Cardiovascular Physiology of Pregnancy

Clinical Features and Outcomes of Pregnancy-Related Acute Aortic Dissection

Importance

Women with aortopathy conditions are at risk for pregnancy-related aortic dissection, and these conditions may not be recognized until after the aortic dissection occurs.

Objective

To examine the clinical characteristics, imaging features, and outcomes in women with pregnancy-related acute aortic dissection.

Design, Setting, and Participants

A cohort study, comprising data from the International Registry of Acute Aortic Dissection (IRAD) (February 1, 1998, to February 28, 2018). The multicenter referral center study included 29 women with aortic dissection during pregnancy or less than 12 weeks post partum in IRAD from 1998 to 2018.

Main Outcomes and Measures

Clinical features of pregnancy-related aortic dissection to be studied included underlying aortopathy, aortic size, type of aortic dissection, timing of dissection, hypertension, and previous aortic surgery.

Results

A total of 29 women (mean [SD] age, 32 [6] years) had pregnancy-related aortic dissection, representing 0.3% of all aortic dissections and 1% of aortic dissection in women in the IRAD. Among women younger than 35 years, aortic dissection was related to pregnancy in 20 of 105 women (19%). Thirteen women (45%) had type A aortic dissection, and 16 women (55%) had type B. Aortic dissection onset was known in 27 women (93%): 15 during pregnancy, 4 in the first trimester, and 11 in the third trimester; 12 were post partum, occurring a mean (SD) of 12.5 (14) days post partum. At type A aortic dissection diagnosis, the mean (SD) aortic diameters were sinus of Valsalva, 54.5 (5) mm and ascending aorta, 54.7 (6) mm. At type B aortic dissection diagnosis, the mean (SD) descending aortic diameter was 32.5 (5) mm. Twenty women (69%) had an aortopathy condition or a positive family history: 13 women (65%) with Marfan syndrome, 2 women (10%) with Loeys-Dietz syndrome, 2 women (10%) with bicuspid aortic valves, 2 women (10%) with a family history of aortic disease, and 1 woman (5%) with familial thoracic aortic aneurysm. Aortopathy was not recognized until after aortic dissection in 47% of the women. Twenty-eight women (97%) survived aortic dissection hospitalization.

Conclusions and Relevance

Aortic dissection complicating pregnancy is rare. Most pregnancy-related aortic dissection is due to an aortopathy often not diagnosed until after aortic dissection. In this study, type A aortic dissections were associated with a dilated aorta, and type B aortic dissections often were not. Recognition of underlying conditions and risks for aortic dissection may improve management of pregnancy in women with aortopathy.

Resuscitating the Crashing Pregnant Patient

Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.

Unveiling the Mystery of Peripartum Cardiomyopathy: A Traditional Review

Peripartum cardiomyopathy (PPCM) can be classified as a variant of dilated cardiomyopathy identified usually within the first five months of delivery or during the last month of pregnancy. This condition presents as systolic heart failure. PPCM affects thousands of women in the United States each year. Even though it was first noticed in the 1800s, its etiology remains unknown. This study aims to review the pathophysiology and management of PPCM and explore the possible outcomes of peripartum cardiomyopathy. PPCM can lead to maternal death if diagnosis or treatment is delayed. Diagnosing PPCM has been challenging because it can be misdiagnosed or perceived as a sign of pregnancy since most of the symptoms of PPCM strongly match those within the typical pregnancy continuum and postpartum cycle. Patients' implications are fatal and carry a high mortality rate when PPCM is misdiagnosed or treatment is delayed. To accurately identify PPCM, using echocardiography, the left ventricular end-diastolic size and the ejection fraction should be measured to determine the severity of PPCM. Managing peripartum cardiomyopathy involves using traditional treatments for heart failure. Therapeutic recommendations are made depending on the patient's status (pregnancy, breastfeeding, postpartum) while considering the drug-safety profiles before administration. Some other treatments have also been used to control PPCM depending on how severe it has become; for example, antiarrhythmics have been used to treat cardiac arrhythmias when they ensue. In extreme cases, mechanical assistance and transplantation could be required. Based on the proposed pathophysiology involving the 16kDA anti-angiogenic sub-fragment, bromocriptine may be used even though it still needs more assessment due to limited evidence.

Using PubMed as a major search resource, a thorough analysis of publications was carried out after incorporating this review's inclusion and exclusion criteria. A total of 455,141 publications were found using keywords and keyword combinations. With a careful selection of articles, 31 publications provided relevant information on our primary endpoint. All articles in this examination were chosen without limitation to the type of study, including clinical trials, review articles, meta-analyses, and so on. Our review suggests that, based on factors such as early detection and management, disease severity, ethnicity, and quality of patient care, patients with PPCM presented different outcomes and prognosis. However, despite PPCM's high mortality rate and its risk of recurrence, most patients tend to recover within six months of disease onset.

Cardiopulmonary exercise testing during pregnancy

The goal of this review is to examine practical considerations when conducting cardiopulmonary exercise testing during pregnancy. In a clinical and research setting, cardiopulmonary exercise testing during pregnancy is valuable in identifying underlying cardiopulmonary conditions, stratifying the risk of adverse pregnancy outcomes, as well as establishing exercise tolerance/limitations. This review encompasses information regarding the unique physiological adaptations that occur throughout gestation (e.g., changes in resting heart rate, blood pressure, glucose, etc.) and how these adaptations impact the interpretation of physiological measurements. There are also key concerns that are unique to pregnant populations that should be considered when participating in exercise (i.e., fetus, ventilation, thermoregulation, urinary incontinence, low back pain, and pelvic girdle pain). This step-by-step review of cardiopulmonary exercise testing outlines pregnancy related adjustments to standardized methods (i.e., screening/documentation, pre- and post-test measurements, protocol specifics, modality selection, and fetal monitoring) which should be considered for the safety of both the participant and fetus. Currently, pregnancy specific exercise testing guidelines are lacking. Therefore, we will be discussing the limitations of current recommendations such as a safe cut off for resting heart rate and pregnancy specific test termination criteria.

Pregnancy Per- and Polyfluoroalkyl Substance Concentrations and Postpartum Health in Project Viva: A Prospective Cohort

CONTEXT

Per- and polyfluoroalkyl substances (PFAS) are environmental chemicals linked to weight gain and type 2 diabetes.

OBJECTIVE

We examined the extent to which PFAS plasma concentrations during pregnancy were associated with postpartum anthropometry and biomarkers.

DESIGN, PATIENTS, AND MEASURES

We studied women recruited between 1999 and 2002 in the Project Viva prospective cohort with pregnancy plasma concentrations of PFAS, including perfluorooctanesulfonic acid (PFOS), perfluorooctanoic acid (PFOA), and 2-(N-ethyl-perfluorooctane sulfonamide) acetic acid (EtFOSAA). Three-year postpartum anthropometry measurements were available from 786 to 801 women, blood pressure from 761 women, and blood biomarkers from 450 to 454 women. We used multivariable regression to evaluate the association of log2-transformed PFAS with postpartum anthropometry, blood pressure, and blood biomarkers (leptin, adiponectin, sex hormone binding globulin [SHBG], hemoglobin A1c, interleukin-6 [IL-6], C-reactive protein), adjusting for age, prepregnancy body mass index, marital status, race/ethnicity, education, income, smoking, parity, and breastfeeding history.

RESULTS

Pregnancy concentrations of certain PFAS were associated with greater adiposity (eg, 0.4 cm [95% confidence interval [95%CI]: -0.1, 0.9] greater waist circumference per doubling in EtFOSAA; 0.2 cm [95%CI: -0.1, 0.5] greater mid-upper arm circumference per doubling in PFOA; 1.2 mm [95%CI: 0.1, 2.2] thicker sum of subscapular and triceps skinfolds per doubling in PFOS) and higher systolic blood pressure (eg, 1.2 mm Hg [95%CI: 0.3, 2.2] per doubling in PFOS) at 3 years postpartum. Higher EtFOSAA concentrations were also associated with 10.8% higher IL-6 (95%CI: 3.3, 18.9) and 6.1% lower SHBG (95%CI: 0.7, 11.2) per doubling.

CONCLUSIONS

Pregnancy concentrations of EtFOSAA, PFOS, and PFOA were associated with adverse postpartum cardiometabolic markers.

Association between Pregnancy and Cervical Artery Dissection

OBJECTIVE

We wanted to determine whether pregnancy is associated with cervical artery dissection.

METHODS

We performed a case-control study using claims data from all nonfederal emergency departments and acute care hospitals in New York and Florida between 2005 and 2015. Cases were women 12-42 years of age hospitalized with cervical artery dissection, defined using validated diagnosis codes for carotid/vertebral artery dissection. Controls were women 12-42 years of age with a primary diagnosis of renal colic. Cases and controls were matched 1:1 on age, race, insurance, income, state, and visit year. The exposure variable was pregnancy, defined as labor and delivery within 90 days before or 6 months after the index visit. Logistic regression was used to compare the odds of pregnancy between cases and controls. We performed a secondary cohort-crossover study comparing the risk of cervical artery dissection during pregnancy versus the same time period 1 year later.

RESULTS

Pregnancy was twice as common among 826 women with cervical artery dissection compared with the 826 matched controls with renal colic (odds ratio, 2.5; 95% confidence interval [CI], 1.3-4.7). In our secondary analysis, pregnancy was associated with a higher risk of cervical artery dissection (incidence rate ratio [IRR], 2.2; 95% CI, 1.3-3.5), with the heightened risk limited to the postpartum period (IRR, 5.5; 95% CI, 2.6-11.7).

INTERPRETATION

Pregnancy, specifically the postpartum period, was associated with hospitalization for cervical artery dissection. Although these findings might in part reflect ascertainment bias, our results suggest that arterial dissection is one mechanism by which pregnancy can lead to stroke. ANN NEUROL 2020;88:596-602.

Number of Pregnancies and Risk of Atrial Fibrillation

Pregnancy is associated with major structural and hemodynamic changes in the cardiovascular system that predispose women to an increased risk of atrial fibrillation. While these changes generally resolve after parturition, the impact of subsequent pregnancies on the risk of atrial fibrillation is unknown. We searched through PubMed for studies that have investigated the impact of multiparity on the risk of atrial fibrillation. The following Medical Subject Headings terms were used: ([repeated pregnancies] OR parity) AND ([Atrial fibrillation] OR AF). Studies with complete data were included in the current study. Out of 135 studies identified through the prespecified criteria, we selected 2 studies with relevant data. Increasing number of pregnancies was associated with an increased risk of atrial fibrillation in a dose-response relationship. Our systematic review suggests that multiparity is associated with an increased risk of atrial fibrillation. More studies are warranted to elucidate the association between repeated pregnancies and atrial fibrillation.

Downregulated expression of microRNAs associated with cardiac hypertrophy and fibrosis in physiological pregnancy and the association with echocardiographically-evaluated myocardial function

The aim of the present study was to analyze the profiles of cardiac microRNAs (miRNAs/miRs) in healthy pregnant women and non-pregnant controls. A total of 61 healthy women >18 years of age with singleton pregnancies in the third trimester were compared with 19 non-pregnant controls. Specifically, expression of miRNAs associated with cardiac hypertrophy (miR-1, miR-17-5, miR-22, miR-34a, miR-124, miR-133a, miR-195, miR-199a-3p, miR-199b, miR-210, miR-222 and miR-1249) and miRNAs associated with cardiac hypertrophy and fibrosis (miR-15b, miR-21, miR-26a, miR-29-a, miR-29c, miR-30c, miR-101, miR-146a, miR-191, miR-208a-5p and miR-328) were analyzed and compared with echocardiographic examination results. Both groups had similar cardiac miRNA expression profiles, but differed in quantitative evaluation. Women in the third trimester of physiological pregnancy exhibited downregulation of certain profibrotic miRNAs (miR-21, miR-30c and miR-328), decreased expression of a hypertrophic and antimetabolic miRNAs (miR-146a), downregulation of an antifibrotic miRNA (miR-222), and downregulation of a hypertrophic miRNA (miR-195). In pregnant women, the indices of systolic function were associated with miR-195 expression, and an interplay between miR-17-5p and diastolic function was observed. While the profiles of cardiac miRNAs expressed in healthy pregnant women and healthy non-pregnant controls were similar, these two groups differed in terms of expression of specific miRNAs. In the third trimester of physiological pregnancy, a downregulation of miR-17-5p, miR-21, miR-30c, miR-146a, miR-195, miR-222 and miR-328 was observed. The differences in the association between echocardiographic indices with miRNAs in pregnant and non-pregnant women suggest that miRNAs regulate both the structure and function of the pregnant heart, influencing cardiac muscle thickness as well as systolic and diastolic function.

Evaluation of Vascular Reactivity of Maternal Vascular Adaptations of Pregnancy With Quantitative MRI: Pilot Study

BACKGROUND

Abnormal maternal vascular function during pregnancy stemming from systemic endothelial dysfunction (EDF) has a central role in the pathophysiology of preeclampsia (PE).

PURPOSE

To utilize quantitative MRI to investigate changes in physiological measures of vascular reactivity during normal pregnancy, and to explore EDF associated with preeclampsia.

STUDY TYPE

Prospective.

POPULATION

Healthy pregnant (HP) (n = 14, mean GA = 26 ± 7 weeks) and nonpregnant women (NP; n = 14); newly postpartum (PP <48 hours) women with severe PE (PP-PE; n = 4) and normotensive pregnancy (PP-HP; n = 5).

FIELD STRENGTH/SEQUENCE

1.5T/3T. RF spoiled multiecho gradient-recalled echo, 1D phase-contrast MRI, time-of-flight.

ASSESSMENT

The micro- and macrovascular function (vasodilatory capacity of arterioles and conduit arteries, respectively) of the femoral vascular bed was evaluated with MRI-based venous oximetry, arterial velocimetry, and luminal flow-mediated dilation quantification, during cuff-induced reactive hyperemia. Aortic arch pulse-wave velocity (aPWV) was quantified to assess arterial stiffness using an ungated 1D technique.

STATISTICAL TESTS

Two-tailed unpaired t-tests were performed to address our two, primary a priori comparisons, HP vs. NP, and PP-PE vs. PP-HP. Given the pilot nature of this study, adjustments for multiple comparisons were not performed.

RESULTS

In HP, microvascular function was attenuated compared to NP by a significant increase in the washout time (10 ± 2 vs. 8 ± 2 sec; P < 0.05) and reduced upslope (2.1 ± 0.5 vs. 3.2 ± 0.8%HbO₂ /s; P < 0.05), time of forward flow (28 ± 5 vs. 33 ± 6 sec, P < 0.05), and hyperemic index (11 ± 3 vs. 16 ± 4 cm/s² ; P < 0.05), but luminal flow-mediated dilatation (FMD_L )was comparable between HP and NP. PP-PE exhibited significant vascular dysfunction compared to PP-HP, as evidenced by differences in upslope (2.2 ± 0.6 vs. 1.3 ± 0.2%HbO₂ /s, P < 0.05), overshoot (16 ± 5 vs. 7 ± 3%HbO₂ , P < 0.05), time of forward flow (28 ± 6 vs. 15 ± 7 s, P < 0.05), and aPWV (7 ± 1 vs. 8 ± 1 m/s, P < 0.05).

DATA CONCLUSION

Attenuated vascular reactivity during pregnancy suggests that the systemic vasodilatory state partially depletes nitric oxide bioavailability. Preliminary data support the potential for MRI to identify vascular dysfunction in vivo that underlies PE. Level of Evidence 2 Technical Efficacy Stage 1 J. MAGN. RESON. IMAGING 2021;53:447-455.

Postpartum Hypertension

PURPOSE OF REVIEW

Hypertension affects approximately 10% of pregnancies and may persist in the postpartum period. Furthermore, de novo hypertension may present after delivery, but its exact prevalence is not verified. Both types of hypertension expose the mother to eventually severe complications like eclampsia, stroke, pulmonary edema, and HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome.

RECENT FINDINGS

Until today, there are limited data regarding the risk factors, pathogenesis, and pathophysiology of postpartum hypertensive disorders. However, there is certain evidence that preeclampsia may in large part be responsible. Women who experienced preeclampsia during pregnancy, although considered cured after delivery and elimination of the placenta, continue to present endothelial and renal dysfunction in the postpartum period. The brain and kidneys are particularly sensitive to this pathological vascular condition, and severe complications may result from their involvement. Large randomized trials are needed to give us the evidence that will allow a timely diagnosis and treatment. Until then, medical providers should increase their knowledge regarding hypertension after delivery because many times there is an underestimation of the complications that can ensue after a misdiagnosed or undertreated postpartum hypertension.

Epigenetic age and pregnancy outcomes: GrimAge acceleration is associated with shorter gestational length and lower birthweight

BACKGROUND

Advanced biological aging, as measured by epigenetic aging indices, is associated with early mortality and morbidity. Associations between maternal epigenetic aging indices in pregnancy and pregnancy outcomes, namely gestational length and birthweight, have not been assessed. The purpose of this study was to examine whether epigenetic age during pregnancy was associated with gestational length and birthweight.

RESULTS

The sample consisted of 77 women from the Los Angeles, CA, area enrolled in the Healthy Babies Before Birth study. Whole blood samples for DNA methylation assay were obtained during the second trimester (15.6 ± 2.15 weeks gestation). Epigenetic age indices GrimAge acceleration (GrimAgeAccel), DNAm PAI-1, DNAm ADM, and DNAm cystatin C were calculated. Gestational length and birthweight were obtained from medical chart review. Covariates were maternal sociodemographic variables, gestational age at blood sample collection, and pre-pregnancy body mass index. In separate covariate-adjusted linear regression models, higher early second trimester GrimAgeAccel, b(SE) = - .171 (.056), p = .004; DNAm PAI-1, b(SE) = - 1.95 × 10-4 (8.5 × 10-5), p = .004; DNAm ADM, b(SE) = - .033 (.011), p = .003; and DNAm cystatin C, b(SE) = 2.10 × 10-5 (8.0 × 10-5), p = .012, were each associated with shorter gestational length. Higher GrimAgeAccel, b(SE) = - 75.2 (19.7), p < .001; DNAm PAI-1, b(SE) = - .079(.031), p = .013; DNAm ADM, b(SE) = - 13.8 (3.87), p = .001; and DNAm cystatin C, b(SE) = - .010 (.003), p = .001, were also associated with lower birthweight, independent of gestational length.

DISCUSSION

Higher maternal prenatal GrimAgeAccel, DNAm PAI-1, DNAm ADM, and DNAm cystatin C were associated with shorter gestational length and lower birthweight. These findings suggest that biological age, as measured by these epigenetic indices, could indicate risk for adverse pregnancy outcomes.

Severe Cardiopulmonary Disease in a Parturient With Noonan Syndrome

Noonan syndrome is a relatively common genetic disorder and the second most common cause of congenital heart disease after trisomy 21. The spectrum of cardiac anomalies in Noonan syndrome typically involves pulmonary valve stenosis occasionally in conjunction with hypertrophic cardiomyopathy. Mitral valve involvement is a rare finding in Noonan syndrome and is most commonly associated with either mitral valve prolapse or abnormal valvular insertion causing left ventricular outflow tract obstruction. Patients with Noonan syndrome typically have preserved fertility and, given the success of cardiac surgery and medical management of heart failure in this population, are beginning to present more commonly as parturients in adulthood. Maternal physiologic changes during pregnancy introduce an added complexity to hemodynamic management and anesthetic considerations during labor and delivery. In this article, we present a case of a patient with Noonan syndrome with severe mitral stenosis, pulmonary valve insufficiency, and severe restrictive and obstructive pulmonary disease who presented preterm for delivery due to increased dyspnea at rest. Here we review the pathophysiology behind Noonan syndrome and peripartum management strategies in a patient with severe combined cardiac and pulmonary disease.

Shock Index and Postpartum Hemorrhage in Vaginal Deliveries: A Multicenter Retrospective Study

INTRODUCTION

Shock index (SI), calculated by dividing heart rate by systolic blood pressure, is used to detect hemodynamic instability and hypovolemia. In obstetric practice, limited evidence is available regarding its usefulness in detecting postpartum hemorrhage (PPH). We aimed to evaluate the usefulness of SI in detecting PPH in vaginal deliveries using clinical data from 12 primary maternity care units in Japan.

MATERIAL AND METHODS

In this multicenter retrospective study, a total of 30,820 women who delivered vaginally at term at 12 primary maternity care units from January 2012 to December 2018 were included. Systolic and diastolic blood pressures and heart rate were measured at five different time points from admission to postpartum 2 h, and postpartum blood loss was measured. We evaluated the trend of average SI and the performance of each vital sign for detection of PPH.

RESULTS

The trend of average SI during labor and the immediate postpartum period was approximately 0.7 in women with blood loss of <500 mL. SI from the time of delivery of the placenta increased with an increase in blood loss. SI had the highest area under the receiver operating characteristic curve of 0.699 [95% confidence interval (CI), 0.682-0.716] and 0.758 (95% CI, 0.729-0.788) for PPH of ≥1,000 and ≥1,500 mL, respectively. However, both sensitivity of SI (1.0) for PPH (≥1,000 mL; 29.9%, and ≥1,500 mL; 40.5%, respectively) and correlation between maximum SI and blood loss (coefficient of correlation, 0.263) were low.

CONCLUSIONS

SI is a better parameter for PPH detection in vaginal deliveries than other vital signs. However, clinical judgment must incorporate other vital signs and symptoms associated with hypovolemic shock due to the low sensitivity of SI.

Anatomical and physiological alterations of pregnancy

The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Management of valvular heart disease in the pregnant patient

INTRODUCTION

Among cardiovascular disease in pregnancy, valvular heart disease remains a prevalent cause of maternal and fetal morbidity. The physiological changes of pregnancy can lead to decompensation of known or silent valvular heart disease. This poses a challenge to both physicians and patients in determining the best timing and management of valvular disease in the pre and post conception settings. This condition requires specific care to minimize both maternal and fetal morbidity and mortality.

AREAS COVERED

In this article, we review the recommended management of valvular heart disease in pregnancy, which include stenotic lesions, regurgitant lesions and prosthetic valves.

EXPERT OPINION

Overall, left sided stenotic lesions are poorly tolerated and require intervention prior to pregnancy in cases of severe or symptomatic stenosis. Regurgitant lesions, isolated right sided lesions and bioprosthetic valves are better tolerated. Mechanical valves pose a challenging scenario given the high risk for valve thrombosis which must be balanced with the risk of bleeding and fetal embryopathy. Shared decision making is primordial in choosing the anticoagulant strategy during pregnancy in patients with mechanical valves.

Life Course Changes in Cardiometabolic Risk Factors Associated With Preterm Delivery: The 30-Year CARDIA Study

Background

Women who deliver preterm infants (<37 weeks) have excess cardiovascular risk; however, it is unclear whether the unfavorable changes in the cardiometabolic profile associated with preterm delivery initiate before, during, or after childbearing.

Methods and Results

We identified 1306 women (51% Black) with births between baseline (1985–1986) and year 30 in the CARDIA (Coronary Artery Risk Development in Young Adults) study. We compared life course changes in blood pressure, body mass index, waist circumference, and lipids in women with preterm deliveries (n=318) with those with all term deliveries (n=988), using piecewise linear mixed‐effects models. Specifically, we evaluated group differences in rates of change before and after the childbearing period and change in level across the childbearing period. After adjusting for the covariates, women with preterm deliveries had a higher change in diastolic blood pressure across the childbearing period than those with all term deliveries (1.59 versus −0.73 mm Hg, P<0.01); the rates of change did not differ by group, both prechildbearing and postchildbearing. Women with preterm deliveries had a larger body mass index increase across the childbearing period (1.66 versus 1.22 kg/m², P=0.03) compared with those with all term deliveries, followed by a steeper increase after the childbearing period (0.22 versus 0.17 kg/m² per year, P=0.02).

Conclusions

Preterm delivery was associated with unfavorable patterns of change in diastolic blood pressure and adiposity that originate during the childbearing years and persist or exacerbate later in life. These adverse changes may contribute to the elevated cardiovascular risk among women with preterm delivery.

Cardiac arrhythmias in pregnant women: need for mother and offspring protection

Cardiac arrhythmias are the most common cardiac complication reported in pregnant women with and without structural heart disease (SHD); they are more frequent among women with SHD, such as cardiomyopathy and congenital heart disease (CHD). While older studies had indicated supraventricular tachycardia as the most common tachyarrhythmia in pregnancy, more recent data indicate an increase in the frequency of arrhythmias, with atrial fibrillation (AF) emerging as the most frequent arrhythmia in pregnancy, attributed to an increase in maternal age, cardiovascular risk factors and CHD in pregnancy. Importantly, the presence of any tachyarrhythmia during pregnancy may be associated with adverse maternal and fetal outcomes, including death. Thus, both the mother and the offspring need to be protected from such consequences. The use of antiarrhythmic drugs (AADs) depends on clinical presentation and on the presence of underlying SHD, which requires caution as it promotes pro-arrhythmia. In hemodynamically compromised women, electrical cardioversion is successful and safe to both mother and fetus. Use of beta-blockers appears quite safe; however, caution is advised when using other AADs, while no AAD should be used, if at all possible, during the first trimester when organogenesis takes place. Regarding the anticoagulation regimen in patients with AF, warfarin should be substituted with heparin during the first trimester, while direct oral anticoagulants are not indicated given the lack of data in pregnancy. Finally, for refractory arrhythmias, ablation and/or device implantation can be performed with current techniques in pregnant women, when needed, using minimal exposure to radiation. All these issues and relevant current guidelines are herein reviewed.

Pregnant Women in Trials of Covid-19: A Critical Time to Consider Ethical Frameworks of Inclusion in Clinical Trials

Ethical issues abound during this unprecedented international public health crisis of Covid-19. While the trade-off between societal and individual interests that occurs at the intersection of public health ethics and clinical ethics affects all populations, this calculus has particular relevance for pregnant women and the question of when they will have access to new Covid-19 therapies and vaccines. Pregnant women are a "scientifically complex" population whose inclusion in clinical research must be done with consideration of the unique state of pregnancy. Yet research on the impact of Covid-19 on pregnant women is lagging. In a rush to prevent and treat SARS-CoV-2 infection, it is crucial that the interests of pregnant women be prioritized to enable them to make autonomous, informed decisions about participating in clinical trials. The global pandemic calls for a revisiting of frameworks for the inclusion of pregnant women in research, as these women have an important stake in the prevention and treatment of Covid-19.

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.

A comprehensive echocardiographic study of the right ventricular systolic function in pregnant women with inherited thrombophilia

Impact of the gestational changes on cardiac contractility is not clearly defined. Our aim was to evaluate subtle changes of the right ventricular systolic function during pregnancy, assessed by new echocardiographic techniques, in a population tested for inherited thrombophilia. 87 pregnant women, with a mean age of 32 ± 4 years, genetically tested for inherited thrombophilia (22 with high-risk inherited thrombophilia and 65 control group) were included. All participants had four echocardiographic assessments, three during pregnancy (one in each trimester) and the forth at 6 months after giving birth. The right ventricular (RV) systolic function was assessed by fractional area change, ejection fraction (EF) by 3D echocardiography, tricuspid annular velocity by tissue Doppler, tricuspid annular plane systolic excursion, and strain by speckle tracking. Pulmonary artery pressure was estimated using the pressure gradient between right atrium and RV. Parameters of RV systolic function, at visits 2-4, had lower values compared with the first visit and were significantly lower in the high-risk thrombophilia group. Tricuspid regurgitation and pressure gradient between the right atrium and the RV had a significant increase during pregnancy for all subjects. At visit 1, there were no differences between groups, but at the next three visits there were higher values of the gradient in the high-risk thrombophilia group. High-risk inherited thrombophilia impacts the RV contractility, with higher pulmonary artery pressure. Further studies are needed to assess long-term impact on RV of high-risk inherited thrombophilia.

Anesthetic management of women with heart failure during pregnancy: a retrospective cohort study

BACKGROUND

The incidence of heart failure among pregnant women with pre-existing cardiac disease is quoted as 13%, with 10% requiring hospitalization. There is limited literature on heart failure in the pregnant population. The study objective was to describe the etiology and management of women hospitalized in our institution for heart failure during pregnancy.

METHODS

A retrospective cohort study investigated women who presented with heart failure in pregnancy between 2004 and 2017. Hospital records were interrogated using International Classification of Diseases v10 codes for heart failure. Patient characteristics, investigations, treatment, obstetric and anesthetic management, and maternal-fetal outcome data were collected and summarized using descriptive statistics.

RESULTS

One-hundred-and-twenty cases (in 93 122 deliveries) were identified across the 13-year period (antepartum heart failure 51%, postpartum heart failure 49%).The most common etiologies were pre-eclampsia (28%), cardiomyopathy (22%), and valvular heart disease (18%). Cesarean delivery occurred in 76% of cases (13% because of the maternal cardiac condition). Neuraxial techniques were used for most deliveries (cesarean 83%; vaginal 90%). For cesarean delivery, titrated epidural or general anesthesia was employed in 48% and 16%, respectively. Cardiac arrest occurred in two cases (1.7%) and 44% required coronary or intensive care unit admission.

CONCLUSIONS

The incidence of heart failure was 0.13% (1:776 deliveries). Pre-eclampsia was the leading cause but may have been historically under-acknowledged. Anesthetic and obstetrical decisions were tailored by means of multidisciplinary input, with cesarean delivery and regional anesthesia used in the majority. The postpartum period warrants heightened attention for these patients.

Exosomes as Messengers Between Mother and Fetus in Pregnancy

The ability of exosomes to transport different molecular cargoes and their ability to influence various physiological factors is already well known. An exciting area of research explores the functions of exosomes in healthy and pathological pregnancies. Placenta-derived exosomes were identified in the maternal circulation during pregnancy and their contribution in the crosstalk between mother and fetus are now starting to become defined. In this review, we will try to summarize actual knowledge about this topic and to answer the question of how important exosomes are for a healthy pregnancy.

Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association

Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.

Retrospective Review of Pregnant Patients Presenting for Evaluation of Acute Neurologic Complaints

STUDY OBJECTIVE

Data suggest an increase in neurologic-related hospitalizations during pregnancy. It is crucial for health care providers to develop effective strategies to evaluate this young, generally healthy cohort of patients for whom missed neurologic diagnoses can have devastating results. We aim to describe the epidemiology of this high risk patient population by investigating exam findings, imaging studies, and clinical outcomes of pregnant women presenting to the emergency department (ED) with acute neurologic complaints.

METHODS

We conducted a 7-year retrospective chart review of pregnant patients presenting with neurologic chief complaints to the emergency department of an urban tertiary academic medical center in the northeastern United States. We investigated examination findings, imaging studies, and clinical outcomes.

RESULTS

Between January 1, 2010, and May 31, 2017, 205 pregnant patients presented to the ED with a neurologic chief complaint. The majority of patients had a normal neurologic examination result. Patients with an abnormal examination result were not more likely to have clinically significant imaging findings. Within our population, 28% underwent imaging, and noncontrast magnetic resonance imaging was the most common modality. Five patients had clinically significant imaging findings. Specifically, 3.3% of patients with abnormal examination result had significant findings and 2.3% of those with a normal examination result had significant findings. A minority of the patients with a visit resulting in discharge (9.8%) returned to the ED within a 7-day period. None required additional neuroimaging.

CONCLUSION

To our knowledge, our study is unique in that it incorporated all neurologic complaints. Headache was the most common complaint, followed by dizziness and seizures. Most of the headaches were related to first-trimester migraines. There was a high incidence of imaging used in clinical practice even when there was a normal neurologic examination result. A normal examination result does not adequately exclude serious intracranial pathology, and diagnostic vigilance is justified.

Pregnancy-induced Cardiovascular Pathologies: Importance of Structural Components and Lipids

Pregnancy leads to adaptations for maternal and fetal energy needs. The cardiovascular system bears the brunt of the adaptations as the heart and vessels enable nutrient supply to maternal organs facilitated by the placenta to the fetus. The components of the cardiovascular system are critical in the balance between maternal homeostatic and fetus driven homeorhetic regulation. Since lipids intersect maternal cardiovascular function and fetal needs with growth and in stress, factors affecting lipid deposition and mobilization impact risk outcomes. Here, the cardiovascular components and functional derangements associated with cardiovascular pathology in pregnancy, vis-à-vis lipid deposition, mobilization and maternal and/or cardiac and fetal energy needs are detailed. Most reports on the components and associated pathology in pregnancy, are on derangements affecting the extracellular matrix and epicardial fat, followed by the endothelium, vascular smooth muscle, pericytes and myocytes. Targeted studies on all cardiovascular components and pathological outcomes in pregnancy will enhance targeted interventions.

Clinical management of the pregnant patient undergoing non-obstetric surgery: Review of guidelines

The management principles of non-obstetric surgery during pregnancy are important concepts for all health care providers to be cognizant of. The goals of non-obstetric surgery are to ensure maternal safety, maintain the pregnancy, and ensure fetal well-being. In this regard, organogenesis occurs roughly between days 7-57 and thus, certain medications have a higher incidence of fetal teratogenicity in this first trimester. Some examples of common surgeries performed urgently or emergently include appendectomies, ovarian detorsions, bowel obstruction, trauma, and cholecystectomies. The choice of anesthetic technique and the selection of appropriate anesthetic drugs should be guided by indication for surgery, the nature of the surgery, and the site of the surgical procedure. Many of the concerns for any patients undergoing urgent or emergent surgery must be considered by anesthesia providers along with steps to ensure the fetus has the best outcome.

Prehypertension prior to pregnancy is associated with hypertensive disorders of pregnancy and postpartum metabolic syndrome in Chinese women

Objective: To examined whether prehypertension prior to pregnancy increased the risk of hypertensive disorders of pregnancy (HDP) and postpartum metabolic syndrome.Methods:1060 singleton pregnancy women with physical examination data before pregnancy were enrolled through the Kailuan study. Women with pre-pregnancy hypertension, metabolic syndrome, or no postpartum follow-up data were excluded. Pre-pregnancy prehypertension was defined as elevated blood pressure (130-139/85-89 mmHg) at the last physical examination before pregnancy. Multivariable Logistic and Cox Regression were used to examine the association between pre-pregnancy prehypertension and outcomes. Kaplan-Meier survival curve was used to analyze the cumulative incidence of postpartum metabolic syndrome.Results: Among the 801 women enrolled at baseline, 173 (21.6%) had prehypertension. Overall, 61 women (7.6%) developed HDP. Kaplan-Meier survival curve showed that the incidence of postpartum metabolic syndrome was significantly higher in prehypertensive women. After adjusting for confounders, women with pre-pregnancy prehypertension were 2.09 (95% CI 1.19-3.70) and 1.91 (95% CI 1.23-2.97) times as likely to develop HDP and postpartum metabolic syndrome, compared to normotensive women.Conclusion: Women with pre-pregnancy prehypertension may benefit from the more intensive monitor for HDP and postpartum metabolic syndrome.

Pregnancy-associated cardiac dysfunction and the regulatory role of microRNAs

Many crucial cardiovascular adaptations occur in the body during pregnancy to ensure successful gestation. Maladaptation of the cardiovascular system during pregnancy can lead to complications that promote cardiac dysfunction and may lead to heart failure (HF). About 12% of pregnancy-related deaths in the USA have been attributed to HF and the detrimental effects of cardiovascular complications on the heart can be long-lasting, pre-disposing the mother to HF later in life. Indeed, cardiovascular complications such as gestational diabetes mellitus, preeclampsia, gestational hypertension, and peripartum cardiomyopathy have been shown to induce cardiac metabolic dysfunction, oxidative stress, fibrosis, apoptosis, and diastolic and systolic dysfunction in the hearts of pregnant women, all of which are hallmarks of HF. The exact etiology and cardiac pathophysiology of pregnancy-related complications is not yet fully deciphered. Furthermore, diagnosis of cardiac dysfunction in pregnancy is often made only after clinical symptoms are already present, thus necessitating the need for novel diagnostic and prognostic biomarkers. Mounting data demonstrates an altered expression of maternal circulating miRNAs during pregnancy affected by cardiovascular complications. Throughout the past decade, miRNAs have become of growing interest as modulators and biomarkers of pathophysiology, diagnosis, and prognosis in cardiac dysfunction. While the association between pregnancy-related cardiovascular complications and cardiac dysfunction or HF is becoming increasingly evident, the roles of miRNA-mediated regulation herein remain poorly understood. Therefore, this review will summarize current reports on pregnancy-related cardiovascular complications that may lead to cardiac dysfunction and HF during and after pregnancy in previously healthy women, with a focus on the pathophysiological role of miRNAs.

Pregnancy, postpartum and parity: Resilience and vulnerability in brain health and disease

Risk and resilience in brain health and disease can be influenced by a variety of factors. While there is a growing appreciation to consider sex as one of these factors, far less attention has been paid to sex-specific variables that may differentially impact females such as pregnancy and reproductive history. In this review, we focus on nervous system disorders which show a female bias and for which there is data from basic research and clinical studies pointing to modification in disease risk and progression during pregnancy, postpartum and/or as a result of parity: multiple sclerosis (MS), depression, stroke, and Alzheimer's disease (AD). In doing so, we join others (Shors, 2016; Galea et al., 2018a) in aiming to illustrate the importance of looking beyond sex in neuroscience research.

Plasma volume variation across the menstrual cycle among healthy women of reproductive age: A prospective cohort study

Increases in reproductive hormones like estrogen, play an important role in the remarkable increases in plasma volume observed in pregnancy. Accurate estimates of plasma volume expansion during pregnancy depend on correctly timing and measuring plasma volume in nonpregnant women. However, to date, there is no consensus on the pattern of plasma volume across the menstrual cycle. We prospectively measured plasma volume in 45 women across a single menstrual cycle. A urine-based fertility monitor was used to time three clinic visits to distinct points in the menstrual cycle: the early follicular phase (~day 2), periovulation (~day 12), and the mid-point of the luteal phase (~day 21)-based on a 28-day cycle length. Healthy women aged 18-41 years with regular menstrual cycles and a healthy body weight were enrolled in the study. At each visit, blood samples were collected before and after injection of 0.25 mg/kg body weight of indocyanine green dye (ICG). Pre- and post-ICG injection plasma samples were used to measure plasma volume. Preinjection samples were used to measure ovarian hormones and plasma osmolality. Mean plasma volume was highest during the early follicular phase (2,276 ± 478 ml); it declined to 2,232 ± 509 ml by the late follicular phase and to 2,228 ± 502 ml by the midluteal phase. This study found that overall variations in plasma volume are small across the menstrual cycle. Therefore, in clinical practice and research, the menstrual cycle phase may not be an important consideration when evaluating plasma volume among women of reproductive age.

Risk of First Hemorrhage of Brain Arteriovenous Malformations During Pregnancy: A Systematic Review of the Literature

BACKGROUND

Recommendations on the management of brain arteriovenous malformations (bAVM) with respect to pregnancy are based upon conflicting literature.

OBJECTIVE

To systematically review the reported risk and annualized rate of first intracranial hemorrhage (ICH) from bAVM during pregnancy and puerperium.

METHODS

MEDLINE, EMBASE, and Scopus databases were searched for relevant articles in English published before April 2018. Studies providing a quantitative risk of ICH in bAVM during pregnancy were eligible.

RESULTS

From 7 initially eligible studies, 3 studies met the criteria for providing quantitative risk of first ICH bAVM during pregnancy. Data from 47 bAVM ICH during pregnancy across 4 cohorts were extracted for analysis. Due to differences in methodology and definitions of exposure period, it was not appropriate to combine the cases. The annualized risk of first ICH during pregnancy for these 4 cohorts was 3.0% (95% confidence interval [CI]: 1.7-5.2%); 3.5% (95% CI: 2.4-4.5%); 8.6% (95% CI: 1.8-25%); and 30% (95% CI: 18-49%). Only the last result from the last cohort could be considered significantly increased in comparison with the nonpregnant period (relative rate 6.8, 95% CI: 3.6-13). The limited number of eligible studies and variability in results highlighted the need for enhanced rigor of future research.

CONCLUSION

There is no conclusive evidence of an increased risk of first hemorrhage during pregnancy from bAVM. Because advice to women with bAVM may influence the management of pregnancy or bAVM with significant consequences, we believe that a retrospective multicenter, case crossover study is urgently required.

Extracellular vesicles in normal pregnancy and pregnancy-related diseases

Extracellular vesicles (EVs) are nanosized, membranous vesicles released by almost all types of cells. Extracellular vesicles can be classified into distinct subtypes according to their sizes, origins and functions. Extracellular vesicles play important roles in intercellular communication through the transfer of a wide spectrum of bioactive molecules, contributing to the regulation of diverse physiological and pathological processes. Recently, it has been established that EVs mediate foetal‐maternal communication across gestation. Abnormal changes in EVs have been reported to be critically involved in pregnancy‐related diseases. Moreover, EVs have shown great potential to serve as biomarkers for the diagnosis of pregnancy‐related diseases. In this review, we discussed about the roles of EVs in normal pregnancy and how changes in EVs led to complicated pregnancy with an emphasis on their values in predicting and monitoring of pregnancy‐related diseases.

ACOG Practice Bulletin No. 212: Pregnancy and Heart Disease

Maternal heart disease has emerged as a major threat to safe motherhood and women's long-term cardiovascular health. In the United States, disease and dysfunction of the heart and vascular system as "cardiovascular disease" is now the leading cause of death in pregnant women and women in the postpartum period () accounting for 4.23 deaths per 100,000 live births, a rate almost twice that of the United Kingdom (). The most recent data indicate that cardiovascular diseases constitute 26.5% of U.S. pregnancy-related deaths (). Of further concern are the disparities in cardiovascular disease outcomes, with higher rates of morbidity and mortality among nonwhite and lower-income women. Contributing factors include barriers to prepregnancy cardiovascular disease assessment, missed opportunities to identify cardiovascular disease risk factors during prenatal care, gaps in high-risk intrapartum care, and delays in recognition of cardiovascular disease symptoms during the puerperium. The purpose of this document is to 1) describe the prevalence and effect of heart disease among pregnant and postpartum women; 2) provide guidance for early antepartum and postpartum risk factor identification and modification; 3) outline common cardiovascular disorders that cause morbidity and mortality during pregnancy and the puerperium; 4) describe recommendations for care for pregnant and postpartum women with preexisting or new-onset acquired heart disease; and 5) present a comprehensive interpregnancy care plan for women with heart disease.

Blood Pressure Variability in Pregnancy: an Opportunity to Develop Improved Prognostic and Risk Assessment Tools

PURPOSE OF REVIEW

This review discusses the mortality and morbidity of hypertensive disorders of pregnancy (HDP) and the current diagnostic thresholds. It then explores measurement of variability in blood pressure (BP) during pregnancy as an opportunity to identify women at high risk of cardiovascular disease (CVD) later in life.

RECENT FINDINGS

HDP is known to be associated with increased risk of long-term CVD. Current CVD prognostic tools do not incorporate a history of HDP given a lack of improved risk discrimination. However, HDP diagnostic criteria are currently based on a binary threshold, and there is some evidence for the use of variability in BP throughout gestation as a marker of CVD risk. HDP increases long-term risk of CVD. Future studies investigating changes in diagnostic criteria, including the use of BP variability, may improve long-term CVD risk prediction and be incorporated into future risk assessment tools.

Ischemic stroke and cerebral venous sinus thrombosis in pregnancy

Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.

Does Gender Influence the Relationship Between High Blood Pressure and Dementia? Highlighting Areas for Further Investigation

BACKGROUND

Gender differences have been noted in studies linking blood pressure to all-cause dementia, and the two most common forms of dementia: Alzheimer's disease (AD) and vascular dementia (VaD). However, how gender modifies the relationship between blood pressure and dementia remains unclear.

OBJECTIVE

To review evidence for a gender modifying effect on the link between blood pressure and all-cause dementia.

METHODS

A systematic review was conducted according to PRISMA guidelines. Sixteen out of 256 reviewed articles met inclusion criteria.

RESULTS

For women, higher midlife systolic blood pressure (SBP) and hypertension were both associated with greater risk of all-cause dementia, AD, and VaD, in six out of seven studies. Two of these studies reported higher midlife SBP/hypertension were associated with greater risk for all-cause dementia in women, but not men. One study reported higher midlife SBP associated with greater AD risk in women, but not men. However, another study reported that midlife hypertension associated with AD risk in men, but not women. No clear gender differences were reported in the relationship between late-life high blood pressure/hypertension with all-cause dementia or AD.

CONCLUSION

Studies rarely, and inconsistently, analyzed or reported gender effects. Therefore, interpretation of available evidence regarding the role of gender in blood pressure associated dementia was difficult. Several studies indicated higher midlife SBP was associated with greater risk of all-cause dementia for women, compared to men. Future studies should evaluate women-specific aging processes that occur in midlife when considering the association between blood pressure and dementia risk.

Adenoviral transduction of EGFR into pregnancy-adapted uterine artery endothelial cells remaps growth factor induction of endothelial dysfunction

During pregnancy, uterine vascular vasodilation is enhanced through adapted Ca2+ signaling, facilitated through increased endothelial connexin 43 (Cx43) gap junctional communication (GJC). In preeclampsia (PE), this adaptive response is missing. Of note, the angiogenic factor VEGF can also act via Src and ERK to close Cx43 gap junctions. While VEGFR2 is necessary for such closure, a role VEGFR1 is less clear. We reasoned if VEGFR2 is acting alone, then substituting another growth factor receptor with VEGFR2-like signaling should have the same effect. In uterine artery endothelial cells derived from pregnant sheep (P-UAEC), endogenous EGFR expression is very low. When we used adenovirus to raise EGFR, we also dose-dependently induced EGF-sensitive Cx43 phosphorylation mainly via ERK, and corresponding loss of Ca2+ bursts, but eliminated VEGF effects on phosphorylation of Cx43 or loss of Ca2+ bursting. This surprising observation suggests that while activated EGFR may indeed substitute for VEGFR2, it also sequesters a limited pool of effector molecules needed for VEGFR2 to phosphorylate Cx43. Thus, low endogenous EGFR expression in P-UAEC may be a necessary strategy to allow VEGFR-2 control of GJC, a first step in initiating angiogenesis in healthy pregnancy. Of further note, trophoblasts are rich in EGFR, and we have demonstrated shed PLAP+/EGFR + extracellular vesicles in maternal circulation in first trimester plasma samples using nanoscale high resolution flow cytometry. Collectively our data suggest that placenta derived exosomes positive for EGFR should be further considered as a possible cause of endothelial dysfunction in women with PE.

Cardiac hypertrophy with obesity is augmented after pregnancy in C57BL/6 mice

BACKGROUND

Over a third of reproductive-age women in the USA are obese, and the prevalence of cardiovascular disease (CVD) is rising in premenopausal women. Cardiac hypertrophy is an independent predictor of CVD. In contrast to pregnancy, where transiently increased left ventricular (LV) mass is not associated with cardiac damage, obesity-mediated cardiac hypertrophy is pathological. There is a paucity of data describing the effect of obesity during pregnancy on maternal cardiovascular health. The purpose of this study was to determine the long-term effect of obesity during pregnancy on cardiac function and structure in mice.

METHODS

Female C57BL/6 J mice were fed a high-fat (HF) or a low-fat (LF) diet for 20 weeks. After 4 weeks, LF- and HF-fed female mice were either crossed with males to become pregnant or remained non-pregnant controls. Following delivery, pups were euthanized, and females maintained on respective diets. After 20 weeks of diet feeding, cardiac function was quantified by echocardiography, and plasma leptin and adiponectin concentrations quantified in LF- and HF-fed postpartum and nulliparous females. mRNA abundance of genes regulating cardiac hypertrophy and remodeling was quantified from left ventricles using the NanoString nCounter Analysis System. Cardiac fibrosis was assessed from picrosirius red staining of left ventricles.

RESULTS

HF-fed postpartum mice had markedly greater weight gain and fat mass expansion with obesity, associated with significantly increased LV mass, cardiac output, and stroke volume compared with HF-fed nulliparous mice. Plasma leptin, but not adiponectin, concentrations were correlated with LV mass in HF-fed females. HF feeding increased LV posterior wall thickness; however, LV chamber diameter was only increased in HF-fed postpartum females. Despite the marked increase in LV mass in HF-fed postpartum mice, mRNA abundance of genes regulating fibrosis and interstitial collagen content was similar between HF-fed nulliparous and postpartum mice. In contrast, only HF-fed postpartum mice exhibited altered expression of genes regulating the extracellular matrix.

CONCLUSIONS

These results suggest that the combined effects of pregnancy and obesity augment cardiac hypertrophy and promote remodeling. The rising prevalence of CVD in premenopausal women may be attributed to an increased prevalence of women entering pregnancy with an overweight or obese BMI.