M.E.A. Spaanderman

Latent hemodynamic abnormalities in symptom-free women with a history of preeclampsia

OBJECTIVEnMost women with a pregnancy complicated by preeclampsia have either hypertension or a disorder with a thrombophilic phenotype or both of these. In this study we evaluated whether hemodynamic variables and volume homeostasis in a subgroup of normotensive women with a history of preeclampsia with normal clotting function (defined as the symptom-free subgroup) were comparable with those in a healthy parous control group.nnnSTUDY DESIGNnIn a group of 58 subjects with a history of preeclampsia and a group of 11 healthy parous control subjects we measured the following variables > or = 5 months post partum at day 5 +/- 2 of the menstrual cycle: body weight and length, mean arterial pressure, heart rate, cardiac output, plasma volume, glomerular filtration rate, effective renal plasma flow, and plasma concentrations of volume regulatory hormones, clotting factors, antiphospholipid antibodies, and homocysteine before and after a methionine load. From the measured data we calculated body mass index, body surface area, cardiac index, left ventricular work, total peripheral and renal vascular resistances, effective renal blood flow, and renal filtration fraction.nnnRESULTSnAmong women with a history of preeclampsia 26 were normotensive with thrombophilia (45%), 14 had hypertension (24%), and 18 were normotensive without thrombophilia (31%). These last symptom-free subjects with a history of preeclampsia were more obese than were control subjects. They also had higher cardiac output and left ventricular work and a lower plasma volume than the healthy parous control subjects. Thus they resemble the second subgroup of subjects (subjects with hypertension and a history of preeclampsia) rather than the control subjects. The hemodynamic and renal functions in the subgroup of subjects with a history of preeclampsia with normotension and thrombophilia were similar to those in healthy parous control subjects.nnnCONCLUSIONnOn the basis of this study we conclude that hemodynamic parameters and volume homeostasis in the symptom-free subgroup of women with a history of preeclampsia are different from those in healthy parous control subjects. Hemodynamic parameters and volume homeostasis in this subgroup resemble those of women with hypertension and a history of preeclampsia. We therefore propose the classification of these symptom-free subjects with a history of preeclampsia as having latent hypertension.

Non-pregnant circulatory volume status predicts subsequent pregnancy outcome in normotensive thrombophilic formerly preeclamptic women

BACKGROUNDnPreeclampsia seems to be superimposed upon a preexisting hemodynamic, hemostatic, autoimmune or metabolic disorder. We tested the hypothesis that in normotensive thrombophilic formerly preeclamptic subjects, the non-pregnant circulatory volume status predicts the development of subsequent hypertensive pregnancy and/or fetal growth restriction.nnnMETHODSnIn 250 non-diabetic formerly preeclamptic women and 15 normal parous controls, we measured and calculated the following variables at least 5 months postpartum at day 5 (+/-2) of the menstrual cycle: mean arterial pressure, body mass index, plasma volume and the clotting function. In the subsequent pregnancy we determined, birth weight, birth-weight centile and the incidence of preterm birth, fetal growth restriction, pregnancy-induced hypertension, preeclampsia and HELLP-syndrome. We only included in the final analysis normotensive subjects with a thrombophilic phenotype at the time of the pre-pregnant screening, who had a subsequent singleton pregnancy, ongoing beyond 16 weeks gestation within 1 year after pre-pregnant evaluation. As a consequence, 23 formerly preeclamptic women and 12 controls were eligible for final analysis. The thrombophilic formerly preeclamptic participants received aspirin in combination with low-molecular-weight heparin throughout pregnancy. If thrombophilia was diagnosed on the basis of hyperhomocysteinemia, the treatment consisted of aspirin, pyridoxine and folic acid, instead.nnnRESULTSnAmong 250 formerly preeclamptic 131/250 (52%) had a normotensive thrombophilic phenotype. Only 23 (18%) of these 131 participants had an ongoing pregnancy within 1 year. They were allocated to subgroup THROMB. None of the controls had hypertension or thrombophilia. In contrast, 12/15 (80%) controls had an ongoing pregnancy within a year. The observations in the THROMB subgroup were compared with those in the control group. None of the baseline demographic and blood pressure variables differed between THROMB and controls. With respect to pregnancy outcome, the incidence of the following pregnancy complications were observed in THROMB subjects: preterm birth: 9%, pregnancy-induced hypertension: 44%, preeclampsia: 13%, HELLP-syndrome: 13%, and fetal growth restriction: 30%. A low non-pregnant plasma volume was found to predispose for hypertensive complications in a subsequent pregnancy.nnnCONCLUSIONnPre-pregnant plasma volume in normotensive thrombophilic formerly preeclamptic women have predictive value with respect to hypertensive complications in the subsequent pregnancy.

Metabolic syndrome and the risk for recurrent pre-eclampsia: a retrospective cohort study

To compare the prevalence of recurrent pre‐eclampsia between women who have and do not have metabolic syndrome when non‐pregnant.

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

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

Cardiac diastolic dysfunction and metabolic syndrome in young women after placental syndrome.

OBJECTIVE: To estimate whether women with a recent history of a placental syndrome and concomitant metabolic syndrome have reduced cardiac diastolic function. METHODS: In this cohort study, women with a history of a placental syndrome were included. We assessed body mass index, blood pressure, fasting serum lipids, glucose and insulin levels, and 24-hour urinary protein and albumin output after an interval of at least 6 months postpartum. Cardiac diastolic function was assessed by echocardiography. RESULTS: Metabolic syndrome was found in 22% of the women evaluated. Diastolic dysfunction was seen in 24% of the women with the metabolic syndrome compared with 6.3% in those without (odds ratio 4.77, 95% confidence interval 2.18–10.41; adjusted odds ratio 6.09, 95% confidence interval 2.64–14.04). Univariable analysis showed that all the constituents of the metabolic syndrome related to diastolic dysfunction. CONCLUSION: In women with a history of placental syndrome complicating pregnancy, the presence of metabolic syndrome increases the risk of cardiac diastolic dysfunction fourfold. LEVEL OF EVIDENCE: II

Vasodilator Reactivity to Calcitonin Gene-Related Peptide Is Increased in Mesenteric Arteries of Rats during Early Pregnancy

The objective of the present study was to determine the effect of early pregnancy on the sensitivity to, and endogenous production of calcitonin gene-related peptide (CGRP). Contractile responses of arteries of 10-day pregnant and nonpregnant rats were studied in myographs. During contractions induced by 40 mmol/l K+, exogenous CGRP elicited an approximately 30% stronger relaxation in mesenteric arteries in pregnancy, an effect not seen in renal and uterine arteries. Capsaicin treatment during K+-induced contractions caused a persistent potentiation of the contractile response in mesenteric arteries, indicating that K+ stimulates the endogenous release of CGRP. This potentiation was similar in the pregnant and nonpregnant state (+81 ± 23% and +82 ± 23%, respectively), suggesting no effect of pregnancy on the endogenous CGRP release. The latter was paralleled by comparable CGRP content in the arteries of both groups, indicating similar tissue CGRP availability. The results of this study support the concept that early pregnancy is associated with a rise in the vascular sensitivity to CGRP in selected areas of the vascular bed without concomitant increase in the vascular CGRP production and release.

Mechanisms Leading to Increased Vasodilator Responses to Calcitonin-Gene-Related Peptide in Mesenteric Resistance Arteries of Early Pregnant Rats

The objective of this study was to explore the mechanism responsible for the higher relaxing responses of mesenteric arteries to calcitonin-gene-related peptide (CGRP) in pregnancy. We performed myograph and ligand binding studies to determine the role of matrix metalloproteinase-2 (MMP-2) and CGRP receptor density. MMP activity was manipulated in isolated arteries by exposing them to the blocking effects of doxycycline. Vascular activity of MMP-2 was studied by gelatin zymography, and CGRP receptor density was determined by ligand binding analysis. Compared to nonpregnant rats, CGRP elicited stronger arterial relaxation in pregnant rats. The latter effect was neither accompanied by a change in relaxing responses to direct activation of adenylyl cyclase by forskolin nor by a change in the response to stimulation of G-protein-coupled adrenergic receptors by isoproterenol. Doxycycline did not affect the stronger arterial relaxation in pregnancy in spite of the observed more than threefold higher arterial MMP-2 activity. Density of binding sites for [125I]CGRP in arteries from pregnant rats (64 ± 14 fmol/mg protein) and from virgin rats (54 ± 5 fmol/mg protein) were comparable. The results of this study provide evidence for increased coupling of CGRP receptors to adenylyl cyclase in early pregnancy.

The impact of obesity on outcomes of midwife-led pregnancy and childbirth in a primary care population: a prospective cohort study

To assess the impact of obesity on the likelihood of remaining in midwife‐led care throughout pregnancy and childbirth.

Impaired fetal growth and low plasma volume in adult life.

OBJECTIVE: To estimate whether normotensive women who were born small for gestational age have low plasma volume in adult life, which is associated with later chronic hypertension. METHODS: In 280 normotensive women with a history of hypertension in pregnancy, we recorded recalled gestational age and weight at birth and measured plasma volume (I125-human serum albumin indicator dilution method). To correct for possible confounders, we recorded recent obstetric history and measured in each individual all constituents of the metabolic syndrome (World Health Organization criteria), sex hormones (progesterone and estradiol), renal function, and cardiac performance at rest (echocardiography). We estimated daily activity level with a validated questionnaire (Short Questionnaire to Assess Health-enhancing physical activity). We studied the relation between womens own birth weight centile and her adult plasma volume (mL) and adjusted for the effects of confounding variables using multiple linear regression analysis. RESULTS: Birth weight correlated positively with adult plasma volume (P<.001). Linear regression analysis demonstrated that each 10 centile change in birth weight is associated with an average change of 46.6 mL (95% confidence interval [CI] 30.8–62.3) in adult plasma volume. This association persisted after adjustment for confounding factors (current body surface area, mean arterial pressure, total vascular resistance, glomerular filtration rate, and a total 24 hours of sodium output). After adjustment, each 10 centile change in birth weight was associated with an average change of 32.1 mL (95% CI 19.6–44.6) in adult plasma volume. Birth centile contributes 14% to the variation in total adult plasma volume. CONCLUSION: Impaired fetal growth is associated with low plasma volume in adult life. LEVEL OF EVIDENCE: II

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.