To compare the colposcopic appearance of the cervico-vaginal epithelium with spermicide use versus condom use in a low risk population.
This was an ancillary study of a trial comparing the efficacy of 5 nonoxynol-9 (N-9) spermicides. A cohort of women using condoms without spermicide served as a control group. Colposcopic examinations were performed during product use to identify genital lesions.
One hundred fifty-one participants had ≥1 follow-up examinations. At baseline, study groups differed only by the prevalence of baseline lesions. New lesions were identified at 49% of follow-up visits. Controlling for the presence of a baseline lesion, compared to condom use none of the spermicides were associated with an increase in new lesions (overall OR 0.8, 95% CI 0.4-1.6, p=0.5); and lesions characterized by epithelial disruption were less frequent with spermicide use (overall OR 0.3, 95% CI 0.1-0.6, p<0.001).
In a low risk population, women using N-9 spermicides were less likely to have lesions with epithelial disruption, and equally likely to have any new lesion compared to condom use.
Colposcopy; vaginal spermicides; epithelial disruption; Nonoxynol-9
To describe the effect of lifting maneuver and quantity of weight lifted on the generation of intra-abdominal pressure.
Forty-one women undergoing urodynamic evaluation performed four lifting maneuvers, each while lifting 0, 2.5, 5, 10, and 15 kg. The lifting maneuvers were routine activities including squatting with and without assistance, lifting from a counter and receiving weight. Pressure was recorded with a rectal microtip catheter. Each lift was performed twice and the average pressure change was analyzed.
Controlling for potential confounding variables, repeated-measures ANOVA revealed a significant interaction between lift weight and lift maneuver (p= <0.001). Squatting was associated with generation of higher intra-abdominal pressure than lifting from a counter or receiving weights into outstretched arms (p= <0.001). Lifting ≥2.5 kg resulted in significant changes in intra-abdominal pressure regardless of lift maneuver (p= <0.001).
Both lifting maneuver and quantity of weight should be considered when counseling patients regarding postoperative lifting.
Intra-abdominal pressure; weight lifting; postoperative instructions; pelvic floor surgery
Goals of the study are to estimate the pharmacokinetic(PK) parameters of standard dose betamethasone in a large obstetrical population and evaluate the effect of maternal body size and multiple gestation on the PK parameters and their observed variability.
Prospective PK study. Liquid chromatography mass spectrometry was used to measure betamethasone plasma concentrations. PK parameters and significant clinical covariates were estimated using mixed effect modeling. Bootstrap analysis confirmed validity of the model.
Two hundred and seventy four blood samples from 77 patients were obtained. Greatest effect on PK variability was observed with maternal lean body weight(LBW). The relationship between the PK parameters and LBW remained linear over a wide range of maternal body sizes. Multiple gestations did not affect the PK parameters.
Individualization of betamethasone dosing by maternal LBWreduces variability in drug exposure. Mutiple gestations do not require betamethasone dosing adjustment, because PK are the same as singleton gestations.
Antenatal steroids; Betamethasone; prematurity; pharmacokinetics
The aim of this study was to outline the surgical management and outcomes for patients diagnosed with intravenous leiomyomatosis with intracardiac extension at a single institution.
This was a retrospective review of patients diagnosed with intravenous leiomyomatosis with intracardiac extension between 2002–2008.
Four patients were identified. The surgical approach in 3 (75%) patients was a single-stage operation. Four (100%) patients presented with cardiac symptoms: 3 (75%) with syncope and 1 (25%) with an abnormal electrocardiogram. Mean age at presentation was 48 years (range, 42–58 years). Complete resection of tumor was obtained in 1 (25%) patient and 3 (75%) patients experienced incomplete resection. Mean follow-up, including surveillance imaging, was 25.5 months (range, 8–57 months) and all 4 patients (100%) are currently free of recurrence.
Surgical excision remains an effective therapy for treating patients with benign metastasizing leiomyomatosis. Incomplete surgical resection may result in favorable response.
cardiac mass; fibroid; intravenous leiomyomatosis
Obesity and estrogen are strong risk factors for endometrial cancer (EC). While diabetes also increases risk, little is known about related insulin resistance (IR). The purpose of this study was to determine the prevalence of IR in newly diagnosed EC patients.
EC patients from a large, metropolitan county were prospectively enrolled from 2005–2008. Fasting serum was analyzed for glucose and insulin. IR was defined as a history of diabetes or a QUICKI [1/(log fasting insulin + log fasting glucose)] value of <0.357.
Among 99 patients, diabetes was present in 30, and an abnormal QUICKI was found in 36 additional patients. Increased risk of IR was significantly associated with higher BMI (p<0.001), lower socioeconomic status (p=0.007), and nulliparity (p=0.029).
IR was highly prevalent in endometrial cancer patients, including non-obese women. Better characterization of metabolic risks in addition to obesity may provide avenues for targeted cancer prevention in the future.
diabetes; endometrial cancer; insulin resistance; obesity
Using a cohort of 110,447 singleton, term pregnancies, we aimed to validate the previously proposed customized standard of LGA birthweight, derive an additional customized LGA model excluding maternal weight, and evaluate the association between differing definitions of customized LGA and perinatal morbidities.
Three customized LGA classifications, in addition to population-based 90th percentile (LGAPop), were made according to the principals described by Gardosi: 1) customized LGA using Gardosi’s previously published coefficients (LGAGard), 2) customized LGA using coefficients derived by a similar method but from our larger cohort, and 3) derived without customization for maternal weight. Associations between the LGA classifications and various perinatal morbidity outcomes were evaluated.
Coefficients derived here for physiologic and pathologic effects on birthweight were similar to those previously reported (LGAGard). Customized LGA (any method) generally identified more births to younger, non-white, nulliparous mothers with female neonates of lower birthweight compared to LGAPop. Rates of maternal and neonatal morbidity were greatest in births classified by both LGAPop and customized LGA (any method). However, the model which excluded customization for maternal weight, revealed a greater proportion of women previously unidentified by LGAPop who were more frequently black (40 vs. 25%) and obese (30 vs. 5.1 %), along with greater rates of shoulder dystocia, neonatal intensive care unit admission and neonatal respiratory complications, than with LGAGard.
The utility of customized methods of defining LGA was not decisively superior compared to LGAPop, but custom LGA may be improved by modification of the parameters included in customization.
large for gestational age; macrosomia; customized birthweight; neonatal morbidity; neonatal mortality; delivery complications
We used validated sensitive and specific questions associated with clinically-confirmed diagnoses of unexplained vulvar pain (Vulvodynia) to compare the cumulative incidence of vulvar pain and prevalence of care seeking behavior in Boston, Massachusetts metropolitan area (BMA) and in Minneapolis/St. Paul (MSP), Minnesota, between 2001–2005 using census-based data, and 2010–2012, using outpatient community-clinic data, respectively.
We received self-administered questionnaires from 5,440 women in BMA and 13,681 in MSP, 18–40 years of age, describing their history of vulvar burning or pain on contact that persisted >3 months that limited/prevented intercourse.
By age 40, 7–8% in BMA and MSP reported vulvar pain consistent with Vulvodynia. Women of Hispanic/Latina origin compared to Caucasians were 1.4 times more likely to develop vulvar pain symptoms (95%CI: 1.1–1.8). Many women in MSP (48%) and BMA (30%) never sought treatment, and >50% who sought care with known health care access received no diagnosis.
Using identical screening methods, we report high prevalence of vulvar pain in two geographical regions, and that access to health care does not increase the likelihood of seeking care for chronic vulvar pain.
Ethnic groups; Health services accessibility; Prevalence; Vulvodynia
To evaluate the quality of compounded 17-hydroxyprogesterone caproate (17-OHPC)
Compounded 17-OHPC was obtained from 15 compounding pharmacies throughout the U.S. and analyzed for potency, impurities, sterility, and pyrogen status.
Eighteen samples were supplied by 15 compounding pharmacies. The concentration of 17-OHPC in all samples was within the specification limits and all tested samples passed sterility and pyrogen testing. Only 1 of 18 samples was out of specification limits for impurities.
Compounded 17-OHPC obtained from 15 pharmacies throughout the U.S. did not raise safety concerns when assessed for potency, sterility, pyrogen status or impurities.
compounded 17-OHPC; impurity analysis; potency; sterility and pyrogen status
We sought to determine a microRNA (miRNA) profile of surgically staged endometrial cancers.
RNA was extracted from archival primary endometrial cancers, and an miRNA profile was established using a microarray and confirmed with real-time polymerase chain reaction. Targets of differentially expressed miRNAs were explored using real-time polymerase chain reaction and Western blot in endometrial cell lines.
Endometrial cancer has an miRNA profile distinct from normal endometrium, even in patients with stage IA grade 1 tumors. This miRNA cancer profile was able to correctly assign a specimen as a malignancy with a sensitivity of 92%. Overexpressed miRNAs were predicted to target PTEN, and transfection of cell lines with these miRNAs led to down-regulation of PTEN expression. In advanced disease, an miRNA pattern distinct from early-stage disease was seen, and overexpression of mir-199c predicted improved cancer survival in this population.
Endometrial cancer has a distinct miRNA profile, and miRNAs can be used as a predictive biomarker.
biomarker; endometrial cancer; microRNA
This study was undertaken to develop a representative murine model for human leiomyoma.
Human fibroid tumor tissues were cut into small pieces and treated with medium alone, adenoviral-β-galactosidase, adenoviral-vascular endothelial growth factor-A, adenoviral-cyclooxygenase-2, or both adenoviral-vascular endothelial growth factor-A and adenoviral- cyclooxygenase-2. Tissue pieces were inserted subcutaneously in the flank of each severe combined immunodeficient mouse. The developed lesion was measured twice per week. Xenograft tissues were harvested after 30 days and analyzed.
Tissue pieces transfected with both adenoviral-cyclooxygenase-2 and adenoviral-vascular endothelial growth factor-A continued to grow up to 30 days postimplantation. The number of proliferating and apoptotic cells, as well as the expression of smooth muscle actin, desmin, vimentin, estrogen receptors, and progesterone receptors was similar between retrieved grafts from that group and the original patient tissue. Furthermore, hematoxylin and eosin and Masson’s Trichrome stains confirmed this similarity.
Human uterine leiomyoma xenografts, pretreated with both adenoviral- cyclooxygenase-2 and adenoviral-vascular endothelial growth factor-A and implanted subcutaneously in severe combined immunodeficient mice, represent a novel model for human uterine leiomyoma.
cyclooxygenase-2; leiomyoma models; severe combined immunodeficient mice; uterine leiomyoma; vascular endothelial growth factor-A
Neonatal diagnoses are often used as surrogate endpoints for longer-term outcomes. We sought to characterize the correlation between neonatal diagnoses and early childhood neurodevelopment.
We conducted secondary analysis of a multicenter randomized controlled trial of antenatal magnesium sulfate vs placebo administered to women at imminent risk for delivery <32.0 weeks to prevent death and cerebral palsy in their offspring. Singletons and twins delivering 23.0–33.9 weeks who survived to hospital discharge and had 2-year-old outcome data were included. Those surviving to age 2 years were assessed by trained physicians and the Bayley II Scales of Infant Development Mental Development and Psychomotor Development Indices. Neonatal diagnoses at the time of each baby’s initial hospital discharge were examined singly and in combination to determine those most predictive of childhood neurodevelopmental impairment, defined as a childhood diagnosis of moderate/severe cerebral palsy and/or Bayley scores >2 SD below the mean. Data were analyzed by multiple regression models and area under receiver operating characteristic curves.
A total of 1771 children met criteria. Children were delivered at a mean of 29.4 weeks’ gestation. In all, 459 (25.9%) had neuro-developmental impairment. In models controlling for gestational age at delivery, maternal education, maternal race, tobacco/alcohol/drug use during pregnancy, randomization to magnesium, fetal sex, and chorioamnionitis, individual neonatal morbidities were moderately predictive of childhood neurodevelopmental impairment (best model area under receiver operating characteristic curve, 0.68; 95% confidence interval, 0.65–0.71). Combinations of 2, 3, and 4 morbidities did not improve the prediction of neurodevelopmental impairment.
Approximately 1 in 4 previously preterm children had neurodevelopmental impairment at age 2 years. Prediction of childhood outcomes from neonatal diagnoses remains imperfect.
neonatal outcomes; neurodevelopment; prematurity
Data regarding long-term outcomes of neonates reaching viability following early preterm premature rupture of membranes (PPROM; <25.0 weeks at rupture) are limited. We hypothesized that babies delivered after early PPROM would have increased rates of major childhood morbidity compared with those with later PPROM (≥25.0 weeks at rupture).
This was a secondary analysis of a multicenter randomized controlled trial of magnesium sulfate vs placebo for cerebral palsy prevention. Women with singletons and PPROM of 15-32 weeks were included. All women delivered at 24.0 weeks or longer. Those with PPROM less than 25.0 weeks (cases) were compared with women with PPROM at 25.0-31.9 weeks (controls). Composite severe neonatal morbidity (sepsis, severe intraventricular hemorrhage, periventricular leukomalacia, severe necrotizing enterocolitis, bronchopulmonary dysplasia, and/or death) and composite severe childhood morbidity at age 2 years (moderate or severe cerebral palsy and/or Bayley II Infant and Toddler Development scores greater than 2 SD below the mean) were compared.
A total of 1531 women (275 early PPROM cases) were included. Demographics were similar between the groups. Cases delivered earlier (26.6 vs 30.1 weeks, P < .001) and had a longer rupture-to-delivery interval (20.0 vs 10.4 days, P < .001). Case neonates had high rates of severe composite neonatal morbidity (75.6% vs 21.8%, P < .001). Children with early PPROM had higher composite severe childhood morbidity (51.6% vs 22.5%, P < .001). Early PPROM remained associated with composite severe childhood morbidity in multivariable models, even when controlling for delivery gestational age and other confounders.
Early PPROM is associated with high rates of neonatal morbidity. Early childhood outcomes at age 2 years remain poor compared with those delivered after later PPROM.
childhood outcomes; neonatal outcomes; preterm pre-mature rupture of membranes
We hypothesized that genetic variation affects responsiveness to 17-alpha hydroxyprogesterone caproate (17P) for recurrent preterm birth prevention.
Women of European ancestry with ≥1 spontaneous singleton preterm birth at <34 weeks’ gestation who received 17P were recruited prospectively and classified as a 17P responder or nonresponder by the difference in delivery gestational age between 17P-treated and -untreated pregnancies. Samples underwent whole exome sequencing. Coding variants were compared between responders and nonresponders with the use of the Variant Annotation, Analysis, and Search Tool (VAASl), which is a probabilistic search tool for the identification of disease-causing variants, and were compared with a Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway candidate gene list. Genes with the highest VAAST scores were then classified by the online Protein ANalysis THrough Evolutionary Relationships (PANTHER) system into known gene ontology molecular functions and biologic processes. Gene distributions within these classifications were compared with an online reference population to identity over and under represented gene sets.
Fifty women (9 nonresponders) were included. Responders delivered 9.2 weeks longer with 17P vs 1.3 weeks’ gestation for nonresponders (P < .001). A genome wide search for genetic differences implicated the NOS1 gene to be the most likely associated gene from among genes on the KEGG candidate gene list (P < .00095). PANTHER analysis revealed several over represented gene ontology categories that included cell adhesion, cell communication, signal transduction, nitric oxide signal transduction, and receptor activity (all with significant Bonferroni-corrected probability values).
We identified sets of over-represented genes in key processes among responders to 17P, which is the first step in the application of pharmacogenomics to preterm birth prevention.
pharmacogenomics; progesterone; spontaneous preterm birth
Worldwide, obesity has become a major public health crisis. Overweight and obesity not only increase the risk of cardiovascular disease and type-2 diabetes, but also are now known risk factors for a variety of cancer types. Among all cancers, increasing body mass index is most strongly associated with endometrial cancer incidence and mortality. The molecular mechanisms underlying how adipose tissue and obesity contribute to the pathogenesis of endometrial cancer are becoming better understood and have revealed a number of rational strategies, both behavioral and pharmaceutical, for the prevention of both primary and recurrent disease.
endometrial cancer; estrogen; insulin; obesity; prevention
To evaluate the biologic validity of ovarian cancer (OVCA) screening and early detection efforts and to characterize signaling pathways associated with human cancer metastasis and patient survival.
Using genome-wide expression profiling and DNA sequencing, we compared pelvic and matched extra-pelvic implants from 30 patients with advanced-stage OVCA for expression of molecular signaling pathways and p53 gene mutations. Differentially expressed pathways were further evaluated in a series of primary or early-stage versus metastatic or recurrent cancer samples from 389 ovarian, prostate, and oral cancer patients. Metastasis pathways were also evaluated for associations with survival in nine independent clinico-genomic datasets from 1,691 ovarian, breast, colon, brain, and lung cancer and leukemia patients. The inhibitory effects of one pathway (TGF-WNT) on in-vitro OVCA cell migration were studied.
Pelvic and extra-pelvic OVCA implants demonstrated similar patterns of signaling pathway expression and identical p53 mutations. However, we identified 3 molecular pathways/cellular processes that were differentially expressed between pelvic and extra-pelvic OVCA samples and between primary/early-stage and metastatic/advanced or recurrent ovarian, oral, and prostate cancers. Furthermore, their expression was associated with overall survival from ovarian cancer (P=0.006), colon cancer (1 pathway at P=0.005), and leukemia (P=0.05). Artesunate-induced TGF-WNT pathway inhibition impaired OVCA cell migration.
Advanced-stage OVCA has a unifocal origin in the pelvis, supporting validity of early detection/screening efforts. Molecular pathways associated with extra-pelvic OVCA spread are also associated with metastasis from other human cancers and with overall patient survival. Such pathways represent appealing therapeutic targets for patients with metastatic disease.
Gene Expression; p53 mutation; Serous Ovarian Cancer; Unifocal
To evaluate the efficacy and safety of transdermal nitroglycerin as tocolytic agent in women with preterm labor.
Systematic review and meta-analysis of randomized controlled trials.
Thirteen studies (1302 women) were included. Two studies evaluated transdermal nitroglycerin versus placebo (N=186), 9 evaluated transdermal nitroglycerin versus β2-adrenergic-receptor agonists (N=1024), and 1 each evaluated transdermal nitroglycerin versus nifedipine (N=50) and transdermal nitroglycerin versus magnesium sulfate (N=42). There were no significant differences between transdermal nitroglycerin and placebo for delivery within 48 hours of initiation of treatment or before 28, 34 or 37 weeks’ gestation, adverse neonatal outcomes, and neurodevelopmental status at 24 months of age. Nevertheless, one study found a marginally significant reduction in the risk of a composite outcome of significant neonatal morbidity and perinatal mortality (3/74 [4.1%] versus 11/79 [13.9%]; relative risk 0.29, 95% confidence interval 0.08–1.00). When compared with β2-adrenergic-receptor agonists, transdermal nitroglycerin was associated with a significant reduction in the risk of preterm birth <34 and <37 weeks’ gestation, admission to the neonatal intensive care unit, use of mechanical ventilation, and maternal side effects. There were no significant differences between transdermal nitroglycerin and nifedipine and magnesium sulfate in delivery within 48 hours of treatment and pregnancy prolongation, respectively. Overall, women receiving transdermal nitroglycerin had a higher risk of headache.
Although transdermal nitroglycerin appears to be more effective than β 2-adrenergic-receptor agonists, the current evidence does not support its routine use as tocolytic agent for the treatment of preterm labor. Further additional double-blind placebo-controlled trials are needed.
Nitric oxide donors; β2-adrenergic-receptor agonists; nifedipine; magnesium sulfate; tocolytic agents; preterm birth; neonatal morbidity
We evaluated the risk of first-trimester exposures among nurses and the risk of preterm birth among participants of the Nurses’ Health Study II.
Log binomial regression was used to estimate the relative risk (RR) for preterm birth in relation to occupational risk factors, adjusting for age, parity, work schedule, physical factors, and exposures to chemicals and x-rays.
Part-time work (<= 20 hours a week) was associated with a lower risk for preterm birth [RR=0.7, 95% confidence interval (CI) = 0.6–0.9]. Self-reported exposure to sterilizing agents was associated with an increased risk (RR=1.9, 95% CI = 1.1–3.4). Other exposures, including shift work, physical factors, anesthetic gases, antineoplastic drugs, antiviral drugs, and x-ray radiation were not associated with risk of preterm birth.
These data suggest that sterilizing agents may be related to preterm birth, while physically demanding work and work schedule are not strong predictors.
Nurses; Occupational Exposure; Pregnancy; Preterm Birth; Work Schedule Tolerance
We hypothesized that gestationally” programmed non-alcoholic fatty liver disease (NAFLD) in low birth weight (LBW) offspring is mediated via nutrient sensors (SIRT1/AMPK).
Pregnant dams received ad libitum food or were 50% food restricted from pregnancy day 10 to 21 to produce Control and LBW newborns, respectively. All pups were nursed by control dams and weaned to ad libitum feed. We determined hepatic SIRT1 (NAD+-dependent histone deacetylase) and AMPK (AMP-activated protein kinase) activities, and protein expression of lipid targets in LBW and Control fetuses (e20), newborns (p1) and adults (3 months).
LBW fetuses demonstrate increased prenatal hepatic SIRT1 activity though with increased lipogenesis. Following birth, LBW undergo postnatal suppression of hepatic SIRT1 and AMPK activities in conjunction with increased lipogenesis, decreased lipolysis and increased fat stores.
These findings suggest that undernutrition stress in utero may program hepatic nutrient sensors to perceive normal postnatal nutrition as a state of nutrient excess with induction of hepatic lipid storage.
Programmed fatty liver; nutrient/metabolic sensors; lipogenesis; lipolysis
To determine whether contraceptive choice is influenced by social and reproductive characteristics in a cohort of high-risk women.
This is a cross-sectional analysis of baseline date from a randomized clinical trial. We evaluated characteristics associated with oral contraceptive use, male condom use, or use of no contraceptive method.
Women using OCs were less likely to have less than a high school education, to be African American or Hispanic, and to pay out of pocket for medical services compared to women not using any form of contraception. Women using OCs differed compared to women using condoms in that they were less likely to pay out of pocket for medical services. Finally, while number of sexual partners was associated with contraceptive choice, other reproductive characteristics, were not.
Among this cohort of women at high-risk for STDs and unintended pregnancy, sociodemographic characteristics influenced contraceptive choice.
To assess the relationship between strength of preference for vaginal birth and likelihood of vaginal delivery among women attempting this delivery mode.
We conducted a longitudinal study of mode of delivery preferences among women who were less than 36 weeks pregnant. Participants completed a sociodemographic and clinical questionnaire and were asked if they preferred vaginal or cesarean delivery. Participants who preferred vaginal delivery completed a standard gamble exercise to assess the strength of this preference on a 0-to-1 scale (higher scores indicate stronger preference for vaginal delivery); those preferring cesarean delivery were assigned a value of 0. Data on clinical characteristics and delivery mode was obtained via telephone interview or chart review. Logistic regression was used to identify predictors of delivery mode among women who attempted a vaginal delivery.
Of 210 participants, 156 attempted a vaginal delivery. Their mean and median vaginal delivery preference scores were 0.70 (SD 0.31) and 0.75 (IQR 0.50–0.99), respectively. In multivariate analyses, women with a prior cesarean delivery (aOR 0.08, CI 0.02–0.39) or who delivered an infant ≥4000 grams (aOR 0.04, CI 0.01–0.28) had significantly lower odds of having a vaginal delivery. After controlling for potential confounders, participants with a stronger preference for vaginal delivery were at significantly higher odds of having a vaginal delivery (aOR 1.54, CI 1.01–2.34 for every 0.2 increase on the 0-to-1 scale).
Among women who attempt a vaginal delivery, the strength of preference for vaginal birth is predictive of the delivery mode ultimately undergone.
Patient preferences; delivery mode
This study aims to evaluate perceived lifetime stress (LS), perceived stress during pregnancy (PS), chronic hypertension (CH) and their joint association with preeclampsia risk.
This study includes 4,314 women who delivered a singleton live birth at the Boston Medical Center from October 1998 through February 2008. CH is defined as hypertension diagnosed before pregnancy. Information regarding LS and SP was collected by questionnaire. Preeclampsia was diagnosed by clinical criteria.
LS, SP and CH were each associated with an increased risk of preeclampsia (OR(95%CI)=2.1(1.6–2.8) for LS; 1.7(1.3–2.1) for SP; 11.1(8.1–15.4) for CH). Compared with normotensive pregnancy with low LS, both normotensive pregnancy with high LS (2.1(1.5–2.9)) and pregnancy with CH and low LS (10.6(7.5–15.1)) showed an increased risk of preeclampsia, while pregnancy with high LS and CH yielded the highest risk of preeclampsia (21.3(10.3–44.3)). The joint association of SP and CH on preeclampsia was very similar to that of the joint association of LS and CH.
This finding indicates that high psychosocial stress and CH can act in combination to increase the risk of preeclampsia up to 20-fold. This finding underscores the importance of efforts to prevent, screen and manage CH, along with reducing psychosocial stress, particularly among women with CH.
Psychosocial stress; chronic hypertension; combined effect; preeclampsia