Maternal cardiac risks in pre-eclamptic patients

Serum cystatin-c as predictive factor of preeclampsia: A meta-analysis of 27 observational studies

OBJECTIVE

Serum cystatin-c is a protein that is filtered freely through the glomerulus and reabsorbed and degraded by proximal tubular cells and can be used as a biomarker of renal function. Its levels rise during the third trimester and decrease in the postpartum period. The purpose of the present meta-analysis is to assess the performance of serum cystatin-c for the prediction of preeclampsia.

DESIGN AND METHODS

We used the Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar. We selected all observational studies (both prospective and retrospective) that investigated the accuracy of cystatin-c in predicting preeclampsia. Statistical meta-analysis was performed with the RevMan 5.3 and Stata/IC 13.0 software, using hierarchical models to develop the SROC curve.

RESULTS

The quantitative synthesis was based in 27 studies with a total number of 2,320 women. Serum cystatin-c levels were higher in preeclamptic women compared to healthy pregnant controls (MD: 0.40 mg/l, 95% CI [0.33, 0.46]). The pooled sensitivity of serum cystatin-c for the prediction of preeclampsia was 0.85 (95% CI [0.79-0.89]) and the pooled specificity 0.84 (95% CI [0.77-0.90]. Fagan's nomogram indicated that the post-test probability increased to 14% (positive test) and decreased to 1% (negative test), when the pre-test probability was set at 3%.

CONCLUSIONS

According to the findings of our study serum cystatin-c seems to be a promising biomarker for the detection of preeclampsia during the third trimester of pregnancy. Therefore, its implementation in future predictive models in the field is recommended.

Epidemiological analysis of maternal lipid levels during the second trimester in pregnancy and the risk of adverse pregnancy outcome adjusted by pregnancy BMI

BACKGROUND

Pregnancy is accompanied by profound changes in lipid metabolism. We aimed to assess whether effects of second trimester body mass index and maternal lipid concentrations are associated with an increased risk of adverse pregnancy outcomes.

METHODS

We investigated the serum levels of maternal lipids during the second trimester in pregnancy, and analyzed associations between the lipid levels and the risk of adverse pregnancy outcome. Seven hundred and seventy-four pregnant women were enrolled in this study between February 2016 and June 2016. Multivariate logistic regression analysis was conducted to estimate the relative risk between maternal lipids and adverse pregnancy outcome.

RESULTS

Compared with the control group, during the second trimester of pregnancy, BMI, TG, and Lp(a) were risk factors for gestational diabetes mellitus; middle trimester pregnancy BMI, Lp(a), and APO-B were risk factors for pre-eclampsia; second trimester BMI and TG/HDL-C were risk factors for macrosomia; age and Lp(a) were uterine atony postpartum hemorrhage risk factors, while APO-AI was a protective factor of uterine inertia and postpartum hemorrhage; second trimester BMI, TCH, Lp(a), and TG/HDL-C were risk factors for fetal distress, while parity was a protective factor against fetal distress.

CONCLUSION

Abnormal blood lipid levels in pregnancy are significantly associated with GDM, pre-eclampsia, and other adverse pregnancy outcomes.

Study on the correlation between adipocyte fatty-acid binding protein, glucolipid metabolism, and pre-eclampsia

AIM

We aimed to explore the relation between the level of adipocyte fatty-acid binding protein (A-FABP) in the gestational period and related indices of glucolipid metabolism, and the possible mechanisms of occurrence and development of pre-eclampsia.

METHODS

Seventy-six pre-eclampsia patients were enrolled and divided into the mild pre-eclampsia (n = 42) and severe pre-eclampsia (n = 34) groups. Forty-eight healthy pregnant women were selected as a control group. The indices of all participants were examined, including serum A-FABP, fasting insulin (FINS), fasting blood glucose, total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL), and homeostatic model assessment insulin resistance (HOMA-IR) index was calculated. After the delivery of the placenta, the level of A-FABP in the placenta was detected by immunochemistry. Then, the correlation between serum A-FABP and indices of glucolipid metabolism and placental A-FABP were analyzed.

RESULTS

Serum A-FABP, FINS, TG, TC, HOMA-IR, and placental A-FABP were significantly higher in pre-eclampsia patients and the level of HDL was obviously lower than in the control group. Serum A-FABP was positively correlated with FINS, TG, TC, and HOMA-IR, and placental A-FABP was negatively correlated with HDL in pre-eclampsia patients. In the control group, serum A-FABP was positively correlated only with TG, and uncorrelated with the other indices (P > 0.05).

CONCLUSION

The level of A-FABP was correlated with insulin resistance and indices of glucolipid metabolism in pre-eclampsia patients. High-levels of A-FABP might increase insulin resistance by causing glucose and lipid metabolism disorders and ultimately inducing the occurrence and development of pre-eclampsia.

[Relationship between lipid alterations during pregnancy and adverse pregnancy outcomes]

Lipids play an important role during pregnancy, and in this period major changes occur in lipoprotein metabolism. During the third trimester plasma cholesterol and triglyceride levels are substantially increased, returning to normal after delivery. Described associations between increased morbidity during pregnancy and excessive increases in plasma cholesterol and triglycerides. For this reason we have reviewed the relationship between lipid alterations, preeclampsia, gestational diabetes and preterm birth. The overall metabolic control can improve pregnancy outcomes, and the assessment of supraphysiological changes in lipid profile will classify pregnancy risk at a higher level, which would entail a stricter control.

Lipoprotein (a): impact by ethnicity and environmental and medical conditions

Levels of lipoprotein (a) [Lp(a)], a complex between an LDL-like lipid moiety containing one copy of apoB, and apo(a), a plasminogen-derived carbohydrate-rich hydrophilic protein, are primarily genetically regulated. Although stable intra-individually, Lp(a) levels have a skewed distribution inter-individually and are strongly impacted by a size polymorphism of the LPA gene, resulting in a variable number of kringle IV (KIV) units, a key motif of apo(a). The variation in KIV units is a strong predictor of plasma Lp(a) levels resulting in stable plasma levels across the lifespan. Studies have demonstrated pronounced differences across ethnicities with regard to Lp(a) levels and some of this difference, but not all of it, can be explained by genetic variations across ethnic groups. Increasing evidence suggests that age, sex, and hormonal impact may have a modest modulatory influence on Lp(a) levels. Among clinical conditions, Lp(a) levels are reported to be affected by kidney and liver diseases.

Pre-Conception Dyslipidemia Is Associated with Development of Preeclampsia and Gestational Diabetes Mellitus

Introduction

The association between glucose intolerance, elevated blood pressure and abnormal lipid levels is well established and comprises the basis of metabolic syndrome pathophysiology. We hypothesize that abnormal preconception lipid levels are associated with the increased risk of severe pregnancy complications such as preeclampsia and gestational diabetes mellitus.

Methods

We included all singleton deliveries (n = 27,721) of women without known cardiovascular morbidity and preeclampsia and gestational diabetes mellitus during previous pregnancies. Association between preconception low high density lipoprotein cholesterol (HDLc level≤50 mg/dL), high triglycerides (level≥150 mg/dL) and the primary outcome (composite of gestational diabetes mellitus/or preeclampsia) was assessed using Generalized Estimation Equations.

Results

Primary outcome of preeclampsia and/or gestational diabetes was observed in a total of 3,243 subjects (11.7%). Elevated triglycerides and low HDLc were independently associated with the primary outcome: with odds ratio (OR) of 1.61 (95% CI 1.29–2.01) and OR = 1.33 (95% CI 1.09–1.63), respectively, after adjusting for maternal age, weight, blood pressure, repeated abortions, fertility treatments and fasting glucose. There was an interaction between the effects of HDLc≤50 mg/dL and triglycerides≥150 mg/dL with an OR of 2.69 (95% CI 1.73–4.19).

Conclusions

Our analysis showed an increased rate of preeclampsia and/or gestational diabetes in women with low HDLc and high triglycerides values prior to conception. In view of the severity of these pregnancy complications, we believe this finding warrants a routine screening for the abnormal lipid profile among women of a child-bearing age.

Hypertension in pregnancy is associated with elevated homocysteine levels later in life

OBJECTIVE

Hyperhomocysteinemia is associated with an elevated cardiovascular disease risk. We examined whether women with a history of hypertension in pregnancy are more likely to have a high level of serum homocysteine decades after pregnancy.

STUDY DESIGN

Serum homocysteine was measured at a mean age of 60 years in nulliparous women (n = 216), and women with a history of normotensive (n = 1825) or hypertensive (n = 401) pregnancies who participated in the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Relationships between homocysteine and pregnancy history were examined by linear and logistic regression, controlling for multiple covariates including personal and family history of hypertension, diabetes, obesity, tobacco use, and demographics.

RESULTS

A history of hypertension in pregnancy, when compared with normotensive pregnancy, was associated with a 4.5% higher serum homocysteine level (P = .015) and 1.60-fold increased odds of having an elevated homocysteine (95% confidence interval, 1.15-2.21; P = .005) after adjusting for potentially confounding covariates. In contrast, a history of normotensive pregnancy, as compared with nulliparity, was associated with a 6.1% lower serum homocysteine level (P = .005) and a 0.49-fold reduced odds of elevated homocysteine levels (95% confidence interval, 0.32-0.74; P < .001).

CONCLUSION

Homocysteine levels decades after pregnancy are higher in women with a history of pregnancy hypertension, even after controlling for potential confounders. Thus, pregnancy history may prompt homocysteine assessment and risk modification in an attempt at primary prevention of cardiovascular disease.

Cardiovascular risk, lipids and pregnancy: preeclampsia and the risk of later life cardiovascular disease

It has been widely thought that the effects of hypertension in pregnancy reversed after delivery and hypertension values returned to their pre-pregnancy level as it was seen as a disease of short duration in otherwise healthy young women. However, recent studies have demonstrated that the principal underlying abnormality, endothelial dysfunction, remains in women who had preeclampsia and that it is this damage that increases the risk of developing cardiovascular disease (CVD) in later life. The contributions of hypertension and dyslipidaemia before and during the pregnancy are also important and contribute to future risk. Serum lipids are complex and change dramatically in pregnancy. In general there is an increase in most plasma lipid components, notably triglycerides, total cholesterol and the major particles of HDL and LDL. Aberrations or exaggerations in this shift (i.e. decrease HDL and a greater increase in LDL) are associated with poor outcomes of pregnancy such as preeclampsia. Long term cardiovascular disease is influenced by preeclampsia and in part potentially by the lipid changes which escalate late in disease. Whether we can influence the risk of preeclampsia by controlling cardiovascular risk factors preceding or during preeclampsia, or cardiovascular disease after preeclampsia is yet to be determined. Ultimately, strategies to control lipid concentrations will only be viable when we understand the safety to the mother at the time of the pregnancy, and to the foetus both immediately and in the very long term. Strategies to control blood pressure are well established in the non-pregnant population, and previous preeclampsia and gestational hypertension should be considered in any cardiovascular risk profile. Whether control of blood pressure in the pregnancy per se is of any longer term benefit is also yet to be determined.

Maternal serum cholesterol levels are elevated from the 1st trimester of pregnancy: a cross-sectional study

Cholesterol is monitored in the non-pregnant adult population, where normal values are established. Although reported to be elevated in pregnancy, cholesterol is neither routinely measured nor treated. We aimed to investigate cholesterol levels throughout pregnancy and to establish reference values for cholesterol in healthy pregnant women. This was a cross-sectional analysis of serum cholesterol in healthy women with an uncomplicated singleton pregnancy. Pregnant women attending for antenatal care were recruited and cholesterol levels assayed at 12, 20, 28 and 36 weeks' gestation and on day 1-3 postpartum. A total of 222 women were recruited. The majority (95%) were white Irish, with a median age of 31 years (range 16-46). Median BMI was 25.9 kg/m2 (range 18-40) and 16% were smokers. Cholesterol levels were elevated in all trimesters of pregnancy, with median values from 1st trimester raised outside the non-pregnant adult range. High-density lipoprotein (HDL) levels ranged from 0.9 to 3.7 mmol/l and low-density lipoprotein (LDL) levels ranged from 1.3 to 6.1 mmol/l. Fasting, smoking and obesity did not have any significant effects on results. Total and LDL-cholesterol levels were raised throughout pregnancy. Levels were above non-pregnant adult ranges as early as the 1st trimester. The implications of this on fetus and mother are undetermined and deserve further investigation.

The current status of lipoprotein (a) in pregnancy: a literature review

BACKGROUND AND PURPOSE

Lipoprotein (Lp) (a) is a neglected element of the blood lipid profile. It is now recognized as a determinant of coronary heart disease progression and its role in atherosclerosis and its ability to induce thrombosis make it potentially important in the course of normal and complicated pregnancies. Pregnancy involves a major transformation of metabolism to sustain fetal growth. Multiple studies have been conducted on Lp(a) in pregnancy, and it is timely to synthesize and evaluate this evidence.

METHODS AND SUBJECTS

We reviewed the MEDLINE database for all articles published concerning "lipoprotein a" and "pregnancy" from May 2003 to May 2012. A previous comprehensive review assessed the literature up to May 2003.

RESULTS

We critically analyzed 14 studies detailing the effect of complications in pregnancy on Lp(a) profile, and subsequent pregnancy outcomes where available. Studies evaluating the normal metabolic response to pregnancy, pregnancies complicated by pre-eclampsia and intra-uterine growth restriction were reviewed.

CONCLUSIONS

A substantial mass of data has accumulated describing Lp(a) changes in pregnancy. The diversity of study design limits the ability to draw broad-ranging conclusions, but brings into focus the important questions remaining, which we discuss.

Positive correlation between serum levels of adiponectin and homocysteine in pre-eclampsia

AIM

The aims of the present study were to assess the correlation between homocysteine and adiponectin and the homocysteine-to-adiponectin ratio in pre-eclampsia compared with normal pregnant women.

MATERIALS AND METHODS

The study population consisted of 30 women with pre-eclampsia and 30 normal pregnant women. Serum levels of total adiponectin and total homocysteine were assessed using commercially available enzyme-linked immunosorbent assay methods. Data are presented as median.

RESULTS

Serum levels of total adiponectin correlated directly with total homocysteine in both pre-eclampsia (r = 0.48, P = 0.01) and normal pregnancy (r = 0.68, P = 0.001). The homocysteine-to-adiponectin ratio was increased significantly in pre-eclampsia compared with normal pregnancy (0.90 vs 0.70, P = 0.03). Compared with normal pregnancy, women with severe pre-eclampsia showed significant increase in total adiponectin (14.29 vs 10.24, P = 0.01), total homocysteine (13.80 vs 7.25, P = 0.000) and homocysteine-to-adiponectin ratio (0.92 vs 0.70, P = 0.02). Women with mild pre-eclampsia had higher values of total adiponectin (16.19 vs 10.24, P = 0.000) and total homocysteine (13.11 vs 7.25, P = 0.000) compared with normal pregnancy. No significant differences were observed between mild and severe pre-eclampsia.

CONCLUSION

The present study showed a positive association between adiponectin and homocysteine in pre-eclampsia. The homocysteine-to-adiponectin ratio may be an informative biomarker for the disease diagnosis and therapeutic monitoring.