Early Prophylactic Enoxaparin for the Prevention of Preeclampsia and Intrauterine Growth Restriction: A Randomized Trial.

BACKGROUND: Preeclampsia (PE) and intrauterine growth restriction (IUGR) are major causes of maternal and perinatal morbidity and mortality. Previous studies have shown that intervention with low-dose aspirin resulted in a reduction in the occurrence of preterm PE. However, no data are currently available on the effect of low-molecular-weight heparin (LMWH) for the prevention of pregnancy complications in women enrolled at first trimester screening. OBJECTIVE: We aimed to assess the effectiveness of LMWH in the prevention of PE, IUGR, fetal death, and abruptio placentae in women classified as high risk based on their medical history and in women selected by first trimester screening of PE. Study -Design: This was a multicenter, randomized, open-label, parallel controlled trial in women without thrombophilia between 6.0 and 15.6 weeks of gestation. Inclusion criteria were severe PE or IUGR before 34 weeks of gestation and/or abruptio placentae or unexplained intrauterine death in a previous pregnancy; uterine artery mean pulsatility index Doppler >95th percentile and/or positive first trimester screening for PE. Pregnant women were randomly assigned to receive no intervention or LMWH until the 36th week of gestation. The primary composite outcome consisted of 1 or more of the following: development of PE, IUGR, abruptio placentae, and intrauterine fetal death. RESULTS: A total of 278 pregnant women were randomly allocated to receive LMWH (n = 134) or no intervention (n = 144). Overall, 115 (41%) women experienced placental insufficiency complications, with no significant differences between the 2 arms: 50/144 (34.7%) in the LMWH arm and 43/134 (32%) in the control arm (p = 0.64, OR: 1.13, 95% CI: 0.68-1.85). CONCLUSION: LMWH did not reduce the incidence of placenta-mediated complications either in women with previous adverse obstetric history without thrombophilia or in women selected by first trimester screening for PE. Based on these results, we cannot recommend the use of LMWH alone in women at risk of placental complications.

Placenta-related complications in women carrying a foetus with congenital heart disease.

INTRODUCTION: Recent studies pointed to an intrinsically angiogenic imbalance in CHD in the maternal and foetal circulation suggestive of impaired placentation. OBJECTIVES: To assess whether pregnant women with a CHD foetus are at greater risk of placenta-related complications. METHODS: Perinatal results of women with a CDH foetus were compared with those of a non-selected population followed up at our centre. Multiple pregnancies and chromosomal abnormalities were excluded from the analysis. RESULTS: About 279 pregnancies with CHD foetuses were included. Mothers were classified in three groups according to the foetal cardiac defect: 104 (37.3%) atrioventricular defect, 102 (36.5%) conotruncal anomalies and 73 (26.2%) left-ventricular outflow tract obstruction. A significantly higher incidence of pre-eclampsia was observed in the CHD group compared with the normal population (5.7% versus 1.2% p < 0.0001) [OR 5.96 (95% CI - 3.19-10.54)]. About 9.7% of foetuses with CHD had < 3rd birth weight percentile compared with 3% for the normal population [OR 3.32 (95% CI - 2.39-4.56)]. A higher incidence of stillbirth was also observed in the CHD group compared with the normal population (2.5% versus 0.4%) [OR 9.45 (95% CI - 3.35-23.3)]. CONCLUSIONS: Women carrying a foetus with CHD have a high risk of pre-eclampsia and intrauterine growth restriction. The relationship between CHD and placenta-related complications could be an encouraging topic for future research.

Angiogenic Gene Expression in Down Syndrome Fetal Hearts.

INTRODUCTION: Forty percent of Down syndrome (DS) fetuses have congenital heart defects (CHD). An abnormal angiogenic environment has been described in euploid fetuses with CHD. However, the underlying pathophysiologic pathway that contributes to CHD in DS remains unknown. The objective was to compare the expression of angiogenic factors and chronic hypoxia genes in heart tissue from DS and euploid fetuses with and without CHD. METHODS: The gene expression profile was determined by real-time PCR quantification in heart tissue from 33 fetuses with DS, 23 euploid fetuses with CHD and 23 control fetuses. RESULTS: Angiogenic factors mRNA expression was significantly increased in the DS group compared to the controls (soluble fms-like tyrosine kinase-1, 81%, p = 0.007; vascular endothelial growth factor A, 57%, p = 0.006, and placental growth factor, 32%, p = 0.0227). Significant increases in the transcript level of hypoxia-inducible factor-2α and heme oxygenase 1 were also observed in the DS group compared to the controls. The expression of angiogenic factors was similar in DS fetuses and CHD euploid fetuses with CHD. CONCLUSION: Abnormal angiogenesis was detected in the hearts of DS fetuses with and without CHD. Our results suggest that DS determines an intrinsically angiogenic impairment that may be present in the fetal heart.

Prevalence of antibody to Bordetella pertussis in neonates and prevalence of recent pertussis infection in pregnant women in Catalonia (Spain) in 2003 and 2013.

BACKGROUND: Infections because of Bordetella pertussis still occur in infants and adults in European countries, despite vaccination coverage against pertussis being high. METHODS: IgG antibody titers to pertussis toxin (anti-PT) were assessed using an enzyme-linked immunosorbent assay test (Serion ELISA classic) in 353 cord blood samples from neonates of a representative sample of pregnant women obtained in Catalonia (Spain) in 2013. Neonates with anti-PT titers ≤ 40 international units (IU)/mL were considered to be unprotected against pertussis. IgG-PT titers >100 IU/mL in umbilical cord samples were considered to be indicative of a current or recent pertussis infection (12 months) in pregnant women. The age-standardized prevalence of recent pertussis infection obtained in this study was compared with the prevalence obtained in 2003. RESULTS: The mean anti-PT titer in neonates was 10.8 IU/mL and 89.8% of neonates were unprotected against pertussis. The prevalence of unprotected neonates as defined by cord blood anti-PT ≤ 40 IU/mL was 90%. The prevalence of recent pertussis infection in pregnant women as defined by cord blood anti-PT >100 IU/mL was 2%. The diphtheria-tetanus-pertussis vaccination coverage during childhood in pregnant women was 75%. The age-standardized prevalence of recent pertussis infection in pregnant women observed in this study (2.2%) was slightly higher than the prevalence obtained in 2003 (1.5%), with an odds ratio = 1.45 (95% confidence intervals: 0.5-3.9), although differences were not statistically significant. CONCLUSIONS: Most neonates are unprotected against pertussis and pertussis infections are frequent in pregnant women in Catalonia. Infants and pregnant women should be the priority population groups for pertussis prevention programs in Catalonia.

Maternal and foetal angiogenic imbalance in congenital heart defects.

AIMS: Animal models showed that angiogenesis is related to abnormal heart development. Our objectives were to ascertain whether a relationship exists between congenital heart defects (CHDs) and angiogenic/anti-angiogenic imbalance in maternal and foetal blood and study the expression of angiogenic factors in the foetal heart. METHODS AND RESULTS: Maternal and cord blood placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng) were compared in 65 cases of CHD and 204 normal controls. Angiogenic factor expression and markers of hypoxia were measured in heart tissue from 23 CHD foetuses and 8 controls. In the CHD group, compared with controls, plasma PlGF levels were significantly lower (367 ± 33 vs. 566 ± 26 pg/mL; P < 0.0001) and sFlt-1 significantly higher (2726 ± 450 vs. 1971 ± 130 pg/mL, P = 0.0438). Foetuses with CHD had higher cord plasma sFlt-1 (442 ± 76 vs. 274 ± 26 pg/mL; P = 0.0285) and sEng (6.76 ± 0.42 vs. 4.99 ± 0.49 ng/mL, P = 0.0041) levels. Expression of vascular endothelial growth factor (VEGF), sFlt-1, markers of chronic hypoxia, and antioxidant activity were significantly higher in heart tissue from CHD foetuses compared with normal hearts (VEGF, 1.59-fold; sFlt-1, 1.92-fold; hypoxia inducible factor (HIF)-2α, 1.45-fold; HO-1, 1.62-fold; SOD1, 1.31-fold). CONCLUSION: An intrinsically angiogenic impairment exists in CHD that appears to be present in both the maternal and foetal circulation and foetal heart. Our data suggest that an imbalance of angiogenic-antiangiogenic factors is associated with developmental defects of the human heart.

Telomeric repeat-containing RNA and telomerase in human fetal oocytes.

STUDY QUESTION: What is the distribution of telomeric repeat-containing RNA (TERRA) and of telomerase in human fetal oocytes? SUMMARY ANSWER: TERRA forms discrete foci at telomeres of human fetal oocytes and it co-localizes with both the shelterin component telomeric repeat-binding factor 2 (TRF2) and the catalytic subunit of human telomerase at the telomeres of meiotic chromosomes. WHAT IS KNOWN ALREADY: TERRA is a structural element of the telomeric chromatin that has been described in somatic cells of many different eukaryote species. The telomerase enzyme is inactive in adult somatic cells but is active in germ cells, stem cells and in the majority of tumors; however, its distribution in oocytes is still unknown. STUDY DESIGN, SIZE, DURATION: For this study, ovarian samples from four euploid fetuses of 22 gestational weeks were used. These samples were obtained with the consent of the parents and of the Ethics Committee of Hospital de la Vall d'Hebron. PARTICIPANTS/MATERIALS, SETTING, METHODS: We analyzed the distribution of TERRA and telomerase in cells derived from human fetal ovaries. The co-localization of TERRA, telomerase and telomeres was performed by optimizing a combination of immunofluorescence (IF) and RNA-fluorescent in situ hybridization (RNA-FISH) techniques. The synaptonemal complex protein 3 (SYCP3), TRF2 and protein component of telomerase [telomerase reverse transcriptase (TERT)] were detected by IF, whereas TERRA was revealed by RNA-FISH using a (CCCTAA)(3) oligonucleotide. SYCP3 signals allowed us to identify oocytes that had entered meiosis and classify them into the different stages of prophase I, whereas TRF2 indicated the telomeric regions of chromosomes. MAIN RESULTS AND THE ROLE OF CHANCE: We show for the first time the presence of TERRA and the intracellular distribution of telomerase in human fetal ovarian cells. TERRA is present, forming discrete foci, in 75% of the ovarian tissue cells and most of TERRA molecules (≈ 83%) are at telomeres (TRF2 co-localization). TERRA levels are higher in oocytes than in ovarian tissue cells (P = 0.00), and do not change along the progression of the prophase I stage (P = 0.37). TERRA is present on ≈ 23% of the telomeres in all cell types derived from human fetal ovaries. Moreover, ≈ 22% of TERRA foci co-localize with the protein component of telomerase (TERT). LIMITATIONS, REASONS FOR CAUTION: We present a descriptive/qualitative study of TERRA in human fetal ovarian tissue. Given the difficult access and manipulation of fetal samples, the number of fetal ovaries used in this study was limited. WIDER IMPLICATIONS OF THE FINDINGS: This is the first report on TERRA expression in oocytes from human fetal ovaries. The presence of TERRA at the telomeres of oocytes from the leptotene to pachytene stages and its co-localization with the telomerase protein component suggests that this RNA might participate in the maintenance of the telomere structure, at least through the processes that take place during the female meiotic prophase I. Since telomeres in oocytes have been mainly studied regarding the bouquet structure, our results introduce a new viewpoint of the telomeric structure during meiosis.

Smoking during pregnancy: changes in mid-gestation angiogenic factors in women at risk of developing preeclampsia according to uterine artery Doppler findings.

OBJECTIVES: To ascertain whether angiogenic factors are altered in smokers at increased risk of preeclampsia (PE) according to uterine artery Doppler (UAD) assessment. METHODS: Uterine artery mean pulsatility index (PI), maternal placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFlt-1) serum levels were measured in 125 healthy pregnant women at 24 weeks of gestation. Smoking status was determined based on cotinine levels in maternal blood. RESULTS: Smokers had significantly higher PlGF concentration compared with nonsmokers [median PlGF levels: 575 (511) vs. 277 (259) pg/mL, respectively, p = 0.001]. The differences in PlGF levels were also observed between smokers and nonsmokers within the group of women with abnormal UAD and therefore at high risk of developing PE [median PlGF levels: 472 (434) vs. 235 (169) pg/mL, respectively, p = 0.0005]. In our patient cohort, 16 women developed PE (12.8%), of whom only 3 were smokers [odds ratios (ORs): 0.49; 95% confidence interval (CI) (0.13-1.84)]. In patients who finally developed intrauterine growth restriction, the PlGF/sFlt-1 ratio was significantly higher in the group of smokers compared with that of nonsmokers [0.39 (0.28) vs. 0.13 (0.21), respectively, p = 0.0311]. CONCLUSION: The effect of smoking in reducing the risk of PE may be due to the increase of PlGF and PlGF/sFlt-1 ratio in maternal blood, even among women with abnormal UAD.

Arabin cervical pessary to prevent preterm birth in severe twin-to-twin transfusion syndrome treated by laser surgery.

OBJECTIVES: To describe the outcome of patients with twin-to-twin transfusion syndrome and cervical length ≤ 25 mm, treated with laser and an Arabin cervical pessary. METHODS: Retrospective analysis of a consecutive series of all cases with severe twin-to-twin transfusion syndrome who underwent laser surgery: a group with cervical length above 25 mm (group A) and two groups who had a cervical length of 25 mm or less prior to the procedure. The first 8 cases (group B) were managed expectantly and the next 8 cases had a cervical pessary inserted immediately after laser surgery (group C). Gestational age at birth was the primary outcome. The secondary outcome was a composite one encompassing severe neonatal morbidity. RESULTS: The median gestational age at laser surgery was 20 weeks in all groups but the median gestational age at delivery was significantly higher in group C versus B (28 vs 32 weeks, p = 0.01). Severe neonatal morbidity was present in 18% in group C and 70% in group B (p < 0.01). CONCLUSION: Early results suggest a potential role for pessary use in prolonging gestation in cases with shortened cervix at the time of laser. A randomized trial to test this hypothesis should be performed.

Are we ready for a new look at the diagnosis of premature rupture of membranes?

Premature rupture of membranes is a significant contributor to preterm birth with its associated short- and long-term complications. The absence of a standard approach to its management places a burden on the clinicians' ability to promptly and accurately diagnose premature rupture of membranes. For the last half century, there have been no significant changes in the way premature ruptured membranes is diagnosed. With the advent of newer, amniotic fluid-specific, noninvasive, and accurate markers, there is an opportunity to update the diagnosis of premature rupture of membranes.

Maternal history and uterine artery Doppler in the assessment of risk for development of early- and late-onset preeclampsia and intrauterine growth restriction.

Objective. To examine the value of one-step uterine artery Doppler at 20 weeks of gestation in the prediction pre-eclampsia (PE) and/or intrauterine growth restriction (IUGR). Methods. A prospective multicentre study that included all women with singleton pregnancies at 19-22 weeks of gestation (w). The mean pulsatility index (mPI) of both uterine arteries was calculated. Receiver-operating characteristics curves (ROC) were drawn to compare uterine artery Doppler and maternal risk factors for the prediction of early-onset PE and/or IUGR (before 32 w) and late-onset PE and/or IUGR. Results. 6,586 women were included in the study. Complete outcome data was recorded for 6,035 of these women (91.6%). PE developed in 75 (1.2%) and IUGR in 69 (1.1%) cases. Uterine Doppler mPI was 0.99 and the 90th centile was 1.40. For 10% false-positive rate, uterine Doppler mPI identified 70.6% of pregnancies that subsequently developed early-onset PE and 73.3% of pregnancies that developed early-onset IUGR. The test had a lower detection rate for the late-onset forms of the disease (23.5% for PE and 30% for IUGR). Maternal history has a low sensitivity in the detection of early-onset cases, although it is better at detecting late-onset PE. Conclusion. Uterine artery Doppler and maternal risk factors seem to select two different populations - early and late-onset PE which might suggest a different pathogenesis.

Introital ultrasonography: a comparison of women with stress incontinence due to urethral hypermobility and continent women.

OBJECTIVE: To determine if there is a variable on introital ultrasonography (IUS) that can be used to distinguish between women with stress urinary incontinence (SUI) due to urethral hypermobility (UH) and continent women. PATIENTS AND METHODS: This single-centre, prospective, blind, cohort, observational study comprised 383 women (245 continent and 138 incontinent) who were all appropriately informed volunteers selected according to the inclusion criteria. IUS with a convex probe was performed on all women; the measurement plane was standardized and coordinates were obtained at rest and on straining. Several distances were measured to determine if any provided an objective distinction between continent and incontinent women. RESULTS: Among all the IUS variables assessed, sliding (calculated as the difference between the distance urethra-bladder neck, U-BN, at rest and under stress) was the best for distinguishing continent and incontinent women. The receiver operating characteristic curves showed that with a threshold of 8 mm, sliding had a sensitivity of 92% and a specificity of 79.6% for detecting SUI due to UH. The distances symphysis-urethra (S-U) and U-BN at rest could also discriminate, but with lower significance. CONCLUSIONS: IUS is an important tool for diagnosing SUI; there are three independent variables, one dynamic (sliding) and two static (distances S-U and U-BN), that can be used to distinguish between continent women and those with SUI due to UH. Sliding is the most reliable, as it has the highest sensitivity and specificity. We think that the simplicity, low financial cost and reliability of IUS could allow it to be a routine procedure for physicians working in incontinence units.

Feasibility of retroviral vector-mediated in utero gene transfer to the fetal rabbit.

OBJECTIVES: Successful treatment or prevention of severe hereditary diseases could conceivably be achieved by genetic intervention early in development. Viral vector-mediated fetal gene transfer is proving a valuable tool to test the above concept in relevant animal models. Although the pregnant rabbit is a well-recognized model for fetal therapy, few preclinical assays have used it to validate fetal gene transfer approaches. In this preliminary study we assessed for the first time the feasibility of retroviral vector-mediated in utero gene transfer in the fetal rabbit. METHODS: Different amounts of the vesicular stomatitis virus G pseudotyped MFG(nls)LacZ retroviral vector, expressing a nuclear-localized beta-galactosidase reporter protein were injected intraperitoneally and -hepatically into 20- to 22-day-old fetuses. At 8-9 days post-treatment, the pups were sacrificed and the tissues harvested for analysis. Evidence of gene transfer was obtained by PCR amplification of proviral sequences within genomic DNA isolated from the treated samples. Transgenic beta-galactosidase expression was assessed by X-gal histochemical staining. RESULTS: By intraperitoneal injection 43% of the viable fetuses treated (3/7) showed evidence of successful LacZ gene transfer and low-level beta-galactosidase expression into liver and heart, whereas by intrahepatic injection roughly 38% (3/8) of the livers were positive for LacZ gene transfer and expression. The success rate for the viable fetuses rose to 67% positive livers (4/6) when a near double amount of recombinant virus was injected using a 10-fold concentrated virus stock. In terms of short-term safety, fetal and maternal survival rates approached 80% of treated fetuses, and 100% of treated does. CONCLUSIONS: The pregnant rabbit is a useful and reliable model allowing the design of further studies to optimize the conditions for effective, safer, and persistent retroviral vector-mediated fetal gene transfer.

Atherogenic lipoprotein subfraction profile in preeclamptic women with and without high triglycerides: different pathophysiologic subsets in preeclampsia.

Abnormal lipid metabolism has been proposed as a pathogenic factor of preeclampsia, although whether it is a constant feature in all preeclamptic patients is unclear. We assessed whether plasma triglyceride (TG) levels can distinguish a subgroup of preeclamptic women with alterations in lipoprotein profile from those with normal lipid metabolism and can be used to identify 2 distinct pathogenic groups in preeclampsia. This prospective study included 34 women with preeclampsia and 23 healthy pregnant women. Preeclamptic women were further subclassified into normal-TG (<250 mg/dL) and high-TG (>or=250 mg/dL) groups on the basis of the 90th percentile in our population. Low-density lipoproteins (LDLs) were ultracentrifuged and were separated into 4 subfractions, and lipid distribution in the subfractions was analyzed in all study groups. Vascular cell adhesion molecule-1 was also measured as a marker of endothelial dysfunction. Sixteen women with preeclampsia had high TGs (47% vs 13% in control subjects, P<.001). This subgroup showed a significant shift in lipid distribution, mainly, TGs, toward the small, dense LDL subfractions. However, preeclamptic patients in the normal-TG subgroup showed LDL subfraction lipid distribution similar to that of healthy pregnancies. Vascular cell adhesion molecule-1 levels were significantly elevated in preeclamptic patients in comparison with those in control subjects regardless of TG levels. The presence of a proatherogenic lipoprotein profile, previously described in preeclampsia, is characterized by increased small dense LDL and is exclusive to a subset of preeclamptic patients with high TG levels. These findings support the concept of heterogeneous pathogenic lines in preeclampsia and the use of subclassifications in pathophysiologic research on this condition.

A comprehensive study of oxidative stress and antioxidant status in preeclampsia and normal pregnancy.

Oxidative stress has been increasingly postulated as a major contributor to endothelial dysfunction in preeclampsia (PE), although evidence supporting this hypothesis remains inconsistent. This study aimed to analyze in depth the potential role of oxidative stress as a mechanism underlying endothelial damage in PE and the pregnant woman's susceptibility to the disease. To this end, indicative markers of lipoperoxidation and protein oxidation and changes in antioxidant defense systems were measured in blood samples from 53 women with PE and 30 healthy pregnant controls. Results, analyzed in relation to disease severity, showed PE women, compared with women with normal pregnancy, to have: (1) significantly enhanced antioxidant enzyme SOD and GPx activities in erythrocytes; (2) similar plasma alpha-tocopherol levels and significantly increased alpha-tocopherol/lipids in both mild and severe PE; (3) significantly decreased plasma vitamin C and protein thiol levels; (4) similar erythrocyte glutathione content, total plasma antioxidant capacity, and whole plasma oxidizability values; (5) significantly elevated plasma total lipid hydroperoxides, the major initial reaction products of lipid peroxidation, in severe PE; (6) no intracellular or extracellular increases in any of the secondary end-products of lipid peroxidation, malondialdehyde or lipoperoxides; (7) similar oxidative damage to proteins quantified by plasma carbonyl levels, immunoblot analysis, and advanced oxidation protein products assessment; and (8) significantly elevated and severity-related soluble vascular cell adhesion molecule-1 serum levels reflecting endothelial dysfunction. No correlations were found among plasma levels of circulating adhesion molecules with regard to lipid and protein oxidation markers. Globally, these data reflect mild oxidative stress in blood of preeclamptic women, as oxidative processes seem to be counteracted by the physiologic activation of antioxidant enzymes and by the high plasma vitamin E levels that would prevent further oxidative damage. These results do not permit us to conclude that oxidative stress might be a pathogenetically relevant process causally contributing to the disease.

Increased susceptibility to low density lipoprotein oxidation in women with a history of pre-eclampsia.

OBJECTIVES: To evaluate the susceptibility to oxidation of low density lipoprotein (LDL) in women with a history of pre-eclampsia. DESIGN: A case-control study. SETTING: The departments of obstetrics and gynaecology at two university teaching hospitals. POPULATION: Women delivering one to three years before enrollment, 35 who were diagnosed with severe pre-eclampsia and 35 controls matched for age, body mass index (BMI), smoking and parity. METHODS: Plasma samples were analysed for total cholesterol, high density lipoprotein (HDL) cholesterol, LDL cholesterol, triglycerides and lipoprotein A. The in vitro susceptibility to oxidation of LDL was measured and expressed in minutes (lag time). Results are expressed as mean and standard deviation. MAIN OUTCOME MEASURES: Serum lipid profile and in vitro susceptibility to oxidation of LDL. RESULTS: Mean LDL cholesterol (116 [37] vs 98 [20] mg/dL, P < 0.05) and trygliceride (112 [56] vs 78 [38] mg/dL, P < 0.05) levels were significantly higher in the groups of women who had pre-eclampsia compared with controls. The rest of the measured lipid parameters were similar between the two study groups. The susceptibility to oxidation of LDL was also significantly higher in the pre-eclampsia group (lag time: 37.9 [8.4] vs 44.8 [9.1] minutes, P < 0.01). CONCLUSION: Women with a history of pre-eclampsia have significant differences in lipid parameters and an increased susceptibility to lipoprotein oxidation when compared with women who had a normal pregnancy one to three years after delivery.