Obstetric haemorrhage and risk of cardiovascular disease after three decades: a population-based cohort study.

OBJECTIVE: To investigate the association between obstetric haemorrhage and cardiovascular disease up to three decades after pregnancy. DESIGN: Population-based cohort study. SETTING AND POPULATION: All women who delivered between 1989 and 2016 in Quebec, Canada. METHODS: Using hospital admissions data, 1 224 975 women were followed from their first delivery until March 2018. The main exposure measures were antenatal (placenta praevia, placental abruption, peripartum haemorrhage) or postpartum haemorrhage, with or without transfusion. Adjusted Cox regression models were used to assess the association between obstetric haemorrhage and future cardiovascular disease. MAIN OUTCOME MEASURE: Cardiovascular hospitalisation. RESULTS: Among 104 291 (8.5%) women with haemorrhage, 4612 (4.4%) required transfusion. Women with haemorrhage had a higher incidence of cardiovascular hospitalisation than women without haemorrhage (15.5 versus 14.1 per 10 000 person-years; 2437 versus 28 432 events). Risk of cardiovascular hospitalisation was higher for obstetric haemorrhage, with or without transfusion, compared with no haemorrhage (adjusted hazard ratio [aHR] 1.06, 95% CI 1.02-1.10). Women with haemorrhage and transfusion had a substantially greater risk of cardiovascular hospitalisation (aHR 1.47, 95% CI 1.23-1.76). Among transfused women, placental abruption (aHR 1.79, 95% CI 1.06-3.00) and postpartum haemorrhage (aHR 1.38, 95% CI 1.13-1.68) were both associated with risk of cardiovascular hospitalisation. Antenatal haemorrhage with transfusion was associated with 2.46 times the risk of cardiovascular hospitalisation at 5 years (95% CI 1.59-3.80) and 2.14 times the risk at 10 years (95% CI 1.47-3.12). CONCLUSIONS: Obstetric haemorrhage requiring transfusion is associated with maternal cardiovascular disease. The benefit of cardiovascular risk prevention in pregnant women with obstetric haemorrhage requires further investigation. TWEETABLE ABSTRACT: Risk of future cardiovascular disease is increased for women with obstetric haemorrhage who require transfusion.

Out-of-office blood pressure measurement for the diagnosis of hypertension in pregnancy: Survey of Canadian Obstetric Medicine and Maternal Fetal Medicine specialists.

BACKGROUND: Multiple hypertension guidelines recommend out-of-office measurements for the diagnosis of hypertension in non-pregnant adults, whereas pregnancy guidelines recommend in-office blood pressure measurements. The objective of our study was to determine how Canadian Obstetric Medicine and Maternal Fetal Medicine specialists measure blood pressure in pregnancy. METHODS: An email survey was sent to 69 Canadian Obstetric Medicine and Maternal Fetal Medicine specialists in academic centers across Canada to explore the practice patterns of blood pressure measurement in pregnant women. RESULTS: The response rate was 48%. The majority of respondents (63.6%) preferred office blood pressure measurement for diagnosing hypertension, but relied on home blood pressure readings for ongoing monitoring and management of hypertension during pregnancy (59.4%). The preferred method of out-of-office blood pressure measurement was home monitoring; 24-hour ambulatory blood pressure monitoring was not used due to limited availability and cost. CONCLUSIONS: There is wide practice variation in methods of measuring blood pressure among Canadian specialists managing hypertension in pregnancy.

Haemoglobin levels in early pregnancy and severe maternal morbidity: population-based cohort study.

OBJECTIVE: Data regarding low maternal haemoglobin concentration and severe maternal morbidity (SMM) are limited and potentially biased. This study evaluated the relation between early maternal haemoglobin concentration and SMM or maternal mortality. DESIGN: Population-based cohort study. SETTING: Ontario, Canada, in a public healthcare system. POPULATION: 737 393 births with a routine outpatient haemoglobin measured at a calculated gestational age of 2-16 weeks. METHODS: The relation between early-pregnancy outpatient blood haemoglobin concentration and each study outcome was expressed as adjusted relative risks (aRR) and absolute risk differences (aRD), with 95% confidence intervals (CI), generated by modified Poisson regression. MAIN OUTCOME MEASURES: The primary outcome was SMM or maternal mortality, from 23 weeks' gestation to 42 days postpartum. RESULTS: The mean (SD) haemoglobin concentration was 126.9 (9.3) g/l. Overall, SMM or death occurred in 13 514 pregnancies (1.8%). Relative to a haemoglobin level of 125-129 g/l, the aRR was 1.07 (95% CI 1.02-1.13) and aRD (0.09%, 95% CI 0.01-0.18) at 120-124 g/l; aRR 1.31 (95% CI 1.17-1.46) and aRD 0.47% (95% CI 0.24-0.69) at 105-109 g/l; and aRR 4.53 (95% CI 3.59-5.72) and aRD 5.94% (95% CI 4.12-7.76) at <90 g/l. In all, 5961 women (0.8%) required red cell transfusion, with significantly higher risks at all haemoglobin concentrations below 125-129 g/l, peaking at a haemoglobin level <90 g/l (aRR 11.82, 95% CI 9.30-15.03). CONCLUSION: There is a gradual increase in the risk of SMM or death, as well as red cell transfusion, starting from the lower level of the normal range of haemoglobin of non-pregnant women. TWEETABLE ABSTRACT: Women with low haemoglobin in early pregnancy are at higher future risk of morbidity, death and blood transfusion.

Severe maternal morbidity in women with high BMI in IVF and unassisted singleton pregnancies.

STUDY QUESTION: Is there a synergistic risk of severe maternal morbidity (SMM) in overweight/obese women who conceived by IVF compared to normal-weight women without IVF? SUMMARY ANSWER: SMM was more common in IVF pregnancies, and among overweight/obese women, but we did not detect a synergistic effect of both factors. WHAT IS KNOWN ALREADY: While much is known about the impact of overweight and obesity on success rates after IVF, there is less data on maternal health outcomes. STUDY DESIGN, SIZE, DURATION: This is a population-based cohort study of 114 409 singleton pregnancies with conceptions dating from 11 January 2013 until 10 January 2014 in Ontario, Canada. The data source was the Canadian Assisted Reproductive Technologies Register (CARTR Plus) linked with the Ontario birth registry (BORN Information System). PARTICIPANTS/MATERIALS, SETTING, METHODS: We included women who delivered at ≥20 weeks gestation, and excluded those younger than 18 years or with twin pregnancies. Women were classified according to the mode of conception (IVF or unassisted) and according to pre-pregnancy BMI (high BMI (≥25 kg/m2) or low-normal BMI (<25 kg/m2)). The main outcome was SMM, a composite of serious complications using International Classification of Diseases, 10th revision (ICD-10) codes. Secondary outcomes were gestational hypertension, pre-eclampsia, gestational diabetes and cesarean delivery. Adjusted risk ratios (aRR) with 95% CI were estimated using log binomial regression, adjusted for maternal age, parity, education, income and baseline maternal comorbidity. MAIN RESULTS AND THE ROLE OF CHANCE: Of 114 409 pregnancies, 1596 (1.4%) were IVF conceptions. Overall, 41.2% of the sample had high BMI, which was similar in IVF and non-IVF groups. We observed 674 SMM events (rate: 5.9 per 1000 deliveries). IVF was associated with an increased risk of SMM (rate 11.3/1000; aRR 1.89, 95% CI: 1.06-3.39). High BMI was modestly associated with SMM (rate 7.0/1000; aRR 1.23, 95% CI: 1.04-1.45) There was no interaction between the two factors (P = 0.22). We noted supra-additive effects of high BMI and IVF on the risk of pre-eclampsia and gestational diabetes, but not gestational hypertension or cesarean delivery. LIMITATIONS, REASONS FOR CAUTION: We were unable to assess outcomes according to reason for treatment. Type II error (beta ~25%) may affect our results. WIDER IMPLICATIONS OF THE FINDINGS: Our results support previous data indicating a greater risk of SMM in IVF pregnancies, and among women with high BMI. However, these factors do not interact. Overweight and obese women who seek treatment with IVF should be counseled about pregnancy risks. The decision to proceed with IVF should be based on clinical judgment after considering an individual's chance of success and risk of complications. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by the Research Institute of the McGill University Health Centre (grant 6291) and also supported by the Trio Fertility (formerly Lifequest) Research Fund. The authors report no competing interests. TRIAL REGISTRATION NUMBER: Not applicable.

Compounds leached from quinoa seeds inhibit matrix metalloproteinase activity and intracellular reactive oxygen species.

OBJECTIVE: Quinoa (Chenopodium quinoa Willd.) is a seed crop rich in bioactive compounds including phytoecdysones (especially 20-hydroxyecdysone, 20HE), polyphenols, proteins and essential fatty acids. We previously reported a method to leach and concentrate quinoa bioactives into a complex phytochemical mixture termed quinoa leachate (QL). Here, we aimed to determine the effect of QL and its chemically distinct fractions on five biochemical endpoints relevant to skin care applications: (i) cell viability, (ii) matrix metalloproteinase (MMP) mRNA expression, (iii) MMP enzymatic activity, (iv) tyrosinase enzymatic activity and (v) intracellular reactive oxygen species (ROS) production. METHODS: Quinoa leachate was fractionated and chemically characterized using column chromatography and liquid chromatography-mass spectrometry (LC-MS). Cell viability was determined using a MTT assay in four mammalian cell lines. MMP-1 mRNA expression was assessed in human dermal fibroblasts (HDF) via qRT-PCR. The enzymatic activity of MMP-9 and tyrosinase was measured using fluorometric and colorimetric in vitro assays, respectively. Lipopolysaccharide (LPS)-induced ROS production was determined in human dermal fibroblasts by fluorescence intensity of an oxidant-sensitive probe. RESULTS: Quinoa leachate was separated into three fractions: (i) carbohydrate-rich fraction (QL-C; 71.3% w/w of QL); (ii) phytoecdysone, polyphenol and protein-rich fraction (QL-P, 13.3% w/w of QL); (iii) oil-rich fraction (QL-O, 10.8% w/w of QL). QL did not reduce cell viability in any of the four cell lines tested. QL, QL-P and QL-O each significantly inhibited MMP-1 mRNA expression in HDF at a concentration of 5 µg mL(-1) . QL and QL-P also significantly inhibited MMP-9 enzymatic activity, whereas QL-P demonstrated significant tyrosinase enzymatic inhibition. Furthermore, QL, QL-P, QL-O and 20HE significantly inhibited intracellular ROS production. CONCLUSION: This study is the first to demonstrate the MMP, tyrosinase and ROS inhibiting properties of multiple different phytochemical components derived from quinoa seeds. Our work indicates that quinoa phytochemicals may play a role in the treatment and prevention of skin ageing through a multiplicity of effects.

Preliminary evaluation of the genotoxic potential of a hydrophilic polymer with three preservation systems.

This study compared the genotoxic potential of a polymeric associative thickener used in topically applied emulsions preserved with three different preservative systems. The method used for the assessment of genotoxicity is the in vitro micronucleus test [Organization for Economic Cooperation and Development (OECD) guideline number 487]. When changing an additive such as a preservation system in a raw material, it is crucial to re-evaluate its toxicity potential because this change may significantly alter its properties. This study shows that at the levels tested neither of the systems evaluated demonstrated any cytotoxic or genotoxic effects. Skin exposure must take into consideration factors such as duration, skin condition and metabolism, but most importantly concentration. Although preservatives can be toxic at high concentrations, they are usually safe at the concentrations used in cosmetic raw materials and formulations. If used to preserve raw materials, they undergo further dilution when added to the formulation.

Genotoxic potential evaluation of a cosmetic insoluble substance by the micronuclei assay.

An optical brightener (OB) powder (INCI: sodium silicoaluminate (and) glycidoxypropyl trimethyloxysilane/PEI-250 cross fluorescent brightener 230 salt (and) polyvinylalcohol crosspolymer) that is used in cosmetic facial products was tested for its genotoxic potential using the micronuclei test (MNT). It is a solid dry powder with an average size of 5 microns that is insoluble but dispersible in water. This study describes the exposure of cell culture to positive controls with and without enzymatic activation and to the test compound in different concentrations. We evaluated three end points: microscopic observation and quantification of micronuclei formation, and cell viability and proliferation. Both positive controls induced significant changes that were observed under the microscope and quantified. Based on its chemical nature, it was not anticipated that the test substance will degrade under the conditions of the experiments. However, the test is required to make sure that when solublized, impurities that may be present, even at trace levels, will not induce a genotoxic effect. The test compound did not promote micronuclei formation or change the viability or proliferation rate of cells. During this study we faced challenges such as solubilization and correlating viability data to genotoxicity data. These are described in the body of the paper. We believe that with the emergence of the 7(th) European amendment that bans animal testing, sharing these data and the study protocol serves as a key in building the understanding of the utilization of in vitro studies in the safety assessment of cosmetic ingredients.

The risk of venous thrombosis, including cerebral vein thrombosis, among women with thrombophilia and oral contraceptive use: a meta-analysis.

Several small studies have reported an elevated risk of venous thrombosis (VT) with thrombophilia and oral contraceptive (OCP) use. We aimed to summarize the risk of VT among women with thrombophilia and OCP use and to assess the interaction between the 2 factors. We selected 15 studies that assessed the prevalence of OCP use and thrombophilia among reproductive-aged women. Odds ratios (ORs) were calculated for each study and pooled using the random effects model. We found an increased risk of VT among women with OCP use (pooled OR 3.0, 95% confidence interval [CI] 1.9-4.5) and with thrombophilia (pooled OR 4.5, CI 3.4-5.9), respectively. Heterogeneity was significant (I (2) >80%). Women with both thrombophilia and OCP use had a 14-fold risk of VT compared to healthy OCP nonusers (pooled OR 14.25, CI 6.2-32.8). Oral contraceptive use and thrombophilia similarly increase VT risk. Our study confirms an interaction between OCP use and thrombophilia.

A comparative evaluation of photo-toxic effect of fractionated melanin and chlorpromazine hydrochloride on human (dermal fibroblasts and epidermal keratinocytes) and mouse cell line/s (fibroblast Balb/c 3T3).

Fractionated melanin (Mel-HEV), a bleached version of natural melanin, offers protection against the high energy visible (HEV/UVA) and ultraviolet (specifically UVA) irradiation making it a potential compound to be added to skin care and sunscreen formulations and other cosmetic and personal care products. Chlorpromazine (CPZ) has been shown to exhibit photosensitivity and phototoxicity reaction in vitro and in vivo. Comparative evaluation of chemotoxicity and phototoxicity using Mel-HEV and CPZ (as positive control) was performed on mouse fibroblast cell line 'Balb/c 3T3'. This is the recommended method for evaluating the phototoxic potential of compounds under the European Center of Validation of Alternative Methods (ECVAM) guidelines (OECD, 2004). This study was expanded from a mouse cell line - Balb 3T3/c to two human cell lines - HDF and HEKn for two reasons: to compare the difference between the sensitivity and behavior of two fibroblast cell lines (Balb/c 3T3 vs. HDF) and to compare the differences between two fibroblast cell lines with the keratinocyte cell line (HDF & Balb/c 3T3 vs. HEKn). It was found that Balb/c 3T3 and HEKn were both sensitive to the phototoxic potential of CPZ. However, HDF showed insensitivity to phototoxic evaluation. The test compound, Mel-HEV, was found to be non-phototoxic. The mean toxic concentration (MTC) for CPZ during HEV and UVA exposure conditions was found to be similar using Balb/c 3T3 (36.25 µg/ml) and HEKn (39.99 µg/ml) showing that cells exhibit similar responses at HEV/UVA- conditions. However, Balb/c 3T3 showed more sensitivity to CPZ at HEV/UVA+ condition (MTC=0.87 µg/ml; mean PIF=55.33; MPE=0.395) than HEKn (MTC=5.35 µg/ml; PIF=7.61; MPE=0.276) making it the preferred cell line for phototoxicity evaluations.

Intracellular delivery mediated by an ethosomal carrier.

The goal of this work was to investigate the efficiency of transcellular delivery into Swiss albino mice 3T3 fibroblasts of molecules with various physico-chemical characteristics from ethosomes, phospholipid vesicular carriers containing ethanol. The probes chosen were: 4-(4-diethylamino) styryl-N-methylpyridinium iodide (D-289), rhodamine red dihexadecanoylglycerophosphoethanolamine (RR) and fluorescent phosphatidylcholine (PC*). The penetration of these fluorescent probes into fibroblasts and nude mice skin was examined by CLSM and FACS. CLSM micrographs showed that ethosomes facilitated the penetration of all probes into the cells, as evident from the high-intensity fluorescence. In comparison, when incorporated in hydroethanolic solution or classic liposomes, almost no fluorescence was detected. The intracellular presence of each of the three probes tested, was evident after 3 min of incubation. Furthermore, with ethosomal D-289, fluorescence was also seen in the fibroblast nucleus. Enhanced delivery of molecules from the ethosomal carrier was also observed in permeation experiments with the hydrophilic calcein and lypophilic RR to whole nude mouse skin. Calcein penetrated the skin to a depth of 160, 80 and 60 microm from ethosomes, hydroethanolic solution and liposomes, respectively. Maximum fluorescence intensities measured for RR delivered from ethosomes, hydroethanolic solution and liposomes were 150, 40 and 20 AU, respectively. Fibroblast viability tests showed that the ethosomal carrier is not toxic to the cultured cells.

Carriers for skin delivery of trihexyphenidyl HCl: ethosomes vs. liposomes.

The purpose of this work was to characterize a novel ethosomal carrier containing trihexyphenidyl HCl (THP) and to investigate the delivery of THP from ethosomes versus classic liposomes. THP-ethosomal systems were shown by electron microscopy to contain small, phospholipid vesicles. As the THP concentration was increased from 0 to 3%, the size of the vesicles decreased from 154 to 90 nm. This is most likely due to the surface activity of THP (critical micelle concentration of 5.9 mg/ml), as measured in this work. In addition, the ethosome zeta potential value increased as a function of THP concentration, from -4.5 to +10.4 when the THP concentration was increased from 0 to 3%. In contrast, THP liposomes were much larger and their charge was not affected by THP. When compared with standard liposomes, ethosomes had a higher entrapment capacity and a greater ability to deliver entrapped fluorescent probe to the deeper layers of skin. The flux of THP through nude mouse skin from THP ethosomes (0.21 mg/cm2 h) was 87, 51 and 4.5 times higher than from liposomes, phosphate buffer and hydroethanolic solution, respectively (p < 0.01). The quantity of THP remaining in the skin at the end of the 18-h experiment was statistically significantly greater from the ethosomal system than from liposomes or a control hydroethanolic solution. Our results indicate that the ethosomal THP system may be a promising candidate for transdermal delivery of THP.

Ethosomes - novel vesicular carriers for enhanced delivery: characterization and skin penetration properties.

This work describes a novel carrier for enhanced skin delivery, the ethosomal system, which is composed of phospholipid, ethanol and water. Ethosomal systems were much more efficient at delivering a fluorescent probe to the skin in terms of quantity and depth, than either liposomes or hydroalcoholic solution. The ethosomal system dramatically enhanced the skin permeation of minoxidil in vitro compared with either ethanolic or hydroethanolic solution or phospholipid ethanolic micellar solution of minoxidil. In addition, the transdermal delivery of testosterone from an ethosomal patch was greater both in vitro and in vivo than from commercially available patches. Skin permeation of ethosomal components, ethanol and phospholipid, was demonstrated in diffusion-cell experiments. Ethosomal systems composed of soy phosphatidylcholine 2%, ethanol 30% and water were shown by electron microscopy to contain multilamellar vesicles. 31P-NMR studies confirmed the bilayer configuration of the lipids. Calorimetry and fluorescence measurements suggested that the vesicular bilayers are flexible, having a relatively low T(m) and fluorescence anisotropy compared with liposomes obtained in the absence of ethanol. Dynamic light scattering measurements indicated that ethanol imparted a negative charge to the vesicles. The average vesicle size, as measured by dynamic light scattering, was modulated by altering the ethosome composition. Experiments using fluorescent probes and ultracentrifugation showed that the ethosomes had a high entrapment capacity for molecules of various lyophilicities.

Diethylene glycol monoethyl ether (Transcutol) displays antiproliferative properties alone and in combination with xanthines.

In the present study we have investigated the effects of diethylene glycol monoethyl ether (Transcutol) in combination with theophylline, caffeine and dyphylline and alone on 3T3 mouse fibroblast proliferation. These three xanthines (1-0.01 mM) inhibited fibroblast proliferation by themselves. Enhancement of the effect was detected by addition of 1 and 0.1 mM Transcutol. Transcutol alone also displayed a dose-dependent inhibition (2-0.01 mM) of both 3T3 and human normal and psoriatic fibroblasts, although normal human fibroblasts were the least sensitive to Transcutol antiproliferative activity. Transcutol was assessed for its antiproliferative effects on YAC lymphoma and P-815 mastocytoma human cell lines. Transcutol inhibited cell proliferation of both these cell lines, being more effective towards P-815 mastocytoma (at 2 mM it displayed 3.95-fold vs. 2.4-fold inhibition towards YAC lymphoma). In conclusion, we have shown that Transcutol has antiproliferative effects on 3T3 murine, human normal and psoriatic fibroblasts and tumour cell lines. In addition it enhances xanthine antiproliferative effects on 3T3 fibroblasts. Therefore it might be a useful topical drug alone or in combination with xanthines in the treatment of skin hyperproliferative disorders.

Cyclosporin A affects red blood cell deformability in vivo but not in vitro in guinea pig.

A hemorheological mechanism has been proposed for the hemodynamic effects of cyclosporin A (CsA). In vivo and in vitro effects of CsA on red blood cell (RBC) deformability were investigated in guinea pigs. RBC transit time, measured by a cell transit analyzer, was found to be prolonged, implying impaired deformability in guinea pigs treated with CsA (10 mg/kg/day) for 7 days. Blood CsA concentration was approximately 900 ng/ml. RBC cytosolic calcium concentration was higher in the CsA-treated groups than in the control group. RBC lipid peroxidation was not affected. Combining pentoxifylline injections (100 mg/kg/day) with CsA therapy did not prevent the effect on RBC deformability and cytosolic calcium concentration. CsA did not affect RBC transit time and cytosolic calcium concentration in vitro. Thus, the influence of CsA on RBC deformability appears to be an indirect effect that is mediated by the alterations in RBC calcium homeostasis.

Dyphylline liposomes for delivery to the skin.

Delivery of dyphylline to the skin using liposomes was investigated. Xanthines are inhibitors of cAMP phosphodiesterase and have been considered for treatment of psoriasis. Dyphylline was chosen because of its solubility in water, which should allow for incorporation of higher concentrations within the liposomes. Liposomes containing dyphylline were prepared by a method using sonication. Transmission electron micrography (TEM) visualization showed small particles ranging from 40 to 100 nm, and particle size distribution determined by light scattering showed the vesicles to have an average diameter of 360 nm. The transdermal delivery of free dyphylline and dyphylline incorporated in unilamellar liposomes was measured from polyethylene glycol (PEG), Carbopol gel, a PEG enhancer base, and water. For comparison, similar experiments were carried out with theophylline as well. When the drugs were incorporated in Carbopol gel, a large difference was seen between their fluxes, with free dyphylline having the highest permeation, followed by liposomal dyphylline, and then theophylline. With the PEG enhancer base, a very high permeation of theophylline was observed relative to dyphylline and liposomal dyphylline. From the PEG base, liposomal dyphylline exhibited the lowest skin permeation flux relative to other bases. Using the PEG base for dyphylline incorporated in liposomes, a high skin partitioning of the drug, along with low transdermal permeation, was measured. These results may indicate that the drug is localized in the skin.