S. Zullino

Inflammation modulates LC3 expression in human preterm delivery

Abstract Objective: Autophagy is an inducible intracellular process acting under stressor conditions, such as infections, inflammation and hypoxia. The aim of the present study was to analyze autophagy expression in preterm delivered human placenta. Methods: Autophagy marker LC3 was analyzed in 25 consecutive human placentas delivered before 34 weeks of gestation, analyzed by immunohistochemistry, immunofluorescence and quantitative real-time PCR, according to the histologic classification of preterm delivery (PTD) (cases with or without placental inflammatory lesions). Results: LC3 expression was observed both in cases with and without inflammatory lesions. In cases with histological inflammation, strong immunoreactivity for LC3 autophagic marker was observed in the inflammatory cell infiltration composed by neutrophils. In all PTD cases, trophoblastic cells in chorion laeve express LC3, with variable staining intensity: a significant reduction of LC3 expression was observed in chorion laeve of PTD with histological inflammation compared to PTD without inflammatory lesions. Moreover, the decrement of LC3 staining was observed to be associated to the increasing severity of the histological signs of fetal inflammatory response. Conclusions: Our data show that the expression of LC3 varies depending on different histological features, indicating an interesting and possibly clinically relevant relation between autophagy expression levels and the inflammatory status.

New lenses to look at preeclampsia

Hypertensive disorders of pregnancy (HDP) are associated with severe obstetric complications representing a leading cause of maternal mortality [1]. Furthermore, HDP can be related to pregnancy complications like iatrogenic preterm delivery, intrauterine growth restriction (IUGR) and perinatal death [2]. Traditional classification of HDP includes preeclampsia (PE), chronic hypertension with superimposed PE, gestational hypertension (GH) and chronic hypertension [3,4]. Its incidence greatly varies according to local population characteristics as a consequence of ethnicity, obesity, parity and other maternal risk factors. The incidence of PE alone is reported to be between 2% and 8% [5,6]. Scientific societies and committees attempted to improve the applicability of the traditional classification criteria of HDP to clinical practice by means of a detailed description of maternal functions and organs associated with hypertension in pregnancy [7,8]. The list of complications that classify GH as a preeclamptic phenotype had been recently enriched by IUGR, even in the absence of proteinuria [8]. In fact, beyond different maternal complications and despite intensive research in the past years, the diagnosis of PE is still based on clinical manifestations, as it has been defined many decades ago as a disease characterized by hypertension and proteinuria with or without organ failure [9]. An attempt to fit clinical phenotypes into this generalist criterion is the partition of HDP based on the temporal classification according to the gestational age at diagnosis (and in some cases gestational age at delivery) into earlyand late-onset, with 34 weeks of gestation as the most commonly used cut-off [10]. Although early-onset PE, which is more frequently associated with IUGR [10], is related with a higher rate of neonatal mortality and morbidity, the late-onset PE is almost three times more frequent and accounts worldwide for the substantial proportion of late preterm birth [11] and severe adverse outcome for the mother. Thus, it is not surprising that recently the members of the Global Pregnancy CoLaboratory [12] suggested a revision of the main phenotypes of PE based not only on gestational age at onset but also on the co-occurrence of IUGR, deficient angiogenic factors, maternal risk conditions such as obesity, diabetes and others. It is very likely, as it has been supported by histopathological and clinical studies since the late 1990s, that the common pathway underlying the clinical signs and symptoms of PE is represented by endothelial damage [13]. A recent contribution has been added by Baschat [14] and co-workers who revised in a seminal work the main risk profiles of pregnant women that might sum up to placental disease and trigger the development of cardiovascular and endothelial dysfunction. Maternal body mass index (BMI) and uterine arteries Doppler velocimetry resulted to be the two major determinants among the risk factors for PE. These findings on the role of BMI underline, on one side, the role of maternal predisposing conditions for metabolic syndrome, low-grade inflammation, the endothelial dysfunction that might be associated to late placental damage and hypertension not associated with IUGR. On the other side, shallow trophoblastic placentation, reflected by abnormal uterine arteries Doppler velocimetry, is at the basis of the trophoblastic oxidative stress and disbalance of angiogenic and anti-angiogenic factors [15,16]. The latter, ultimately, might damage maternal endothelium at the basis of systemic hypertension and/or cause other function or organ damage. In this case, the clinical manifestation will be associated with IUGR caused by placental insufficiency. These findings are in agreement with epidemiological studies [11] and with predictive studies as we will see in the next paragraph [15–19]. Indeed, the multi-facets clinical manifestations of HDP [9,10] could fit well into two different pathophysiological models and, consequently, two completely different patterns of placental damage and clinical phenotypes: on one hand, the placenta with incomplete spiral artery remodeling resulting in HDP associated with IUGR (HDP-IUGR), and on the other hand, the placenta with deregulated perfusion due to an over-expansion of terminal villi [20,21] resulting in HDP associated with fetuses with appropriate for gestational age growth (HDP-AGAf).

P25.08: Maternal hemodynamic profile in pregnancies complicated by intrauterine growth restriction

Objectives: To compare published reference charts of Umbilical Artery (UA), Middle Cerebral Artery (MCA) Doppler and Cerebroplacental Ratio (CPR), in order to assess the clinical impact in management arising from the variation between different reference charts. Methods: MEDLINE was searched for all the studies published between 1988 and 2016 whose only aim was to create fetal Doppler reference values. The search yielded 725 possible citations, of which 21 studies reporting normal Doppler reference values were finally included in the review for Umbilical Artery (11), Middle Cerebral Artery (12) and Cerebroplacental Ratio (3). The differences between Pulsatility Index (PI) cut-off values at clinically relevant centiles were expressed in percentage form by subtracting the lowest from the highest PI and dividing by the highest. A simulation analysis was performed on a historical cohort of SGA fetuses (n= 617) to evaluate the impact of this variability on clinical management. Results: Wide discrepancies in reported Doppler references values were found. Middle cerebral artery showed the greatest differences between clinically relevant PI cut-off values: for the 5th centile of MCA PI there was up to 47.2% variation between published references at 36-37 weeks of gestation. Differences between the 95th PI umbilical artery cut-off centile were above 20% at 28-38 weeks. For the CPR the 5th centile values varied from 17% (at 39 weeks) to 35% (at 37 weeks). Simulation analysis showed that, depending on the chart used, the prevalence of abnormal UA, MCA and CPR varied in our historical cohort from 18.2% to 2.1%, 0.7% to 22.6% and 4.3% to 26.5% respectively. Conclusions: Large differences exist in current fetal Doppler reference charts at clinically relevant cut-offs. The choice of chart used could lead to a significant change in clinical management. Therefore, an attempt to standardise fetal Doppler reference ranges is mandatory, as this variability may lead to suboptimal outcomes in clinical practice and research.

OP01.11: Maternal hemodynamic in pregnancies complicated by intrauterine growth restriction and hypertensive disorders

Methods: 10733 women with a complete first trimester screening were included. Potential predictors for birth weight included maternal age, BMI, parity, smoking status, type of conception, time difference (days) between date of pregnancy based on CRL and LMP (CRL-LMP), uterine artery lowest PI (UtA-LPI), PAPP-A and bHCG (MoM) as well as abdominal circumference (AC, Z-score). Bootstrap methods were used for model selection and estimation, under an approximately uniform distribution of birth weight. A model was built to predict individual birthweight using first trimester variables. The additional value of these variables was quantified by comparing the birthweight absolute percent prediction error (APPE) given by the model to the percent error using the average weight reference provided by the Intergrowth study. Small and large for gestational age (SGA and LGA) were defined by birth weight <10th centile and >90th centile respectively. Results: The prediction model included BMI, parity, smoking status, time difference between date of pregnancy based on CRL and LMP, UtA-LPI, PAPP-A, bHCG and AC. in SGA newborns, first trimester individual birthweight predictions were significantly closer to the actual birthweight (median APPE=17% IQR=10-23) compared to population references (median APPE 24% IQR=20-30). However, in the overall population as in LGA newborns, first trimester did not improve birthweight prediction compared to the average weight reference. Conclusions: Birthweight predictions based on a combination of maternal history, ultrasound, and biochemistry in the first trimester significantly improved screening for SGA with a significant contribution of CRL-LMP.

Bedside cardiovascular maternal interrogation in the first trimester to predict different phenotypes of hypertensive disorders in pregnancy

OBJECTIVE The aim is to evaluate if maternal cardiovascular indices, in the first trimester of pregnancy, might be useful to differentiate women who develop different hypertensive disorders of pregnancy (HDP). STUDY DESIGN Method: 1399 pregnant women attending screening for chromosomal aneuploidies were recruited. The following parameters were measured: Doppler Velocimetry of uterine arteries; Peripheral blood pressure; Aortic Pressure derived from applanation tonometry. Primary outcome were: women who developed HDP associated with newborns with an appropriate weight for local gestational age standards (AGA) and women that developed HDP associated with a newborn weight below the 10th centile (SGA). RESULTS Mean UtA PI was significantly higher in the HDP-SGA compared with controls. HDP-AGA showed a higher rate of family history of hypertension and a higher BMI. In HDP-AGA Brachial and Aortic mean pressure were higher than controls. The most significant contributors for all forms of HDP were mean UtA PI for HDP-SGA and mean arterial blood pressure for HDP-AGA. The multivariate logistic regression for HDP-SGA shows an AUC 0.88, whereas the AUC for the prediction of HDP-AGA group was 0.71. CONCLUSION HDP-SGA were characterized by significantly higher values of UtA-PI, whereas HDP-AGA by mean aortic and brachial pressure and risk factors for endothelial dysfunction.

H2. Maternal hemodynamic status in pregnancies complicated by intrauterine growth restriction (IUGR) and post-partum follow up

Abstract Aims: To investigate maternal hemodynamic status in pregnancies complicated by IUGR and in the post-partum. Methods: In this prospective study, we enrolled pregnant women between 24 and 38 weeks divided in severe and mild IUGR and a group of controls matched for gestational age. Severe IUGR was defined as abdominal circumference <5th centile and a Doppler velocimetry in umbilical artery42SD. Mild IUGR was defined as an abdominal circumference <10th centile and a Doppler velocimetry in umbilical artery <2SD. A cardiologist performed maternal echocardiographies at diagnosis and 6–12 weeks post-partum, to calculate cardiac output (CO), total vascular resistance (TVR) and indexes of diastolic dysfunction evaluated with tissue Doppler (E0/A0). Results: We recruited 14 severe IUGR, 43 mild IUGR and 19 controls. CO was significantly decreased and TVR significantly increased in IUGR compared to controls. The group of severe IUGR showed the highest values. Only severe IUGR showed a decrease of the heart rate during pregnancy and maintains a low CO in the post-partum. Discussion: The hemodynamic parameters correlate with the degree of placental insufficiency.

C1. Maternal hemodynamic profile in hypertensive disorders of pregnancy (HDP) and intrauterine growth restriction

Abstract Aims: To investigate maternal hemodynamic status in pregnancies complicated by HDP and/or IUGR and by severe IUGR without HDP. Methods: In this prospective study we enrolled pregnant women between 24 and 38 weeks divided in: HDP with appropriate for gestational age fetuses (HDP-AGA), HDP associated with IUGR (HDPIUGR), severe IUGR and a group of controls matched for gestational age. Severe IUGR was defined as abdominal circumference <5th centile and a Doppler velocimetry in umbilical artery42SD. Diagnosis of HDP was made according to the criteria of the ISSHP. A cardiologist performed maternal echocardiographies to calculate cardiac output (CO), total vascular resistance (TVR) and indexes of diastolic dysfunction evaluated with tissue Doppler (E’/A’). Results: We recruited 16 HDP-AGA, 20 HDP-IUGR, 14 severe IUGR and 19 controls. Heart rate (HR) and CO were significantly decreased and TVR significantly increased in HDP-IUGR and severe IUGR compared to controls. HDP-AGA shows a significantly decrease in E0/A0 compared to all other groups. Discussion: Hemodynamic parameters have different patterns in pregnancies complicated by HDP and/or IUGR. Severe IUGR and HDP-IUGR show a similar profile, despite the absence of abnormal blood pressure in the former group. HDP-AGA, that in our data showed a maternal predisposition to metabolic syndrome, has a different hemodynamic profile, with a predominant diastolic dysfunction respect to the group of HDP-IUGR.

E3. Maternal haemodynamics follow-up after pregnancies complicated by HDP and/or IUGR

Abstract Aims: To compare maternal hemodynamic profile during pregnancy and at 6–12 months after delivery in pregnancies with different HDP phenotypes or severe IUGR. Methods: We enrolled patients between 24 and 38 weeks of gestation: HDP with appropriate for gestational age foetuses (HDP-AGAf), HDP with IUGR (HDP-IUGR), severe IUGR and Controls matched for gestational age. Severe IUGR was defined as abdominal circumference <5th centile and a PI in umbilical artery42SD. Diagnosis of HDP was made according to the criteria of the ISSHP. Maternal echocardiography was performed during pregnancy and at 6–12 months after delivery to compare in each group cardiac output (CO), total vascular resistance (TVR) and tissue Doppler E’/A’ wave ratio. Results: Maternal heart rate and CO were reduced and TVR increased during pregnancy, and did not change significantly at follow-up in the 10 HDP-IUGR and in the 8 severe IUGR recruited. Heart rate, CO and TVR in the 8 HDP-AGAf were similar to Controls both during pregnancy and at follow-up except for a significantly increased MAP and a reduced E’/A’ ratio. Discussion: Maternal hemodynamic changes at 6–12 months postpartum varies according to different physio-pathological phenotypes of maternal HDP and placental damage.

Gestational Diabetes and Maternogenic Preeclampsia: By-products of the Accelerated Metabolic Syndrome in Pregnancy

The changes driven by feto-placental unit in maternal organism, tantamount to a cardiovascular and metabolic stress test. The adaptative mechanisms that accommodate energy and nutritional requirements for the placenta and the fetus modify glucose-insulin balance as well as gluconeogenesis and lipid metabolism. The microbiota follows the same purpose. When these changes meet with an unbalanced diet, as typical as the Western supermarket diet, adaptative mechanisms turn into an accelerated metabolic syndrome. Unfortunately, this condition adds its risk factors to the pro-inflammatory TH1 milieu of late gestation. In fact, in late gestation villi crowding and reduced intervillous space produce an oxidative stress similar to that produced since early gestation in the case of shallow trophoblastic invasion (i.e., preeclampsia associated with fetal growth restriction). Decidual vascular atherosis might be nurtured by dyslipidemia of metabolic syndrome to an even worse intervillous perfusion. Increased venous abdominal pressure is enhanced by visceral fat and multiplies its impact on renal venous pressure and the renin-angiotensin-aldosterone balance. All these factors conjure to damage either the energy metabolism (gestational diabetes) or the endothelial function into hypertension and various end-organ damage (preeclampsia with normal grown fetus).

OP09.05: Pulse wave analysis: evaluation of arterial stiffness in first trimester for prediction of placental and maternal pre‐eclampsia (PE)

care in a tertiary Brazilian hospital. The base-cohort population was 487 singleton pregnancies, including 9 case subjects who developed PE requiring delivery before 34 weeks (early PE) and 22 with late PE, 47 with gestational hypertension, and 409 cases subjects (84%) who were unaffected by PE or gestational hypertension. Maternal history, body mass index (BMI), mean arterial pressure (MAP), and uterine artery pulsatility index were recorded in all of the cases. Univariate and logistic regression analysis was used to derive algorithms for the prediction of hypertensive disorders. Results: The maternal characteristics selected by regression analysis to be part of the final predictive model were nulliparity, previous personal and family history of PE. MAP was higher (86 versus 78 mmHg) in patients who developed PE (P < 0.01). The uterine artery percentile of mean PI was higher in the PE than in the control group (50.3% ± 31.7% versus 37.4% ± 30.0%; P < 0.01). It was estimated that, with the algorithm for PE, 78%, 45%, and 26% of early PE, late PE, and gestational hypertension, respectively, could be detected with a 10% false-positive rate. Conclusions: The traditional approach to screening for PE, which is based on maternal demographic characteristics and medical history, identifies ∼60% of cases destined to develop early PE for a falsepositive rate of 10%. This study proposes that a combination of maternal risk factors, mean arterial blood pressure, and uterine artery Doppler, for the same false-positive rate of 10%, could identify 78% of cases of early PE.