Placental Vessel Segmentation Using Pix2pix Compared to U-Net

Computer-assisted technologies have made significant progress in fetoscopic laser surgery, including placental vessel segmentation. However, the intra- and inter-procedure variabilities in the state-of-the-art segmentation methods remain a significant hurdle. To address this, we investigated the use of conditional generative adversarial networks (cGANs) for fetoscopic image segmentation and compared their performance with the benchmark U-Net technique for placental vessel segmentation. Two deep-learning models, U-Net and pix2pix (a popular cGAN model), were trained and evaluated using a publicly available dataset and an internal validation set. The overall results showed that the pix2pix model outperformed the U-Net model, with a Dice score of 0.80 [0.70; 0.86] versus 0.75 [0.0.60; 0.84] (p-value < 0.01) and an Intersection over Union (IoU) score of 0.70 [0.61; 0.77] compared to 0.66 [0.53; 0.75] (p-value < 0.01), respectively. The internal validation dataset further validated the superiority of the pix2pix model, achieving Dice and IoU scores of 0.68 [0.53; 0.79] and 0.59 [0.49; 0.69] (p-value < 0.01), respectively, while the U-Net model obtained scores of 0.53 [0.49; 0.64] and 0.49 [0.17; 0.56], respectively. This study successfully compared U-Net and pix2pix models for placental vessel segmentation in fetoscopic images, demonstrating improved results with the cGAN-based approach. However, the challenge of achieving generalizability still needs to be addressed.

Cumulative effect of maternal vascular malperfusion types in the placenta on adverse pregnancy outcomes

INTRODUCTION

Placental vascular disease, characterized by Maternal Vascular Malperfusion (MVM) lesions, is considered to be the underlying cause of pregnancy complications. Aim is to evaluate the relationship between the cumulative number of MVM lesion types, and adverse pregnancy- and neonatal outcomes.

METHODS

This retrospective cohort study included 272 women with singleton gestations who gave birth at a Dutch tertiary hospital between 2017 and 2018 with available placental histopathology reports. Analyzed according to the Amsterdam Placental Workshop Group Consensus Statement, placentas were divided into groups based on the cumulative number of MVM lesions: no lesions (n = 124), 1-2 types (n = 124) and 3-5 types of lesions (n = 24).

RESULTS

The proportion of placenta syndrome (PS) was highest (95.8%) in the 3-5 MVM lesions group (p < 0.001). The presence of MVM lesions was highly associated with PS during pregnancy (aOR 6.81, 95% CI 3.76-12.33). Furthermore, every additional type of MVM lesion corresponded with a threefold increased odds for the occurrence of PS (aOR 3.00, 95% CI 2.10-4.29). The group with 3-5 types of MVM lesions showed the highest incidence of adverse neonatal outcomes, lower mean birth weight, prolonged hospitalization, NICU admissions and neonatal deaths (aOR 6.47, 95% CI 0.33-127.68), corresponding with a fourfold increased odds for the occurrence of neonatal death for every additional MVM lesion (aOR 4.19, 95% CI 1.39-12.68).

DISCUSSION

A higher number of MVM lesion types is strongly associated with an increased incidence of adverse pregnancy- and neonatal outcomes, indicating that guidelines should focus also on the amount of MVM lesion types for the monitoring/management of subsequent pregnancies.

Angiotensin receptor blockers are equally effective in women and men; a systematic review and meta-analysis

Background

Hypertension is the leading risk factor for cardiovascular disease (CVD) and is the most substantial and neglected health burden in women. While treatment of high blood pressure is essential in the global prevention strategies of CVD it is assumed that effectiveness of pharmacological treatment may be hampered by sex differences. However, it is still not known whether sex differences exist in the effect of the antihypertensive medications.

Purpose

To evaluate sex-stratified effects for angiotensin receptor blockers (ARBs) on blood pressure (BP) and cardiac function in female compared to male hypertensive participants.

Methods

A series of systematic reviews and meta-analysis was performed. PubMed and EMBASE were systematically searched for studies evaluating the effects of the five major groups of antihypertensive medication from 1945 to May 2020. Randomized control trials and observational studies in humans (≥18 years) were included investigating beta-blockers (BB), angiotensin converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), calcium channel blockers (CCB), and diuretics. In this study data on ARB's was analyzed. Studies had to present both baseline and follow-up measurements of at least one of the outcome variables of interest and present their data in a sex-stratified manner. Data on BPand cardiac function where retrieved from studies. Risk of bias was assessed using the Cochrane risk of bias tool.

Results

The search strategy resulted in 73,867 hits. After first screening based on title and abstract, 15,130 articles where suitable for full test screening. After excluding all studies that matched the exclusion criteria, 205 studies with 15,570 participants where eligible for analysis for the five antihypertensive drugs. Studies investigating ARB's (n=17) where used in this review. Seven trials (41%) had a low risk of bias. ARB decreased BP significantly and comparably in both women and men. Systolic BP −18.2 mmHg (95% CI, −24.8 to −11.5) vs −20.1 mmHg (95% CI, −26.7 to −13.6) and diastolic BP −11.6 mmHg (95% CI, −14.7 to −8.4) vs −12.3 mmHg (95% CI, −16.4 to −8.1). LVEF did not change significantly in either group. LV mass was only reported in males and did not change significantly −11.8 g (95% CI, −25.6 to 1.9).

Conclusion

Our meta-analysis shows that based on the current studies, no sex differences exists in the effect of ARB on blood pressure or cardiac function.

Funding Acknowledgement

Type of funding sources: None.

Second-Trimester Constituents of the Metabolic Syndrome and Pregnancy Outcome: An Observational Cohort Study

Background: Gestational diabetes mellitus (GDM) increases the risk of type 2 diabetes mellitus and cardiovascular disease (CVD) in women in later life. In the general population, metabolic syndrome (MetS) shows identical associations. The aim of this study was to evaluate the association between GDM, constituents of MetS and pregnancy outcomes. Methods: Of 2041 pregnant women undergoing an oral glucose tolerance test (OGTT) between 22 and 30 weeks of gestation, data were collected to evaluate the constituents of MetS. Odds ratios (ORs) were calculated to determine the associations between MetS and pregnancy outcomes. Results: GDM and obesity did not affect the risk of fetal growth abnormalities (SGA/LGA), preterm birth or preeclampsia (PE). Hypertension significantly increased the risk of SGA (OR—1.59), PE (OR—3.14), and preterm birth <37 weeks (OR—2.17) and <34 weeks (OR—2.96) and reduced the occurrence of LGA (OR—0.46). Dyslipidemia increased the risk of PE (OR—2.25), while proteinuria increased the risk of PE (OR—12.64) and preterm birth (OR—4.72). Having ≥2 constituents increased the risk of PE and preterm birth. Conclusions: Constituents of metabolic syndrome, rather than treating impaired glucose handling, increased the risk of preeclampsia, altered fetal growth and preterm birth. Obesity was not related to adverse outcomes.

O-182 No higher prevalence of metabolic dysfunction among subfertile women in an urban population

Study question

What is the prevalence of metabolic dysfunction, like insulin resistance, hyperglycaemia, hypertension, and/or dyslipidaemia, among subfertile women compared to healthy controls?

Summary answer

Signs of metabolic dysfunction were not observed more frequently in subfertile women than in controls. Overweight and obese patients were at risk for metabolic dysfunction.

What is known already

Metabolic dysfunction is known to impair female fecundity as it is linked to a longer time-to-pregnancy and to subfertility. Three times as many PCOS patients are diagnosed with metabolic syndrome than age matched controls. Moreover, a recent study showed a higher prevalence among the entire subfertile population. Metabolic disorders have been connected to the impairment of normal ovarian function and pituitary-hypothalamic axis. Obesity is correlated with menstrual irregularities, ovulation disorders and infertility. On top, it can increase risk of miscarriage and reduce chances with assisted reproductive technologies. Therefore, metabolic dysfunction might also be a driving factor behind unexplained subfertility.

Study design, size, duration

This cross-sectional observational case control study was performed in a secondary and tertiary care fertility clinic (MUMC+, Maastricht, The Netherlands). Patients were referred to the fertility clinic with either primary or secondary subfertility (inability to conceive after one year of regular unprotected intercourse), controls were healthy, parous women. All participants were aged between 18 and 41 years at time of inclusion. 119 patients and 68 controls were included over a time span of 3 years.

Participants/materials, setting, methods

A basic medical history was collected using questionnaires. Physical examination included measurement of weight, height, waist and hip circumference, blood pressure and pulse. Venipuncture was performed after an overnight fast on cycle day 2-4; including insulin, glucose, triglycerides, high-density lipid cholesterol, total cholesterol, glomerular filtration rate, urea, uric acid, creatinine, follicle stimulating hormone, estradiol and anti-Mullarian hormone. Urine was collected to measure protein and creatinine. Metabolic syndrome was diagnosed according to Adult Treatment Panel-III guidelines.

Main results and the role of chance

Body weight and BMI were similarly distributed between patients and controls. Main causes of subfertility comprised male factor (12%), anovulation (20%) and unexplained subfertility (47%). Comparing patients to controls, unexplained subfertility only had slightly higher HDL cholesterol levels (p = 0.046). Anovulatory patients showed 2% higher glucose (p = 0.003) and 133% higher AMH levels (p &lt; 0.001). Metabolic syndrome was diagnosed in 6% of unexplained subfertility patients, in 4% of male factor patients and in 5% of anovulatory patients. No controls were diagnosed with metabolic syndrome.

In a comparison of overweight and obese patients to normal weight patients we observed resp. 16% and 37% higher waist circumference (p &lt; 0.001), 7% and 11% higher waist-to-hip ratio (p &lt; 0.01), 37% and 197% higher fasting insulin (p &lt; 0.01), 30% and 198% higher HOMA-IR (p &lt; 0.02) and 8% and 24% higher uric acid levels (p &lt; 0.03). Concomitantly, obese patients showed dyslipidemia with 98% higher triglyceride levels (p &lt; 0.001) and 24% lower HDL cholesterol (p &lt; 0.01). 181% higher AMH levels were found in obese patients (p &lt; 0.01). Metabolic syndrome was diagnosed in 1% of normal weight patients, 4% of overweight patients and in 25% of obese patients.

Limitations, reasons for caution

Participants were young and remarkably healthy, which might account for the low prevalence of metabolic disorders. It is known that the prevalence of metabolic dysfunction is strongly dependent on socioeconomic and geographic determinants in various populations. Our findings apply to a largely ethnically homogeneous Caucasian female population in the Netherlands.

Wider implications of the findings

We found that the presence or specific cause of subfertility per se, cannot be regarded as a reliable and strong predictor of metabolic dysfunction, even in anovulatory subfertility. As can be expected, metabolic dysfunction is highly associated with BMI and obese patients should consider lifestyle intervention to prevent future complications.

Trial registration number

Not applicable

Role of Beta Cell Function and Insulin Resistance in the Development of Gestational Diabetes Mellitus

Background: Gestational diabetes mellitus (GDM) is a pregnancy complication characterized by second trimester hyperglycemia. Untreated, GDM is related to an increased risk for adverse pregnancy outcomes. Both beta cell dysfunction and insulin resistance underlie impaired glucose tolerance. Understanding the dominant mechanism predisposing to GDM may be important to provide effective treatment in order to improve perinatal outcomes. We hypothesize that insulin resistance rather that beta cell dysfunction predisposes to GDM. Methods: A 75g oral glucose tolerance test (OGTT) was performed on 2112 second-trimester pregnant women to determine the relationship between insulin resistance (HOMA-IR), beta cell function (HOMA-β), and the prevalence of abnormal glucose handling. Results: High insulin resistance raised the risk of GDM (relative risk (RR) 6.1, 95% confidence interval (CI) (4.4–8.5)), as did beta cell dysfunction (RR 3.8, 95% CI (2.7–5.4)). High insulin resistance, but not beta cell function, enhances the necessity for additional glucose lowering medication on top of a low carbohydrate diet in women diagnosed with GDM. Conclusions: Both high insulin resistance and beta cell dysfunction increase the risk of GDM. As increased insulin resistance, rather than beta cell function, is related to an insufficient response to a low carbohydrate diet, we speculate that insulin sensitizers rather than insulin therapy may be the most targeted therapeutic modality in diet-insensitive GDM.

The association between decidual vasculopathy and abnormal uterine artery Doppler measurement

INTRODUCTION

Placental syndrome is an umbrella term encompassing the clinical phenotypes of preeclampsia and fetal growth restriction, and is associated with high maternal and neonatal morbidity. In women with placental syndrome, histologicl examination of the uteroplacental unit commonly demonstrates pathological lesions, such as decidual vasculopathy. Decidual vasculopathy are pathological changes in the spiral arteries, which are associated with adverse outcome in preeclampsia and long-term maternal cardiovascular health. The relation between placental syndrome phenotypes and placental pathology has been previously demonstrated; however, the role of uteroplacental Doppler measurements as a link between placental syndrome phenotypes and the underlying placental pathology is still unclear. We hypothesized that decidual vasculopathy is associated with abnormal uteroplacental Doppler profiles and ultrasound placental parameters, independent of clinical phenotype.

MATERIAL AND METHODS

We performed a retrospective analysis of data from a prospective cohort of pregnancies with placental syndrome, as well as cases without hypertensive disease or fetal growth restriction. The study group was divided into women with decidual vasculopathy on histologic analysis of placental specimen and those without the lesions. Outcome parameters included maternal and fetal Dopplers, estimated fetal weight, placental weight and thickness, placental lacunae and abnormal placental calcification.

RESULTS

Compared with the women without the lesions (n = 91), the group with decidual vasculopathy (n = 25) had a higher mean uterine artery pulsatility index (1.70 vs 0.81, p < 0.001) and uterine artery pulsatility index percentile (>p99 vs p67, p < 0.001). Decidual vasculopathy was associated with abnormal uterine artery Doppler profile (defined as pulsatility index p > 95 and/or bilateral notch) (82%) compared with women without the lesions (33%) (odds ratio [OR] 9.3, 95% CI 2.4-36.0), which remained significant after adjusting for possible confounding factors preeclampsia, tobacco use and gestational age at birth (OR 7.1, 95% CI 1.3-39.1). Decidual vasculopathy was not associated with fetal Doppler abnormalities or placental parameters and only modestly so with lower cerebroplacental ratio (p = 0.036).

CONCLUSIONS

Histologic decidual vasculopathy is associated with abnormal uterine artery Doppler, independent of clinical phenotype during pregnancy.

Blood pressure adjustments throughout healthy and hypertensive pregnancy: A systematic review and meta-analysis

Gestational hypertensive complications are preceded by deviant hemodynamic adjustments affecting blood pressure. Our objective was to determine the timing and magnitude of changes in blood pressure during singleton normotensive and hypertensive pregnancies. PubMed (NCBI) and Embase (Ovid) databases were searched for relevant studies up to November 2019. Studies reporting original blood pressure measurements during pregnancy together with a non-pregnant reference measurement were included. Studies including women with a history of cardiovascular or metabolic disease, or women using antihypertensive drugs were excluded. Pooled mean differences between pregnant and non-pregnant women, and absolute blood pressure values were calculated for predefined gestational intervals in normotensive and hypertensive pregnancy, using a random-effects model. Meta-regression analysis was used to analyze group differences in adjustments. In early normotensive pregnancy, both systolic and diastolic blood pressure decreased, reaching their maximum reduction of -4 mmHg (95%CI -6 to -1 mmHg) and -4 mmHg (95%CI, -5 to -3 mmHg), respectively in the second trimester. Thereafter, blood pressure gradually increased towards non-pregnant values. All absolute blood pressure measurements throughout normotensive pregnancy were below 130/80 mmHg. In hypertensive pregnancies, only diastolic blood pressure decreased early in pregnancy. In conclusion, this meta-analysis showed a clinically moderate, but significant mid-pregnancy drop in blood pressure during normotensive pregnancy. Reference curves with absolute values underscore the current liberal cut-off limit for gestational hypertension. A lack of a mid-pregnancy systolic blood pressure drop might reflect increased vascular resistance in women destined to develop hypertensive pregnancy complications.

Ultrasound evaluation of the placenta in healthy and placental syndrome pregnancies: A systematic review

INTRODUCTION

An antepartum screening method to determine normal and abnormal placental function is desirable in the prevention of maternal and fetal pregnancy complications. Placental appearance can easily be obtained and evaluated using 2D ultrasonography, but surprisingly little is known about the change in placental appearance during gestation. Aim of this systematic review was to describe the antepartum placental appearance in placenta syndrome (PS) pregnancies, and to compare this to the appearance in healthy pregnancies.

METHODS

A systematic review investigating placental thickness, -lakes and/or -calcifications by ultrasound examination in both uncomplicated (reference group) and PS pregnancies in relation to gestational age was performed. English literature was searched using PubMed (NCBI), EMBASE (Ovid) and the Cochrane Library, from database inception until September 2020. Data on placental thickness was presented as a continuous variable or as the proportion of abnormal placental thickness. Data on placental lakes and -calcifications was presented as prevalence (%). There was no restriction applied on the definition of placental lakes or -calcifications. Due to heterogeneity, pooling of the results was not performed.

RESULTS

A total of 28 studies were included describing 1719 PS cases; consisting of 370 (21 %) cases with preeclampsia or pregnancy induced hypertension, 1341 (78 %) cases with fetal growth restriction (FGR) or small for gestational age (SGA), and 8 (1%) cases with combined clinical expressions. In addition, the reference group comprised 3315 pregnant women. Placental thickness showed an increase between the first and second trimester, which was higher in PS- compared to uncomplicated pregnancies. Placental lakes were frequently observed in FGR and SGA pregnancies, especially in the second trimester. Grade 3 calcifications were most prominent in the PS pregnancies, specifically in the late second and third trimester. Moreover, in the reference group, no grade 3 calcifications were reported before 35 weeks of gestation.

CONCLUSION

Placental appearance in PS-pregnancies shows higher placental thickness and greater presence of placental lakes and -calcifications compared to uncomplicated pregnancies. Standardized definitions of (ab-)normal placental appearance and longitudinal research in both healthy and complicated pregnancies are needed to improve personalized obstetric care.

Study protocol for the randomized controlled EVA (early vascular adjustments) trial: tailored treatment of mild hypertension in pregnancy to prevent severe hypertension and preeclampsia

BACKGROUND

In contrast to severe gestational hypertension, it is questioned whether antihypertensive medication for mild to moderate gestational hypertension prevents adverse maternal and offspring outcomes. Hypertensive drugs halve the risk of severe hypertension, but do not seem to prevent progression to preeclampsia or reduce the risk of complications in offspring. In fact, beta-blockers, a first line therapy option, are suspected to impair foetal growth. Disappointing effects of antihypertensive medication can be anticipated when the pharmacological mode of action does not match the underlying haemodynamic imbalance. Hypertension may result from 1) high cardiac output, low vascular resistance state, in which beta blockade is expected to be most effective, or 2) low cardiac output, high vascular resistance state where dihydropyridine calcium channel blockers or central-acting alpha agonists might be the best corrective medication. In the latter, beta-blockade might be maternally ineffective and even contribute to impaired foetal growth by keeping cardiac output low. We propose a randomized controlled trial to determine whether correcting the haemodynamic imbalance in women with mild to moderate hypertension reduces the development of severe hypertension and/or preeclampsia more than non-pharmacological treatment does, without alleged negative effects on foetal growth.

METHODS

Women diagnosed with mild to moderate hypertension without proteinuria or signs of other organ damage before 37 weeks of pregnancy are invited to participate in this randomized controlled trial. Women randomized to the intervention group will be prescribed tailored antihypertensive medication, using a simple diagnostic and treatment algorithm based on the mean arterial pressure/heart rate ratio, which serves as an easy-to-determine proxy for maternal circulatory state. Women randomized to the control group will receive non-pharmacological standard care according to national and international guidelines. In total, 208 women will be randomized in a 1:1 ratio. The primary outcome is progression to severe hypertension and preeclampsia and the secondary outcomes are adverse maternal and neonatal outcomes.

DISCUSSION

This trial will provide evidence of whether tailoring treatment of mild to moderate gestational hypertension to the individual haemodynamic profile prevents maternal disease progression.

TRIAL REGISTRATION

NCT02531490 , registered on 24 August 2015.

Fertility, pregnancy and neonatal outcomes of patients with adenomyosis: a systematic review and meta-analysis

This study aimed to investigate the association of adenomyosis with fertility, pregnancy and neonatal outcomes. An electronic search was conducted using the MEDLINE, PubMed and Cochrane databases up to April 2020. Seventeen observational studies were included. Adenomyosis was significantly associated with a lower clinical pregnancy rate (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.51-0.94) and higher miscarriage rate (OR 2.17; 95% CI 1.25-3.79) after treatment with assisted reproductive technology (ART). The lower clinical pregnancy rate was more significant in the subgroup of patients with short down-regulation protocols. Similar associations were recorded after age adjustment. Adenomyosis was also significantly associated with an increased risk of pre-eclampsia, preterm delivery, Caesarean section, fetal malpresentation, small for gestational age infancy and post-partum haemorrhage, which was confirmed after correction for age and mode of conception. In conclusion, adenomyosis is associated with negative effects on fertility after ART. The potentially protective role of the ultra-long down-regulation protocols needs further evaluation in randomized controlled studies. Adenomyosis is also associated (independently of the mode of conception) with adverse pregnancy and neonatal outcomes. Proper counselling prior to ART and close monitoring of pregnancy in patients with adenomyosis should be recommended.

Accuracy and precision of USCOM versus transthoracic echocardiography before and during pregnancy

OBJECTIVE

Monitoring hemodynamic status throughout pregnancy may help in identifying women with maladaptation predisposing to hypertensive complications. The Ultrasonic Cardiac Output Monitor (USCOM) is an easy-to-operate device for measuring cardiac output (CO) quickly. Our aim was to assess agreement between USCOM and transthoracic echocardiography (TTE) in: 1) non-pregnant women to correct for possible sources of discrepancy; 2) women longitudinally over the course of the pregnancy.

STUDY DESIGN

High-risk women admitted for cardiovascular risk factor evaluation before pregnancy and multiple times during pregnancy, were included. CO was measured by TTE directly followed by USCOM measurements.

MAIN OUTCOME MEASURES

Bias, limits of agreement (LOA) and percentage error between the two methods by Bland-Altman analysis.

RESULTS

Despite comparable non-pregnant CO levels (4.6 L/min), LOA and percentage error between the two methods improved moderately by optimizing the measurements using only the highest quality USCOM recordings in 132 non-pregnant women (percentage error of 39% and 30%, respectively). During pregnancy, in total 83, 106, 96 and 77 measurements were evaluated at respectively 12, 16, 20 and 30 weeks gestational age. Mean CO in USCOM was about 0.6 L/min higher compared to TTE in all trimesters; percentage error ranged from 35% to 45%. Linear mixed model analysis showed no association between bias and moment of measurement.

CONCLUSION

Agreement between USCOM and TTE in pregnancy was outside our a priori determined level of acceptability and therefore absolute values of USCOM and TTE cannot be used interchangeably. Future research should focus on the agreement of USCOM and TTE in clinical decision-making.

Low-flow mediated constriction as a marker of endothelial function in healthy pregnancy and preeclampsia: A pilot study

OBJECTIVES

Overwhelming clinical evidence exists on disturbed vascular and endothelial function in the pathophysiology of preeclampsia (PE). In a non-pregnant (NP) population, L-FMC (low-flow mediated constriction) provides insight in the 'resting' endothelial capacity in contrast to the gold standard of flow mediated dilatation (FMD), reflecting endothelial nitric oxide bioavailability.

STUDY DESIGN

Longitudinal follow-up of 100 healthy pregnant (HP) women, 33 PE women and 16 NP controls with non-invasive vascular assessments. HP women were evaluated at 12 and 35 weeks of gestation and at 6 months postpartum. PE patients were assessed at diagnosis (mean 30 weeks) and 6 months postpartum.

MAIN OUTCOME MEASURES

Endothelial function (L-FMC, FMD, peripheral arterial tonometry (PAT)) and arterial stiffness (pulse wave velocity (PWV) and analysis (PWA)) were measured at the different visits and compared between groups.

RESULTS

Overall endothelial dysfunction is present in PE (FMD HP 9.09 ± 4.20 vs PE 5.21 ± 4.47, p = 0.0004; L-FMC HP -1.90 ± 2.66 vs PE -0.40 ± 2.09, p = 0.03). L-FMC gradually elevates during the course of a HP (1st trim -0.31 ± 1.75 vs 3rd trim -1.97 ± 3.02, p < 0.0001) and is present in 85% of women in the third trimester. In NP, only 27% of women has L-FMC. In PE, L-FMC is present in 50% of cases. Arterial stiffness is increased in PE (all p < 0.0001). There is no correlation between L-FMC and other markers of vascular function (p > 0.05).

CONCLUSION

PE is characterized by dysfunction of both resting and recruitable endothelial capacity. This study offers new insights in different aspects of endothelial function in pregnancy, since L-FMC reflects an adaptation in HP that is absent in PE.

Assessment of venous hemodynamics and volume homeostasis during pregnancy: recommendations of the International Working Group on Maternal Hemodynamics

Venous hemodynamics and volume homeostasis are important aspects of cardiovascular physiology. However, today their relevance is still very much underappreciated. Their most important role is maintenance and control of venous return and, as such, cardiac output. A high-flow/low-resistance circulation, remaining constant under physiological circumstances, is mandatory for an uncomplicated course of pregnancy. In this article, characteristics of normal and abnormal venous and volume regulating functions are discussed with respect to normal and pathologic outcomes of pregnancy, and current (non-invasive) methods to assess these functions are summarized. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Oxidative stress and endothelial function in normal pregnancy versus pre-eclampsia, a combined longitudinal and case control study

Background

Pre-eclampsia (PE) is related to an impaired endothelial function. Endothelial dysfunction accounts for altered vascular reactivity, activation of the coagulation cascade and loss of vascular integrity. Impaired endothelial function originates from production of inflammatory and cytotoxic factors by the ischemic placenta and results in systemic oxidative stress (OS) and an altered bioavailability of nitric oxide (•NO). The free radical •NO, is an endogenous endothelium-derived relaxing factor influencing endothelial function. In placental circulation, endothelial release of •NO dilates the fetal placental vascular bed, ensuring feto-maternal exchange. The Endopreg study was designed to evaluate in vivo endothelial function and to quantify in vitro OS in normal and pre-eclamptic pregnancies.

Methods/design

The study is divided into two arms, a prospective longitudinal study and a matched case control study. In the longitudinal study, pregnant patients ≥18 years old with a singleton pregnancy will be followed throughout pregnancy and until 6 months post-partum. In the case control study, cases with PE will be compared to matched normotensive pregnant women. Maternal blood concentration of superoxide (O₂•) and placental concentration of •NO will be determined using EPR (electron paramagnetic resonance). Endothelial function and arterial stiffness will be evaluated using respectively Peripheral Arterial Tonometry (PAT), Flow-Mediated Dilatation (FMD) and applanation tonometry. Placental expression of eNOS (endothelial NOS) will be determined using immune-histochemical staining. Target recruitment will be 110 patients for the longitudinal study and 90 patients in the case-control study.

Discussion

The results of Endopreg will provide longitudinal information on in vivo endothelial function and in vitro OS during normal pregnancy and PE. Adoption of these vascular tests in clinical practice potentially predicts patients at risk to develop cardiovascular events later in life after PE pregnancies. •NO, O₂•⁻ and eNOS measurements provide further inside in the pathophysiology of PE.

Trial registration

This trial has been registered on clinicaltrials.gov. ClinicalTrials.gov Identifier: NCT02603913. Registered October 2015.

Flow-mediated dilation and peripheral arterial tonometry are disturbed in preeclampsia and reflect different aspects of endothelial function

Endothelial function and arterial stiffness are known to be altered in preeclamptic pregnancies. Previous studies have shown conflicting results regarding the best technique for assessing vascular function in pregnancy. In this study, we made a comprehensive evaluation of in vivo vascular function [including flow-mediated dilatation (FMD), peripheral arterial tonometry (PAT), and arterial stiffness] in preeclamptic patients and compared them with normal pregnancies. In addition, we assessed the relation between vascular function and systemic inflammation. Fourteen patients with preeclampsia (PE) and 14 healthy pregnant controls were included. Endothelial function was determined by FMD and PAT and arterial stiffness by carotid-femoral pulse-wave velocity and augmentation index. Systemic inflammation was assessed using mean platelet volume (MPV) and neutrophil-lymphocyte ratio (NLR). The reactive hyperemia index, assessed using PAT, is decreased at the third trimester compared with the first trimester in a normal, uncomplicated pregnancy (P = 0.001). Arterial stiffness is significantly higher in PE versus normal pregnancy (P < 0.001). Endothelial function, obtained by FMD, is deteriorated in PE versus normal pregnancy (P = 0.015), whereas endothelial function assessment by PAT is improved in PE versus normal pregnancy (P = 0.001). Systemic inflammation (MPV and NLR) increases during normal pregnancy. FMD and PAT are disturbed in PE. Endothelial function, assessed by FMD and PAT, shows distinct results. This may indicate that measurements with FMD and PAT reflect different aspects of endothelial function and that PAT should not be used as a substitute for FMD as a measure of endothelial function in pregnancy.

Is middle cerebral artery Doppler related to neonatal and 2-year infant outcome in early fetal growth restriction?

BACKGROUND

Reduced fetal middle cerebral artery Doppler impedance is associated with hypoxemia in fetal growth restriction. It remains unclear as to whether this finding could be useful in timing delivery, especially in the third trimester. In this regard there is a paucity of evidence from prospective studies.

OBJECTIVES

The aim of this study was to determine whether there is an association between middle cerebral artery Doppler impedance and its ratio with the umbilical artery in relation to neonatal and 2 year infant outcome in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation). Additionally we sought to explore which ratio is more informative for clinical use.

STUDY DESIGN

This is a secondary analysis from the Trial of Randomized Umbilical and Fetal Flow in Europe, a prospective, multicenter, randomized management study on different antenatal monitoring strategies (ductus venosus Doppler changes and computerized cardiotocography short-term variation) in fetal growth restriction diagnosed between 26⁺⁰ and 31⁺⁶ weeks. We analyzed women with middle cerebral artery Doppler measurement at study entry and within 1 week before delivery and with complete postnatal follow-up (374 of 503). The primary outcome was survival without neurodevelopmental impairment at 2 years corrected for prematurity. Neonatal outcome was defined as survival until first discharge home without severe neonatal morbidity. Z-scores were calculated for middle cerebral artery pulsatility index and both umbilicocerebral and cerebroplacental ratios. Odds ratios of Doppler parameter Z-scores for neonatal and 2 year infant outcome were calculated by multivariable logistic regression analysis adjusted for gestational age and birthweight p50 ratio.

RESULTS

Higher middle cerebral artery pulsatility index at inclusion but not within 1 week before delivery was associated with neonatal survival without severe morbidity (odds ratio, 1.24; 95% confidence interval, 1.02-1.52). Middle cerebral artery pulsatility index Z-score and umbilicocerebral ratio Z-score at inclusion were associated with 2 year survival with normal neurodevelopmental outcome (odds ratio, 1.33; 95% confidence interval, 1.03-1.72, and odds ratio, 0.88; 95% confidence interval, 0.78-0.99, respectively) as were gestation at delivery and birthweight p50 ratio (odds ratio, 1.41; 95% confidence interval, 1.20-1.66, and odds ratio, 1.86; 95% confidence interval, 1.33-2.60, respectively). When comparing cerebroplacental ratio against umbilicocerebral ratio, the incremental range of the cerebroplacental ratio tended toward zero, whereas the umbilicocerebral ratio tended toward infinity as the values became more abnormal.

CONCLUSION

In a monitoring protocol based on ductus venosus and cardiotocography in early fetal growth restriction (26⁺⁰-31⁺⁶ weeks of gestation), the impact of middle cerebral artery Doppler and its ratios on outcome is modest and less marked than birthweight and delivery gestation. It is unlikely that middle cerebral artery Doppler and its ratios are informative in optimizing the timing of delivery in fetal growth restriction before 32 weeks of gestation. The umbilicocerebral ratio allows for a better differentiation in the abnormal range than the cerebroplacental ratio.

Heart failure with preserved ejection fraction in women: the Dutch Queen of Hearts program

Heart failure (HF) poses a heavy burden on patients, their families and society. The syndrome of HF comes in two types: with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The latter is on the increase and predominantly present in women, especially the older ones. There is an urgent need for mortality-reducing drugs in HFpEF, a disease affecting around 5 % of those aged 65 years and over. HFpEF develops in patients with risk factors and comorbidities such as obesity, hypertension, diabetes, COPD, but also preeclampsia. These conditions are likely to drive microvascular disease with involvement of the coronary microvasculature, which may eventually evolve into HFpEF. Currently, the diagnosis of HFPEF relies mainly on echocardiography. There are no biomarkers that can help diagnose female microvascular disease or facilitate the diagnosis of (early stages of) HFpEF. Recently a Dutch consortium was initiated, Queen of Hearts, with support from the Netherlands Heart Foundation, with the aim to discover and validate biomarkers for diastolic dysfunction and HFpEF in women. These biomarkers come from innovative blood-derived sources such as extracellular vesicles and circulating cells. Within the Queen of Hearts consortium, we will pursue female biomarkers that have the potential for further evolution in assays with point of care capabilities. As a spin-off, the consortium will gain knowledge on gender-specific pathology of HFpEF, possibly opening up novel treatment options.

What Makes for Good Collaboration and Communication in Maternity Care? A Scoping Study

BACKGROUND: Good communication and collaboration are critical to safe care for mothers and babies.

OBJECTIVE: To identify factors associated with good collaboration and communication among maternity care professionals and between both professionals and parents.

METHOD: Scoping study. We searched PubMed and Web of Science for peer reviewed, quantitative and qualitative, original, primary research in Western societies on communication and collaboration in maternity care among professionals (Search 1) and between professionals and parents (Search 2).

FINDINGS: The 40 studies (14 in Search 1; 26 in Search 2) that met our selection criteria highlighted several factors associated with good communication and collaboration. We grouped these factors into 6 categories: Expertise, Partnership, Context, Attitude, Trust, and Communication style. Studies of communication and collaboration among professionals foregrounded work-related aspects, whereas studies examining collaboration between professionals and parents paid more attention to interpersonal aspects. Before 2012, few studies covered positive aspects of communication and collaboration. We also found an underrepresentation of parents in study populations.

CONCLUSION: Our study is part of a growing trend of identifying the positive aspects of communication and collaboration in maternity care. As the study of collaboration in practice continues, researchers need to be sure to involve all stakeholders, including parents.

Smartphone-based analysis of biochemical tests for health monitoring support at home

In the context of home-based healthcare monitoring systems, it is desirable that the results obtained from biochemical tests - tests of various body fluids such as blood and urine - are objective and automatically generated to reduce the number of man-made errors. The authors present the StripTest reader - an innovative smartphone-based interpreter of biochemical tests based on paper-based strip colour using image processing techniques. The working principles of the reader include image acquisition of the colour strip pads using the camera phone, analysing the images within the phone and comparing them with reference colours provided by the manufacturer to obtain the test result. The detection of kidney damage was used as a scenario to illustrate the application of, and test, the StripTest reader. An extensive evaluation using laboratory and human urine samples demonstrates the reader's accuracy and precision of detection, indicating the successful development of a cheap, mobile and smart reader for home-monitoring of kidney functioning, which can facilitate the early detection of health problems and a timely treatment intervention.

Long-Term Risk to Develop Hypertension in Women With Former Preeclampsia: A Longitudinal Pilot Study

INTRODUCTION

Women with former preeclampsia (exPE) develop chronic hypertension 4 times more often than healthy parous controls. Women, destined to develop remote chronic hypertension, had increased left ventricular mass index (LVMI) and diastolic blood pressure (BP) prior to the onset of hypertension as compared to those remaining normotensive. However, longitudinal data on the progress of this increased LVMI in women destined to develop hypertension are lacking.

METHODS

We included 20 women with exPE and 8 parous controls. At both 1- and 14-year postpartum (pp), we performed cardiac ultrasound and determined circulating levels of the metabolic syndrome variables. Of 14-year pp, 7 (35%) former patients had developed chronic hypertension. We compared these 7 former patients with both the 13 former patients who remained normotensive and the 8 parous controls using the Mann-Whitney U test and Kruskal-Wallis analysis.

RESULTS

Women with hypertensive exPE differed from their normotensive counterparts by a higher incidence of early-onset preeclampsia (PE) in their index pregnancy and a higher rate of recurrence in next pregnancies. At 1-year pp, they also had high/normal BP and higher fasting insulin levels. At 14 years pp, the relative left ventricular wall thickness was higher, and the E/A ratio was lower, in the hypertensive group relative to those remaining normotensive.

CONCLUSION

Women with exPE are at increased risk of developing chronic hypertension, when (1) the PE in the index pregnancy had an early-onset and/or recurred in next pregnancies and (2) the 1-year pp. Blood pressure was high normal. We also noticed that at 14 years pp, the hypertensive group showed signs of concentric left ventricular remodeling along with a decreased E/A ratio.

Foley catheter versus vaginal misoprostol: randomized controlled trial (PROBAAT-M study) and systematic review and meta-analysis of literature

OBJECTIVES

To assess effectiveness and safety of Foley catheter versus vaginal misoprostol for term induction of labor.

STUDY DESIGN

This trial randomly allocated women with singleton term pregnancy to 30-mL Foley catheter or 25-μg vaginal misoprostol tablets. Primary outcome was cesarean delivery rate. Secondary outcomes were maternal and neonatal morbidity and time to birth. Additionally, a systematic review was conducted.

RESULTS

Fifty-six women were allocated to Foley catheter, 64 to vaginal misoprostol tablets. Cesarean delivery rates did not differ significantly (25% Foley versus 17% misoprostol; relative risk [RR] 1.46, 95% confidence interval [CI] 0.72 to 2.94), with more cesarean deliveries due to failure to progress in the Foley group (14% versus 3%; RR 4.57, 95% CI 1.01 to 20.64). Maternal and neonatal outcomes were comparable. Time from induction to birth was longer in the Foley catheter group (36 hours versus 25 hours; p < 0.001). Meta-analysis showed no difference in cesarean delivery rate and reduced vaginal instrumental deliveries and hyperstimulation in the Foley catheter group. Other outcomes were not different.

CONCLUSION

Our trial and meta-analysis showed no difference in cesarean delivery rates and less hyperstimulation with fetal heart rate changes and vaginal instrumental deliveries when using Foley catheter, thereby supporting potential advantages of the Foley catheter over misoprostol as ripening agent.

Hypertension after preeclampsia is preceded by changes in cardiac structure and function

Preeclampsia is associated with a 4-fold higher risk for developing remote chronic hypertension. Preeclampsia is accompanied by left ventricular hypertrophy and decreased diastolic function, which may or may not resolve postpartum. We tested the hypothesis that increased measures of cardiac geometry and decreased cardiac function persisting for ≥ 6 months postpartum in normotensive women with a history of preeclampsia precede the development of later chronic hypertension. Formerly preeclamptic women (n=652) underwent echocardiography at 9 months (range, 6-19) postpartum. We excluded women with preexisting hypertension (n=42), hypertension at the postpartum screening (n=133), and those that did not return any checklist (n=128). Eventually, 349 women were included. Remote health was evaluated by a biennially checklist. We used Cox regression for analysis. Twenty-seven (8%) normotensive women had developed chronic hypertension during a medium follow-up period of 6 years. At screening they differed from their counterparts who remained normotensive by hazard ratio for left ventricular mass index (1.11; 95% confidence interval [CI], 1.03-1.18), diastolic blood pressure (1.13; 95% CI, 1.06-1.20), systolic blood pressure (1.07; 95% CI, 1.02-1.11), mean arterial pressure (1.11; 95% CI, 1.05-1.18), heart rate (1.05; 95% CI, 1.01-1.10), and E/A ratio (0.22; 95% CI, 0.06-0.85). Backward stepwise analysis showed independent hazard ratio for left ventricular mass index and diastolic blood pressure 1.08 (95% CI, 1.01-1.16) and 1.13 (95% CI, 1.06-1.21), respectively. In conclusion, the development of later chronic hypertension in initially normotensive formerly preeclamptic women is preceded by increased left ventricular mass index and diastolic blood pressure at postpartum screening.

Cost-effectiveness of induction of labour at term with a Foley catheter compared to vaginal prostaglandin E₂ gel (PROBAAT trial)

OBJECTIVE

To assess the economic consequences of labour induction with Foley catheter compared to prostaglandin E2 gel.

DESIGN

Economic evaluation alongside a randomised controlled trial.

SETTING

Obstetric departments of one university and 11 teaching hospitals in the Netherlands.

POPULATION

Women scheduled for labour induction with a singleton pregnancy in cephalic presentation at term, intact membranes and an unfavourable cervix; and without previous caesarean section.

METHODS

Cost-effectiveness analysis from a hospital perspective.

MAIN OUTCOME MEASURES

We estimated direct medical costs associated with healthcare utilisation from randomisation to 6 weeks postpartum. For caesarean section rate, and maternal and neonatal morbidity we calculated the incremental cost-effectiveness ratios, which represent the costs to prevent one of these adverse outcomes.

RESULTS

Mean costs per woman in the Foley catheter group (n = 411) and in the prostaglandin E₂ gel group (n = 408), were €3297 versus €3075, respectively, with an average difference of €222 (95% confidence interval -€157 to €633). In the Foley catheter group we observed higher costs due to longer labour ward occupation and less cost related to induction material and neonatal admissions. Foley catheter induction showed a comparable caesarean section rate compared with prostaglandin induction, therefore the incremental cost-effectiveness ratio was not informative. Foley induction resulted in fewer neonatal admissions (incremental cost-effectiveness ratio €2708) and asphyxia/postpartum haemorrhage (incremental cost-effectiveness ratios €5257) compared with prostaglandin induction.

CONCLUSIONS

Foley catheter and prostaglandin E2 labour induction generate comparable costs.

OS105. Increased left ventricular mass index in normotensive formerly preeclamptic women is associated with the later development of chronic hypertension

INTRODUCTION

A history of preeclampsia is associated with a 4-fold increased risk to develop chronic hypertension later in life. Interestingly, preeclampsia and chronic hypertension share the presence of increased left ventricular mass and increased left atrial diameter. Whether these increases are also present in the preclinical phase of chronic hypertension in women with a history of preeclampsia is still unknown.

OBJECTIVES

To evaluate whether increased left ventricular mass index and/or left atrial widening in normotensive formerly preeclamptic women are associated with the development of chronic hypertension.

METHODS

324 Women with a history of preeclampsia, who were normotensive at the time of a diagnostic work-up 4 months postpartum, were included in this study. The tests employed included cardiac ultrasound and blood pressure measurements. Left ventricular mass was indexed (LVMi) for length in meters(2.7). To follow up on the health state, we send a health checklist to each screened former patient once every two years. The information of the diagnostic work-up and the one of the returned checklists were used for the statistical analysis by Uni- and Multivariate Cox regression analysis.

RESULTS

Women who had developed chronic hypertension during a medium follow-up period of 6 years showed a significant Hazard Ratio (HR) of 1.11 (95% CI 1.03-1.18) for Left ventricular mass index, 1.13 (95% CI 1.06-1.20) for diastolic BP, 1.07 (95% CI 1.02-1.11) for systolic BP, 1.05 (95% CI 1.01-1.10) for Heart Rate and 0.215 (95% CI 0.055-0.848) for EA ratio. The multivariate top-down analysis showed a significant HR only for LVMi and diastolic BP, 1.08 (95% CI 1.00-1.18) and 1.10 (95% CI 1.02-1.19), respectively.

CONCLUSION

Increased diastolic blood pressure and increased LVMi in normotensive formerly preeclamptic women are both associated with the development of chronic hypertension.