Cardiovascular Physiology of Pregnancy

High-Sensitivity Troponin T and I Among Pregnant Women in the US-The National Health and Nutrition Examination Survey, 1999-2004

This cross-sectional study investigates the expected physiologic concentrations of high-sensitivity cardiac troponin in normal pregnancy.

Systematic review and meta-analysis of birth weight and PFNA exposures

We used a systematic review that included risk of bias and study sensitivity analysis to identify 34 studies examining changes in birth weight (BWT) in relation to PFNA biomarker measures (e.g., maternal serum/plasma or umbilical cord samples). We fit a random effects model of the overall pooled estimate and stratified estimates based on sample timing and overall study confidence. We conducted a meta-regression to further examine the impact of gestational age at biomarker sample timing. We detected a -32.9 g (95%CI: -47.0, -18.7) mean BWT deficit per each ln PFNA increase from 27 included studies. We did not detect evidence of publication bias (p_E = 0.30) or between-study heterogeneity in the summary estimate (p_Q = 0.05; I² = 36%). The twelve high confidence studies yielded a smaller pooled effect estimate (β = -28.0 g; 95%CI: -49.0, -6.9) than the ten medium (β = -39.0 g; 95%CI: -61.8, -16.3) or four low (β = -36.9 g; 95%CI: -82.9, 9.1) confidence studies. The stratum-specific results based on earlier pregnancy sampling periods in 11 studies showed smaller deficits (β = -22.0 g; 95%CI: -40.1, -4.0) compared to 10 mid- and late-pregnancy (β = -44.2 g; 95%CI: -64.8, -23.5) studies and six post-partum studies (β = -42.9 g; 95%CI: -88.0, 2.2). Using estimates of the specific gestational week of sampling, the meta-regression showed results consistent with the categorical sample analysis, in that as gestational age at sampling time increases across these studies, the summary effect estimate of a mean BWT deficit got larger. Overall, we detected mean BWT deficits for PFNA that were larger and more consistent across studies than previous PFAS meta-analyses. Compared to studies with later sampling, BWT deficits were smaller but remained sizeable for even the earliest sampling periods. Contrary to earlier meta-analyses for PFOA and PFOS, BWT deficits that were detected across all strata did not appear to be fully explained by potential bias due to pregnancy hemodynamics from sampling timing differences.

Pulmonary Arteriovenous Malformation Unmasked by Pregnancy: A Review of Pulmonary Arteriovenous Malformations and Cardiovascular and Respiratory Changes in Pregnancy

Pulmonary arteriovenous malformations are abnormal, direct communications between the branches of the pulmonary artery and pulmonary veins, but without pulmonary capillaries between them. During pregnancy, PAVMs can enlarge and become symptomatic, causing even serious complications like haematothorax. To recognize the PAVM that becomes symptomatic in pregnancy, one must be able to distinguish the patient’s symptoms caused by developing complications of PAVM, as in the case we present, from physiological changes accompanying a healthy pregnancy, including their degree in relation to the stage of pregnancy. The modified early obstetric warning score charts are a very helpful tool in the assessment of (ab)normal signs and symptoms in pregnant women, especially for physicians who rarely manage pregnant women.

Anesthesia during delivery in pregnant women with dilated cardiomyopathy

Emergency cesarean delivery in patients with heart failure increases maternal and fetal mortality. The present study aimed to identify the relationship between the use of anesthesia for delivery and progressive cardiac deterioration in women with dilated cardiomyopathy (DCM) and to examine its implications on maternal and fetal outcomes. Twenty-nine pregnancies in 25 women with DCM from the National Cerebral and Cardiovascular Center Hospital (Suita, Japan) were included in this retrospective longitudinal study. Fourteen of the patients (48.3%) delivered via cesarean section. Among these, 4 patients (13.8%) experienced heart failure within 42 days of delivery. The indication for cesarean delivery was heart failure in 3 patients and induction failure in 1 patient. The types of anesthesia used for these patients included general (n = 1), combined spinal-epidural (n = 2), and epidural (n = 1). Two of these cesarean deliveries were performed preterm. The left ventricular ejection fraction of patients with heart failure was ≤ 35% before 34 weeks gestation. Among the 25 patients without heart failure, 2 exhibited a left ventricular ejection fraction of ≤ 35% before 34 weeks gestation. Meanwhile, the types of anesthesia used for remaining 10 patients who did not experience heart failure included general (n = 1), combined spinal-epidural (n = 8), and epidural (n = 1). The rate of general anesthesia was 25% in patients who experienced heart failure and 4% in others. There was no incidence of maternal or fetal death. A preterm anesthetic evaluation may be warranted to optimize anesthetic management when the ejection fraction decreases to ≤ 35% before 34 weeks gestation in patients with DCM.

Alterations in Vessel Hemodynamics Across Uncomplicated Pregnancy

Pregnancy is marked by the onset of rapid hemodynamic alterations in order to accommodate the needs of the developing fetus. Arterial stiffness is an independent predictor of cardiovascular events and mortality, and its measurement in clinical practice has been recommended. It follows a U-shaped curve in uncomplicated pregnancy, decreasing to a nadir in mid-pregnancy and rising at term. Systemic vasodilation occurs due to elevated nitric oxide, prostacyclin, endothelium-derived hyperpolarizing factor, estrogen, progesterone, and relaxin. Vascular resistance decreases to a nadir in mid-pregnancy, while endothelial function is enhanced starting in the first trimester. Plasma volume increases by about 50%, and total red blood cell mass increases by up to 40%. Cardiac output increases by up to 45%, at first due primarily to elevated stroke volume, then mainly due to increased heart rate. Along with echocardiography, cardiac magnetic resonance imaging is safe for use in pregnancy. It may assess cardiac function more accurately than echocardiography, and may be indicated in specific clinical cases. Moreover, blood pressure decreases to a nadir in mid-pregnancy and rises to near preconception values postpartum. An appreciation of the vascular changes occurring in healthy pregnancy can aid in the prediction and diagnosis of pregnancy complications, such as preeclampsia and other hypertensive disorders of pregnancy, and inform treatment. In particular, noninvasive arterial stiffness/hemodynamics assessment provides unique clinical information beyond blood pressure and traditional maternal characteristics, and can signal a need for further testing, or be used in combination with other tests to predict or diagnose complications of pregnancy.

Joint associations of pregnancy complications and postpartum maternal renal biomarkers with severe cardiovascular morbidities: A US racially diverse prospective birth cohort study

Rationale & Objective

Pregnancy complications are risk factors for cardiovascular diseases (CVD). Little is known about the role of renal biomarkers measured shortly after delivery, individually or in combination with pregnancy complications, in predicting subsequent severe maternal CVD.

Methods

This study included 576 mothers of diverse ethnicities from the Boston Birth cohort, enrolled at delivery and followed prospectively. Plasma creatinine and cystatin C were measured 1-3 days after delivery. CVD during follow-up was defined by physician diagnoses in electronic medical records. Associations of renal biomarkers and pregnancy complications with time-to-CVD events were assessed using Cox proportional hazards models.

Results

During an average of 10.3±3.2 years of follow-up, 34 mothers developed one or more CVD events. Although no significant associations were found between creatinine and risk of CVD, per unit increase of cystatin C (CysC) was associated with a hazard ratio (HR) of 5.21 (95%CI = 1.49-18.2) for CVD. A borderline significant interactive effect was observed between elevated CysC (≥75th percentile) and preeclampsia. Compared to those without preeclampsia and with normal CysC level (<75 th percentile), mothers with preeclampsia and elevated CysC had the highest risk of CVD (HR=3.8, 95%CI = 1.4-10.2), while mothers with preeclampsia only or with elevated CysC only did not have significantly increased CVD risk. Similar synergistic effects for CVD were observed between CysC and preterm delivery.

Conclusions

In this sample of US, traditionally under-represented multi-ethnic high-risk mothers, elevated maternal plasma cystatin C and pregnancy complications synergistically increased risk of CVD later in life. These findings warrant further investigation.

Clinical Perspectives

What is new?Maternal postpartum elevated levels of cystatin C are independently associated with higher risk of cardiovascular diseases (CVD) later in life.Maternal pregnancy complications coupled with postpartum elevated levels of cystatin C synergistically increased future risk of CVD.What are the clinical implications?These findings, if further confirmed, suggest that women with pregnancy complications and elevated postpartum cystatin C may be at particular high risk for CVD later in life compared to women without these risk factors.

The biodistribution of placental and fetal extracellular vesicles during pregnancy following placentation

Human pregnancy is a highly orchestrated process requiring extensive cross-talk between the mother and the fetus. Extracellular vesicles released by the fetal tissue, particularly the placenta, are recognized as important mediators of this process. More recently, the importance of placental extracellular vesicle biodistribution studies in animal models has received increasing attention as identifying the organs to which extracellular vesicles are targeted to helps us understand more about this communication system. Placental extracellular vesicles are categorized based on their size into macro-, large-, and small-extracellular vesicles, and their biodistribution is dependent on the extracellular vesicle's particle size, the direction of blood flow, the recirculation of blood, as well as the retention capacity in organs. Macro-extracellular vesicles are exclusively localized to the lungs, while large- and small-extracellular vesicles show high levels of distribution to the lungs and liver, while there is inconsistency in the reporting of distribution to the spleen and kidneys. This inconsistency may be due to the differences in the methodologies employed between studies and their limitations. Future studies should incorporate analysis of placental extracellular vesicle biodistribution at the macroscopic level on whole animals and organs/tissues, as well as the microscopic cellular level.

Chromogranin A: An Endocrine Factor of Pregnancy

Pregnancy is a state of physiological and hormonal changes. One of the endocrine factors involved in these processes is chromogranin A, an acidic protein produced, among others, by the placenta. Although it has been previously linked to pregnancy, no existing articles have ever managed to clarify the role of this protein regarding this subject. Therefore, the aim of the present study is to gather knowledge of chromogranin A's function with reference to gestation and parturition, clarify elusive information, and, most importantly, to formulate hypotheses for the future studies to verify.

Prevalence and Correlates of Elevated NT-proBNP in Pregnant Women in the General U.S. Population

BACKGROUND

Physiologic changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) across trimesters of pregnancy have not been well studied.

OBJECTIVES

The authors aimed to measure NT-proBNP in adult women, by pregnancy status and trimester, in a nationally representative sample from the National Health and Nutrition Examination Survey 1999 to 2004.

METHODS

We conducted a cross-sectional analysis of 2,134 women (546 pregnant) aged 20 to 40 years without a history of cardiovascular disease.

RESULTS

Among pregnant women in the first trimester, the prevalence of elevated NT-proBNP (>125 pg/mL) was 20.0% (SE, 6.6%) compared to 2.4% (SE, 0.8%) among women in the third trimester and 8.0% among nonpregnant women. After adjustment for demographics and cardiovascular risk factors, NT-proBNP was 44% higher (absolute difference 26.4 [95% CI: 11.2-41.6] pg/mL) in the first trimester of pregnancy compared to nonpregnant women. Among pregnant women only, adjusted NT-proBNP was 46% lower (absolute difference -22.2 [95% CI: -36.9 to -7.5] pg/mL) in women in the third trimester compared to women in the first trimester. NT-proBNP was inversely associated with body mass index and with systolic blood pressure.

CONCLUSIONS

Women in the first trimester of pregnancy had significantly higher NT-proBNP than those in the third trimester and compared to similarly aged nonpregnant women. The dynamic nature of NT-proBNP should be taken into consideration when ordering NT-proBNP lab tests in pregnant women.

Ionizable Lipid Nanoparticles for In Vivo mRNA Delivery to the Placenta during Pregnancy

Ionizable lipid nanoparticles (LNPs) are the most clinically advanced nonviral platform for mRNA delivery. While they have been explored for applications including vaccines and gene editing, LNPs have not been investigated for placental insufficiency during pregnancy. Placental insufficiency is caused by inadequate blood flow in the placenta, which results in increased maternal blood pressure and restricted fetal growth. Therefore, improving vasodilation in the placenta can benefit both maternal and fetal health. Here, we engineered ionizable LNPs for mRNA delivery to the placenta with applications in mediating placental vasodilation. We designed a library of ionizable lipids to formulate LNPs for mRNA delivery to placental cells and identified a lead LNP that enables in vivo mRNA delivery to trophoblasts, endothelial cells, and immune cells in the placenta. Delivery of this top LNP formulation encapsulated with VEGF-A mRNA engendered placental vasodilation, demonstrating the potential of mRNA LNPs for protein replacement therapy during pregnancy to treat placental disorders.

Perinatal outcomes in pregnancies complicated by maternal cardiomyopathy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess perinatal outcomes of pregnancies complicated by maternal cardiomyopathy.

DATA SOURCES

PubMed, Ovid Embase, Ovid MEDLINE, the Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to August 25, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, case-control, and case-cohort studies in human populations were included if they reported predefined perinatal outcomes in pregnant women with cardiomyopathy (any subtype) and an appropriate control population (either pregnant women with no known cardiac disease or pregnant women with noncardiomyopathy cardiac disease).

METHODS

Of note, 2 reviewers independently assessed the articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Data were extracted and synthesized according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines.

RESULTS

Here, 13 studies (representing 2,291,024 pregnancies) were eligible for inclusion. Perinatal death was more likely in neonates born to women with cardiomyopathy than in (1) neonates born to women with no cardiac disease (stillbirth: odds ratio, 20.82; 95% confidence interval, 6.68-64.95; I² = not available; P<.00001; neonatal mortality: odds ratio, 6.75; 95% confidence interval, 3.54-12.89; I²=0%; P<.00001) and (2) neonates born to women with other forms of cardiac disease (stillbirth: odds ratio, 3.75; 95% confidence interval, 1.86-7.59; I²=0%; P=.0002; neonatal mortality: odds ratio, 2.42; 95% confidence interval, 1.39-4.21; I²=0%; P=.002). Pregnancies affected by maternal cardiomyopathy were significantly more likely to result in preterm birth (odds ratio, 2.21; 95% confidence interval, 1.31-3.73; I²=77%; P=.003) and small-for-gestational-age neonates (odds ratio, 2.97; 95% confidence interval, 2.38-3.70; I²=47%; P<.00001), both major causes of short- and long-term morbidities, than pregnancies affected by other forms of cardiac disease.

CONCLUSION

There was an increased likelihood of adverse perinatal outcomes in pregnancies affected by maternal cardiomyopathy compared with both pregnancies affected by noncardiomyopathy cardiac disease and pregnancies without cardiac disease. Women with cardiomyopathy who plan to get pregnant should receive detailed counseling regarding these risks and have their pregnancies managed by experienced multidisciplinary teams that can provide close fetal monitoring and neonatology expertise.

The prenatal weekly temperature exposure and neonatal congenital heart disease: a large population-based observational study in China

We aim to explore the link between maternal weekly temperature exposure and CHD in offspring and identify the relative contributions from heat and cold and from moderate and extreme atmospheric temperature. From January 2019 to December 2020, newborns who were diagnosed with CHD by echocardiography in the Network Platform for Congenital Heart Disease (NPCHD) from 11 cities in eastern China were enrolled in the present study. We appraised the exposure lag response relationship between temperature and CHDs in the distributed lag nonlinear model and further probed the pooled estimates by multivariate meta-analysis. We further performed the exposure-response curves in extreme temperature (5th percentile for cold and 95th for hot events). We also delve into the cumulative risk ratios (CRRs) of temperature on CHDs in general and subgroups. In this study, 5904 of 983, 523 infants were diagnosed with CHDs. The temperature-CHD combination performed positive significance in two exposure windows, gestational weeks 10-16 and 26-31, and reached the maximum effect in the 28th week. Compared with extreme cold (5th, 6.14℃), these effects were higher in extreme heat (95th, 29.26℃). The cumulative exposure-response curve showed a steep nonlinear rise in the hot tail but showed non-significance at low temperatures. In this range, the CRRs of temperature showed an increment to a ceiling of 3.781 (95% CI: 1.460-10.723). The temperature- CHD curves for both sex groups showed a general growth trend. No statistical significance was observed between these two groups (P = 0.106). The cumulative effect of the temperature related CHD was significant in regions with lower education levels (maximum CRR was 9.282 (3.019-28.535)). A degree centigrade increase in temperature exposure was associated with the increment of CHD risk in the first and second trimesters, especially in extreme heat. Neonates born in lower education regions were more vulnerable to temperature-related CHDs.

Echocardiographic changes and impact on clinical management in pregnant women with heart disease

BACKGROUND

While guidelines recommend echocardiography for pregnant women with heart disease, there are limited data on its effect on clinical practice. In this study, we investigated pregnancy-associated echocardiographic changes and their impact on management.

METHODS

This was a retrospective study of pregnant women with heart disease followed at an academic medical centre from 2016 to 2020. Data on maternal intrapartum and postpartum echocardiograms were collected and the impact on management analysed.

RESULTS

421 echocardiograms in 232 pregnancies were included in the study. The most common cardiac diagnosis was CHD (60.8% of pregnancies), followed by cardiomyopathy (9.9%). The frequency of baseline echocardiographic abnormalities varied by diagnosis, with abnormal right ventricular systolic pressure being the most common (15.0% of pregnancies in CHD and 23.1% of pregnancies with cardiomyopathy). 39.2% of the 189 follow-up echocardiograms had a significant change from the prior study, with the most common changes being declines in right ventricular function (4.2%) or left ventricular function (3.7%), and increases in right ventricular systolic pressure (5.3%) and aortic size (21.2%). 17.8% of echocardiograms resulted in a clinical management change, with the most common change being shorter interval follow-up.

CONCLUSIONS

Echocardiographic changes in pregnant women with heart disease are common, in particular increases in aortic size. Echocardiography results in changes in management in a small but significant proportion of patients. Further studies are needed to determine how other factors, including patient access and resource allocation, factor into the use of echocardiography during pregnancy.

Hypertension in Pregnancy: What We Now Know

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy remain a highly morbid condition that affects both the mother and fetus, complicate approximately 10% of pregnancies worldwide, and contribute to immediate and long-term cardiovascular outcomes. There is still much to learn regarding pathogenesis and treatment goals.

RECENT FINDINGS

There is updated information on the pathogenesis of preeclampsia and treatment thresholds for HTN in pregnancy. l-Kynurenine, a metabolite of the essential amino acid l-tryptophan, has been implicated in preeclampsia as decreased levels were found in a uninephrectomized pregnant mouse model of preeclampsia, where replacement of l-kynurenine rescued the preeclamptic state. Further, data from CHIPS (The Control of HTN in Pregnancy Study) and CHAP (Chronic HTN and Pregnancy) trials demonstrate not only the safety of lowering blood pressure to either a diastolic goal of 85 mmHg (CHIPS) or less than 160/105 mmHg (CHAP) without detriment to the fetus but the CHAPS trial has also shown a decrease in the rate of preeclampsia in the treatment group.

SUMMARY

We will summarize the different types of hypertensive disorders in pregnancy, updates on the pathogenesis of preeclampsia, and appropriate HTN management based on the latest evidence in order to better care for mother and child.

Pharmacokinetics of antibodies during pregnancy: General pharmacokinetics and pregnancy related physiological changes (Part 1)

Pharmacokinetics (PK) studies are important to determine a safe and effective dose of both small and large molecule drugs. Intrinsic factors such as pregnancy can substantially alter the PK of a drug. Several PK studies have been published for small molecules administered during pregnancy, but such investigations are scarce for macromolecules including monoclonal and polyclonal antibodies. In this part 1 of 2 reviews, we first provide a general description of macromolecule drugs, the PK differences with small molecules, and current knowledge on their absorption, distribution, metabolism and elimination in non-pregnant subjects. We then review in detail the physiological changes during pregnancy. While some of the physiologic adaptions of pregnancy, for example increased plasma volume and cardiac output, are expected to impact PK of antibody therapeutics, the effects of others, such as increased GFR and altered immune responses are not fully understood. We conclude that further investigations are needed to fully elucidate how pregnancy can impact PK properties of macromolecules.

Arterial stiffness for the early prediction of pre-eclampsia compared with blood pressure, uterine artery Doppler and angiogenic biomarkers: a prospective cohort study

OBJECTIVE

Our aim was to evaluate the ability of arterial stiffness parameters to predict pre-eclampsia early compared with peripheral blood pressure, uterine artery Doppler and established angiogenic biomarkers.

DESIGN

Prospective cohort study.

SETTING

Tertiary care antenatal clinics in Montreal, Canada.

POPULATION

Women with singleton high-risk pregnancies.

METHODS

In the first trimester, arterial stiffness was measured by applanation tonometry, along with peripheral blood pressure and serum/plasma angiogenic biomarkers; uterine artery Doppler was measured in the second trimester. The predictive ability of different metrics was assessed through multivariate logistic regression.

MAIN OUTCOME MEASURES

Arterial stiffness (carotid-femoral pulse wave velocity, carotid-radial pulse wave velocity) and wave reflection (augmentation index, reflected wave start time), peripheral blood pressure, ultrasound indices of velocimetry and circulating angiogenic biomarker concentrations.

RESULTS

In this prospective study, among 191 high-risk pregnant women, 14 (7.3%) developed pre-eclampsia. A first-trimester 1 m/s increase in carotid-femoral pulse wave velocity was associated with 64% increased odds (P < 0.05), and a 1-millisecond increase in time to wave reflection with 11% decreased odds for pre-eclampsia (P < 0.01). The area under the curve of arterial stiffness, blood pressure, ultrasound indices and angiogenic biomarkers was 0.83 (95% confidence interval [CI] 0.74-0.92), 0.71 (95% CI 0.57-0.86), 0.58 (95% CI 0.39-0.77), and 0.64 (95% CI 0.44-0.83), respectively. With a 5% false-positive rate, blood pressure had a sensitivity of 14% for pre-eclampsia and arterial stiffness a sensitivity of 36%.

CONCLUSIONS

Arterial stiffness predicted pre-eclampsia earlier and with greater ability than blood pressure, ultrasound indices or angiogenic biomarkers.

Pregnancy complications and later life women's health

There has been increasing recognition of the association between various pregnancy complications and development of chronic disease in later life. Pregnancy has come to be regarded as a physiological stress test, as the strain it places on a woman's body may reveal underlying predispositions to disease that would otherwise remain hidden for many years. Despite the increasing body of data, there is a lack of awareness among healthcare providers surrounding these risks. We performed a narrative literature review and have summarized the associations between the common pregnancy complications including gestational hypertension, pre-eclampsia, gestational diabetes, placental abruption, spontaneous preterm birth, stillbirth and miscarriage and subsequent development of chronic disease. Hypertensive disorders of pregnancy, spontaneous preterm birth, gestational diabetes, pregnancy loss and placental abruption are all associated with increased risk of various forms of cardiovascular disease. Gestational diabetes, pre-eclampsia, early miscarriage and recurrent miscarriage are associated with increased risk of diabetes mellitus. Pre-eclampsia, stillbirth and recurrent miscarriage are associated with increased risk of venous thromboembolism. Pre-eclampsia, gestational diabetes and stillbirth are associated with increased risk of chronic kidney disease. Gestational diabetes is associated with postnatal depression, and also with increased risk of thyroid and stomach cancers. Stillbirth, miscarriage and recurrent miscarriage are associated with increased risk of mental health disorders including depression, anxiety and post-traumatic stress disorders. Counseling in the postnatal period following a complicated pregnancy, and advice regarding risk reduction should be available for all women. Further studies are required to establish optimal screening intervals for cardiovascular disease and diabetes following complicated pregnancy.

Temporal changes in the systemic concentrations of retinoids in pregnant and postpartum women

Retinoids and vitamin A are essential for multiple biological functions, including vision and immune responses, as well as the development of an embryo during pregnancy. Despite its importance, alterations in retinoid homeostasis during normal human pregnancy are incompletely understood. We aimed to characterize the temporal changes in the systemic retinoid concentrations across pregnancy and postpartum period. Monthly blood samples were collected from twenty healthy pregnant women, and plasma concentrations of retinol, all-trans-retinoic acid (atRA), 13-cis-retinoic acid (13cisRA), and 4-oxo-retinoic acids were measured using liquid chromatography-tandem mass spectrometry. Significant decreases in 13cisRA concentrations over the pregnancy were observed, with rebound increases in retinol and 13cisRA levels after delivery. Of note, atRA concentrations exhibited a unique temporal pattern with levels peaking at mid-pregnancy. While the 4-oxo-atRA concentration was below the limit of quantification, 4-oxo-13cisRA was readily detectable, and its temporal change mimicked that of 13cisRA. The time profiles of atRA and 13cisRA remained similar after correction by albumin levels for plasma volume expansion adjustment. Together, the comprehensive profiling of systemic retinoid concentrations over the course of pregnancy provides insights into pregnancy-mediated changes in retinoid disposition to maintain its homeostasis.

Estrogen Actions in Placental Vascular Morphogenesis and Spiral Artery Remodeling: A Comparative View between Humans and Mice

Estrogens, mainly 17β-estradiol (E2), play a critical role in reproductive organogenesis, ovulation, and fertility via estrogen receptors. E2 is also a well-known regulator of utero-placental vascular development and blood-flow dynamics throughout gestation. Mouse and human placentas possess strikingly different morphological configurations that confer important reproductive advantages. However, the functional interplay between fetal and maternal vasculature remains similar in both species. In this review, we briefly describe the structural and functional characteristics, as well as the development, of mouse and human placentas. In addition, we summarize the current knowledge regarding estrogen actions during utero-placental vascular morphogenesis, which includes uterine angiogenesis, the control of trophoblast behavior, spiral artery remodeling, and hemodynamic adaptation throughout pregnancy, in both mice and humans. Finally, the estrogens that are present in abnormal placentation are also mentioned. Overall, this review highlights the importance of the actions of estrogens in the physiology and pathophysiology of placental vascular development.

Cumulative effects of temperature on blood pressure during pregnancy: A cohort study of differing effects in three trimesters

BACKGROUND

Little is known about the non-linear cumulative effects of temperature on blood pressure (BP) during pregnancy. We investigated the differing effects of daily ambient temperature on BP for up to 30 days in three trimesters.

METHODS

The first, second, and third trimester analyses included 2547, 2299, and 2011 pregnant women, respectively, from a prospective cohort in Nanjing from January 2017 to January 2020. BP was measured at each follow-up visit. The individual daily temperature exposures were calculated for 30 days prior to the follow-up date. The Distributed Lag Non-linear Model was used to investigate the relationship between temperature and BP in each trimester.

RESULTS

Temperatures under 15 °C elevate systolic, diastolic BP, and mean arterial pressure (SBP, DBP, and MAP) in the first trimester, while temperatures above 15 °C reduce SBP in the second and third trimesters. By using Distributed Lag Linear Models, we estimated that with a 1 °C decrease in daily temperature, the SBP and DBP increased by 0.32 (95 % CI: 0.12, 0.52) and 0.23 (95 % CI: 0.07, 0.39) mmHg, respectively, in the first trimester with a 20-day cumulative lag, while with a 1 °C increase in daily temperature, the SBP decreased by 0.23 (0.35, 0.10) mmHg in the third trimester with a 30-day cumulative lag. The significant effects of temperature mainly manifested between 2 and 4 weeks of exposure.

CONCLUSIONS

Temperature has different effects on BP over three trimesters. Protective measures to reduce cold-related BP rise will help reduce the risk of hypertensive disorders of pregnancy.

Outcome predictors and patient progress following delivery in pregnant and postpartum patients with severe COVID-19 pneumonitis in intensive care units in Israel (OB-COVICU): a nationwide cohort study

BACKGROUND

A key unresolved controversy in severe COVID-19 pneumonitis in pregnancy is the optimum timing of delivery and whether delivery improves or worsens maternal outcomes. We aimed to assess clinical data on every intensive care unit (ICU) day for pregnant and postpartum women admitted to the ICU with COVID-19, with a particular focus on the days preceding and following delivery.

METHODS

In this multicentre, nationwide, prospective and retrospective cohort study, we evaluated all pregnant women who were admitted to an ICU in Israel with severe COVID-19 pneumonitis from the 13th week of gestation to the 1st week postpartum. We excluded pregnant patients in which the ICU admission was unrelated to severe COVID-19 pneumonitis. We assessed maternal and neonatal outcomes and longitudinal clinical and laboratory ICU data. The primary overall outcome was maternal outcome (worst of the following: no invasive positive pressure ventilation [IPPV], use of IPPV, use of extracorporeal membrane oxygenation [ECMO], or death). The primary longitudinal outcome was Sequential Organ Failure Assessment (SOFA) score, and the secondary longitudinal outcome was the novel PORCH (positive end-expiratory pressure [PEEP], oxygenation, respiratory support, chest x-ray, haemodynamic support) score. Patients were classified into four groups: no-delivery (pregnant at admission and no delivery during the ICU stay), postpartum (ICU admission ≥1 day after delivery), delivery-critical (pregnant at admission and receiving or at high risk of requiring IPPV at the time of delivery), or delivery-non-critical (pregnant at admission and not critically ill at the time of delivery).

FINDINGS

From Feb 1, 2020, to Jan 31, 2022, 84 patients were analysed: 34 patients in the no-delivery group, four in postpartum, 32 in delivery-critical, and 14 in delivery-non-critical. The delivery-critical and postpartum groups had worse outcomes than the other groups: 26 (81%) of 32 patients in the delivery-critical group and four (100%) of four patients in the postpartum group required IPPV; 12 (38%) and three (75%) patients required ECMO, and one (3%) and two (50%) patients died, respectively. The delivery-non-critical and no-delivery groups had far better outcomes than other groups: six (18%) of 34 patients and two (14%) of 14 patients required IPPV, respectively; no patients required ECMO or died. Oxygen saturation (SpO₂), SpO₂ to fraction of inspired oxygen (FiO₂) ratio (S/F ratio), partial pressure of arterial oxygen to FiO₂ ratio (P/F ratio), ROX index (S/F ratio divided by respiratory rate), and SOFA and PORCH scores were all highly predictive for adverse maternal outcome (p<0·0001). The delivery-critical group deteriorated on the day of delivery, continued to deteriorate throughout the ICU stay, and took longer to recover (ICU duration, Mantel-Cox p<0·0001), whereas the delivery-non-critical group improved rapidly following delivery. The day of delivery was a significant covariate for PORCH (p<0·0001) but not SOFA (p=0·09) scores.

INTERPRETATION

In patients who underwent delivery during their ICU stay, maternal outcome deteriorated following delivery among those defined as critical compared with non-critical patients, who improved following delivery. Interventional delivery should be considered for maternal indications before patients deteriorate and require mechanical ventilation.

FUNDING

None.

Hemodynamic changes in pregnancy: does central blood pressure have any role?

Pregnancy is associated with alteration in the hemodynamic state. In clinical practice, only peripheral blood pressure is measured; however, central blood pressure is a better predictor of cardiovascular events. We have investigated variations in peripheral blood pressure, central blood pressure, and augmentation index in healthy non-pregnant and pregnant women. This was a cross-sectional study of 107 pregnant women (I trimester n = 19, II trimester n = 39, and III trimester n = 49) and age-matched 53 non-pregnant women (Follicular phase n = 25 and luteal phase n = 28). The augmentation index showed a significant decrease with the progression of pregnancy. Central systolic blood pressure showed a decreasing trend (non-significant) with the progression of pregnancy. Heart rate shows a significant increase from follicular to luteal phase in non-pregnant women, which further increases with the progression of pregnancy. Longitudinal studies involving larger sample sizes might provide some insights into the significance of including central blood pressure and augmentation index for routine checkups in both non-pregnant and pregnant women.

Indications for Maternal Echocardiography in Detecting Disease and the Impact on Pregnancy Management

OBJECTIVE

Few obstetric-specific guidelines detail the indications for screening echocardiography in pregnancy. The objective of the study is to examine the association of common indications for maternal echocardiography with the likelihood of abnormality identification, pregnancy management alteration, and conformity with current American College of Cardiology Foundation (ACCF) guidelines.

STUDY DESIGN

This retrospective cohort analysis categorized all echocardiograms performed within pregnancy and the first month postpartum within a tertiary health system to correlate indications with abnormal findings.

RESULTS

Data from 226 echocardiograms were analyzed from 205 women. The most common indication for initial echocardiography was cardiac symptoms (34.6%). History of cardiac disease was the only indication demonstrating a significant association with an abnormal finding on initial echocardiography (odds ratio [OR]: 2.6; p = 0.006). Postpartum status (OR: 4.9; p < 0.001), multiparity (p < 0.001), and tobacco use (OR: 2.2; p = 0.011) were demographic characteristics associated with the identification of abnormal findings on initial echocardiography. Abnormal echocardiographic findings were associated with changes in clinical management but did not correlate with adverse obstetric or neonatal outcomes, which may support the impact of a multidisciplinary programmatic approach. ACCF appropriateness criteria correlated well with identification of abnormal echocardiographic results (p = 0.034).

CONCLUSION

Although the presence of cardiac symptoms or history of diabetes failed to demonstrate association with abnormal echocardiographic findings, a history of prior cardiac disease, tobacco use, multiparity, and postpartum status were factors associated with identification of abnormal findings on initial maternal echocardiography. The ACCF appropriateness criteria for obtaining echocardiography can be applied to pregnant women with consideration for these additional risk factors.

KEY POINTS

· The ACCF criteria are applicable in pregnancy for appropriateness of echocardiography indications.. · Several clinical factors often prompt performance of echocardiography in pregnancy without merit.. · Consideration for multiparty, tobacco abuse, and postpartum state should coincide with ACCF criteria..

ERα/ERβ-directed CBS transcription mediates E2β-stimulated hUAEC H2S production

Elevated endogenous estrogens stimulate human uterine artery endothelial cell (hUAEC) hydrogen sulfide (H2S) production by selectively upregulating the expression of H2S synthesizing enzyme cystathionine β-synthase (CBS), but the underlying mechanisms are underdetermined. We hypothesized that CBS transcription mediates estrogen-stimulated pregnancy-dependent hUAEC H2S production. Estradiol-17β (E2β) stimulated CBS but not cystathionine γ-lyase (CSE) expression in pregnant human uterine artery ex vivo, which was attenuated by the estrogen receptor (ER) antagonist ICI 182,780. E2β stimulated CBS mRNA/protein and H2S production in primary hUAEC from nonpregnant and pregnant women, but with greater responses in pregnant state; all were blocked by ICI 182,780. Human CBS promoter contains multiple estrogen-responsive elements (EREs), including one ERE preferentially binding ERα (αERE) and three EREs preferentially binding ERβ (βERE), and one full ERE (α/βERE) and one half ERE (½α/βERE) binding both ERα and ERβ. Luciferase assays using reporter genes driven by human CBS promoter with a series of 5'-deletions identified the α/βEREs binding both ERα and ERβ (α/βERE and ½α/βERE) to be important for baseline and E2β-stimulated CBS promoter activation. E2β stimulated ERα/ERβ heterodimerization by recruiting ERα to α/βEREs and βERE, and ERβ to βERE, α/βEREs, and αERE. ERα or ERβ agonist alone trans-activated CBS promoter, stimulated CBS mRNA/protein and H2S production to levels comparable to that of E2β-stimulated, while ERα or ERβ antagonist alone abrogated E2β-stimulated responses. E2β did not change human CSE promoter activity and CSE mRNA/protein in hUAEC. Altogether, estrogen-stimulated pregnancy-dependent hUAEC H2S production occurs by selectively upregulating CBS expression via ERα/ERβ-directed gene transcription.

Baseline associations between household air pollution exposure and blood pressure among pregnant women in the Household Air Pollution Intervention Network (HAPIN) multi-country randomized controlled trial

Cooking and heating using solid fuels can result in dangerous levels of exposure to household air pollution (HAP). HAPIN is an ongoing randomized controlled trial assessing the impact of a liquified petroleum gas stove and fuel intervention on HAP exposure and health in Guatemala, India, Peru, and Rwanda among households that rely primarily on solid cooking fuels. Given the potential impacts of HAP exposure on cardiovascular outcomes during pregnancy, we seek to characterize the relationship between personal exposures to HAP and blood pressure among pregnant women at baseline (prior to intervention) in the study. We assessed associations between PM2.5 (particulate matter with an aerodynamic diameter ≤2.5 μm), BC (black carbon), and CO (carbon monoxide) exposures and blood pressure at baseline, prior to intervention, among 3195 pregnant women between 9 and 19 weeks of gestation. We measured 24-hour personal exposure to PM2.5/BC/CO and gestational blood pressure. Multivariable linear regression models were used to evaluate associations between personal exposures to three air pollutants and blood pressure parameters. Trial-wide, we found moderate increases in systolic blood pressure (SBP) and decreases in diastolic blood pressure (DBP) as exposure to PM2.5, BC, and CO increased. None of these associations, however, were significant at the 0.05 level. HAP exposure and blood pressure associations were inconsistent in direction and magnitude within each country. We observed effect modification by body mass index (BMI) in India and Peru. Compared to women with normal weights, obese women in India and Peru (but not in Rwanda or Guatemala) had higher SBP per unit increase in log transformed PM2.5 and BC exposures. We did not find a cross-sectional association between HAP exposure and blood pressure in pregnant women; however, HAP may be associated with higher blood pressure in pregnant women who are obese, but this increase was not consistent across settings.

Myopia and its associated factors among pregnant women at health institutions in Gondar District, Northwest Ethiopia: A multi-center cross-sectional study

Background

Myopia is the most common form of uncorrected refractive error with a growing burden worldwide. It is the principal complaint of most women during pregnancy. Although myopia has led to several consequences across the standard life of pregnant women, there is no previous study in Ethiopia regarding this topic. Thus, this study determined the prevalence of myopia and identifies its associated factors among pregnant women attending antenatal care units at governmental health institutions in Gondar City District, Northwest Ethiopia.

Methods

An institution-based cross-sectional study design was conducted from 08 February to 08 April 2021. From the selected health centres, study participants were recruited by systematic random sampling technique. A pre-tested, structured-interviewer-administered questionnaire consisting of socio-demographic variables, obstetric and clinical-related variables was used to collect the required data. Non-cycloplegic refraction was performed using trial lenses, trial frames, and retinoscopy in a semi-dark examination room. EpiData 3 and STATA 14 were used for data entry and statistical analysis respectively. Both bivariable and multivariable binary logistic regression analyses were executed to identify associated factors of myopia. Variables with a p-value ≤0.05 in the multivariable logistic regression analysis were declared as statistically significant with myopia. Model fitness was checked by Hosmer and Lemeshow goodness of test (at p > 0.05).

Results

A total of four-hundred and twenty-three pregnant women participated with a 100% response rate in this study. The overall prevalence of myopia among pregnant women was 26.48% (95% CI: 22.48-30.91). Eighty-Eight (20.81%) and Eighty-Four (19.85%) of the study participants had myopia in their right and left eyes respectively. The prevalence of myopia was significantly associated with age (AOR = 1.17; 95% CI: 1.09-1.28), the third trimester of gestation (AOR = 2.05, 95% CI: 1.08-3.90), multi & grand multipara (AOR = 3.15; 95% CI: 1.59-6.25), and history of contraceptive use (AOR = 3.30; 95% CI: 1. 50-7.28).

Conclusion

The finding of our study shows that there is a higher prevalence of myopia among pregnant women in our study area. Further prospective analytical studies regarding visual systems among pregnant women, particularly as a result of pregnancy, are strongly recommended.

Infection and disruption of placental multidrug resistance (MDR) transporters: Implications for fetal drug exposure

P-glycoprotein (P-gp, encoded by the ABCB1 gene) and breast cancer resistance protein (BCRP/ABCG2) are efflux multidrug resistance (MDR) transporters localized at the syncytiotrophoblast barrier of the placenta and protect the conceptus from drug and toxin exposure throughout pregnancy. Infection is an important modulator of MDR expression and function. This review comprehensively examines the effect of infection on the MDR transporters, P-gp and BCRP in the placenta. Infection PAMPs such as bacterial lipopolysaccharide (LPS) and viral polyinosinic-polycytidylic acid (poly I:C) and single-stranded (ss)RNA, as well as infection with Zika virus (ZIKV), Plasmodium berghei ANKA (modeling malaria in pregnancy - MiP) and polymicrobial infection of intrauterine tissues (chorioamnionitis) all modulate placental P-gp and BCRP at the levels of mRNA, protein and or function; with specific responses varying according to gestational age, trophoblast type and species (human vs. mice). Furthermore, we describe the expression and localization profile of Toll-like receptor (TLR) proteins of the innate immune system at the maternal-fetal interface, aiming to better understand how infective agents modulate placental MDR. We also highlight important gaps in the field and propose future research directions. We conclude that alterations in placental MDR expression and function induced by infective agents may not only alter the intrauterine biodistribution of important MDR substrates such as drugs, toxins, hormones, cytokines, chemokines and waste metabolites, but also impact normal placentation and adversely affect pregnancy outcome and maternal/neonatal health.

Predictors of Preeclampsia in the First Trimester in Normotensive and Chronic Hypertensive Pregnant Women

Preeclampsia (PE) is characterized by the new onset of hypertension (HT) and proteinuria beyond the 20th week of gestation. We aimed to find the best predictor of PE and find out if it is different in women with or without HT. Consecutively attended pregnant women were recruited in the first trimester of pregnancy and followed-up. Laboratory and office and 24 h-ambulatory blood pressure (BP) data were collected. PE occurred in 6.25% of normotensives (n = 124). Both office mean BP and 24 h-systolic BP in the first trimester were higher in women with versus those without PE (p ≤ 0.001). In women with chronic hypertension (cHT), PE occurred in 55%; office SBP (p = 0.769) and 24 h-SBP (p = 0.589) were similar between those with and those without PE. Regarding biochemistry, in cHT, plasma urea and creatinine were higher in PE women than in those without cHT (p = 0.001 and p = 0.004 for the differences in both parameters). These differences were not observed in normotensives. In normotensives, mean BP was the best predictor of PE [ROC curve = 0.91 (95%CI 0.82-0.99)], best cut-off = 80.3 mmHg. In cHT, plasma urea and creatinine were the best predictors of PE, with ROC curves of 0.94 (95%CI 0.84-1.00) and 0.93 (95%CI 0.83-1.00), respectively. In the first trimester of pregnancy, the strongest predictor of PE in normotensive women is office mean BP, while in cHT, renal parameters are the strongest predictors. Otherwise, office BP is non-inferior to 24 h ambulatory BP to predict PE.

Assessing maternal cardiac function by obstetricians: technique and reference ranges

BACKGROUND

A strong body of evidence has now coalesced indicating that some obstetrical syndromes may result from maladaptive responses of the maternal cardiovascular system. Longitudinal studies have shown that these changes are complex and present before the clinical recognition of preeclampsia and fetal growth restriction, suggesting that hemodynamic maladaptation may play an etiologic role in obstetrical complications. Chronic hypertension is one of the most frequent complications of pregnancy, and recent evidence suggests that control of mild hypertension in early pregnancy improves outcome. The management of chronic hypertension can be improved by understanding specific cardiovascular hemodynamic abnormalities such as increased cardiac output or increased systemic vascular resistance, which can respond to either beta or calcium channel blockers, depending on the hemodynamic findings. Evaluation of maternal cardiac function has not been previously available to obstetrical healthcare providers using diagnostic ultrasound equipment used for fetal evaluation.

OBJECTIVE

Obstetrical ultrasound machines may be configured for various probes (endovaginal, abdominal, 3D/4D, and cardiac). This study used a cardiac probe placed in the suprasternal notch to image and measure the descending aorta diameter and the velocity time integral using pulsed and continuous wave Doppler ultrasound in normal pregnant women between 11 and 39 weeks of gestation. These measurements were followed by computation of maternal left ventricular preload, afterload, contractility, and blood flow.

STUDY DESIGN

This was a prospective cross-sectional study. A total of 400 pregnant women were recruited between 11 and 39 weeks of gestation. Imaging of the maternal aortic arch was performed by placing a cardiac probe in the suprasternal notch to identify the aortic arch using 2D and color Doppler ultrasound. The end-systolic diameter of the aorta was measured at the junction of the left subclavian artery with the descending aorta, which was followed by insonation of the descending aorta to obtain the Doppler waveform. Following insonation of the descending aorta, measurements of the aortic diameter, velocity time integral, ejection time, mean pressure gradient, heart rate, maternal weight and height, and systolic and diastolic blood pressures were entered into an Excel spreadsheet to compute the following: (1) preload measurements of stroke volume, stroke volume index, and stroke work index; (2) afterload measurements of systemic vascular resistance and the potential-to-kinetic energy ratio; (3) contractility measurements of inotropy and the Smith-Madigan inotropy index; and (4) blood flow measurements of cardiac output and the cardiac output index. Fractional polynomial regression analysis was performed for each of the above measurements using gestational age as the independent variable.

RESULTS

The diastolic and mean arterial blood pressure decreased from 11 to 18 weeks of gestation and then increased until term. The afterload measurements demonstrated similar characteristics, as all values decreased from 11 weeks until the mid and late second trimester, after which all values increased until term. Changes in contractility demonstrated an increase from 11 weeks to 25 to 28 weeks, followed by a decline until term. Changes in blood flow demonstrated an increase from 11 to 27 weeks and then declined until term. The continuous wave Doppler values were greater than the pulsed Doppler values except for the contractility measurements. Examples of abnormal cardiac measurements were identified in pregnant patients with hypertension and fetal growth restriction. An Excel calculator was created to provide quick computation of z-score measurements and their corresponding centiles described in this study.

CONCLUSION

The technique for evaluation of maternal cardiac function described in this study would allow screening of maternal left ventricular preload, afterload, contractility, and blood flow in the obstetrical clinical milieu once a cardiac probe is acquired for obstetrical ultrasound machines used for fetal evaluation. The above measurements would allow the clinician to select appropriate hypertensive medication on the basis of the results of the evaluation of the maternal left ventricle.

Multiscale asymmetry reveals changes in the maternal short-term heart rate dynamics of preeclamptic women during labor

BACKGROUND

It is known that acceleration and deceleration patterns in heart rate variability (HRV) are asymmetrically distributed in healthy subjects. Accordingly, novel approaches for assessing the asymmetrical properties of HRV, such as the multiscale asymmetry (MSA), have been applied in the perinatal field.

OBJECTIVE

To study the asymmetry of accelerations and decelerations of maternal short-term cardiac dynamics of thirty-six normotensive and preeclamptic women during labor/nonlabor by MSA analysis.

METHODS

The RR interval time series obtained from these participants were classified into four groups: normotensive (control) without labor C-NL, n= 10; control with labor C-L, n= 10; and two preeclamptic groups with absence or presence of labor P-NL, n= 6; and P-L, n= 10, respectively. Multiscale indices of heart rate asymmetry (HRA) such as Porta (P%), Guzik (G%) and Ehlers (E) were used to explore the changes of HRA in the normotensive and preeclamptic groups in the presence or absence of labor.

RESULTS

The main result of this study shows that preeclamptic women manifest decreased magnitude of decelerations of heart rate dynamics compared to normotensive women indicated by G% and E. We speculate that a lower cardiac parasympathetic response may be manifested in preeclamptic women during labor/nonlabor compared to normotensive women.

CONCLUSIONS

These observations represented a new insight into the autonomic cardiovascular regulation in preeclampsia, which could contribute to the perinatal field in the future.

Predictive Model for Preeclampsia Combining sFlt-1, PlGF, NT-proBNP, and Uric Acid as Biomarkers

N-terminal pro-brain natriuretic peptide (NT-proBNP) and uric acid are elevated in pregnancies with preeclampsia (PE). Short-term prediction of PE using angiogenic factors has many false-positive results. Our objective was to validate a machine-learning model (MLM) to predict PE in patients with clinical suspicion, and evaluate if the model performed better than the sFlt-1/PlGF ratio alone. A multicentric cohort study of pregnancies with suspected PE between 24+0 and 36+6 weeks was used. The MLM included six predictors: gestational age, chronic hypertension, sFlt-1, PlGF, NT-proBNP, and uric acid. A total of 936 serum samples from 597 women were included. The PPV of the MLM for PE following 6 weeks was 83.1% (95% CI 78.5−88.2) compared to 72.8% (95% CI 67.4−78.4) for the sFlt-1/PlGF ratio. The specificity of the model was better; 94.9% vs. 91%, respectively. The AUC was significantly improved compared to the ratio alone [0.941 (95% CI 0.926−0.956) vs. 0.901 (95% CI 0.880−0.921), p < 0.05]. For prediction of preterm PE within 1 week, the AUC of the MLM was 0.954 (95% CI 0.937−0.968); significantly greater than the ratio alone [0.914 (95% CI 0.890−0.934), p < 0.01]. To conclude, an MLM combining the sFlt-1/PlGF ratio, NT-proBNP, and uric acid performs better to predict preterm PE compared to the sFlt-1/PlGF ratio alone, potentially increasing clinical precision.

Acute coronary syndrome during pregnancy and postpartum in France: the nationwide CONCEPTION study

BACKGROUND

Cardiovascular diseases, including acute coronary syndromes, are the leading cause of maternal death in many developed countries.

OBJECTIVE

We assessed acute coronary syndrome incidences during pregnancy, peripartum, and postpartum periods. We also compared overall pregnancy (ie, covering all 3 periods) incidence with that found in nonpregnant women of childbearing age.

STUDY DESIGN

All women aged between 15 and 49 years without ischemic heart disease who delivered between 2010 and 2018 in France were included in the CONCEPTION cohort. Data were extracted from the French National Health Insurance Information System database. Acute coronary syndromes were defined according to the International Classification of Diseases, Tenth Revision codes recorded in the principal hospital diagnosis. We used Poisson regression to estimate crude acute coronary syndrome incidences, and tested age-adjusted Poisson models to compare the incidence risk ratio of acute coronary syndrome between pregnant and nonpregnant women, with 95% confidence intervals.

RESULTS

Among 6,298,967 deliveries in France, we observed 225 first-time acute coronary syndrome diagnoses during overall pregnancy (overall pregnancy-related acute coronary syndrome incidence, 4.34/100,000 person-years; 1 case/23,000 pregnancies). In multivariate analysis, independent factors associated with acute coronary syndrome were age, social deprivation, obesity, tobacco use, chronic hypertension, and hypertensive disorders of pregnancy (all P<.05). Among the nonpregnant women aged 15 to 49 years in the general French population, 18,247 cases of acute coronary syndrome (incidence, 16.5/100,000 person-years) occurred throughout the whole study period (>100 million person-years). Compared with the acute coronary syndrome incidence in nonpregnant women, age-adjusted overall pregnancy-related acute coronary syndrome incidence was lower (incidence rate ratio, 0.76; 95% confidence interval, 0.57-0.98; P<.05). Although compared with nonpregnant women, age-adjusted incidence rates were lower during pregnancy, risk was increased during peripartum and postpartum periods.

CONCLUSION

With an incidence of 4.34 per 100,000 person-years, acute coronary syndrome still accounts for a significant proportion of maternal mortality. The peripartum and postpartum periods remain high-risk periods, and greater efforts should be made in terms of acute coronary syndrome prevention, especially because several cardiovascular risk factors are treatable, such as tobacco use and hypertensive disorders of pregnancy.

Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes

Stroke is a particularly important issue for women. Women account for over half of all persons who experienced a stroke. The lifetime risk of stroke is higher in women than in men. In addition, women have worse stroke outcomes than men. Several risk factors have a higher association with stroke in women than in men, and women-specific risk factors that men do not have should be considered. This focused review highlights recent findings in stroke epidemiology, risk factors, and outcomes in women.

Cardiovascular Complications During Delivery Admissions Associated With Assisted Reproductive Technology (from a National Inpatient Sample Analysis 2008 to 2019)

Women who conceive through assisted reproductive technology (ART) have a known increased risk of obstetric complications. However, whether ART is also associated with higher risk of developing cardiovascular complications during delivery admissions has not been well established. We used data from the National Inpatient Sample (2008 to 2019) and used the International Classification of Diseases codes to identify delivery hospitalizations and ART procedures. A total of 45,867,086 weighted delivery cases were identified, of which 0.24% were among women who conceived through ART (n = 108,542). Women with an ART history were older at the time of delivery (median 35 vs 28 years, p <0.01) and had a higher prevalence of hypertension, gestational diabetes, and dyslipidemia (all, p <0.01). After adjustment for age, race/ethnicity, co-morbidities, multiple gestation, insurance, and income, ART remained an independent predictor of peripartum cardiovascular complications, including pre-eclampsia/eclampsia (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.45 to 1.51), heart failure (aOR 1.94, 95% CI 1.10 to 3.40), and cardiac arrhythmias (aOR 1.39, 95% CI 1.30 to 1.48), compared with natural conception. Likewise, the risk of acute kidney injury (aOR 2.57, 95% CI 2.25 to 2.92), ischemic stroke (aOR 1.73, 95% CI 1.24 to 2.43), hemorrhagic stroke (aOR 1.63, 95% CI 1.27 to 2.11), pulmonary edema (aOR 2.29, 95% CI 2.02 to 2.61), and venous thromboembolism (aOR 1.92, 95% CI 1.63 to 2.25) were higher with ART. However, odds of developing peripartum cardiomyopathy or acute coronary syndrome were not associated with ART. Length of stay (3 vs 2 days, p <0.01) and cost of hospitalization ($5,903 vs $3,922, p <0.01) were higher for deliveries among women with a history of ART. In conclusion, women who conceived with ART had higher risk of pre-eclampsia, heart failure, arrhythmias, stroke, and other complications during their delivery hospitalizations. This may, in part, contribute to their increased resource utilization seen.

Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice

Hypertensive disorders of pregnancy (HDP) are the most common causes of maternal and perinatal morbidity and mortality. They are responsible for 16% of maternal deaths in high-income countries and approximately 25% in low- and middle-income countries. The impact of HDP can be lifelong as they are a recognized risk factor for future cardiovascular disease. During pregnancy, the cardiovascular system undergoes significant adaptive changes that ensure adequate uteroplacental blood flow and exchange of oxygen and nutrients to nurture and accommodate the developing fetus. Failure to achieve normal cardiovascular adaptation is associated with the development of HDP. Hemodynamic alterations in women with a history of HDP can persist for years and predispose to long-term cardiovascular morbidity and mortality. Therefore, pregnancy and the postpartum period are an opportunity to identify women with underlying, often unrecognized, cardiovascular risk factors. It is important to develop strategies with lifestyle and therapeutic interventions to reduce the risk of future cardiovascular disease in those who have a history of HDP.

Pregnancy outcomes among women affected with thalassemia traits

OBJECTIVE

To compare the maternal and perinatal outcomes between a group of pregnant women diagnosed with thalassemia traits and normal controls.

STUDY DESIGN

A retrospective cohort study was conducted on singleton pregnant women affected and unaffected by thalassemia traits who attended an antenatal care clinic and delivered in Siriraj Hospital. Thalassemia status for all subjects was diagnosed by hemoglobin typing and/or DNA analysis. Patient charts were reviewed from January 2007 to December 2018. The control participants were randomly selected from the same period, with a control-case ratio of around 1:1.

RESULTS

Overall, 1288 women with thalassemia traits (348 with α thal-1 trait, 424 with β thal trait and 516 with HbE trait) and 1305 women in the control group were recruited. Baseline characteristics of both groups were similar, with the exception that the hematocrit level in the first trimester in the thalassemia trait group was significantly lower than that in the control group (34.8 ± 3.4% VS 36.9 ± 3.0%; p < 0.001). The prevalence of pregnancy-induced hypertension (PIH) was higher in the thalassemia trait group, at 6.9% VS 4.7% in the control group; p = 0.018. When subgroups were analyzed between each thalassemia trait, the number of maternal anemias in the first and third trimester was higher for all thalassemia traits compared to the normal group. The β thal and HbE traits increased the risk of PIH, with a relative risk (RR) = 1.67 and 1.66, respectively.

CONCLUSIONS

Thalassemia traits minimally but significantly increase the risk of hypertensive disorders and maternal anemia. In addition, physiological changes during pregnancy may worsen the severity of anemia in the pregnant women with thalassemia traits.

The Multidisciplinary Heart Team in Cardiovascular Medicine: Current Role and Future Challenges

Cardiovascular multidisciplinary heart teams (MDHTs) have evolved significantly over the past decade. These teams play a central role in the treatment of a wide array of cardiovascular diseases affecting interventional cardiology, cardiac surgery, interventional imaging, advanced heart failure, adult congenital heart disease, cardio-oncology, and cardio-obstetrics. To meet the specific needs of both patients and heart programs, the composition and function of cardiovascular MDHTs have had to adapt and evolve. Although lessons have been learned from multidisciplinary cancer care, best practices for the operation of cardiovascular MDHTs have yet to be defined, and the evidence base supporting their effectiveness is limited. This expert panel review discusses the history and evolution of cardiovascular MDHTs, their composition and role in treating patients across a broad spectrum of disciplines, basic tenets for successful operation, and the future challenges facing them.

A High Cholesterol Diet During Late Pregnancy Impairs Long-Term Maternal Vascular Function in Mice

BACKGROUND

Gestational dyslipidemia is associated with pregnancy complications including preeclampsia. However, whether gestational dyslipidemia leads postpartum vascular dysfunction, which could increase the risk for cardiovascular complications later in life, is not known. Here, we aimed to determine whether a gestational dyslipidemia affects postpartum vascular health and induces early signs of atherosclerosis.

METHODS

Pregnant C57BL/6 mice received a high cholesterol diet or control diet from gestational day 13.5 until term. After delivery, all mice received the control diet for ≈3 months postpartum (PP). Age-matched nulliparous females were on the same diets for equal periods. After 3 months, all mice were euthanized, serum was collected, and aortas were isolated to assess vascular function (wire myography) and markers of oxidative stress and early atherosclerosis.

RESULTS

PP-high cholesterol diet females had increased circulating cholesterol levels compared with PP-control diet mice, without effect of the diet in nulliparous mice. Methacholine-induced vasodilation was impaired, and nitric oxide contribution reduced, by the high cholesterol diet in aortas of PP mice, but not in nulliparous mice. Exposure to oxidized low-density-protein cholesterol further impaired methylcholine-induced vasodilation in PP-high cholesterol diet aortas only. Compared with PP-control diet mice, aortic inducible nitric oxide synthase expression, reactive oxygen species and nitrotyrosine levels were increased in aortas from PP-high cholesterol diet mice. No differences in aortic lipid deposition and macrophage infiltration were found.

CONCLUSIONS

Exposure to a high cholesterol diet in pregnancy impairs vascular function postpartum. Our results support the hypothesis that gestational dyslipidemia impacts maternal vascular function after pregnancy, which could potentially predispose these women to future cardiovascular complications.

Relationship between birth weight and ambient temperature during pregnancy in a cross-sectional study of the residents of Suzhou, China

Objective

The association between birth weight and ambient temperature during pregnancy remains inconclusive, and data from Chinese populations are scarce. We conducted a cross-sectional study to investigate the association between birth weight and ambient temperature during pregnancy among the residents of Suzhou Industrial Park, Suzhou, China.

Methods

Information regarding 10,903 infants born between January 2018 and December 2018 who were born at the hospitals in Suzhou Industrial Park, Jiangsu province was obtained via public birth records.

Results

This study found that the ambient temperature during the first trimester of pregnancy was negatively correlated with birth weight, suggesting that elevated temperature may be related to lower birth weight. However, the ambient temperatures during the second and third trimesters of pregnancy were positively correlated with birth weight. Moreover, when the ambient temperature was below 15°C during the second trimester of pregnancy, the birth weight increased with temperature. However, when the temperature was higher than 15°C, the birth weight decreased with temperature. The relationship between ambient temperature in the third trimester and birth weight presented an inverted "U" curve. When the ambient temperature was lower than 20°C, the birth weight increased with ambient temperature, but when the ambient temperature was higher than 20°C, the increase of ambient temperature showed no significant relationship with the increase of birth weight.

Conclusion

The ambient temperature was correlated with birth weight. The ambient temperature during the first trimester of pregnancy was negatively correlated with birth weight. The relationship between ambient temperature in the third trimester and birth weight presented an inverted "U" curve.

Associations Between Parity and Cognition: Race/Ethnic Differences

BACKGROUND

Race/ethnicity is associated with differences in reproductive history and cognition individually, yet it remains an understudied factor in the relationship between parity and later-life cognition.

OBJECTIVE

To evaluate if the association between parity and cognition differs between racial/ethnic groups.

METHODS

Participants included 778 older, postmenopausal women from the Health and Nutrition Examination Survey (Latina: n = 178, Non-Latino Black [NLB]: n = 169, Non-Latino White [NLW]: n = 431) who self-reported at least one birth. Cognitive outcomes included working memory, learning memory, and verbal fluency. Covariates included age, education, cardiovascular and other reproductive health factors, adult socioeconomic status (SES) and depressive symptoms. We fit a series of linear models to examine a) whether parity was associated with cognitive functioning, b) if this association varied by race/ethnicity through parity by race/ethnicity interactions, and c) individual parity with cognition associations stratified by race/ethnicity.

RESULTS

In the full sample, parity was significantly negatively associated with Digit Symbol Substitution Test (DSST) performance (b = -0.70, p = 0.024) but not Animal Fluency or word-list learning and memory. Tests of race/ethnicity-by-parity interactions were not statistically significant (ps > 0.05). However, stratified analyses by race/ethnicity showed a differential effect of parity on DSST performance, such that parity was significantly negatively associated with DSST performance (b = -1.66, p = 0.007) among Latinas but not in NLWs (b = -0.16, p = 0.74) or NLBs (b = -0.81, p = 0.191).

CONCLUSION

Among Latina, but not NLB or NLW women, greater parity was associated with worse processing speed/executive functioning later in life. Further research is needed to understand the mechanisms driving racial/ethnic differences.

Previous pregnancy loss and gestational cardiovascular health: A prospective cohort of nulliparous women

Objectives

To estimate the association of previous pregnancy loss with subsequent cardiovascular health during gestation and to examine the role of high-sensitivity C reactive protein (hs-CRP) in the association.

Methods

A total of 2,778 nulliparous pregnant women were recruited between March 2015 and November 2020 in Hefei city, China. Their cardiovascular health (CVH) including prepregnancy body mass index (BMI), blood pressure, total cholesterol, fasting plasma glucose, and smoke status were recorded at 24-28 weeks' gestation, as well as their reproductive history. Multivariate linear and logistic regression were performed to examine the association of pregnancy loss with cardiovascular health. And the role of hs-CRP between pregnancy loss and CVH was assessed by the mediation analysis.

Results

Compared with women who have no pregnancy loss, women with a history of spontaneous or induced abortions had higher BMI (β, 0.72, 95% CI, 0.50 to 0.94) and fasting plasma glucose (β, 0.04, 95% CI, 0.01 to 0.07), and had lower total CVH scores after adjusting for confounders (β, -0.09, 95% CI, -0.18 to -0.01). CVH scores were most significantly decreased among women with 3 or more induced abortions (β, -0.26, 95% CI, -0.49, -0.02). The contribution of pregnancy loss to poorer gestational CVH mediated by increased hs-CRP levels was 23.17%.

Conclusion

Previous pregnancy loss was associated with poorer cardiovascular health during gestation, which may be mediated by their gestational inflammatory status. Exposure to miscarriage alone was not a significant predictor of poorer CVH.

The association between sleep-disordered breathing and maternal endothelial and metabolic markers in pregnancies complicated by obesity

STUDY OBJECTIVES

To evaluate the impact of sleep-disordered breathing (SDB) on vascular, angiogenic and metabolic analytes in pregnancy.

METHODS

Participants with a body mass index ≥30 kg/m2 underwent polysomnography at 14-20 weeks gestation (visit 1). Participants with SDB (defined as an apnea-hypopnea index ≥5 events/h) were then enrolled in a separate trial. SDB-negative participants returned for a polysomnogram at 28-31 weeks (visit 2) and were recategorized as persistent-negative SDB or new-onset SDB. Mean arterial blood pressure, mean uterine artery Doppler pulsatility index, endoglin, soluble Feline McDonough Sarcoma-like tyrosine kinase 1, placental growth factor, and the homeostatic model assessment for insulin resistance were measured after each visit. Our primary outcome was a composite of uterine artery Doppler pulsatility index, soluble FMS-like tyrosine kinase 1/placental growth factor ratio, and homeostatic model assessment for insulin resistance. For secondary analyses, each outcome variable was analyzed independently.

RESULTS

A total of 242 and 130 participants completed visit 1 and visit 2, respectively. Newly diagnosed SDB was present in 37% of individuals at visit 1 and 31% of individuals at visit 2. No significant differences in our composite outcome vector were observed in individuals with and without SDB at either visit. In our secondary analysis, mean arterial blood pressure (88.7 ± 7.3 mm Hg vs 85.4 ± 7.1 mm Hg, P = .04) and fasting glucose (92.4 ± 15.2 mg/dL vs 86.6 ± 11.5 mg/dL, P = .05) were higher in participants with early pregnancy SDB. These associations were not observed for new-onset SDB. No associations were observed between uterine artery Doppler pulsatility index and angiogenic markers and SDB in pregnancy.

CONCLUSIONS

SDB in early pregnancy was not associated with our composite primary outcome but was associated with higher mean arterial blood pressure and fasting glucose. The pathophysiologic changes that occur in pregnant individuals with SDB and how they lead to an increased risk of preeclampsia and gestational diabetes remain poorly understood.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Sleep Disordered Breathing, Obesity and Pregnancy Study (SOAP); URL: https://clinicaltrials.gov/ct2/show/NCT02086448; Identifier: NCT02086448.

CITATION

Onslow ML, Wolsk J, Wisniewski S, et al. The association between sleep-disordered breathing and maternal endothelial and metabolic markers in pregnancies complicated by obesity. J Clin Sleep Med. 2023;19(1):97-109.

Tissue inhibitor of metalloproteinase-4 deletion in mice impacts maternal cardiac function during pregnancy and postpartum

Reversible physiological cardiac hypertrophy of the maternal heart occurs during pregnancy and involves extracellular matrix (ECM) remodeling. Previous mouse studies revealed that changes in ECM molecules accompany functional changes in the left ventricle (LV) during late pregnancy and postpartum. We evaluated the effect of global Timp4 deletion in female mice on LV functional parameters and ECM molecules during pregnancy and the postpartum period. Heart weights normalized to tibia lengths were increased in Timp4 knockout (Timp4 KO) virgin, pregnant, and postpartum day 2 mice compared with wild types. Serial echocardiography performed on pregnancy days 10, 12, and 18 and postpartum days (ppds) 2, 7, 14, 21, and 28 revealed that both wild-type and Timp4 KO mice increased end systolic and end diastolic volumes (ESV, EDV) by mid to late pregnancy compared with virgins, with EDV changes persisting through the postpartum period. When compared with wild types, Timp4 KO mice exhibited higher ejection fractions in virgins, at pregnancy days 10 and 18 and ppd2 and ppd14. High-molecular weight forms of COL1A1 and COL3A1 proteins in LV were greater in Timp4 KO virgins, and COL1A1 was higher in late pregnancy and on ppd2 compared with wild types. With exceptions, Timp4 KO mice during late pregnancy and the early postpartum period were able to maintain stroke volume similar to wild-type mice through increased ejection fraction. Although TIMP4 deletion in females exhibited altered ECM molecules, it did not adversely affect cardiac function during first pregnancies and lactation.NEW & NOTEWORTHY Pregnancy and lactation increase volume load on the heart. Defects in cardiac remodeling during pregnancy and postpartum can result in peripartum cardiomyopathy. TIMPs participate in cardiac remodeling. The present study reports the cardiac function in Timp4 knockout adult female mice during pregnancy and lactation. Timp4 knockout females at many time points have higher ejection fraction to maintain stroke volume. Global deletion of Timp4 was not detrimental to maternal heart function during first pregnancies and lactation.

POTS and Pregnancy: A Review of Literature and Recommendations for Evaluation and Treatment

Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system most commonly affecting women of reproductive age. Studies on POTS and pregnancy are limited, and there is a lack of clinical guidelines regarding assessment and management of pregnant women with POTS. The purpose of this review is to summarize data from the available studies on the topic of pregnancy in POTS and common comorbid conditions and to provide the clinical recommendations regarding evaluation and treatment of POTS in pregnant women, based on the available studies and clinical experience. We conclude that pregnancy appears to be safe for women with POTS and is best managed by a multi-disciplinary team with knowledge of POTS and its various comorbidities. Importantly, large, prospective studies are needed to better delineate the course and outcomes of pregnancy, as well as possible pregnancy-related complications in women with POTS. Clinicians should be aware of the clinical presentation, diagnostic criteria, and treatment options in pregnant women with POTS to optimize outcomes and improve medical care during pregnancy and post-partum period.