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Gyselaers W, Dreesen P. Maternal hemodynamics assessment: Key to unlocking ignored functionalities of the female circulation. Best Pract Res Clin Obstet Gynaecol 2025; 99:102595. [PMID: 40112759 DOI: 10.1016/j.bpobgyn.2025.102595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 02/24/2025] [Indexed: 03/22/2025]
Abstract
This chapter focuses on currently underappreciated aspects of the maternal circulation: blood pressure phenotypes, venous hemodynamics, intra-abdominal pressure, and body water homeostasis. Based on the hemodynamic balance between cardiac output and total peripheral resistance, flow-dominant and resistance-dominant phenotypes of normotension and hypertension exist, with different impacts on gestational outcome. Cardiac diastolic function and venous hemodynamics play a prominent role in gestational changes in cardiac output. An increase in intra-abdominal pressure during pregnancy interferes with body water volume homeostasis, similar to syndromes of multi-organ dysfunctions in non-pregnant individuals. Today, non-invasive maternal hemodynamics assessment allows for obtaining important information on these ignored circulatory functions in addition to conventional sphygmomanometric blood pressure measurement. This offers perspectives to improve current strategies for screening, diagnosis, and management of gestational hypertension disorders, a path, however, to be paved first by intensified multifaceted and multidisciplinary research.
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Affiliation(s)
- Wilfried Gyselaers
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590, Diepenbeek, Belgium; Department of Obstetrics & Gynecology, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium.
| | - Pauline Dreesen
- Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590, Diepenbeek, Belgium; Future Health, Ziekenhuis Oost-Limburg, 3600, Genk, Belgium.
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Zhang M, Ren X, Song D. The impact of aspirin combined with labetalol on coagulation function and pregnancy outcomes in pre-eclamptic pregnant women. BMC Pregnancy Childbirth 2025; 25:215. [PMID: 40016668 PMCID: PMC11866632 DOI: 10.1186/s12884-025-07314-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Accepted: 02/10/2025] [Indexed: 03/01/2025] Open
Abstract
BACKGROUND This study aimed to analyze the impact of aspirin combined with labetalol on coagulation function and pregnancy outcomes in women with pre-eclampsia. METHODS A total of 98 pregnant women with pre-eclampsia admitted to our hospital from September 2019 to March 2021 were selected for the retrospective analysis. Patient records were reviewed and divided into a control group (n = 49) who received labetalol and an observation group (n = 49) who received aspirin combined with labetalol. Extracted from the case collection system and observed: clinical efficacy, occurrence of adverse pregnancy outcomes, and adverse reactions. RESULTS The total effective rate in the observation group was higher than that in the control group. After treatment, the observation group had lower systolic blood pressure, diastolic blood pressure, D-D, Scr, β2-MG, and MA levels compared to the control group, and higher TT, PT and APTT levels. The occurrence rate of adverse pregnancy outcomes such as preterm delivery, intrauterine distress, postpartum hemorrhage, and fetal heart abnormalities was lower in the observation group than in the control group. There were no statistically significant differences in adverse reactions such as nausea, vomiting, hypotension, ocular tremor, and facial flushing between the two groups. CONCLUSION Aspirin combined with labetalol has ideal therapeutic efficacy in women with pre-eclampsia. It can enhance the antihypertensive effect, improve the coagulation status of the body, protect renal function, improve adverse pregnancy outcomes, and is considered safe and reliable, deserving adoption.
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Affiliation(s)
- Min Zhang
- The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin City, China
| | - Xiaoxuan Ren
- The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin City, China
| | - Dianrong Song
- The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin City, China.
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di Pasquo E, Ghi T. Reply to letter to the editor regarding "The preeclampsia and hypertension target treatment study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings". Am J Obstet Gynecol MFM 2025:101601. [PMID: 39824308 DOI: 10.1016/j.ajogmf.2025.101601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Accepted: 12/17/2024] [Indexed: 01/20/2025]
Affiliation(s)
- Elvira di Pasquo
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Women and Child Health, Women's Health Area, Fondazione Policlinico Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico, Catholic University of Sacred Heart, Rome, Italy
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Conti-Ramsden F, de Marvao A, Chappell LC. Pharmacotherapeutic options for the treatment of hypertension in pregnancy. Expert Opin Pharmacother 2024; 25:1739-1758. [PMID: 39225514 PMCID: PMC11881908 DOI: 10.1080/14656566.2024.2398602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy affect approximately one in 10 pregnancies and are associated with increased risk of adverse fetal, neonatal and maternal outcomes. There is strong evidence that effective treatment of hypertension (blood pressure ≥ 140/90 mmHg), and enhanced monitoring throughout pregnancy reduces these risks. AREAS COVERED This article provides a contemporaneous review of treatment of hypertension in pregnancy with antihypertensive agents. We completed a systematic search and review of all meta-analyses and systematic reviews of studies comparing antihypertensives for treatment of pregnancy hypertension in the last five years. We provide a clinically focused summary of when to treat hypertension in pregnancy and which antihypertensive agents can be offered. Special scenarios reviewed include treatment-resistant hypertension and pre-pregnancy antihypertensive optimization. EXPERT OPINION Several antihypertensives are considered safe and are known to be effective for treatment of hypertension in pregnancy. Given the current uncertainty as to which antihypertensive(s) are superior for treatment of hypertension in pregnancy, women should be counselled and offered a range of antihypertensive options in keeping with evidence on clinical effectiveness, local context and availability of antihypertensive(s), potential side effect profile, and women's preference. Further research is required to help guide clinical decision making, and move toward personalized treatment.
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Affiliation(s)
- Frances Conti-Ramsden
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
| | - Antonio de Marvao
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London, London, UK
- Medical Research Council Laboratory of Medical Sciences, Imperial College London, London, UK
| | - Lucy C. Chappell
- Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK
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Sampson R, Davis S, Wong R, Baranco N, Silverman RK. Pulse Pressure as a Hemodynamic Parameter in Preeclampsia with Severe Features Accompanied by Fetal Growth Restriction. J Clin Med 2024; 13:4318. [PMID: 39124585 PMCID: PMC11312723 DOI: 10.3390/jcm13154318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Modern management of preeclampsia can be optimized by tailoring the targeted treatment of hypertension to an individual's hemodynamic profile. Growing evidence suggests different phenotypes of preeclampsia, including those with a hyperdynamic profile and those complicated by uteroplacental insufficiency. Fetal growth restriction (FGR) is believed to be a result of uteroplacental insufficiency. There is a paucity of research examining the characteristics of patients with severe preeclampsia who do and who do not develop FGR. We aimed to elucidate which hemodynamic parameters differed between these two groups. Methods: All patients admitted to a single referral center with severe preeclampsia were identified. Patients were included if they had a live birth at 23 weeks of gestation or higher. Multiple gestations and pregnancies complicated by fetal congenital anomalies and/or HELLP syndrome were excluded. FGR was defined as a sonographic estimation of fetal weight (EFW) < 10th percentile or abdominal circumference (AC) < 10th percentile. Results: There were 76% significantly lower odds of overall pulse pressure upon admission for those with severe preeclampsia comorbid with FGR (aOR = 0.24, 95% CI = 0.07-0.83). Advanced gestational age on admission was associated with lower odds of severely abnormal labs and severely elevated diastolic blood pressure in preeclampsia also complicated by FGR. Conclusions: Subtypes of preeclampsia with and without FGR may be hemodynamically evaluated by assessing pulse pressure on admission.
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Affiliation(s)
- Rachael Sampson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Sidney Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Roger Wong
- Department of Public Health and Preventive Medicine, Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
- Department of Geriatrics, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Nicholas Baranco
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Robert K. Silverman
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
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Thomopoulos C, Hitij JB, De Backer T, Gkaliagkousi E, Kreutz R, Lopez-Sublet M, Marketou M, Mihailidou AS, Olszanecka A, Pechère-Bertschi A, Pérez MP, Persu A, Piani F, Socrates T, Stolarz-Skrzypek K, Cífková R. Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'. J Hypertens 2024; 42:1109-1132. [PMID: 38690949 DOI: 10.1097/hjh.0000000000003739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.
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Affiliation(s)
- Costas Thomopoulos
- Department of Cardiology, General Hospital of Athens 'Laiko', Athens, Greece
| | - Jana Brguljan Hitij
- Department of Hypertension, University Medical Centre Ljubljana, Medical University Ljubljana, Slovenia
| | - Tine De Backer
- Cardiovascular Center & Clinical Pharmacology, University Hospital Gent, Belgium
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Reinhold Kreutz
- Charite-Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Marilucy Lopez-Sublet
- AP-HP, Hopital Avicenne, Centre d'Excellence Europeen en Hypertension Arterielle, Service de Medecine Interne, INSERM UMR 942 MASCOT, Paris 13-Universite Paris Nord, Bobigny, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists)
| | - Maria Marketou
- School of Medicine, University of Crete, Heraklion, Greece
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Royal North Shore Hospital, St Leonards
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Agnieszka Olszanecka
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | | | - Mariana Paula Pérez
- Department of Hypertension. Hospital de Agudos J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Federica Piani
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thenral Socrates
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence University Hospital Basel, Basel, Switzerland
| | - Katarzyna Stolarz-Skrzypek
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital
- Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic
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7
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di Pasquo E, Giannubilo SR, Valentini B, Salvi S, Rullo R, Fruci S, Filippi E, Ornaghi S, Zullino S, Rossi F, Farsetti D, Di Martino DD, Vasapollo B, Locatelli A, De Santis M, Ciavattini A, Lanzone A, Mecacci F, Ferrazzi E, Valensise H, Ghi T. The "Preeclampsia and Hypertension Target Treatment" study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings. Am J Obstet Gynecol MFM 2024; 6:101368. [PMID: 38574856 DOI: 10.1016/j.ajogmf.2024.101368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Despite major advances in the pharmacologic treatment of hypertension in the nonpregnant population, treatments for hypertension in pregnancy have remained largely unchanged over the years. There is recent evidence that a more adequate control of maternal blood pressure is achieved when the first given antihypertensive drug is able to correct the underlying hemodynamic disorder of the mother besides normalizing the blood pressure values. OBJECTIVE This study aimed to compare the blood pressure control in women receiving an appropriate or inappropriate antihypertensive therapy following the baseline hemodynamic findings. STUDY DESIGN This was a prospective multicenter study that included a population of women with de novo diagnosis of hypertensive disorders of pregnancy. A noninvasive assessment of the following maternal parameters was performed on hospital admission via Ultrasound Cardiac Output Monitor before any antihypertensive therapy was given: cardiac output, heart rate, systemic vascular resistance, and stroke volume. The clinician who prescribed the antihypertensive therapy was blinded to the hemodynamic evaluation and used as first-line treatment a vasodilator (nifedipine or alpha methyldopa) or a beta-blocker (labetalol) based on his preferences or on the local protocols. The first-line pharmacologic treatment was retrospectively considered hemodynamically appropriate in either of the following circumstances: (1) women with a hypodynamic profile (defined as low cardiac output [≤5 L/min] and/or high systemic vascular resistance [≥1300 dynes/second/cm2]) who were administered oral nifedipine or alpha methyldopa and (2) women with a hyperdynamic profile (defined as normal or high cardiac output [>5 L/min] and/or low systemic vascular resistances [<1300 dynes/second/cm2]) who were administered oral labetalol. The primary outcome of the study was to compare the occurrence of severe hypertension between women treated with a hemodynamically appropriate therapy and women treated with an inappropriate therapy. RESULTS A total of 152 women with hypertensive disorders of pregnancy were included in the final analysis. Most women displayed a hypodynamic profile (114 [75.0%]) and received a hemodynamically appropriate treatment (116 [76.3%]). The occurrence of severe hypertension before delivery was significantly lower in the group receiving an appropriate therapy than in the group receiving an inappropriately treated (6.0% vs 19.4%, respectively; P=.02). Moreover, the number of women who achieved target values of blood pressure within 48 to 72 hours from the treatment start was higher in the group who received an appropriate treatment than in the group who received an inappropriate treatment (70.7% vs 50.0%, respectively; P=.02). CONCLUSION In pregnant individuals with de novo hypertensive disorders of pregnancy, a lower occurrence of severe hypertension was observed when the first-line antihypertensive agent was tailored to the correct maternal hemodynamic profile.
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Affiliation(s)
- Elvira di Pasquo
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi)
| | - Stefano Raffaele Giannubilo
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy (Drs Giannubilo and Ciavattini)
| | - Beatrice Valentini
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi)
| | - Silvia Salvi
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Roberta Rullo
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Stefano Fruci
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Elisa Filippi
- Department of Obstetrics and Gynecology, Ospedale Ca Foncello, Treviso, Italy (Drs Filippi and Santis)
| | - Sara Ornaghi
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Sara Zullino
- High-Risk Pregnancy Unit, Department of Women's and Children's Health, Azienda Ospedaliera Careggi, Florence, Italy (Drs Zullino and Dr Mecacci)
| | - Francesca Rossi
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Daniele Farsetti
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Daniela Denis Di Martino
- Unit of Obstetrics, Division of Obstetrics and Gynecology, Department of Woman, Child, and Newborn, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino and Ferrazzi)
| | - Barbara Vasapollo
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Anna Locatelli
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Michela De Santis
- Department of Obstetrics and Gynecology, Ospedale Ca Foncello, Treviso, Italy (Drs Filippi and Santis)
| | - Andrea Ciavattini
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy (Drs Giannubilo and Ciavattini)
| | - Antonio Lanzone
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Federico Mecacci
- High-Risk Pregnancy Unit, Department of Women's and Children's Health, Azienda Ospedaliera Careggi, Florence, Italy (Drs Zullino and Dr Mecacci)
| | - Enrico Ferrazzi
- Unit of Obstetrics, Division of Obstetrics and Gynecology, Department of Woman, Child, and Newborn, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino and Ferrazzi)
| | - Hebert Valensise
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi); Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy (Dr Ghi).
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Zambrano MA, Rojas-Suarez JA, Peña-Zarate EE, Carvajal JA, Gutierrez-Puerto LS, Aguilar-Cano F, Santacruz-Arias J, Rodríguez-Lopez M, Fernanda Escobar M. Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis. Hypertens Pregnancy 2023; 42:2272176. [PMID: 38059821 DOI: 10.1080/10641955.2023.2272176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/07/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy. METHODS Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension. RESULTS Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome. CONCLUSION Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.
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Affiliation(s)
| | - Jose A Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Cartagena, Colombia
- GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia
| | - Evelyn E Peña-Zarate
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - Javier Andres Carvajal
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de Alta Complejidad Obstétrica, Departamento de Obstetricia y Ginecología, Fundación Valle del Lili, Cali, Colombia
| | | | | | - Jose Santacruz-Arias
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Cartagena, Colombia
| | | | - María Fernanda Escobar
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de Alta Complejidad Obstétrica, Departamento de Obstetricia y Ginecología, Fundación Valle del Lili, Cali, Colombia
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9
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Lopian M, Kashani-Ligumsky L, Many A. A Balancing Act: Navigating Hypertensive Disorders of Pregnancy at Very Advanced Maternal Age, from Preconception to Postpartum. J Clin Med 2023; 12:4701. [PMID: 37510816 PMCID: PMC10380965 DOI: 10.3390/jcm12144701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The decision to postpone parenting has gained momentum in recent years, a shift driven by evolving social dynamics and improved access to fertility treatments. Despite their increasing prevalence, pregnancies at advanced maternal ages are associated with increased risks of adverse maternal and neonatal outcomes. This article addresses the association between advanced maternal age and hypertensive disorders of pregnancies (HDPs), which are more prevalent and a significant cause of maternal morbidity and mortality in this population. This review explores the biological mechanisms and age-related risk factors that underpin this increased susceptibility and offers practical management strategies that can be implemented prior to, as well as during, each stage of pregnancy to mitigate the incidence and severity of HDPs in this group. Lastly, this review acknowledges both the short-term and long-term postpartum implications of HDPs in women of advanced maternal age.
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Affiliation(s)
- Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Kashani-Ligumsky
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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10
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Palmrich P, Haase N, Sugulle M, Kalafat E, Khalil A, Binder J. Maternal haemodynamics in Hypertensive Disorders of Pregnancy under antihypertensive therapy (HyperDiP): study protocol for a prospective observational case-control study. BMJ Open 2023; 13:e065444. [PMID: 37263704 DOI: 10.1136/bmjopen-2022-065444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are associated with a high incidence of maternal and perinatal morbidity and mortality. HDP, in particular pre-eclampsia, have been determined as risk factors for future cardiovascular disease. Recently, the common hypothesis of pre-eclampsia being a placental disorder was challenged as numerous studies show evidence for short-term and long-term cardiovascular changes in pregnancies affected by HDP, suggesting a cardiovascular origin of the disease. Despite new insights into the pathophysiology of HDP, concepts of therapy remain unchanged and evidence for improved maternal and neonatal outcome by using antihypertensive agents is lacking. METHODS AND ANALYSIS A prospective observational case-control study, including 100 women with HDP and 100 healthy controls, which will assess maternal haemodynamics using the USCOM 1A Monitor and Arteriograph along with cardiovascular markers (soluble fms-like kinase 1/placental-like growth factor, N-terminal pro-B type natriuretic peptide) in women with HDP under antihypertensive therapy, including a follow-up at 3 months and 1 year post partum, will be conducted over a 50-month period in Vienna. A prospective, longitudinal study of cardiovascular surrogate markers conducted in Oslo will serve as a comparative cohort for the Vienna cohort of haemodynamic parameters in pregnancy including a longer follow-up period of up to 3 years post partum. Each site will provide a dataset of a patient group and a control group and will be assessed for the outcome categories USCOM 1A measurements, Arteriograph measurements and Angiogenic marker measurements. To estimate the effect of antihypertensive therapy on outcome parameters, ORs with 95% CIs will be computed. Longitudinal changes of outcome parameters will be compared between normotensive and hypertensive pregnancies using mixed-effects models. ETHICS AND DISSEMINATION Ethical approval has been granted to all participating centres. Results will be published in international peer-reviewed journals and will be presented at national and international conferences.
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Affiliation(s)
- Pilar Palmrich
- Division of Obstetrics and Feto-Maternal Medicine, Hospital of the Medical University of Vienna, Vienna, Austria
| | - Nadine Haase
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin, Berlin, Germany
- Max-Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Meryam Sugulle
- Division of Gynecology and Obstetrics, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University Hospital, Istanbul, Turkey
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
| | - Julia Binder
- Division of Obstetrics and Feto-Maternal Medicine, Hospital of the Medical University of Vienna, Vienna, Austria
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Dall'Asta A, Minopoli M, Ramirez Zegarra R, Di Pasquo E, Ghi T. An update on maternal cardiac hemodynamics in fetal growth restriction and pre-eclampsia. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:265-272. [PMID: 36377677 DOI: 10.1002/jcu.23392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/03/2022] [Accepted: 10/28/2022] [Indexed: 06/16/2023]
Abstract
Pre-eclampsia and fetal growth restriction (FGR) have been long related to primary placental dysfunction, caused by abnormal trophoblast invasion. Nevertheless, emerging evidence has led to a new hypothesis for the origin of pre-eclampsia and FGR. Suboptimal maternal cardiovascular adaptation has been shown to result in uteroplacental hypoperfusion, ultimately leading to placental hypoxic damage with secondary dysfunction. In this review, we summarize current evidence on maternal cardiac hemodynamics in FGR and pre-eclampsia. We also discuss the different approaches for antihypertensive treatment according to the hemodynamic phenotype observed in pre-eclampsia and FGR.
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Affiliation(s)
- Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Monica Minopoli
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Ruben Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Elvira Di Pasquo
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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Ling HZ, Jara PG, Nicolaides KH, Kametas NA. Impact of maternal height, weight at presentation and gestational weight gain on cardiac adaptation in pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:523-531. [PMID: 35020246 DOI: 10.1002/uog.24858] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- H Z Ling
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - P Garcia Jara
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - N A Kametas
- Fetal Medicine Research Institute, King's College Hospital, London, UK
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13
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Orabona R, Sciatti E, Vizzardi E, Bonadei I, Metra M, Sartori E, Frusca T, Pinna A, Bellocco R, Prefumo F. Maternal Left Ventricular Function in Uncomplicated Twin Pregnancies: A Speckle-Tracking Imaging Longitudinal Study. J Clin Med 2022; 11:jcm11185283. [PMID: 36142928 PMCID: PMC9504023 DOI: 10.3390/jcm11185283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/28/2022] [Accepted: 09/06/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Rossana Orabona
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, 25123 Brescia, Italy
- Correspondence: ; Tel.: +39-030-399-5365; Fax: +39-030-399-6401
| | - Edoardo Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
| | - Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
| | - Ivano Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
| | - Marco Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy
| | - Enrico Sartori
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, 25123 Brescia, Italy
| | - Tiziana Frusca
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, 25123 Brescia, Italy
- Department of Obstetrics and Gynecology, University of Parma, 43121 Parma, Italy
| | - Antonio Pinna
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
| | - Rino Bellocco
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 171 65 Stockholm, Sweden
| | - Federico Prefumo
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, 25123 Brescia, Italy
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Ornaghi S, Caricati A, Di Martino DD, Mossa M, Di Nicola S, Invernizzi F, Zullino S, Clemenza S, Barbati V, Tinè G, Mecacci F, Ferrazzi E, Vergani P. Non-invasive Maternal Hemodynamic Assessment to Classify High-Risk Pregnancies Complicated by Fetal Growth Restriction. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:851971. [PMID: 36992751 PMCID: PMC10012115 DOI: 10.3389/fcdhc.2022.851971] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022]
Abstract
ObjectivesTo verify whether the use of the temporal criterion of 32 weeks’ gestation is effective in identifying maternal hemodynamic differences between early- and late-onset fetal growth restriction (FGR), and to test the statistical performance of a classificatory algorithm for FGR.Materials and methodsA prospective multicenter study conducted at three centers over 17 months. Singleton pregnant women with a diagnosis of FGR based on the international Delphi survey consensus at ≥ 20 weeks of gestation were included. FGR was classified as early-onset if diagnosed <32 weeks’ gestation and as late-onset if ≥32 weeks. Hemodynamic assessment was performed by USCOM-1A at the time of FGR diagnosis. Comparisons between early- and late-onset FGR among the entire study cohort, FGR associated with hypertensive disorders of pregnancy (HDP-FGR), and isolated FGR (i-FGR) were performed. In addition, HDP-FGR cases were compared to i-FGR, regardless of the temporal cut-off of 32 weeks’ gestation. Finally, a classificatory analysis based on the Random Forest model was performed to identify significant variables with the ability to differentiate FGR phenotypes.ResultsDuring the study period, 146 pregnant women fulfilled the inclusion criteria. In 44 cases, FGR was not confirmed at birth, thus limiting the final study population to 102 patients. In 49 (48.1%) women, FGR was associated to HDP. Fifty-nine (57.8%) cases were classified as early-onset. Comparison of the maternal hemodynamics between early- and late-onset FGR did not show any difference. Similarly, non-significant findings were observed in sensitivity analyses performed for HDP-FGR and for i-FGR. In turn, comparison between pregnant women with FGR and hypertension and women with i-FGR, independently of the gestational age at FGR diagnosis, revealed substantial differences, with the former showing higher vascular peripheral resistances and lower cardiac output, among other significant parameters. The classificatory analysis identified both phenotypic and hemodynamic variables as relevant in distinguishing HDP-FGR from i-FGR (p=0.009).ConclusionsOur data show that HDP, rather than gestational age at FGR diagnosis, allows to appreciate specific maternal hemodynamic patterns and to accurately distinguish two different FGR phenotypes. In addition, maternal hemodynamics, alongside phenotypic characteristics, play a central role in classifying these high-risk pregnancies.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
- *Correspondence: Sara Ornaghi,
| | - Andrea Caricati
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Mossa
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Di Nicola
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Francesca Invernizzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Sara Clemenza
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Valentina Barbati
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriele Tinè
- Department of Economics and Quantitative Methods, University of Milan-Bicocca, Monza, Italy
| | - Federico Mecacci
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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Bone JN, Sandhu A, Abalos ED, Khalil A, Singer J, Prasad S, Omar S, Vidler M, von Dadelszen P, Magee LA. Oral Antihypertensives for Nonsevere Pregnancy Hypertension: Systematic Review, Network Meta- and Trial Sequential Analyses. Hypertension 2022; 79:614-628. [PMID: 35138877 PMCID: PMC8823910 DOI: 10.1161/hypertensionaha.121.18415] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/15/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND We aimed to address which antihypertensives are superior to placebo/no therapy or another antihypertensive for controlling nonsevere pregnancy hypertension and provide future sample size estimates for definitive evidence. METHODS Randomized trials of antihypertensives for nonsevere pregnancy hypertension were identified from online electronic databases, to February 28, 2021 (registration URL: https://www.crd.york.ac.uk/PROSPERO/; unique identifier: CRD42020188725). Our outcomes were severe hypertension, proteinuria/preeclampsia, fetal/newborn death, small-for-gestational age infants, preterm birth, and admission to neonatal care. A Bayesian random-effects model generated estimates of direct and indirect treatment comparisons. Trial sequential analysis informed future trials needed. RESULTS Of 1246 publications identified, 72 trials were included; 61 (6923 women) were informative. All commonly prescribed antihypertensives (labetalol, other β-blockers, methyldopa, calcium channel blockers, and mixed/multi-drug therapy) versus placebo/no therapy reduced the risk of severe hypertension by 30% to 70%. Labetalol decreased proteinuria/preeclampsia (odds ratio, 0.73 [95% credible interval, 0.54-0.99]) and fetal/newborn death (odds ratio, 0.54 [0.30-0.98]) compared with placebo/no therapy, and proteinuria/preeclampsia compared with methyldopa (odds ratio, 0.66 [0.44-0.99]) and calcium channel blockers (odds ratio, 0.63 [0.41-0.96]). No other differences were identified, but credible intervals were wide. Trial sequential analysis indicated that 2500 to 10 000 women/arm (severe hypertension or safety outcomes) to >15 000/arm (fetal/newborn death) would be required to provide definitive evidence. CONCLUSIONS In summary, all commonly prescribed antihypertensives in pregnancy reduce the risk of severe hypertension, but labetalol may also decrease proteinuria/preeclampsia and fetal/newborn death. Evidence is lacking for many other safety outcomes. Prohibitive sample sizes are required for definitive evidence. Real-world data are needed to individualize care.
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Affiliation(s)
- Jeffrey N. Bone
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Akshdeep Sandhu
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Edgardo D. Abalos
- Centro Rosarino de Estudios Perinatales, Rosario, Argentina (E.D.A.)
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George’s University Hospitals, NHS Foundation Trust, United Kingdom (A.K.)
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, United Kingdom (A.K.)
| | - Joel Singer
- School of Population and Public Health, UBC, Canada (J.S.)
| | - Sarina Prasad
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Shazmeen Omar
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Canada (J.N.B., A.S., S.P., S.O., M.V.)
| | - Peter von Dadelszen
- Department of Women and Children’s Health, King’s College London, United Kingdom (P.v.D., L.A.M.)
| | - Laura A. Magee
- Department of Women and Children’s Health, King’s College London, United Kingdom (P.v.D., L.A.M.)
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 412] [Impact Index Per Article: 137.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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Gyselaers W. Hemodynamic pathways of gestational hypertension and preeclampsia. Am J Obstet Gynecol 2022; 226:S988-S1005. [PMID: 35177225 DOI: 10.1016/j.ajog.2021.11.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/01/2022]
Abstract
Gestational hypertension and preeclampsia are the 2 main types of hypertensive disorders in pregnancy. Noninvasive maternal cardiovascular function assessment, which helps obtain information from all the components of circulation, has shown that venous hemodynamic dysfunction is a feature of preeclampsia but not of gestational hypertension. Venous congestion is a known cause of organ dysfunction, but its potential role in the pathophysiology of preeclampsia is currently poorly investigated. Body water volume expansion occurs in both gestational hypertension and preeclampsia, and this is associated with the common feature of new-onset hypertension after 20 weeks of gestation. Blood pressure, by definition, is the product of intravascular volume load and vascular resistance (Ohm's law). Fundamentally, hypertension may present as a spectrum of cardiovascular states varying between 2 extremes: one with a predominance of raised cardiac output and the other with a predominance of increased total peripheral resistance. In clinical practice, however, this bipolar nature of hypertension is rarely considered, despite the important implications for screening, prevention, management, and monitoring of disease. This review summarizes the evidence of type-specific hemodynamic profiles in the latent and clinical stages of hypertensive disorders in pregnancy. Gestational volume expansion superimposed on an early gestational closed circulatory circuit in a pressure- or volume-overloaded condition predisposes a patient to the gradual deterioration of overall circulatory function, finally presenting as gestational hypertension or preeclampsia-the latter when venous dysfunction is involved. The eventual phenotype of hypertensive disorder is already predictable from early gestation onward, on the condition of including information from all the major components of circulation into the maternal cardiovascular assessment: the heart, central and peripheral arteries, conductive and capacitance veins, and body water content. The relevance of this approach, outlined in this review, openly invites for more in-depth research into the fundamental hemodynamics of gestational hypertensive disorders, not only from the perspective of the physiologist or the scientist, but also in assistance of clinicians toward understanding and managing effectively these severe complications of pregnancy.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost-Limburg, Genk, Belgium; and Faculty of Medicine and Life Sciences, Department Physiology, Hasselt University, Belgium.
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Preeclampsia has two phenotypes which require different treatment strategies. Am J Obstet Gynecol 2022; 226:S1006-S1018. [PMID: 34774281 DOI: 10.1016/j.ajog.2020.10.052] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 12/15/2022]
Abstract
The opinion on the mechanisms underlying the pathogenesis of preeclampsia still divides scientists and clinicians. This common complication of pregnancy has long been viewed as a disorder linked primarily to placental dysfunction, which is caused by abnormal trophoblast invasion, however, evidence from the previous two decades has triggered and supported a major shift in viewing preeclampsia as a condition that is caused by inherent maternal cardiovascular dysfunction, perhaps entirely independent of the placenta. In fact, abnormalities in the arterial and cardiac functions are evident from the early subclinical stages of preeclampsia and even before conception. Moving away from simply observing the peripheral blood pressure changes, studies on the central hemodynamics reveal two different mechanisms of cardiovascular dysfunction thought to be reflective of the early-onset and late-onset phenotypes of preeclampsia. More recent evidence identified that the underlying cardiovascular dysfunction in these phenotypes can be categorized according to the presence of coexisting fetal growth restriction instead of according to the gestational period at onset, the former being far more common at early gestational ages. The purpose of this review is to summarize the hemodynamic research observations for the two phenotypes of preeclampsia. We delineate the physiological hemodynamic changes that occur in normal pregnancy and those that are observed with the pathologic processes associated with preeclampsia. From this, we propose how the two phenotypes of preeclampsia could be managed to mitigate or redress the hemodynamic dysfunction, and we consider the implications for future research based on the current evidence. Maternal hemodynamic modifications throughout pregnancy can be recorded with simple-to-use, noninvasive devices in obstetrical settings, which require only basic training. This review includes a brief overview of the methodologies and techniques used to study hemodynamics and arterial function, specifically the noninvasive techniques that have been utilized in preeclampsia research.
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Wang Q, Liu D, Liu G. Value of Ultrasonic Image Features in Diagnosis of Perinatal Outcomes of Severe Preeclampsia on account of Deep Learning Algorithm. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4010339. [PMID: 35035520 PMCID: PMC8759876 DOI: 10.1155/2022/4010339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 11/30/2022]
Abstract
This study is aimed at discussing the value of ultrasonic image features in diagnosis of perinatal outcomes of severe preeclampsia on account of deep learning algorithm. 140 pregnant women singleton with severe preeclampsia were selected as the observation group. At the same time, 140 normal singleton pregnant women were selected as the control group. The hemodynamic indexes were detected by color Doppler ultrasound. The CNN algorithm was used to classify ultrasound images of two groups of pregnant women. The differential scanning calorimetry (DSC), mean pixel accuracy (MPA), and mean intersection of union (MIOU) values of CNN algorithm were 0.9410, 0.9228, and 0.8968, respectively. Accuracy, precision, recall, and F1-score were 93.44%, 95.13%, 95.09%, and 94.87%, respectively. The differences were statistically significant (P < 0.05). Compared with the normal control group, the umbilical artery (UA), uterine artery-systolic/diastolic (UTA-S/D), uterine artery (UTA), and digital video (DV) of pregnant women in the observation group were remarkably increased; the minimum alveolar effective concentration (MCA) of the observation group was obviously lower than the MCA of the control group, and the differences between groups were statistically valid (P < 0.05). Logistic regression analysis showed that UA-S/D, UA-resistance index (UA-RI), UTA-S/D, UTA-pulsatility index (UTA-PI), DV-peak velocity index for veins (DV-PVIV), and MCA-S/D were independent risk factors for the outcome of perinatal children with severe preeclampsia. In the perinatal management of severe epilepsy, the combination of the above blood flow indexes to select the appropriate delivery time had positive significance to improve the pregnancy outcome and reduce the perinatal mortality.
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Affiliation(s)
- Qiang Wang
- Department of Ultrasonography, Yidu Central Hospital of Weifang, Qingzhou, 262500 Shandong, China
| | - Dong Liu
- Department of Ultrasonography, Yidu Central Hospital of Weifang, Qingzhou, 262500 Shandong, China
| | - Guangheng Liu
- Department of Ultrasonography, Weifang People's Hospital, Weifang, 261041 Shandong, China
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20
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Acute pulmonary edema due to severe preeclampsia in advanced maternal age women. Pregnancy Hypertens 2021; 25:150-155. [PMID: 34144403 DOI: 10.1016/j.preghy.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/27/2021] [Accepted: 05/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Acute pulmonary edema is a rare complication in women with preeclampsia especially at advanced maternal age. We aimed to determine the cardiovascular hemodynamics in advanced maternal age women who developed acute pulmonary edema and preeclampsia. STUDY DESIGN Retrospective cohort study of women aged over 45 years giving birth at single university affiliated tertiary medical center which developed acute pulmonary edema due to severe preeclampsia. Clinical features were identified in order to predict and potentially prevent this severe complication of pregnancy. MAIN OUTCOME MEASURES Advanced maternal age women who developed acute pulmonary edema due to preeclampsia. RESULTS Overall, during the study period 90,540 women delivered in our hospital, of them, 540 women (0.6%) above the age of 45 years gave birth. Of those, 67 women (12.4%) had preeclampsia in which 4 women (6%) were complicated with acute pulmonary edema. The common clinical relevant characteristics for all four women were: preterm delivery by cesarean section for preeclampsia with severe features, non-restrictive fluid management around the time of delivery, post-partum pain control medication with non-steroidal anti-inflammatory drug, blood pressure stabilization with oral labetalol and a sudden hemodynamic deterioration to hypertensive crisis and pulmonary edema between post-operative days 4-9. CONCLUSION Although the precise trigger for the sudden presentation of acute pulmonary edema remains unknown, we suggest that there is a multi-factorial combination of etiologies that are common to women of advanced maternal age and women with preeclampsia that could have contributed to the development of pulmonary edema.
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21
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Mulder EG, Ghossein-Doha C, Cauffman E, Lopes van Balen VA, Schiffer VMMM, Alers RJ, Oben J, Smits L, van Kuijk SMJ, Spaanderman MEA. Preventing Recurrent Preeclampsia by Tailored Treatment of Nonphysiologic Hemodynamic Adjustments to Pregnancy. Hypertension 2021; 77:2045-2053. [PMID: 33813842 DOI: 10.1161/hypertensionaha.120.16502] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Eva G Mulder
- Department of Obstetrics and Gynecology (E.G.M., E.C., V.A.L.v.B., V.M.M.M.S., R.J.A., M.E.A.S.), Maastricht University Medical Centre, the Netherlands.,GROW School for Oncology and Developmental Biology (E.G.M., C.G.D., V.A.L.v.B., V.M.M.M.S., R.J.A.), Maastricht University Medical Centre, the Netherlands
| | - Chahinda Ghossein-Doha
- GROW School for Oncology and Developmental Biology (E.G.M., C.G.D., V.A.L.v.B., V.M.M.M.S., R.J.A.), Maastricht University Medical Centre, the Netherlands.,Department of Cardiology (C.G.D., J.O.), Maastricht University Medical Centre, the Netherlands.,Cardiovascular Research Institute Maastricht (C.G.D.), Maastricht University Medical Centre, the Netherlands
| | - Ella Cauffman
- Department of Obstetrics and Gynecology (E.G.M., E.C., V.A.L.v.B., V.M.M.M.S., R.J.A., M.E.A.S.), Maastricht University Medical Centre, the Netherlands
| | - Veronica A Lopes van Balen
- Department of Obstetrics and Gynecology (E.G.M., E.C., V.A.L.v.B., V.M.M.M.S., R.J.A., M.E.A.S.), Maastricht University Medical Centre, the Netherlands.,GROW School for Oncology and Developmental Biology (E.G.M., C.G.D., V.A.L.v.B., V.M.M.M.S., R.J.A.), Maastricht University Medical Centre, the Netherlands
| | - Veronique M M M Schiffer
- Department of Obstetrics and Gynecology (E.G.M., E.C., V.A.L.v.B., V.M.M.M.S., R.J.A., M.E.A.S.), Maastricht University Medical Centre, the Netherlands.,GROW School for Oncology and Developmental Biology (E.G.M., C.G.D., V.A.L.v.B., V.M.M.M.S., R.J.A.), Maastricht University Medical Centre, the Netherlands
| | - Robert-Jan Alers
- Department of Obstetrics and Gynecology (E.G.M., E.C., V.A.L.v.B., V.M.M.M.S., R.J.A., M.E.A.S.), Maastricht University Medical Centre, the Netherlands.,GROW School for Oncology and Developmental Biology (E.G.M., C.G.D., V.A.L.v.B., V.M.M.M.S., R.J.A.), Maastricht University Medical Centre, the Netherlands
| | - Jolien Oben
- Department of Cardiology (C.G.D., J.O.), Maastricht University Medical Centre, the Netherlands
| | - Luc Smits
- Department of Epidemiology (L.S.), Maastricht University Medical Centre, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (S.M.J.v.K.), Maastricht University Medical Centre, the Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology (E.G.M., E.C., V.A.L.v.B., V.M.M.M.S., R.J.A., M.E.A.S.), Maastricht University Medical Centre, the Netherlands
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22
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Yin O, Woods A, Koos B, DeVore G, Afshar Y. Central hemodynamics are associated with fetal outcomes in pregnancies of advanced maternal age. Pregnancy Hypertens 2019; 19:67-73. [PMID: 31923879 DOI: 10.1016/j.preghy.2019.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/17/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Age is a known risk factor for both maternal cardiovascular disease and adverse outcomes in pregnancy. We aimed to characterize the hemodynamic profiles in pregnancies of advanced maternal age (AMA) and correlate these with fetal outcomes. STUDY DESIGN This was a prospective observational study of pregnancies undergoing antenatal testing. Maternal hemodynamics were measured non-invasively using an imaging probe at the descending aorta and the Uscom BP + arm cuff utilizing pulse pressure wave analysis. The Wilcoxon rank-sum test, Fisher's exact test, and Spearman rank correlation test were used for statistical analysis in R. MAIN OUTCOME MEASURES Hemodynamic measurements, neonatal birthweight. RESULTS Twenty-one AMA and twenty-four control patients were enrolled. Mean age ± SD was 39 ± 3.22 in the AMA cohort and 28 ± 4.32 in the control cohort (p < 0.001). AMA patients were evaluated at a later gestational age (36 4/7 weeks) compared to control (34 1/7 weeks, p = 0.02). Between groups, there was no difference in BMI, race, hypertensive disease, diabetes, asthma, drug use, or indication for antenatal testing. 38% (AMA) and 37% (control) had hypertensive disorders of pregnancy. In AMA patients but not control patients, cardiac output (r = 0.52, p = 0.01), systemic vascular resistance (r = -0.53, p = 0.01), and systemic vascular resistance index (r = -0.62, p = 0.002) were significantly correlated with neonatal birthweight percentile. CONCLUSIONS Hemodynamic alterations consistent with a low output, high resistance cardiovascular circuit were associated with lower birthweight in AMA, but not in control pregnancies.
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Affiliation(s)
- Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, United States
| | - Allison Woods
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, United States
| | - Brian Koos
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, United States
| | - Greggory DeVore
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, United States
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, United States.
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23
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Westberg SM, Pereira C, Rosdahl R, Do A, Moon JY, Melnik T. Management of hypertension in pregnancy: a descriptive report of two clinic practices. Hypertens Pregnancy 2019; 39:43-47. [PMID: 31777293 DOI: 10.1080/10641955.2019.1697702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To describe the current clinical practice in the treatment of hypertension in pregnancy.Methods: Retrospective chart review described hypertension treatment of pregnant women in two urban clinics in Minnesota USA, over 27 months. Data elements collected: blood pressure (BP) readings with gestational age, goal BP documented, and pharmacological treatments utilized.Results: Sixty patients had multiple elevated BP readings in prenatal care encounters. Of 60 included patients, 18 were treated with antihypertensives and 11 had documented BP goals. Documented goal BPs varied in numeric goal and some only listed systolic or diastolic goal.Conclusion: Inconsistencies exist in current treatment and documentation of hypertension in pregnancy.
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Affiliation(s)
- Sarah M Westberg
- University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Chrystian Pereira
- University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Rebecca Rosdahl
- University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Annette Do
- Pharmacy Practice Resident, Minneapolis Veteran's Affairs Medical Center, Minnesota, United States
| | - Jean Y Moon
- University of Minnesota College of Pharmacy, Minneapolis, MN, United States
| | - Tanya Melnik
- University of Minnesota College of Pharmacy, Minneapolis, MN, United States
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24
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Affiliation(s)
- Basky Thilaganathan
- From the Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, United Kingdom (B.T.).,Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Erkan Kalafat
- Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara University, Turkey (E.K.)
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25
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Magee LA, von Dadelszen P. State-of-the-Art Diagnosis and Treatment of Hypertension in Pregnancy. Mayo Clin Proc 2018; 93:1664-1677. [PMID: 30392546 DOI: 10.1016/j.mayocp.2018.04.033] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 04/12/2018] [Accepted: 04/20/2018] [Indexed: 12/20/2022]
Abstract
Hypertension complicates up to 10% of pregnancies worldwide. Pregnancy hypertension is defined as systolic blood pressure (BP) equal to or greater than 140 mm Hg or diastolic BP equal to or greater than 90 mm Hg, usually on the basis of measurements in office/clinic settings and using various BP devices. Hypertensive disorders of pregnancy are classified into (1) chronic hypertension diagnosed before pregnancy or before 20 weeks' gestation, (2) gestational hypertension diagnosed at equal to or greater than 20 weeks, or (3) preeclampsia, defined restrictively as gestational hypertension with proteinuria or broadly as gestational hypertension with proteinuria or an end-organ manifestation consistent with preeclampsia. Absolute BP values equal to or greater than 140/90 mm Hg are associated with increased maternal and perinatal risks, particularly with preeclampsia. This review focuses on antihypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy. Underpinning this therapy is the need for accurate measurement of BP, agreed-upon classification of pregnancy hypertension, agreed-upon BP thresholds for enhanced surveillance and antihypertensive treatment, and collaborative teamwork in management. Challenges relate to the methodology of studies on which care is based, as well as aspects of the care itself, particularly the unregulated use of home BP monitoring. Pitfalls include the unsubstantiated belief that nifedipine and magnesium sulfate cannot be used together and the perception that severe hypertension and nonsevere hypertension are separate entities rather than lying along a spectrum of BP values. The following must be addressed by future research: guidance for nuanced care as women transition between severe and nonsevere hypertension, personalized antihypertensive therapy, and incorporation of women's values into research priorities and clinical practice when antihypertensive care is chosen.
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Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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26
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Novelli GP, Vasapollo B, Valensise H. Hemodynamic Prediction and Stratification of Hypertensive Disorders of Pregnancy: A Dream That Is Coming True? J Am Heart Assoc 2018; 7:JAHA.118.010084. [PMID: 30007938 PMCID: PMC6064850 DOI: 10.1161/jaha.118.010084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Gian Paolo Novelli
- Department of Cardiology, Ospedale San Sebastiano Martire, Frascati, Rome, Italy
| | - Barbara Vasapollo
- Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Herbert Valensise
- Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy.,Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
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27
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McLaughlin K, Zhang J, Lye SJ, Parker JD, Kingdom JC. Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy. J Am Heart Assoc 2018; 7:JAHA.118.009595. [PMID: 30007936 PMCID: PMC6064839 DOI: 10.1161/jaha.118.009595] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypertensive disorders complicating pregnancy are a major cause of maternal death. Our objective was to evaluate maternal clinical, hemodynamic, and placental prognostic indicators in a consolidated manner to identify women who develop hypertension in pregnancy. METHODS AND RESULTS Twenty-six normotensive pregnant women from a specialized Placenta Clinic at increased risk of developing de novo hypertension and 20 normotensive healthy pregnant controls were recruited at 22 to 26 weeks' gestation. Fourteen maternal clinical, hemodynamic, and placental characteristics were assessed in the second trimester and aggregated. Principal component analysis of this combined data set determined that 3 dimensions accounted for 56% of the cohort variability. The first dimension accounted for 31% of the cohort variability, with significant contributions from total peripheral resistance, endoglin, and cardiac output. The second dimension was predominantly influenced by body mass index and mean arterial pressure, while uric acid and myeloperoxidase mainly contributed to the third dimension. Unsupervised clustering identified 3 groups within this combined data set. Total peripheral resistance was the most significant distinguishing parameter between these groups (P<0.0001), followed by placental growth factor, endoglin, and cardiac output (P<0.0001). Using these 4 parameters, a receiver operating curve was constructed with an area under the curve of 0.975 (95% confidence interval 0.93-1) for the prediction of developing hypertension in pregnancy. CONCLUSIONS Consolidated assessment of prognostic indicators in the second trimester of pregnancy may be useful to characterize and distinguish pathways by which women may develop hypertension in pregnancy. This approach could contribute to the development of pathway-specific preventative and antihypertensive treatment strategies.
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Affiliation(s)
- Kelsey McLaughlin
- Division of Cardiology, Department of Medicine, Sinai Health System University of Toronto, Canada.,The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada
| | - Jianhong Zhang
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada
| | - Stephen J Lye
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System University of Toronto, Canada
| | - John D Parker
- Division of Cardiology, Department of Medicine, Sinai Health System University of Toronto, Canada
| | - John C Kingdom
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada .,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System University of Toronto, Canada
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28
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McLaughlin K, Scholten RR, Kingdom JC, Floras JS, Parker JD. Should Maternal Hemodynamics Guide Antihypertensive Therapy in Preeclampsia? Hypertension 2018; 71:550-556. [DOI: 10.1161/hypertensionaha.117.10606] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Kelsey McLaughlin
- From the Division of Cardiology, Department of Medicine (K.M., J.S.F., J.D.P.) and Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology (R.R.S., J.C.K.), Sinai Health System, University of Toronto, ON, Canada; and Centre for Women’s and Infant’s Health, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada (K.M., J.C.K.)
| | - Ralph R. Scholten
- From the Division of Cardiology, Department of Medicine (K.M., J.S.F., J.D.P.) and Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology (R.R.S., J.C.K.), Sinai Health System, University of Toronto, ON, Canada; and Centre for Women’s and Infant’s Health, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada (K.M., J.C.K.)
| | - John C. Kingdom
- From the Division of Cardiology, Department of Medicine (K.M., J.S.F., J.D.P.) and Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology (R.R.S., J.C.K.), Sinai Health System, University of Toronto, ON, Canada; and Centre for Women’s and Infant’s Health, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada (K.M., J.C.K.)
| | - John S. Floras
- From the Division of Cardiology, Department of Medicine (K.M., J.S.F., J.D.P.) and Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology (R.R.S., J.C.K.), Sinai Health System, University of Toronto, ON, Canada; and Centre for Women’s and Infant’s Health, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada (K.M., J.C.K.)
| | - John D. Parker
- From the Division of Cardiology, Department of Medicine (K.M., J.S.F., J.D.P.) and Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology (R.R.S., J.C.K.), Sinai Health System, University of Toronto, ON, Canada; and Centre for Women’s and Infant’s Health, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada (K.M., J.C.K.)
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29
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Dassios T, Greenough A, Leontiadi S, Hickey A, Kametas NA. Admissions for hypoglycaemia after 35 weeks of gestation: perinatal predictors of cost of stay. J Matern Fetal Neonatal Med 2018; 32:448-454. [PMID: 28922987 DOI: 10.1080/14767058.2017.1381905] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Hypoglycaemia accounts for approximately one-tenth of term admissions to neonatal units can cause long-term neurodevelopmental impairment and is associated with the significant burden to the affected infants, families and the health system. OBJECTIVE To define the prevalence, length and cost of admissions for hypoglycaemia in infants born at greater than 35 weeks gestation and to identify antenatal and perinatal predictors of those outcomes. MATERIALS AND METHODS This was a retrospective audit of infants admitted for hypoglycaemia between 1 January 2012 and 31 December 2015, in a level three neonatal intensive care unit at King's College Hospital NHS Foundation Trust, London. The main outcome measures were the prevalence, length and cost of admissions for hypoglycaemia and antenatal and postnatal predictors of the length and cost of the stay. RESULTS There were 474 admissions for hypoglycaemia (17.8% of total admissions). Their median (IQR) blood glucose on admission was 2.1 (1.7-2.4) mmol/l, gestation at delivery 38.1 (36.7-39.3) weeks, birthweight percentile 31.4 (5.4-68.9), their length of stay was 3.0 (2.0-5.0). Admissions equated to a total of 2107 hospital days. The total cost of the stay was 1,316,591 Great Britain pound. The antenatal factors associated with admission for hypoglycaemia were maternal hypertension (19.8%), maternal diabetes (24.5%), foetal growth restriction (FGR) (25.9%) and pathological intrapartum cardiotocograph (23.4%). In 13.7% of cases, there was no associated pregnancy complication. Multivariate logistic regression analysis demonstrated lower gestational age, z-score birthweight squared, exclusive breastfeeding and maternal prescribed nifedipine were independently associated with the length and cost of the stay. CONCLUSION Hypoglycaemia accounted for approximately one-fifth of admissions after 35-week gestation. Lower gestational age and admission blood glucose, low and high z-score birthweight, maternal nifedipine and exclusive breastfeeding are associated with longer duration of stay.
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Affiliation(s)
- Theodore Dassios
- a Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust , Denmark Hill, London , UK
| | - Anne Greenough
- b Division of Asthma , Allergy and Lung Biology, MRC-Asthma UK National , London , UK.,c Institute for Health Research (NIHR) Biomedical Research Centre , King's College London , UK.,d King's College Hospital NHS Foundation Trust, Denmark Hill , London , UK
| | - Stamatina Leontiadi
- a Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust , Denmark Hill, London , UK
| | - Ann Hickey
- a Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust , Denmark Hill, London , UK
| | - Nikos A Kametas
- e Antenatal Hypertension Clinic, Fetal Medicine Research Institute, King's College Hospital , London , UK
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30
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Ghossein-Doha C, Khalil A, Lees CC. Maternal hemodynamics: a 2017 update. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:10-14. [PMID: 28058786 DOI: 10.1002/uog.17377] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- C Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC) & Cardiology Department, Zuyderland Medisch Centrum Heerlen, Maastricht, The Netherlands
| | - A Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University of London, London, UK
| | - C C Lees
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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