Red blood cells from endothelial nitric oxide synthase-deficient mice induce vascular dysfunction involving oxidative stress and endothelial arginase I.

BACKGROUND & AIMS: Nitric oxide bioactivity (NO) from endothelial NO synthase (eNOS) importantly contributes to the maintenance of vascular homeostasis, and reduced eNOS activity has been associated with cardiovascular disease. Emerging evidence suggests interaction(s) between red blood cells (RBCs) and the endothelium in vascular control; however, the specific role of RBC eNOS is less clear. We aimed to investigate the hypothesis that a lack of RBC eNOS induces endothelial dysfunction. METHODS & RESULTS: RBCs from global eNOS knockout (KO) and wildtype (WT) mice were co-incubated ex vivo overnight with healthy mouse aortic rings, followed by functional and mechanistic analyses of endothelium-dependent and independent relaxations. RBCs from eNOS KO mice induced endothelial dysfunction and vascular oxidative stress, whereas WT RBC did not. No differences were observed for endothelium-independent relaxations. This eNOS KO RBC-induced endothelial dysfunctional phenotype was prevented by concomitant co-incubation with reactive oxygen species scavenger (TEMPOL), arginase inhibitor (nor-NOHA), NO donor (detaNONOate) and NADPH oxidase 4 (NOX4) inhibitor. Moreover, vessels from endothelial cell-specific arginase 1 KO mice were resistant to eNOS KO-RBC-induced endothelial dysfunction. Finally, in mice aortae co-incubated with RBCs from women with preeclampsia, we observed a significant reduction in endothelial function compared to when using RBCs from healthy pregnant women or from women with uncomplicated gestational hypertension. CONCLUSIONS: RBCs from mice lacking eNOS, and patients with preeclampsia, induce endothelial dysfunction in adjacent blood vessels. Thus, RBC-derived NO bioactivity acts to prevent induction of vascular oxidative stress occurring via RBC NOX4-derived ROS in a vascular arginase-dependent manner. Our data highlight the intrinsic protective role of RBC-derived NO bioactivity in preventing the damaging potential of RBCs. This provides novel insight into the functional relationship between RBCs and the vasculature in health and cardiovascular disease, including preeclampsia.

Red blood cells from patients with pre-eclampsia induce endothelial dysfunction.

RATIONALE: Pre-eclampsia is a multisystem disorder associated with systemic vascular dysfunction and decreased nitric oxide (NO) bioactivity. Arginase competes with NO synthase (NOS) for l-arginine, and its upregulation may reduce NOS-derived NO formation or induce production of reactive oxygen species (ROS) via uncoupling of NOS, resulting in endothelial dysfunction. Red blood cells (RBCs) have emerged as key players in NO homeostasis via their interactions with the endothelium. Studies have demonstrated that abnormal RBC arginase function in patients with diabetes contributes to oxidative stress and endothelial dysfunction. AIM: The aim of the study was to investigate if reduced NO bioavailability and increased ROS in pre-eclampsia is mediated via RBC-dependent mechanisms. METHODS: In this translational study, plasma and RBCs were isolated from gestationally matched pre-eclamptic and healthy pregnant women and co-incubated overnight with mouse aortas for vascular reactivity studies. NO bioactivity, that is, nitrate, nitrite and cGMP, was assessed in plasma. Arginase activity and expression were analysed in RBCs. RESULTS: Plasma markers of NO homeostasis and signalling were decreased in pre-eclamptic women vs. healthy pregnant women. Co-incubation of aorta with pre-eclamptic RBCs, but not healthy pregnant RBCs, induced endothelial dysfunction, which was ameliorated by pharmacological inhibition of arginase, scavenging of ROS, and by nitrite treatment. This pathological vascular phenotype was not observed following incubation with pre-eclamptic plasma. Arginase expression and activity in RBCs were increased in pre-eclamptic vs. healthy pregnant women and was associated with pre-eclampsia severity. Pre-eclamptic RBC-induced endothelial dysfunction was not because of increased haemolysis/cell-free haemoglobin. CONCLUSION: This study demonstrates a novel role of the RBC in mediating the endothelial dysfunction associated with pre-eclampsia through arginase-dependent and oxidative stress-dependent mechanisms. Targeting of RBC arginase may provide a novel treatment modality for pre-eclampsia.

Increased incidence of obstetric and perinatal complications in pregnancies achieved using donor oocytes and single embryo transfer in young and healthy women. A prospective hospital-based matched cohort study.

In this single-center matched-cohort study, women who underwent IVF/ICSI with donor oocytes between 2007 and 2014 (n = 259) were compared to women undergoing autologous cycles during the same time period (n = 515). The matching (1:2) took into consideration the women's age, type of treatment (IVF/ICSI), and year of embryo transfer. All women were healthy and below 40 years of age at the time of IVF/ICSI, and the treatments were performed using a strict policy of single embryo transfer. Multiple logistic regression analysis, adjusted for body mass index (BMI), smoking, and parity, showed a four times increased risk of gestational hypertensive disorders (adjusted odds ratio, AOR 4.25; 95% confidence interval (CI), 2.61-6.92) and pre-eclampsia (AOR 3.99; 95% CI 2.27-7.00) in pregnancies achieved with donor oocytes. There was also a higher rate of cesarean section in women who gave birth after oocyte donation (AOR 1.69; 95% CI 1.22-2.35) and a higher risk of postpartum hemorrhage >1000 mL (AOR 1.59; 95% CI, 1.11-2.27). After further adjustment for preeclampsia in the logistic regression analysis, no additional increased perinatal risks were found. The incidence of preterm delivery, low weight at birth, need of neonatal intensive care, Apgar scores, and incidence of perinatal death were also similar between the groups.

MAGDALENA: study protocol of a randomised, placebo-controlled trial on cognitive development at 2 years of age in children exposed to SSRI in utero.

INTRODUCTION: Ten per cent of all pregnant women are depressed. Standard therapy of pregnant women with moderate depression is selective serotonin reuptakeinhibitors (SSRI). Observational studies on neurodevelopment after fetal SSRI exposure show conflicting results. Our primary objective is to compare the cognitive development in children exposed to sertraline and maternal depression with those exposed to maternal depression and placebo in utero. We hypothesise that there is a significant neurodevelopmental difference between the groups. As a secondary objective, we study the add-on effect of sertraline to internet-based cognitive behavioural therapy (ICBT) to treat moderate depression during pregnancy. METHODS AND ANALYSIS: MAGDALENA is a randomised, placebo-controlled, double-blinded trial in Stockholm Healthcare Region with 2.3 million inhabitants. The women are recruited in weeks 9-21 of pregnancy either through Antenatal Health Clinics or through social media. They are to be diagnosed with moderate depression without ongoing antidepressive therapy or any serious comorbidity. The women in the intervention arm receive sertraline combined with a 12-week period of ICBT; the control arm is treated with placebo and ICBT. We assess the cognitive development in the offspring at the age of 2 years using Bayley Scales of Infant and Toddler Development, third edition (BSID-III). We aim at recruiting 200 women, 100 women in each treatment arm, to ensure statistical power to detect a clinically relevant difference between the groups. ETHICS AND DISSEMINATION: This randomised trial will provide long-sought evidence about the effects of SSRI and maternal depression during pregnancy on the neurodevelopment in the offspring. The study is approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm and the Swedish Medical Products Agency. It is registered with the European Clinical Trials Database (EudraCT), Number: 2013-004444-31. Results will be disseminated at scientific conferences, published in peer-reviewed journals and made available to the public. TRIAL REGISTRATION NUMBER: EudraCT2013-004444-31; Pre-results.

Pregnancy Achieved Using Donor Eggs in Cancer Survivors with Treatment-Induced Ovarian Failure: Obstetric and Perinatal Outcome.

BACKGROUND: Egg donation is a common fertility treatment in female cancer survivors with reproductive wish and iatrogenic ovarian failure. We examined whether women previously treated for cancer have a higher risk of pregnancy complications after egg donation treatments when compared to women without cancer history. METHODS: In this prospective cohort treated during 2003-2015 at a single center, 31 women with previous history of cancer achieved 25 deliveries and 212 women without cancer history achieved 244 deliveries. All egg donor treatments were performed with a strict policy of single embryo transfer to reduce pregnancy and perinatal complications. Data were analyzed using logistic regression with adjustment for relevant confounders, to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for perinatal and obstetric outcomes. Women without previous history of cancer were used as the reference group in the regression models. RESULTS: Women with a history of cancer presented with a significantly increased risk of pregnancy complications, including preterm birth (aOR 5.54, 95% CI 2.01-15.31) and preeclampsia (aOR 2.79, 95% CI 1.07-7.34), compared to women without cancer history. CONCLUSIONS: The findings of this study suggest that the risks of preterm birth and preeclampsia in women with prior cancers who become pregnant by egg donor treatment significantly exceed those of women without cancer history undergoing similar treatments. As pregnancies using donor eggs are already acknowledged of higher risk for hypertensive pathologies, this study alerts toward characterization of specific increased risks in women who are cancer survivors to provide adapted pregnancy monitoring.

High- but not low-grade histologic chorioamnionitis is associated with spontaneous preterm birth in a Swedish cohort.

OBJECTIVE: To examine whether different grades of placenta inflammation are associated with risk for spontaneous preterm birth, taking into consideration maternal and delivery factors. Placentas from spontaneous preterm births were compared with a control group from full-term deliveries. METHODS: Placentas from 98 full-term, 71 late preterm (gestational week 34-37), and 65 early preterm (gestational week 22-33) singleton deliveries were analysed from the Karolinska University Hospital in Stockholm. The placentas were examined for histologic chorioamnionitis (HCA) grade 1 (low) and 2 (high). Mother, child, and delivery parameters were collected from maternity centre and delivery forms. RESULTS: There was a relatively low incidence of HCA in the preterm groups (26.7% and 38.5% in the late and early preterm groups, respectively). HCA 2 was most common in the early preterm group and HCA 1 was most common in the full-term group. The odds of early preterm birth was lower for placentas with HCA 1 compared to HCA 2 (OR = 0.17) and higher for placentas with HCA 2 compared to no HCA (OR = 2.17). CONCLUSIONS: Despite a relatively low incidence of HCA in the preterm groups, HCA 2 seems to be associated with early preterm birth whereas HCA 1 seems to be part of the full-term delivery.

Internet delivered cognitive behavior therapy for antenatal depression: A randomised controlled trial.

Major depression occurs in 5-10% of pregnancies and is associated with many negative effects for mother and child, yet treatment options are scarce. To our knowledge, this is the first published randomised controlled trial on Internet delivered Cognitive Behavior Therapy (ICBT) for this group. OBJECTIVE: To test the efficacy of a pregnancy adapted version of an existing 10-week ICBT-program for depression as well as assessing acceptability and adherence DESIGN: Randomised controlled trial. SETTING: Online and telephone. POPULATION OR SAMPLE: Self-referred pregnant women (gestational week 10-28 at intake) currently suffering from major depressive disorder. METHODS: 42 pregnant women (gestational week 12-28) with major depression were randomised to either treatment as usual (TAU) provided at their antenatal clinic or to ICBT as an add-on to usual care. MAIN OUTCOME MEASURES: The primary outcome was depressive symptoms measured with the Montgomery-Åsberg depression rating scale-self report (MADRS-S). The Edinburgh Postnatal Depression Scale and measures of anxiety and sleep were used. Credibility, satisfaction, adherence and utilization were also assessed. RESULTS: The ICBT group had significantly lower levels of depressive symptoms post treatment (p < 0.001, Hedges g =1.21) and were more likely to be responders (i.e. achieve a statistically reliable improvement) (RR = 0.36; p = 0.004). Measures of treatment credibility, satisfaction, utilization, and adherence were comparable to implemented ICBT for depression. LIMITATIONS: Small sample size and no long-term evaluation. CONCLUSION: Pregnancy adapted ICBT for antenatal depression is feasible, acceptable and efficacious. These results need to be replicated in larger trials to validate these promising findings.

Hypoxic ischemic encephalopathy in newborns linked to placental and umbilical cord abnormalities.

OBJECTIVE: Birth asphyxia and hypoxic ischemic encephalopathy (HIE) of the newborn remain serious complications. We present a study investigating if placental or umbilical cord abnormalities in newborns at term are associated with HIE. MATERIALS AND METHODS: A prospective cohort study of the placenta and umbilical cord of infants treated with hypothermia (HT) due to hypoxic brain injury and follow-up at 12 months of age has been carried out. The study population included 41 infants treated for HT whose placentas were submitted for histopathological analysis. Main outcome measures were infant development at 12 months, classified as normal, cerebral palsy, or death. A healthy group of 100 infants without HIE and normal follow-up at 12 months of age were used as controls. RESULTS: A velamentous or marginal umbilical cord insertion and histological abruption was associated with the risk of severe HIE, OR = 5.63, p = 0.006, respectively, OR = 20.3, p = 0.01 (multiple-logistic regression). Velamentous or marginal umbilical cord insertion was found in 39% among HIE cases compared to 7% in controls. CONCLUSIONS: Placental and umbilical cord abnormalities have a profound association with HIE. A prompt examination of the placentas of newborns suffering from asphyxia can provide important information on the pathogenesis behind the incident and contribute to make a better early prognosis.

Placental pathology in smoking and non-smoking preeclamptic women.

OBJECTIVE: To ascertain whether the protective effect of smoking during preeclampsia (PE) can be visualized in the placenta. METHODS: The study cohort consisted of placentas (n = 523) from pregnancies complicated by PE, delivered at Karolinska University Hospital in Stockholm during the period 2000-2009. Of the women included in the study, 488 were non-smokers and 35 were smokers at first visit to maternity care. Outcome variables were placental infarctions and decidual arteriopathy. RESULTS: Infarctions (affecting ≥5% of the placental tissue) were found in 15.6% of the placentas from non-smokers and in 25.7% of the placentas from smokers (OR 1.88: CI 0.84-4.16, p = 0.12). Decidual arteriopathy was found in 27.5% of the placentas from non-smokers and in 40.0% of the placentas from smokers (1.76: CI 0.87-3.56, p = 0.12). When diagnosed histopathologically, placental abruption was found in 15.4% among non-smokers and in 17.1% among smokers (1.14: CI 0.46-2.84, p = 0.98). Those differences did not show any statistical significance. CONCLUSION: No significant differences concerning placental infarctions, decidual arteriopathy or abruption were found between preeclamptic placentas from non-smokers compared to smokers.

Association between cerebral palsy and microscopically verified placental infarction in extremely preterm infants.

INTRODUCTION: Previously, cerebral palsy has been associated with placental infarctions diagnosed macroscopically by midwifes. However, the risk of misclassification of infarctionsis is high without a histological verification. Therefore, the objective of this study was to study placental histopathology in relation to developmental outcome at 2.5 years corrected age in a population born extremely preterm. MATERIAL AND METHODS: A prospective cohort study was carried out at Karolinska University Hospital, Stockholm, Sweden on a population of 139 live born infants delivered <27 gestational weeks during 2004-2007. A senior perinatal pathologist, who was blinded to outcome data, evaluated all placental slides microscopically. Neuromotor and sensory functions of the children were evaluated. Bayley Scales of Infant and Toddler Development-III (Bayley-III) were used to assess development at corrected age 2.5 years. The outcome data were evaluated without reference to obstetrical and pathology data. The primary outcome measure was neurological and developmental status at 2.5 years of corrected age. This was measured as diagnosis of cerebral palsy, visual impairment, hearing impairment as well as performance on Bayley-III scales evaluating cognitive, language and motor functions. RESULTS: Two out of seven children with placental infarction were diagnosed with cerebral palsy compared with one child of 51 without placental infarction (p = 0.036). For developmental outcome according to Bayley-III at 2.5 years no statistically significant associations with placental pathology were found. CONCLUSION: A possible association between placental infarction, verified by microscopic examination, and cerebral palsy has been identified in this extremely preterm population.

Placental pathology in relation to stillbirth and neonatal outcome in an extremely preterm population: a prospective cohort study.

OBJECTIVE: To study associations between placental histopathology and stillbirth as well as neonatal outcome in a population born extremely preterm. DESIGN: Prospective cohort study. SETTING: Stockholm, Sweden. POPULATION: 167 infants born <27 gestational weeks during 2004-2007. METHODS: One senior perinatal pathologist, blinded to outcome data, evaluated all placental slides. MAIN OUTCOME MEASURES: Intrauterine fetal death, small-for-gestational age, major neonatal morbidity (intraventricular hemorrhage ≥grade 3, retinopathy of prematurity ≥grade 3, necrotizing enterocolitis, cystic periventricular leukomalacia or severe bronchopulmonary dysplasia) and neonatal mortality. Additional outcome variables were Apgar score at 5 min, sepsis, and treated patent ductus arteriosus. RESULTS: Accelerated villous maturation was associated with a decreased risk for Apgar score <7 at 5 min (p = 0.041). Fetal thrombosis and low placental weight were associated with an increased risk for both intrauterine fetal death (p < 0.001 and p = 0.011, respectively) and small-for-gestational age (p < 0.001 and p < 0.001, respectively). CONCLUSION: Placental histology may have prognostic value as it appears to be associated with intrauterine fetal death, as well as with being small-for-gestational age and assignment of a low Apgar score at birth.

Guidelines for maternal and neonatal "point of care": needs of and attitudes towards a computerized clinical decision support system in rural Burkina Faso.

BACKGROUND: In 2010, 245,000 women died due to pregnancy-related causes in sub-Saharan Africa and southern Asia. Our study is nested into the QUALMAT project and seeks to improve the quality of maternal care services through the introduction of a computerized clinical decision support system (CDSS) to help healthcare workers in rural areas. Healthcare information technology applications in low-income countries may improve healthcare provision but recent studies demonstrate unintended consequences with underuse or resistance to CDSS and that the fit between the system and the clinical needs does present challenges. AIMS: To explore and describe perceived needs and attitudes among healthcare workers to access WHO guidelines using CDSS in maternal and neonatal care in rural Burkina Faso. METHODS: Data were collected with semi-structured interviews in two rural districts in Burkina Faso with 45 informants. Descriptive statistics were used for the analysis of the quantitative part of the interview corresponding to informants' background. Qualitative data were analyzed using manifest content analysis. RESULTS: Four main findings emerged: (a) an appreciable willingness among healthcare workers for and a great interest to adapt and use modern technologies like computers to learn more in the workplace, (b) a positive attitude to easy access of guidelines and implementation of decision-support using computers in the workplace, (c) a fear that the CDSS would require more working time and lead to double-work, and (d) that the CDSS is complicated and requires substantial computer training and extensive instructions to fully implement. CONCLUSIONS: The findings can be divided into aspects of motivators and barriers in relation to how the CDSS is perceived and to be used. These aspects are closely connected to each other as the motivating aspects can easily be turned into barriers if not taken care of properly in the final design, during implementation and maintenance of the CDSS at point of care.

Association between placental pathology and neonatal outcome in preeclampsia: a large cohort study.

OBJECTIVE: To study associations between placental histopathology and neonatal outcome in preeclampsia (PE). STUDY DESIGN: The cohort consisted of 544 singleton pregnancies complicated by PE and managed at Karolinska University Hospital, Stockholm, Sweden during 2000-2009. Evaluation of placental histopathology was made by one senior perinatal pathologist, blinded to outcome. Clinical outcome was obtained from prospectively collected medical registry data and medical records. Main outcome measures were intrauterine fetal death, smallness for gestational age, admission to neonatal unit, major neonatal morbidity (defined as presence of intraventricular hemorrhage ≥ grade 3, retinopathy of prematurity ≥ grade 3, necrotizing enterocolitis, cystic periventricular leucomalacia and/or severe bronchopulmonary dysplasia) and neonatal mortality. Logistic regression analyses including gestational age were performed. RESULTS: Abnormal placental weight, both low (adjusted odds ratio (OR) [95% confidence interval] 5.2 [1.1-24], p = 0.03) and high (adjusted OR 1048 [21-51 663], p < 0.001) for gestational age, was associated with major neonatal morbidity in preterm infants. Accelerated villous maturation was less prevalent in intrauterine fetal death pregnancies (adjusted OR 0.18 [0.04-0.77], p = 0.02). Decidual arteriopathy increased the odds for admission to neonatal care (adjusted OR 2.7 [1.1-6.5], p = 0.03). Infarction involving ≥5% of the placenta was associated with intrauterine fetal death and small for gestational age infants (adjusted OR's 75 [5.5-1011], p = 0.001 and 3.2 [1.7-5.9], p < 0.001; respectively). No relations between histological variables and neonatal mortality could be found. CONCLUSION: Placental pathology in PE reflects adverse perinatal events and deviant placental weight predicts adverse neonatal outcome in preeclamptic women delivering preterm. Placental investigation without delay can contribute to neonatal risk assessment.

The severity of clinical manifestations in preeclampsia correlates with the amount of placental infarction.

OBJECTIVE: To correlate placental histopathology, in particular ischemic changes, with the clinical severity of preeclampsia. DESIGN: A blinded retrospective study. SETTING: One Swedish hospital. SAMPLE: One hundred and fifty-seven women with severe (n= 116) or mild (n= 41) preeclampsia and 157 normotensive women matched according to gestational-age. METHODS: One senior pathologist, blinded to clinical data and group, examined all histological slides. In the statistical analyses, adjustment for gestational week was done when appropriate. MAIN OUTCOME MEASURES: Placental histopathological findings. RESULTS: Amount of infarction increased with the severity of preeclampsia (p < 0.001). Infarction involving ≥5% of the placental tissue was seen in 39.7% of severe preeclampsia, 17.1% of mild preeclampsia and 5.1% of non-preeclampsia. When comparing placentas in severe preeclampsia, mild preeclampsia and non-preeclampsia, there was an increase in the presence of any infarction (80.2%, 61.0%, vs. 20.4%). Also, there was a difference in the presence of decidual arteriopathy (35.3%, 22.0%, vs. 3.8%) and accelerated villous maturation (71.6%, 53.3%, vs. 12.6%). We found no difference in intervillous thrombosis, abruption placenta or placental weight in relation to gestational week. CONCLUSIONS: In pregnancies with mild or severe preeclampsia, a large proportion of the placentas had histological signs of pathology, in particular signs of ischemia. The pathology was similar, but more pronounced in severe compared to mild preeclampsia, suggesting mild and severe preeclampsia to have similar underlying etiology.

Aortic dissection in pregnancy: a life-threatening disease and a diagnosis of worth considering.

Acute aortic dissection is a life-threatening disease. To increase the awareness of this diagnosis as a cause of feto-maternal mortality during pregnancy, we have analyzed risk factors using information from five pregnant women admitted for acute aortic dissection to the Karolinska University Hospital over an eight-year period (1999-2007). Four of the women died and only one survived. One fetus was stillborn and all newborn infants showed signs of asphyxia at birth. Of the women, who were on average five years above the mean age for delivery in Sweden, three had hypertension, two had first-degree relatives with aortic dissection which had occurred during the second half of pregnancy (gestational age at diagnosis 26-41 weeks). The most common presenting symptoms were severe back, abdominal and leg pain, and confusion. If a rapid diagnosis is not made, the risk of mortality for both mother and fetus is high. The incidence of aortic rupture during pregnancy in Sweden appears to be 14.5/1,000,000 and the case maternal fatality ratio 4.4/1,000,000.

Severe preeclampsia with and without HELLP differ with regard to placental pathology.

The aim of the present study was to evaluate the histopathology in placentas from patients with severe preeclampsia with and without hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. An additional aim was to compare the prevalence of infants born small for gestational age in the 2 groups. The study is retrospective and includes 178 women who have been diagnosed at the Karolinska University Hospital Huddinge or at the Free University Medical Center between 2000 and 2005 with severe preeclampsia. A total of 96 women had severe preeclampsia without signs of HELLP (preeclampsia group), whereas 82 fulfilled the criteria for having HELLP syndrome (HELLP group). Infarction (P=0.014), intervillous thrombosis (P<0.001), and abruption (P=0.002) were more common in the preeclampsia group than in the HELLP group. There was no statistically significant difference in the frequency of accelerated villous maturation (P=0.61), decidual arteriopathy (P=0.27), or chorioamnionitis (P=0.61). Furthermore, there was a higher mean placental weight, adjusted for gestational age, in the Swedish HELLP material than in the preeclampsia group (P<0.001). Finally, mothers in the preeclampsia group gave birth significantly more often to small for gestational age babies than mothers suffering from HELLP syndrome (P<0.001). The histopathologic profile and the range of placental lesions were partly different in the preeclampsia and HELLP patients. Considering the central role that placenta seems to have in preeclampsia, the present result might suggest that different underlying pathogenetic mechanisms and courses can be in play in patients with preeclampsia and HELLP syndrome.