomenon is explained by the dysregulation of various kinds of vascular factors and proteases. The purpose of this study was to compare the circulating levels of sFlt-1, cathepsin B, and cystatin C in preeclamptic and normotensive pregnancies. STUDY DESIGN Sixty-two pregnant women were enrolled in this prospective study. Twenty women were preeclamptic and 42 were normotensive. Serum levels of sFlt-1, cathepsin B, and cystatin C were measured using an enzyme-linked immunosorbent assay kit. RESULTS Circulating levels of sFlt-1, cathepsin B, and cystatin C were significantly higher in preeclamptic than in normotensive pregnant women (p < 0.001; p = 0.017; p = 0.003). Preeclamptic women with severe features demonstrated significantly higher levels of cathepsin B (p = 0.05). Serum sFlt-1 and cystatin C levels were positively correlated with elevated systolic and diastolic blood pressure. The levels of cathepsin B were positively correlated with alanine and aspartate aminotransferase. The amount of 24 h proteinuria was positively, but non-significantly correlated with sFlt-1 and cystatin C. CONCLUSIONS In addition to sFlt-1 levels, the serum levels of cathepsin B and cystatin C significantly change when preeclampsia develops. These markers are associated with severity markers of elevated blood pressure and liver injury in preeclampsia.
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Affiliation(s)
- Ye Sul Park
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yezi Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ho Yeon Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Ki-Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Soon-Cheol Hong
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min-Jeong Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hai-Joong Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
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20
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Stepan H, Hund M, Andraczek T. Combining Biomarkers to Predict Pregnancy Complications and Redefine Preeclampsia: The Angiogenic-Placental Syndrome. Hypertension 2020; 75:918-926. [PMID: 32063058 PMCID: PMC7098437 DOI: 10.1161/hypertensionaha.119.13763] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Placental dysfunction underlies a spectrum of perinatal pathologies, including preeclampsia and fetal growth restriction. Angiogenesis-related factors, including sFlt-1 (soluble fms-like tyrosine kinase 1) and PlGF (placental growth factor), play an important role in placental dysfunction; altered levels are detectable several weeks before onset of pregnancy complications. In vitro diagnostic tests for these biomarkers can improve early diagnosis and facilitate prediction of maternal and fetal outcomes. We assessed evidence for combining angiogenic biomarkers with other biomarkers or clinical parameters to predict maternal/fetal outcomes in pregnant women with placental dysfunction. Pooled information on placental perfusion (ultrasonography, mean arterial pressure), clinical characteristics, and biomarker levels (PlGF) can improve first-trimester prediction and preeclampsia diagnosis. Angiogenic factors (sFlt-1/PlGF ratio; PlGF alone) with or without clinical characteristics can facilitate second-/third-trimester prediction of early-onset and late-onset preeclampsia. A combination of increased sFlt-1/PlGF ratio and ultrasound can rule out early fetal growth restriction. The sFlt-1/PlGF ratio is also a reliable tool for discriminating between pregnancy-related hypertensive disorders, including superimposed preeclampsia and gestational hypertension. Analysis of angiogenic factors with or without uterine Doppler substantially improves sensitivity and specificity for predicting adverse outcomes and iatrogenic preterm delivery. We propose to extend the American College of Obstetricians and Gynecologists definition of preeclampsia in the future to include the combination of new-onset hypertension and new-onset of altered angiogenic factors (sFlt-1/PlGF ratio or PlGF alone). In summary, altered angiogenic biomarkers indicate placental dysfunction, and their implementation into clinical practice will help reduce the considerable burden of morbidity and mortality associated with adverse pregnancy outcomes as a consequence of angiogenic-placental syndrome.
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Affiliation(s)
- Holger Stepan
- From the Department of Obstetrics, Leipzig University, Leipzig, Germany (H.S., T.A.)
| | - Martin Hund
- Roche Diagnostics International, Ltd, Rotkreuz, Switzerland (M.H.)
| | - Theresa Andraczek
- From the Department of Obstetrics, Leipzig University, Leipzig, Germany (H.S., T.A.)
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21
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Orozco Guillén AO, Velazquez Silva RI, Moguel González B, Guell YA, Garciadiego Fossas P, Custodio Gómez IG, Miranda Araujo O, Soto Abraham V, Piccoli GB, Madero M. Acute IgA-Dominant Glomerulonephritis Associated with Syphilis Infection in a Pregnant Teenager: A New Disease Association. J Clin Med 2019; 8:jcm8010114. [PMID: 30669309 PMCID: PMC6352144 DOI: 10.3390/jcm8010114] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 01/08/2019] [Accepted: 01/14/2019] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) is increasingly recognized as a risk factor in pregnancy; the differential diagnosis between CKD and preeclampsia (PE) may be of pivotal importance for pregnancy management and for early treatment of CKD. Acknowledging this connection may be useful also in a wider context, such as in the case reported in this paper, which for the first time describes an association between syphilis infection and IgA-dominant glomerulonephritis. A 16-year-old woman, referred to a general hospital due to a seizure, was found to be unknowingly pregnant. Based on hypertension and nephrotic proteinuria, she was initially diagnosed with PE. Immunological tests, as well as hepatitis and HIV tests showed negative results. However, secondary syphilis was diagnosed. In discordance with the PE diagnosis, urinalysis showed glomerular microhematuria with cellular casts. Proteinuria and hypertension did not remit after delivery, which was made via caesarean section, due to uncontrolled hypertension, at an estimated gestational age of 29 weeks. A male baby, weighing 1.1 kg (6.5 centile) was born. The baby was hospitalized in the neonatal intensive care unit, where he developed subependymal hemorrhage and thrombocytopenia, and neonatal syphilis was diagnosed. The mother underwent a kidney biopsy one week after delivery, leading to the diagnosis of IgA-dominant postinfectious glomerulonephritis. Mother and child were treated with support and antibiotic therapy, and were discharged in good clinical conditions four weeks later. Four months after delivery, the mother was normotensive without therapy, with normal kidney function and without hematuria or proteinuria. In conclusion, this case suggests that IgA-dominant postinfectious glomerulonephritis should be added to the spectrum of syphilis-associated glomerulonephritides, and underlines the need for a careful differential diagnosis with CKD in all cases of presumed PE. While diagnosis relies on kidney biopsy, urinary sediment, a simple and inexpensive test, can be the first step in distinguishing PE from other nephropathies.
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Affiliation(s)
| | | | - Bernardo Moguel González
- Department of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City 14080, Mexico.
| | - Yubia Amaya Guell
- Department of Foetal Medicine, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Pamela Garciadiego Fossas
- Department of Infectolog, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Iris Guadalupe Custodio Gómez
- Department of Gynaecology and Obstetrics, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Osvaldo Miranda Araujo
- Department of Gynaecology and Obstetrics, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City 11000, Mexico.
| | - Virgilia Soto Abraham
- Department of Pathology, National Institute of Cardiology "Ignacio Chávez", Mexico City 14000, Mexico.
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences University of Torino, 10043 Torino, Italy.
- Department of Nephrology, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Magdalena Madero
- Department of Pathology, National Institute of Cardiology "Ignacio Chávez", Mexico City 14000, Mexico.
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Saleh L, van den Meiracker AH, Geensen R, Kaya A, Roeters van Lennep JE, Duvekot JJ, Verdonk K, Steegers EAP, Russcher H, Danser AHJ, Visser W. Soluble fms-like tyrosine kinase-1 and placental growth factor kinetics during and after pregnancy in women with suspected or confirmed pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:751-757. [PMID: 28600845 DOI: 10.1002/uog.17547] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/21/2017] [Accepted: 05/26/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the evolution of the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio in women with suspected or confirmed pre-eclampsia (PE), and to investigate the changes in sFlt-1 and PlGF levels in pre-eclamptic women after delivery. METHODS This was an exploratory study in which secondary analysis was performed on a prospective cohort study that enrolled women with a singleton pregnancy and suspected or confirmed PE from 18 weeks' gestation, carried out between December 2013 and April 2016 at the Department of Obstetrics of the Erasmus Medical Center in Rotterdam. sFlt-1 and PlGF were determined using Roche Diagnostics Elecsys assays in two groups of patients. In the first group, patients with suspected or confirmed PE had sFlt-1 and PlGF levels measured at least twice during their pregnancy. Changes in these biomarkers over the course of pregnancy were compared for patients in this group with a baseline sFlt-1/PlGF ratio of ≤ 38 and for those with a ratio > 38. In the second group, sFlt-1 and PlGF levels of women with PE or HELLP syndrome were measured before and after delivery. For this group, pre- and postpartum sFlt-1 and PlGF levels were compared and half-lives were calculated. RESULTS Women with suspected or confirmed PE for whom sFlt-1 and PlGF levels were measured at least twice during pregnancy (n = 46) had a median gestational age at inclusion of 26 weeks (range, 18-40 weeks). In 27 of the 30 patients with sFlt-1/PlGF ratio ≤ 38 at baseline, thereby ruling out PE, the sFlt-1/PlGF ratio remained stable for up to 100 days. In the remaining three patients with a ratio ≤ 38 and in most of the 16 patients with a ratio > 38, the ratio increased further. For women diagnosed with PE or HELLP syndrome for whom sFlt-1 and PlGF levels were measured before and after delivery (n = 26), median gestational age at inclusion was 29 weeks (range, 16-37 weeks) and median time between antepartum measurement and delivery was 2 days (range, 1-17 days). In this group, after delivery, sFlt-1 dropped to < 1% of its pre-delivery value, with a half-life of 1.4 ± 0.3 days, while PlGF dropped to ∼30% of its pre-delivery value, with a half-life of 3.7 ± 4.3 days. CONCLUSIONS Based on this small cohort, up to 10% of pregnant women admitted with suspected or confirmed PE presenting with a sFlt-1/PlGF ratio of ≤ 38 display a rise in sFlt-1/PlGF ratio in subsequent weeks, implying that repeat determination of the sFlt-1/PlGF ratio is required to exclude definitively a diagnosis of PE. Furthermore, the rapid and pronounced decline in sFlt-1 levels after delivery in patients with PE/HELLP syndrome suggests that sFlt-1, in contrast to PlGF, is almost entirely derived from the placenta. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L Saleh
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A H van den Meiracker
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - R Geensen
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Kaya
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J E Roeters van Lennep
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K Verdonk
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - E A P Steegers
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - H Russcher
- Department of Clinical Chemistry, Erasmus MC, Rotterdam, The Netherlands
| | - A H J Danser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - W Visser
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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23
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Sabriá E, Lequerica-Fernández P, Lafuente-Ganuza P, Eguia-Ángeles E, Escudero AI, Martínez-Morillo E, Barceló C, Álvarez FV. Addition of N-terminal pro-B natriuretic peptide to soluble fms-like tyrosine kinase-1/placental growth factor ratio > 38 improves prediction of pre-eclampsia requiring delivery within 1 week: a longitudinal cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:758-767. [PMID: 29498431 DOI: 10.1002/uog.19040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/19/2018] [Accepted: 02/19/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Short-term prediction of pre-eclampsia (PE) using the soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio is characterized by frequent false-positive results. As such, no treatment can be recommended to test-positive patients and multiple measurements are often required. The aim of this study was to evaluate the effectiveness of N-terminal pro-B natriuretic peptide (NT-proBNP), uric acid and the sFlt-1/PlGF ratio for prediction of delivery with PE within 1 week in singleton pregnancies with suspected PE and sFlt-1/PlGF ratio > 38. METHODS This was a longitudinal prospective cohort study of singleton pregnancies presenting at 24 + 0 to 36 + 6 weeks of gestation with clinically suspected PE and sFlt-1/PlGF ratio > 38, enrolled between January 2015 and June 2017. Multiple samples per patient were allowed but were restricted to one sample per gestational week. From 495 enrolled patients, 270 blood samples from 134 patients were ultimately analyzed. By using generalized estimating equations (GEE), the best-fit model was selected for prediction of delivery with PE within 1 week. The predictive value of this model was then assessed using area under the paired-ROC curve (AUC) analysis. RESULTS The best-fit model included the sFlt-1/PlGF ratio, NT-proBNP and the gestational week at the time of the measurement. This combined model was compared with the GEE model based on the sFlt-1/PlGF ratio and the gestational week at the time of the measurement (reduced model). The AUC for the combined model was 0.845 (95% CI, 0.787-0.896), which was significantly greater (P = 0.011) than that of the reduced model (0.786 (95% CI, 0.722-0.844)). CONCLUSION The addition of NT-proBNP assessment improves the short-term prediction of delivery as a result of PE compared with sFlt-1/PlGF ratio alone, when the sFlt-1/PlGF ratio is > 38. This finding should be considered in future research on the assessment of short-term risk of delivery as a result of PE. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- E Sabriá
- Obstetrics and Gynaecology Department, Hospital-Residència Sant Camil, Barcelona, Spain
| | - P Lequerica-Fernández
- Biochemistry Department, Laboratory Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - P Lafuente-Ganuza
- Biochemistry Department, Laboratory Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - E Eguia-Ángeles
- Biochemistry Department, Laboratory Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - A I Escudero
- Obstetrics and Gynaecology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - E Martínez-Morillo
- Obstetrics and Gynaecology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - C Barceló
- Department of Computer Science and Applied Mathematics, Universitat de Girona, Girona, Spain
| | - F V Álvarez
- Biochemistry Department, Laboratory Medicine, Hospital Universitario Central de Asturias, Oviedo, Spain
- Department of Biochemistry and Molecular Biology, Universidad de Oviedo, Oviedo, Spain
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24
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First and Second Trimester Serum sFlt-1/PlGF Ratio and Subsequent Preeclampsia: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:618-626. [DOI: 10.1016/j.jogc.2017.07.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/13/2017] [Accepted: 07/16/2017] [Indexed: 12/29/2022]
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25
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Webster LM, Gill C, Seed PT, Bramham K, Wiesender C, Nelson-Piercy C, Myers JE, Chappell LC. Chronic hypertension in pregnancy: impact of ethnicity and superimposed preeclampsia on placental, endothelial, and renal biomarkers. Am J Physiol Regul Integr Comp Physiol 2018. [PMID: 29513563 DOI: 10.1152/ajpregu.00139.2017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Black ethnicity is associated with worse pregnancy outcomes in women with chronic hypertension. Preexisting endothelial and renal dysfunction and poor placentation may contribute, but pathophysiological mechanisms underpinning increased risk are poorly understood. This cohort study aimed to investigate the relationship between ethnicity, superimposed preeclampsia, and longitudinal changes in markers of endothelial, renal, and placental dysfunction in women with chronic hypertension. Plasma concentrations of placental growth factor (PlGF), syndecan-1, renin, and aldosterone and urinary angiotensinogen-to-creatinine ratio (AGTCR), protein-to-creatinine ratio (PCR), and albumin-to-creatinine ratio (ACR) were quantified during pregnancy and postpartum in women with chronic hypertension. Comparisons of longitudinal biomarker concentrations were made using log-transformation and random effects logistic regression allowing for gestation. Of 117 women, superimposed preeclampsia was diagnosed in 21% ( n = 25), with 24% ( n = 6) having an additional diagnosis of diabetes. The cohort included 63 (54%) women who self-identified as being of black ethnicity. PlGF concentrations were 67% lower [95% confidence interval (CI) -79 to -48%] and AGTCR, PCR, and ACR were higher over gestation, in women with subsequent superimposed preeclampsia (compared with those without superimposed preeclampsia). PlGF <100 pg/ml at 20-23.9 wk of gestation predicted subsequent birth weight <3rd percentile with 88% sensitivity (95% CI 47-100%) and 83% specificity (95% CI 70-92%). Black women had 43% lower renin (95% CI -58 to -23%) and 41% lower aldosterone (95%CI -45 to -15%) concentrations over gestation. Changes in placental (PlGF) and renal (AGTCR/PCR/ACR) biomarkers predated adverse pregnancy outcome. Ethnic variation in the renin-angiotensin-aldosterone system exists in women with chronic hypertension in pregnancy and may be important in treatment selection.
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Affiliation(s)
- Louise M Webster
- Women's Health Academic Centre, King's College London, St. Thomas' Hospital , London , United Kingdom
| | - Carolyn Gill
- Women's Health Academic Centre, King's College London, St. Thomas' Hospital , London , United Kingdom
| | - Paul T Seed
- Women's Health Academic Centre, King's College London, St. Thomas' Hospital , London , United Kingdom
| | - Kate Bramham
- Women's Health Academic Centre, King's College London, St. Thomas' Hospital , London , United Kingdom
| | - Cornelia Wiesender
- Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, University Hospitals of Leicester National Health Service Trust , Leicester , United Kingdom
| | - Catherine Nelson-Piercy
- Women's Health Academic Centre, King's College London, St. Thomas' Hospital , London , United Kingdom
| | - Jenny E Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre , Manchester , United Kingdom.,St. Mary's Hospital, Manchester University National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Lucy C Chappell
- Women's Health Academic Centre, King's College London, St. Thomas' Hospital , London , United Kingdom
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26
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Abstract
Preeclampsia is characterized by blood pressure greater than 140/90 mmHg in the second half of pregnancy. This disease is a major contributor to preterm and low birth weight babies. The early delivery of the baby, which becomes necessary for maintaining maternal well-being, makes preeclampsia the leading cause for preterm labor and infant mortality and morbidity. Currently, there is no cure for this pregnancy disorder. The current clinical management of PE is hydralazine with labetalol and magnesium sulfate to slow disease progression and prevent maternal seizure, and hopefully prolong the pregnancy. This review will highlight factors implicated in the pathophysiology of preeclampsia and current treatments for the management of this disease.
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Cerdeira AS, Agrawal S, Staff AC, Redman CW, Vatish M. Angiogenic factors: potential to change clinical practice in pre-eclampsia? BJOG 2017; 125:1389-1395. [PMID: 29193681 PMCID: PMC6175139 DOI: 10.1111/1471-0528.15042] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2017] [Indexed: 12/17/2022]
Abstract
Pre‐eclampsia is a complex disease with significant maternal and fetal morbidity and mortality. Its syndromic nature makes diagnosis and management difficult. The field is rapidly evolving with the definition of pre‐eclampsia being challenged by some organisations, with proteinuria no longer being essential in the presence of other features. In the last decade, angiogenic factors, in particular soluble fms‐like tyrosine kinase 1 (sFlt‐1), have emerged as important molecules in the pathogenesis of pre‐eclampsia. Here we review the most recent evidence regarding the potential of these factors as biomarkers and therapeutic targets for pre‐eclampsia. Tweetable abstract A review of angiogenic factors, sFlt‐1 and PlGF, in the diagnosis, prediction and management of pre‐eclampsia. A review of angiogenic factors, sFlt‐1 and PlGF, in the diagnosis, prediction and management of pre‐eclampsia.
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Affiliation(s)
- A S Cerdeira
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - S Agrawal
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - A C Staff
- Division of Obstetrics and Gynaecology, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - C W Redman
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - M Vatish
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
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Kemse N, Sundrani D, Kale A, Joshi S. Maternal Micronutrients, Omega-3 Fatty Acids and Gene Expression of Angiogenic and Inflammatory Markers in Pregnancy Induced Hypertension Rats. Arch Med Res 2017; 48:414-422. [PMID: 29133192 DOI: 10.1016/j.arcmed.2017.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 10/17/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Preeclampsia is a disorder of pregnancy and is associated with inflammation and altered angiogenesis. The present study examines the effect of micronutrient and omega-3 fatty acid supplementation (individual, as well as combined) on genes involved in inflammation and angiogenesis, as well as global DNA methylation levels in a pregnancy induced hypertension (PIH) rat model. METHODS Pregnant Wistar rats were randomly assigned to six dietary groups: control, PIH (Pregnancy induced hypertension) Induced; PIH Induced with micronutrient supplements with vitamin B12 (PIHB), folate (PIHF), omega-3 fatty acid (PIHO), and combined supplementation (PIHC) (micronutrients and omega-3 fatty acids). Half the dams were dissected on 20 d of gestation to collect placental tissue, and half were allowed to deliver normally on 22 d of gestation and were assigned to a postnatal control diet. The offspring were dissected at 3 month of age. RESULTS PIH induction increased the mRNA levels of the pro inflammatory cytokine IL-6 (p <0.01), while lowering the placental anti inflammatory cytokine IL-10 (p <0.05) at d20 of gestation. It also increased the expression of TNF-α (p <0.05) in the liver of 3 month old offspring. The combined supplementation of folic acid, vitamin B12 and omega-3 fatty acids improved placental IL-10 levels and decreased TNF-α levels in offspring livers. CONCLUSION Our data indicate that a combined supplementation of vitamin B12, folic acid and omega-3 fatty acid was useful for the better management of preeclampsia in an animal model.
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Affiliation(s)
- Nisha Kemse
- Department of Nutritional Medicine, Interactive Research School for Health Affairs, Bharati Vidyapeeth University, Pune Satara Road, Pune, India
| | - Deepali Sundrani
- Department of Nutritional Medicine, Interactive Research School for Health Affairs, Bharati Vidyapeeth University, Pune Satara Road, Pune, India
| | - Anvita Kale
- Department of Nutritional Medicine, Interactive Research School for Health Affairs, Bharati Vidyapeeth University, Pune Satara Road, Pune, India
| | - Sadhana Joshi
- Department of Nutritional Medicine, Interactive Research School for Health Affairs, Bharati Vidyapeeth University, Pune Satara Road, Pune, India.
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Piccoli GB, Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Spotti D, Giacchino F, Attini R, Limardo M, Maxia S, Fois A, Gammaro L, Todros T. A best practice position statement on the role of the nephrologist in the prevention and follow-up of preeclampsia: the Italian study group on kidney and pregnancy. J Nephrol 2017; 30:307-317. [PMID: 28434090 DOI: 10.1007/s40620-017-0390-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/09/2017] [Indexed: 02/07/2023]
Abstract
Preeclampsia (PE) is a protean syndrome causing a transitory kidney disease, characterised by hypertension and proteinuria, ultimately reversible after delivery. Its prevalence is variously estimated, from 3 to 5% to 10% if all the related disorders, including also pregnancy-induced hypertension (PIH) and HELLP syndrome (haemolysis, increase in liver enzyme, low platelets) are included. Both nephrologists and obstetricians are involved in the management of the disease, according to different protocols, and the clinical management, as well as the role for each specialty, differs worldwide. The increased awareness of the role of chronic kidney disease in pregnancy, complicating up to 3% of pregnancies, and the knowledge that PE is associated with an increased risk for development of CKD later in life have recently increased the interest and redesigned the role of the nephrologists in this context. However, while the heterogeneous definitions of PE, its recent reclassification, an emerging role for biochemical biomarkers, the growing body of epidemiological data and the new potential therapeutic interventions lead to counsel long-term follow-up, the lack of resources for chronic patients and the increasing costs of care limit the potential for preventive actions, and suggest tailoring specific interventional strategies. The aim of the present position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature and to try to identify theoretical and pragmatic bases for an agreed management of PE in the nephrological setting, with particular attention to the prevention of the syndrome (recurrent PE, presence of baseline CKD) and to the organization of the postpartum follow-up.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy. .,Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
| | | | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milan, Italy
| | - Donatella Spotti
- Nephrology and Dialysis, IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Turin, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Antioco Fois
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Linda Gammaro
- Nephrology Ospedale Fracastoro San Bonifacio, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Turin, Italy
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