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OBJECTIVE: Pre-eclampsia (PE) is associated with maternal cardiac remodeling and diastolic dysfunction. The aim of this study was to assess and compare maternal left ventricular structure and diastolic function and levels of brain natriuretic peptide (BNP) in women with early-onset (< 34 weeks' gestation) vs those with late-onset (≥ 34 weeks' gestation) PE. METHODS: This was a prospective, cross-sectional, observational study of 30 women with early-onset PE, 32 with late-onset PE and 23 normotensive controls. Maternal cardiac structure and diastolic function were assessed by echocardiography and plasma levels of BNP were measured by enzyme immunoassay. RESULTS: Early- and late-onset PE were associated with increased left ventricular mass index and relative wall thickness compared with normotensive controls. In women with early-onset PE, the prevalence of concentric hypertrophy (40%) and diastolic dysfunction (23%) was also significantly higher (both P < 0.05) compared with women with late-onset PE (16% for both). Maternal serum BNP levels were significantly higher (P < 0.05) in women with early-onset PE and correlated with relative wall thickness and left ventricular mass index. CONCLUSIONS: Early-onset PE is associated with more severe cardiac impairment than is late-onset PE, as evidenced by an increased prevalence of concentric hypertrophy, diastolic dysfunction and higher levels of BNP. These findings suggest that early-onset PE causes greater myocardial damage, increasing the risk of both peripartum and postpartum cardiovascular morbidity. Although these cardiovascular effects are easily identified by echocardiographic parameters and measuring BNP, further studies are needed to assess their clinical utility. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

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Silibinin is a polyphenolic plant flavonoid with anti-inflammatory properties. The present study investigated the effect of silibinin on oxidative metabolism and cytokine production - tumor necrosis factor-alpha (TNF-α), interleukin (IL)12, granulocyte-macrophage colony-stimulating factor (GM-CSF), IL-6, IL-10, and transforming growth factor beta (TGF-ß1) - by peripheral blood monocytes (PBM) from preeclamptic pregnant women. It is a case-controlled study involving women with preeclampsia (PE, n = 30) compared with normotensive pregnant (NT, n = 30) and with non-pregnant (NP, n = 30) women. Monocytes were obtained and cultured with or without silibinin (5 µM or 50 µM) for 18 h. Superoxide anion (O2-) and hydrogen peroxide (H2O2) release were determined by specific assays, and cytokine levels were determined by immunoenzymatic assays (ELISA). Monocytes from preeclamptic women cultured without stimulus released higher levels of O22, H2O2 and TNF-α, and lower levels of IL-10 and TGF-ß1 than did monocytes from NT and NP women. Treatment in vitro with silibinin significantly inhibited spontaneous O2- and H2O2 release and TNF-α production by monocytes from preeclamptic women. The main effect of silibinin was obtained at 50 µM concentration. Thus, silibinin exerts anti-oxidative and anti-inflammatory effects on monocytes from preeclamptic pregnant women by inhibiting the in vitro endogenous release of reactive oxygen species and TNF-α production.

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INTRODUCTION: Pre-eclampsia (PE) is associated with profound changes in the maternal cardiovascular system. The new concept of early and late preeclampsia established the hypothesis that these two entities may be associated with different models of vascular adaptation. Studies of central hemodynamics are limited. The applanation tonometry is able to evaluate, noninvasively, several vascular features and can be used to study the pathophyology of different forms of preeclampsia. OBJECTIVES: To compare vascular parameters of pulse wave analysis in pregnant women with early and late preeclampsia, determined by applanation tonometry. METHODS: This was a cross-sectional study involving pregnant women with 34 early-onset PE (<34 weeks) and 51 late-onset (⩾34 weeks) PE. Central blood pressure, peripheral and central pulse pressure, augmentation index, the augmentation pressure, subendocardial viability ratio and the ejection duration were assessed noninvasively using applanation tonometry (SphygmoCor ®). Data were expressed as means±SD or as median and percentage. The mean was used for parameters with normal distribution and median for parameters that were not normally distribution. Comparisons between groups were performed using t-test, Mann-Whitney test or chi-square(c(2)) for numerical and categorical data, respectively. It was considered a significance level of 5%. Statistical analysis were done using SPSS 10.5. RESULTS: Compared to late-onset PE group, women that developed early-onset PE had higher augmentation index (24.2±13.1 vs 18.8±12.5; p=0.03). Any other paremeters presented significant differences between the groups. CONCLUSION: We found that early-onset PE is characterized by increased maternal arterial stiffness when compared late-onset PE, using applanation tonometry.

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INTRODUCTION: Preeclampsia is a human pregnancy-specific syndrome characterized by the onset of hypertension and proteinuria. These manifestations may occur before the 34th week of gestation or from this period on, being denominated early-onset or late-onset preeclampsia respectively. The etiology of both disorders seems to differ qualitatively; therefore, different strategies of prevention and treatment must be studied. OBJECTIVES: The aim of the present study is to determine whether the plasma levels of heat-shock proteins Hsp60 and Hsp70 as well as specific antibodies anti-Hsp60 and anti-Hsp70 may differentiate early-onset from late-onset preeclampsia. METHODS: We evaluated 175 pregnant women with PE (55 early-onset PE and 120 late-onset PE). Plasma was obtained from peripheral blood and Hsp60, Hsp70 as well as anti-Hsp60 and anti-Hsp70 antibody levels were determined by enzyme immunoassay. Uric acid levels were also determined in the plasma of patients. For statistical analyses, the Mann-Whitney U-test and the Spearman rank order correlation were applied with significance level set at 5%. RESULTS: Hsp70 levels obtained from early-onset PE group were significantly higher than the late-onset PE women and showed positive correlation with uric acid (r=0.4547; p=0.0028). The Hsp60 production was similar in both groups. Our results also indicate that there was no significant difference of anti-Hsp60 and anti-Hsp70 antibody levels between women with early- and late-onset PE. However,these antibody levels were high,indicating a strong relationship with the production of HSP60 and Hsp70 protein. CONCLUSION: Association between levels of Hsp70 and uric acid in plasma of patients with early-onset PE seems to reflect the oxidative stress in this group of patients. This study provides evidence that Hsp70 determination may be utilized to assess the differentiation between early- and late-onset PE. FINANCIAL SUPPORT: FAPESP 2010/09241-2.

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INTRODUCTION: Toll-like receptor (TLR)-4 and TLR-2 are involved in inflammatory response of monocytes. These cells are activated in pregnant women with preeclampsia (PE), and over-produce inflammatory cytokines. TLR4 may recognize endogenous ligands, the so-called danger signals released by damaged cells, leading to production of pro-inflammatory cytokines. OBJECTIVES: This study investigated TLR2 and TLR4 expression and cytokine production by monocytes from women with PE before and after stimulation with TLR ligands. METHODS: Monocytes (5×10(5)cell/mL) were obtained from 32 preeclamptic (PE) and 20 normotensive (NT) pregnant women in the last trimester of pregnancy. TLR2 and TLR4 expression on monocyte surface was determined by flow cytometry in non-stimulated cells, and after 18h of culture with lipopysaccharide (LPS) and peptidoglycan (PG). TNF-α, IL-10 and IL-12p70 production by these cells stimulated or not with LPS or PG was evaluated by enzyme immunoassay. Results were analyzed by non-parametric tests with significance level set at 5%. RESULTS: In the absence of stimulation, the basal TLR4 expression by monocytes detected by the median fluorescence intensity (MFI) was significantly higher in the PE group than in the NT group while no significant differences were observed between groups in relation to endogenous TLR2 expression. An increase in TLR4 MFIs was detected after monocytes from NT pregnant women were stimulated with LPS while TLR2 expression was increased after PG-stimulation. No alterations in TLR expression was detected after LPS or PG-stimulation in monocytes from patients with PE. Evaluation of endogenous cytokine levels in supernatant culture of monocytes showed higher concentrations of TNF-α and IL-12p70 in preeclamptic women in comparison with the NT group, whereas IL-10 values were significantly higher in NT pregnant women than in the PE group. In contrast, when monocytes were stimulated with the TLRs ligands LPS and PG, the release of TNF-α was significantly reduced, while IL-12p70 levels were significantly higher in women with PE compared to NT group. IL-10 production was similar in both groups studied. CONCLUSION: The basal up-regulation of TLR4 expression associated with endogenous high TNF-α and IL-12p70 production by monocytes from preeclamptic women confirms the activated profile of these cells by the disease process. These findings provide new insights into possible roles for TLRs in the pathogenesis of systemic inflammation detected in PE. FINANCIAL SUPPORT: FAPESP 2009/11924-3 and 2010/20207-0.

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INTRODUCTION: Monocytes from peripheral blood of pregnant women with preeclampsia are endogenously activated and secrete high levels of free radicals and inflammatory cytokines. OBJECTIVES: This study aimed at evaluating whether the inflammatory state of monocytes observed in preeclampsia is associated with the polarization of monocyte to M1 profile in peripheral blood, correlating the expression of surface receptors CD64, TLR2, TLR4, and CD163 and CD206 with cytokine production. METHODS: We studied 90 pregnant women, 30 normotensive and 60 with preeclampsia, matched for gestational age. Peripheral blood monocytes obtained from normotensive pregnant or preeclamptic pregnant women were cultured for 18h, and the expression of surface receptors on M1 inflammatory monocyte subpopulation (TLR2, TLR4 and CD64) and M2 suppressor monocyte subpopulation (CD163 and CD206) were evaluated by flow cytometry, using specific monoclonal antibodies, labeled with fluorochromes. The values were expressed as ??the mean fluorescence intensity. Moreover, the production of proinflammatory cytokines associated with M1 profile (TNF-α, IL-12p70 and IL-23) and the anti-inflammatory cytokine associated with M2 profile (IL-10) were evaluated in the monocyte supernatant of culture by enzyme immunoassay. Results were analyzed using nonparametric tests with significance level set at 5%. RESULTS: The expression of CD4 and TLR4 on monocyte surface, from women with preeclampsia was significantly higher, while the expression of CD163 and CD206 was significantly decreased compared with normotensive pregnant women, suggesting the predominance of monocyte M1 profile. Endogenous production of TNF-α, IL-12p70 and IL-23 by monocytes was increased, while synthesis of IL-10 was lower in women with preeclampsia compared with normotensive pregnant women. Positive correlations between TLR4 and CD64 (r=0.5849), TLR4 and TNF-α (r=0.5126) or TLR4 and IL-23 (r=0.8095), as well as between CD64 and TNF-α (r = 0.7133) or CD64 and IL-23 (r = 0.6051) were observed in the preeclamptic group. The results confirm the activated state of monocytes from women with preeclampsia by increased production of proinflammatory cytokines and the expression of receptors characteristic of the M1 subpopulation. CONCLUSION: This study provides evidence that monocytes from women with preeclampsia are classically activated and the systemic inflammatory environment may differentiate and polarize these cells to the M1 profile. FINANCIAL SUPPORT: CNPq, FAPESP 2009/11924-3 and 2010/20207-0.

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INTRODUCTION: High prevalence of pre-pregnancy weight excess, as well as evidence of increased risk of maternal and perinatal complications associated with nutritional states have been observed lately. Considering the possible ethnic and environmental influences few studies have assessed this risk in pregnant Brazilian women. OBJECTIVES: This study aimed at determining the prevalence of pre-pregnancy weight excess (overweight and obesity) and its association with maternal and perinatal complications in a Brazilian women population. METHODS: We conducted a prospective cross-sectional study with 3,300 women who had birth care at the Asa Sul Regional Hospital of Brasília - Federal District (FD), from October 2009 to May 2010. Nutritional status was determined by body mass index (BMI), according to WHO criteria (2000): Low weight (BMI<18.5kg/m(2)), Normal weight (BMI between 18.5 and 24.9kg/m(2)), Weight excess (BMI⩾25kg/m(2)), Overweight (BMI between 25 and 29.9kg/m(2)) and obesity (BMI⩾30kg/m(2)). The outcome variables were: pre-clinical complications such as chronic hypertension and diabetes, manifestation of gestational hypertension/preeclampsia, pregnancy duration and resolution as well as perinatal outcomes. The association among these variables was assessed using chi-square (Pearson) and Fisher's exact test. Results were considered significant when p<0.05. RESULTS: In this population, weight excess before pregnancy had a prevalence of 27.2%, being 19.7% and 7.5% of pregnant women presenting, respectively, overweight and obesity. The prevalence of normal weight was 64.6% and low weight was 8.3%. Comparing the weight excess (BMI⩾25kg/m(2)) group with the normal weight group it was observed predominant hypertension (23% vs. 10%) and diabetes (10.1% vs. 3.6%), prolonged pregnancy (14.4% vs. 10.7%) and cesarean section rate (58.1% vs. 47.2%) in the weight excess group. Newborn weight equal to or greater than 4,000 g (9.5% vs. 4.5%) as well as fetal macrosomia (14.6% vs. 7.4%) also predominated in weight excess group. The comparison among the groups normal weight, overweight and obesity showed predominance of hypertension, diabetes cesarean section rate, newborns weight and fetal macrosomia in the obesity group. CONCLUSION: In the population analyzed, the prevalence of pre-pregnancy weight excess, particularly obesity, was high and associated with maternal and perinatal complications. Weight excess pre-pregnancy should be considered a risk to the pregnancy, demanding different obstetric care. Efforts should be made so that, in the pre-pregnancy period, women's weight can be as close to the normal weight as possible.

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The objective of this study was to determine the effect of maternal hydration with oral isotonic solution and water on the amniotic fluid (AF) index of women with normohydramnios. Women with a normal AF index and gestational age between 33 and 36 weeks without maternal complications were randomized into three groups [isotonic solution (Gatorade®), water, control]. The isotonic solution and water groups were instructed to drink 1.5 L of the respective solution and the control group was instructed to drink 200 mL water over a period of 2 to 4 h. AF index was measured before and after hydration by Doppler ultrasonography. The investigator performing the AF index measurement was blind to the subject’s group. Ninety-nine women completed the study without any adverse maternal effects. The median increase in AF index after hydration was significantly greater for the isotonic solution and water groups than for the control group. There was no significant difference between the isotonic solution and water groups. Hydration with isotonic solution and water caused a 10-fold (95 percentCI: 2.09-49.89) and 6-fold (95 percentCI: 1.16-30.95) increase in the chance of a 20 percent increase of AF index, respectively. Maternal hydration with isotonic solution or water increased the AF index in women with normohydramnios.

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The objective of this study was to determine the effect of maternal hydration with oral isotonic solution and water on the amniotic fluid (AF) index of women with normohydramnios. Women with a normal AF index and gestational age between 33 and 36 weeks without maternal complications were randomized into three groups [isotonic solution (Gatorade(®)), water, control]. The isotonic solution and water groups were instructed to drink 1.5 L of the respective solution and the control group was instructed to drink 200 mL water over a period of 2 to 4 h. AF index was measured before and after hydration by Doppler ultrasonography. The investigator performing the AF index measurement was blind to the subject's group. Ninety-nine women completed the study without any adverse maternal effects. The median increase in AF index after hydration was significantly greater for the isotonic solution and water groups than for the control group. There was no significant difference between the isotonic solution and water groups. Hydration with isotonic solution and water caused a 10-fold (95%CI: 2.09-49.89) and 6-fold (95%CI: 1.16-30.95) increase in the chance of a 20% increase of AF index, respectively. Maternal hydration with isotonic solution or water increased the AF index in women with normohydramnios.

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