Maternal cardiovascular function at 35-37 weeks' gestation: relation to maternal characteristics

Do maternal haemodynamics have a causal influence on treatment for gestational diabetes?

BACKGROUND

Arterial stiffening is believed to contribute to the worsening of insulin resistance, and factors which are associated with needing pharmacological treatment of gestational diabetes (GDM), such as maternal obesity or advanced age, are associated with impaired cardiovascular adaptation to pregnancy. In this observational study, we aimed to investigate causal relationships between maternal haemodynamics and treatment requirement amongst women with GDM.

METHODS

We assessed maternal haemodynamics in women with GDM, comparing those who remained on dietary treatment with those who required pharmacological management. Maternal haemodynamics were assessed using the Arteriograph® (TensioMed Ltd, Budapest, Hungary) and the NICOM® non-invasive bio-reactance method (Cheetah Medical, Portland, Oregon, USA). A graphical causal inference technique was used for statistical analysis.

RESULTS

120 women with GDM were included in the analysis. Maternal booking BMI was identified as having a causative influence on treatment requirement, with each unit increase in BMI increasing the odds of needing metformin and/or insulin therapy by 12% [OR 1.12 (1.02 - 1.22)]. The raw values of maternal heart rate (87.6 ± 11.7 vs. 92.9 ± 11.90 bpm, p = 0.014) and PWV (7.8 ± 1.04 vs. 8.4 ± 1.61 m/s, p = 0.029) were both significantly higher amongst the women requiring pharmacological management, though these relationships did not remain significant in causal logistic regression.

CONCLUSIONS

Maternal BMI at booking has a causal, rather than simply associational, relationship on the need for pharmacological treatment of GDM. No significant causal relationships were found between maternal haemodynamics and the need for pharmacological treatment.

The updated understanding of advanced maternal age

The rising rates of pregnancies associated with advanced maternal age (AMA) have created unique challenges for healthcare systems worldwide. The elevated risk of poor maternal outcomes among AMA pregnancies is only partially understood and hotly debated. Specifically, AMA is associated with reduced fertility and an increased incidence of pregnancy complications. Finding a balance between global fertility policy, socioeconomic development and health care optimization ultimately depends on female fertility. Therefore, there is an urgent need to develop technologies and identify effective interventions. Support strategies should include prepregnancy screening, intervention and postpartum maintenance. Although some reviews have considered the relationship between AMA and adverse pregnancy outcomes, no previous work has comprehensively considered the long-term health effects of AMA on mothers. In this review, we will begin by presenting the current knowledge of global health issues associated with AMA and the effects of advanced age on the female reproductive system, endocrine metabolism, and placental function. We will then discuss physiological alterations, pregnancy complications, and long-term health problems caused by AMA.

Impact of maternal height, weight at presentation and gestational weight gain on cardiac adaptation in pregnancy

OBJECTIVE

To compare longitudinal maternal hemodynamic changes throughout gestation between different groups stratified according to weight at presentation and assess the relative influence of height, weight at presentation and gestational weight gain on cardiac adaptation.

METHODS

This was a prospective, longitudinal study assessing maternal hemodynamics using bioreactance technology at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. Women were divided into three groups according to maternal weight at presentation at the first visit at 11 + 0 to 13 + 6 weeks: Group 1, < 60.0 kg (n = 421); Group 2, 60.0-79.7 kg (n = 904); Group 3, > 79.7 kg (n = 427). A multilevel linear mixed-effects model was used to compare the repeated measures of hemodynamic variables, correcting for demographics, medical and obstetric history, pregnancy complications, maternal weight and time of evaluation. The linear mixed-effects model was then repeated using maternal height, weight at presentation and gestational weight gain Z-scores, and the standardized coefficients were used to evaluate the relative impact of each of these demographic parameters on longitudinal changes of maternal hemodynamics.

RESULTS

Compared with Group 1, women in Group 3 demonstrated higher cardiac output (CO), heart rate (HR) and mean arterial pressure (MAP) throughout pregnancy. Groups 2 and 3 had higher stroke volume (SV) than Group 1 at the first visit, but their SV plateaued between the first and second visits and demonstrated an earlier significant decrease from the second visit to the third visit when compared with Group 1. Compared with Groups 1 and 2, there was a higher prevalence of pre-eclampsia, gestational hypertension and gestational diabetes in Group 3. Maternal height was the most important contributor to CO, peripheral vascular resistance (PVR), SV and HR, while weight at presentation was the most important contributor to MAP. Gestational weight gain was the second most important characteristic influencing the longitudinal changes of PVR and SV.

CONCLUSIONS

Women with greater weight at presentation have a pathological hemodynamic profile, with higher CO, HR and MAP compared to women with lower weight at presentation. Height is the main determinant of CO, SV, HR and PVR, weight is the main determinant of MAP, and gestational weight gain is the second most important determinant of SV and PVR. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The correlation between maternal age, parity, cardiac diastolic function and occurrence rate of pre-eclampsia

To evaluate the effect of age and parity on maternal cardiac diastolic function in second trimester among pregnant women with normal left ventricular ejection fraction. To analyze the correlation between impaired diastolic function and pre-eclampsia. It had been suggested that maternal cardiac adaptations during pregnancy differed between nulliparous and primiparous women and also varied according to age. Impaired cardiac function may precede pre-eclampsia. Therefore, we examined the effects of parity and age on cardiac diastolic function during pregnancy and whether impaired diastolic function during the second trimester correlates with pre-eclampsia. Women with singleton pregnancies at 13 + 0 to 27 + 6 weeks’ gestation and left ventricular ejection fraction (LVEF) ≥ 50% were retrospectively identified. Diastolic function parameters were assessed using transthoracic echocardiography. Pre-eclampsia was identified from medical records. The effect of age and parity on maternal cardiac diastolic function as well as the correlation between impaired diastolic function and occurrence rate of pre-eclampsia were examined. 376 pregnant women were included (median age: 30 years; median gestational age: 14 weeks; 171 primiparous women). LVEF was 66%. Impaired cardiac diastolic function was seen in 7.8% of pregnant women < 35 years compared with 28.6% of those ≥ 35 years (p = 0.000). ROC curve showed women with maternal age over 32 began to have a higher rate of impaired cardiac diastolic function (AUC = 0.704, p = 0.000, sensitivity = 54.5%, specificity = 75.3%). There was no difference in diastolic function indices between maternal women grouped by parity. Higher maternal age was an independent risk factor of declining Em (p < 0.05). Em < 13 cm/s was significantly associated with pre-eclampsia occurrence (HR 8.56; 95% CI 3.40–21.57) after being adjusted for confounders. Maternal age is an independent risk factor for diastolic function decline. There is no difference in cardiac diastolic function between nulliparous women and primiparous women. Pre-eclampsia occurrence is significantly higher in patients with impaired diastolic function at mid-gestation. The application of risk grading using diastolic function at mid-gestation may improve the survival outcomes of pregnant women.

Effect of race on longitudinal central hemodynamics in pregnancy

OBJECTIVE

To compare central hemodynamics between white, black and Asian women in pregnancy.

METHODS

This was a prospective, longitudinal study of maternal central hemodynamics in white, black and Asian women with a singleton pregnancy, assessed using a bioreactance method at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. At each visit, cardiac output (CO), stroke volume (SV), heart rate (HR), peripheral vascular resistance (PVR) and mean arterial pressure were recorded. Multilevel linear mixed-effects analysis was performed to compare the repeated measures of the cardiac variables between white, black and Asian women, controlling for maternal characteristics, medical history and medication use.

RESULTS

The study population included 1165 white, 247 black and 116 Asian women. CO increased with gestational age to a peak at 32 weeks and then decreased; the highest CO was observed in white women and the lowest in Asian women. SV initially increased after the first visit but subsequently declined with gestational age in white women, decreased with gestational age in black women and remained static in Asian women. In all three study groups, HR increased with gestational age until 32 weeks and then remained constant; HR was highest in black women and lowest in white women. PVR showed a reversed pattern to that of CO; the highest values were in Asian women and the lowest in white women. The least favorable hemodynamic profile, which was observed in black and Asian women, was reflected in higher rates of a small-for-gestational-age infant.

CONCLUSIONS

There are race-specific differences in maternal cardiac adaptation to pregnancy. White women have the most favorable cardiac adaptation by increasing SV and HR, achieving the highest CO and lowest PVR. In contrast, black and Asian women have lower CO and higher PVR than do white women, with CO increasing through a rise in HR due to declining or static SV. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Maternal Cardiac Assessment at 35 to 37 Weeks Improves Prediction of Development of Preeclampsia

Preeclampsia at term accounts for half of maternal deaths from hypertensive disorders. We aimed to assess differences in maternal cardiac indices at 35⁺⁰ to 36⁺⁶ weeks' gestation between women who subsequently developed preeclampsia at term compared with those with uncomplicated pregnancy and to evaluate whether cardiac indices offer incremental prognostic value to the available screening algorithm for preeclampsia. We recruited 1602 women with singleton pregnancies who attended for a routine hospital visit at 35⁺⁰ to 36⁺⁶ weeks' gestation between April and November 2018. We recorded maternal characteristics and preeclampsia-risk-score derived from a competing risks model and measured cardiac indices. Preeclampsia developed in 3.12% (50/1602) of participants. Women with preeclampsia, compared with those without, had increased mean arterial pressure (97.6, SD, 5.53 versus 87.9, SD, 6.82 mm Hg), systemic vascular resistance (1500, interquartile range, 1393-1831 versus 1400, interquartile range, 1202-1630 PRU) and preeclampsia-risk-score (23.4, interquartile range, 9.13-40 versus 0.9, interquartile range, 0.32-3.25). Multivariable analysis demonstrated independent association between the incidence of preeclampsia and E/e' (hazard ratio, 1.19/unit [95% CI, 1.03-1.37]; P=0.018) as well as left ventricular mass indexed for body surface area (hazard ratio, 1.03/[g·m²] [95% CI, 1.003-1.051]; P=0.029). Women with E/e' ≥7.3 and left ventricular mass indexed for body surface area ≥63.2 g/m² had an increased risk for developing preeclampsia, despite low preeclampsia-risk-score <5% (hazard ratio, 20.1 [95% CI, 10.5-38.7], P<0.001). Increased left ventricular mass and E/e' offer incremental information to available scoring systems and better stratify women at risk of developing preeclampsia at term.

Multivariable evaluation of maternal hemodynamic profile in pregnancy complicated by fetal growth restriction: prospective study

OBJECTIVE

To evaluate the association between fetal growth restriction (FGR) and maternal hemodynamic parameters using multivariable analysis, adjusting for major confounding factors, such as hypertensive disorders of pregnancy (pre-eclampsia and gestational hypertension).

METHODS

A prospective cohort study was conducted between January 2013 and April 2016. Two cohorts of patients were recruited, between 24 and 39 weeks of gestation, in a high-risk outpatient setting. These cohorts comprised 49 appropriate-for-gestational-age singleton fetuses and 93 that were FGR (abdominal circumference (AC) at recruitment in the second half of pregnancy ≤ 10th percentile with a previous normal AC at 20-22 weeks). Maternal echocardiography was performed at the time of enrolment and included hemodynamic parameters of systolic and diastolic function and cardiac remodeling indices. Data were analyzed using a multivariable generalized linear model to estimate the association of FGR with maternal hemodynamic parameters after adjusting for significant confounding factors.

RESULTS

In the multivariable analysis, after adjustment for hypertensive disorders of pregnancy and smoking, FGR was associated with a 14% increase in maternal total vascular resistance, 16% reduction in cardiac output, 13% reduction in left ventricular mass and 11% reduction in heart rate; similar results were observed for the corresponding indexed parameters. Hypertensive disorders of pregnancy in the absence of FGR were associated with a 25% increase in total vascular resistance, 16% increase in left ventricular mass and 14% reduction in diastolic function; similar results were observed for the corresponding indexed parameters.

CONCLUSION

FGR is significantly and independently associated with several maternal hemodynamic parameters, even after adjustment for major confounding factors, such as hypertensive disorders of pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Cardiac output measurements during high-risk Cesarean section using electrical bioreactance or arterial waveform analysis: assessment of agreement

OBJECTIVE

Maternal hemodynamics change significantly during Cesarean section complicated by massive hemorrhage or severe hypertensive disease. Cardiac output (CO) monitoring aids early, goal-directed hemodynamic therapy. The aim of this study was to record hemodynamic changes observed during Cesarean section in pregnancies at high risk of hemodynamic instability, using invasive (LiDCOrapid™) and non-invasive (NICOM®) devices, and to assess agreement between the two devices in measuring CO.

METHODS

Simultaneous intraoperative hemodynamic measurements were taken using the LiDCOrapid and NICOM devices, following standardized techniques, in women at high risk of hemodynamic instability undergoing Cesarean section. Agreement in CO measurements between the two devices was assessed using Bland-Altman plots and the agreement:tolerability index (ATI). Agreement analyses were performed for repeated measures in subjects, using centiles.

RESULTS

From 10 women, 307 paired measurements were analyzed. Mean bias (defined as the mean difference in CO measurements between the LiDCOrapid and NICOM devices) was 3.05 (95% CI, 1.89 to 4.21) L/min. Limits of agreement ranged from -1.58 (95% CI, -4.47 to -0.14) to 7.68 (95% CI, 6.24 to 10.56) L/min. The resulting agreement interval was 9.26 L/min which returned an ATI of 2.3.

CONCLUSIONS

There are large mean differences between CO measurements obtained during Cesarean section using the LiDCOrapid and NICOM hemodynamic monitors in pregnant women at high risk of hemodynamic instability, indicating that they should not be considered interchangeable clinically. There is an unacceptably low level of agreement (ATI > 2) in CO measurements between the devices, conferring a high risk of clinical misclassification during massive hemorrhage. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Maternal Cardiovascular Dysregulation During Early Pregnancy After In Vitro Fertilization Cycles in the Absence of a Corpus Luteum

Commonly used in vitro fertilization protocols produce pregnancies without a corpus luteum (CL), a major source of reproductive hormones. In vitro fertilization pregnancies without a CL showed deficient gestational increases of central (aortic) arterial compliance during the first trimester and were at increased risk for developing preeclampsia. Here, we investigated whether there was generalized impairment of cardiovascular adaptation in in vitro fertilization pregnancies without a CL compared with pregnancies conceived spontaneously or through ovarian stimulation, which lead to 1 and >1 CL, respectively (n=19-26 participants per cohort). Prototypical maternal cardiovascular adaptations of gestation were serially evaluated noninvasively, initially during the follicular phase before conception, 6× in pregnancy, and then, on average, 1.6 years post-partum. The expected increases of cardiac output, left atrial dimension, peak left ventricular filling velocity in early diastole (E wave velocity), peripheral/central arterial pulse pressure ratio, and global AC, as well as decrease in augmentation index were significantly attenuated or absent during the first trimester in women who conceived without a CL, when compared with the 1 and >1 CL cohorts, which were comparable. Thereafter, these cardiovascular measures showed recovery in the 0 CL group except for E wave velocity, which remained depressed. These results provided strong support for a critical role of CL factor(s) in the transformation of the maternal cardiovascular system in early gestation. Regimens that lead to the development of a CL or replacement of missing CL factor(s) may be indicated to improve cardiovascular function and reduce preeclampsia risk in in vitro fertilization pregnancies.

Effect of change in posture on maternal functional hemodynamics at 35-37 weeks' gestation

OBJECTIVES

To evaluate the effect of posture change from the supine to the sitting position and before and after passive leg raising on maternal functional hemodynamics in pregnant women at 35-37 weeks' gestation, and to compare the changes in pregnancies that subsequently developed pre-eclampsia (PE) or gestational hypertension (GH) with those that remained normotensive.

METHODS

In 2764 singleton pregnancies at 35-37 weeks' gestation, maternal cardiovascular parameters were measured using an automated non-invasive cardiac monitor. The hemodynamic response to a change from the supine to the sitting position and before and after passive leg raising in the left lateral position was examined and compared between women who subsequently developed PE or GH and those who remained normotensive.

RESULTS

In normotensive singleton pregnancies at 35-37 weeks' gestation, both change from the supine to the sitting position and passive leg raising were associated with an increase in cardiac index and stroke volume index and a decrease in total peripheral resistance index; there was a small increase in mean arterial pressure with both postural changes and a slight decrease in heart rate with passive leg raising. In pregnancies that subsequently developed PE or GH, compared with normotensive pregnancies, cardiac index and stroke volume index were lower and total peripheral resistance index was higher. In general, change from the supine to the sitting position and passive leg raising were associated with similar but less marked changes in cardiovascular parameters as in normotensive pregnancies.

CONCLUSIONS

Paradoxically, in late third-trimester normal pregnancy, both change from the supine to a sitting position and passive leg raising may result in an increase in preload with a consequent increase in cardiac and stroke volume indices and a decrease in total peripheral resistance index. In pregnancies that develop PE or GH, the effects of postural change on cardiovascular parameters are similar but less marked than in normotensive pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Impact of clinical pharmacists intervention on management of hyperglycemia in pregnancy in Jordan

Background and objective Hyperglycemia in pregnancy is a risk factor for cardiovascular disease and postpartum (PP) diabetes. This study aimed to assess the impact of the clinical pharmacist-assisted program (CPAP) of optimizing drug therapy and intensive education on main management outcome measures of patient knowledge about diabetes, Quality of life (QoL) as measured by SF-36 including maternal complications, fasting plasma glucose (FPG) control, and HbA1c. Method This is a randomized controlled study. Pregnant (20-28 weeks) patients with hyperglycemia received CPAP (n = 51) as compared with conventional management (n = 34). Patients were then followed up for 6 weeks pp. Results A significant change was shown in the intervention group for diabetes knowledge (3.47% vs. control 2.03%, P < 0.05) and three aspects of health-related QoL. The need for caesarian delivery (58.8% vs. control 35.3%) and severe episodes of hypoglycemia (0% vs. control 8.8%) were significantly (P < 0.05) reduced in the intervention group. Six weeks PP reduction in HbA1c values was greater in the intervention group (- 0.54% vs. control - 0.08%, P = 0.04) with more FPG-controlled patients during pregnancy (94% vs. control 64.7%). Conclusion Clinical pharmacist assisted services in the management of pregnancy hyperglycemia fundamentally and significantly improve knowledge and disease control.

Maternal cardiac function at 35-37 weeks' gestation: relationship with birth weight

OBJECTIVE

To evaluate the relationship between maternal cardiovascular parameters and neonatal birth weight and examine the potential value of these parameters in improving the prediction of small-for-gestational-age (SGA) and large-for-gestational-age (LGA) neonates provided by maternal characteristics and medical history.

METHODS

In 2835 singleton pregnancies maternal characteristics and medical history were recorded and maternal cardiovascular parameters were measured. The observed measurements of cardiovascular parameters were expressed as multiples of the normal median (MoM) values after adjustment for those characteristics found to provide a substantial contribution to their measurement. Regression analysis was used to determine the significance of association between the normalized values of the cardiovascular parameters with birth-weight Z-score. Multivariable logistic regression analysis was then used to determine if the maternal factors, fetal biometry and maternal cardiovascular parameters had a significant contribution to predicting SGA and LGA neonates. The performance of screening was determined by the area under receiver-operating characteristics curves (AUC).

RESULTS

In the study population there were significant positive associations between maternal cardiac output and heart rate with neonatal birth-weight Z-score, and significant negative associations between total peripheral resistance and mean arterial pressure (MAP) with neonatal birth-weight Z-score. In pregnancies delivering SGA neonates (n = 249 (8.8%)), cardiac output and heart rate were lower and total peripheral resistance and MAP were higher, whereas in pregnancies delivering LGA neonates (n = 292 (10.3%)) cardiac output and heart rate were higher and total peripheral resistance and MAP were lower. The performance of screening for delivery of SGA neonates achieved by maternal characteristics and fetal biometry was not improved by the measurement of maternal cardiovascular parameters. There was a small but significant improvement in the performance of screening for delivery of LGA neonates by maternal factors and fetal biometry with the addition of maternal heart rate (comparison of AUC, P = 0.0095).

CONCLUSIONS

There are significant associations between maternal cardiac output, heart rate, total peripheral resistance and MAP and neonatal birth-weight Z-score; such findings reflect the close relationship between maternal cardiac function and fetal demands. However, assessment of these parameters at 35-37 weeks' gestation is unlikely to improve substantially the performance of screening for SGA or LGA neonates provided by a combination of maternal factors and fetal biometry. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Maternal cardiac function at 35-37 weeks' gestation: prediction of pre-eclampsia and gestational hypertension

OBJECTIVE

To investigate the potential value of combining maternal factors with multiples of the normal median values of maternal cardiovascular parameters at 35-37 weeks' gestation in the prediction of pre-eclampsia (PE) and gestational hypertension (GH).

METHODS

In 2764 singleton pregnancies maternal characteristics and medical history were recorded; uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP) and maternal cardiovascular parameters were measured. Multivariable logistic regression analysis was then used to determine if the maternal factors and maternal cardiovascular parameters made a significant contribution to predicting PE and GH. The performance of screening was determined by the area under receiver-operating characteristics curves.

RESULTS

In pregnancies that subsequently delivered with PE or GH, total peripheral resistance and MAP were higher and maternal cardiac output was lower, mainly owing to a decrease in heart rate in PE and a decrease in stroke volume in GH. The increases in total peripheral resistance and MAP were inversely related to gestational age at delivery. The performance of screening for PE and GH achieved by maternal characteristics and medical history was improved by the inclusion of MAP, but not by UtA-PI or maternal cardiovascular parameters.

CONCLUSIONS

In women developing term PE total peripheral resistance and MAP are increased and maternal cardiac output is reduced. However, assessment of maternal cardiac function at 35-37 weeks' gestation is unlikely to improve the performance of screening for PE provided by maternal factors and MAP alone. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.