Insights into cardiac alterations after pre-eclampsia: an echocardiographic study

Feto-maternal indicators of cardiac dysfunction as a justification for the cardiac origins for pre-eclampsia

While the pathophysiology of pre-eclampsia has been postulated as being secondary to placental dysfunction, a cardiac origin has more recently been proposed. Although an association between fetal congenital cardiovascular disease and pre-eclampsia has been demonstrated, no precise pathophysiologic mechanism for this association has been described. This review highlights the current biophysical (including echocardiography and Doppler indices) and biochemical (including proteomic, metabolomic and genetic/transcriptomic) markers of cardiac dysfunction that have been investigated in maternal and fetal cardiac disease and their overlap with predictors of pre-eclampsia.   Common pathways of inflammatory and anti-angiogenesis imbalance, endothelial damage, and oxidative stress have been demonstrated in both cardiovascular disease and pre-eclampsia and further investigation into these pathways could help to elucidate the common pathophysiologic mechanisms linking these disorders.

Three-dimensional echocardiography and strain cardiac imaging in women with pre-eclampsia with follow-up to 6 months postpartum

OBJECTIVE

Epidemiological studies have established that women with pre-eclampsia (PE) are at increased long-term cardiovascular risk. Mild cardiac functional changes have been documented during pregnancy in women with PE, but their evolution from presentation to the postpartum period remains poorly defined. The aim of this study was to assess biventricular cardiovascular indices using novel and sensitive two-dimensional and three-dimensional (3D) echocardiographic modalities in pregnancy and to track alterations in both risk factors and cardiovascular indices in the postpartum period.

METHODS

A total of 59 women with PE were examined at 34 (interquartile range, 31-37) weeks' gestation and at 2-3 days, 3 months and 6 months postpartum. During pregnancy, 118 women with a normotensive pregnancy were also recruited as controls. Biventricular ejection fraction and left ventricular mass were measured by 3D echocardiography. Biventricular global longitudinal strain and strain of the left atrium were assessed using speckle-tracking imaging.

RESULTS

In women with PE, compared with controls, there was lower left ventricular diastolic function (left atrial reservoir strain, 44.1% vs 49.2%) and increased left ventricular mass index (148 vs 128 g/m2 ), but there was no significant difference in right ventricular functional indices. These alterations in cardiac indices were mostly explained by differences in maternal risk factors. In the postpartum period, most cardiac indices improved by 3 months. Multivariable linear mixed-model analysis demonstrated that this improvement was mostly attributed to reduction in weight and blood pressure.

CONCLUSION

In women with PE, there is postpartum improvement in cardiac functional and structural indices in parallel with improvement in their risk factor profile. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Quantification of Myocardial Work by 2-D Echocardiography during a Normal Pregnancy: A Preliminary Study

This study was aimed at investigating the adaptive changes in myocardial work (MyW) during normal pregnancy. Sequential 2D standard and speckle-tracking echocardiography was performed on 41 pregnant women in each gestational trimester and 4 to 11 mo after delivery. Thirty-eight age-matched, healthy, non-pregnant women served as controls. Four components of MyW-global myocardial work index (GWI), constructive work (GCW), wasted work (GWW) and work efficiency (GWE)-were calculated. GWI began to decline early in the first trimester and remained at a low level until delivery; GCW gradually decreased with gestational progression and reached its lowest level in the third trimester. When compared with the values for non-pregnant women and those postpartum, GWE and GWW remained unchanged in gestation. This study provides normal ranges of MyW during pregnancy. Despite the adapted decrease in GWI and GCW, the myocardium manages to work efficiently in the healthy pregnancy with drastic hemodynamic alternations.

Altered cardiac and vascular stiffness in pregnancy after a hypertensive pregnancy

Hypertensive disorders of pregnancy are an important cause of morbidity and mortality, impacting on both maternal and fetal wellbeing. Affected women are at higher risk of future cardiovascular morbidity and mortality. Our study objective was to assess differences in cardiovascular function in pregnant women previously affected by gestational hypertension or preeclampsia. Pregnant women diagnosed with gestational hypertension or preeclampsia in a previous pregnancy were recruited at the start of a subsequent pregnancy and compared to healthy pregnant and non-pregnant controls. All patients underwent pulse wave analysis and echocardiography. Indexes of echocardiography-derived arterial and left ventricular elastance were calculated. In our study women with prior hypertension (n = 25) were more likely to have blood pressure in the 120-139/80-99 mmHg (prehypertension) range. Women with previous hypertension in pregnancy had increased late diastolic transmitral flow velocities (A wave) and increased augmentation index. Women without prior hypertension (n = 50) demonstrated more compliance (reduced EaI and Ees) compared to the non-pregnant controls (n = 40). This adaptation was not seen in pregnancy with prior hypertension, where increased arterial stiffness was observed. In conclusion we have shown increased prevalence of prehypertension and increased arterial stiffness in pregnant women previously affected by gestational hypertensive disease. An increased atrial component to ventricular filling reflects altered diastolic function after hypertensive pregnancy. These women are at increased future cardiovascular risk due to altered cardiac and vascular function and require effective risk mitigation.

Maternal hemodynamic profile during pregnancy and in the post-partum in hypertensive disorders of pregnancy and fetal growth restriction

BACKGROUND

Maternal cardiovascular changes, occurring since the beginning of pregnancy, are necessary for normal placentation and regular evolution of pregnancy.

OBJECTIVE

This study aimed to compare the hemodynamic profiles and cardiac remodeling of women with hypertensive disorders of pregnancy and either appropriate for gestational age fetuses or growth-restricted fetuses, women with normotensive pregnancies complicated by fetal growth restriction, and women with uncomplicated pregnancies, during pregnancy and the postpartum period.

STUDY DESIGN

A prospective longitudinal case-control design was used for this study. Over the study period, 220 eligible women with singleton pregnancies were selected for the analysis and divided into 4 groups: (1) hypertensive disorders of pregnancy with appropriate for gestational age fetuses; (2) hypertensive disorders of pregnancy with fetal growth restriction; (3) normotensive fetal growth restriction; and (4) controls. Ultrasound fetal biometry and fetoplacental Doppler velocimetry were performed at recruitment. Maternal hemodynamic assessment using transthoracic echocardiography was performed at the time of recruitment by a dedicated cardiologist blinded to maternal clinical data. The same assessments were performed in 104 patients at 32 weeks (interquartile range, 24-40) after delivery by the same cardiologist.

RESULTS

During pregnancy, women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction group showed significantly lower cardiac output and increased compared with those in the control group. These values were associated with concentric remodeling of the left ventricle owing to relatively increased wall thickness, which was not accompanied by an increase in left ventricular mass. Isolated fetal growth restriction presented similar but less important hemodynamic changes; however, there was no change in relative wall thickness. At postpartum follow-up, the hemodynamic parameters of women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and isolated-fetal-growth-restriction groups reverted to values similar to those of the control group. Only 8.3% of women in these groups experienced hypertension even in the postpartum period, and asymptomatic stage-B cardiac failure was observed for 17% at echocardiography. In the group of women with hypertensive disorders of pregnancy and appropriate for gestational age fetuses, cardiac output increased as in normal pregnancies, but total vascular resistance was significantly higher; hypertension then occurred, along with ventricular concentric hypertrophy and diastolic dysfunction. At postpartum follow-up, women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed significantly higher mean arterial pressure, total vascular resistance, and left ventricular mass compared with those in the control group. Persistent hypertension and asymptomatic stage-B cardiac failure were observed in 39.1% and 13% of women in the former group, respectively.

CONCLUSION

Pregnancies with hypertensive disorders of pregnancy and fetal growth restriction and normotensive pregnancies with fetal growth restriction were associated with the hemodynamic profile of lower heart rate and cardiac output, most likely because of abnormal adaptation to pregnancy, as confirmed by abnormal changes from pregnancy to the postpartum period. The heart rates and cardiac output of women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed changes opposite to those observed in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and fetal-growth-restriction groups. Obesity and other metabolic risk factors, significantly prevalent in women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group, predispose to hypertension and cardiovascular diseases during pregnancy and the postpartum period, potentially offering a window for personalized prevention. Such preventive strategies could differ in women with hypertensive disorders of pregnancy and fetal growth restriction characterized by poor early placental development.

Maternal Right Ventricular and Left Atrial Function in Uncomplicated Twin Pregnancies: A Longitudinal Study

Objective: The knowledge regarding maternal cardiovascular hemodynamic adaptation in twin pregnancies is incomplete. We performed a longitudinal investigation of maternal right ventricular (RV) and left atrial (LA) function in a cohort of uncomplicated twin pregnancies compared to singleton pregnancies. Study design: Healthy women with uncomplicated twin pregnancies were prospectively enrolled and assessed by transthoracic echocardiography at 10−15 weeks’ (w) gestation (T1), 19-26 w gestation (T2), and 30−38 w gestation (T3). Subjects with uneventful singleton pregnancies were selected as controls at the same gestational ages. Cardiac findings were compared to those of women with uneventful singleton gestations. RV systolic and diastolic functions were assessed by conventional echocardiography (FAC, TAPSE, sPAP, E, A, DT) and tissue Doppler imaging (TDI) (E’, A’, S’, IVA, IVCT, IVRT, ET, MPI), and LA dimensions were calculated. Speckle-tracking imaging was also applied to evaluate RV global longitudinal strain and LA 2D strains (at LV end-systole (LAS) and at atrial contraction (LAA)). Results: Overall, 30 uncomplicated twin and 30 uncomplicated singleton pregnancies were included. Regarding maternal RV function in twins, all the parameters (FAC, TAPSE, sPAP, E, A, E/A, DT, E/E’, IVA, IVCT, MPI and 2D longitudinal strain) were almost stable throughout gestation, with the exception of the TDI findings (E’ decreased from T1 to T3 (p = 0.03), while E’/A’ increased from T1 to T2 and then decreased (p = 0.01); A’ and basal S’ increased (p = 0.04 and p = 0.03, respectively), while IVRT and ET significantly decreased (p = 0.009 and p = 0.007, respectively)). These findings were similar to those found for singleton pregnancies. LA dimensions significantly increased throughout gestation in both twins and singletons (p < 0.001), without intergroup difference. LA strains did not vary during either twin or singleton pregnancies, except for LAA in T1, which was higher among twins than among singletons. Conclusion: Maternal RV and LA function in uncomplicated twin pregnancies does not seem to undergo more significant changes than in singletons, being characterized by similar findings in RV systolic and diastolic functions, as well as LA dimensions and strains.

Maternal Left Ventricular Function in Uncomplicated Twin Pregnancies: A Speckle-Tracking Imaging Longitudinal Study

Objective: The knowledge of maternal cardiovascular hemodynamic adaptation in twin pregnancies is incomplete. We aimed to longitudinally investigate maternal left ventricular (LV) function in uncomplicated twin pregnancies. Methods: 30 healthy and uncomplicated twin pregnant women and 30 controls with normal singleton pregnancies were prospectively enrolled to undergo transthoracic echocardiography at 10–15 week’s gestation (w) (T1), 19–26 w (T2) and 30–38 w (T3). LV dimensions and volumes, as well as LV ejection fraction (LVEF), mass (LVM) and diastolic parameters (at transmitral pulsed wave Doppler and mitral annular plane tissue Doppler), were calculated. Speckle-tracking imaging was also applied to evaluate LV global longitudinal (GLS), radial and circumferential 2D strains. Results: During twin pregnancy, maternal LV dimensions, volumes and LVM had an increasing trend from T1 to T3, similar to singletons, while LVEF remained stable. There was LV remodeling/hypertrophy in 50% of women at T2 and T3 in both groups. Diastolic function had a worsening trend from T1 to T3 with no differences between twins and singletons, except for higher LV filling pressure (i.e., E/E′) at T2 in twins. Two-dimensional strains did not vary during gestation in either group, except for a linear trend to increase (i.e., worsen) GLS in singletons. Radial and circumferential 2D strains were impaired in about half of the women at each trimester, while GLS was altered in one-fourth/one-third of them in both groups. Conclusion: Maternal LV geometry, dimensions and function are significantly impaired during twin pregnancies, in particular in the second half of gestation, with no significant differences compared to singletons.

Ventricular-arterial coupling in systemic lupus erythematosus women without cardiovascular risk factors

Systemic lupus erythematosus (SLE) is characterized by endothelial dysfunction, arterial stiffness, and myocardial impairment. We aimed at analyzing the ratio between carotid-femoral pulse wave velocity (cfPWV) and left ventricular global longitudinal strain (GLS) as a new index to approximate ventricular-arterial coupling (VAC) in women with SLE and without cardiovascular risk factors. Half cases had impaired GLS and consequently a hampered ratio. We thus suggest referring SLE patients early to a CV prevention program.

Noninvasive Cardiac Imaging in Formerly Preeclamptic Women for Early Detection of Subclinical Myocardial Abnormalities: A 2022 Update

Preeclampsia is a maternal hypertensive disease, complicating 2–8% of all pregnancies. It has been linked to a 2–7-fold increased risk for the development of cardiovascular disease, including heart failure, later in life. A total of 40% of formerly preeclamptic women develop preclinical heart failure, which may further deteriorate into clinical heart failure. Noninvasive cardiac imaging could assist in the early detection of myocardial abnormalities, especially in the preclinical stage, when these changes are likely to be reversible. Moreover, imaging studies can improve our insights into the relationship between preeclampsia and heart failure and can be used for monitoring. Cardiac ultrasound is used to assess quantitative changes, including the left ventricular cavity volume and wall thickness, myocardial mass, systolic and diastolic function, and strain. Cardiac magnetic resonance imaging may be of additional diagnostic value to assess diffuse and focal fibrosis and perfusion. After preeclampsia, sustained elevated myocardial mass along with reduced myocardial circumferential and longitudinal strain and decreased diastolic function is reported. These findings are consistent with the early phases of heart failure, referred to as preclinical (asymptomatic) or B-stage heart failure. In this review, we will provide an up-to-date overview of the potential of cardiac magnetic resonance imaging and echocardiography in identifying formerly preeclamptic women who are at high risk for developing heart failure. The potential contribution to early cardiac screening of women with a history of preeclampsia and the pros and cons of these imaging modalities are outlined. Finally, recommendations for future research are presented.

Blood pressure variability correlates with right ventricular strain in women with gestational hypertension and preeclampsia

The aim of this study was to evaluate the short- and long-term blood pressure (BP) variability and right ventricular (RV) remodeling in women with gestational hypertension and preeclampsia, as well as their association. This cross-sectional study included 161 pregnant women (56 normotensive controls, 55 patients with gestational hypertension, and 50 patients with preeclampsia) after 20 weeks of gestation. All women underwent 24-h ambulatory BP monitoring and echocardiographic examination. Our findings showed that 24-h, daytime and nighttime systolic and diastolic BPs, as well as visit-to-visit systolic and diastolic BPs, were significantly higher in women with gestational hypertension and preeclampsia than in control group. Parameters of short- and long-term BP variability gradually increased from controls, throughout women with preeclampsia, to those with gestational hypertension. RV diameter, E/e' and PAP were significantly higher in women with gestational hypertension and preeclampsia than in controls. Global and free wall RV longitudinal strains, as well as corresponding endo- and epicardial strains, gradually reduced from controls to women with preeclampsia. Parameters of short- and long-term BP variability were independently associated with global and free wall RV longitudinal strain. In conclusion, short- and long-term BP variability was higher in women with pregnancy-induced hypertensive disorders. RV diastolic function and mechanics were deteriorated in these women comparing with controls. A significant association between BP variability and RV longitudinal strain underlines the importance of determination of short- and long-term BP variability during pregnancy.

Inappropriate left ventricular mass after HELLP syndrome inappropriate LVM after HELLP syndrome

OBJECTIVES

Excessive left ventricular mass (LVM) results in inefficient LV work with energy waste leading to a negative prognostic effect. We aimed at investigating the presence of inappropriate LVM and calculating the myocardial mechano-energetic efficiency index (MEEi) in former pre-eclamptic (PE) women (with or without HELLP syndrome) compared to women who experienced HELLP syndrome without PE.

STUDY DESIGN

In this cross-sectional study, women with a history of normotensive HELLP (n = 32), PE without HELLP (n = 59), and PE with HELLP (n = 101) underwent echocardiography as part of the clinical CV work-up after their complicated pregnancies from 6 months to 4 years postpartum. We excluded women with comorbidities, including chronic hypertension, hypercholesterolemia, and obesity.

MAIN OUTCOME MEASURES

LVM excess was calculated as the ratio between observed LVM and predicted LVM (by sex, stroke work and height), while MEEi was considered as the ratio between stroke work and "double product" (to approximate energy consumption), indexed to LVM.

RESULTS

LV hypertrophy was present in 8-14% and concentric remodeling in 31-42% of women, without intergroup difference. LVM was inappropriate in one-third of normotensive former HELLP and in about one-half of PE with or without HELLP, with no difference among groups. Accordingly, without nominal difference, MEEi showed a tendency towards lower values in former pre-eclamptic individuals.

CONCLUSIONS

Women with a history of HELLP syndrome, independently from the presence/absence of PE, showed inappropriate LVM in the first 4 years after delivery, which may partially explain the elevated CV risk in these women compared to the general female population.

Maternal myocardial dysfunction after hemolysis, elevated liver enzymes, and low platelets syndrome: a speckle-tracking study

OBJECTIVES

Pregnancy complicated by pre-eclampsia (PE) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is associated with an increased risk of cardiovascular (CV) diseases later in life. Subclinical cardiac alterations precede eminent CV diseases. Speckle-tracking echocardiography (STE) is an effective method to assess subclinical myocardial dysfunction. We performed a myocardial speckle tracking study to investigate the prevalence of subclinical myocardial dysfunction in former PE patients (with and without HELLP syndrome) compared to normotensive women affected by HELLP syndrome.

METHODS

In this cross-sectional retrospective study, women with a history of normotensive HELLP (n = 32), PE without HELLP (n = 59), and PE with HELLP (n = 101) underwent conventional and STE as part of the clinical CV work-up after their complicated pregnancies from 6 months to 4 years postpartum. We excluded women with comorbidities, including chronic hypertension, hypercholesterolemia, and obesity.

RESULTS

Women with a history of PE with HELLP syndrome were characterized by a higher prevalence of altered left ventricular circumferential and global longitudinal two-dimensional (2D) strain (74 and 20%, respectively), altered right ventricular longitudinal 2D strain (37%), and left atrial (LA) 2D strain (57%). Moreover, a higher proportion of alterations of biventricular and LA strains was also present in former PE without HELLP as well as in the normotensive HELLP group.

CONCLUSIONS

In the first years after a pregnancy complicated by HELLP syndrome, irrespective of whether there was concomitant PE, a higher rate of abnormal STE myocardial function is observed. Therefore, these women may benefit from CV risk management.

The Impact of Preeclampsia on Women's Health: Cardiovascular Long-term Implications

Importance

Women with a history of preeclampsia have a 2- to 5-fold increased risk of cardiovascular diseases, which represent almost half of mortality in the female population worldwide.

Objective

To summarize the current evidence concerning women's future cardiovascular risk after pregnancies complicated by preeclampsia.

Evidence Acquisition

A PubMed and Web of Science search was conducted in English, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized. Relevant studies on cardiovascular risk after preeclampsia were included.

Results

Evidence suggests that the cardiovascular implications of preeclampsia do not cease with delivery, with a significant proportion of women demonstrating persistent asymptomatic myocardial impairment, aortic stiffening, and microcirculatory dysfunction. More severe and early-onset preeclampsia, as well as preeclampsia with concurrent neonatal morbidity, increases the risk of cardiovascular disease later in life.

Conclusions and Relevance

As former preeclamptics have been shown to be at increased cardiovascular risk, this identifies a subgroup of women who may benefit from early preventive measures.

Influence of chest conformation on ventricular-arterial coupling during normal pregnancy

PURPOSE

There is still controversy regarding the changes of ventricular-arterial coupling (VAC) during normal pregnancy. The possible influence of chest shape on VAC during normal pregnancy has never been investigated.

METHODS

Between October 2019 and June 2020, 59 healthy pregnant women (33.7 ± 4.4 years/old) were consecutively included. They underwent obstetric visit, modified Haller index (MHI) assessment, and complete echocardiographic evaluation with blood pressure measurement to assess arterial elastance (Ea), end-systolic elastance (Ees), and Ea/Ees as an index of VAC, at 12-14 weeks and 36-38 weeks gestation, then 6-9 weeks after delivery.

RESULTS

VAC progressively increased from the first to the third trimester of pregnancy, then decreased in the postpartum (P < 0.0001) in the whole study population. Women with concave-shaped chest wall (MHI >2.5, n = 31) but not women with normal chest shape (MHI ≤2.5, n = 28) showed a progressive increase in VAC during normal pregnancy. Women with MHI >2.5 showed a significantly less pronounced increase in stroke volume index (SVi) from the first to the third trimester of pregnancy. There was a strong linear correlation between third trimester MHI and VAC (r = 0.93).

CONCLUSIONS

Anatomical and/or extrinsic mechanical factors rather than impaired arterial elastance or reduced left ventricular contractility may contribute to changes in VAC during normal pregnancy in women with concave-shaped chest wall.

Maternal myocardial dysfunction after normotensive fetal growth restriction compared with hypertensive pregnancies: a speckle-tracking study

OBJECTIVE

Pregnancy complicated by preeclampsia and fetal growth restriction (FGR) relates to increased risk of cardiovascular disease later in life, but to different extents. Subclinical cardiac alterations precede eminent cardiovascular disease. Speckle-tracking echocardiography is an elegant method to assess subclinical myocardial dysfunction. We performed a myocardial speckle tracking study to evaluate the prevalence of subclinical myocardial dysfunction in former preeclampsia patients (with and without FGR) compared with normotensive women with FGR.

METHODS

For this cross-sectional study, we retrospectively selected women with a history of normotensive FGR (n = 17), preeclampsia with FGR (n = 26) and preeclampsia without FGR (n = 134) who underwent conventional echocardiography as part of the clinical cardiovascular work-up after complicated pregnancies between 6 months and 4 years postpartum in Maastricht, The Netherlands. We excluded women with chronic hypertension, hypercholesterolemia and obesity.

RESULTS

Women with normotensive FGR showed subclinical left ventricular (LV) impairment in systodiastolic function with concentric remodeling, slight alteration in right ventricular systolic function and left atrial strain, similarly to the preeclampsia group independently from the fetal growth. LV hypertrophy was only present in about 10% of cases who experienced preeclampsia (independently from the fetal growth) but not in those with normotensive FGR.

CONCLUSION

Similar to women with a history preeclampsia, women with a history of normotensive pregnancy but with FGR have abnormal myocardial function, shown with speckle-tracking echocardiography. Therefore, both preeclampsia and normotensive FGR should be viewed upon as risk indicator for subclinical myocardial impairment that may benefit from cardiovascular risk management.

Speckle Tracking Echocardiography in Hypertensive Pregnancy Disorders: A Systematic Review

Importance

Hypertensive pregnancy disorders (HPDs) are associated with an increased risk of long-term cardiovascular disease. Speckle tracking echocardiography (STE) might be useful in the early detection of preclinical cardiac changes in women with HPDs.

Objective

The aim of this study was to study whether STE is a suitable method to detect differences in cardiac function in pregnant women with HPD compared with normotensive pregnant women or between women with a history of a pregnancy complicated by HPD compared with women with a history of an uncomplicated pregnancy.

Evidence Acquisition

The databases Medline, EMBASE, and Central were systematically searched for studies comparing cardiac function measured with STE in pregnant women with HPD or women with a history of HPD and women with a history of normotensive pregnancies.

Results

The search identified 16 studies, including 870 women with a history of HPD and 693 normotensive controls. Most studies during pregnancy (n = 12/13) found a decreased LV-GLS (left ventricular global longitudinal strain) in HPD compared with normotensive pregnant controls. LV-GRS (left ventricular global radial strain) and LV-GLCS (left ventricular global circumferential strain) are decreased in women with early-onset and severe preeclampsia. Women with a history of early-onset preeclampsia show lasting myocardial changes, with significantly decreased LV-GLS, LV-GLCS, and LV-GRS.

Conclusions and Relevance

LV-GLS is significantly decreased in pregnant women with HPD compared with normotensive pregnant women. Other deformation values show a significant decrease in women with severe or early-onset preeclampsia, with lasting myocardial changes after early-onset preeclampsia.

Severe Preeclampsia is Associated with Functional and Structural Cardiac Alterations: A Case-control Study

BACKGROUND

The aim of the current study is to compare electrocardiographic and echocardiographic changes in patients with severe preeclampsia (PE) and those with uncomplicated pregnancies.

METHODS

This is a case-controlled prospective study consisting of 21 pregnant women with severe preeclampsia and a control group consisting of age- and gestational age-matched 24 healthy pregnant women. All patients underwent electrocardiographic and echocardiographic investigation.

RESULTS

QRS intervals were shorter and PR intervals were longer in the PE group (QRS duration: 80 (60-120) ms and 80 (40-110) ms, p=0.035; PR duration: 160 (100-240) ms and 120 (80-200) ms, respectively; p=0.046). The left ventricular end-systolic diameters of the patients with severe PE group were significantly larger than the control group (31 (24-36) mm and 30 (24-33) mm, respectively; p=0.05). Similarly, posterior wall thickness values of the PE group were significantly higher compared to the control group (9 (7-11) mm vs. 8 (6-10) mm, respectively; p=0.020). Left ventricular mass (146.63±27.73 g and 128.69±23.25 g, respectively; p=0.033) and relative wall thickness values (0.385±0.054 and 0.349±0.046, respectively; p=0.030) were also higher in the PE group. In addition, patients with early-onset severe PE had significantly a higher left ventricular end-diastolic diameter and volume compared with late-onset PE patients.

CONCLUSIONS

The structural changes detected in the severe PE group suggest a chronic process rather than an acute effect. In addition, diastolic dysfunction and left ventricular remodeling are most marked in patients with severe early-onset PE.

Evolution of cardiac geometry and function in women with severe preeclampsia from immediately post-delivery to 1 year postpartum

Preeclampsia is associated with left ventricular (LV) geometrical and functional changes, which could be related to cardiovascular risk later in life. The purpose of our study was to evaluate evolution of LV dimensions and function in severe preeclamptic women from immediately post-delivery to 1 year postpartum. Twenty-five women with severe preeclampsia and 15 healthy term controls underwent standard and speckle-tracking echocardiography 1 day after delivery and 1 year postpartum. On day 1 post-delivery preeclamptic women were exposed to higher preload (p = 0.003) and afterload (p < 0.001) compared to controls. Parameter of longitudinal LV systolic function s' was significantly lower in preeclamptic compared to control group (p = 0.017) 1 day post-delivery. Additionally, diastolic function parameters were significantly more impaired in preeclamptic compared to control group (lower e' (p = 0.02) and higher E/e' ratio (p = 0.003) in preeclamptic group). Larger LV mass (p = 0.03) and a trend of higher proportion of altered cardiac geometry (p = 0.061) were observed in preeclampsia 1 day post-delivery. One year after delivery both groups had comparable geometric and functional parameters with similar afterload and preload (p > 0.05, for all). In preeclamptic group systolic and diastolic functional parameters improved significantly during follow-up (p < 0.05), while no such evolution was noted in controls (> 0.05). In women with severe preeclampsia subtle cardiac functional impairment immediately post-delivery completely resolved 1 year postpartum. Observed cardiac alterations suggest intrinsic myocardial dysfunction in preeclampsia, which became unmasked or exacerbated by higher load imposed on the LV immediately post-delivery that disappeared in mid-term follow-up.

Noninvasive Assessment of Right Ventricle Function and Pulmonary Artery Pressure Using Transthoracic Echocardiography in Women With Pre-Eclampsia: An Exploratory Study

Background and objective

Pre-eclampsia (PEC) is associated with the release of anti-angiogenic factors that are incriminated in raising systemic and pulmonary vascular resistance (PVR). Compared to the left heart and systemic circulation, much less attention has been paid to the right heart and pulmonary circulation in patients with PEC. We used transthoracic echocardiography (TTE) to estimate pulmonary artery (PA) pressure and right ventricular (RV) function in women with PEC.

Materials and methods

We conducted a case-control study at a tertiary care academic center. Ten early PEC (<34-week gestation) and nine late PEC (≥34-week gestation) patients with 11 early and 10 late gestational age-matched controls were enrolled. Two-dimensional TTE was performed on all patients. The estimated mean PA pressure (eMPAP) was calculated based on PA acceleration time (PAAT). PVR was estimated from eMPAP and RV cardiac output (RV CO). RV myocardial performance index (RV MPI), tricuspid annular plane systolic excursion (TAPSE), tissue tricuspid annular displacement (TTAD), and lateral tricuspid annular tissue peak systolic velocity (S’) were measured.

Results

Compared to early controls, in early PEC, the eMPAP and estimated PVR (ePVR) were elevated, PAAT was reduced, RV MPI was increased, TTAD was reduced, and TAPSE and TV S’ were unchanged. Compared to late controls, in late PEC, the eMPAP and ePVR were elevated, PAAT was reduced, and RV MPI was increased, while TAPSE, TTAD, and TV S’ were unchanged.

Conclusions

In a sample of women with PEC, early PEC was found to be associated with increased eMPAP and ePVR and subclinical decrement of RV function as assessed by TTE. TTE may be a useful noninvasive screening tool for early detection of pulmonary hypertension and RV dysfunction in PEC. An adequately powered longitudinal study is needed to determine the implications of these findings on long-term outcomes.

Maternal hemodynamics, arterial stiffness and elastic aortic properties in twin pregnancy

OBJECTIVE

There is scant information about maternal cardiovascular hemodynamic change during twin pregnancies. Aim of the study is to investigate longitudinal changes in maternal arterial stiffness, elastic aortic properties and ventricular-arterial coupling (VAC) in uncomplicated twin pregnancies compared to singleton ones.

APPROACH

In this prospective longitudinal study, we performed applanation tonometry and transthoracic echocardiography in the first (T1; 10-15 weeks' gestation (w)), second (T2; 19-26 w) and third trimesters (T3; 30-38 w) in women with uncomplicated twin pregnancies, both monochorionic and dichorionic. Heart-rate-corrected augmentation index (AIx@75) was studied as indicator of arterial stiffness. Aortic diameters and elastic properties were calculated. VAC was defined as the ratio between aortic elastance (Ea) and left ventricular end-systolic elastance (Ees). Finally, stroke volume (SV), cardiac output (CO) and total vascular resistance (TVR) were evaluated. The findings were compared to those of women with uncomplicated singleton pregnancies.

MAIN RESULTS

Thirty women with twin gestations (11 monochorionic) and 30 singleton controls were obtained for analysis. Blood pressure and TVR significantly decreased from T1 to T2 and then rose in T3, with higher values in twins than in singletons. AIx@75 showed the same trend in both groups with lower values at T2 in twins. SV and CO linearly increased throughout gestation with no significant intergroup difference. Aortic diameters and elastic properties remained stable throughout gestation, with no significant intergroup differences. Both Ea and Ees were greater (i.e. worse) in twins than in singletons at T1 and T3, showing a significant linear trend towards reduction in the two groups, meaning lower vascular and ventricular loads. Using longitudinal analysis blood pressure, TVR, Ea and Ees depended from both multiple gestation and gestational age.

SIGNIFICANCE

In twins, maternal hemodynamics does not seem to undergo more significant changes than in singletons being characterized by higher blood pressures and TVR with no differences in CO, SV, aortic dimensions and elastic properties. Despite VAC is maintained within its normal range, total vascular load (i.e., Ea) resulted higher in twin than singleton pregnancies throughout gestation. It is conceivable that these findings may represent one of the underlying cause for the increased risk of adverse obstetric outcomes described in multiple gestations.

Epicardial adipose tissue thickness as a potential predictor of pre-eclampsia

OBJECTIVE

Pre-eclampsia (PE) is a leading cause of maternal and fetal morbidity and mortality. Our aim was to assess epicardial adipose tissue (EAT) thickness as a potential effective screening parameter to predict PE in the first trimester.

METHODS

133 women with PE were enrolled in this study, and divided into the early-onset and late-onset subgroups. 150 healthy women were enrolled as control group. Anthropometric and echocardiographic parameters were obtained, including EAT thickness. Generalized linear models was used to assess the predict efficiency of EAT with fdds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

Compared to the controls, EAT thickness was higher in PE patients (P < 0.05). Multivariate regression analysis indicated that EAT thickness was associated with PE risk (OR = 1.50, 95%CI: 1.19-1.88, P < 0.05). The area under curves of EAT thickness was 0.616. When the cutoff value for EAT thickness was set to 5.26 mm, the sensitivity was 78.2% and the specificity was 44.7%. EAT thickness significantly both higher in the early-onset and late-onset groups compared to the controls; Meanwhile, EAT thickness was higher in the early-onset group than late-onset group (P < 0.05). Logistic regressionrevealed the close relationship between onset time of PE and EAT thickness (OR = 1.59, 95%CI: 1.28-1.98, P < 0.001).

CONCLUSIONS

Measured EAT thickness using echocardiography could identify high-risk people for PE as early as the first trimester. Echocardiographic EAT has the potential to be a predictor for PE prior to actual clinical diagnosis.

Angiogenic Factors and Long-Term Cardiovascular Risk in Women That Developed Preeclampsia During Pregnancy

Preeclampsia is caused by placental impairment with increased expression of sFlt-1 (soluble fms-like tyrosine kinase 1) and decreased PlGF (placental growth factor); it has been associated with cardiovascular morbidity and mortality later in life, but the underlying mechanism remains unknown. The aim of this study was to determine whether sFlt-1 and PlGF levels during preeclampsia are associated to long-term cardiovascular risk. We prospectively recruited 43 women with previous preeclampsia and 21 controls with uncomplicated pregnancies. Cardiovascular risk assessment ≈12 years later included maternal hemodynamic, cardiac function and structure, biomarker analysis, and carotid-intima thickness evaluation. Women with previous preeclampsia had higher prevalence of hypertensive disorders and dyslipidemia than controls. In addition, they had worse global longitudinal strain, thicker left ventricular septal and posterior walls, more myocardial mass and increased carotid intima-media thickness compared with controls. PlGF during pregnancy correlated positively with high-density lipoprotein (r=0.341; P=0.006), and negatively with global longitudinal strain (r=-0.581; P<0.001), carotid intima-media thickness (r=-0.251; P=0.045), and mean arterial blood pressure (r=-0.252; P=0.045), when adjusted by study group. sFlt correlated negatively with high-density lipoprotein (r=-0.372; P=0.002) and apolipoprotein A-1 (r=-0.257; P=0.040), and positively with carotid intima-media thickness (r=0.269; P=0.032) and left ventricular posterior wall thickness (r=0.368; P=0.003). The antiangiogenic state present in preeclampsia is related to greater prevalence of cardiovascular risk factors ≈12 years after delivery. The knowledge of altered angiogenic factors may help detect women with a higher risk for premature cardiovascular disease, who will require earlier follow-up after delivery.

Evaluation of systo-diastolic cardiac function and arterial stiffness in subjects with new diagnosis of coeliac disease without cardiovascular risk factors

In literature, there are conflicting opinions on the development of cardiovascular disease risk in patients with coeliac disease (CD). The aim of the research was to identify in young subjects without cardiovascular risk factor and newly diagnosed CD, alterations in different instrumental parameters that are associated with an augmented cardiovascular risk. Twenty-one consecutive young adults with a new diagnosis of CD and without cardiovascular risk factors were prospectively enrolled and underwent transthoracic echocardiography to analyse ascending aorta elastic properties [including tissue Doppler imaging strain (TDI-ε)] and left ventricular 2D strains (global longitudinal, radial and circumferential), and applanation tonometry by SphygmoCor. Cases were compared with 21 age- and sex-matched healthy controls. Mean age of the cases was 38 ± 9 years and 15 of them (71%) were female. Brachial and central blood pressure was higher in the CD group. Elastic properties of the ascending aorta were all impaired in the CD group: TDI-ε was altered in 57% of cases (0% of controls, p < 0.001). Concentric remodelling and grade I diastolic dysfunction were present in 38% and 24% of cases, respectively (0% of controls, p < 0.001). Global longitudinal strain was normal in all subjects, while radial and circumferential strain were altered in 67% and 35%, respectively (0% of controls, p < 0.001). In young subjects without cardiovascular risk factor, a newly diagnosed CD is associated with altered aortic elastic properties, left ventricular concentric remodelling and diastolic dysfunction and altered radial and circumferential strain.

Elastic properties of ascending aorta and ventricular-arterial coupling in women with previous pregnancy complicated by HELLP syndrome

OBJECTIVE

To compare the elastic properties of the ascending aorta and ventricular-arterial coupling (VAC) in women with a previous pregnancy complicated by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, women who experienced preeclampsia, and healthy controls.

METHODS

Women with a history of preeclampsia (n = 60) or HELLP syndrome (n = 49) and matched healthy controls (n = 60) underwent transthoracic echocardiography at 6 months to 4 years after delivery. Aortic M-mode and tissue Doppler imaging (TDI) parameters were measured. Aortic diameters were assessed at end-diastole at four levels: Valsalva sinuses, sinotubular junction, tubular tract, and aortic arch. Aortic compliance, distensibility, stiffness index, Peterson's elastic modulus, pulse-wave velocity, and M-mode strain were calculated using standard formulae. Aortic expansion velocity, early and late diastolic retraction velocities, and peak systolic tissue strain (TDI-ε) were determined. VAC was defined as the ratio between aortic elastance (Ea) and left ventricular end-systolic elastance (Ees). All women were free from cardiovascular risk factors.

RESULTS

Women with a history of HELLP syndrome showed larger aortas than those with previous preeclampsia or controls, probably related to a higher blood pressure. Aortic elastic properties, including Ea, were similar between HELLP and preeclampsia groups, even comparing cases with early-onset preeclampsia and HELLP. In contrast, Ees was more impaired in the HELLP group than in the other two. Consequently, about one-quarter of women who experienced HELLP syndrome had a pathological VAC, whereas only 5% of previously preeclamptic patients did. Multivariate analysis confirmed the association between HELLP syndrome and VAC, whereas other parameters including aortic compliance, distensibility, stiffness index, and elastic modulus are linked only to gestational age at preeclampsia onset, ad also Ea and Ees did.

CONCLUSIONS

We found a significant overlap between the aortic elastic properties in women with a history of preeclampsia and those with a previous HELLP syndrome, suggesting a common pathophysiologic pathway. However, women who experienced HELLP syndrome showed a higher blood pressure than other cases and controls, probably determining larger aortas. In addition, VAC was more altered in the HELLP group than in the others because of a higher Ea and a lower Ees.

Speckle Tracking Echocardiography: New Ways of Translational Approaches in Preeclampsia to Detect Cardiovascular Dysfunction

Several studies have shown that women with a preeclamptic pregnancy exhibit an increased risk of cardiovascular disease. However, the underlying molecular mechanisms are unknown. Animal models are essential to investigate the causes of this increased risk and have the ability to assess possible preventive and therapeutic interventions. Using the latest technologies such as speckle tracking echocardiography (STE), it is feasible to map subclinical changes in cardiac diastolic and systolic function as well as structural changes of the maternal heart. The aim of this work is to compare cardiovascular changes in an established transgenic rat model with preeclampsia-like pregnancies with findings from human preeclamptic pregnancies by STE. The same algorithms were used to evaluate and compare the changes in echoes of human and rodents. Parameters of functionality such as global longitudinal strain (animal -23.54 ± 1.82% vs. -13.79 ± 0.57%, human -20.60 ± 0.47% vs. -15.45 ± 1.55%) as well as indications of morphological changes such as relative wall thickness (animal 0.20 ± 0.01 vs. 0.25 ± 0.01, human 0.34 ± 0.01 vs. 0.40 ± 0.02) are significantly altered in both species after preeclamptic pregnancies. Thus, the described rat model simulates the human situation quite well and is a valuable tool for future investigations regarding cardiovascular changes. STE is a unique technique that can be applied in animal models and humans with a high potential to uncover cardiovascular maladaptation and subtle pathologies.

Placental Growth Factor as an Indicator of Maternal Cardiovascular Risk After Pregnancy

BACKGROUND

Angiogenic placental growth factor (PlGF) concentrations rise during pregnancy, peaking at the end of midpregnancy. Low PlGF concentrations during pregnancy are associated with pregnancy complications with recognized later-life cardiovascular risk. We hypothesized that low PlGF concentrations, especially in midpregnancy, identify not only a subset of women at risk for pregnancy complications but also women with greater cardiovascular risk factor burden after pregnancy regardless of pregnancy outcome.

METHODS

In a population-based prospective cohort study of 5475 women, we computed gestational age-adjusted multiples of the medians of early pregnancy and midpregnancy PlGF concentrations. Information on pregnancy complications (preeclampsia, small for gestational age, and spontaneous preterm birth) was obtained from hospital registries. Six years after pregnancy, we measured maternal systolic and diastolic blood pressures, cardiac structure (aortic root diameter, left atrial diameter, left ventricular mass, and fractional shortening), carotid-femoral pulse wave velocity, and central retinal arteriolar and venular calibers. Blood pressure was also measured 9 years after pregnancy.

RESULTS

Women were on average 29.8 (SD, 5.2) years of age in pregnancy, were mostly European (55.2%), and 14.8% developed a pregnancy complication. Quartile analysis showed that especially women with midpregnancy PlGF in the lowest quartile (the low-PlGF subset) had a larger aortic root diameter (0.40 mm [95% CI, 0.08-0.73]), left atrial diameter (0.34 mm [95% CI, -0.09 to 0.78]), left ventricular mass (4.6 g [95% CI, 1.1-8.1]), and systolic blood pressure (2.3 mm Hg [95% CI, 0.93-3.6]) 6 years after pregnancy than women with the highest PlGF. Linear regression analysis showed that higher midpregnancy PlGF concentrations were associated with a smaller aortic root diameter (-0.24 mm [95% CI, -0.39 to -0.10]), smaller left atrial diameter (-0.75 mm [95% CI, -0.95 to -0.56]), lower left ventricular mass (-3.9 g [95% CI, -5.5 to -2.3]), and lower systolic blood pressure (-1.1 mm Hg [95% CI, -1.7 to -0.46]). These differences persisted after the exclusion of women with complicated pregnancies.

CONCLUSIONS

Women with low PlGF in midpregnancy have a greater aortic root diameter, left atrial diameter, and left ventricular mass and higher systolic blood pressure 6 and 9 years after pregnancy compared to women with higher PlGF, including women with uncomplicated pregnancies. The pathophysiological implications of lower PlGF concentrations in midpregnancy might provide insight into the identification of pathways contributing to greater cardiovascular risk factor burden.

Evaluation of Cardiac Function in Women With a History of Preeclampsia: A Systematic Review and Meta-Analysis

Background

Women with a history of preeclampsia are at increased risk of cardiovascular morbidity and mortality. However, the underlying mechanisms of disease association, and the ideal method of monitoring this high‐risk group, remains unclear. This review aims to determine whether women with a history of preeclampsia show clinical or subclinical cardiac changes when evaluated with an echocardiogram.

Methods and Results

A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify studies that examined cardiac function in women with a history of preeclampsia, in comparison with those with normotensive pregnancies. In the 27 included studies, we found no significant differences between preeclampsia and nonpreeclampsia women with regard to left ventricular ejection fraction, isovolumetric relaxation time, or deceleration time. Women with a history of preeclampsia demonstrated a higher left ventricular mass index and relative wall thickness with a mean difference of 4.25 g/m² (95% CI, 2.08, 6.42) and 0.03 (95% CI, 0.01, 0.05), respectively. In comparison with the nonpreeclampsia population, they also demonstrated a lower E/A and a higher E/e′ ratio with a mean difference of −0.08 (95% CI, −0.15, −0.01) and 0.84 (95% CI, 0.41, 1.27), respectively.

Conclusions

In comparison with women who had a normotensive pregnancy, women with a history of preeclampsia demonstrated a trend toward altered cardiac structure and function. Further studies with larger sample sizes and consistent echocardiogram reporting with the use of sensitive preclinical markers are required to assess the role of echocardiography in monitoring this high‐risk population group.

Pre-eclampsia and long-term cardiac dysfunction: A review of asymptomatic cardiac changes existing well beyond the post-partum period

BACKGROUND

Pre-eclampsia is a disease of pregnancy characterised by the manifestations of multi-organ dysfunction. The recent use of transthoracic echocardiography in the assessment of women with pre-eclampsia has allowed the detection of cardiac systolic and diastolic dysfunction in the acute phase. Women with a history of pre-eclampsia also have increased lifelong risks of cardiovascular disease and mortality that persists well beyond the post-partum period. These developments raise the possibility that pre-eclampsia may be an early marker of cardiovascular disease and the potential role for echocardiography in guiding the detection and management of this. This review aims to summarise the existing evidence of echocardiographic cardiac assessment of women with a history of pre-eclampsia performed more than 12 weeks post-partum.

METHODS

A systematic search of PubMed and OVID EMBASE databases was performed to identify studies featuring assessment of cardiac function performed after 12 weeks post-partum in women with a history of pre-eclampsia. Studies without post-partum cardiac assessment or with other documented causes for cardiomyopathy were excluded.

RESULTS

Thirteen studies were identified that measured cardiac function by transthoracic echocardiography between 6 months and 18 years following a pregnancy complicated by pre-eclampsia. Common findings across the studies were of increased diastolic dysfunction, increased left ventricular mass index (LVMI) and concentric hypertrophy in women with a history of pre-eclampsia, as compared to women with uncomplicated pregnancy histories. This was predominantly seen in those with a history of early or preterm pre-eclampsia.

CONCLUSIONS

Women with a history of early or preterm pre-eclampsia have an increased prevalence of diastolic dysfunction. This review demonstrates that the cardiac dysfunction associated with previous pre-eclampsia is quantifiable and persistent. Progression of heart failure from asymptomatic to symptomatic stages carries a fivefold increase in mortality. The use of echocardiography could detect cardiac dysfunction in the asymptomatic stage and guide more intensive risk factor modification in these women.

Preeclampsia: Maternal Systemic Vascular Disorder Caused by Generalized Endothelial Dysfunction Due to Placental Antiangiogenic Factors

Preeclampsia, a systemic vascular disorder characterized by new-onset hypertension and proteinuria after 20 weeks of gestation, is the leading cause of maternal and perinatal morbidity and mortality. Maternal endothelial dysfunction caused by placental factors has long been accepted with respect to the pathophysiology of preeclampsia. Over the past decade, increased production of placental antiangiogenic factors has been identified as a placental factor leading to maternal endothelial dysfunction and systemic vascular dysfunction. This review summarizes the recent advances in understanding the molecular mechanisms of endothelial dysfunction caused by placental antiangiogenic factors, and the novel clinical strategies based on these discoveries.

Elevated soluble-St2 concentrations in preeclampsia correlate with echocardiographic parameters of diastolic dysfunction and return to normal values one year after delivery

Objectives: To compare soluble-ST2 (sST2) concentrations in patients with severe features of preeclampsia and healthy pregnant controls before as well as 1 year after delivery. Another objective was to assess potential correlation between sST2 concentrations and myocardial function.Methods: Patients with singleton pregnancy complicated by severe features of preeclampsia and healthy controls were included in a prospective observational study. Plasma sST2 concentrations were measured within 24 h before delivery and 1 year after delivery. Standard two-dimensional and Doppler echocardiography was performed at the time of first sST2 measurement before delivery. Mann-Whitney U test was used to compare sST2 values in preeclamptic patients versus controls. Kendall's tau was used to assess correlation between sST2 values and echocardiographic measures of left ventricular systolic and diastolic function (p < .05 significant).Results: We included 24 patients with severe preeclampsia and 29 controls. One year after delivery, sST2 concentrations were available for 24 (45%) participants (13 in preeclampsia group and 11 controls). Concentrations of sST2 were markedly elevated in patients with severe preeclampsia compared to healthy controls before delivery (p = .04), but not 1 year after delivery (p = .80). There was no significant correlation between sST2 and parameters of systolic function. In preeclamptic patients, we found a significant inverse correlation between sST2 and markers of diastolic function: peak early mitral inflow velocity E (Kendall's tau = -0.40; p = .02), peak early diastolic myocardial velocities at septal and lateral mitral annulus (e') (Kendall's tau = -0.354, p = .04) and ratio between e' and peak systolic myocardial velocities at the septal and lateral mitral annulus (e'/s') (Kendall's tau = -0.362, p = .04).Conclusions: Preeclampsia with severe features is associated with increased maternal plasma concentrations of sST2, which return to normal values in the first year after delivery. Higher sST2 levels in preeclamptic patients correlate with impaired parameters of left ventricular diastolic function.

Maternal Cardiac Function after Normal Delivery, Preeclampsia, and Eclampsia: A Prospective Study

Introduction

The aim of this study is to assess maternal cardiac function in the postpartum period, after 2 and 6 months in the parturient with preeclampsia and eclampsia.

Materials and Methods

Prospective study: 90 postpartum women after preeclampsia and eclampsia and 55 patients after an uncomplicated pregnancy. The parameters of maternal hemodynamics were recorded on days 1, 3, 5, 9, and 14 of postpartum period, after 2 and 6 months. The cardiac parameters were assessed.

Results

PE is accompanied by increased peripheral vascular resistance. The indicator of vascular resistance, SVR, is elevated for both mild and severe PE. With mild PE, a significant increase in SVR is observed up to 5 days of postpartum period, with severe PE/E up to 9 days. We found that in case of severe PE, SVR remains elevated to 6 months after delivery. The parameters of the contractile function of the heart (ESV, EDV, SV, SI, CO, СI, MVCF) were significantly decreased: with mild PE up to 5-9 days, with severe up to 9-14 days of puerperia. ESV, SV, SI, CO, and CI remain low with severe PE up to 6 months. The revealed decreasing of contractile function of the heart is a sign of asymptomatic heart failure.

Conclusions

The hemodynamics of the puerperas after PE and E is characterized by impaired contractility of the myocardium and an increase in the indices of peripheral resistance. The degree of deviation in the parameters of cardiac hemodynamics and vascular resistance depended on the severity of hypertensive complications of pregnancy.

Inappropriate left ventricular mass after preeclampsia: another piece of the puzzle Inappropriate LVM and PE

Excessive left ventricular (LV) mass (LVM) increase results in inefficient LV work with high energy waste and a negative prognostic effect. We aimed to investigate the presence of inappropriate LVM and to calculate the myocardial mechanoenergetic efficiency index (MEEi) in asymptomatic women with a history of early-onset (EO) or late-onset (LO) pre-eclampsia (PE). Among all women diagnosed with PE in the years 2009-2013, after applying inclusion/exclusion criteria and cost-effectiveness analysis, we randomly selected thirty women who experienced EO-PE, thirty with a previous LO-PE and thirty healthy controls to undergo echocardiography from 6 months to 4 years after delivery. Data regarding gestational age (GA) and mean uterine artery (UtA) pulsatility index (PI) at PE onset were collected from medical records. All women were free from cardiovascular risk factors. LVM excess was calculated as the ratio between observed LVM and predicted LVM (by sex, stroke work and height), while MEEi was calculated as the ratio between stroke work and "double product" (to approximate energy consumption), indexed to LVM. Concentric remodeling was present in 60% of EO-PE and 53% of LO-PE. LVM excess was significantly more often present in the EO-PE group than in the control group. LVM was inappropriate in 52% of EO-PE and 17% of LO-PE. MEEi showed a tendency towards lower values in the EO-PE group. Multivariate regression analysis showed that both LVM excess and MEEi were independently associated with lower GA and higher mean UtA PI at PE onset. Inappropriate LVM with a tendency towards reduced MEEi in the first 4 years after delivery may partially explain the elevated cardiovascular risk in former pre-eclamptic women compared to the general population.

Ultrasound evaluation of left ventricular and aortic fibrosis after pre-eclampsia

OBJECTIVES

Myocardial fibrosis is associated with adverse clinical outcome in adults. Our aim was to investigate using echocardiographic calibrated integrated backscatter (cIBS) the presence of myocardial and/or aortic fibrosis in asymptomatic women with a history of early-onset (EO) or late-onset (LO) pre-eclampsia (PE).

METHODS

Thirty non-pregnant women whose most recent pregnancy was complicated by EO-PE, 30 with previous LO-PE pregnancy and 30 controls who had experienced only uncomplicated pregnancy previously were selected retrospectively from our electronic database and recalled between 6 months and 4 years after delivery. Data regarding gestational age (GA) and mean uterine artery (UtA) pulsatility index (PI) at diagnosis of PE were collected from their medical records. The women underwent cardiovascular assessment, during which the presence of fibrosis was investigated, by means of cIBS, at the basal interventricular septum (cIBS_IVS ), the basal posterior wall (cIBS_PW ) and the anterior wall of the ascending aorta, 3 cm above the valve (cIBS_AO ). These findings were compared between the three patient groups.

RESULTS

Using cIBS imaging, we found significant left ventricular (LV) fibrosis in women with a history of EO-PE compared with those with previous LO-PE pregnancy and controls (intergroup ANOVA P < 0.001 for cIBS_IVS and P = 0.005 for cIBS_PW ), whereas aortic fibrosis did not differ significantly among cases and controls. Stepwise multivariate regression analysis showed that LV fibrosis was associated independently with lower GA and higher mean UtA-PI at diagnosis of PE, while cIBS_AO correlated with aortic diameters, stiffness and ventricular-arterial coupling.

CONCLUSIONS

Women with a history of EO-PE show LV fibrosis in the short-medium term after delivery compared with women with previous LO-PE pregnancy and controls. LV fibrosis is associated with GA and mean UtA-PI at onset of PE. Larger studies using cardiac magnetic resonance imaging are needed to validate and confirm our findings. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Peripartum Cardiomyopathy and Preeclampsia: Overlapping Diseases of Pregnancy

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy (HDP) often result in cardiac dysfunction and have been variably included as a risk factor for peripartum cardiomyopathy (PPCM). However, there is debate regarding the relationship between the two entities.

RECENT FINDINGS

Diastolic dysfunction appears to be more predominant among gravidas with HDP, while systolic dysfunction predominates in PPCM. However, this finding is not consistent in all studies. Recent examinations of mortality and morbidity associated with PPCM in the setting of HDP do not demonstrate a predominant pattern with a mixture of results. Further, right ventricular dysfunction is identified to be a common theme in both populations. From a basic science perspective, there is evidence to demonstrate a predominantly anti-angiogenic milieu in both PPCM and HDP. PPCM and HDP associated cardiomyopathy overlap significantly. As such, unifying theories for their pathophysiology should be investigated.

Cardiovascular origins of preeclampsia

PURPOSE OF REVIEW

To review the current data on maternal cardiovascular adaptation in normal pregnancy and preeclampsia.

RECENT FINDINGS

Defective placentation causes early-onset preeclampsia, a disease entity that is considered more or less distinct from late-onset preeclampsia. The latter has been attributed as 'maternal' preeclampsia. There are inconsistencies with the placental origins hypothesis, especially when considering the lack of a causative association with abnormal placental histology or impaired fetal growth. An alternative explanation is that placental dysfunction is secondary to maternal cardiovascular maladaptation in pregnancy. The concept that placental dysfunction is secondary to a maternal disorder is not new when one considers the clinical similarities between preeclampsia and gestational diabetes - both pregnancy-specific conditions that are cured by birth. It is accepted that gestational diabetes develops when the maternal pancreas is unable to manage the increasing glucose load of pregnancy. It is now apparent that pregnancy presents a substantial cardiovascular load on the maternal heart, and that cardiovascular dysfunction precedes the disorder, predominates in the clinical syndrome and persists for several decades postpartum. It is time to consider the evidence that failure of the maternal cardiovascular system to adapt to pregnancy may well be the primary mechanism leading to secondary placental dysfunction in preeclampsia.

SUMMARY

Many of the existing paradoxes of preeclampsia challenge the placental origin hypothesis and are explained if one considered preeclampsia to be a cardiovascular syndrome.

Cardiac maladaptation in term pregnancies with preeclampsia

OBJECTIVES

To study biventricular cardiac changes with conventional echocardiography and new echocardiographic speckle tracking technologies such strain, twist and torsion in pregnant women with preeclampsia at term and normotensive control term pregnant women.

STUDY DESIGN

For this prospective single centre case-control study, we consecutively recruited 30 women with preeclampsia at term as cases and 40 healthy control term pregnant women. All women underwent transthoracic echocardiographic examination at the time point of inclusion into the study.

MAIN OUTCOME MEASURES

Signs of systolic and/or diastolic cardiac maladaptation to the increased volume load associated with pregnancy.

RESULTS

Conventional echocardiography revealed mild left sided diastolic impairment in the form of significantly increased E/E' in preeclampsia (7.58 ± 1.72 vs. 6.18 ± 1.57, p = 0.001) compared to normotensive controls, but no evidence of systolic impairment. With speckle tracking analysis, significant decreases in left ventricular global (-13.32 ± 2.37% vs. -17.61 ± 1.89%, p < 0.001), endocardial (-15.64 ± 2.79% vs. -19.84 ± 2.35%, p < 0.001) and epicardial strain (-11.48 ± 2.15% vs. -15.73 ± 1.66%, p < 0.001) as well as left ventricular longitudinal strain rate (-0.84 ± 0.14 s^-1 vs. -0.98 ± 0.12 s^-1, p < 0.001) and left ventricular early diastolic strain rate (0.86 ± 0.30 s^-1 vs. 1.24 ± 0.26 s^-1, p < 0.001) could be observed in women with term preeclampsia.

CONCLUSIONS

The findings of this study demonstrate that pregnant women with term preeclampsia with minimal functional changes on conventional echocardiography, demonstrated significant subclinical myocardial changes on speckle tracking analysis.

Early-onset preeclampsia predisposes to preclinical diastolic left ventricular dysfunction in the fifth decade of life: An observational study

Background

Systemic inflammation, endothelial dysfunction and deficient vascularization of either uterus or myocardium are mechanistic hallmarks of early-onset preeclampsia and heart failure with preserved ejection fraction (HFpEF). HFpEF is especially prevalent in elderly women and preceded in middle age by preclinical left ventricular (LV) diastolic dysfunction.

To detect if preeclampsia predisposes to HFpEF at later age, echocardiographic indices of LV function and of LV structure and biomarkers of systemic inflammation and of endothelial dysfunction were compared in middle-aged women with a history of early-onset preeclampsia or uncomplicated pregnancy.

Methods and findings

Middle-aged women with a history of early-onset preeclampsia (n = 131) or uncomplicated pregnancy (n = 56) were prospectively recruited 9 to 16 years after pregnancy.

Women with a history of preeclampsia had higher body mass index (p = 0.006), blood pressure (p<0.001) and plasma levels of interleukin-6 (p = 0.005) and soluble intercellular adhesion molecule-1 (sICAM-1) (p = 0.014). They had thicker septal (p = 0.001) and posterior (p = 0.003) LV walls and worse diastolic LV function evident from reduced mean mitral annular lengthening velocity (E’mean; p = 0.007) and higher ratio of early diastolic mitral flow velocity (E) over E’mean (E/E’mean; p<0.001). Differences of sICAM-1, E’mean and E/E’mean remained significant after accounting for BMI and blood pressure.

Conclusions

History of preeclampsia predisposes in middle age to worse LV diastolic function, which could increase the likelihood of later HFpEF development. This predisposition derives not only from persistent cardiovascular risk but may also be caused by persistent endothelial dysfunction hindering adequate vascularization in the uterus during pregnancy and in the myocardium in middle age.

Maternal cardiac function after HELLP syndrome: an echocardiography study

OBJECTIVE

To evaluate maternal hemodynamics in asymptomatic women with a previous pregnancy affected by hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome and compare the findings to those of women with previous pre-eclampsia (PE) and controls with a previous uncomplicated pregnancy.

METHODS

Women with a history of PE (n = 60) or HELLP syndrome (n = 49) and matched healthy controls (n = 60) underwent echocardiography at 6 months to 4 years after delivery, recording left ventricular (LV) dimensions, ejection fraction (LVEF) and mass, right ventricular (RV) tricuspid annular plane systolic excursion and fractional area change (FAC). Diastolic filling (E/A and E/E' ratios) and tissue Doppler imaging were evaluated for both ventricles and the myocardial performance index was calculated.

RESULTS

Only women with previous HELLP syndrome showed significant LV concentric hypertrophy (20.4%). However, in both HELLP and PE groups, LV concentric remodeling (46.9% and 46.7%, respectively), diastolic dysfunction (expressed as altered E/A and E/E' ratios) and reduced LVEF (14.3% and 21.7%, respectively) were documented. RV variables did not differ significantly between cases and controls, except for FAC and E/E' ratio, which were slightly impaired in women with previous HELLP syndrome compared to those with previous PE (16.3% vs 10.0%, P = 0.04; 14.3% vs 3.3%, P = 0.03, respectively).

CONCLUSIONS

The significant overlap of echocardiographic features in women with previous PE and HELLP syndrome suggests that these two conditions share the same pathophysiology. However, HELLP syndrome may lead to more severe cardiovascular remodeling in the short to medium term after delivery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Exposure to placental ischemia impairs postpartum maternal renal and cardiac function in rats

Women with a history of preeclampsia (PE) have an increased risk to develop cardiovascular and renal diseases later in life, but the mechanisms underlying this effect are unknown. In rats, we assessed whether placental ischemia results in long-term effects on the maternal cardiovascular and renal systems using the reduced uterine perfusion pressure (RUPP) model for PE. Sprague-Dawley rats received either a Sham or RUPP operation at gestational day 14 The rats were followed for 8 wk after delivery (Sham n = 12, RUPP n = 21) at which time mean arterial pressure (MAP; conscious), 24-h albuminuria, glomerular filtration rate (GFR; transcutaneous, FITC-sinistrin), and cardiac function (Vevo 770 system) were assessed. Subsequently, all rats were euthanized for mesenteric artery vasorelaxation and histology of heart and kidney. At 8 wk after delivery, there was no difference in MAP and albuminuria. However, RUPP rats showed a significantly reduced GFR [2.61 ± 0.53 vs. 3.37 ± 0.74 ml/min; P = 0.01]. Ultrasound showed comparable cardiac structure, but RUPP rats had a lower left ventricular ejection fraction (62 ± 7 vs. 69 ± 10%; P = 0.04). Heart and kidney histology was not different between Sham or RUPP rats. Furthermore, there were no differences in endothelial-dependent or -independent vasorelaxation. We show that exposure to placental ischemia in rats is accompanied by functional disturbances in maternal renal and cardiac function 8 wk after a preeclamptic pregnancy. However, these changes were not dependent on differences in blood pressure, small artery vasorelaxation, or cardiac and renal structure at this time point postpartum.