The association between maternal intra-abdominal pressure and hypertension in pregnancy

Sajith Jayasundara; Malik Goonewardene; Lanka Dassanayake

doi:10.1371/journal.pone.0284230

Peer Review History

Original SubmissionMarch 26, 2023
21 Jun 2023 Decision Letter - Surangi Jayakody, Editor PONE-D-23-06569The association between maternal intra-abdominal pressure and hypertension in pregnancyPLOS ONE Dear Dr. Sajith, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Aug 05 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for your efforts and hard work. Can you please clarify these points: 1- Why you only included the patients who are having Caesarian sections? Have you put into your consideration that the pain, the reduced bowel movements, and even the ileus after the C.S can make some bias in measuring the post-operative intraabdominal pressure measurements? 2- Your assumption that the increased intraabdominal pressure is associated with PIH doesn't explain why molar pregnancy is a risk factor for PIH and preeclampsia. As well doesn't explain why we have postpartum preeclampsia and postpartum high BP while the IAP is decreased. on the other hand doesn't explain the normotensive patients who have a reason to have an increase on their IAP as in LGA, Uterine fibroids, and polyhydramnios. can you highlight these conditions, please? 3- What is your objective after concluding that hypertension during pregnancy is associated with raised antepartum and postpartum IAP, any recommendations? 4- All your references are of more than 5 years, Any chance you can have updated references to your topic? Reviewer #2: Very interesting study, Thank you for bringing new interesting thought of parameter for evaluate Pregnancy induced hypertension. In Pregnancy induced hypertension one of the main physiological change in maternal body is fluid retention. Therefore I think it is important to find out association between maternal weight gain with Intra abdominal pressure. There could be increase abdominal pressure due to abdominal wall swelling! Also according to study result there is no correlation with fetal weight and abdominal hypertension in Pregnancy induced hypertension group. I think post partum pain management is very important in planning to measure abdominal pressure in both groups. Therefore it is very important to describe post partum pain management in study. Thank you! ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. 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Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0284230.r001
Revision 1
19 Aug 2023 Author Response Reviewer #1: 1- Why you only included the patients who are having caesarean deliveries ? IAP measurement includes the insertion of a urinary catheter for IVP measurement. This procedure is commonly done during CD, and the catheter is kept in place until the patient can start moving in the post-operative period. We have decided to utilize this routine practice as an opportunity for our study methodology, rather than introducing an additional intervention for participants. However, for vaginal deliveries, urinary catheter insertion is not a routine protocol. Therefore, we have not included vaginal delivery as part of our study. This information is now included in the manuscript under Methods- Line number 127-128 2. Have you put into your consideration that the pain, the reduced bowel movements, and even the ileus after the C.S can make some bias in measuring the post-operative intraabdominal pressure measurements? As part of the post-CD analgesic protocol. To ensure effective pain management, post-operative pain levels are consistently assessed using a pain score, and analgesics are administered following the WHO analgesics ladder guidelines. Clinical assessments post-CD focus on identifying potential complications such as post-operative bleeding, surgical infections, constipation, and post-operative ileus. None of the participants experienced any of these complications during their hospital stay following the operation. This information is now included in the manuscript under Methods - Line number 141-144 3 . Your assumption that the increased intraabdominal pressure is associated with PIH doesn't explain why molar pregnancy is a risk factor for PIH and preeclampsia. As well doesn't explain why we have postpartum preeclampsia and postpartum high BP while the IAP is decreased. on the other hand doesn't explain the normotensive patients who have a reason to have an increase on their IAP as in LGA, Uterine fibroids, and polyhydramnios. can you highlight these conditions, please? The development of PIH is influenced by multiple factors. The placenta plays central role in the pathogenesis of preeclampsia, specifically in relation to the imbalance of placental pro-angiogenic and anti-angiogenic factors. Genetic factors and immune factors have also been established as contributors to the development of preeclampsia. Additionally, increased IAP may serve as a contributing factor [1]. The extent of each factor's contribution to the pathogenesis may vary depending on individual circumstances. In the pathogenesis of preeclampsia, the presence of amplified anti-angiogenic factors from the placenta is believed to be particularly prominent in cases of molar pregnancy as compared to other factors. Additionally, changing partners between pregnancies increases the risk of preeclampsia, where immune maladaptation at the fetal-maternal interface could be an underlying mechanism more than other factors. The role of IAP in the development of preeclampsia may align with the traditional concept of disease causation, where the virulence of the agent and the susceptibility of the host play a crucial role. Consequently, elevated IAP might not always lead to preeclampsia in situations that raise the IAP, for instance, polyhydramnios, fetal macrosomia, uterine fibroids, or ovarian cysts. After delivery of fetus and placenta, IAP levels typically decrease. Nevertheless, the effects of pathological processes following delivery can either linger or diminish, contingent upon individual factors. In particular, the presence of elevated levels of placental pathological agents in circulation post-delivery can contribute to the development of postpartum preeclampsia and hypertension [2]. 1. Marshalov DV, Shifman EM, Salov IA, Petrenko AP, Ioscovich A. Preeclampsia is a Syndrome of Intra-Abdominal Hypertension in Pregnancy - would a Hypothesis become a Theory?. J Clin Anesth Manag. 2017;2(1): doi http://doi.org/10.16966/2470-9956.122 2. Brien ME, Boufaied I, Soglio DD, Rey E, Leduc L, Girard S. Distinct inflammatory profile in preeclampsia and postpartum preeclampsia reveal unique mechanisms. Biol Reprod. 2019 Jan 1;100(1):187-194. doi: 10.1093/biolre/ioy164. PMID: 30010720 This information is now included in the manuscript under Introduction- Line number 92- 109 4. What is your objective after concluding that hypertension during pregnancy is associated with raised antepartum and postpartum IAP, any recommendations? It is very interesting to consider that preeclampsia only occurs spontaneously in humans and apes, and has been reported in a baboon with twins. – it is a very human and primate specific disease [1]. This may be because almost all other animals carry their young standing on four legs with the abdomen suspended inferiorly, which would be associated with a low IAP in pregnancy. Exploring the potential therapeutic implications of reducing IAP during pregnancy on PIH remains an understudied area. Interestingly, 60 years ago, a method involving the application of negative abdominal pressure externally was described as a treatment for preeclampsia. A pilot study reported a positive response to this treatment in 90% of cases [2]. However, this device never gained widespread acceptance or use. Recent study found that prone position may reduce systolic blood pressure in women with preeclampsia without immediate obvious adverse effects [3]. We would suggest prone position or all four-leg position in pregnancy may reduce the IAP and development and progression of preeclampsia. 1. Chau K, Welsh M, Makris A, Hennessy A. Progress in preeclampsia: the contribution of animal models. J Hum Hypertens. 2022 Aug;36(8):705-710. doi: 10.1038/s41371-021-00637-x. Epub 2021 Nov 26. PMID: 34837033; PMCID: PMC8617007. 2. Blecher JA, Heyns OS. Abdominal decompression in the treatment of the toxaemias of pregnancy. Lancet. 1967;2(7517):621-624. doi:10.1016/s0140-6736(67)90678-2 3. Dennis AT, Hardy L, Leeton L. The prone position in healthy pregnant women and in women with preeclampsia - a pilot study. BMC Pregnancy Childbirth. 2018;18(1):445. Published 2018 Nov 16. doi:10.1186/s12884-018-2073-x This information is now included in the manuscript under Discussion- Line number 259- 272 5. All your references are of more than 5 years, Any chance you can have updated references to your topic? Agreed with your valuable comment. There is a dearth of scientific literature on this topic. However, we have included recently published evidence. We included following references: 1. Arora V, Tyagi A, Ramanujam M, Luthra A. Intraabdominal pressure in non-laboring preeclamptic vs normotensive patients undergoing cesarean section: A prospective observational study. Acta Obstet Gynecol Scand. 2020; 99: 1031- 1038. 2. Arruda Correia ML, Peixoto Filho FM, Gomes Júnior SC, Peixoto MVM. Effects of intra-abdominal hypertension on maternal-fetal outcomes in term pregnant women: A systematic review. PLoS One. 2023;18(6):e0280869. Published 2023 Jun 27. doi:10.1371/journal.pone.0280869 This information is now included in the manuscript under Discussion- Line number 229- 231 and 237 -242 Reviewer #2: 1. In Pregnancy induced hypertension one of the main physiological change in maternal body is fluid retention. Therefore I think it is important to find out association between maternal weight gain with Intra abdominal pressure. There could be increase abdominal pressure due to abdominal wall swelling! Also according to study result there is no correlation with fetal weight and abdominal hypertension in Pregnancy induced hypertension group. Agreed with your valuable comment. We conducted a cross sectional study. However, prospective cohort study design with serial measurement of IAP in different gestations and postpartum, maternal weight gain, fetal weight gain in HIP and normotensive groups may be more informative. In our study, IAP is correlate with birth weight in normotensive pregnancy. Interestingly, It is not correlate with birthweight in HIP group. It raises the suspicious of “IAP in PIH group may not only result of growing fetus compare to the normotensive group – Additional increased IAP may play role in pathogenesis of HIP’’. 2. I think post partum pain management is very important in planning to measure abdominal pressure in both groups. Therefore it is very important to describe post partum pain management in study. As part of the post-CD analgesic protocol. To ensure effective pain management, post-operative pain levels are consistently assessed using a pain score, and analgesics are administered following the WHO analgesics ladder guidelines. Clinical assessments post-CD focus on identifying potential complications such as post-operative bleeding, surgical infections, constipation, and post-operative ileus. None of the participants experienced any of these complications during their hospital stay following the operation. This information is now included in the manuscript under Methods - Line number 141-144 Attachments Attachment Submitted filename: Response to Reviewer # 2 Comments .docx https://doi.org/10.1371/journal.pone.0284230.r002
3 Oct 2023 Decision Letter - Surangi Jayakody, Editor The association between maternal intra-abdominal pressure and hypertension in pregnancy PONE-D-23-06569R1 Dear Dr. Sajith, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: I Don't Know ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for addressing all the previous reviewers' comments. I would accept this paper so far for publication. Reviewer #3: Congratulations to the authors who have addressed a rarely explored topic. Preeclampsia is an important topic and the current article notes an association of IAP around the time of delivery with HIP. The article is well written and an interesting read. Previous reviewer comments have all been addressed in the current version. Recommendation- Accept ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Mena Abdalla Reviewer #3: Yes: indu asanka jayawardane ******** https://doi.org/10.1371/journal.pone.0284230.r003
Formally Accepted
9 Oct 2023 Acceptance Letter - Surangi Jayakody, Editor PONE-D-23-06569R1 The association between maternal intra-abdominal pressure and hypertension in pregnancy Dear Dr. Jayasundara: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr Surangi Jayakody Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0284230.r004

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