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Introduction: The aim of this study was to assess perinatal outcomes in women with chronic hypertension (CH) stratified into four groups according to their blood pressure (BP) control in the first trimester of pregnancy., Material and Methods: This was a prospective cohort study between January 2011 and June 2017, based in a university hospital in London, UK. The population consisted of four groups: group 1 included women without history of CH, presenting in the first trimester with BP >140/90 mmHg (n = 100). Groups 2-4 had prepregnancy CH; group 2 had BP <140/90 mmHg without antihypertensives (n = 234), group 3 had BP <140/90 mmHg with antihypertensives (n = 272), and group 4 had BP ≥140/90 mmHg despite antihypertensives (n = 194). The main outcome measures were: fetal growth restriction, admission to neonatal (NNU) or neonatal intensive care unit (NICU) for ≥2 days, composite neonatal morbidity, and composite serious adverse neonatal outcome. Outcomes were collected from the hospital databases and for up to 6 weeks postnatally. Differences between groups were assessed using chi-squared test and multivariate logistic regression was used to assess the independent contribution of the four groups to the prediction of pertinent outcomes, after controlling for maternal characteristics., Results: There was a higher incidence of fetal growth restriction in groups 3 (17.6%) and 4 (18.2%), compared with groups 1 (10.0%) and 2 (11.1%) (P = .04). There were more admissions to the NNU for ≥2 days in groups 3 (23.2%) and 4 (25.0%), compared with groups 1 (17.0%) and 2 (13.2%) (P = .008); and more admissions to NICU for ≥2 days in groups 3 (9.2%) and 4 (9.4%), compared with groups 1 (3.0%) and 2 (3.4%) (P = .01). Composite neonatal morbidity was higher in groups 3 (22.4%) and 4 (21.4%), compared with groups 1 (17.0%) and 2 (11.5%) (P = .009). Composite serious adverse postnatal outcome was higher in groups 3 (3.3%) and 4 (4.2%), compared with groups 1 (1.0%) and 2 (0.9%) but the difference did not reach statistical significance (P = .09). These results were also observed when values were adjusted for maternal characteristics., Conclusions: In CH adverse perinatal outcomes are worse in women who are known to have CH and need antihypertensives in the first trimester of pregnancy. Women with newly diagnosed CH in the first trimester have similar outcomes to those with known CH who have antihypertensive treatment discontinued., (© 2021 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: Chronic hypertension complicates 1%-2% of pregnancies and is one of the most significant risk factors for the development of preeclampsia. Inflammatory mediators, such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), vascular cell adhesion molecule (VCAM) and endothelin have been implicated in the endothelial dysfunction that is pathognomonic of preeclampsia and may serve as useful first trimester biomarkers for the prediction of preeclampsia. The objectives of this study are: first, to investigate differences in serum levels of IL-6, TNF-α, VCAM and endothelin at 11 +0 to 13 +6 weeks' gestation in women with chronic hypertension who developed superimposed preeclampsia with those who did not and normotensive controls and, second, to evaluate the performance of these biomarkers in the prediction of preeclampsia., Material and Methods: The study population was comprised of 650 women with chronic hypertension, including 202 who developed superimposed preeclampsia and 448 who did not, and 142 normotensive controls matched to the chronic hypertension group for storage time and racial origin. Serum concentrations of IL-6, TNF-α, VCAM and endothelin were measured and the values were converted into multiples of the expected median using multivariate regression analysis in the control group. The multiples of the median values of the biomarkers between the two groups of women with chronic hypertension and the controls were compared, and the receiver operating characteristic curve (ROC) was used to assess the performance of these variables for the prediction of preeclampsia., Results: In women with chronic hypertension, compared with the normotensive controls, there was a significantly higher first trimester median concentration of endothelin but not of VCAM, IL-6 or TNF-α. Within the cohort of women with chronic hypertension, those who developed superimposed preeclampsia, compared with those who did not, had higher first trimester serum concentration of VCAM but not of endothelin, IL-6 or TNF-α. However, serum VCAM provided a poor prediction of superimposed preeclampsia (area under the ROC curve 0.537, 95% CI 0.487-0.587)., Conclusions: Women with chronic hypertension have increased serum endothelin in the first trimester of pregnancy and those who develop superimposed preeclampsia have higher levels of VCAM. None of the inflammatory mediators performed well in the first trimester in the prediction of preeclampsia., (© 2020 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: The replacement of 24-h urine collection by protein-creatinine ratio (PCR) for the diagnosis of preeclampsia has been recently recommended. However, the literature is conflicting and there are concerns about the impact of demographic characteristics on the performance of PCR., Material and Methods: This was an implementation audit of the introduction of PCR in a London Tertiary obstetric unit. The performance of PCR in the prediction of proteinuria ≥300 mg/day was assessed in 476 women with suspected preeclampsia who completed a 24-h urine collection and an untimed urine sample for PCR calculation. Multivariate logistic regression was used to assess the independent predictors of significant proteinuria., Results: In a pregnant population, ethnicity and PCR are the main predictors of ≥300 mg proteinuria in a 24-h urine collection. A PCR cut-off of 30 mg/mmol would have incorrectly classified as non-proteinuric, 41.4% and 22.9% of black and non-black women, respectively. Sensitivity of 100% is achieved at cut-offs of 8.67 and 20.56 mg/mmol for black and non-black women, respectively. Applying these levels as a screening tool to inform the need to perform a 24-h urine collection in 1000 women, would lead to a financial saving of €2911 in non-black women and to an additional cost of €3269 in black women., Conclusions: Our data suggest that a move from screening for proteinuria with a 24-h urine collection to screening with urine PCR is not appropriate for black populations. However, the move may lead to cost-saving if used in the white population with a PCR cut-off of 20.5., (© 2018 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction: Fetal growth restriction (FGR) is associated with poor perinatal outcomes. Screening and prevention tools for FGR, such as uterine artery Doppler imaging and aspirin, underperform in high-risk groups, compared with general antenatal populations. There is a paucity of sensitive screening tests for the early prediction of FGR in high-risk pregnancies., Materials and Methods: This was a prospective observational study based in a dedicated antenatal hypertension clinic at a tertiary UK hospital. We assessed maternal demographic and central hemodynamic variables as predictors for FGR in a group of women at high risk for placental insufficiency due to chronic hypertension (n = 55) or a history of hypertension in a previous pregnancy (n = 71). Outcome variables were birthweight z-score as well as development of FGR (defined as birthweight below the 5th or 3rd centile). Maternal hemodynamics were assessed using a noninvasive transthoracic bioreactance monitor (Cheetah NICOM)., Results: The mean gestation at presentation was 13.6 (range: 8.5-19.5) weeks. Sixteen women delivered babies below the 5th centile. Ten of these were below the 3rd centile. Independent predictors of birthweight z-score were body surface area, peripheral vascular resistance and white ethnicity (R(2) = 0.26, p < 0.0001). Independent predictors of FGR were maternal height and cardiac output. The area under the receiver operator characteristic curve for prediction of FGR was 0.915 (95% CI 0.859-0.972) and 0.9079 (95% CI 0.823-0.990) for FGR below the 5th and 3rd centiles, respectively., Conclusion: In women with chronic hypertension or a history of hypertension in a previous pregnancy, maternal size and cardiac output at booking provide a sensitive screening tool for FGR., (© 2015 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To determine if maternal thyroid function in the first trimester is altered in pregnancies that subsequently develop preeclampsia (PE)., Methods: Mean arterial pressure (MAP), uterine artery pulsatility index (PI) maternal serum thyroid stimulating hormone (TSH), free thyroxine (FT4) and free triiodothyronine (FT3) at 11 to 13 weeks of gestation were measured in 102 singleton pregnancies that subsequently developed PE, and the values were compared to the results of 4318 normal pregnancies., Results: In both the PE groups that required delivery before 34 weeks (early-PE) and the late-PE group, compared with the unaffected group, the median MAP multiple of the normal median (MoM) and uterine artery PI MoM were significantly increased. In late-PE but not in early-PE, compared with the unaffected group, the median TSH MoM was significantly increased and the median FT4 MoM was decreased. Logistic regression analysis demonstrated that TSH MoM provided a significant contribution in the prediction of late-PE., Conclusion: Impaired thyroid function may predispose to the development of late-PE, and measurement of maternal serum TSH can improve the prediction of late-PE provided by a combination of factors in the maternal history and the measurements of MAP and uterine artery PI.

Background: Pregnancy at high altitude has been associated with intrauterine growth restriction and preeclampsia. These conditions, at sea level, have been linked to increased hematocrit and blood viscosity. The aim of this study was to investigate the effect of high altitude on maternal hemorheology., Methods: This was a cross-sectional study. We examined 94 pregnant women at 10-38 weeks of gestation resident at high altitude (4370 m above sea level) and 75 at sea level, and 24 and 17 nonpregnant women at each altitude, respectively. Blood and plasma viscosity, hematocrit, plasma fibrinogen, albumin and total protein concentrations were determined in blood samples obtained after an overnight period of fasting., Results: Pregnancy at high altitude, compared to sea level, is characterized by higher hematocrit, blood viscosity (at high shear rate), plasma viscosity, total protein and fibrinogen concentrations (25%, 38%, 7%, 13.3% and 25%, respectively) and 6% lower albumin concentration. Nonpregnant women at high altitude, compared to sea level, had higher hematocrits, blood viscosity, plasma viscosity, total protein and fibrinogen concentrations (25%, 55%, 18%, 26% and 98%, respectively) and 13% lower albumin concentration., Conclusion: Pregnancy at high altitude compared to sea level is characterized by increased blood viscosity as a result of increased hematocrit and plasma viscosity.