Central hemodynamic assessment of normal term pregnancy

Genetics, Pregnancy, and Aortic Degeneration

We present a case of familial thoracic aortic aneurysm and dissection (FTAAD) in a pregnant female. FTAAD is an inherited, nonsyndromic aortopathy resulting from several genetic mutations critical to aortic wall integrity have been identified. One such mutation is the myosin heavy chain gene (MYH11) which is responsible for 1-2% of all FTAAD cases. This mutation results in aortic medial degeneration, loss of elastin, and reticulin fiber fragmentation predisposing to TAAD. Aortic disease is more aggressive during pregnancy as a result of increased wall stress from hyperdynamic cardiovascular changes and estrogen-induced aortic media degeneration. Our patient was a 29-year-old G2P1 woman at 26 weeks gestation presenting with abdominal and back pain. Work-up revealed a 6.4-cm ascending aortic aneurysm with a type A dissection extending into all arch vessels, aortic coarctation at the isthmus, and a separate focal type B aortic dissection with visceral involvement. Surgical management included concomitant cesarean section with delivery of a live premature infant, tubal ligation, ascending aortic replacement with reconstruction of the arch vessels, and aortic valve resuspension. The type B dissection was managed medically without complication. This is the first reported case of aortic dissection in a patient with FTAAD/MYH11 mutation and pregnancy. This case highlights that FTAAD and pregnancy cause aortic degeneration via distinct mechanisms and that hyperdynamics of pregnancy increase aortic wall stress. Management of pregnancy associated with aortopathy requires early transfer to a tertiary center, careful investigation to identify familial aortopathy, fetal monitoring, and a multidisciplinary team approach.

Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute

Pregnancy outcomes in patients with pulmonary hypertension remain poor despite advanced therapies. Although consensus guidelines recommend against pregnancy in pulmonary hypertension, it may nonetheless occasionally occur. This guideline document sought to discuss the state of knowledge of pregnancy effects on pulmonary vascular disease and to define usual practice in avoidance of pregnancy and pregnancy management. This guideline is based on systematic review of peer-reviewed, published literature identified with MEDLINE. The strength of the literature was graded, and when it was inadequate to support high-level recommendations, consensus-based recommendations were formed according to prespecified criteria. There was no literature that met standards for high-level recommendations for pregnancy management in pulmonary hypertension. We drafted 38 consensus-based recommendations on pregnancy avoidance and management. Further, we identified the current state of knowledge on the effects of sex hormones during pregnancy on the pulmonary vasculature and right heart and suggested areas for future study. There is currently limited evidence-based knowledge about both the basic molecular effects of sex hormones and pregnancy on the pulmonary vasculature and the best practices in contraception and pregnancy management in pulmonary hypertension. We have drafted 38 consensus-based recommendations to guide clinicians in these challenging topics, but further research is needed in this area to define best practices and improve patient outcomes.

Influence of antenatal physical exercise on haemodynamics in pregnant women: a flexible randomisation approach

Background

Normal pregnancy is associated with marked changes in haemodynamic function, however the influence and potential benefits of antenatal physical exercise at different stages of pregnancy and postpartum remain unclear. The aim of this study was therefore to characterise the influence of regular physical exercise on haemodynamic variables at different stages of pregnancy and also in the postpartum period.

Methods

Fifity healthy pregnant women were recruited and randomly assigned (2 × 2 × 2 design) to a land or water-based exercise group or a control group. Exercising groups attended weekly classes from the 20th week of pregnancy onwards. Haemodynamic assessments (heart rate, cardiac output, stroke volume, total peripheral resistance, systolic and diastolic blood pressure and end diastolic index) were performed using the Task Force haemodynamic monitor at 12–16, 26–28, 34–36 and 12 weeks following birth, during a protocol including postural manoeurvres (supine and standing) and light exercise.

Results

In response to an acute bout of exercise in the postpartum period, stroke volume and end diastolic index were greater in the exercise group than the non-exercising control group (p = 0.041 and p = 0.028 respectively). Total peripheral resistance and diastolic blood pressure were also lower (p = 0.015 and p = 0.007, respectively) in the exercise group. Diastolic blood pressure was lower in the exercise group during the second trimester (p = 0.030).

Conclusions

Antenatal exercise does not appear to substantially alter maternal physiology with advancing gestation, speculating that the already vast changes in maternal physiology mask the influences of antenatal exercise, however it does appear to result in an improvement in a woman’s haemodynamic function (enhanced ventricular ejection performance and reduced blood pressure) following the end of pregnancy.

Trial registration

ClinicalTrials.gov NCT02503995. Registered 20 July 2015.

Natriuretic peptide testing in high-risk pregnancy: a preventive opportunity?

Natriuretic peptide testing has been widely utilized in the heart failure and cardiac patient population, but there is limited utilization during pregnancy. Patients with hypertensive diseases of pregnancy have been shown to experience elevation of circulating natriuretic peptide levels compared to normal pregnancies, especially in the setting of preeclampsia. Natriuretic peptide testing can be utilized in patients presenting with signs and symptoms suspicious of heart failure in order to rule out underlying cardiac causes. Meanwhile, monitoring natriuretic peptide levels in those with established heart diseases (both congenital and acquired) may facilitate careful management of cardiac status during the course of pregnancy. Further investigations in the judicious use of selected medications (particularly loop diuretics) in the setting of elevated natriuretic peptide levels are warranted.

Distribution and biomarker of carbon-14 labeled fullerene C60 ([(14) C(U)]C60 ) in pregnant and lactating rats and their offspring after maternal intravenous exposure

A comprehensive distribution study was conducted in pregnant and lactating rats exposed to a suspension of uniformly carbon-14 labeled C60 ([(14) C(U)]C60 ). Rats were administered [(14) C(U)]C60 (~0.2 mg [(14) C(U)]C60 kg(-1) body weight) or 5% polyvinylpyrrolidone (PVP)-saline vehicle via a single tail vein injection. Pregnant rats were injected on gestation day (GD) 11 (terminated with fetuses after either 24 h or 8 days), GD15 (terminated after 24 h or 4 days), or GD18 (terminated after 24 h). Lactating rats were injected on postnatal day 8 and terminated after 24 h, 3 or 11 days. The distribution of radioactivity in pregnant dams was influenced by both the state of pregnancy and time of termination after exposure. The percentage of recovered radioactivity in pregnant and lactating rats was highest in the liver and lungs. Radioactivity was quantitated in over 20 tissues. Radioactivity was found in the placenta and in fetuses of pregnant dams, and in the milk of lactating rats and in pups. Elimination of radioactivity was < 2% in urine and feces at each time point. Radioactivity remained in blood circulation up to 11 days after [(14) C(U)]C60 exposure. Biomarkers of inflammation, cardiovascular injury and oxidative stress were measured to study the biological impacts of [(14) C(U)]C60 exposure. Oxidative stress was elevated in female pups of exposed dams. Metabolomics analysis of urine showed that [(14) C(U)]C60 exposure to pregnant rats impacted the pathways of vitamin B, regulation of lipid and sugar metabolism and aminoacyl-tRNA biosynthesis. This study demonstrated that [(14) C(U)]C60 crosses the placenta at all stages of pregnancy examined, and is transferred to pups via milk.

Haemodynamic assessment in pregnancy and pre-eclampsia: A Guytonian approach

OBJECTIVES

Hypertensive disorders of pregnancy continue to be amongst the leading causes of maternal morbidity and mortality. There is debate about the optimal monitoring and treatment for these women, particularly in regard to circulatory and fluid management. A restrictive fluid strategy is advocated, which conflicts with the prevailing view that the circulating volume is contracted in pre-eclampsia. This belief has been erroneously reinforced by use of the central venous pressure (CVP) as a measure of the volume state.

METHODS

We used a Guytonian model of the circulation involving the mean systemic filling pressure (Pms) to review published data using a cohort of normal pregnant/post partum women and a pre-eclamptic cohort. The Pms is the pressure left in the circulation when the heart is stopped, arguably the true volume state measure. An analogue of the Pms (Pmsa) can be calculated using commonly measured haemodynamic variables.

RESULTS

Our results show the Pmsa to be elevated in normal pregnancy versus post partum (10.79 vs. 9.58, a 12.6% difference) and elevated further in pre-eclamptic pregnancy (13.86, 29% higher than the normal pregnant group).

CONCLUSIONS

There is scope to challenge the long held belief that the volume state is contracted in pre-eclampsia. This approach indicates that the maternal volume state in pre-eclampsia is often elevated. When viewed in combination with recent echocardiographic insights this model helps to explain some of the haemodynamic management paradoxes that these women present. Most importantly, it provides a sound physiological basis for the restrictive fluid strategy that is currently recommended.

Management of critical asthma syndrome during pregnancy

One-third of pregnant asthmatics experience a worsening of their asthma that may progress to a critical asthma syndrome (CAS) that includes status asthmaticus (SA) and near-fatal asthma (NFA). Patients with severe asthma before pregnancy may experience more exacerbations, especially during late pregnancy. Prevention of the CAS includes excellent asthma control involving targeted early and regular medical care of the pregnant asthmatic, together with medication compliance. Spontaneous abortion risk is higher in pregnant women with uncontrolled asthma than in non-asthmatics. Should CAS occur during pregnancy, aggressive bronchodilator therapy, montelukast, and systemic corticosteroids can be used in the context of respiratory monitoring, preferably in an Intensive Care Unit (ICU). Systemic epinephrine should be avoided due to potential teratogenic side-effects and placental/uterine vasoconstriction. Non-invasive ventilation has been used in some cases. Intratracheal intubation can be hazardous and rapid-sequence intubation by an experienced physician is recommended. Mechanical ventilation parameters are adjusted based on changes to respiratory mechanics in the pregnant patient. An inhaled helium-oxygen gas admixture may promote laminar airflow and improve gas exchange. Permissive hypercapnea is controversial, but may be unavoidable. Sedation with propofol which itself has bronchodilating properties is preferred to benzodiazepines. Case reports delineating good outcomes for both mother and fetus despite intubation for SA suggest that multidisciplinary ICU care of the pregnant asthmatic with critical asthma are feasible especially if hypoxemia is avoided.

Anesthetic Management of Parturients With a Fontan Circulation

Parturients with Fontan physiology provide unique and complex challenges to anesthesiologists. Such challenges include the maintenance of a perfect balance between preload, pulmonary vascular resistance, afterload, and cardiac output in a setting of a single ventricle physiology. The physiological changes of pregnancy add additional burden to an already “fragile” physiology, making the anesthetic management for labor and/or cesarean delivery even more complex. Understanding the impact of these changes on the Fontan physiology and the effect of anesthetic choices on this dyad (pregnancy–Fontan) is an imperative prior to caring for these patients. In an effort to determine how these patients are best managed for labor and/or cesarean delivery, we have reviewed the literature examining the peripartum anesthetic management of parturients with Fontan circulation and have identified 27 case reports.

Highlights from the United States Food and Drug Administration's public workshop on the development of animal models of pregnancy to address medical countermeasures in an "at-risk" population of pregnant women: Influenza as a case study

The U.S. Food and Drug Administration (FDA) and other federal agencies partner to ensure that medical countermeasures (e.g., drug therapies and vaccines) are available for public health emergencies (FDA, 2014). Despite continuing progress, providing medical countermeasures and treatment guidelines for certain populations (e.g., pregnant women) is challenging due to the lack of clinical and/or animal data. Thus, a workshop was convened to discuss animal models of pregnancy for the evaluation of disease progression and medical countermeasures.

Critical care in pregnancy--is it different?

In the first part of this review, the epidemiology of obstetric critical care is discussed. This includes the incidence of severe morbidity in pregnancy, identification of critically ill and potentially critically ill patients, the incidence of obstetric ICU admissions, the type of critical illness by stage of pregnancy, ICU admission diagnoses, the severity of illness in obstetric ICU patients compared to non-obstetric patients, ICU mortality of obstetric patients, the ICU proportion of total maternal mortality, and the causes of death for obstetric patients in ICU. In the second part, the management of obstetric patients who happen to be admitted to a general ICU is discussed. Rather than focusing on the management of particular obstetric conditions, general principles of ICU management will be discussed as applied to obstetric ICU patients. These include drug safety, monitoring the fetus, management of the airway, sedation, muscle relaxation, ventilation, cardiovascular support, thromboprophylaxis, and radiology and ethical issues.

Pregnancy in women after coronary revascularization

Pregnancy after coronary revascularization presents unique challenges to the management of antiplatelet therapy, anesthesia and mode of delivery. We present two cases where women of reproductive age required coronary revascularization with drug eluting stents after a myocardial infarction, and discuss key aspects of pregnancy and labor management.

Aortopathy in pregnancy

Up to half of all aortic dissections and ruptures in women younger than 40 years are associated with pregnancy. In pregnancy, women with aortic disease such as arteritis and aortitis are at significant risk of aneurysmal formation and dissection with potential for catastrophic outcomes. Pregnancy places predisposed women at an increased risk of dissection due to physiological and hormonal changes that occur, particularly those with connective tissue disorders, genetic syndromes, congenital heart disease, and other heritable and acquired conditions involving the aorta. Thus, preconception counseling and preparation are advised to determine which patients may cautiously pursue pregnancy, to optimize medical management prior to conception (antihypertensive medications and anticoagulants in the setting of mechanical valves), to identify women in whom aortic root repair should occur prior to pregnancy, and lastly, those in whom pregnancy is contraindicated. Additionally, discussion of the heritable nature of many aortic conditions and associated syndromes is indicated. Preconception and genetic counseling, management by a multidisciplinary team, along with close echocardiographic surveillance and medical management, are recommended if precursors of dissection are identified.

Intrapartum obstetric management

Maternal cardiac disease complicates approximately 1-2% of all pregnancies in the United States. Just as during the antepartum period, in the immediate period surrounding delivery, obstetrical patients with cardiac disease (both congenital and acquired) will have specialized needs, tailored to the patient and her specific lesion. While the basic principles of labor and delivery management protocols are relevant to this subgroup of patients, there are certain areas in which adjustments must be made. These include endocarditis prophylaxis, recent anticoagulation, fluid management, and the need for increased maternal cardiac monitoring. Awareness of the challenges of the intrapartum period combined with a multi-disciplinary approach from anesthesia, cardiology, and the obstetrical provider will optimize the patient for a safe delivery.

Medical and obstetric complications among pregnant women aged 45 and older

OBJECTIVE

The number of women aged 45 and older who become pregnant is increasing. The objective of this study was to estimate the risk of medical and obstetric complications among women aged 45 and older.

METHODS

The Nationwide Inpatient Sample was used to identify pregnant woman during admission for delivery. Deliveries were identified using International Classification of Diseases, Ninth Revision (ICD-9-CM) codes. Using ICD-9-CM codes, pre-existing medical conditions and medical and obstetric complications were identified in women at the time of delivery and were compared for women aged 45 years and older to women under age 35. Outcomes among women aged 35-44 were also compared to women under age 35 to determine if women in this group demonstrated intermediate risk between the older and younger groups. Logistic regression analyses were used to calculate odds ratios with 95% confidence intervals for pre-existing medical conditions and medical and obstetric complications for both older groups relative to women under 35. Multivariable logistic regression analyses were also developed for outcomes at delivery among older women, while controlling for pre-existing medical conditions, multiple gestation, and insurance status, to determine the effect of age on the studied outcomes.

RESULTS

Women aged 45 and older had higher adjusted odds for death, transfusion, myocardial infarction/ischemia, cardiac arrest, acute heart failure, pulmonary embolism, deep vein thrombosis, acute renal failure, cesarean delivery, gestational diabetes, fetal demise, fetal chromosomal anomaly, and placenta previa compared to women under 35.

CONCLUSION

Pregnant women aged 45 and older experience significantly more medical and obstetric complications and are more likely to die at the time of a delivery than women under age 35, though the absolute risks are low and these events are rare. Further research is needed to determine what associated factors among pregnant women aged 45 and older may contribute to these findings.

Physiologic and pharmacokinetic changes in pregnancy

Physiologic changes in pregnancy induce profound alterations to the pharmacokinetic properties of many medications. These changes affect distribution, absorption, metabolism, and excretion of drugs, and thus may impact their pharmacodynamic properties during pregnancy. Pregnant women undergo several adaptations in many organ systems. Some adaptations are secondary to hormonal changes in pregnancy, while others occur to support the gravid woman and her developing fetus. Some of the changes in maternal physiology during pregnancy include, for example, increased maternal fat and total body water, decreased plasma protein concentrations, especially albumin, increased maternal blood volume, cardiac output, and blood flow to the kidneys and uteroplacental unit, and decreased blood pressure. The maternal blood volume expansion occurs at a larger proportion than the increase in red blood cell mass, which results in physiologic anemia and hemodilution. Other physiologic changes include increased tidal volume, partially compensated respiratory alkalosis, delayed gastric emptying and gastrointestinal motility, and altered activity of hepatic drug metabolizing enzymes. Understating these changes and their profound impact on the pharmacokinetic properties of drugs in pregnancy is essential to optimize maternal and fetal health.

Factors associated with the change in prevalence of cardiomyopathy at delivery in the period 2000-2009: a population-based prevalence study

OBJECTIVE

Cardiomyopathy (CM) at delivery is increasing in prevalance. The objective of this study was to determine which medical conditions are attributable to this increasing prevalance.

DESIGN

Population prevalence study from 2000 to 2009.

SETTING

The Nationwide Inpatient Sample (NIS).

SAMPLE

Pregnant women admitted for delivery were identified in the NIS for the years 2000-2009.

METHODS

Temporal trends in pre-existing medical conditions and in medical and obstetric complications at delivery admissions were determined by linear regression. The change in the prevalence of CM among all pregnant women was compared with the change in the prevalance of CM among pregnant women without pre-existing conditions or complications.

MAIN OUTCOME MEASURE

Prevalence of CM.

RESULTS

The prevalence of CM increased from 0.25 per 1000 deliveries in 2000 to 0.43 per 1000 deliveries in 2009 (P < 0.0001). Women with chronic hypertension had increased odds of developing CM compared with women without chronic hypertension (odds ratio, OR, 13.2; 95% confidence interval, 95% CI, 12.5-13.7). The linear increase in chronic hypertension over the 10-year period was the single identified pre-existing medical condition that explained the increasing prevalence of CM at delivery (P = 0.005 for the differences in slopes for linear trends).

CONCLUSIONS

Pregnant women with chronic hypertenion are at an increased risk for CM at delivery, and the increasing prevalence of chronic hypertension is an important factor associated with the increasing prevalence of CM at the time of delivery. Among women without chronic hypertension, the prevalence of CM at delivery did not change during the time period.

Maternal cardiac metabolism in pregnancy

Pregnancy causes dramatic physiological changes in the expectant mother. The placenta, mostly foetal in origin, invades maternal uterine tissue early in pregnancy and unleashes a barrage of hormones and other factors. This foetal 'invasion' profoundly reprogrammes maternal physiology, affecting nearly every organ, including the heart and its metabolism. We briefly review here maternal systemic metabolic changes during pregnancy and cardiac metabolism in general. We then discuss changes in cardiac haemodynamic during pregnancy and review what is known about maternal cardiac metabolism during pregnancy. Lastly, we discuss cardiac diseases during pregnancy, including peripartum cardiomyopathy, and the potential contribution of aberrant cardiac metabolism to disease aetiology.

Hysterectomy and kidney cancer risk: a meta-analysis

Recent cohort findings suggest that women who underwent a hysterectomy have an elevated relative risk of kidney cancer, although evidence from past studies has been inconsistent. We conducted a systematic review and meta-analysis of published cohort and case-control studies to summarize the epidemiologic evidence investigating hysterectomy and kidney cancer. Studies published from 1950 through 2012 were identified through a search of PubMed and of references from relevant publications. Meta-analyses were conducted using random-effects models to estimate summary relative risks (SRRs) and 95% confidence intervals (CIs) for hysterectomy, age at hysterectomy (<45, 45+ years) and time since hysterectomy (<10, 10+ years). The SRR for hysterectomy and kidney cancer for all published studies (seven cohort, six case-control) was 1.29 (95% CI, 1.16-1.43), with no evidence of between-study heterogeneity or publication bias. The summary effect was slightly weaker, although still significant, for cohorts (SRR, 1.26; 95% CI, 1.11-1.42) compared with case-control findings (1.37; 95% CI, 1.09-1.73) and was observed irrespective of age at hysterectomy, time since the procedure and model adjustment for body mass index, smoking status and hypertension. Women undergoing a hysterectomy have an approximate 30% increased relative risk of subsequent kidney cancer. Additional research is needed to elucidate the biological mechanisms underlying this association.

Parity and kidney cancer risk: evidence from epidemiologic studies

BACKGROUND

Observational studies have reported conflicting results between parity and kidney cancer risk. To our knowledge, a comprehensive and quantitative assessment of the association between parity and kidney cancer has not been reported. Thus, we conducted a systematic review and dose-response meta-analysis of published epidemiologic studies to summarize the evidence of this association.

METHODS

Relevant published studies of parity and kidney cancer were identified using MEDLINE (PubMed) database through end of June 2013. Two authors independently assessed eligibility and extracted data. Six prospective and eight case-control studies reported relative risk (RR) estimates and 95% confidence intervals (CI) of kidney cancer associated with parity or parity number. Fixed- or random-effects models were used to estimate summary relative risk.

RESULTS

The summary relative risk of kidney cancer for the parity versus nulliparous was 1.23 (95% CI, 1.10-1.36; Q = 12.41; P = 0.413; I(2) = 3.3%). In addition, significant association was also found for the highest versus lowest parity number, with summary RR = 1.36 (95% CI, 1.19-1.56; Q = 8.24; P = 0.766; I(2) = 0%). In the dose-response analysis, the summary per one live birth relative risk was 1.08 (95% CI: 1.05-1.10; Q = 9.34; P = 0.500; I(2) = 0%), also indicating the positive effect of parity on kidney cancer risk. No evidence of publication bias and significant heterogeneity between subgroups was detected by meta-regression analyses.

CONCLUSIONS

In summary, findings from this meta-analysis suggest that ever parity and higher parity number is significantly associated with increased risk of kidney cancer.

IMPACT

The present results suggest a positive association between parity and kidney cancer risk.

Maternal sepsis

Maternal sepsis is relatively common. Most of these infections are the result of tissue damage during labor and delivery and physiologic changes normally occurring during pregnancy. These infections, whether directly pregnancy-related or simply aggravated by normal pregnancy physiology, ultimately have the potential to progress to severe sepsis and septic shock. This article discusses commonly encountered entities and septic shock. The expeditious recognition of common maternal sepsis and meticulous attention to appropriate management to prevent the progression to severe sepsis and septic shock are emphasized. Also discussed are principles and new approaches for the management of septic shock.

Alterations in physiology and anatomy during pregnancy

Pregnant women undergo profound anatomical and physiological changes so that they can cope with the increased physical and metabolic demands of their pregnancies. The cardiovascular, respiratory, haematological, renal, gastrointestinal and endocrine systems all undergo important physiological alterations and adaptations needed to allow development of the fetus and to allow the mother and fetus to survive the demands of childbirth. Such alterations in anatomy and physiology may cause difficulties in interpreting signs, symptoms, and biochemical investigations, making the clinical assessment of a pregnant woman inevitably confusing but challenging. Understanding these changes is important for every practicing obstetrician, as the pathological deviations from the normal physiological alterations may not be clear-cut until an adverse outcome has resulted. Only with a sound knowledge of the physiology and anatomy changes can the care of an obstetric parturient be safely optimized for a better maternal and fetal outcome.

Noninvasive cardiac monitoring in pregnancy: impedance cardiography versus echocardiography

OBJECTIVE

The objective of this study was to report thoracic impedance cardiography (ICG) measurements and compare them with echocardiography (echo) measurements throughout pregnancy and in varied maternal positions.

METHOD

A prospective cohort study involving 28 healthy parturients was performed using ICG and echo at three time points and in two maternal positions. Pearson's correlations, Bland-Altman plots and paired t-tests were used for statistical analysis.

RESULT

Significant agreements between many but not all ICG and echo contractility, flow and resistance measurements were demonstrated. Differences in stroke volume (SV) due to maternal position were also detected by ICG in the antepartum (AP) period. Significant trends were observed by ICG for cardiac output and thoracic fluid content (TFC; P<0.025) with advancing pregnancy stages.

CONCLUSION

ICG and echo demonstrate significant correlations in some but not all measurements of cardiac function. ICG has the ability to detect small changes in SV associated with maternal position change. ICG measurements reflected maximal cardiac contractility in the a AP period yet reflected a decrease in contractility and an increase in TFC in the postpartum period.

Altered arterial compliance in hypertensive pregnant women is associated with preeclampsia

BACKGROUND

Vascular alterations are present in pregnant women affected by preeclampsia. In this study, we assessed arterial compliance in women affected by hypertensive disorders of pregnancy. We hypothesized that arterial compliance is reduced in women affected by preeclampsia.

METHODS

Forty-three hypertensive pregnant women undergoing evaluation for preeclampsia were studied. Clinical data about each patient and pregnancy were collected. Large (C1) and small (C2) artery compliance were assessed by radial tonometry, while the patients underwent laboratory tests to diagnose preeclampsia. At the time of delivery, gestational age and newborn data were recorded.

RESULTS

Eighteen women were diagnosed with preeclampsia. C2 levels were lower among preeclamptic versus hypertensive aproteinuric women (mean ± SD, 4.5 ± 1.3 vs 5.9 ± 2.3 mL/mm Hg · 100, P = 0.013, 95% confidence interval [CI] of difference 0.32-2.55), whereas C1 levels did not differ. In the preeclampsia group, C2 levels correlated with urine total protein concentrations measured the same day (Spearman ρ = -0.49, P = 0.047, upper 95% CI -0.01) and with gestational age at first occurrence of hypertension (Spearman ρ = 0.59, P = 0.010, lower 95% CI 0.17). Among singleton gestations, C2 also correlated with newborn birth weight measured at delivery (Spearman ρ = 0.43, P = 0.009, lower 95% CI 0.11). Women who were hypertensive but aproteinuric at the time of compliance assessment, but who subsequently developed preeclampsia (n = 6), had C2 levels similar to those with an early diagnosis of preeclampsia (mean difference 0.37 mL/mm Hg · 100, 95% CI -2.42 to 1.67) and lower C2 levels than women diagnosed with gestational hypertension (P = 0.019, 95% CI 0.33-4.42 mL/mm Hg · 100).

CONCLUSIONS

The noninvasive assessment of arterial elasticity may contribute toward characterization of the nature of the pathophysiology in pregnancy-induced hypertensive disorders. The vascular alterations of the small arteries, as assessed by C2, may reflect the extent of vascular alterations present with preeclampsia.

Reproductive factors and kidney cancer risk in 2 US cohort studies, 1993-2010

Clinical and experimental findings suggest that female hormonal and reproductive factors could influence kidney cancer development. To evaluate this association, we conducted analyses in 2 large prospective cohorts (the National Institutes of Health-AARP Diet and Health Study (NIH-AARP), 1995-2006, and the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), 1993-2010). Cohort-specific and aggregated hazard ratios and 95% confidence intervals relating reproductive factors and kidney cancer risk were computed by Cox regression. The analysis included 792 incident kidney cancer cases among 283,952 postmenopausal women. Women who had undergone a hysterectomy were at a significantly elevated kidney cancer risk in both NIH-AARP (hazard ratio = 1.28, 95% confidence interval: 1.09, 1.50) and PLCO (hazard ratio = 1.41, 95% confidence interval: 1.06, 1.88). Similar results were observed for both cohorts after analyses were restricted to women who had undergone a hysterectomy with or without an oophorectomy. For the NIH-AARP cohort, an inverse association was observed with increasing age at menarche (P for trend = 0.02) and increasing years of oral contraceptive use (P for trend = 0.02). No clear evidence of an association with parity or other reproductive factors was found. Our results suggest that hysterectomy is associated with increased risk of kidney cancer. The observed associations with age at menarche and oral contraceptive use warrant further investigation.

Severe sepsis and septic shock in pregnancy

Pregnancies complicated by severe sepsis and septic shock are associated with increased rates of preterm labor, fetal infection, and preterm delivery. Sepsis onset in pregnancy can be insidious, and patients may appear deceptively well before rapidly deteriorating with the development of septic shock, multiple organ dysfunction syndrome, or death. The outcome and survivability in severe sepsis and septic shock in pregnancy are improved with early detection, prompt recognition of the source of infection, and targeted therapy. This improvement can be achieved by formulating a stepwise approach that consists of early provision of time-sensitive interventions such as: aggressive hydration (20 mL/kg of normal saline over the first hour), initiation of appropriate empiric intravenous antibiotics (gentamicin, clindamycin, and penicillin) within 1 hour of diagnosis, central hemodynamic monitoring, and the involvement of infectious disease specialists and critical care specialists familiar with the physiologic changes in pregnancy. Thorough physical examination and imaging techniques or empiric exploratory laparotomy are suggested to identify the septic source. Even with appropriate antibiotic therapy, patients may continue to deteriorate unless septic foci (ie, abscess, necrotic tissue) are surgically excised. The decision for delivery in the setting of antepartum severe sepsis or septic shock can be challenging but must be based on gestational age, maternal status, and fetal status. The natural inclination is to proceed with emergent delivery for a concerning fetal status, but it is imperative to stabilize the mother first, because in doing so the fetal status will likewise improve. Aggressive [corrected] treatment of sepsis can be expected to reduce the progression to severe sepsis and septic shock and prevention strategies can include preoperative skin preparations and prophylactic antibiotic therapy as well as appropriate immunizations.

The pregnant patient with congenital heart disease

Advances in the surgical palliation and correction of congenital heart lesions have improved survival and increased the number of patients living into adulthood. Although pregnancy outcomes will be favorable for most patients with congenital heart disease, the cardiovascular challenges associated with pregnancy and delivery are best managed with a multidisciplinary approach during the puerperium. This review addresses the prevalence, physiology, risk assessment, peripartum complications, and anesthetic management of the pregnant patient with underlying congenital heart disease.

Pregnancy reduces RhoA/Rho kinase and protein kinase C signaling pathways downstream of thromboxane receptor activation in the rat uterine artery

During pregnancy, reduced vascular responses to constrictors contribute to decreased uterine and total vascular resistance. Thromboxane A(2) (TxA(2)) is a potent vasoconstrictor that exerts its actions via diverse signaling pathways, and its biosynthesis increases in preeclampsia. In this study, we hypothesized that maternal vascular responses to TxA(2) will be attenuated via Rho kinase, PKC, p38 MAPK, and ERK1/2 signaling pathways. Isolated ring segments of uterine and small mesenteric arteries from late pregnant (19-21 days) and virgin rats were suspended in a myograph, and isometric force was measured. Pregnancy did not affect uterine and mesenteric artery responses to the TxA(2) analog U-46619 (10(-9)-10(-5) M), but transduction signals associated with these contractions were different between pregnant and nonpregnant rats. Inhibition of Rho kinase (10(-6) M Y-27632) reduced sensitivity to U-46619 in virgin uterine vessels but did not inhibit these contractions in pregnant uterine arteries and had no effect on mesenteric vessels. Treatment of arterial segments with a PKC inhibitor (10(-6) M bisindolylmaleimide I) reduced U-46619-induced contractions in virgin uterine and mesenteric arteries and in pregnant mesenteric arteries. Pregnant uterine arteries, however, were unresponsive to PKC inhibition. Inhibition of ERK1/2 (10(-5) M PD-98059) and p38 MAPK (10(-5) M SB-203580) reduced U46619-induced contractions in nonpregnant vessels and in pregnant uterine and mesenteric vessels. These data suggest that normal pregnancy does not affect uterine and mesenteric contractile responses to TxA(2) but reduces the contribution of Rho kinase and PKC signaling pathways to these contractions in the uterine vasculature. In contrast, the role of ERK1/2 and p38 MAPK in U-46619-induced uterine contractions remains unchanged with pregnancy. TxA(2)-associated transduction signals and its regulators might present potential targets for the development of new treatments for preeclampsia and other pregnancy-associated vascular diseases.

Maternal adaptations and inheritance in the transgenerational programming of adult disease

Adverse exposures in utero have long been linked with an increased susceptibility to adult cardio-renal and metabolic diseases. Clear gender differences exist, whereby growth-restricted females, although exhibiting some phenotypic modifications, are often protected from overt disease outcomes. One of the greatest physiological challenges facing the female gender, however, is that of pregnancy; yet little research has focused on the outcomes associated with this, as a potential 'second-hit' for those who were small at birth. We review the limited evidence suggesting that pregnancy may unmask cardio-renal and metabolic disease states and the consequences for long-term maternal health in females who were born small. Additionally, a growing area of research in this programming field is in the transgenerational transmission of low birth weight and disease susceptibility. Pathways for transmission might include an abnormal adaptation to pregnancy by the growth-restricted mother and/or inheritance via the parental germline. Strategies to optimise the pregnancy environment and/or prevent the consequences of inheritance of programmed deficits and dysfunction are of critical importance for future generations.

Pandemic influenza H1N1 2009 virus infection in pregnancy in Turkey

OBJECTIVES

To describe the clinical characteristics of the pregnant women who were hospitalized in a tertiary referral hospital with pandemic influenza H1N1 2009 virus infection and neonatal outcomes from October 2009 to December 2009 during which the pandemic influenza cases peaked in Turkey.

MATERIALS AND METHODS

Twenty-five pregnant women who were hospitalized with influenza-like illness and who had laboratory confirmation for pandemic influenza H1N1 virus infection were evaluated prospectively.

RESULTS

Of the 25 patients, 4 (16%) were in the first trimester, 8 (32%) were in the second trimester, and 13 (52%) were in the third trimester. The median time from the onset of symptoms to the initiation of antiviral therapy was 1 day (range 1-9 days). Nineteen (76%) patients received oseltamivir treatment. It took 1.6 days on the average for the fever defervescence after the initiation of treatment or hospitalization. Of the 14 patients who underwent chest radiography, three had findings consistent with pneumonia. The mean duration of hospitalization was 4.8 days. Four women (16%) were admitted to an intensive care unit, but there were no maternal or neonatal deaths in this series. At the time of their H1N1 hospitalization, seven women delivered by cesarean at 33-40 weeks gestation, two vaginally at 38 weeks gestation, and two had an abortion at 10 weeks and 16 weeks of gestation, respectively. None of the infants had any evidence of influenza infection.

CONCLUSION

Pregnant women are at increased risk for complications from pandemic influenza H1N1 virus infection. Timely medical attention with early recourse to antiviral therapy is associated with a better outcome in H1N1-affected pregnant women.