Clinical and protein correlations of prophylactic treatments for preeclampsia

The prophylactic benefit of aspirin in the prevention of preeclampsia is now widely recognized and increasingly utilized. However, its mechanism of action and optimal clinical utility in the prevention of preeclampsia remains a subject of ongoing research. This thesis examined the mechanism of action of aspirin in preventing preeclampsia with specific focus on its anti-inflammatory role, through the 15-epilipoxin-A4, aspirin triggered lipoxin (ATL), pathway. This thesis also examined for the influence of dose of aspirin in pregnancy through a pharmacokinetic assessment, and the influence of inadequate adherence to aspirin on the desired clinical outcomes in high-risk pregnancy. Additionally, this thesis also examined for factors that influenced women’s adherence to aspirin in pregnancy. A non-interventional, multi-centre, longitudinal cohort study was prospectively undertaken to achieve the aims of this thesis. In keeping with recent data, this thesis demonstrated that aspirin is an effective prophylactic intervention for preeclampsia amongst high-risk women when adequate adherence is observed. In addition to its known anti-platelet effect, the outcomes of this thesis suggest that aspirin is likely to play a role in placental development through its ATL mediated anti-inflammatory effect in high-risk pregnant women. Additionally, the studies in this thesis also suggest the potential need for aspirin dose adjustment in pregnancy given its altered pharmacokinetic in pregnancy. Importantly, this thesis also demonstrates the importance of adequate adherence with aspirin and emphasizes on the importance of assessment of adherence to aspirin in pregnancy, both in clinical and research settings

Pregnancy-induced atypical haemolytic uremic syndrome : a new era with Eculizumab

Pregnancy is a well-recognised trigger of atypical haemolytic syndrome (P-aHUS) and often occurs in the post-partum period. Similar to atypical haemolytic uremic syndrome, it carries a poor prognosis with high morbidity particularly in the form of renal failure. Early recognition and intervention is crucial in its management particularly with the recent availability of Eculizumab, a humanized monoclonal antibody to complement component C5, which has demonstrated drastic improvement in prognosis. The issue, however, is arriving at a timely diagnosis given the considerable amount of overlap in the clinical and biochemical manifestation of P-aHUS, HELLP syndrome (haemolysis, elevated liver enzyme and low platelet count) and other hypertensive disorders of pregnancy. We present a case report and literature review that highlights the clinical conundrum of arriving at the diagnosis. We also highlight the importance of early management of P-aHUS with Eculizumab and its impact on improving morbidity

Aspirin in the prevention of preeclampsia : the conundrum of how, who and when

Aspirin is widely used in preventing early onset preeclampsia in women who are identified as being high risk. Although the benefit of aspirin is increasingly evident and acknowledged, there remains many unanswered questions with regards to its optimal application in pregnancy. The issues mainly centre around the relatively modest risk reduction that is observed with the use of aspirin prophylactically. We aim to explore the reasons behind the conservative rate of benefit and aim to explore factors that are likely to influence the outcomes with the use of aspirin

Assessment and management of primary aldosteronism in pregnancy : a case-control study

Context: Primary aldosteronism (PA) is a common secondary cause of hypertension. Literature regarding PA in pregnancy has demonstrated poor outcomes. Objective: Compare the management and outcomes of PA in pregnancy to both high and low-risk matched controls. Methods: This was a case-control trial conducted in a network of metropolitan hospitals in Sydney, Australia. PA women (positive salt suppression test) with singleton pregnancies delivered after 20 weeks' gestation were matched to women with high- and low-risk pregnancies. Management outcomes included pre-eclampsia prophylaxis and antihypertensive medications required prenatally, antenatally, and postnatally. Maternal outcomes included incidence of pre-eclampsia, gestational diabetes, hypokalemia, mode of delivery, and length of stay postpartum. Neonatal outcomes included gestation, birthweight, intensive care unit admission, and length of stay. Results: Fifty-nine women with 60 pregnancies were included (20 PA, 20 high risk, and 20 low risk). The number of antihypertensive medications women with PA took prepregnancy was similar to the high-risk group. A similar proportion of women in the PA and high-risk groups were prescribed pre-eclampsia prophylaxis and developed pre-eclampsia. Even after adjustment for several factors, PA was not independently associated with pre-eclampsia development. Women with PA had higher antihypertensive requirements and a longer stay in hospital postpartum than the high-risk group (both P = .02). There was no difference in neonatal adverse outcomes. Four women took epleronone during pregnancy without any adverse effects noted. Conclusion: Women with PA required more antihypertensives and had a longer postpartum length of stay than matched high-risk women, but similar rates of pre-eclampsia. There was no difference in the rate of neonatal intensive care admissions or adverse outcomes for neonates

Galectin-1-related modulation of trophoblast endothelial interactions by integrins α1 and β1

During normal trophoblast invasion, integrins α6β4 are downregulated, and α1β1 are upregulated in invasive cytotrophoblast cells. In preeclampsia both interstitial and endovascular invasion are shallow and cytotrophoblasts fail to upregulate α1β1 and downregulate α6β4. This study aims to investigate the role of integrins α1β1 and α6β4 on cellular pathways influencing trophoblast integration into endothelial cellular networks in vitro. Red fluorescent-labeled human uterine myometrial microvascular endothelial cells (UtMVECs) were seeded on Matrigel to form endothelial networks. Green fluorescent-labeled trophoblastic HTR-8/SVneo cells pre-incubated with 20 μg/ml of neutralizing antibodies (anti-α1, β1, α6, β4, α1 + β1, or α6 + β4) for 1 h were then co-cultured with endothelial networks with the neutralizing antibodies for 24 h. Fluorescent images were captured, and quantified utilizing Image J. Cells were retrieved to analyze mRNA expression of galectin-1, TIMP-1, and PAI-1 by quantitative PCR. MMP-2, MMP-9, free sFlt-1, and PlGF from conditioned media were measured by ELISA. The integration of trophoblast cells into endothelial cellular networks was inhibited by anti-β1(− 28 ± 3%, p < 0.0001), and increased by anti-α6(+ 19 ± 5%, p < 0.01). Galectin-1 mRNA expression was decreased by anti-α1(− 35 ± 7%, p < 0.001), anti-β1(− 23 ± 5%, p < 0.05), and anti-α1+β1(− 35 ± 5%, p < 0.001). The mRNA expression of TIMP-1 was inhibited by anti-α1(− 59 ± 9%, p < 0.01) and anti-β1(− 63 ± 7%, p < 0.001) while PAI-1 mRNA expression was increased by anti-α1 + β1(+ 285 ± 70%, p < 0.0001). In the conditioned medium, anti-α1 reduced MMP-2(−28 ± 1%, p < 0.001), MMP-9(−27 ± 8%, p < 0.01), and sFlt-1(−27 ± 5%, p < 0.001) production. Anti-β1 reduced MMP-2(− 15 ± 2%, p < 0.05) production. There were no changes in PlGF. Appropriate integrins α1β1 modulate trophoblast cell integration into endothelial cellular networks in vitro through invasive pathways including galectin-1, TIMP-1, PAI-1, MMP-2, and MMP-9 production

R emote blood pressure monitoring in high risk pregnancy — study protocol for a randomised controlled trial (REMOTE CONTROL trial)

Abstract Background Pregnant women at high risk for developing a hypertensive disorder of pregnancy require frequent antenatal assessments, especially of their blood pressure. This expends significant resources for both the patient and healthcare system. An alternative to in-clinic assessments is a remote blood pressure monitoring strategy, in which patients self-record their blood pressure at home using a validated blood pressure machine. This has the potential to be cost-effective, increase patient satisfaction, and reduce outpatient visits, and has had widespread uptake recently given the increased need for remote care during the ongoing COVID-19 pandemic. However robust evidence supporting this approach over a traditional face-to-face approach is lacking, and the impact on maternal and foetal outcomes has not yet been reported. Thus, there is an urgent need to assess the efficacy of remote monitoring in pregnant women at high risk of developing a hypertensive disorder of pregnancy. Methods The REMOTE CONTROL trial is a pragmatic, unblinded, randomised controlled trial, which aims to compare remote blood pressure monitoring in high-risk pregnant women with conventional face-to-face clinic monitoring, in a 1:1 allocation ratio. The study will recruit patients across 3 metropolitan Australian teaching hospitals and will evaluate the safety, cost-effectiveness, impact on healthcare utilisation and end-user satisfaction of remote blood pressure monitoring. Discussion Remote blood pressure monitoring is garnering interest worldwide and has been increasingly implemented following the COVID-19 pandemic. However, robust data regarding its safety for maternofoetal outcomes is lacking. The REMOTE CONTROL trial is amongst the first randomised controlled trials currently underway, powered to evaluate maternal and foetal outcomes. If proven to be as safe as conventional clinic monitoring, major potential benefits include reducing clinic visits, waiting times, travel costs, and improving delivery of care to vulnerable populations in rural and remote communities. Trial registration The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12620001049965p, on October 11th, 2020)

The effect of acetyl salicylic acid (Aspirin) on trophoblast-endothelial interaction in vitro

Early administration of low dose acetyl salicylic acid (Aspirin) in high risk women reduces the risk of early onset preeclampsia. This study aims to investigate the effect of aspirin on trophoblast integration and the its effect on angiogenic and invasive pathways in an in-vitro model of preeclampsia. Red fluorescent-labeled human uterine myometrial microvascular endothelial cells (UtMVECs) were seeded on matrigel to form endothelial networks. Green fluorescent-labeled trophoblastic HTR-8/SVneo cells were co-cultured with the endothelial networks with/without TNF-a (0.5 ng/mL) and/or aspirin (0.1 mM) for 24 h. Fluorescent images were captured and quantified by Image J to examine the effects of TNF-a and aspirin on the trophoblast-endothelial integration. Conditioned media were collected to measure free VEGF, PlGF and sFlt-1 by ELISA and PGF1a by Enzyme immunoassay (EIA). Cells were retrieved to examine mRNA expression of angiogenic factors (VEGF, PlGF and sFlt-1), invasion markers (MMP-2 and TIMP-1), endothelial cell activation markers (E-selectin and VCAM), eNOS and cyclooxygenase (COX)-2 by quantitative PCR. Aspirin reversed the inhibitory effect of TNF-a on trophoblast cell integration into endothelial cellular networks. TNF-a increased PGF1a production (128 +_ 11%, p < 0.05), whilst aspirin reversed the TNF-a effect on PGF1a production (19 +¬_ 4%, p < 0.01). TNF-a decreased the mRNA expression of PlGF, eNOS, MMP-2 and TIMP-1, and stimulated COX2, E-selectin and VCAM mRNA expression. Aspirin did not reverse the TNF-a effect on these molecules. Aspirin improves trophoblast cell integration into endothelial cellular networks by inhibiting the effect of TNF-a via PGI2 with no significant effect on antiangiogenic, invasive or endothelial activation markers

Clinical influence of nonadherence with prophylactic aspirin in preventing preeclampsia in high-risk pregnancies : a multicenter, prospective, observational cohort study

Aspirin nonadherence and its associated increase in cardiovascular and cerebrovascular events is well described; however, the prevalence of aspirin nonadherence among high-risk pregnant women at risk of preeclampsia and its influence on clinical outcomes remains unclear. Our study examined the prevalence of aspirin nonadherence and resistance among high-risk pregnant women quantitatively (platelet function analyzer 100 and plasma salicylic acid) and clinical outcomes relative to adherence. High-risk pregnant women were recruited across 3 centers in the South West Sydney Local Health District. Simultaneous clinic data, blood sample, and self-reported adherence assessment were prospectively collected at 4-week intervals from 12 to 36 weeks of gestation. Nonadherence was defined as normal platelet function analyzer 100 and nondetectable plasma salicylic acid in <90% of time points. Value of <90% is based on current data. Two hundred twenty women were recruited over 25 months. No woman was aspirin resistant, and 63 (44%) women demonstrated inadequate adherence. Women with inadequate adherence had higher incidence of early-onset preeclampsia (17% versus 2%; odds ratio [OR], 1.9 [95% CI, 1.1–8.7]; P=0.04), late-onset preeclampsia (41% versus 5%; OR, 4.2 [95% CI, 1.4–19.8]; P=0.04), intrauterine growth restriction (29% versus 5%; OR, 5.8; [95% CI, 1.2–8.3]; P=0.001), preterm delivery (27% versus 10%; OR, 5.2 [95% CI, 1.5–8.7]; P=0.008), and higher likelihood of increase in antihypertensives antenatally (60% versus 10%; OR, 4.6 [95% CI, 1.2–10.5]; P=0.003). Kaplan-Meier analysis demonstrated lower incidence of premature delivery in the ≥90% adherent group (HR, 0.3 [95% CI, 0.2–0.5]; P<0.001).Kappa coefficient agreement between qualitative and quantitative assessment of adherence was moderate (κ=0.48; SE=0.029; P<0.0001). Our data demonstrates that aspirin is an effective prophylactic agent with an absolute risk reduction of 51% (number needed to treat, 2) when adherence is ≥90%, compared with women with inadequate adherence. Women who were <90% adherent had higher rates of preeclampsia, intrauterine growth restriction, preterm delivery, and increase in antenatal antihypertensive requirements. Self-reported adherence does not accurately reflect actual adherence

The 15-epilipoxin-A4 pathway (ATL) with prophylactic aspirin in preventing preeclampsia : a longitudinal-cohort study

Introduction: The benefit of aspirin in preventing preeclampsia is increasingly recognised, however, its mechanism of action remains unclear. Non-obstetric studies have described an anti-inflammatory effect of aspirin through 15-epilipoxin-A4(ATL). However, the anti-inflammatory mechanism of aspirin in the prevention of preeclampsia remains unknown. Objective/Hypothesis: To examine the (1) difference in longitudinal endogenous lipoxin-A4(EnLipoxin-A4) concentration in low-risk(LR) and high-risk(HR) pregnancies, (2)effect of aspirin on endogenous ATL concentration and the associated effect on cytokine profile of HR women. Methods: Plasma from 220 HR women were collected at 12,16,20,24,28,32 and 36 weeks of gestation. Adherence to aspirin was biochemically verified. Plasma En-Lipoxin-A4 and ATL concentrations were analysed through liquid-chromatography mass-spectrometry(LC-MS/MS) and cytokines;IL-10, TNF-α, IFN-ɣ, IL-8 and IL-1β with high-sensitivity multi-bead Luminex® assay. Results: HR women have up to 70% lower plasma concentration of En-Lipoxin-A4(p<0.001) compared to LR women. HR women with adequate aspirin adherence(HR-AA)(n=82) had higher plasma concentration of ATL(p<0.001), lower concentration of IL-8 from 16-36 weeks of gestation(p<0.001) )and increased IL-10 concentration from 16 – 28 weeks of gestation (p=0.03) in comparison to high-risk women who were not on aspirin(HR-NA). HR-AA who did not develop preeclampsia had higher plasma En-lipoxin-A4(p<0.0001), ATL(p=0.02) and IL-10 concentrations(p<0.001) with lower IL-8 concentration(p=0.004) compared to HR who developed preeclampsia. Discussion: Plasma concentration of En-Lipoxin-A4 is lower in HR women compared to LR controls. Adequate adherence with aspirin results in an increase in ATL and IL-10 with reduced IL-8 plasma concentration. This study suggests a potential anti-inflammatory role of aspirin, through the ATL pathway with prophylactic aspirin in HR pregnant women

Vertebral artery dissection in hypertensive disorders of pregnancy : a case series and literature review

Background: Arterial dissection is a rare complication of pregnancy and puerperium. There have been reports of aortic, coronary and cervical artery dissection in association with preeclampsia, however, vertebral artery dissection is rarely reported particularly in the antenatal setting in the presence of a Hypertensive Disorder of Pregnancy (HDP).The general annual incidence of symptomatic spontaneous cervicocephalic arterial dissection is 0.0026 % and a data registry reported that 2.4 % of these occurred in the post-partum period. The actual incidence of vertebral artery dissection in HDP is unknown as the current literature consists of case series and reports only with most documenting adverse outcomes. Given the presence of collateral circulation, unilateral vertebral artery dissections may go unrecognised and may be more common than suspected. Case presentation: We present a case series of four patients with vertebral artery dissection in association with HDP, two of which occurred in the antenatal setting and two in the post-partum setting. All our patients had favourable outcome with no maternal neurological deficit and live infants. Our discussion covers the proposed pathophysiology of vertebral artery dissection in HDP and the management of it. Conclusion: Our case series highlights the need to consider VAD an important differential diagnosis when assessing pregnant women with headache and neck pain particularly in the context of HDP