Preeclampsia: a couple's disease with maternal and fetal manifestations

Preeclampsia still ranks as one of obstetrics major problems. Clinicians typically encounter preeclampsia as maternal disease with variable degrees of fetal involvement. More and more the unique immunogenetic maternal-paternal relationship is appreciated, and as such also the specific 'genetic conflict' that is characteristic of haemochorial placentation. From that perspective preeclampsia can also been seen as a disease of an individual couple with primarily maternal and fetal manifestations. Factors that are unique to a specific couple would include the length and type of sexual relationship, the maternal (decidual natural killer cells) acceptation of the invading cytotrophoblast (paternal HLA-C), and seminal levels of transforming growth factor-beta and probably other cytokines. The magnitude of the maternal response would be determined by factors including a maternal set of genes determining her characteristic inflammatory responsiveness, age, quality of her endothelium, obesity/insulin resistance and probably a whole series of susceptibility genes amongst which the thrombophilias received a lot of attention in recent years.     

Obstetric and neonatal outcomes in grand multiparity

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among grand multiparas with age-matched multiparas. METHODS: Six hundred twenty-one grand multiparas (para more than 4) women were prospectively compared with 621 age-matched multiparous (para 2-4) controls. RESULTS: Grand multiparity was associated with low socioeconomic status and education (odds ratio [OR]6.4; 95% confidence interval [CI] 4.5, 9.0), poorer prenatal care (OR 3.1; 95% CI 1.5, 6.1), smoking (OR 2.2; 95% CI 1.5, 3.2), and alcohol consumption (OR 9.0; 95% CI 2.1, 39.3). Grand multiparas had a higher body mass index (OR 1.5; 95% CI 1.2, 1.9) and rate of insulin-dependent gestational diabetes (OR 1.7; 95% CI 1.02, 3.1). They had more previous intrauterine (OR 4.2; 95% CI 1.5, 11.3) and perinatal deaths (OR 3.2; 95% CI 2.0, 5.0). They had fewer intrapartum complications (arrests of cervical dilatation [OR 0.19; 95% CI 0.06, 0.66], instrumental deliveries [OR 0.31; 95% CI 0.16, 0.59], and fever during labor [OR 0.47; 95% CI 0.26, 0.86]). Conditional logistic regression models found that grand multiparity was the most closely correlated factor to a previous history of fetal death (OR 4.3; 95% CI 1.6, 11.6), but it was not an independent predictor of insulin-dependent gestational diabetes mellitus (OR 1.3; 95% CI 0.75, 2.2). CONCLUSION: Grand multiparas, when compared with same-age multiparous controls, appear to have fewer intrapartum complications. However, they present several prenatal risk factors that require special antenatal care. LEVEL OF EVIDENCE: II-3