Relevance of Haemodynamics in Treating Pre-eclampsia

Subphenotypes of severe early-onset pre-eclampsia at hospital admission. A Latin American single-center exploratory latent class analysis

OBJECTIVES

To identify distinct subphenotypes of severe early-onset pre-eclampsia in Latin America and analyze biomarker and hemodynamic trends between subphenotypes after hospital admission.

METHODS

A single-center prospective cohort study was conducted in Colombia. The latent class analysis identified subphenotypes using clinical variables, biomarkers, laboratory tests, and maternal hemodynamics. Class-defining variables were restricted to measurements at and 24 h after admission. Primary and secondary outcomes were severe maternal and perinatal complications.

RESULTS

Among 49 patients, two subphenotypes were identified: Subphenotype 1 (34.7%) had a higher likelihood of an sFlt-1/PlGF ratio ≤ 38, maternal age > 35, and low probability of TPR > 1400, CO <8, and IUGR; Subphenotype 2 (65.3%) had a low likelihood of an sFlt-1/PlGF ratio < 38, maternal age > 35, and high probability of TPR > 1400, CO <8, and IUGR. At 24 h postadmission, 64.7% of subphenotype 1 patients changed to subphenotype 2, while 25% of subphenotype 2 patients were reclassified as subphenotype 1. Subphenotype 1 displayed significant changes in CO and TPR, while subphenotype 2 did not. Maternal complications were more prevalent in subphenotype 2, with an odds ratio of 5.3 (95% CI: 1.3-22.0; P = 0.02), but no significant differences in severe neonatal complications were observed.

CONCLUSIONS

We identified two distinct subphenotypes in a Latin American cohort of patients with severe early-onset pre-eclampsia. Subphenotype 2, characterized by higher TPR, sFlt-1, and serum creatinine and lower CO and PlGF at admission, was associated with worse maternal outcomes and appeared less modifiable after in-hospital treatment.

The "Preeclampsia and Hypertension Target Treatment" study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings

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.

The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia

Preeclampsia remains the leading cause of maternal morbidity and mortality and is associated with abnormal body fluid homeostasis and cardiovascular dysfunction. Moreover, 2 distinct hemodynamic phenotypes have been described in preeclampsia, which might require different therapeutic approaches. Fluid restriction is mandatory in women at risk of pulmonary edema, whereas additional fluid administration may be required to correct tissue hypoperfusion in women with intravascular volume depletion. As clinical examination alone cannot discriminate among different hemodynamic patterns, optimal management of women with preeclampsia remains challenging. Noninvasive bedside ultrasound has become an important diagnostic and monitoring tool in critically ill patients, and it has been demonstrated that it can also be used in the monitoring of women with preeclampsia. Echocardiography in combination with lung ultrasound provides information on hemodynamic status, cardiac function, lung congestion, and fluid responsiveness and, therefore, could help clinicians identify women at higher risk of life-threatening complications. This review describes the cardiovascular changes in preeclampsia and provides an overview of the ultrasound methodologies that could be efficiently used for better hemodynamic assessment and management of women with preeclampsia.

Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine

OBJECTIVE

 The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art.

STUDY DESIGN

 AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

RESULTS

 More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life.

CONCLUSION

 Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications.

KEY POINTS

· Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..

NO donors on top of anti-hypertensive therapy reduces complications in chronic hypertensive pregnancies with hypodynamic circulation

OBJECTIVES

Chronic hypertension is associated with significant adverse maternal and fetal outcomes that appear to be often associated to a hypodynamic circulation. Treatment of hypertensive disorders of pregnancy tailored on maternal hemodynamics might reduce or mitigate these complications. Our purpose was to assess the hemodynamic modifications induced by the addition of NO donors and increased oral fluid intake on top of standard antihypertensive therapy in hypodynamic chronic hypertensive patients. We further evaluated if the possible hemodynamic modification induced by NO donors and increased oral fluid intake might be associated to a reduction of the severity and rate of complications vs. patients on antihypertensive standard treatment.

STUDY DESIGN

This was a case-control study of 321 chronic hypertensive patients with a hypodynamic circulation at the echocardiographic evaluation at 24 weeks' gestation. We included 160 controls (standard antihypertensive therapy) and 161 cases (standard therapy + NO donor patches + increased oral fluid intake). Student T test for paired and unpaired data, univariate logistic regression analysis, ROC curve analysis, and Cox Hazards Regression analysis were used as appropriate.

RESULTS

At enrollment the hemodynamic parameters were similar between the two groups. After 3-4 weeks stroke volume (77 ± 19 mL vs. 69 ± 19 mL; p < 0.001), and cardiac output (6.2 ± 1.7 L vs. 5.0 ± 1.6 L; p < 0.001) were higher and total peripheral vascular resistance (1465 ± 469 dyne·s·cm-5 vs. 1814 ± 524 dyne·s·cm-5; p < 0.001) was lower in the cases vs controls. Superimposed preeclampsia, preterm delivery before 34 weeks, abruptio placentae, HELLP Syndrome, fetal growth restriction, and perinatal death were more represented in the standard treatment group vs NO treated patients (81% vs 53%; p < 0.001). In particular, the standard treatment group showed 48% fetal growth restriction vs 34% in the NO treated group (p < 0.011). The Cox proportional-hazards regression showed a lower proportion of event-free pregnancies in controls on standard treatment (HR 2.6; 95% CI 2.0-3.5; p < 0.0001), and a prolongation of pregnancies in CH cases complicated by fetal growth restriction taking NO donors (HR 0.29; 95% CI 0.19-0.43; p = 0.0001).

CONCLUSIONS

The tailored treatment with NO donors and oral fluids of hypodynamic CH might have positive effects on the reduction or mitigations of adverse outcomes.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Cumulative effect of maternal vascular malperfusion types in the placenta on adverse pregnancy outcomes

INTRODUCTION

Placental vascular disease, characterized by Maternal Vascular Malperfusion (MVM) lesions, is considered to be the underlying cause of pregnancy complications. Aim is to evaluate the relationship between the cumulative number of MVM lesion types, and adverse pregnancy- and neonatal outcomes.

METHODS

This retrospective cohort study included 272 women with singleton gestations who gave birth at a Dutch tertiary hospital between 2017 and 2018 with available placental histopathology reports. Analyzed according to the Amsterdam Placental Workshop Group Consensus Statement, placentas were divided into groups based on the cumulative number of MVM lesions: no lesions (n = 124), 1-2 types (n = 124) and 3-5 types of lesions (n = 24).

RESULTS

The proportion of placenta syndrome (PS) was highest (95.8%) in the 3-5 MVM lesions group (p < 0.001). The presence of MVM lesions was highly associated with PS during pregnancy (aOR 6.81, 95% CI 3.76-12.33). Furthermore, every additional type of MVM lesion corresponded with a threefold increased odds for the occurrence of PS (aOR 3.00, 95% CI 2.10-4.29). The group with 3-5 types of MVM lesions showed the highest incidence of adverse neonatal outcomes, lower mean birth weight, prolonged hospitalization, NICU admissions and neonatal deaths (aOR 6.47, 95% CI 0.33-127.68), corresponding with a fourfold increased odds for the occurrence of neonatal death for every additional MVM lesion (aOR 4.19, 95% CI 1.39-12.68).

DISCUSSION

A higher number of MVM lesion types is strongly associated with an increased incidence of adverse pregnancy- and neonatal outcomes, indicating that guidelines should focus also on the amount of MVM lesion types for the monitoring/management of subsequent pregnancies.

Phenotype‐Directed Management of Hypertension in Pregnancy

Hypertensive disorders of pregnancy are among the most serious conditions that pregnancy care providers face; however, little attention has been paid to the concept of tailoring clinical care to reduce associated adverse maternal and perinatal outcomes based on the underlying disease pathogenesis. This narrative review discusses the integration of phenotype‐based clinical strategies in the management of high‐risk pregnant patients that are currently not common clinical practice: real‐time placental growth factor testing at Mount Sinai Hospital, Toronto and noninvasive hemodynamic monitoring to guide antihypertensive therapy at the University of Washington Medical Center, Seattle. Future work should focus on promoting more widespread integration of these novel strategies into obstetric care to improve outcomes of pregnancies at high risk of adverse maternal‐fetal outcomes from these complications of pregnancy.

The evolution of the diagnostic criteria of preeclampsia-eclampsia

As the understanding of the pathophysiology of preeclampsia has improved, its diagnostic criteria have evolved. The classical triad of hypertension, edema, and proteinuria has become hypertension and organ dysfunction-renal, hepatic, neurologic, hematological, or uteroplacental. However, the most recent definitions have largely been based off consensus and expert opinion, not primary research. In this review, we explore how the criteria have evolved, particularly through the second half of the 20^th and the beginning of the 21st century and offer a critical appraisal of the evidence that has led the criteria to where they stand today. Some key themes are the following: the debate between having a simple and convenient blood pressure cutoff vs a blood pressure cutoff that accounts for influencing factors such as age and weight; whether a uniform blood pressure threshold, a rise in blood pressure, or a combination is most discriminatory; whether existing evidence supports blood pressure and proteinuria thresholds in diagnosing preeclampsia; and whether using flow-charts and decision trees might be more appropriate than a single set of criteria. We also discuss the future of a preeclampsia diagnosis. We challenge the move toward a broad (vs restrictive) diagnosis, arguing instead for criteria that directly relate to the prognosis of preeclampsia and the response to treatments.

High-output Cardiac Failure: A Forgotten Phenotype in Clinical Practice

INTRODUCTION

The knowledge on High-Output Cardiac Failure (HOCF) has greatly improved in the last two decades. One of the advances was the identification of a new phenotype of HOCF, characterized by the absence of ventricular dilation, already associated with liver disease, Arteriovenous Fistulas (AVF), lung disease, myelodysplastic syndromes, and obesity. However, it has been noted that any aetiology can present with one of the two phenotypes, depending on the evolution.

OBJECTIVE

The study aims to describe, through an integrative review, the physiopathology and aetiologies of HOCF and to discuss phenotypes associated with this condition.

METHODS

Revisions, guidelines, case-controls, cohort studies and clinical studies were searched in MEDLINE and LILACS, using the connectives in the "cardiac output, high" database (MeSH Terms) OR "high cardiac output" (All Fields).

DISCUSSION

Two distinct phenotypes are currently described in the HOCF, regardless of the aetiology: 1) one with enlarged cardiac chambers; and 2) with normal heart chambers. The mechanisms related to HOCF are vasodilation, arteriovenous shunts that cause increased microvascular density, Reduced Systemic Vascular Resistance (RSVR), and high metabolism. These mechanisms lead to activation of the renin-angiotensin-aldosterone system, sodium and water retention, activation of neprilysin, of the sodium-glucose-2 transporter, which promote interstitial fibrosis, ventricular remodeling and a consequent increase in cardiac output >8L/min.

CONCLUSION

Many aetiologies of HOCF have been described, and some of them are potentially curable. Prompt recognition of this condition and proper treatment may lead to better outcomes.

Pulse pressure as a predictor of response to treatment for severe hypertension in pregnancy

BACKGROUND

Pulse pressure is a proposed means of tailoring antihypertensive therapy for treatment of acute-onset, severe hypertension in pregnancy.

OBJECTIVE

This study aimed to determine whether pulse pressure predicts response to the various first-line antihypertensive medications.

STUDY DESIGN

This is a retrospective cohort study from a single academic tertiary care center between 2015 and 2018. Patients were screened for inclusion if they had severe hypertension (defined as systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg) lasting at least 15 minutes and were initially treated with intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine. If a patient had multiple episodes of acute treatment during the pregnancy, only one episode was included in the analysis. The primary outcome was time to resolution (in minutes) of severe hypertension. To adjust for factors that may have affected time to resolution, we first compared baseline characteristics on the basis of the antihypertensive agent received. We then assessed the association between baseline characteristics and resolution of severe hypertension within 60 minutes of treatment. Regression analysis incorporated pulse pressure and antihypertensive agents into a model to predict resolution within 60 minutes of onset of severe hypertension.

RESULTS

A total of 479 women hospitalized with severe maternal hypertension met the inclusion criteria. Hydralazine was the initial antihypertensive agent administered to 113 women, whereas 233 received labetalol, and 133 received nifedipine. Those who initially received nifedipine had a shorter mean time to resolution of severe hypertension (32.6 minutes vs 46.3 for hydralazine and 50.3 for labetalol; P<.01) and were more likely to have resolution of severe hypertension within 60 minutes (91.0% vs 77.9% for hydralazine and 76.8% for labetalol; P<.01). Nifedipine also resulted in a lower mean posttreatment blood pressure. Regression analysis revealed that a lack of resolution of severe hypertension within 60 minutes was independently associated with 2 measures of hypertension severity (mean arterial pressure of ≥125 mm Hg and the need for ≥2 doses of medication) and pulse pressure of >75 mm Hg at the time of treatment, initial treatment with labetalol, and gestational age of <37 weeks at the time of the hypertensive event (or at delivery if treatment was after delivery). The model's bias-corrected bootstrapped area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.79-0.88). Interaction terms between pulse pressure and each antihypertensive agent were not significant and therefore not incorporated into the final model.

CONCLUSION

Pulse pressure did not predict response to the various first-line antihypertensive agents. Initial treatment with oral nifedipine was associated with a higher likelihood of resolution of severe hypertension within 60 minutes of treatment than with intravenous labetalol.

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

Importance

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

Objective

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

Evidence Acquisition

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

Results

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

Conclusions and Relevance

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

Acute pulmonary edema due to severe preeclampsia in advanced maternal age women

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.

Relative Sinus Bradycardia: An Unexpected Finding in Preeclampsia With Acute Pulmonary Edema

Preeclampsia is a multifactorial pregnancy-specific syndrome, which can result in significant alterations in cardiovascular hemodynamics. We report an observation of unexpected relative bradycardia in a previously healthy woman who presented with postpartum preeclampsia and acute pulmonary edema. We observed an increase in heart rate following normalization of blood pressure, which suggested that the initial slower than expected heart rate may reflect a baroreceptor response to hypertension. Whether this finding should be regarded as a severe aspect of the disease spectrum needs further study.

Pregnancy complications in chronic hypertensive patients are linked to pre-pregnancy maternal cardiac function and structure

BACKGROUND

Chronic hypertension complicates around 3% of all pregnancies and is associated with an increased risk for pregnancy complications such as superimposed preeclampsia, fetal growth restriction, preterm delivery, and stillbirth, reaching a rate of complications of up to 25-28%.

OBJECTIVE

We performed an echocardiographic study to evaluate pre-pregnancy cardiac geometry and function, along with the hemodynamic features of treated chronic hypertension patients, searching for a possible correlation with the development of feto-maternal complications and with pre-pregnancy therapy.

MATERIALS AND METHODS

This was a prospective observational cohort study of 192 consecutive patients receiving treatment for chronic hypertension (calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, α1-adrenoceptor antagonists, and/or diuretics). Patients underwent echocardiography before pregnancy, assessing left ventricular morphology and function, cardiac output, and total vascular resistance. Pre-pregnancy therapy was noted, patients were shifted to α-methyldopa right before pregnancy, and were followed until delivery, noting major early (<34weeks' gestation) and late (≥34 weeks' gestation) complications. Comparisons among the 3 groups (ie, those with no complications, early complications, and late complications) were performed with 1-way analysis of variance with Student-Newman-Keuls correction for multiple comparisons. The Mann-Whitney U test was used for non-normally distributed data. Comparison of proportions was used as appropriate. Receiver operating characteristic curve analysis was used to identify cutoff values of diastolic dysfunction in this population using the E/e' ratio, and separate cutoff of values for total vascular resistance for the prediction of early and late complications of pregnancy. Binary univariate and multivariate logistic regression as well as Cox proportional hazards regression were used to evaluate the possible correlation among angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and/or calcium channel blocker pre-pregnancy therapy, cardiovascular features, and the risk for subsequent early and late complications of pregnancy.

RESULTS

Of 192 patients, 141 had no complications, and 51 had a complicated pregnancy (24 had early complications and 27 had late complications). Concentric geometry was more frequent in those women with early versus late and no complications (50% vs 13.5% and 11.1%, respectively; P < .05), whereas eccentric hypertrophy was more represented in women with late versus early and no complications (32% versus 12.5% and 1.4%, respectively; P < .05). The receiver operating characteristic curve showed an E/e' ratio value >7.65 (sensitivity, 59.6%; specificity, 68.6%) as a predictor of subsequent complications of pregnancy, whereas total vascular resistance <1048 (sensitivity, 83.7%; specificity, 55.6%) was predictive for late complications and total vascular resistance >1498 (sensitivity, 87.5%; specificity, 78.0%) for the early complications of pregnancy. Univariate analysis showed that the following parameters were predictive for complications of pregnancy: altered geometry of the left ventricle (odds ratio, 5.94; 95% confidence interval, 2.90-12.19), diastolic dysfunction (odds ratio, 3.22; 95% confidence interval, 1.63-6.37), altered total vascular resistance (odds ratio, 3.52; 95% confidence interval, 1.78-6.97), and pre-pregnancy therapy without calcium channel blockers/angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (odds ratio, 2.73; 95% confidence interval, 1.37-5.42). These parameters, except for altered total vascular resistance, were independent predictors in the multivariate analysis corrected for body mass index, heart rate, parity, and mean arterial pressure.

CONCLUSION

Chronic hypertension patients with pre-pregnancy cardiac remodeling and dysfunction more often develop early and late complications of pregnancy. Pre-pregnancy therapy for chronic hypertension patients with calcium channel blockers and/or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers may positively influence cardiac profiles and the outcome of a future pregnancy with a reduced rate of complications.

Preeclampsia Is a Syndrome with a Cascade of Pathophysiologic Events

This review integrates the currently available information on the molecular, cellular, and systemic mechanisms involved in the pathophysiology of preeclampsia. It highlights that the growth, protection, and promotion of the conceptus requires the modulation of an intact maternal immune system, communication between the mother and fetus, and adaptation of the maternal organic functions. A malfunction in any of these factors, on either side, will result in a failure of the cascade of events required for the normal course of pregnancy. Maladaptive processes, initially aiming to protect the conceptus, fail to anticipate the gradually increasing cardiovascular volume load during the course of pregnancy. As a result, multiple organ dysfunctions install progressively and eventually reach a state where mother and/or fetus are at risk of severe morbidity or even mortality, and where the termination of pregnancy becomes the least harmful solution. The helicopter view on pathophysiologic processes associated with preeclampsia, as presented in this paper, illustrates that the etiology of preeclampsia cannot be reduced to one single mechanism, but is to be considered a cascade of consecutive events, fundamentally not unique to pregnancy.

Immediate postpartum management of patients with severe hypertensive disorders of pregnancy: pathophysiology guiding practice

Developing clinically-focused evidence and experience-based approaches to improve maternity care is a national priority. Safety and quality collaborative initiatives related to management of hypertensive disorders of pregnancy are vital in the implementation of improved care. We reviewed the obstetric literature to construct a concise summary of the core pathophysiologic issues, practice principles and clinical interventions which are foundational for physicians providing immediate postpartum care for patients with severe pregnancy-related hypertension (including those with eclampsia, HELLP syndrome, and superimposed preeclampsia inclusive of those with gestational hypertension that develop severe range blood pressures). While based largely upon the American College of Obstetrics and Gynecology (ACOG) Hypertension Task Force Guidelines released in 2013 as well as updated 2018 guidelines set forth by ACOG for hypertensive disorders of pregnancy, this summary goes beyond the basic safety bundles for hypertension management and lays a pathophysiologic foundation for the immediate postpartum care of patients with severe hypertensive disorders of pregnancy.

Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms

BACKGROUND

A primary role of maternal heart dysfunction in the pathophysiology of preeclampsia had been previously advocated although if contradictory results have been reported.

OBJECTIVES

The objectives of the study were to describe maternal hemodynamic parameters according to 2 main preeclampsia phenotypes and to investigate whether cardiac findings may be helpful in characterizing the severity and the progression of the disease.

STUDY DESIGN

This was a prospective cohort study. We used an ultrasonic cardiac output monitor system to compare the hemodynamic parameters of women with preeclampsia with a group of healthy normotensive women enrolled as controls with a ratio of 1:2. Cardiac output, systemic vascular resistance, and stroke volume were compared among controls and preeclamptic women who were grouped in accordance to the following characteristics: early preeclampsia (<34 weeks' gestation) vs late preeclampsia onset (≥34 weeks' gestation); preeclampsia associated with appropriate for gestational age or small-for-gestational-age newborns. Hemodynamic characteristics were also compared between preeclamptic women with a mild form vs those who progressed toward a severe form.

RESULTS

A total of 38 preeclamptic women and 61 normotensive women were included in the study. Both cases of preeclampsia associated with small-for-gestational-age neonates as those with normal-sized ones showed higher systemic vascular resistance compared with the control group (respectively, 1580.6 ± 483.2 vs 1479.1 ± 433.3 vs 1105.3 ± 293.1; P < .0001), while a lower cardiac output was reported only for preeclamptic women with small-for-gestational-age neonates compared with controls (5.7 ± 1.5 vs 6.5 ± 1.3; P = .02). Maternal cardiac parameters were comparable between these 2 groups of preeclamptic women (small-for-gestational-age vs appropriate-for-gestational-age preeclampsia) with the exception of a lower stroke volume in the former one (64.8 ± 24.4 vs 75.2 ± 17.8; P = .04). Similarly, women with both early and late preeclampsia showed higher systemic vascular resistance compared with controls (1559.5 ± 528.3 vs 1488.5 ± 292.9 vs 1105.3 ± 293.1, respectively; P < .001), while a lower cardiac output was noted only in the early-onset group compared with controls (5.5 ± 1.2 P = .02). Maternal cardiac findings were similar between women with early vs late-onset preeclampsia. Hemodynamic parameters are significantly different between those women with mild preeclampsia who remained stable compared with those who progressed toward a severe disease. Cardiac output Z-score, systemic vascular resistance Z-score, and uterine arteries' pulsatility index Z-score showed similar sensitivity (80% vs 75% vs 80%, respectively) and specificity (73% vs. 73% vs 74%, respectively), while the association of systemic vascular resistance Z-score and uterine arteries pulsatility index Z-score showed a sensitivity of 95% and a specificity of 80% (area under the curve, 0.90) in predicting evolution toward severe forms.

CONCLUSION

Evaluation of maternal cardiovascular system could help clinician in defining a subset of preeclamptic patients with more profound placental impairment and might predict the likelihood of progression toward a severe condition in cases with a mild preeclampsia at clinical onset.

Development of a biophysical screening model for gestational hypertensive diseases

Background

To investigate the possibility of using maternal biophysical parameters only in screening for the different types of gestational hypertensive diseases.

Methods

A total of 969 pregnant women were randomly screened in first and second trimester, of which 8 developed Early-onset Preeclampsia, 29 Late-onset Preeclampsia, 35 Gestational Hypertension and 897 women had a normal outcome. An observational maternal hemodynamics assessment was done via standardized electrocardiogram-Doppler ultrasonography, Impedance Cardiography and bio-impedance, acquiring functional information on heart, arteries, veins and body fluid. Preliminary prediction models were developed to test the screening potential for early preeclampsia, late preeclampsia and gestational hypertension using a Partial Least Square Discriminant Analysis.

Results

A combined model using maternal characteristics with cardiovascular parameters in first and second trimester offers high screening performance with Area Under the Curve of 99,9% for Early-onset Preeclampsia, 95,3% for Late-onset Preeclampsia and 94% for Gestational Hypertension.

Conclusions

Using biophysical parameters as fundament for a new prediction model, without the need of biochemical parameters, seems feasible. However, validation in a large prospective study will reveal its true potential.

Accuracy and precision of USCOM versus transthoracic echocardiography before and during pregnancy

OBJECTIVE

Monitoring hemodynamic status throughout pregnancy may help in identifying women with maladaptation predisposing to hypertensive complications. The Ultrasonic Cardiac Output Monitor (USCOM) is an easy-to-operate device for measuring cardiac output (CO) quickly. Our aim was to assess agreement between USCOM and transthoracic echocardiography (TTE) in: 1) non-pregnant women to correct for possible sources of discrepancy; 2) women longitudinally over the course of the pregnancy.

STUDY DESIGN

High-risk women admitted for cardiovascular risk factor evaluation before pregnancy and multiple times during pregnancy, were included. CO was measured by TTE directly followed by USCOM measurements.

MAIN OUTCOME MEASURES

Bias, limits of agreement (LOA) and percentage error between the two methods by Bland-Altman analysis.

RESULTS

Despite comparable non-pregnant CO levels (4.6 L/min), LOA and percentage error between the two methods improved moderately by optimizing the measurements using only the highest quality USCOM recordings in 132 non-pregnant women (percentage error of 39% and 30%, respectively). During pregnancy, in total 83, 106, 96 and 77 measurements were evaluated at respectively 12, 16, 20 and 30 weeks gestational age. Mean CO in USCOM was about 0.6 L/min higher compared to TTE in all trimesters; percentage error ranged from 35% to 45%. Linear mixed model analysis showed no association between bias and moment of measurement.

CONCLUSION

Agreement between USCOM and TTE in pregnancy was outside our a priori determined level of acceptability and therefore absolute values of USCOM and TTE cannot be used interchangeably. Future research should focus on the agreement of USCOM and TTE in clinical decision-making.

Investigation of elevation as a risk factor for hypertensive disorders of pregnancy among Colorado women between 2007 and 2015

OBJECTIVE

The purpose of this study is to determine the association between high elevation and hypertensive disorders of pregnancy (HDP).

METHODS

Retrospective cohort study using Colorado birth certificate data to compare HDP at high (≥8,000 ft), moderate (4,501-7,999 ft), or low (≤4,500 ft) elevation using logistic regression.

RESULTS

Among the cohort (n = 314,431), 3.4% of women developed a HDP. High or moderate elevation was not significantly associated with HDP relative to low elevation (adjusted odds ratio [aOR] 1.16, 95% confidence interval [CI] 0.93-1.43; aOR 1.14, 95% CI 0.98-1.31, respectively).

CONCLUSION

Women living at high or moderate elevation do not have higher odds of HDP.

Mitochondrial DNA Copy Number in Peripheral Blood in the First Trimester of Pregnancy and Different Preeclampsia Clinical Phenotypes Development: A Pilot Study

Inflammation and oxidative stress are intrinsically linked to early poor placentation, typical of pregnancies complicated by preeclampsia associated with intrauterine growth restriction (PE-IUGR). Low mitochondrial DNA copy number (mtDNAcn) in peripheral blood constitutes a good peripheral surrogate marker of inflammation and oxidative stress. On these basis, we explored a possible correlation between mtDNAcn in peripheral blood in the first trimester of pregnancy and the PE-IUGR onset. To shed light on this issue, we setup a nested case-control study from a prospective cohort of pregnant women undergoing first-trimester aneuploidies screening. Two groups of patients affected by PE classified according to the clinical phenotype were identified: (1) patients who developed PE-IUGR and (2) patients who developed PE associated with appropriate for gestational age intrauterine fetal growth (PE-AGAf). Controls were women with a physiologic pregnancy matched to cases on the basis of age (±6 months, ratio 2:1). Mitochondrial DNA copy number was quantified using real-time polymerase chain reaction and normalized to nuclear DNA. The median (interquartile range) mtDNAcn in peripheral blood in patients with PE-IUGR (n = 12) and in patients with PE-AGAf (n = 16) was 70 (44-97) and 108 (95-145), respectively (P = .004). Both these values were significantly lower than that detected in the control group (161[133-183], P < .001). The area under the receiver-operator curve for PE-IUGR and PE-AGAf were 0.94 (95% confidence interval [CI]: 0.88-1.00, P < .001) and 0.81 (95%CI: 0.70-0.91, P < .001), respectively. In conclusion, MtDNAcn in peripheral blood resulted significantly lower both in patients affected by PE-IUGR and in those affected by PE-AGAf when compared to controls. The accuracy of this biomarker resulted particularly good in predicting PE-IUGR.

MicroRNA-132 controls water homeostasis through regulating MECP2-mediated vasopressin synthesis

Fine-tuning of the body’s water balance is regulated by vasopressin (AVP), which induces the expression and apical membrane insertion of aquaporin-2 water channels and subsequent water reabsorption in the kidney. Here we demonstrate that silencing of microRNA-132 (miR-132) in mice causes severe weight loss due to acute diuresis coinciding with increased plasma osmolality, reduced renal total and plasma membrane expression of aquaporin-2, and abrogated increase in AVP levels. Infusion with synthetic AVP fully reversed the antagomir-132-induced diuresis, and low-dose intracerebroventricular administration of antagomir-132 similarly caused acute diuresis. Central and intracerebroventricular antagomir-132 injection both decreased hypothalamic AVP mRNA levels. At the molecular level, antagomir-132 increased the in vivo and in vitro mRNA expression of methyl-CpG-binding protein-2 (MECP2), which is a miR-132 target and which blocks AVP gene expression by binding its enhancer region. In line with this, treatment of hypothalamic N6 cells with a high-salt solution increased its miR-132 levels, whereas it attenuated endogenous Mecp2 mRNA levels. In conclusion, we identified miR-132 as a first miRNA regulating the osmotic balance by regulating the hypothalamic AVP gene mRNA expression.

Effects of compound Danshen injection combined with magnesium sulfate on serum MPO and hs-CRP in patients with severe preeclampsia

Effects of compound Danshen injection combined with magnesium sulfate on serum myeloperoxidase (MPO) and hypersensitive C-reactive protein (hs-CRP) in patients with severe preeclampsia (PE) were investigated. Five hundred patients with severe PE were randomly divided into early-onset observation, early-onset control, late-onset observation and late-onset control groups. Control group was treated with magnesium sulfate, while patients in observation group were treated with magnesium sulfate combined with compound Danshen injection. Serum levels of MPO and hs-CRP were measured by enzyme-linked immunosorbent assay (ELISA) and turbidimetric assay. The effects of compound Danshen injection combined with magnesium sulfate on the above indexes were observed. Serum levels of MPO and hs-CRP significantly decreased in early-onset observation, late-onset observation, early-onset control and late-onset control groups after treatment (p<0.05). After treatment, levels of MPO and hs-CRP were significantly lower in early-onset observation group than in early-onset control group (p<0.05), and levels of MPO and hs-CRP were also significantly lower in late-onset observation group than in late-onset control group (p<0.05). Total effective rate of early-onset observation group and late-onset observation group were higher than that of early-onset control group and late-onset control group. Compound Danshen injection combined with magnesium sulfate achieved better treatment outcomes in the treatment of severe PE than magnesium sulfate alone. The combined treatment can effectively reduce the serum levels of MPO and hs-CRP.

Modeling Superimposed Preeclampsia Using Ang II (Angiotensin II) Infusion in Pregnant Stroke-Prone Spontaneously Hypertensive Rats

Hypertensive disorders of pregnancy are the second leading cause of maternal deaths worldwide. Superimposed preeclampsia is an increasingly common problem and often associated with impaired placental perfusion. Understanding the underlying mechanisms and developing treatment options are crucial. The pregnant stroke-prone spontaneously hypertensive rat has impaired uteroplacental blood flow and abnormal uterine artery remodeling. We used Ang II (angiotensin II) infusion in pregnant stroke-prone spontaneously hypertensive rats to mimic the increased cardiovascular stress associated with superimposed preeclampsia and examine the impact on the maternal cardiovascular system and fetal development. Continuous infusion of Ang II at 500 or 1000 ng/kg per minute was administered from gestational day 10.5 until term. Radiotelemetry and echocardiography were used to monitor hemodynamic and cardiovascular changes, and urine was collected prepregnancy and throughout gestation. Uterine artery myography assessed uteroplacental vascular function and structure. Fetal measurements were made at gestational day 18.5, and placentas were collected for histological and gene expression analyses. The 1000 ng/kg per minute Ang II treatment significantly increased blood pressure (P<0.01), reduced cardiac output (P<0.05), and reduced diameter and increased stiffness of the uterine arteries (P<0.01) during pregnancy. The albumin:creatinine ratio was increased in both Ang II treatment groups (P<0.05; P<0.0001). The 1000 ng/kg per minute-treated fetuses were significantly smaller than vehicle treatment (P<0.001). Placental expression of Ang II receptors was increased in the junctional zone in 1000 ng/kg per minute Ang II-treated groups (P<0.05), with this zone showing depletion of glycogen content and structural abnormalities. Ang II infusion in pregnant stroke-prone spontaneously hypertensive rats mirrors hemodynamic, cardiac, and urinary profiles observed in preeclamptic women, with evidence of impaired fetal growth.

Maternal hemodynamics: a method to classify hypertensive disorders of pregnancy

BACKGROUND

The classification of hypertensive disorders of pregnancy is based on the time at the onset of hypertension, proteinuria, and other associated complications. Maternal hemodynamic interrogation in hypertensive disorders of pregnancy considers not only the peripheral blood pressure but also the entire cardiovascular system, and it might help to classify the different clinical phenotypes of this syndrome.

OBJECTIVE

This study aimed to examine cardiovascular parameters in a cohort of patients affected by hypertensive disorders of pregnancy according to the clinical phenotypes that prioritize fetoplacental characteristics and not the time at onset of hypertensive disorders of pregnancy.

STUDY DESIGN

At the fetal-maternal medicine unit of Ziekenhuis Oost-Limburg (Genk, Belgium), maternal cardiovascular parameters were obtained through impedance cardiography using a noninvasive continuous cardiac output monitor with the patients placed in a standing position. The patients were classified as pregnant women with hypertensive disorders of pregnancy who delivered appropriate- and small-for-gestational-age fetuses. Normotensive pregnant women with an appropriate-for-gestational-age fetus at delivery were enrolled as the control group. The possible impact of obesity (body mass index ≥30 kg/m²) on maternal hemodynamics was reassessed in the same groups.

RESULTS

Maternal age, parity, body mass index, and blood pressure were not significantly different between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and hypertensive disorders of pregnancy/small-for-gestational-age groups. The mean uterine artery pulsatility index was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group. The cardiac output and cardiac index were significantly lower in the hypertensive disorders of pregnancy/small-for-gestational-age group (cardiac output 6.5 L/min, cardiac index 3.6) than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group (cardiac output 7.6 L/min, cardiac index 3.9) but not between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and control groups (cardiac output 7.6 L/min, cardiac index 4.0). Total vascular resistance was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group and the control group. All women with hypertensive disorders of pregnancy showed signs of central arterial dysfunction. The cardiovascular parameters were not influenced by gestational age at the onset of hypertensive disorders of pregnancy, and no difference was observed between the women with appropriate-for-gestational-age fetuses affected by preeclampsia or by gestational hypertension with appropriate-for-gestational-age fetuses. Women in the obese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and obese/hypertensive disorders of pregnancy/small-for-gestational-age groups showed a significant increase in cardiac output, as well as significant changes in other parameters, compared with the nonobese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and nonobese/hypertensive disorders of pregnancy/small-for-gestational-age groups.

CONCLUSION

Significantly low cardiac output and high total vascular resistance characterized the women with hypertensive disorders of pregnancy associated with small for gestational age due to placental insufficiency, independent of the gestational age at the onset of hypertension. The cardiovascular parameters were not significantly different in the women with appropriate-for-gestational-age or small-for-gestational-age fetuses affected by preeclampsia or gestational hypertension. These findings support the view that maternal hemodynamics may be a candidate diagnostic tool to identify hypertensive disorders in pregnancies associated with small-for-gestational-age fetuses. This additional tool matches other reported evidence provided by uterine Doppler velocimetry, low vascular growth factors in the first trimester, and placental pathology. Obesity is associated with a significantly higher cardiac output and outweighs other determinants of hemodynamics in pregnancy; therefore, in future studies on hypertensive disorders, obesity should be studied as an additional disease and not simply as a demographic characteristic.