Management of allergic diseases in pregnancy.

Allergic diseases like asthma, allergic rhinitis, food allergy, hymenoptera allergy, or atopic dermatitis are highly prevalent in women of childbearing age and may affect up to 30% of this age group. This review focuses on the management of allergic diseases during pregnancy. Furthermore, we discuss the challenges of counseling women with allergic diseases in the reproductive age, including considerations relevant to the ongoing SARS-CoV-2 pandemic. To create the optimal milieu for the unborn child, a multitude of immunological changes occur during pregnancy which may favor type 2 responses and aggravate disease phenotypes. In co-occurrence with suboptimal preconception disease control, this elevated Th2 responses may aggravate allergic disease manifestations during pregnancy and pose a risk for mother and child. Due to limitations in conducting clinical trials in pregnant women, safety data on anti-allergic drugs during pregnancy are limited. The lack of information and concerns among pregnant patients demands counseling on the benefits of anti-allergic drugs and the potential and known risks. This includes information on the risk for mother and child of disease aggravation in the absence of treatment. By doing so, informed decisions and shared decision-making can take place.

Placental Findings in Postpartum Preeclampsia: A Comparative Retrospective Study.

OBJECTIVE: Preeclampsia is a multifactorial placental disease that can occur after delivery. The pathophysiology of postpartum preeclampsia remains unknown. The objective was to describe placental findings in postpartum preeclampsia. STUDY DESIGN: This is a case-control study, comparing the placental histologic findings in four groups of 30 patients with postpartum preeclampsia, early-onset preeclampsia, late-onset preeclampsia, and normotensive controls. RESULTS: Placentas of postpartum preeclampsia had a mean placental weight not different from that of late-onset preeclampsia at a similar gestational age (479.0 ± 152.7 vs. 521.3 ± 144.1 g, p = 0.07); they showed a higher rate of acute deciduitis of 42.4% than early preeclampsia (5.7%, p < 0.01) or in controls (3.2%, p < 0.01); 18.2% had decidual arteriolopathy, with no significant difference with other groups. These placentas had fewer villous infarcts as compared with early preeclampsia (9.1 vs. 62.9%, p < 0.01) and less accelerated maturation of villi (24.2 vs. 74.3%, p < 0.01). CONCLUSION: There were no significant differences for decidual arteriolopathy and villous infarcts among postpartum preeclampsia, late-onset preeclampsia, and the controls. This suggests that postpartum preeclampsia is more of a maternal disease in which the placenta may act as a priming effect in predisposed mothers and becomes clinically apparent after delivery.

Nutritional approach to preeclampsia prevention.

PURPOSE OF REVIEW: Although not fully understood, the physiopathology of preeclampsia is thought to involve an abnormal placentation, diffuse endothelial cell dysfunction and increased systemic inflammation. As micronutrients play a key role in placental endothelial function, oxidative stress and expression of angiogenic factors, periconceptional micronutrient supplementation has been proposed to reduce the risk of preeclampsia. However, recent studies reported conflicting results. RECENT FINDINGS: Calcium intake (>1 g/day) may reduce the risk of preeclampsia in women with low-calcium diet. Data from recently updated Cochrane reviews did not support routine supplementation of vitamins C, E or D for either the prevention or treatment of preeclampsia. Evidences are also poor to support zinc or folic acid supplementation for preeclampsia prevention. Dark chocolate, flavonoid-rich food, and long-chain polyunsaturated fatty acids might also be candidates for prevention of preeclampsia. SUMMARY: Through antioxidant, anti-inflammatory or vasoactive proprieties, micronutrients are good candidates for preeclampsia prevention. Calcium supplementation is recommended to prevent preeclampsia in women with low-calcium intake. Despite positive clinical and in-vitro data, strong evidence to support periconceptional supplementation of other micronutrients for preeclampsia risk-reduction is still lacking. Further studies are also needed to evaluate the benefit of nutritional supplementation such as chocolate and long-chain polyunsaturated fatty acids.

[Pre-gestational diabetes : an increasingly common entity]. / Diabète prégestationnel : une entité de plus en plus fréquente.

Pre-gestational diabetes, which is defined by the presence of diabetes prior to pregnancy, is an ever-increasing entity. Its management includes an optimization of the glycemic control before the beginning of pregnancy, but also a constant adaptation of the treatment during pregnancy. Good monitoring and adequate glycemic control throughout pregnancy are of course necessary to minimize complications for both the fetus and the mother.

Le diabète prégestationnel, qui se définit par la présence d'un diabète antérieur à une grossesse, est une entité en constante augmentation. Sa prise en charge comprend d'une part une optimisation du contrôle glycémique avant le début de la grossesse, mais également une constante adaptation du traitement antidiabétique durant la grossesse. Une bonne surveillance et un bon contrôle glycémique durant toute la grossesse sont bien évidemment nécessaires afin de limiter au mieux les complications tant pour le fœtus que pour la mère.

[Obstetrics]. / Obstétrique.

During the past year, we have renewed interest in old well-known problems. New studies and guidelines have been issued about lung maturation in cases of preterm delivery after 37 weeks of gestation. Short term benefits have been proven but the number of cases needed to treat to prevent one case of respiratory complications is high and with possible neurological long-term effects. Also, several studies have shown the benefits of including the ultrasound measurement of the inferior segment of the uterus in order to attempt vaginal delivery after caesarean section with the lowest risk for uterine rupture, while others studies have shown the best procedure to close the uterus during cesarean section. And finally, we will discuss about an old friend: aspirin to reduce the risk of pre-eclampsia.

Au cours de l'année écoulée, l'intérêt pour de vieux problèmes bien connus de notre spécialité médicale a été renouvelé. De nouvelles études et lignes directrices ont été publiées concernant la maturation pulmonaire en cas d'accouchement prématuré après 37 semaines de gestation. Bien qu'un bénéfice à court terme ait été prouvé, le nombre de cas à traiter pour prévenir une complication respiratoire néonatale est élevé, avec des effets neurologiques potentiels à long terme. Afin de promouvoir la tentative d'accouchement vaginal après césarienne sans augmenter le risque de rupture utérine, différents travaux indiquent qu'il faut intégrer la mesure du segment inférieur de l'utérus dans la discussion de la voie d'accouchement. D'autres ont montré la meilleure procédure pour fermer l'utérus pendant la césarienne. Enfin, nous allons parler d'une vieille amie : l'aspirine pour réduire le risque de prééclampsie.

Diagnosis and Management of HELLP Syndrome Complicated by Liver Hematoma.

Subcapsular liver hematoma is a rare but potentially life-threatening complication of preeclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. It may present with nonspecific signs and symptoms, none of which are diagnostic, and can mimic pulmonary embolism of cholecystitis. There is no consensus on the management of subcapsular liver hematoma. Unruptured liver hematoma can be conservatively managed. When rupture occurs, surgical, endovascular approaches and, rarely, liver transplantation, may be required. Actual literature is scant and retrospective in nature. Data on follow-up, time to resolution and outcome of subsequent pregnancies are very limited. We here review the diagnosis and management of liver hematoma.

[Obstetric medicine : the success of a transdisciplinary approach to the maternal health]. / Gynécologie-obstétrique. Médecine interne obstétricale : le succès d'une approche transdisciplinaire de la santé maternelle.

Obstetric medicine is a specialty that addresses maternal health and medical complications during pregnancy. This emerging specialty responds to the increasing need for specialized intervention in cases of high risk pregnancies, at a time when pregnancies can occur at more advanced ages and where advances in therapeutics now allow to consider pregnancy in mothers with chronic illness. Furthermore, medical conditions specific to pregnancy, such as hypertensive disorders of pregnancy or gestational diabetes, are now recognized as emerging risk factors for cardiovascular, metabolic and renal diseases, for which longitudinal care beyond the maternity ward is of critical importance.

La médecine interne obstétricale est une spécialité dédiée à la santé maternelle et aux affections médicales de la grossesse. Il s'agit d'une spécialité novatrice, répondant à la demande croissante d'aide spécialisée dans la prise en charge des grossesses à haut risque, à une époque où l'âge de la grossesse est de plus en plus tardif et où les avancées thérapeutiques permettent d'envisager la grossesse en cas d'affection chronique. De plus, les complications médicales de la grossesse, telles que les hypertensions gravidiques ou le diabète gestationnel, sont désormais reconnues comme des facteurs de risque cardiovasculaires, métaboliques et rénaux émergents, pour lesquelles la continuité des soins à long terme est nécessaire.

[The placenta : a new target organ for hypertension ?] / Le placenta : nouvel organe cible de l'hypertension artérielle ?

The placenta has generated many beliefs over centuries and in all ethnicities. Considered in our society as a surgical waste, it is elsewhere contemplated for its mysterious protective powers, viewed as the seat of the soul, disposed of, burnt or even buried. However, once time is taken for its examination, the placenta tells a story. Of interest is the similarity observed between placental vascular disease in hypertensive pregnancy and atherosclerosis in coronary artery disease for example. Hypertension in pregnancy is frequent and associated with increased adverse obstetrical outcomes, and long-term risk of cardiovascular and kidney disease. This article will discuss the role of placental histopathology in hypertensive pregnancies, its indicative value for long-term cardiovascular risk in mothers and for subsequent pregnancy.

De tout temps, le placenta a fait l'objet de croyances. Simple déchet anatomique dans nos sociétés, il est ailleurs le siège de l'âme, brûlé, jeté, enterré. Pourtant, si l'on prend la peine de l'examiner, le placenta nous raconte une histoire. En effet, on observe un mimétisme entre les atteintes artérielles placentaires des grossesses hypertensives et les lésions d'artériosclérose de la coronaropathie par exemple. Les grossesses hypertensives sont fréquentes, associées à court terme à un risque accru de complications obstétricales, et à long terme de maladies cardiovasculaires et rénales. Cet article se propose de discuter l'utilité de l'examen du placenta en cas d'hypertension, de sa valeur indicative sur la survenue d'événements cardiovasculaires à long terme chez la mère, et du risque sur le déroulement d'une grossesse ultérieure.

[Hypertension In pregnancy: practical considerations]. / Hypertensions gravidiques: considérations pratiques.

Hypertension is the most frequent medical disorder of pregnancy. Whether in the form of a chronic hypertension or a pregnancy induced-hypertension, or preeclampsia, it is associated with major maternal and neonatal morbidity and mortality. Improvement of prenatal care allowed a reduction in the number of poor outcomes. However, our partial understanding of the origin of gestational hypertension and preeclampsia limits the establishment of robust prediction models and efficient preventive interventions. This review discusses actual considerations on the clinical approach to hypertension in pregnancy.

[Impact of salt intake on health: beliefs of the Swiss population]. / Impact de la consommation de sel sur la santé: les croyances de la population suisse.

Excessive salt intake increases the risk of developing hypertension and cardiovascular disease. Sodium intake remains high both in developed and emerging countries. The Swiss Federal Office of Public Health has ordered a national survey on the salt intake in Switzerland, realized in different centers. This article presents the results of the awareness of the Swiss population concerning the relationship between excessive salt intake and health. This survey reveals a lack of knowledge regarding the association between high salt intake and cardiovascular disease, the sodium content of usual food, and the recommended daily value of sodium intake. Strategies to reduce salt consumption need to be reinforced by collaborations between health authorities and health care professionals.

[Renovascular prognosis of preeclampsia on the mother and the child]. / Pronostic réno-vasculaire de la prééclampsie chez la mère et l'enfant.

Preeclampsia is a pregnancy-related disease that affects 2 to 8% of pregnancy worldwide. It is now a well-established risk factor for cardiovascular and renal diseases. Preeclampsia is a well-recognized risk factor for future cardiovascular, renal and neurological disorders for the mother. It predetermines the risk profile of the future child's health. A long-term follow-up aimed on prevention and screening should be offered. Further studies are needed to determine the modality of that follow-up as well as the prevention strategies specific for that population. This article proposes a non-exhaustive review of the cardiovascular, renal and neurological consequences of the disease on the mother and child's health.

[Infections related to water activities]. / Infections liées aux activités aquatiques.

Infections acquired by exposure to water are common. The evolution of these infections found in our region is benign. However, some acquired in our regions or during travel abroad, may have a severe clinical course that requires early diagnosis. This article proposes a non-exhaustive review of the most common infections encountered in our regions or acquired abroad. The review excludes gastrointestinal infections acquired after ingestion of contaminated water.

Prevalence of Hypertensive Phenotypes After Preeclampsia: A Prospective Cohort Study.

Preeclampsia is associated with increased cardiovascular and renal risk. The aim of this prospective cohort study was to characterize the early postpartum blood pressure (BP) profile after preeclampsia. We enrolled 115 women with preeclampsia and 41 women with a normal pregnancy in a prospective cohort study. At 6 to 12 week postpartum, we assessed the prevalence of different hypertensive phenotypes using 24-hour ambulatory BP monitoring (ABPM), as well as the risk of salt sensitivity and the variability of BP derived from ABPM parameters. Among patients with preeclampsia, 57.4% were still hypertensive at the office. Daytime ABP was significantly higher in the preeclampsia group (118.9±15.0/83.2±10.4 mm Hg) than in controls (104.8±7.9/71.6±5.3 mm Hg; P<0.01). Differences between groups were similar for nocturnal BP values. Fifty percent of preeclampsia women remained hypertensive on ABPM in the postpartum, of whom 24.3% were still under antihypertensive treatment; 17.9% displayed a white-coat hypertension and 11.6% had masked hypertension. In controls, 2.8% had white-coat hypertension; none had masked hypertension or needed hypertensive treatment. The prevalence of nondippers was similar 59.8% in the preeclampsia group versus 51.4% in controls. High-risk class of salt sensitivity of BP was increased in preeclampsia women (48.6%) compared with controls (17.1%); P<0.01. In conclusion, ABPM 6 to 12 weeks after delivery reveals a high rate of sustained ambulatory, nocturnal, and masked hypertension after preeclampsia. This finding may help identify women who should be included in a postpartum cardiovascular risk management program. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01095939.

Endoplasmic reticulum stress responses in placentation - A true balancing act.

The unfolded protein response (UPR) is recognized as a key mechanism to promote protein folding and processing in eukaryotes when endoplasmic reticulum stress (ERS) occurs. Some conditions such as hypoxia or glucose deprivation are factors that may elicit ERS response. Recent literature collectively proposes that ERS response is crucial for mammalian reproduction by allowing decidualization and placentation to occur. However, prolonged ERS and activation of UPR pathways can lead to apoptosis and autophagy, which in turn could pose adverse effects on pregnancy outcomes and placentation. ERS associated pregnancy pathologies include intrauterine growth restriction and early-onset preeclampsia. Given these findings, evidence suggests that overactivation of UPR may lead to harmful reproductive circumstances, whereas physiological regulation of ERS response is essential for mammalian reproduction and placental function. In this review, we discuss the dual role of UPR activation with respect to its contribution to placental development as well as pathologies caused by pathway overactivation. In addition, we suggest potential protein markers associated with the UPR, as circulating C-terminal GRP78 or anti-GRP78 autoantibodies which may prove to be of clinical interest.

Biological rhythms and preeclampsia.

The impact of impaired circadian rhythm on health has been widely studied in shift workers and trans-meridian travelers. A part from its correlation with sleep and mood disorders, biological rhythm impairment is a recognized risk factor for cardiovascular diseases and breast cancer. Preeclampsia is a major public health issue, associated with a significant maternal and fetal morbidity and mortality worldwide. While the risks factors for this condition such as obesity, diabetes, pre-existing hypertension have been identified, the underlying mechanism of this multi-factorial disease is yet not fully understood. The disruption of the light/dark cycle in pregnancy has been associated with adverse outcomes. Slightly increased risk for "small for gestational age" babies, "low birth weight" babies, and preterm deliveries has been reported in shift working women. Whether altered circadian cycle represents a risk factor for preeclampsia or preeclampsia is itself linked with an abnormal circadian cycle is less clear. There are only few reports available, showing conflicting results. In this review, we will discuss recent observations concerning circadian pattern of blood pressure in normotensive and hypertensive pregnancies. We explore the hypothesis that circadian misalignments may represent a risk factor for preeclampsia. Unraveling potential link between circadian clock gene and preeclampsia could offer a novel approach to our understanding of this multi-system disease specific to pregnancy.

Increased salt sensitivity of ambulatory blood pressure in women with a history of severe preeclampsia.

Cardiovascular diseases are the principal cause of death in women in developed countries and are importantly promoted by hypertension. The salt sensitivity of blood pressure (BP) is considered as an important cardiovascular risk factor at any BP level. Preeclampsia is a hypertensive disorder of pregnancy that arises as a risk factor for cardiovascular diseases. This study measured the salt sensitivity of BP in women with a severe preeclampsia compared with women with no pregnancy hypertensive complications. Forty premenopausal women were recruited 10 years after delivery in a case-control study. Salt sensitivity was defined as an increase of >4 mm Hg in 24-hour ambulatory BP on a high-sodium diet. The ambulatory BP response to salt was significantly increased in women with a history of preeclampsia compared with that of controls. The mean (95% confidence interval) daytime systolic/diastolic BP increased significantly from 115 (109-118)/79 (76-82) mm Hg on low-salt diet to 123 (116-130)/80 (76-84) on a high-salt diet in women with preeclampsia, but not in the control group (from 111 [104-119]/77 [72-82] to 111 [106-116]/75 [72-79], respectively, P<0.05). The sodium sensitivity index (SSI=Δmean arterial pressure/Δurinary Na excretion×1000) was 51.2 (19.1-66.2) in women with preeclampsia and 6.6 (5.8-18.1) mm Hg/mol per day in controls (P=0.015). The nocturnal dip was blunted on a high-salt diet in women with preeclampsia. Our study shows that women who have developed preeclampsia are salt sensitive before their menopause, a finding that may contribute to their increased cardiovascular risk. Women with a history of severe preeclampsia should be targeted at an early stage for preventive measures of cardiovascular diseases.