The association between body mass index and preeclampsia: a meta-analysis

Hypertensive Disorders of Pregnancy: A Literature Review - Pathophysiology, Current Management, Future Perspectives, and Healthcare Disparities

Maternal mortality continues to increase in the US, with hypertensive disorders of pregnancy (HDP) remaining one of the leading causes of morbidity and mortality. In this article, the definition, classification, and pathophysiology of the different forms of HDP, current management of these disorders, disparities in prevalence and management of these conditions, and potential strategies to improve HDP outcomes and combat disparities to reduce maternal morbidity and mortality are reviewed. Current management favors a more conservative approach to treating mild chronic hypertension (140-160/90-100 mmHg) in pregnancy. However, recent data suggests active treatment of mild chronic hypertension improves maternofetal pregnancy related outcomes.

Nutritional status of a young adult population in saline-prone coastal Bangladesh

Introduction

Like many low- and middle-income countries, understanding the nutritional status of the young population in Bangladesh has had less attention. With projected climate change and associated sea level rise, the existing problem of salinity in coastal Bangladesh will significantly increase and further worsen agrobiodiversity. This research aimed to examine the nutritional status of a young population in climate-vulnerable coastal Bangladesh to inform appropriate intervention strategies to reduce the burden on health and economic outcomes.

Methods

A cross-sectional survey was conducted in 2014, and anthropometric measures were conducted for 309 young people aged 19-25 years in a rural saline-prone subdistrict in southwestern coastal Bangladesh. Body mass index (BMI) was calculated from body height and weight, and data about socio-demographic factors were collected. To identify the socio-demographic risk factors affecting undernutrition (BMI <18.5 kg/m²) and overweight/obesity (BMI ≥ 25.0 kg/m²), multinomial logistic regression analysis was used.

Results

Overall, one-fourth of the study population was classified as underweight, and nearly one-fifth were overweight or obese. The proportion of underweight was significantly higher in women (32.5%) compared to that of men (15.2%). Overall, employment, especially in women, was associated with reduced odds of being underweight (adjusted odds ratio-aOR: 0.32; 95% confidence interval - CI: 0.11, 0.89). Subjects with secondary education incomplete (grades 6-9) compared to those with primary or below education (grades 0-5; aOR: 2.51; 95% CI: 1.12, 5.59) and employed compared to those unemployed groups (aOR: 5.84; 95% CI: 2.67, 12.74) were more likely to be overweight or obese in this study population. These associations were more pronounced in women.

Discussion

Multisectoral program strategies are required to tackle the growing burden of malnutrition (both under and overweight) in this young age group tailored to local contexts including in climate-vulnerable coastal Bangladesh.

The model of screening for preeclampsia in the second and third trimesters of gestation

<b>Purpose:</b> Preeclampsia (PE) is a specific syndrome of multiple organ insufficiency in case of pregnancy, which is included in the panel of major obstetric syndromes and is among the main causes of maternal morbidity and mortality in the whole world.<br /> <b>Material and methods</b>: We conducted a prospective cohort study of 91 pregnant women to evaluate the effectiveness of integrated use of maternal risk factors (2019 International Federation of Gynecology and Obstetrics recommendations), placenta location (ultrasound at 18-20 weeks of gestation), and serum cystatin C (at 18-36 weeks of gestation) in screening for pe in the second and third trimesters of gestation.<br /> <b>Results: </b>In the subgroup of pregnant women with cystatin C levels greater than 1.0 mg/L (27 women), PE developed in 26 women, which is 96.29% in percentage terms. When calculating GFR for cystatin C in a group with PE there was a significant violation of the renal filtration system -52.46±2.08 (95% CI, 48.39-56.54), while in healthy group the indicator is within normal limits -97.6±1.64 (95% CI, 94.38-100.82). In the analysis of the ratio of cystatin C levels more than 1.0 mg / l and the development of PE, a sensitivity of 98.46%, specificity of 100% and accuracy of 98.9%, p&lt;0.001.<br /> <b>Conclusions: </b>The data show that the combined model of maternal factors, ultrasound of the placenta and serum cystatin C, is prognostically effective in pregnant women in the second and third trimesters of gestation and is a reliable marker for the development of pe.

A retrospective cohort study of hypertension, cardiovascular disease, and metabolic syndrome risk in women with history of preterm and term preeclampsia five years after delivery

OBJECTIVES

To evaluate maternal hypertension, risk of cardiovascular disease (CVD), and metabolic syndrome five years after delivery in preterm preeclampsia (P-PE), term preeclampsia (T-PE), and normal pregnancy.

STUDY DESIGN

This was a retrospective cohort study of women who delivered at Dr. Soetomo Academic Hospital (Indonesia) in 2013 with a diagnosis of PE and were compared with women with normal pregnancies.

MAIN OUTCOMES MEASURES

Blood pressure, National Cholesterol Education Program Adult Treatment Panel III criteria for metabolic syndrome (NCE-ATP III), and Framingham Risk Score (FRS).

RESULTS

In this study, 92 women participated. They were divided into the P-PE (27), T-PE (35), and control groups (30). Women with a history of PE, P-PE, or T-PE had higher blood pressure five years after delivery than those in the control group (p < 0.05). Systolic blood pressure (SBP) >140 mmHg was seen in 66.7% of P-PE and 25.7% of T-PE, while 55.6% of P-PE and 34.3% of T-PE had diastolic blood pressure (DBP) >90 mmHg (p < 0.05). Women with P-PE had the highest risk of developing hypertension (Relative risk (RR): 20; 95% Confidence interval [CI]: 2.85-139.92). Women with history of P-PE (RR: 1.85; 95% CI: 0.77-4.41), T-PE (RR: 1.28; 95% CI: 0.51-3.19), and total PE (RR: 1.53; 95% CI: 0.68-3.43) had an increased risk of positive NECP-ATP III five years after delivery. Women with history of P-PE (RR: 5.17; 95% CI: 0.26-103.22; p = 0.282) and T-PE (RR: 6.03; 95% CI: 0.32-112.22; p = 0.228) are at a greater risk of having an FRS >10% compared to the control group (p = 0.04).

CONCLUSIONS

History of PE, P-PE, and T-PE increased the risk of hypertension and CVD five years after delivery. The results also showed a tendency toward an increased risk of metabolic syndrome in women with a previous history of PE and P-PE.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Association of serum leptin at 24-28 weeks gestation with initiation and progression of labor in women

Concentrations of the hormone leptin, which is produced by adipose tissue, increase with increasing BMI, whereas leptin sensitivity often declines with higher BMI. Thus, altered leptin signaling may play a role in reproductive health risks observed with increasing BMI, which include later onset and slow progression of labor. Conflicting evidence from clinical, animal and in vitro studies have suggested that leptin either promotes or inhibits labor. We hypothesized that serum leptin concentrations or serum leptin: body mass index (BMI) ratios in women may be associated with the initiation and progression of labor. Following informed consent, serum samples were collected from 90 women with singleton pregnancies at the time of routine glucose-challenge testing, for measurement of leptin. The potential influence of leptin on gestation length and cervical dilation timing were examined by multiple linear regression. Data were analyzed from 63 participants who met exclusion and inclusion criteria. Leptin concentrations (log-transformed) at 24–28 weeks gestation were not significantly correlated with first trimester BMI . Log serum leptin and leptin: BMI ratio each were significantly associated with shorter total gestation length in uncomplicated, term pregnancies. In contrast, the mid-pregnancy leptin concentrations were not associated with progression of labor, assessed by cervical dilation over time. The association between higher serum leptin and shorter gestation length is consistent with the hypothesis that leptin promotes, or is permissive for, the onset of labor.

Effects of preconception weight loss after lifestyle intervention on fertility outcomes and pregnancy complications

It is well documented that obesity decreases natural fertility among men and women as well as pregnancy chances after conventional infertility and assisted reproductive technology (ART)-based treatments. Moreover, pregnancy complications are increased in women with overweight and obesity. General guidelines on the treatment of obesity recommend lifestyle intervention, including diet and exercise as the first-line treatment, coupled with or without medical treatments, such as weight loss medication or bariatric surgery, to reduce complications of obesity in adults. In the context of infertility in various countries and infertility clinics, there is a body mass index limit for public refund of infertility treatment of women with obesity. In this respect, it is important to investigate the evidence of effects of lifestyle intervention preceding infertility treatment on reproductive outcomes. The combined results of 15 randomized controlled trials (RCTs) of the effectiveness of preconception lifestyle intervention on reproductive outcomes documented in the latest systemic review and meta-analysis, together with the most recent RCT performed in 2022 are discussed. The current evidence suggests that greater weight loss and increase in clinical pregnancy, live birth, and natural conception rates after lifestyle intervention compared with no intervention were observed, but it seems no beneficial effect of lifestyle intervention preceding ART was observed on these parameters. With respect to potential harm of lifestyle intervention, there is no significant increased risk of early pregnancy loss, although the most recent RCT (not included in the systematic review and meta-analysis) showed a trend toward an increased risk. Complications during pregnancy, such as early pregnancy loss and maternal as well as fetal and neonatal complications, are underreported in most studies and need further analysis in an individual participant data meta-analysis. Limitations of the studies as well as future perspectives and challenges in this field of research will be highlighted.

The Relationship Between Preeclampsia and Arsenic Concentration in the Peripheral Blood

Preeclampsia (PE) is a pregnancy-specific disorder, which is one of the leading causes of maternal, fetal, and neonatal death, particularly in developing countries. Arsenic (As), which is commonly found in soil and groundwater, has been associated with various complications of pregnancy, such as spontaneous abortion, hypertension, and stillbirth. Hence, the study was used to explore the relationship between PE and blood concentration of As in this study. Blood concentration of As during pregnancy was measured by inductively coupled plasma mass spectrometry (ICP-MS). The results shown that the mean blood concentration of As was gradually increased from the control group to the severe PE group (P < 0.0001). Elevated blood concentration of As was associated with the prevalence of PE (OR = 12.81, 95% CI: 2.43-67.39 and 27.55, 1.75-433.43 for middle and high vs. low). Furthermore, elevated blood concentration of As was associated with the severity of PE. Additionally, we observed that blood concentration of As was associated with the hypoproteinemia (P = 0.001, rs = 0.37). Blood concentration of As was negatively corelated with the mean corpuscular volume (MCV) (P = 0.040, rs =  - 0.23) and positively corelated with the mean corpuscular hemoglobin concentration (MCHC) (P = 0.044, rs = 0.23). Overall, our results indicated that the blood concentration of As can significantly predict the occurrence of PE. Additionally, we provided evidence that blood concentration of As may affect the occurrence of hypoproteinemia. These findings may provide some ideas for the prevention of PE and pregnancy complications.

Knowledge, experiences and attitudes of midwives in maternity care in encounters with pregnant women with obesity - are adverse childhood experiences understood and explored as a contributing factor?

OBJECTIVE

To explore knowledge, experiences and attitudes of midwives in maternity care in encounters with pregnant women with obesity, and whether they investigate adverse childhood experiences as a contributing factor to the weight challenges.

DESIGN

Semi-structured interviews were undertaken to explore midwives' experiences of providing maternity care for women with obesity. For data analysis, Malterud's systematic text condensation was used, a method for thematic cross-case analysis of qualitative data with an inductive approach.

PARTICIPANTS AND SETTING

Nine midwives working in maternity care in Central Norway. The interviews were conducted online or at the midwives' workplace.

FINDINGS

The midwives routinely investigated pregnant women's childhood, but few saw a link between adverse childhood experiences and obesity. Pregnant women with obesity were perceived by the midwives as particularly vulnerable, which led to a sensitive, individualised approach focusing on trust and relationship building. This approach, in addition to pointing out complications that can occur with obesity, was described as a balancing act. The midwives described preventative healthcare as a natural task, but hectic days with many competing tasks were seen as an obstacle. The women's motivation for lifestyle change was experienced differently by the midwives; some described strong motivation while others mentioned poor motivation. The midwives found it reassuring to have experience to draw on in broaching difficult topics.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Midwives' many years of experience enable them to approach obese pregnant women in an individual and careful way. Their mission in public health could be better utilised if they explored negative childhood experiences in relation to pregnant women's weight challenges.

Proton Pump Inhibitors Use and Risk of Preeclampsia: A Meta-Analysis

Evidence from preclinical studies suggests a preventive effect of proton pump inhibitors (PPIs) in preeclampsia. Recently, several epidemiological studies have described a conflicting association between the use of PPIs during pregnancy and preeclampsia risk. This study aimed to evaluate the association between PPI use and the risk of preeclampsia. We searched databases, including MEDLINE, Embase, Scopus, Web of Science Core Collection, Emcare, CINAHL, and the relevant grey literature from inception until 13 September 2021. Studies reporting the preeclampsia risk with the use of PPIs were eligible for inclusion. Literature screening, data extraction, and the risk of bias assessment were performed independently by two investigators. Random-effect meta-analysis was performed to generate relative risks (RR) and 95% confidence intervals (CI). The risk of preeclampsia and preterm preeclampsia among women receiving PPIs during pregnancy were the primary outcomes of interest. This meta-analysis comprised three studies involving 4,877,565 pregnant women, of whom 119,017 were PPI users. The included studies were judged to have a low risk of bias. The risk of preeclampsia among pregnant women who received PPIs anytime during pregnancy was significantly increased (RR 1.27 (95% CI: 1.23-1.31)), although the increase was trivial in absolute terms (2 per 1000). The subgroup analysis revealed that the risk was increased in each of the three trimesters. The risk of preterm preeclampsia among pregnant women receiving PPIs anytime during pregnancy was not significantly increased (RR 1.04 (95% CI: 0.70-1.55)). The certainty evaluated by GRADE in these estimates was low. PPI use may be associated with a trivial increase in the risk of preeclampsia in pregnant women. There is no evidence supporting that PPI use decreases the risk of preeclampsia or preterm preeclampsia.

Unique Cardiovascular Disease Risk Factors in Hispanic Individuals

Purpose of Review

This review summarizes contemporary data on unique cardiovascular disease (CVD) risk factors in Hispanic individuals in the USA, and how addressing these factors is important in addressing health equity.

Recent Findings

Recent studies have shown high rates of traditional CVD risk factors in Hispanic individuals such as obesity, hypertension, diabetes, hyperlipidemia, and emerging CVD risk factors like hypertensive disorders of pregnancy, psychological stress, and occupational exposures. However, most studies fail to consider the significant heterogeneity in risk factor burden and outcomes in atherosclerotic CVD by Hispanic subgroup. Heart failure and rhythm disorders are less well studied in Hispanic adults, making risk assessment for these conditions difficult. High levels of CVD risk factors in Hispanic youth given an aging Hispanic population overall highlight the importance of risk mitigation among these individuals.

Summary

In brief, these data highlight the significant, unique burden of CVD risk among Hispanic individuals in the USA and predict a rising burden of disease among this growing and aging population. Future CVD research should focus on including robust, diverse Hispanic cohorts as well as specifically delineating results for disaggregated Hispanic groups across CVDs. This will allow for better risk assessment, prevention, and treatment decisions to promote health equity for Hispanic patients.

Estimated blood pressure trajectories and hypertension patterns among pregnant women living with HIV, Haiti, 2007-2017

Hypertension in pregnancy is a key driver of mortality and morbidity among Haitian women. HIV infection and treatment may worsen hypertension and increase cardiovascular disease risk. The authors examined blood pressure and hypertension patterns among 1965 women (2306 pregnancies ending in live births) in a prevention of maternal-to-child transmission (PMTCT) program in Port-au-Prince, Haiti, between 2007 and 2017. Hypertension was defined as blood pressure ≥140/90 mm Hg on two consecutive visits. Latent class analysis assessed trajectories of mean arterial pressure (MAP) and multinomial ordinal logistic regression examined factors associated with higher trajectories. Between 2007-2009 and 2013-2016, hypertension at PMTCT entry increased from 1.3% to 3.8% (p = .005), while incidence at any time during PMTCT follow-up increased from 5.0 to 16.1 per 100 person-years (p < .001). Hypertension detected ≤20 weeks and > 20 weeks of gestation (possible gestational hypertension) increased from 1.1% to 3.5% (p = .003) and from 2.3% to 6.9% (p < .001), respectively. Five MAP trajectories ranged from low-stable to high-increasing. In multivariable analysis controlling for history of antiretroviral therapy, age, parity, and weight, program entry in more recent years was associated with greater odds of higher MAP trajectory (adjusted odds ratio for 2013-2016 vs. 2007-2009 = 3.1, 95% confidence interval: 1.7-5.6). The increasing prevalence and incidence of hypertension highlight a need for screening and management prior to PMTCT entry and during follow-up. In a population with limited access to chronic disease care, and where many deliveries occur outside of a clinical setting, the period of PMTCT follow-up represents an opportunity to diagnose and initiate management of preexisting and pregnancy-related hypertension.

Obesity Class Impacts Adverse Maternal and Neonatal Outcomes Independent of Diabetes

INTRODUCTION

Obesity in pregnancy is a known risk factor for adverse maternal and neonatal outcomes. Few studies have compared adverse pregnancy-related outcomes according to obesity severity. Hence, we aimed to examine the impact of obesity class on maternal and perinatal outcomes.

METHODS

We retrospectively analysed data from all singleton births from mothers with obesity from 2013-2017 in Northern Sydney Local Health District in Sydney, Australia. Women were categorised into obesity class I (BMI 30-34.9kg/m2), class II (BMI 35-39.9 kg/m2) or class III (BMI 40+ kg/m2). Across BMI classes, we compared maternal outcomes including mode of delivery, gestational diabetes mellitus (GDM), and preeclampsia, and neonatal outcomes including large- and small-for-gestational age (SGA, LGA), neonatal hypoglycaemia, birth defects and timing of birth. Logistic analyses were performed to explore the impact of maternal obesity class on these outcomes, adjusting for maternal age, country of birth, parity, diabetes (both pre-existing and gestational) and hypertension.

RESULTS

There were 2466 births to women with obesity, class (69.1%), class II (21.8%), and class III (9.2%). 42.5% delivered by Caesarean section, 22.3% developed GDM and 11.2% had a hypertensive disorder in pregnancy, and Caesarean section and GDM were more common in women with higher class obesity. LGA occurred in 27.3% and SGA occurred in 4.0% of women across all classes of obesity. LGA rates were 49% more likely in women with class III compared to women with class I obesity (OR=1.49, CI 1.06-2.09, p=0.02). The presence of diabetes in the index pregnancy did not significantly impact risk of neonatal LGA between maternal obesity classes. Other neonatal adverse outcomes such as stillbirth and birth defects were more common in women with higher class obesity. SGA, neonatal hypoglycaemia, gestational age at delivery, APGAR 5-minute score and NICU admissions were similar across obesity classes, after adjustment for covariates.

CONCLUSIONS

Obesity class increases the risk of many adverse maternal and neonatal outcomes. Obesity class is independently associated with LGA incidence in the neonate, independent of maternal factors including GDM. Ongoing efforts must be made to reduce obesity incidence in women of reproductive age to circumvent the adverse perinatal outcomes associated with obesity.

Comparison of nitric oxide levels, roll over test value, and body mass index in preeclampsia and normotension

OBJECTIVE

The study aims to compare levels NO, the ROT, and BMI values in preeclampsia and normotension.

METHOD

This study was an observational analytical study that combined the draft case-control study and a cross-sectional study (hybrid method) conducted in February-June 2020. This study was conducted in the Hospital Dr. Wahidin Sudirohusodo Makasar, Antang Health Center, Barabaraya Health Center, and Mamajang Health Center. Respondents in this study were pregnant women divided into two groups, 108 mothers with normal pregnancies and 42 mothers with preeclampsia. The criteria of the study respondents were single pregnancies, pregnancy of more than 20 weeks, and the gestational age of 20-35 years old. Data collected includes age, parity, gestational age, pregnancy interval, body mass index (BMI), and education. In addition, Nitric oxide levels are determined using Elisa Kit, and roll over test is collected by performing blood pressure measurements at two different positions.

RESULTS

The mean serum NO levels in the preeclampsia 176.43±50.8 and 152.75±51.3 in normotension, and there is a meaningful relationship p=0.012. Mean value of ROT in preeclampsia 23.21±8.54 and 19.63±8.85 in normotension p=0.026. There is a meaningful difference in IMT with preeclampsia p=0.003.

CONCLUSION

NO, ROT and BMI are significantly higher in pregnant mothers with preeclampsia than in normal pregnancies.

The effectiveness of weight-loss lifestyle interventions for improving fertility in women and men with overweight or obesity and infertility: A systematic review update of evidence from randomized controlled trials

Being overweight or obese can have a negative impact on fertility outcomes. This systematic review updates randomized controlled trial (RCT) findings on the effectiveness of weight loss interventions in reducing weight and improving reproductive outcomes of women and men with overweight or obesity and infertility. Eligible studies, published since the last review, were identified by searching databases from March 20, 2016 until March 31, 2020. RCTs involving any type of lifestyle intervention were considered. Eight RCTs were identified and aggregated with seven RCTs included in our previous review. Meta-analyses revealed that women randomized to a combined diet and exercise intervention were more likely to become pregnant, risk ratio (RR) = 1.87 (95% CI 1.20, 2.93) and achieve a live birth RR = 2.20 (95% CI 1.23, 3.94), compared to women in control groups who received no or minimal intervention. This pattern was not replicated in trials where control groups received immediate access to assisted reproductive technology (ART). No eligible randomized trials involving men were identified. Data were largely obtained from small scale studies. Better designed, adequately powered, robust randomized trials are needed to better understand the effect of weight loss interventions on reproductive outcomes in both women and men.

Adipsin of the Alternative Complement Pathway Is a Potential Predictor for Preeclampsia in Early Pregnancy

Objective

The concentrations of complement proteins (adipsin, C3a, and C5a) and soluble endoglin (sENG) in the plasma were measured in this study, and their value as early-pregnancy predictors and potential diagnostic marker of preeclampsia was assessed, respectively.

Experimental Design

Plasma samples were obtained from healthy and preeclampsia pregnant women before delivery for a cross-sectional study. Plasma samples were collected from healthy and preeclampsia pregnant women throughout pregnancy and postpartum for a follow-up study. Enzyme-linked immunosorbent assays were used to detect plasma levels of several complement proteins (adipsin, C3a, and C5a) and sENG.

Results

The plasma levels of adipsin, C5a, and sENG were significantly increased before delivery in pregnant women with preeclampsia. During pregnancy, the plasma adipsin, C5a, and sENG levels were increased from the third trimester in healthy pregnant women; plasma adipsin levels remained stable after delivery, while C3a levels increased in the second trimester and remained stable afterward. Furthermore, levels of adipsin, C5a, and sENG were higher in preeclampsia patients at different stages of pregnancy; the C3a level presents a similar change and no difference was found in the third trimester. In the first trimester, receiver-operating curve (ROC) curve analysis showed that adipsin (AUC, 0.83 ± 0.06, P=0.001) and sENG (AUC, 0.74 ± 0.09, P=0.021) presented high value as predictors of early pregnancy.

Conclusions

Adipsin is likely a novel plasma biomarker to monitor the increased risk of preeclampsia in early pregnancy. Moreover, the increased plasma levels of adipsin, C5a, and sENG before delivery may be associated with preeclampsia.

Counseling and Behavioral Interventions for Healthy Weight and Weight Gain in Pregnancy: Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Counseling and active behavioral interventions to limit excess gestational weight gain (GWG) during pregnancy may improve health outcomes for women and infants. The 2009 National Academy of Medicine (NAM; formerly the Institute of Medicine) recommendations for healthy GWG vary according to prepregnancy weight category.

OBJECTIVE

To review and synthesize the evidence on benefits and harms of behavioral interventions to promote healthy weight gain during pregnancy to inform the US Preventive Services Task Force recommendation.

DATA SOURCES

Ovid MEDLINE and the Cochrane Library to March 2020, with surveillance through February 2021.

STUDY SELECTION

Randomized clinical trials and nonrandomized controlled intervention studies focused on diet, exercise, and/or behavioral counseling interventions on GWG.

DATA EXTRACTION AND SYNTHESIS

Independent data abstraction and study quality rating with dual review.

MAIN OUTCOMES AND MEASURES

Gestational weight-related outcomes; maternal and infant morbidity and mortality; harms.

RESULTS

Sixty-eight studies (N = 25 789) were included. Sixty-seven studies evaluated interventions during pregnancy, and 1 evaluated an intervention prior to pregnancy. GWG interventions were associated with reductions in risk of gestational diabetes (43 trials, n = 19 752; relative risk [RR], 0.87 [95% CI, 0.79 to 0.95]; absolute risk difference [ARD], -1.6%) and emergency cesarean delivery (14 trials, n = 7520; RR, 0.85 [95% CI, 0.74 to 0.96]; ARD, -2.4%). There was no significant association between GWG interventions and risk of gestational hypertension, cesarean delivery, or preeclampsia. GWG interventions were associated with decreased risk of macrosomia (25 trials, n = 13 990; RR, 0.77 [95% CI, 0.65 to 0.92]; ARD, -1.9%) and large for gestational age (26 trials, n = 13 000; RR, 0.89 [95% CI, 0.80 to 0.99]; ARD, -1.3%) but were not associated with preterm birth. Intervention participants experienced reduced weight gain across all prepregnancy weight categories (55 trials, n = 20 090; pooled mean difference, -1.02 kg [95% CI, -1.30 to -0.75]) and demonstrated lower likelihood of GWG in excess of NAM recommendations (39 trials, n = 14 271; RR, 0.83 [95% CI, 0.77 to 0.89]; ARD, -7.6%). GWG interventions were associated with reduced postpartum weight retention at 12 months (10 trials, n = 3957; mean difference, -0.63 kg [95% CI, -1.44 to -0.01]). Data on harms were limited.

CONCLUSIONS AND RELEVANCE

Counseling and active behavioral interventions to limit GWG were associated with decreased risk of gestational diabetes, emergency cesarean delivery, macrosomia, and large for gestational age. GWG interventions were also associated with modest reductions in mean GWG and decreased likelihood of exceeding NAM recommendations for GWG.

Maternal Hypertensive Pregnancy Disorders and Mental and Behavioral Disorders in the Offspring: a Review

Purpose of Review

We review here recent original research and meta-analytic evidence on the associations of maternal hypertensive pregnancy disorders and mental and behavioral disorders in the offspring.

Recent Findings

Seven meta-analyses and 11 of 16 original research studies published since 2015 showed significant associations between maternal hypertensive pregnancy disorders and offspring mental and behavioral disorders. Evidence was most consistent in meta-analyses and high-quality cohort studies. The associations, independent of familial confounding, were observed on different mental and behavioral disorders in childhood and schizophrenia in adulthood. Preterm birth and small-for-gestational age birth emerged as possible moderators and mediators of the associations. Cross-sectional and case-control studies yielded inconsistent findings, but had lower methodological quality.

Summary

Accumulating evidence from methodologically sound studies shows that maternal hypertensive pregnancy disorders are associated with an increased risk of mental and behavioral disorders in the offspring in childhood. More studies on adult mental disorders are needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11906-021-01141-w.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Systematic review of observational studies of the impact of cardiovascular risk factors on preeclampsia in sub-saharan Africa

BACKGROUND

Maternal mortality is a public health issue, particularly in low- and middle-income countries (LMIC). Sub-Saharan Africa (SSA) is the region most affected worldwide by maternal mortality, and preeclampsia is one of the main causes. We performed a systematic review of observational studies to identify the impact of cardiovascular risk factors on preeclampsia in SSA with a more representative sample.

METHODS

Databases: PubMed and Google Scholar were searched to identify published studies. Studies were included if they reported results on the link between at least one cardiovascular risk factor and preeclampsia. Relevant studies quality was assessed with the Newcastle-Ottawa Scale (NOS). Odds ratios and relative risk (RR) were reported with their confidence intervals.

RESULTS

Twelve articles (8 case-controls, 3 cohorts, 1 cross-sectional) were included in this review, with a total of 24,369 pregnant women. Cardiovascular risk factors such as chronic hypertension, overweight, obesity, diabetes and alcohol were significantly associated with a high risk of preeclampsia. Very few data were available concerning some risk factors. None of the articles reported tobacco consumption as a preeclampsia risk factor. There is a lack of data from French-speaking SSA countries.

CONCLUSION

Cardiovascular risk factors increase the risk of preeclampsia. Our results suggest the need for prospective cohort studies to ascertain this association in order to reduce maternal mortality due to preeclampsia.

Clinical characteristics and risk factors for mortality in obstetric patients with severe COVID-19 in Brazil: a surveillance database analysis

OBJECTIVE

To describe clinical characteristics of pregnant and postpartum women with severe COVID-19 in Brazil and to examine risk factors for mortality.

DESIGN

Cross-sectional study based on secondary surveillance database analysis.

SETTING

Nationwide Brazil.

POPULATION OR SAMPLE

978 Brazilian pregnant and postpartum women notified as COVID-19 Acute Respiratory Distress Syndrome (ARDS) cases with complete outcome (death or cure) up to 18 June 2020.

METHODS

Data was abstracted from the Brazilian ARDS Surveillance System (ARDS-SS) database. All eligible cases were included. Data on demographics, clinical characteristics, intensive care resources use and outcomes were collected. Risk factors for mortality were examined by multivariate logistic regression.

MAIN OUTCOME MEASURES

Case fatality rate.

RESULTS

We identified 124 maternal deaths, corresponding to a case fatality rate among COVID-19 ARDS cases in the obstetric population of 12.7%. At least one comorbidity was present in 48.4% of fatal cases compared with 24.9% in survival cases. Among women who died, 58.9% were admitted to ICU, 53.2% had invasive ventilation and 29.0% had no respiratory support. The multivariate logistic regression showed that the main risk factors for maternal death by COVID-19 were being postpartum at onset of ARDS, obesity, diabetes and cardiovascular disease, whereas white ethnicity had a protective effect.

CONCLUSIONS

Negative outcomes of COVID-19 in this population are affected by clinical characteristics but social determinants of health also seem to play a role. It is urgent to reinforce containment measures targeting the obstetric population and ensure high quality care throughout pregnancy and the postpartum period.

TWEETABLE ABSTRACT

A total of 124 COVID-19 maternal deaths were identified in Brazil. Symptoms onset at postpartum and comorbidities are risk factors.

Understanding maternal mortality in women with obesity and the role of care they receive: a national case-control study

OBJECTIVE

Obesity has significant implications for the health of pregnant women. However, few studies have quantified its association with maternal mortality or examined the relevant underlying causes and the role of care, although this remains the most severe maternal outcome. Our objectives were to quantify the risk of maternal death by prepregnancy body mass index and to determine whether obesity affected the quality of care of the women who died.

DESING

This is a national population-based case-control study in France. Cases were 364 maternal deaths from the 2007-2012 National Confidential Enquiry. Controls were 14,681 parturients from the nationally representative 2010 perinatal survey. We studied the association between categories of prepregnancy BMI and maternal death by multivariable logistic regression, estimating adjusted odds ratios and 95% confidence intervals, overall and by specific causes of death. Individual case reviews assessed the quality of care provided to the women who died, by obesity status.

RESULTS

Compared with women with normal BMI, underweight women (<18.5 kg/m²) had an adjusted OR of death of 0.75 (95% CI, 0.42-1.33), overweight women (25-29.9 kg/m²) 1.65 (95% CI, 1.24-2.19), women with class 1 obesity (30-34.9 kg/m²) 2.22 (95% CI, 1.55-3.19) and those with class 2-3 obesity (≥35 kg/m²) 3.40 (95% CI, 2.17-5.33). Analysis by cause showed significant excess risk of maternal death due to cardiovascular diseases, venous thromboembolism, hypertensive complications and stroke in women with obesity. Suboptimal care was as frequent among women with (35/62, 57%) as without obesity (136/244, 56%), but this inadequate management was directly related to obesity among 14/35 (40%) obese women with suboptimal care. Several opportunities for improvement were identified.

CONCLUSIONS

The risk of maternal death increases with BMI; it multiplied by 1.6 in overweight women and more than tripled in pregnant women with severe obesity. Training clinicians in the specificities of care for pregnant women with obesity could improve their outcomes.

Early-pregnancy transcriptome signatures of preeclampsia: from peripheral blood to placenta

Several studies have linked maternal asthma, excess BMI, and low vitamin D status with increased risk of Preeclampsia (PE) development. Given prior evidence in the literature and our observations from the subjects in the Vitamin D Antenatal Asthma Reduction Trial (VDAART), we hypothesized that PE, maternal asthma, vitamin D insufficiency, and excess body mass index (BMI) might share both peripheral blood and placental gene signatures that link these conditions together. We used samples collected in the VDAART to investigate relationships between these four conditions and gene expression patterns in peripheral blood obtained at early pregnancy. We identified a core set of differentially expressed genes in all comparisons between women with and without these four conditions and confirmed them in two separate sets of samples. We confirmed the differential expression of the shared gene signatures in the placenta from an independent study of preeclampsia cases and controls and constructed the preeclampsia module using protein-protein interaction networks. CXC chemokine genes showed the highest degrees of connectivity and betweenness centrality in the peripheral blood and placental modules. The shared gene signatures demonstrate the biological pathways involved in preeclampsia at the pre-clinical stage and may be used for the prediction of preeclampsia.

Obesity Genomics and Metabolomics: a Nexus of Cardiometabolic Risk

PURPOSE OF REVIEW

Obesity is a significant international public health epidemic with major downstream consequences on morbidity and mortality. While lifestyle factors contribute, there is an evolving understanding of genomic and metabolomic pathways involved with obesity and its relationship with cardiometabolic risk. This review will provide an overview of some of these important findings from both a biologic and clinical perspective.

RECENT FINDINGS

Recent studies have identified polygenic risk scores and metabolomic biomarkers of obesity and related outcomes, which have also highlighted biological pathways, such as the branched-chain amino acid (BCAA) pathway that is dysregulated in this disease. These biomarkers may help in personalizing obesity interventions and for mitigation of future cardiometabolic risk. A multifaceted approach is necessary to impact the growing epidemic of obesity and related diseases. This will likely include incorporating precision medicine approaches with genomic and metabolomic biomarkers to personalize interventions and improve risk prediction.

Advanced glycation end products present in the obese uterine environment compromise preimplantation embryo development

RESEARCH QUESTION

Proinflammatory advanced glycation end products (AGE), highly elevated within the uterine cavity of obese women, compromise endometrial function. Do AGE also impact preimplantation embryo development and function?

DESIGN

Mouse embryos were cultured in AGE equimolar to uterine fluid concentrations in lean (1-2 µmol/l) or obese (4-8 µmol/l) women. Differential nuclear staining identified cell allocation to inner cell mass (ICM) and trophectoderm (TE) (day 4 and 5 of culture). Cell apoptosis was examined by terminal deoxynucleotidyl transferase-mediated dUDP nick-end labelling assay (day 5). Day 4 embryos were placed on bovine serum albumin/fibronectin-coated plates and embryo outgrowth assessed 93 h later as a marker of implantation potential. AGE effects on cell lineage allocation were reassessed following pharmacological interventions: either 12.5 nmol/l AGE receptor (RAGE) antagonist; 0.1 nmol/l metformin; or combination of 10 µmol/l acetyl-l-carnitine, 10 µmol/l N-acetyl-l-cysteine, and 5 µmol/l alpha-lipoic acid.

RESULTS

8 µmol/l AGE reduced: hatching rates (day 5, P < 0.01); total cell number (days 4, 5, P < 0.01); TE cell number (day 5, P < 0.01), and embryo outgrowth (P < 0.01). RAGE antagonism improved day 5 TE cell number.

CONCLUSIONS

AGE equimolar with the obese uterine environment detrimentally impact preimplantation embryo development. In natural cycles, prolonged exposure to AGE may developmentally compromise embryos, whereas following assisted reproductive technology cycles, placement of a high-quality embryo into an adverse 'high AGE' environment may impede implantation success. The modest impact of short-term RAGE antagonism on improving embryo outcomes indicates preconception AGE reduction via pharmacological or dietary intervention may improve reproductive outcomes for overweight/obese women.

Hypoproteinemia as a parameter of poor perinatal/neonatal outcomes in women with preeclampsia diagnosed as hypertension plus proteinuria

OBJECTIVES

To investigate the relationship between serum total protein (TP) levels and maternal/neonatal outcomes among pregnant women with preeclampsia.

STUDY DESIGN

TP was measured at preeclampsia diagnosis and delivery in 94 women with singleton pregnancies and preeclampsia as hypertension with proteinuria who delivered at ≥ 22 gestational weeks (GWs). As a control group, measurements were also made in 188 women with singleton pregnancies without hypertension and/or proteinuria.

MAIN OUTCOME MEASURES

The relationship between serum TP levels and maternal outcomes.

RESULTS

Serum TP levels showed a significantly negative relationship with urine protein-to-creatinine (P/C) ratio at preeclampsia diagnosis and delivery. Serum TP levels at delivery in the preeclampsia group (53 ± 7 g/L) were lower than in the control group (61 ± 4 g/L, P < 0.0001). In each group, there was no relationship between the daily decrease in TP and the daily increase maternal body weight. However, there was a positive relationship between the daily increase in P/C ratio and the daily increase in maternal body weight in the preeclampsia group (P = 0.0021). Severe hypoproteinemia at preeclampsia diagnosis was a predictor of abruptio placentae (TP < 49 g/L; odds ratio, 21.3) and peripartum cardiomyopathy (TP < 45 g/L; odds ratio, 43.5). Furthermore, women with severe hypoproteinemia at delivery had higher morbidity due to pulmonary edema (TP < 55 g/L; odds ratio, 26.4) and central serous chorioretinopathy (TP < 42 g/L; odds ratio, 264).

CONCLUSIONS

Serum TP levels and proteinuria severity at preeclampsia diagnosis and delivery showed a positive relationship and predicted poor maternal outcome.

Maternal prepregnancy overweight and obesity and the risk of preeclampsia: A meta-analysis of cohort studies

OBJECTIVE

The aim of our meta-analysis was to explore whether overweight and obesity was associated with preeclampsia or not.

DESIGN

Three databases were systematically reviewed and reference lists of relevant articles were checked. Meta-analysis of published cohort studies comparing whether overweight and obesity was associated with preeclampsia and adjusting for potential confounding factors. Calculations of pooled estimates were conducted in random-effects models. Heterogeneity was tested by using Chi-square test with Cochrane and heterogeneity was explored with meta-regression. Publication bias was estimated from Egger's test (linear regression method) and Begg's test (rank correlation method).

RESULTS

Nineteen studies met the inclusion criteria. The meta-analysis showed that overweight and obesity was associated with an increased risk of preeclampsia. The aOR calculated for 13 studies (compared overweight to normal weight) was 1.71, 95% CI (1.52, 1.91) for random-effects models and 19 studies (compared obesity to normal weight) was 2.48, 95% CI (2.05, 2.90) for random-effects models, stratified analyses showed no differences regarding quality grade, location of study and period of anthropometric measurement. There was no indication of a publication bias either from the result of Egger's test or Begg's test.

CONCLUSIONS

Our results suggested that prepregnancy maternal overweight and obesity are significantly associated with an increased risk of preeclampsia.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Preeclampsia exposed offspring have greater body mass index than non-exposed offspring during peripubertal life: A meta-analysis

BACKGROUND

This study evaluates the effect of preeclampsia on body mass index (BMI) of offspring who were exposed to preeclampsia in utero.

METHODS

Data were obtained from studies identified by a literature search in electronic databases. Random-effects metanalyses were conducted to achieve mean difference in BMI, waist circumference, gestation length, and birthweight between preeclampsia exposed (PE) and non-exposed (non-PE) offspring older than 5 years. Metaregression analyses were performed to identify factors affecting offspring BMI.

RESULTS

Sixteen studies (11639 PE offspring; age 15.5 years [14.2, 16.8]; 33.3% [32.6, 33.9] males vs 526,576 non-PE offspring; age 15.7 years [15.0, 16.4]; 42.6% [40.6, 44.5] male) were used. Gestation duration and birthweight of PE fetuses were significantly lesser than those of non-PE fetuses (mean difference (MD) -0.66 weeks [-1.25, -0.07]; p = 0.03 and MD -207.9 [-344.0, -71.8]; p = 0.003) respectively. BMI of PE offspring was significantly higher than non-PE offspring (MD 0.54 kg/m² [0.27, 0.82]; p = 0.0001). Odds of being obese was significantly higher in PE than non-PE offspring (odds ratio 2.12 [1.70, 2.66]; P < 0.00001). Waist circumference was also significantly higher in PE than in non-PE offspring (MD 1.37 cm [0.67, 2.06]; p = 0.0001). Offspring BMI was significantly inversely associated with maternal age in both PE and non-PE groups.

CONCLUSION

Preeclampsia poses risk of higher BMI and waist circumference especially to the offspring of older mothers.

Melanocortin-4 Receptor Deficiency Attenuates Placental Ischemia-Induced Hypertension in Pregnant Rats

Preeclampsia is a pregnancy-specific disorder of new-onset hypertension linked to placental ischemia. While obesity is a major risk factor for preeclampsia, not all obese pregnant women develop pregnancy-induced hypertension or preeclampsia. Previously, we reported that placental ischemia-induced hypertension is dependent upon intact signaling of the sympathetic nervous system. Moreover, in various models of obesity, blockade of MC4R (melanocortin-4 receptor) signaling protects against the development of hypertension via suppression of the sympathetic nervous system. Less is known about this pathway during obese pregnancy. Although blockade of MC4R may lead to increased body weight during pregnancy, we tested the hypothesis that placental ischemia-induced hypertension is attenuated in obese MC4R-deficient pregnant rats. On gestational day 14, MC4R wild-type or heterozygous-deficient (MC4R-def) rats were subjected to chronic placental ischemia via the reduced uterine perfusion pressure procedure or Sham surgery then examined on gestational day 19. In Sham MC4R-def versus Sham wild-type pregnant rats, there was increased body weight, fat mass, and circulating leptin levels but they had similar fetus weights. Reduced uterine perfusion pressure reduced fetus weights in both strains. Reduced uterine perfusion pressure increased blood pressure in wild-type rats but this response was significantly attenuated in MC4R-def rats, although blood pressure was elevated in Sham MC4R-def over Sham wild-type. These data indicate that while obese MC4R-def pregnant rats have higher blood pressure during pregnancy, placental ischemia-induced hypertension is attenuated in obese MC4R-def pregnant rats. Thus, obese women with abnormal MC4R signaling may be less susceptible to the development of placental ischemia-induced hypertension.

The effect of vaginal progesterone on Doppler findings in increased uterine artery resistance

OBJECTIVE

The present study aimed to evaluate the effect of vaginal progesterone on Doppler finding in increased uterine artery resistance compared with aspirin.

MATERIALS AND METHODS

This study is a double-blind randomized clinical trial that was conducted on 140 pregnant women with increased uterine artery resistance who were referred to the Shariati hospital (Tehran, Iran) in 2017-2018. Patients were randomized to 1 of the 3 treatment groups - group A: tablet aspirin 80 mg; group B: vaginal suppository progesterone; and group C: control group without any intervention. Low-risk pregnant women at the gestational age of 16-20 weeks, were assessed by the uterine artery Doppler. In the presence of increased resistance of the uterine artery, patients were randomly assigned to one of the three above mentioned groups.

RESULTS

The results of paired t-tests for right uterine artery pulsatility index (RUA.PI), right uterine artery resistance index (RUA.RI), left uterine artery PI (LUA.PI), and left uterine artery RI (LUA.RI) before and after of intervention in the three groups were statistically significant. Also, the one-way analysis of variance (ANOVA) results for comparison between three groups showed that before the intervention only means of RUA.PI has a significant difference between three groups (p = .025), but means of all variables after intervention shows a significant difference (p < .001).

CONCLUSION

The findings showed that the use of vaginal progesterone suppressed the resistance of uterine artery compared to aspirin.

The association between preeclampsia and the risk of metabolic syndrome after delivery: a meta-analysis

OBJECTIVE

We performed a systematic review and meta-analysis to summarize the epidemiologic evidence of the association between preeclampsia and increased risk of metabolic syndrome after delivery.

METHODS

A comprehensive literature search of numerous electronic databases including PubMed, Scopus, and Web of Sciences was performed until 1 July 2019. The pooled odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated as random effect estimates of association among studies. Begg's and Egger's linear regression tests were employed to investigate publication bias.

RESULTS

The pooled estimates of crude and adjusted ORs showed a significant association between preeclampsia and the risk of metabolic syndrome ((crude OR = 2.93, 95% CI = 1.92-4.47) and (adjusted OR = 1.62, 95% CI = 1.25-2.08)), respectively.

CONCLUSIONS

The results of this meta-analysis provide evidence for relation between preeclampsia and increase in risk of metabolic syndrome. However, more epidemiological and clinical studies are needed to explore the mechanism of preeclampsia on increased risk of metabolic syndrome.

Increased BMI has a linear association with late-onset preeclampsia: A population-based study

Background

To investigate the ongoing controversy on the effect of BMI (body mass index) on EOP (early onset preeclampsia) vs LOP (late onset), especially focusing on diabetes and maternal booking/pre-pregnancy BMI as possible independent variables.

Methods

18 year-observational cohort study (2001–2018). The study population consisted of all consecutive births delivered at the Centre Hospitalier Universitaire Hospitalier Sud Reunion’s maternity (ap. 4,300 birth per year, only level 3 maternity in the south of Reunion Island, sole allowed to follow and deliver all preeclampsia cases of the area). History of pregnancies, deliveries and neonatal outcomes have been collected in standardized fashion into an epidemiological perinatal data base.

Results

Chronic hypertension and, history of preeclampsia in multigravidas, were the strongest risk factors for EOP. Primiparity, age over 35 years and BMI ≥ 35 kg/m² were rather associated with LOP. In a multivariate analysis with EOP or LOP as outcome variables compared with controls (normotensive), maternal age and pre-pregnancy BMI were independent risk factors for both EOP and LOP (p < 0.001). However, analyzing by increment of 5 (years of age, kg/m² for BMI) rising maternal ages and incidence of preeclampsia were strictly parallel for EOP and LOP, while increment of BMI was only associated with LOP. Controlling for maternal ages and booking/pre-pregnancy BMI, diabetes was not an independent risk factor neither for EOP or LOP.

Conclusions

Metabolic factors, other than diabetes, associated with pre-pregnancy maternal corpulence are specifically associated with LOP. This may be a direction for future researches on the maternal preeclamptic syndrome. This may explain the discrepancy we are facing nowadays where high-income countries report 90% of their preeclampsia being LOP, while it is only 60–70% in medium-low income countries.

Pregestational body mass index, trimester-specific weight gain and total gestational weight gain: how do they influence perinatal outcomes?

OBJECTIVE

To investigate the association between pre-gestational body mass index (BMI), total gestational weight gain (GWG), and/or trimester-specific weight gain (GWGT) with adverse maternal or perinatal outcomes (AMPOs).

MATERIALS AND METHODS

Maternal clinical characteristics and pregnancy and perinatal outcomes were used to predict AMPOs. The predictive ability of BMI, GWG, or GWGT for AMPOs was analyzed using the area under the curve (AUC). Logistic regression models in a univariate and multivariate analysis were performed to estimate the odds ratios (OR) and 95% confidence intervals (CI) to predict maternal outcomes (pregnancy-induced hypertension, preeclampsia or gestational diabetes mellitus) and perinatal outcomes (small for gestational age, large for gestational age, 5-min Apgar score, admission to neonatal intensive care unit or umbilical cord pH <7.15).

RESULTS

Women with AMPOs (n = 293) were younger with higher rate of nulliparity (p < .001) and with lower height (p = .018) as compared to controls (n = 134). In the univariate study, GWGT in third trimester was associated with double risk of pregnancy-induced hypertension (OR 2.00; 95% CI, 1.01-3.97). Nonetheless, third-trimester GWG and total GWG have a negative relationship with gestational diabetes mellitus OR 0.32 (95% CI, 0.18-0.58) and OR 0.35 (95% CI, 0.21-0.59), respectively. Women with greater overall and in second trimester, GWG have a lower risk of having SGA neonates, OR 0.62 (95% CI, 0.39-0.98) and OR 0.60 (95% CI, 0.37-0.98), respectively. In the multivariate study, pre-gestational BMI is strongly related to the development of preeclampsia and the area under the curve (AUC) of the combination of pre-gestational BMI and total weight gain was 0.832 (95% CI, 0.63-0.81) for preeclampsia and 0.719 (95% CI, 0.71-0.94) for gestational diabetes mellitus.

CONCLUSION

Our results suggest than timing of gestational weight gain influence in maternal and perinatal outcomes. Pre-gestational BMI is a determinant of preeclampsia, maternal weight gain in the third trimester is a determinant of pregnancy-induced hypertension and the increase in total GWG reduces the risk of gestational diabetes mellitus and small for gestational age.

Prediction of pre-eclampsia: review of reviews

OBJECTIVE

Primary studies and systematic reviews provide estimates of varying accuracy for different factors in the prediction of pre-eclampsia. The aim of this study was to review published systematic reviews to collate evidence on the ability of available tests to predict pre-eclampsia, to identify high-value avenues for future research and to minimize future research waste in this field.

METHODS

MEDLINE, EMBASE and The Cochrane Library including DARE (Database of Abstracts of Reviews of Effects) databases, from database inception to March 2017, and bibliographies of relevant articles were searched, without language restrictions, for systematic reviews and meta-analyses on the prediction of pre-eclampsia. The quality of the included reviews was assessed using the AMSTAR tool and a modified version of the QUIPS tool. We evaluated the comprehensiveness of search, sample size, tests and outcomes evaluated, data synthesis methods, predictive ability estimates, risk of bias related to the population studied, measurement of predictors and outcomes, study attrition and adjustment for confounding.

RESULTS

From 2444 citations identified, 126 reviews were included, reporting on over 90 predictors and 52 prediction models for pre-eclampsia. Around a third (n = 37 (29.4%)) of all reviews investigated solely biochemical markers for predicting pre-eclampsia, 31 (24.6%) investigated genetic associations with pre-eclampsia, 46 (36.5%) reported on clinical characteristics, four (3.2%) evaluated only ultrasound markers and six (4.8%) studied a combination of tests; two (1.6%) additional reviews evaluated primary studies investigating any screening test for pre-eclampsia. Reviews included between two and 265 primary studies, including up to 25 356 688 women in the largest review. Only approximately half (n = 67 (53.2%)) of the reviews assessed the quality of the included studies. There was a high risk of bias in many of the included reviews, particularly in relation to population representativeness and study attrition. Over 80% (n = 106 (84.1%)) summarized the findings using meta-analysis. Thirty-two (25.4%) studies lacked a formal statement on funding. The predictors with the best test performance were body mass index (BMI) > 35 kg/m² , with a specificity of 92% (95% CI, 89-95%) and a sensitivity of 21% (95% CI, 12-31%); BMI > 25 kg/m² , with a specificity of 73% (95% CI, 64-83%) and a sensitivity of 47% (95% CI, 33-61%); first-trimester uterine artery pulsatility index or resistance index > 90^th centile (specificity 93% (95% CI, 90-96%) and sensitivity 26% (95% CI, 23-31%)); placental growth factor (specificity 89% (95% CI, 89-89%) and sensitivity 65% (95% CI, 63-67%)); and placental protein 13 (specificity 88% (95% CI, 87-89%) and sensitivity 37% (95% CI, 33-41%)). No single marker had a test performance suitable for routine clinical use. Models combining markers showed promise, but none had undergone external validation.

CONCLUSIONS

This review of reviews calls into question the need for further aggregate meta-analysis in this area given the large number of published reviews subject to the common limitations of primary predictive studies. Prospective, well-designed studies of predictive markers, preferably randomized intervention studies, and combined through individual-patient data meta-analysis are needed to develop and validate new prediction models to facilitate the prediction of pre-eclampsia and minimize further research waste in this field. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Angiogenic factors and the risk of preeclampsia: A systematic review and meta-analysis

Background

The etiological nature of preeclampsia is heterogeneous. The use of biomarkers indices in early pregnancy helps to have appropriate stratification of pregnancies into high- and low risk for the purpose of choosing timely interventions.

Objective

The aim of this systematic review was to determine the pathogenic role of soluble soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) in the prediction of preeclampsia in women.

Materials and Methods

We performed a systematic search of the international databases including PubMed, Scopus, and Web of Science until August 2017. The quality of included studies was assessed using the Newcastle-Ottawa Scale. The primary outcome in this review was preeclampsia. The statistical heterogeneity was assessed using the X2 test and quantified by I2. Pooled effects size was obtained by random effects model. Subgroup analyses were also carried out.

Results

Totally, 284 records were identified in the initial search and 15 records were finally included in the meta-analysis. The pooled odds ratios (ORs) for the association between the high level of sFlt-1 and low level of PlGF and subsequent development of preeclampsia among women were 5.20 (95% CI: 1.24–9.16) and 2.53 (95% CI: 1.33–3.75), respectively. The mean difference for sFlt-1 and PlGF in women with preeclampsia compared to controls was 1.15 (95% CI: 0.43–1.86) and –0.94 (95% CI: –1.37–0.52), respectively.

Conclusion

According to the results from this meta-analysis, increased levels of sFlt-1 and reduced levels of PlGF predict the subsequent development of preeclampsia.

Associations between maternal obesity and severe maternal morbidity: Findings from the French EPIMOMS population-based study

BACKGROUND

Maternal obesity is increasing. There is growing evidence of its effect on severe maternal morbidity. We assessed prepregnancy obesity as an independent risk factor for severe maternal morbidity by timing and cause.

METHODS

We designed a case-control analysis within the EPIMOMS prospective population-based study conducted in six French regions in 2012-2013 (182 309 women who delivered at ≥22 weeks). Cases were all women who experienced severe maternal morbidity during pregnancy to 42 days postpartum as per a multicriteria definition derived by national expert consensus (n = 2540, severe maternal morbidity prevalence 1.4%). Controls were randomly selected from the same health centres (n = 3651). The association between obesity and severe maternal morbidity was assessed from fitting multivariable logistic regression models: overall, by timing (antepartum and intrapartum/ postpartum), and by cause.

RESULTS

Prepregnancy obesity was associated with overall severe maternal morbidity (adjusted odds ratio [OR] 1.34, 95% confidence interval [CI] 1.14, 1.59) and antepartum severe maternal morbidity (OR 2.07, 95% CI 1.61, 2.65), but not with intra/postpartum severe maternal morbidity (OR 1.15, 95% CI 0.96, 1.38). Among antepartum severe maternal morbidity, severe hypertensive disorders were most strongly associated with obesity (OR 2.50, 95% CI 1.85, 3.40) but the risk of antepartum severe maternal morbidity due to other causes was also increased among obese women (OR 1.64, 95% CI 1.13, 2.37). Obesity was not associated with severe postpartum haemorrhage (OR 1.12, 95% CI 0.92, 1.37).

CONCLUSION

Obesity is associated with an increased risk of antepartum, but not intra/ postpartum, severe maternal morbidity.

The association between preeclampsia and autism spectrum disorders among children: a meta-analysis

Purpose

In this meta-analysis, relevant case-control and cohort studies were pooled to evaluate the association between preeclampsia and the risk of autism spectrum disorders (ASDs) in children.

Methods

A search for relevant studies in major databases, including Web of Science, PubMed, and Scopus, was performed up to May 2018. The odds ratios (ORs) or rate ratios (RRs) with 95% confidence intervals (CIs) were extracted from eligible studies to determine the association among studies.

Results

The pooled estimates of ORs and RRs indicated a significant association between preeclampsia and ASD [(OR, 1.36; 95% CI, 1.12–1.60) and (RR, 1.30; 95% CI, 1.20–1.41)].

Conclusions

Despite existing controversy, our findings indicated that preeclampsia was associated with an increased risk of ASD among children.

Risk Factors for Preeclampsia in a High-Risk Cohort of Women Served by a Nursing-based Home Visiting Program

This descriptive study aimed to identify the impact of psychosocial risk factors on pregnancy outcomes for high risk women in an urban setting. Women in this category tend to experience adverse pregnancy outcomes, like preeclampsia, at greater rates than low or medium risk women. A retrospective paper chart review of East Harlem women served by LSA Family Health Service (LSA) Maternal Outreach Program (MOP) was conducted. All women who enrolled in the MOP with a singleton pregnancy from January 2015 to December 2017, were eligible for inclusion in our analyses. Data were analyzed using SPSS (version 23). Of 379 total participants, 68.6% (n=203) were Hispanic/Latina women, 44.8% (n=163) were English only speakers, 67.4% (n=226) were identified as overweight/obese, 90.6% (n=328) were mothers over the age of 20 among those for whom data were available. Sixty-two percent (n=235) initiated prenatal care in their first trimester, and 71.5% (n=271) were referred to the MOP by a hospital or other healthcare provider. The percentage of preeclampsia among mothers was 26.9% (n=102). After adjustment for type of LSA services received, and race/ethnicity, there were no associations between psychosocial risk factors and preeclampsia diagnosis in this population. Further research is needed on the relationship between psychosocial risk factors and preeclampsia to identify potential areas of intervention and reduce the burden of disease.

Contribution of angiotensinogen M235T and T174M gene variants and haplotypes to preeclampsia and its severity in (North African) Tunisians

BACKGROUND

Preeclampsia (PE) is a pregnancy-associated hypertensive disorder and a leading cause of maternal and neonatal morbidity and mortality. While its pathogenesis remains ill defined, several candidate genes for PE have been identified, but results remain inconclusive. We investigated the association of the angiotensinogen ( AGT) gene variants M235T and T174M with PE, and we analyzed the contribution of both variants to the severity of PE.

METHODS

This case-control study enrolled 550 Tunisian pregnant women: 272 with PE, of whom 147 presented with mild, and 125 with severe PE, along with 278 unrelated age- and ethnically matched control women. AGT genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

Significantly higher M235T minor allele frequency (MAF) was associated with increased risk of PE ( p < 0.001). Decreased frequency of heterozygous T174M genotype carriers were found in control women ( p = 0.015), suggesting a protective effect of this genotype (odds ratio (95% confidence interval) = 0.51 (0.29-0.89)). Two-locus haplotype analysis demonstrated MM and TT haplotypes to be negatively and positively associated with PE, respectively. MAF of M253T, but not T174M, was higher in the severe PE group, and carrying M235T or T174M minor allele was associated with increased body mass index ( p < 0.001) among unselected PE women.

CONCLUSIONS

AGT M235T and T174M variants contribute to an increased risk of developing PE, and for M235T to PE severity.

Hypertensive complications of pregnancy: A clinical overview

Hypertensive disorders in pregnancy are a worldwide health problem for women and their infants complicating up to 10% of pregnancies and associated with increased maternal and neonatal morbidity and mortality. In Europe, 2.3-3% of pregnancies are complicated by preeclampsia. Gestational diabetes, obesity, no previous or multiple births, maternal age less than 20 or greater than 35years old and thrombophilia can be some of the possible factors related to increased risk for hypertension in pregnancy. Complications of hypertension during pregnancy affect both mothers and their infants. Ambulatory blood pressure monitoring helps to distinguish true hypertension from the white coat as pregnant women with office abnormal values may have normal out of office blood pressure. Imbalance between proangiogenic and antiangiogenic factors in placenta may lead to endothelial dysfunction, vasoconstriction, activation of the coagulation system, and hemolysis. Carotid intima-media thickness, pulse wave velocity, augmentation index, and arterial wall tension were found to be significantly increased in women with preeclampsia compared to normotensive pregnant women. Uterine artery Doppler and serum biomarkers can be used to evaluate the probability of hypertension and complications during pregnancy, but further research in the field is needed. Lately, micro ribonucleic acids have also been the focus of research as potential biomarkers.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Antepartum Care of Women Who Are Obese During Pregnancy: Systematic Review of the Current Evidence

INTRODUCTION

Nearly 40% of US women of childbearing age are obese. Obesity during pregnancy is associated with multiple risks for both the woman and fetus, yet clinicians often feel unprepared to provide optimal antepartum care for this group of women. We collected and reviewed current evidence concerning antepartum care of women who are obese during pregnancy.

METHODS

We conducted a systematic review using PRISMA guidelines. Current evidence relating to the pregnancy care of women with a prepregnancy body mass index of 30kg/m2 or higher was identified using MEDLINE databases via PubMed, Embase, and Web of Science Core Collection between January 2012 and February 2018.

RESULTS

A total of 354 records were located after database searches, of which 63 met inclusion criteria. Topic areas for of included studies were: pregnancy risk and outcomes related to obesity, communication between women and health care providers, gestational weight gain and activity/diet, diabetic disorders, hypertensive disorders, obstructive sleep apnea, mental health, pregnancy imaging and measurement, late antepartum care, and preparation for labor and birth.

DISCUSSION

Midwives and other health care providers can provide better antepartum care to women who are obese during pregnancy by incorporating evidence from the most current clinical investigations.