Preeclampsia Pregnancy Research Articles

Familial Mediterranean fever as a predictor of preeclampsia in pregnancy: Case report

Familial Mediterranean Fever (FMF) is an autosomal recessive auto inflammatory disorder characterized by recurrent fever and inflammation affecting the serosal membranes. Clinically, patients may experience attacks of recurrent fever and serositis, which can manifest with single or multiple simultaneous symptoms. While most patients are clinically diagnosed above the age of 2, cases diagnosed before 2 years of age, with an isolated fever clinical course, are believed to have a more severe course and an increased risk of developing amyloidosis. Preeclampsia, a serious complication of pregnancy, is characterized by hypertension and organ damage, most commonly affecting the kidneys and liver. In this article, we present a case of a pregnant woman who was admitted during the 27rd week of pregnancy with rapidly developing preeclampsia and HELLP syndrome, despite having no previous history of complications. During the follow-up, we discovered the presence of FMF and certain thrombophilia gene mutations. This case underscores the importance of considering specific diseases or syndromes under any presentation of preeclampsia. Timely identification of underlying conditions, such as FMF and thrombophilia, can aid in early intervention and appropriate management, potentially improving maternal and fetal outcomes

A cross-sectional analysis of syncytiotrophoblast membrane extracellular vesicles-derived transcriptomic biomarkers in early-onset preeclampsia.

Preeclampsia (PE) is a pregnancy-specific hypertensive disorder affecting 2%-8% of pregnancies worldwide. Biomarker(s) for the disorder exists, but while these have excellent negative predictive value, their positive predictive value is poor. Extracellular vesicles released by the placenta into the maternal circulation, syncytiotrophoblast membrane extracellular vesicles (STB-EVs), have been identified as being involved in PE with the potential to act as liquid biopsies. The objective of this study was to identify the difference in the transcriptome of placenta and STB-EVs between preeclampsia and normal pregnancy (NP) and mechanistic pathways. We performed RNA-sequencing on placental tissue, medium/large and small STB-EVs from PE (n = 6) and NP (n = 6), followed by bioinformatic analysis to identify targets that could be used in the future for EV-based diagnostic tests for preeclampsia. Some of the identified biomarkers were validated with real-time polymerase chain reactions. Our analysis identified a difference in the transcriptomic STB-EV cargo between PE and NP. We then identified and verified the differential expression of FLNB, COL17A1, SLC45A4, LEP, HTRA4, PAPP-A2, EBI3, HSD17B1, FSTL3, INHBA, SIGLEC6, and CGB3. Our analysis also identified interesting mechanistic processes via an in silico prediction of STB-EV-based mechanistic pathways. In this study, using comprehensive profiling of differentially expressed/carried genes of three linked sample subtypes in PE, we identified potential biomarkers and mechanistic gene pathways that may be important in the pathophysiology of PE and could be further explored in future studies.

Biomarkers and the Risk of Preeclampsia

(JAMA. 2023;329:539–541) Though maternal and fetal deaths due to preeclampsia and other hypertensive disorders of pregnancy have decreased in recent years, the incidence of preeclampsia has risen. Current clinical practice for preventing preeclampsia includes initiating a low-dose aspirin treatment at the end of the first trimester of pregnancy; it has been shown to largely mitigate the effects of preeclampsia and reduce incidence. One recent study by Mendoza et al examined the effect of discontinuation of aspirin treatment between 24 and 28 weeks of gestation and found discontinuation is non-inferior to continuation of treatment to 36 weeks. This study had some important findings and implications, but is hard to generalize to the United States, as there are some fundamental differences in the aspirin treatment regimen; the dosage in the United States is 81 mg rather than 150 mg, and there is no recommendation to stop treatment at 36 weeks of gestation. Diagnostically, the United States also does not use molecular biomarkers (the sFlt-1:PlGF ratio) but rather clinical factors to determine risk of preeclampsia. Implementing the methods proposed in this recent study would be a major overhaul of current clinical practice in the United States.

Association Between History of Adverse Pregnancy Outcomes and Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography

(JAMA. 2023;329:393–404) Some lifestyle and genetic risk factors for coronary artery disease (CAD) are common between women and men, but others affect only women, such as preeclampsia, gestational hypertension, preterm delivery, and other adverse pregnancy complications and outcomes. Each of these has been linked to an increased risk in CAD, which has long been a leading cause of death. Risk factors for CAD associated with pregnancy outcomes are often overlooked because they tend to occur in younger women who may have otherwise good cardiovascular health. One method used to analyze and diagnose risks related to CAD is coronary computed tomography (CT) angiography; it is a noninvasive technique used to visualize the coronary arteries and screen for occlusion or other markers of subclinical CAD. Previous research has been unclear about the effect of cardiovascular complications during pregnancy on overall later cardiovascular health. This study aimed to understand associations between subclinical CAD as examined by coronary CT angiography and a history of adverse pregnancy outcomes.

A comparative study of performance of first trimester FMF algorithm for prediction of preeclampsia in singleton and twin pregnancies in coastal Karnataka

Preeclampsia is one of the most common disorders of pregnancy known to complicate 5-10% of all the pregnancies, and it is a component of the deadly triad (along with haemorrhage and infection), that contributes greatly to maternal morbidity and mortality rates. The prevalence of preeclampsia in twin pregnancy is 3-4 fold compared to singleton pregnancy. Timely diagnosis and prevention of this condition is therefore critical. Multiple maternal factors and placental biomarkers have shown to predict preeclampsia in singleton pregnancies. Previous Studies have shown that the proposed algorithms for preeclampsia screening in singletons can also be applied in twins, but with slight modifications and lower accuracy. To study the various parameters included in FMF screening algorithm in first trimester for preeclampsia in singleton and twin pregnancies. To find diagnostic accuracy of screening parameters to predict preeclampsia later in second and third trimester. To study sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) in singleton and twin pregnancy. This prospective observational cohort study conducted in department of Obstetrics and Gynecology, Kasturba Medial College, Hospital, Manipal. Patients were recruited from August 2021 to November 2022. A total of 295 pregnant women were included of which 255 were singleton gestation and 40 were twin gestation. All parameters mentioned in FMF algorithm were obtained between 11week to 13+6 weeks. Patients were followed until delivery for occurrence of pre-eclampsia. Individual parameters of first trimester FMF algorithm of pre-eclampsia screening were analyzed in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) in both singleton and twin study subjects and results were then compared among the groups. In this study a total of 295 pregnant women were recruited. 255 were single gestation of which 47 had preeclampsia and 40 were twin gestation of which 4 had preeclampsia. In the cohort of singleton pregnant women with pre-eclampsia, mean age was noted to be higher (32.77±4.27). They had higher BMI (mean 27.61±3.74) and first trimester MAP was also higher. Similarly, cohort of twin pregnancy with preeclampsia had higher mean of maternal age, BMI and MAP (30.33 ±4.46, 22.83 ± 2.93 and 90.40 ± 1.45 respectively). The Preeclampsia group in both singleton and twin subjects had lower serum concentration and lower MoM values of PAPP-A and PlGF while higher values of free beta HCG and uterine artery PI. Therefore the FMF algorithm for first trimester screening of preeclampsia was found to be a good predictor in both singleton and twin pregnancy. The first trimester FMF algorithm for preeclampsia screening had similar utility in the prediction of preeclampsia in both singleton and twin pregnancy with its individual parameters and combined risk model. However, its accuracy was slightly lesser among twins. Therefore, same screening model can be applicable in singleton and twin gestation.

Abstract 13562: Calcium Supplementation to Prevent Pre-Eclampsia and Hypertensive Disorders of Pregnancy: A Meta-Analysis of Randomized Controlled Trials

Background: Pre-eclampsia and eclampsia are common causes of morbidity and mortality, especially in low-income countries. Reducing adverse outcomes associated with hypertensive disorders of pregnancy has been the ultimate priority in recent years. Objective: We aim to evaluate the association between calcium supplements and the risk of preeclampsia and gestational hypertension among pregnant women. Methods: A systematic literature search was performed in electronic databases from inception to 15th May 2023, including only randomized controlled trials involving pregnant women, with one group on calcium supplements and another with a placebo. Pooled odds ratios (OR) were calculated using a random effect model, and a p-value of <0.05 was considered statistically significant. Results: A total of 27 studies with 28,660 patients (14319 patients with calcium supplements and 14341 patients with placebo group) were included in the analysis. The Pooled analysis shows that calcium supplements reduce the risk of preeclampsia by 44% (OR, 0.56(95%CI: 0.45-0.70), P<0.001) compared to placebo. Similarly, calcium supplements were found to significantly reduce the risk of gestational hypertension by 20% (OR, 0.80(95%CI: 0.70-0.91), P<0.001). Conclusion: Our study shows that calcium supplements are associated with a significant reduction in preeclampsia and gestational hypertension which can lead to a reduction in associated morbidity and mortality.

Abstract 12569: The Roles of microRNA in Preeclampsia Induced Fetal Sex-Specific Endothelial Dysfunction

Introduction: Preeclampsia (PE) is a hypertensive disorder that complicates 5-10% of human pregnancies and leads to high fetal morbidity and mortality. Maternal obesity increases the risks of PE by 3-fold in association with elevated circulating pro-inflammatory cytokines which are related to endothelial dysfunction observed in PE. MiR146a-5p is a cardiovascular disease-associated miRNA that regulates endothelial cell responses. We have previously reported fetal sex-specific fetal endothelial dysfunction in PE. Although miR146a-5p has been reported to be dysregulated in PE HUVECs, the role of miR146a-5p in PE-dysregulated fetal sex-specific endothelial dysfunction is unclear. Hypothesis: MiR146a-5p differently mediate PE-induced sex-specific fetal endothelial dysfunction in lean and obese pregnancies. Methods: Human umbilical vein endothelial cells (unpassaged, P0-HUVECs; 5-7 days of culture, P1-HUVECs) were isolated immediately after delivery from normotensive (NT; 39±0.5 wks) and PE (38±0.5 wks) pregnancies (lean and OB) with female (F) and male (M) fetuses. Expression of miR146a-5p was examined in P0-HUVECs using RT-qPCR (n=8-10/group). Bioinformatics analysis was performed with our existing RNAseq data to identify PE-dysregulated miR146a-5p target genes in HUVECs. Endothelial monolayer integrity (MI) responses to cytokines were examined in P1 HUVECs with and without miR146a-5p overexpression and knockdown (n=5-7/group/assay). Results: PE upregulated miR146a-5p in lean F-HUVECs, while downregulated miR146a-5p in obese M-HUVECs. PE differentially dysregulated vascular/endothelial function-associated miR146a-5p target genes (e.g., TNFα-/TGFβ-signaling pathways) in F&M HUVECs. PE further reduced the TNFα-weakened MI in F and M HUVECs in both lean and OB pregnancies. TGFβ1 strengthened MI only in F-HUVECs, which was abolished in lean PE-F-HUVECs and was further decreased in OB PE-F-HUVEC. Knockdown of miR146a-5p rescues the PE-impaired MI responses to TNF-α and TGF-β1 in lean F-HUVECs but only rescues PE-impaired MI responses to TGF-β1 in OB F-HUVECs. Conclusions: MiR146a-5p plays important roles in mediating PE-induced fetal sex-specific fetal endothelial dysfunction in lean and obese pregnancies.

A Comparative Study of Serum and Salivary Uric Acid Measurement in Pre-eclampsia and Normal Pregnancy in a Tertiary Care Hospital in Punjab: A Pilot Study

A Comparative Study of Serum and Salivary Uric Acid Measurement in Pre-eclampsia and Normal Pregnancy in a Tertiary Care Hospital in Punjab: A Pilot Study

Comparison of Thrombocyte Indices and Immature Platelet between Preeclampsia and Normal Pregnancy

The primary pathophysiology of preeclampsia is abnormal trophoblast invasion, vasospasm, and endothelial dysfunction occurring, as well as platelet activation, increased platelet consumption, and the stimulation of the release of new platelets, which affects the platelet indices and immature platelets. This study compared the platelet indices (Mean Platelet Volume=MPV, Platelets Distribution Width=PDW, Platelet Large Cell Ratio=PLCR, and Immature Platelet Fraction (IPF) between preeclampsia and normal pregnancy. This research was an unpaired comparative analytic observational study with a cross-sectional design conducted in the Tangerang District General Hospital from February to August 2020. The platelet indices (MPV, PDW, PLCR) and IPF of preeclampsia subjects (n=33) at Tangerang District General Hospital and normal pregnant subjects (n=38) at Annisa Hospital Tangerang were examined using the Sysmex XN-1000 automatic hematology analyzer. Comparative platelet indices and IPF analysis were carried out by independent T-test or Man-Whitney test. Receiver Operating Characteristics (ROC) analysis was performed to obtain the cut-off value of the platelet indices and IPF to differentiate preeclampsia and normal pregnancy. The platelet indices and IPF were significantly higher in preeclampsia. The mean (SD) MPV was 10.86 (0.9) fL and 10. (0.89) fL, p<0.001; PDW 12.7 (8.7-19.1) fL and 10.85 (8.5-15.7) fL, p<0.001; PLCR 31.96 (7.02) % and 25.06 (6.92) %, p<0.001; and IPF 8.50 (3.10-20.40)% and 2.75 (1.2-9.4)%, p<0.001, respectively in preeclampsia and normal pregnancy. ROC analysis showed that an IPF with an AUC of 0.88 (95% confidence interval (CI) 0.78-0.95) with an IPF cut-off value of >6.5% was a good marker, while the MPV cut-off >10.2 fL, AUC 0.75(95% CI 0.63-0.84), PDW cut-off >11.3fL, AUC 0.77 (95%CI 0.65-0.86) and PLCR cut-off >26.1%, AUC 0.76 (95% CI 0.65-0.85) were good enough markers to differentiate preeclampsia from normal pregnancy. Platelet indices and IPF were statistically significantly higher in preeclampsia. The IPF parameter is a good marker, while the platelet indices can be a pretty good marker to distinguish preeclampsia and normal pregnancy. The IPF parameter and platelet indices can be proposed as a routine examination in pregnancy. Changes in IPF and platelet indices can be early signs of preeclampsia or the development of preeclampsia.

Preliminary evidence that blocking the uptake of placenta-derived preeclamptic extracellular vesicles protects the vascular endothelium and prevents vasoconstriction

Preeclampsia (PE) is a pregnancy syndrome characterized by hypertension and organ damage manifesting after 20 gestational weeks. The etiology is of multifactorial origin, where placental stress causes increased levels of placenta-derived extracellular vesicles (STBEVs) in the maternal circulation, shown to cause inflammation, endothelial activation, vasoconstriction, and anti-angiogenic activity. General endothelial dysfunction is believed to be initiated by endothelial insult during pregnancy that alters vascular function resulting in increased arterial stiffness, cardiac dysfunction, and increased risk of cardiovascular disease later in life. We compared the effect of normal and PE derived STBEVs in vitro on vascular contractility of human subcutaneous arteries using wire myography. Cellular structures of exposed vessels were investigated by transmission electron microscopy. We explored strategies to pharmacologically block the effects of the STBEVs on human vessels. The PE STBEVs caused significantly stronger angiotensin II-mediated contractions and extended structural damage to human subcutaneous arteries compared to normal STBEVs. These negative effects could be reduced by blocking vesicle uptake by endothelial cells, using chlorpromazine or specific antibodies towards the LOX-1 receptor. The therapeutic potential of blocking vesicle uptake should be further explored, to reduce the permanent damage caused on the vasculature during PE pregnancy to prevent future cardiovascular risk.

Inflammation and Oxidative Stress Induced by Obesity, Gestational Diabetes, and Preeclampsia in Pregnancy: Role of High-Density Lipoproteins as Vectors for Bioactive Compounds.

Inflammation and oxidative stress are essential components in a myriad of pathogenic entities that lead to metabolic and chronic diseases. Moreover, inflammation in its different phases is necessary for the initiation and maintenance of a healthy pregnancy. Therefore, an equilibrium between a necessary/pathologic level of inflammation and oxidative stress during pregnancy is needed to avoid disease development. High-density lipoproteins (HDL) are important for a healthy pregnancy and a good neonatal outcome. Their role in fetal development during challenging situations is vital for maintaining the equilibrium. However, in certain conditions, such as obesity, diabetes, and other cardiovascular diseases, it has been observed that HDL loses its protective properties, becoming dysfunctional. Bioactive compounds have been widely studied as mediators of inflammation and oxidative stress in different diseases, but their mechanisms of action are still unknown. Nonetheless, these agents, which are obtained from functional foods, increase the concentration of HDL, TRC, and antioxidant activity. Therefore, this review first summarizes several mechanisms of HDL participation in the equilibrium between inflammation and oxidative stress. Second, it gives an insight into how HDL may act as a vector for bioactive compounds. Third, it describes the relationships between the inflammation process in pregnancy and HDL activity. Consequently, different databases were used, including MEDLINE, PubMed, and Scopus, where scientific articles published in the English language up to 2023 were identified.

Evaluation of carotid artery Doppler measurements in late-onset fetal growth restriction: a cross-sectional study

Background/Aim: It has been reported that both the internal carotid artery (ICA) and the common carotid artery (CCA) are associated with hypoxia, also observed in late-onset fetal growth restriction (FGR). However, it has not yet been investigated whether these Doppler measurements differ in cases of late-onset FGR. This study evaluated the ICA and the CCA Doppler parameters in late-onset FGR fetuses and compared these measurements with those of healthy fetuses. Methods: This cross-sectional observational study comprised 75 singleton pregnancies diagnosed with late-onset FGR between the 32nd and 37th weeks of gestation, alongside 75 healthy fetuses paired 1:1 based on obstetric history and gestational age between June 2022 and May 2023. The Delphi consensus of 2016 was used for the definition of late-onset FGR. The exclusion criteria were congenital anomalies, presence of any additional disease, maternal body mass index over 35 kg/m2, abdominal scars hindering ultrasound visualization, use of medications such as antenatal steroids, sympathomimetics, and indomethacin that affect vascular function, drug use, smoking during pregnancy, concurrent preeclampsia, and multiple pregnancies. Upon the patients' admission to the hospital, their demographic characteristics were documented, and ultrasonographic examinations and Doppler measurements were subsequently performed. The Doppler velocimetry of the umbilical artery (UA) encompassed measurements of the systolic to diastolic ratio (S/D), pulsatility index (PI), and peak systolic velocity (PSV). The carotid artery Doppler velocimetry of the middle cerebral artery (MCA), ICA, and CCA encompassed measurements of the PI, resistance index (RI), and PSV. We assessed the diagnostic performance of Doppler measurements for late-onset FGR through receiver operating characteristic (ROC) analysis. Results: In the late-onset FGR group, the mean UA-SD was higher (2.7 [0.6] vs. 2.5 [0.5], P=0.006), and the mean UA-PI (0.8 [0.2] vs. 0.9 [0.2], P=0.011) and mean PSV (35.6 [8.2] vs. 41.1 [7.1], P<0.001) were lower compared to the control group. In the late-onset FGR group, carotid Doppler measurements were more pronounced than UA Doppler measurements. Moreover, ICA Doppler measurements exhibited superior diagnostic performance in predicting late-onset FGR compared to other Doppler measurements (Area under the curve [AUC]=0.777, P<0.001 for ICA-PI; AUC=0.751, P<0.001 for ICA-RI; AUC=0.749, P<0.001 for ICA-PSV). Conclusion: In fetuses with late-onset FGR, UA Doppler measurements showed minimal differences compared to healthy fetuses, but differences in carotid Doppler measurements, especially in the ICA, were more pronounced. Therefore, in the management of fetuses suspected of having late-onset FGR, a more detailed Doppler examination might be required.

Altered 5-methylcytosine modification of mRNA is involved in the pathogenesis of pre-eclampsia.

5-Methylcytosine (m5 C) is a prevalent RNA modification in messenger RNAs (mRNAs). Despite its abundance, its role in the decidua of pre-eclampsia (PE)remains elusive. In this study, we utilized methylated RNA immunoprecipitation sequencing (MeRIP-seq)and RNA-sequencing (RNA-seq) to map m5 C peaks and mRNA expression profile in the decidua of human early-onset PE (EPE), late-onset PE (LPE), and normal pregnancy (NP). Gene Ontology and Kyoto Encyclopedia of Genes and Genomespathway analyses elucidated potential roles of the differentially methylated mRNAs (DMGs) and differentially expressed mRNAs in decidualization pathways. Integrative analysis of MeRIP-seq and RNA-seq data pinpointed 50 candidate genes linked to PE, marked by both differentially methylated m5 C peaks and congruent expression changes. To validate these observations, we selected nine genes for verification via quantitative PCR. Our results underscore the precision and reproducibility of our bioinformatics approach. Importantly, we propose that changes in m5 C modification and expression of relevant mRNA might influence the pathogenesis of PE by hampering decidualization. This work shines light on the distinct mRNA m5 C modification patterns and expression profiles in the decidua of PE, implicating pivotal signaling disruptions and decidualization impediments in the onset of PE.

A study on the prediction of kallistatin levels in the development and progression of pre-eclampsia

Objective: To explore the expression level of kallistatin in plasma of patients with Pre-Eclampsia (PE) and the predictive value of kalistatin and other parameters in before 20 weeks of pregnancy for PE.

Glycosylated fibronectin improves first-trimester prediction of pre-eclampsia.

To determine whether maternal serum glycosylated fibronectin (GlyFn) level in the first trimester increases the sensitivity of the Fetal Medicine Foundation (FMF) triple test, which incorporates mean arterial pressure, uterine artery pulsatility index and placental growth factor, when screening for pre-eclampsia (PE) in an Asian population. This was a nested case-control study of Chinese women with a singleton pregnancy who were screened for PE at 11-13 weeks' gestation as part of a non-intervention study between December 2016 and June 2018. GlyFn levels were measured retrospectively in archived serum from 1685 pregnancies, including 101 with PE, using an enzyme-linked immunosorbent assay (ELISA), and from 448 pregnancies, including 101 with PE, using a point-of-care (POC) device. Concordance between ELISA and POC tests was assessed using Lin's correlation coefficient and Passing-Bablok and Bland-Altman analyses. GlyFn was transformed into multiples of the median (MoM) to adjust for maternal and pregnancy characteristics. GlyFn MoM was compared between PE and non-PE pregnancies, and the association between GlyFn MoM and gestational age at delivery with PE was assessed. Risk for developing PE was estimated using the FMF competing-risks model. Screening performance for preterm and any-onset PE using different biomarker combinations was quantified by area under the receiver-operating-characteristics curve (AUC) and detection rate (DR) at a 10% fixed false-positive rate (FPR). Differences in AUC between biomarker combinations were compared using the DeLong test. The concordance correlation coefficient between ELISA and POC measurements was 0.86 (95% CI, 0.83-0.88). Passing-Bablok analysis indicated proportional bias (slope, 1.08 (95% CI, 1.04-1.14)), with POC GlyFn being significantly higher compared with ELISA GlyFn. ELISA GlyFn in non-PE pregnancies was independent of gestational age at screening (P = 0.11), but significantly dependent on maternal age (P < 0.003), weight (P < 0.0002), height (P = 0.001), parity (P < 0.02) and smoking status (P = 0.002). Compared with non-PE pregnancies, median GlyFn MoM using ELISA and POC testing was elevated significantly in those with preterm PE (1.23 vs 1.00; P < 0.0001 and 1.18 vs 1.00; P < 0.0001, respectively) and those with term PE (1.26 vs 1.00; P < 0.0001 and 1.22 vs 1.00; P < 0.0001, respectively). GlyFn MoM was not correlated with gestational age at delivery with PE (P = 0.989). Adding GlyFn to the FMF triple test for preterm PE increased significantly the AUC from 0.859 to 0.896 (P = 0.012) and increased the DR at 10% FPR from 64.9% (95% CI, 48.7-81.1%) to 82.9% (95% CI, 66.4-93.4%). The corresponding DRs at 10% FPR for any-onset PE were 52.5% (95% CI, 42.3-62.5%) and 65.4% (95% CI, 55.2-74.5%), respectively. Adding GlyFn to the FMF triple test increased the screening sensitivity for both preterm and any-onset PE in an Asian population. Prospective non-intervention studies are needed to confirm these initial findings. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Case Report: Rectus Sheath Hematoma in a Pregnant Women

Rectus sheath hematoma is a very uncommon cause of acute abdominal pain, especially during pregnancy. Misdiagnosis is likely due to the lack of specific symptoms, which could put the patient and her fetus in danger.. A patient came with sudden severe left upper abdominal pain with history of cough for few days. She was referred from other hospital and diagnosed there as 32 weeks pregnancy preeclampsia with severe disease with HELLP syndrome. Uterus was tender and more prominent on left side, and patient was not in labour. Provisional diagnosis was abruptio placenta with concealed haemorrhage or rupture uterus. But after laparotomy it was diagnosed as a case of rectus sheath haematoma(RSH). Different imaging modalities such as Ultrasonography and CT are the diagnostic methods. Active bleeding can be managed either surgically by evacuating the haematoma and ligating the bleeding vessels. We managed the patient by laparotomy and blood and blood product transfusion and by multidisciplinary approach, but the patient developed multiorgan failure and expired on 16 th POD. The clinical and diagnostic symptoms of rectus sheath hematoma are highlighted in this case report. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(1): 71-74

Swansea criteria evaluation in acute fatty liver of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome, pre-eclampsia, and viral acute liver failure in pregnancy.

SynopsisNot only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria.

Association Of Raised Serum Triglycerides With Incidence Of Pre-Eclampsia

Background: Pre-eclampsia, a serious multi-systemic pregnancy complication is estimated to occur in 5-10% of pregnancies worldwide. Objective: To determine the frequency of pre-eclampsia in pregnant females with hyper-triglyceridemia and to study its associations. Methodology: This Cross-sectional study was conducted at Gynecology Dept. Poly Clinic Hospital, Islamabad (March - Sept. 2022). Pregnant females of age 15-40 years, gestational age 13-20th weeks and singleton pregnancy were included. Known hypertensives, receiving lipid-lowering or anti-hypertensives, chronic kidney or liver disease, teenage pregnancies, primigravida, history of CVA, IHD, epilepsy or endocrine disorders were excluded. After the detailed clinical evaluation, fasting serum triglyceride levels were checked. A total of 225 cases with elevated serum triglycerides were finally selected and evaluated for the presence of pre-eclampsia by monitoring the blood pressure, cardiovascular, gynaecological examination and urine for the presence of proteinuria. Patients were followed till the development of pre-eclampsia or completion of pregnancy. Results: Among 225 pregnant females with raised serum triglycerides, the mean age was 24.28+5.5 years. Pre-eclampsia was observed in 47(20.89%) of patients. The Chi-square tests of association between pre-eclampsia and each of parity, residential status, and socio-economic status were insignificant while BMI and Gestational age were significant. Conclusion: There is a high prevalence of pre-eclampsia in pregnant women with hypertriglyceridemia. Serum triglyceride levels may predict the women at risk for pre-eclampsia. The risk of preeclampsia in women with hyper-triglyceridemia is independent of parity, and socioeconomic or residential status. Hypertriglyceridemia may predispose to pre-eclampsia even at lower BMI levels. The development of hypertriglyceridemia in early gestation may be an additional risk factor. Early screening of women at risk may lead to better outcomes.

Stroke vs. Preeclampsia: Dangerous Liaisons of Hypertension and Pregnancy.

Stroke during pregnancy and preeclampsia are two distinct but interrelated medical conditions, sharing a common denominator-blood control failure. Along with cardiovascular diseases, diabetes, dyslipidemia, and hypercoagulability, hypertension is undoubtedly a major risk factor associated with stroke. Even though men have higher age-specific stroke rates, women are facing higher life-long stroke risk, primarily due to longer life expectancy. Sex hormones, especially estrogen and testosterone, seem to play a key link in the chain of blood pressure control differences between the genders. Women affected with stroke are more susceptible to experience some atypical stroke manifestations, which might eventually lead to delayed diagnosis establishment, and result in higher morbidity and mortality rates in the population of women. Preeclampsia is a part of hypertensive disorder of pregnancy spectrum, and it is common knowledge that women with a positive history of preeclampsia are at increased stroke risk during their lifetime. Preeclampsia and stroke display similar pathophysiological patterns, including hypertension, endothelial dysfunction, dyslipidemia, hypercoagulability, and cerebral vasomotor reactivity abnormalities. High-risk pregnancies carrying the burden of hypertensive disorder of pregnancy have up to a six-fold higher chance of suffering from stroke. Resemblance shared between placental and cerebral vascular changes, adaptations, and sophisticated auto-regulatory mechanisms are not merely coincidental, but they reflect distinctive and complex cardiovascular performances occurring in the maternal circulatory system during pregnancy. Placental and cerebral malperfusion appears to be in the midline of both of these conditions; placental malperfusion eventually leads to preeclampsia, and cerebral to stoke. Suboptimal performances of the cardiovascular system are proposed as a primary cause of uteroplacental malperfusion. Placental dysfunction is therefore designated as a secondary condition, initiated by the primary disturbances of the cardiovascular system, rather than an immunological disorder associated with abnormal trophoblast invasion. In most cases, with properly and timely applied measures of prevention, stroke is predictable, and preeclampsia is a controllable condition. Understanding the differences between preeclampsia and stroke in pregnancy is vital for healthcare providers to enhance their clinical decision-making strategies, improve patient care, and promote positive maternal and pregnancy outcomes. Management approaches for preeclampsia and stroke require a multidisciplinary approach involving obstetricians, neurologists, and other healthcare professionals.

Preterm preeclampsia screening using biomarkers: combining phenotypic classifiers into robust prediction models

Preeclampsia screening is a critical component of antenatal care worldwide. Currently, the most developed screening test for preeclampsia at 11 to 13 weeks' gestation integrates maternal demographic characteristics and medical history with 3 biomarkers-serum placental growth factor, mean arterial pressure, and uterine artery pulsatility index-to identify approximately 75% of women who develop preterm preeclampsia with delivery before 37 weeks of gestation. It is generally accepted that further improvements to preeclampsia screening require the use of additional biomarkers. We recently reported that the levels of specific metabolites and metabolite ratios are associated with preterm preeclampsia. Notably, for several of these markers, preterm preeclampsia prediction varied according to maternal body mass index class. These findings motivated us to study whether patient classification allowed for combining metabolites with the current biomarkers more effectively to improve prediction of preterm preeclampsia. This study aimed to investigate whether metabolite biomarkers can improve biomarker-based preterm preeclampsia prediction in 3 screening resource scenarios according to the availability of: (1) placental growth factor, (2) placental growth factor+mean arterial pressure, and (3) placental growth factor+mean arterial pressure+uterine artery pulsatility index. This was an observational case-control study, drawn from a large prospective screening study at 11 to 13 weeks' gestation on the prediction of pregnancy complications, conducted at King's College Hospital, London, United Kingdom. Maternal blood samples were also collected for subsequent research studies. We used liquid chromatography-mass spectrometry to quantify levels of 50 metabolites previously associated with pregnancy complications in plasma samples from singleton pregnancies. Biomarker data, normalized using multiples of medians, on 1635 control and 106 preterm preeclampsia pregnancies were available for model development. Modeling was performed using a methodology that generated a prediction model for preterm preeclampsia in 4 consecutive steps: (1) z-normalization of predictors, (2) combinatorial modeling of so-called (weak) classifiers in the unstratified patient set and in discrete patient strata based on body mass index and/or race, (3) selection of classifiers, and (4) aggregation of the selected classifiers (ie, bagging) into the final prediction model. The prediction performance of models was evaluated using the area under the receiver operating characteristic curve, and detection rate at 10% false-positive rate. First, the predictor development methodology itself was evaluated. The patient set was split into a training set (2/3) and a test set (1/3) for predictor model development and internal validation. A prediction model was developed for each of the 3 different predictor panels, that is, placental growth factor+metabolites, placental growth factor+mean arterial pressure+metabolites, and placental growth factor+mean arterial pressure+uterine artery pulsatility index+metabolites. For all 3 models, the area under the receiver operating characteristic curve in the test set did not differ significantly from that of the training set. Next, a prediction model was developed using the complete data set for the 3 predictor panels. Among the 50 metabolites available for modeling, 26 were selected across the 3 prediction models; 21 contributed to at least 2 out of the 3 prediction models developed. Each time, area under the receiver operating characteristic curve and detection rate were significantly higher with the new prediction model than with the reference model. Markedly, the estimated detection rate with the placental growth factor+mean arterial pressure+metabolites prediction model in all patients was 0.58 (95% confidence interval, 0.49-0.70), a 15% increase (P<.001) over the detection rate of 0.43 (95% confidence interval, 0.33-0.55) estimated for the reference placental growth factor+mean arterial pressure. The same prediction model significantly improved detection in Black (14%) and White (19%) patients, and in the normal-weight group (18.5≤body mass index<25) and the obese group (body mass index≥30), with respectively 19% and 20% more cases detected, but not in the overweight group, when compared with the reference model. Similar improvement patterns in detection rates were found in the other 2 scenarios, but with smaller improvement amplitudes. Metabolite biomarkers can be combined with the established biomarkers of placental growth factor, mean arterial pressure, and uterine artery pulsatility index to improve the biomarker component of early-pregnancy preterm preeclampsia prediction tests. Classification of the pregnant women according to the maternal characteristics of body mass index and/or race proved instrumental in achieving improved prediction. This suggests that maternal phenotyping can have a role in improving the prediction of obstetrical syndromes such as preeclampsia.