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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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Kantorowska A, Corbo AM, Akerman MB, Gubernikoff G, Kinzler WL, Vintzileos AM, Rekawek P. The value of maternal echocardiography after delivery in patients with severe preeclampsia. Am J Obstet Gynecol 2024:S0002-9378(24)00450-2. [PMID: 38522717 DOI: 10.1016/j.ajog.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Affiliation(s)
- Agata Kantorowska
- Department of Obstetrics and Gynecology, NYU Langone Hospital-Long Island, NYU Grossman Long Island School of Medicine, 259 1st St., Mineola, NY 11501.
| | - Anthony Marco Corbo
- Department of Obstetrics and Gynecology, Lancaster General Health System-Penn Medicine, Lancaster, PA
| | - Meredith B Akerman
- Division of Health Services Research, Department of Foundations of Medicine, NYU Grossman Long Island School of Medicine, Mineola, NY
| | - George Gubernikoff
- Department of Cardiology, NYU Langone Hospital-Long Island, NYU Grossman Long Island School of Medicine, Mineola, NY
| | - Wendy L Kinzler
- Department of Obstetrics and Gynecology, NYU Langone Hospital-Long Island, NYU Grossman Long Island School of Medicine, Mineola, NY
| | - Anthony M Vintzileos
- Department of Obstetrics and Gynecology, Lenox Hill Hospital Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Patricia Rekawek
- Department of Obstetrics and Gynecology, NYU Langone Hospital-Long Island, NYU Grossman Long Island School of Medicine, Mineola, NY
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Casey H, Dennehy N, Fraser A, Lees C, McEniery C, Scott K, Wilkinson I, Delles C. Placental syndromes and maternal cardiovascular health. Clin Sci (Lond) 2023; 137:1211-1224. [PMID: 37606085 PMCID: PMC10447226 DOI: 10.1042/cs20211130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 07/16/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023]
Abstract
The placental syndromes gestational hypertension, preeclampsia and intrauterine growth restriction are associated with an increased cardiovascular risk to the mother later in life. In this review, we argue that a woman's pre-conception cardiovascular health drives both the development of placental syndromes and long-term cardiovascular risk but acknowledge that placental syndromes can also contribute to future cardiovascular risk independent of pre-conception health. We describe how preclinical studies in models of preeclampsia inform our understanding of the links with later cardiovascular disease, and how current pre-pregnancy studies may explain relative contributions of both pre-conception factors and the occurrence of placental syndromes to long-term cardiovascular disease.
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Affiliation(s)
- Helen Casey
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
| | - Natalie Dennehy
- Chelsea and Westminster NHS Foundation Trust, London, England, U.K
| | - Abigail Fraser
- Department of Population Health Sciences, Bristol Medical School, and the MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, U.K
| | - Christoph Lees
- Chelsea and Westminster NHS Foundation Trust, London, England, U.K
| | - Carmel M. McEniery
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, U.K
| | - Kayley Scott
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
| | - Ian B. Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, England, U.K
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, U.K
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Chaiworapongsa T, Romero R, Gotsch F, Suksai M, Gallo DM, Jung E, Krieger A, Chaemsaithong P, Erez O, Tarca AL. Preeclampsia at term can be classified into 2 clusters with different clinical characteristics and outcomes based on angiogenic biomarkers in maternal blood. Am J Obstet Gynecol 2023; 228:569.e1-569.e24. [PMID: 36336082 PMCID: PMC10149598 DOI: 10.1016/j.ajog.2022.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND An antiangiogenic state has emerged as a mechanism of disease in preeclampsia. Angiogenic biomarkers are used in the risk assessment of this syndrome, particularly of early disease. The role of an antiangiogenic state in late preeclampsia is unclear. OBJECTIVE This study aimed to determine the prevalence, characteristics, and clinical significance of angiogenic/antiangiogenic factor abnormalities in women with preeclampsia stratified according to gestational age at delivery. STUDY DESIGN Two studies were conducted: (1) a longitudinal nested case-control study comprising women with preeclampsia (n=151) and a control group (n=540); and (2) a case series of patients with preeclampsia (n=452). In patients with preeclampsia, blood was collected at the time of diagnosis. Plasma concentrations of placental growth factor and soluble fms-like tyrosine kinase-1 were determined by enzyme-linked immunosorbent assays. An abnormal angiogenic profile was defined as a plasma ratio of placental growth factor and soluble fms-like tyrosine kinase-1 expressed as a multiple of the median <10th percentile for gestational age based on values derived from the longitudinal study. The proportion of patients diagnosed with preeclampsia who had an abnormal angiogenic profile was determined in the case-series participants and stratified by gestational age at delivery into early (≤34 weeks), intermediate (34.1-36.9 weeks), and term (≥37 weeks) preeclampsia. The demographics, clinical characteristics, and pregnancy outcomes of women with preeclampsia with and without an abnormal angiogenic profile were compared. RESULTS The prevalence of an abnormal angiogenic profile was higher in preterm than in term preeclampsia (for early, intermediate, and term in the case-control study: 90%, 100%, and 39%; for the case series: 98%, 80%, and 55%, respectively). Women with preeclampsia at term who had an abnormal angiogenic profile were more frequently nulliparous (57% vs 35%), less likely to smoke (14% vs 26%), at greater risk for maternal (14% vs 5%) or neonatal (7% vs 1%) complications, and more often had placental lesions consistent with maternal vascular malperfusion (42% vs 23%; all, P<.05) than those without an abnormal profile. Women with preeclampsia at term who had a normal angiogenic profile had a higher frequency of chronic hypertension (36% vs 21%) and were more likely to have class ≥2 obesity (41% vs 23%) than those with an abnormal profile (both, P<.05). CONCLUSION Patients with early preeclampsia had an abnormal angiogenic profile in virtually all cases, whereas only 50% of women with preeclampsia at term had such abnormalities. The profile of angiogenic biomarkers can be used to classify patients with preeclampsia at term, on the basis of mechanisms of disease, into 2 clusters, which have different demographics, clinical characteristics, and risks of adverse maternal and neonatal outcomes. These findings provide a simple approach to classify preeclampsia at term and have implications for future clinical care and research.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI.
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI.
| | - Francesca Gotsch
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Manaphat Suksai
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dahiana M Gallo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Eunjung Jung
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Arthur Krieger
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Obstetrics and Gynecology, HaEmek Medical Center, Afula, Israel
| | - Adi L Tarca
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI; Department of Computer Science, Wayne State University College of Engineering, Detroit, MI
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5
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Villalaín González C, Herraiz García I, Fernández-Friera L, Ruiz-Hurtado G, Morales E, Solís J, Galindo A. Cardiovascular and renal health: Preeclampsia as a risk marker. Nefrologia 2023; 43:269-280. [PMID: 37635012 DOI: 10.1016/j.nefroe.2022.04.009] [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: 02/07/2022] [Accepted: 04/24/2022] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies. MATERIALS AND METHODS Review of PE and its association with future development of CVD and CKD. RESULTS Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage. CONCLUSIONS The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.
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Affiliation(s)
- Cecilia Villalaín González
- Unidad de Medicina Fetal, Servicio de Obstetricia y Ginecología, Departamento de Salud Pública y Materno-Infantil, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación del Hospital 12 de Octubre (imas12), Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Instituto de Salud Carlos III, Madrid, Spain
| | - Ignacio Herraiz García
- Unidad de Medicina Fetal, Servicio de Obstetricia y Ginecología, Departamento de Salud Pública y Materno-Infantil, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación del Hospital 12 de Octubre (imas12), Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Instituto de Salud Carlos III, Madrid, Spain
| | - Leticia Fernández-Friera
- Hospital Universitario HM Montepríncipe-CIEC, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Gema Ruiz-Hurtado
- Instituto de Investigación del Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Enrique Morales
- Instituto de Investigación del Hospital 12 de Octubre (imas12), Madrid, Spain; Servicio de Nefrología, Departamento de Medicina, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain.
| | - Jorge Solís
- Instituto de Investigación del Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Hospital Universitario 12 de Octubre, Madrid, Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Alberto Galindo
- Unidad de Medicina Fetal, Servicio de Obstetricia y Ginecología, Departamento de Salud Pública y Materno-Infantil, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación del Hospital 12 de Octubre (imas12), Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Instituto de Salud Carlos III, Madrid, Spain
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Sedaghati F, Gleason RL. A mathematical model of vascular and hemodynamics changes in early and late forms of preeclampsia. Physiol Rep 2023; 11:e15661. [PMID: 37186372 PMCID: PMC10132946 DOI: 10.14814/phy2.15661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 05/17/2023] Open
Abstract
Preeclampsia-eclampsia syndrome is a leading cause of maternal mortality. The precise etiology of preeclampsia is still not well-defined and different forms exist, including early and late forms or preeclampsia, which may arise via distinctly different mechanisms. Low-dose aspirin administered at the end of the first trimester in women identified as high risk has been shown to reduce the incidence of early, but not late, preeclampsia; however, current risk factors show only fair predictive capability. There is a pressing need to develop accurate descriptions for the different forms of preeclampsia. This paper presents 1D fluid, solid, growth, and remodeling models for pregnancies complicated with early and late forms of preeclampsia. Simulations affirm a broad set of literature results that early forms of preeclampsia are characterized by elevated uterine artery pulsatility index (UA-PI) and total peripheral resistance (TPR) and lower cardiac output (CO), with modestly increased mean arterial blood pressure (MAP) in the first half of pregnancy, with elevation of TPR and MAP beginning at 20 weeks. Conversely, late forms of preeclampsia are characterized by only slightly elevated UA-PI and normal pre-term TPR, and slightly elevated MAP and CO throughout pregnancy, with increased TPR and MAP beginning after 34 weeks. Results suggest that preexisting arterial stiffness may be elevated in women that develop both early forms and late forms of preeclampsia; however, data that verify these results are lacking in the literature. Pulse wave velocity increases in early- and late-preeclampsia, coincident with increases in blood pressure; however, these increases are mainly due to the strain-stiffening response of larger arteries, rather than arterial remodeling-derived changes in material properties. These simulations affirm that early forms of preeclampsia may be associated with abnormal placentation, whereas late forms may be more closely associated with preexisting maternal cardiovascular factors; simulations also highlight several critical gaps in available data.
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Affiliation(s)
- Farbod Sedaghati
- The George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
| | - Rudolph L. Gleason
- The George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
- The Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
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7
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Di Martino DD, Stampalija T, Zullino S, Fusè F, Garbin M, Parasiliti M, Sterpi V, Farina A, Ferrazzi E. Maternal hemodynamic profile during pregnancy and in the post-partum in hypertensive disorders of pregnancy and fetal growth restriction. Am J Obstet Gynecol MFM 2023; 5:100841. [PMID: 36563878 DOI: 10.1016/j.ajogmf.2022.100841] [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: 11/17/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy (Dr Stampalija); Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy (Dr Stampalija)
| | - Sara Zullino
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Dr Zullino).
| | - Federica Fusè
- Department of Obstetrics and Gynecology, University of Milan, Hospital Luigi Sacco, Milan, Italy (Dr Fusè)
| | - Massimo Garbin
- Unit of Cardiology, Vittore Buzzi Children's Hospital, Milan, Italy (Dr Garbin)
| | - Marco Parasiliti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Vittoria Sterpi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery, IRCCS Sant'Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy (Dr Farina)
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (Dr Ferrazzi)
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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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Hernandez TL, Rozance PJ. Re-examination of the estimated average requirement for carbohydrate intake during pregnancy: Addition of placental glucose consumption. Am J Clin Nutr 2023; 117:227-234. [PMID: 36811561 PMCID: PMC10196558 DOI: 10.1016/j.ajcnut.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 12/23/2022] Open
Abstract
Evidence-based dietary reference intakes for nutrients in healthy individuals were last set in 2005 by the Institute of Medicine. For the first time, these recommendations included a guideline for carbohydrate intake during pregnancy. The recommended dietary allowance (RDA) was set at ≥175 g/d or 45%-65% of total energy intake. In the decades since, carbohydrate intake has been declining in some populations, and many pregnant women consume carbohydrates below the RDA. The RDA was developed to account for both maternal brain and fetal brain glucose requirements. However, the placenta also requires glucose as its dominant energy substrate and is as dependent on maternal glucose as the brain. Prompted by the availability of evidence demonstrating the rate and quantity of human placental glucose consumption, we calculated a potential new estimated average requirement (EAR) for carbohydrate intake to account for placental glucose consumption. Further, by narrative review, we have re-examined the original RDA by applying contemporary measurements of adult brain and whole-body fetal glucose consumption. We also propose, using physiologic rationale, that placental glucose consumption be included in pregnancy nutrition considerations. Calculated from human in vivo placental glucose consumption data, we suggest that 36 g/d represents an EAR for adequate glucose to support placental metabolism without supplementation by other fuels. A potential new EAR of 171 g/d accounts for maternal (100 g) and fetal (35 g) brain, and now placental glucose utilization (36 g), and with extrapolation to meet the needs of nearly all healthy pregnant women, would result in a modified RDA of 220 g/d. Lower and upper safety thresholds for carbohydrate intake remain to be determined, of importance as preexisting and gestational diabetes continue to rise globally, and nutrition therapy remains the cornerstone of treatment.
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Affiliation(s)
- Teri L Hernandez
- College of Nursing, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA; Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA.
| | - Paul J Rozance
- Department of Pediatrics, Perinatal Research Center, University of Colorado School of Medicine, Aurora, CO, USA
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Assessing maternal cardiac function by obstetricians: technique and reference ranges. Am J Obstet Gynecol 2023:S0002-9378(23)00006-6. [PMID: 36627073 DOI: 10.1016/j.ajog.2023.01.003] [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: 11/30/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND A strong body of evidence has now coalesced indicating that some obstetrical syndromes may result from maladaptive responses of the maternal cardiovascular system. Longitudinal studies have shown that these changes are complex and present before the clinical recognition of preeclampsia and fetal growth restriction, suggesting that hemodynamic maladaptation may play an etiologic role in obstetrical complications. Chronic hypertension is one of the most frequent complications of pregnancy, and recent evidence suggests that control of mild hypertension in early pregnancy improves outcome. The management of chronic hypertension can be improved by understanding specific cardiovascular hemodynamic abnormalities such as increased cardiac output or increased systemic vascular resistance, which can respond to either beta or calcium channel blockers, depending on the hemodynamic findings. Evaluation of maternal cardiac function has not been previously available to obstetrical healthcare providers using diagnostic ultrasound equipment used for fetal evaluation. OBJECTIVE Obstetrical ultrasound machines may be configured for various probes (endovaginal, abdominal, 3D/4D, and cardiac). This study used a cardiac probe placed in the suprasternal notch to image and measure the descending aorta diameter and the velocity time integral using pulsed and continuous wave Doppler ultrasound in normal pregnant women between 11 and 39 weeks of gestation. These measurements were followed by computation of maternal left ventricular preload, afterload, contractility, and blood flow. STUDY DESIGN This was a prospective cross-sectional study. A total of 400 pregnant women were recruited between 11 and 39 weeks of gestation. Imaging of the maternal aortic arch was performed by placing a cardiac probe in the suprasternal notch to identify the aortic arch using 2D and color Doppler ultrasound. The end-systolic diameter of the aorta was measured at the junction of the left subclavian artery with the descending aorta, which was followed by insonation of the descending aorta to obtain the Doppler waveform. Following insonation of the descending aorta, measurements of the aortic diameter, velocity time integral, ejection time, mean pressure gradient, heart rate, maternal weight and height, and systolic and diastolic blood pressures were entered into an Excel spreadsheet to compute the following: (1) preload measurements of stroke volume, stroke volume index, and stroke work index; (2) afterload measurements of systemic vascular resistance and the potential-to-kinetic energy ratio; (3) contractility measurements of inotropy and the Smith-Madigan inotropy index; and (4) blood flow measurements of cardiac output and the cardiac output index. Fractional polynomial regression analysis was performed for each of the above measurements using gestational age as the independent variable. RESULTS The diastolic and mean arterial blood pressure decreased from 11 to 18 weeks of gestation and then increased until term. The afterload measurements demonstrated similar characteristics, as all values decreased from 11 weeks until the mid and late second trimester, after which all values increased until term. Changes in contractility demonstrated an increase from 11 weeks to 25 to 28 weeks, followed by a decline until term. Changes in blood flow demonstrated an increase from 11 to 27 weeks and then declined until term. The continuous wave Doppler values were greater than the pulsed Doppler values except for the contractility measurements. Examples of abnormal cardiac measurements were identified in pregnant patients with hypertension and fetal growth restriction. An Excel calculator was created to provide quick computation of z-score measurements and their corresponding centiles described in this study. CONCLUSION The technique for evaluation of maternal cardiac function described in this study would allow screening of maternal left ventricular preload, afterload, contractility, and blood flow in the obstetrical clinical milieu once a cardiac probe is acquired for obstetrical ultrasound machines used for fetal evaluation. The above measurements would allow the clinician to select appropriate hypertensive medication on the basis of the results of the evaluation of the maternal left ventricle.
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Ziganshina MM, Muminova KT, Khasbiullina NR, Khodzhaeva ZS, Yarotskaya EL, Sukhikh GT. Characterization of Vascular Patterns Associated with Endothelial Glycocalyx Damage in Early- and Late-Onset Preeclampsia. Biomedicines 2022; 10:2790. [PMID: 36359309 PMCID: PMC9687171 DOI: 10.3390/biomedicines10112790] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/21/2022] [Accepted: 10/28/2022] [Indexed: 11/15/2023] Open
Abstract
This paper provides an assessment of molecular and functional changes in blood vessels, and a description of vascular patterns during preeclampsia (PE). Patients with normal pregnancy, and pregnancy complicated by PE at earlier (20-34 weeks) and later terms (≥34 weeks) underwent a 24 h monitoring of blood pressure, central hemodynamics, arterial stiffness, and myocardial function. The blood levels of the structural components of endothelial glycocalyx (eGC): syndecan-1 (SDC 1), heparan sulfate proteoglycan 2 (HSPG2), and hyaluronic acid (HA) were determined. In early-onset PE, the vascular pattern comprised changes in all structural components of eGCs, including transmembrane proteoglycans levels, and severe disorders of central hemodynamics, arterial stiffness, and myocardial changes, probably leading to more severe course of PE and the formation of morphological grounds for cardiovascular disorders. The vascular pattern in late-onset PE, including changes in HA levels, central hemodynamics, and myocardial function, may be a signal of potential cardiovascular disorder. PE may change adaptive hemodynamic responses to a pathological reaction affecting both arterial elasticity and the left ventricular myocardium, with its subsequent hypertrophy and decompensation, leading to a delayed development of cardiovascular disorders after PE. Further clinical studies of these indicators will possibly identify predictors of PE and long-term consequences of the disease.
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Affiliation(s)
- Marina M. Ziganshina
- National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Oparina Street 4, Moscow 117997, Russia
| | - Kamilla T. Muminova
- National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Oparina Street 4, Moscow 117997, Russia
| | - Nailia R. Khasbiullina
- National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Oparina Street 4, Moscow 117997, Russia
| | - Zulfiya S. Khodzhaeva
- National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Oparina Street 4, Moscow 117997, Russia
| | - Ekaterina L. Yarotskaya
- National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Oparina Street 4, Moscow 117997, Russia
| | - Gennady T. Sukhikh
- National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Oparina Street 4, Moscow 117997, Russia
- Department of Obstetrics, Gynecology, Perinatology and Reproductology, Institute of Professional Education, I.M. Sechenov First Moscow State Medical University, Trubetskaya Street 8-2, Moscow 119991, Russia
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12
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Zhang X, Xu Q, Yang L, Sun G, Liu G, Lian C, Li Z, Hao D, Yang Y, Li X. Dynamic risk prediction models for different subtypes of hypertensive disorders in pregnancy. Front Surg 2022; 9:1005974. [DOI: 10.3389/fsurg.2022.1005974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022] Open
Abstract
BackgroundHypertensive disorders in pregnancy (HDP) are diseases that coexist with pregnancy and hypertension. The pathogenesis of this disease is complex, and different physiological and pathological states can develop different subtypes of HDP.ObjectiveTo investigate the predictive effects of different variable selection and modeling methods on four HDP subtypes: gestational hypertension, early-onset preeclampsia, late-onset preeclampsia, and chronic hypertension complicated with preeclampsia.MethodsThis research was a retrospective study of pregnant women who attended antenatal care and labored at Beijing Maternity Hospital, Beijing Haidian District Maternal and Child Health Hospital, and Peking University People's Hospital. We extracted maternal demographic data and clinical characteristics for risk factor analysis and included gestational week as a parameter in this study. Finally, we developed a dynamic prediction model for HDP subtypes by nonlinear regression, support vector machine, stepwise regression, and Lasso regression methods.ResultsThe AUCs of the Lasso regression dynamic prediction model for each subtype were 0.910, 0.962, 0.859, and 0.955, respectively. The AUC of the Lasso regression dynamic prediction model was higher than those of the other three prediction models. The accuracy of the Lasso regression dynamic prediction model was above 85%, and the highest was close to 92%. For the four subgroups, the Lasso regression dynamic prediction model had the best comprehensive performance in clinical application. The placental growth factor was tested significant (P < 0.05) only in the stepwise regression dynamic prediction model for early-onset preeclampsia.ConclusionThe Lasso regression dynamic prediction model could accurately predict the risk of four HDP subtypes, which provided the appropriate guidance and basis for targeted prevention of adverse outcomes and improved clinical care.
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Yin A, Guan X, Zhang JV, Niu J. Focusing on the role of secretin/adhesion (Class B) G protein-coupled receptors in placental development and preeclampsia. Front Cell Dev Biol 2022; 10:959239. [PMID: 36187484 PMCID: PMC9515905 DOI: 10.3389/fcell.2022.959239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Preeclampsia, a clinical syndrome mainly characterized by hypertension and proteinuria, with a worldwide incidence of 3–8% and high maternal mortality, is a risk factor highly associated with maternal and offspring cardiovascular disease. However, the etiology and pathogenesis of preeclampsia are complicated and have not been fully elucidated. Obesity, immunological diseases and endocrine metabolic diseases are high-risk factors for the development of preeclampsia. Effective methods to treat preeclampsia are lacking, and termination of pregnancy remains the only curative treatment for preeclampsia. The pathogenesis of preeclampsia include poor placentation, uteroplacental malperfusion, oxidative stress, endoplasmic reticulum stress, dysregulated immune tolerance, vascular inflammation and endothelial cell dysfunction. The notion that placenta is the core factor in the pathogenesis of preeclampsia is still prevailing. G protein-coupled receptors, the largest family of membrane proteins in eukaryotes and the largest drug target family to date, exhibit diversity in structure and function. Among them, the secretin/adhesion (Class B) G protein-coupled receptors are essential drug targets for human diseases, such as endocrine diseases and cardiometabolic diseases. Given the great value of the secretin/adhesion (Class B) G protein-coupled receptors in the regulation of cardiovascular system function and the drug target exploration, we summarize the role of these receptors in placental development and preeclampsia, and outlined the relevant pathological mechanisms, thereby providing potential drug targets for preeclampsia treatment.
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Affiliation(s)
- Aiqi Yin
- Department of Obstetrics, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Xiaonian Guan
- Department of Obstetrics, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
| | - Jian V. Zhang
- Center for Energy Metabolism and Reproduction, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
- Shenzhen Key Laboratory of Metabolic Health, Shenzhen, China
- *Correspondence: Jian V. Zhang, ; Jianmin Niu,
| | - Jianmin Niu
- Department of Obstetrics, Shenzhen Maternity and Child Healthcare Hospital, The First School of Clinical Medicine, Southern Medical University, Shenzhen, China
- *Correspondence: Jian V. Zhang, ; Jianmin Niu,
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Gyselaers W, Lees C. Maternal Low Volume Circulation Relates to Normotensive and Preeclamptic Fetal Growth Restriction. Front Med (Lausanne) 2022; 9:902634. [PMID: 35755049 PMCID: PMC9218216 DOI: 10.3389/fmed.2022.902634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
This narrative review summarizes current evidence on the association between maternal low volume circulation and poor fetal growth. Though much work has been devoted to the study of cardiac output and peripheral vascular resistance, a low intravascular volume may explain why high vascular resistance causes hypertension in women with preeclampsia (PE) that is associated with fetal growth restriction (FGR) and, at the same time, presents with normotension in FGR itself. Normotensive women with small for gestational age babies show normal gestational blood volume expansion superimposed upon a constitutionally low intravascular volume. Early onset preeclampsia (EPE; occurring before 32 weeks) is commonly associated with FGR, and poor plasma volume expandability may already be present before conception, thus preceding gestational volume expansion. Experimentally induced low plasma volume in rodents predisposes to poor fetal growth and interventions that enhance plasma volume expansion in FGR have shown beneficial effects on intrauterine fetal condition, prolongation of gestation and birth weight. This review makes the case for elevating the maternal intravascular volume with physical exercise with or without Nitric Oxide Donors in FGR and EPE, and evaluating its role as a potential target for prevention and/or management of these conditions.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost Limburg, Genk, Belgium.,Department of Physiology, Hasselt University, Hasselt, Belgium
| | - Christoph Lees
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.,Department of Metabolism, Digestion and Reproduction, Institute for Reproductive and Developmental Biology, Imperial College London, London, United Kingdom.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
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Montaguti E, Di Donna G, Youssef A, Pilu G. Hypertensive disorders and maternal hemodynamic changes in pregnancy: monitoring by USCOM ® device. J Med Ultrason (2001) 2022; 49:405-413. [PMID: 35705778 DOI: 10.1007/s10396-022-01225-3] [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: 03/08/2021] [Accepted: 04/13/2022] [Indexed: 11/25/2022]
Abstract
Hypertensive disorders are quite common, complicating about 10% of pregnancies, while preeclampsia occurs in 2-8% of cases. The most recognized etiopathogenetic factor for the development of preeclampsia is deficient remodeling of the spiral arteries during trophoblastic invasion. Recently, some authors speculated about the "cardiovascular origin of preeclampsia"; in particular, they postulate that placental dysfunction is not the primum movens of preeclampsia, but it could be caused by a failure of the maternal cardiovascular system to adapt to the pregnancy itself. Moreover, several studies have also shown that developing preeclampsia in pregnancy is associated with an increased risk of cardiovascular disease later in life. Due to the importance of this pathology, it would be crucial to have an effective screening in order to implement a prophylaxis; for this purpose, it could be useful to have an accurate and noninvasive device for the assessment of maternal hemodynamic variables. USCOM® (Ultrasonic Cardiac Output Monitor) is a noninvasive Doppler ultrasonic technology which combines accuracy, reproducibility, noninvasiveness, and a fast learning curve. Maternal hemodynamic evaluation is important in order to monitor the changes that the maternal organism encounters, in particular a reduction in blood pressure, a decrease in total peripheral resistances, and an increase in cardiac output, resulting in a hyperdynamic circle. These hemodynamic modifications are lacking in pregnancies complicated by preeclampsia. For these reasons, it is crucial to have a tool that allows these parameters to be easily evaluated in order to identify those women at higher risk of hypertensive complications and more severe outcomes.
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Affiliation(s)
- Elisa Montaguti
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy.
| | - Gaetana Di Donna
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
| | - Aly Youssef
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
| | - Gianluigi Pilu
- Obstetric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 13, 40138, Bologna, Italy
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16
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Salud cardiovascular y renal en la mujer: la preeclampsia como marcador de riesgo. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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17
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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: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [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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18
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Nguyen TX, Nguyen VT, Nguyen-Phan HN, Hoang BB. Serum Levels of NT-Pro BNP in Patients with Preeclampsia. Integr Blood Press Control 2022; 15:43-51. [PMID: 35418780 PMCID: PMC9001144 DOI: 10.2147/ibpc.s360584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/25/2022] [Indexed: 11/26/2022] Open
Abstract
Objective This study aims to determine the serum levels of NT-proBNP in women with preeclampsia with and without severe signs and to evaluate the cardiovascular risks in these two groups of participants. Methods A descriptive cross-sectional study was conducted on 52 women with preeclampsia in the Department of Gynecology and Obstetrics – Hue Central Hospital, from August 2019 to September 2020. Results In preeclampsia women, the rate of hypertension in stage 3, stage 2, and stage 1 were 46.1%, 32.7%, and 21.2%, respectively. The average Sokolow-Lyon index in the preeclampsia group with and without severe signs was 22.25 ± 7.38mm, 20.16 ± 5.54mm, respectively. The average left ventricular mass index in the group of preeclampsia patients without and with severe signs was 92.27 ± 14.56g/m2 and 120.68 ± 16.47g/m2, respectively. The average ejection fraction in the group of preeclampsia patients without severe signs and with severe signs was 65.11 ± 3.45%, 56.21 ± 7.12%, correspondingly. In contrast, the difference between the two groups was statistically significant with p < 0.05. The plasma NT-proBNP level in the preeclampsia group without severe signs was 349.12 ± 93.51pg/mL, whereas the concentration in the preeclampsia group with severe signs was 725.32 ± 290.46pg/mL (p < 0.05). Conclusion The NT-proBNP level was statistically significantly increased in the patients with preeclampsia. Analyzing and comparing the figures and changes found in two groups of PE patients, with and without severe signs, we suggest that women diagnosed with PE with severe signs have a higher risk of developing cardiovascular problems forthwith and henceforth.
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Affiliation(s)
- Thanh Xuan Nguyen
- Department of Abdominal Emergency and Pediatric Surgery, Hue Central Hospital, Hue City, 530000, Vietnam
| | - Van Tri Nguyen
- Department of Anesthesiology, Hue International Medical Center, Hue Central Hospital, Hue City, 530000, Vietnam
| | - Hong Ngoc Nguyen-Phan
- Department of Internal Medicine, Hue University of Medicine and Pharmacy, Hue University, Hue City, 530000, Vietnam
| | - Bui Bao Hoang
- Department of Internal Medicine, Hue University of Medicine and Pharmacy, Hue University, Hue City, 530000, Vietnam
- Correspondence: Bui Bao Hoang, Department of Internal Medicine, Hue University of Medicine and Pharmacy, Hue University, 06 Ngo Quyen Street, Hue City, Vietnam, Tel +84 905405005, Email ;
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Lee P, Zhou C, Li Y. Endometriosis does not seem to be an influencing factor of hypertensive disorders of pregnancy in IVF / ICSI cycles. Reprod Biol Endocrinol 2022; 20:57. [PMID: 35337338 PMCID: PMC8957116 DOI: 10.1186/s12958-022-00922-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION To evaluate whether the incidence of hypertensive disorders of pregnancy (HDP) in pregnant women was related to endometriosis (EM), ovulation and embryo vitrification technology. METHODS A retrospective cohort study was conducted on the clinical data of 3674 women who were treated with IVF / ICSI in the Reproductive Medicine Center of the First Affiliated Hospital of Sun Yat-sen University and maintained clinical pregnancy for more than 20 weeks. All pregnancies were followed up until the end of pregnancy. The follow-up consisted of recording the course of pregnancy, pregnancy complications, and basic situation of newborns. RESULTS Compared with NC-FET without EM, HRT-FET without EM was found to have a higher incidence of HDP during pregnancy (2.7% V.S. 6.1%, P<0.001); however, no significant difference was found in the incidence of HDP between NC-FET and HRT-FET combined with EM (4.0% V.S. 5.7%, P>0.05). In total frozen-thawed embryo transfer (total-FET), the incidence of HDP in the HRT cycle without ovulation (HRT-FET) was observed to be higher than that in the NC cycle with ovulation (NC-FET) (2.8% V.S. 6.1%, P<0.001). In patients with EM, no significant difference was found in the incidence of HDP between fresh ET and NC-FET (1.2% V.S. 4.0%, P>0.05). CONCLUSION EM does not seem to have an effect on the occurrence of HDP in assisted reproductive technology. During the FET cycle, the formation of the corpus luteum may play a protective role in the occurrence and development of HDP. Potential damage to the embryo caused by cryopreservation seems to have no effect on the occurrence of HDP.
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Affiliation(s)
- Pingyin Lee
- Reproductive Medicine Center, The First Affiliated Hospital of Sun Yat-sen University, Zhoushan 2 Road, Guangzhou, Guangdong, People's Republic of China
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Zhoushan 2 Road, Guangzhou, Guangdong, People's Republic of China
| | - Canquan Zhou
- Reproductive Medicine Center, The First Affiliated Hospital of Sun Yat-sen University, Zhoushan 2 Road, Guangzhou, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Zhoushan 2 Road, Guangzhou, Guangdong, People's Republic of China.
| | - Yubin Li
- Reproductive Medicine Center, The First Affiliated Hospital of Sun Yat-sen University, Zhoushan 2 Road, Guangzhou, Guangdong, People's Republic of China.
- Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital of Sun Yat-sen University, Zhoushan 2 Road, Guangzhou, Guangdong, People's Republic of China.
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20
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McLaughlin K, Snelgrove JW, Sienas LE, Easterling TR, Kingdom JC, Albright CM. Phenotype‐Directed Management of Hypertension in Pregnancy. J Am Heart Assoc 2022; 11:e023694. [PMID: 35285667 PMCID: PMC9075436 DOI: 10.1161/jaha.121.023694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Kelsey McLaughlin
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - John W. Snelgrove
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - Laura E. Sienas
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
| | - Thomas R. Easterling
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
| | - John C. Kingdom
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine Sinai Health SystemUniversity of Toronto Toronto Canada
| | - Catherine M. Albright
- Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine University of Washington Medical Center Seattle WA
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21
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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: 18] [Impact Index Per Article: 9.0] [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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22
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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: 42] [Impact Index Per Article: 21.0] [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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Liu T, Gao R, Liu Y, Zhao K, Su X, Wong HC, Li L, Xie B, Huang Y, Qiu C, He J, Liu C. Hypertensive disorders of pregnancy and neonatal outcomes in twin vs. singleton pregnancies after assisted reproductive technology. Front Pediatr 2022; 10:839882. [PMID: 36120650 PMCID: PMC9478585 DOI: 10.3389/fped.2022.839882] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Hypertensive disorders of pregnancy (HDP) are associated with an increased risk of adverse neonatal outcomes. Although twin pregnancies had a higher risk of developing HDP, it is not known whether HDP in twins will increase the risk of adverse neonatal outcomes. We aimed to assess whether this association differed in singleton and twin pregnancies in women who conceived with assisted reproductive technology (ART). METHODS We finally included 193,590 live births born via ART from the National Vital Statistics System (NVSS) for the years 2015-2019. We used Log-binomial regression to evaluate the associations between HDP and the risk of adverse neonatal outcomes in ART mothers. RESULTS Among 193,590 ART-treated mothers, there were 140,870 and 52,720 mothers who had singleton pregnancies and twin pregnancies, respectively. Those ART mothers with twin pregnancies had a higher rate of HDP than singleton pregnancies (20.5% vs. 11.0%). In singleton pregnancies, the risks of preterm birth [adjusted risk ratio (aRR)): 2.80, 95% CI 2.67-2.93], low birth weight (aRR: 2.80, 95% CI 2.67-2.93), small for gestational age (aRR: 1.41, 95% CI 1.34-1.49), 5 min Apgar <7 (aRR: 1.66, 95% CI 1.50-1.83) and cesarean section (aRR: 1.23, 95% CI 1.21-1.25) were significantly higher in HDP mothers than in non-HDP mothers respectively. However, in contrast to singleton pregnancies, these associations were weak or reversed in twin pregnancies, after adjusting for confounding factors. CONCLUSION In ART-treated women, although twin pregnancies had a higher HDP rate, the risk of adverse neonatal outcomes associated with HDP was lower than that of singletons.
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Affiliation(s)
- Ting Liu
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Rui Gao
- Shenzhen Birth Cohort Study Center, Nanshan Maternity and Child Healthcare Hospital of Shenzhen, Shenzhen, China
| | - Yong Liu
- Department of Laboratory Medicine, Hospital of Stomatology, Anhui Medical University, Hefei, China
| | - Ke Zhao
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Xiaolin Su
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Hin Ching Wong
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Luyao Li
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Binbin Xie
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Yuanyan Huang
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Chuhui Qiu
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
| | - Jiang He
- Department of Mathematics and Physics, School of Biomedical Engineering, Southern Medical University, Guangzhou, China
| | - Chaoqun Liu
- Department of Nutrition, School of Medicine, Jinan University, Guangzhou, China
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24
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The predictive role of neutrophil-lymphocyte ratio, platelet lymphocyte ratio, and other complete blood count parameters in eclampsia and HELLP syndrome. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.1008359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kidson KM, Lapinsky S, Grewal J. A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient. Can J Cardiol 2021; 37:1979-2000. [PMID: 34534620 DOI: 10.1016/j.cjca.2021.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 01/19/2023] Open
Abstract
Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.
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Affiliation(s)
- Kristen M Kidson
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, Vancouver, British Columbia, Canada; Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Stephen Lapinsky
- Mount Sinai Hospital and the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Jasmine Grewal
- Division of Cardiology, University of British Columbia, Pacific Adult Congenital Heart Disease Program, St Paul's Hospital, Vancouver, British Columbia, Canada.
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Mullan SJ, Vricella LK, Edwards AM, Powel JE, Ong SK, Li X, Tomlinson TM. Pulse pressure as a predictor of response to treatment for severe hypertension in pregnancy. Am J Obstet Gynecol MFM 2021; 3:100455. [PMID: 34375751 DOI: 10.1016/j.ajogmf.2021.100455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Samantha J Mullan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO.
| | - Laura K Vricella
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Alexandra M Edwards
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Jennifer E Powel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Samantha K Ong
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Xujia Li
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Tracy M Tomlinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
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The Impact of Preeclampsia on Women's Health: Cardiovascular Long-term Implications. Obstet Gynecol Surv 2021; 75:703-709. [PMID: 33252700 DOI: 10.1097/ogx.0000000000000846] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Stampalija T, Quadrifoglio M, Casati D, Zullino S, Maggi V, Di Martino D, Rosti E, Mastroianni C, Signorelli V, Ferrazzi E. First trimester placental volume is reduced in hypertensive disorders of pregnancy associated with small for gestational age fetus. J Matern Fetal Neonatal Med 2021; 34:1304-1311. [PMID: 31232131 DOI: 10.1080/14767058.2019.1636026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Trophoblastic invasion and placental growth are critical for pregnancy outcome. The placental volume can be assessed by 3 D ultrasound using Virtual Organ Computer-aided Analysis (VOCAL). Epidemiological and clinical data suggest that there are two different clinical phenotypes of hypertensive disorders of pregnancy (HDP) that coexist at any gestational age: HDP associated to fetal growth impairment and HDP associated to appropriate for gestational age fetal growth. The aim of this study was to determine whether placental volume in the first trimester of pregnancy differs between women with HDP associated or not to fetal growth impairment and uncomplicated pregnancies. METHODS This is a retrospective cross-sectional study of prospectively recruited data in which maternal characteristics, Doppler velocimetry of uterine arteries, and three-dimensional (3 D) volume of the placenta were collected at 11 + 1 - 13 + 6 gestational weeks. The placental quotient (PQ) was calculated as placental volume/crown rump length. RESULTS In a 2-year period, we prospectively collected first trimester data of 1322 women. For the purposes of this cross-sectional study, 57 women that delivered a SGA fetus, 34 that developed HDP-AGA, and six that developed HDP-SGA, respectively, were included in the study as cases. The control group was made of 117 uncomplicated pregnancies. The PQ was higher in women with uncomplicated pregnancies (PQ median 16.36 cm3/cm) than in all other study groups (PQ in SGA: 13.02 cm3/cm, p < .001; PQ in HDP-AGA: 12.65 cm3/cm, p = .002; and PQ in women with HDP-SGA: 8.33 cm3/cm [IQR 6.50-10.13], p < .001). The lowest PQ was observed in women with HDP-SGA and was significantly lower than PQ in either women with SGA or those with HDP-AGA (p = .02 and p = .04, respectively). The mean uterine artery pulsatility index was the highest in women with HDP-SGA (median 2.30) compared to all other groups (uncomplicated pregnancies 1.48, p < .0001; women with SGA 1.59, p = .001; and women with HDP-AGA 1.75, p = .009). DISCUSSION Our findings suggest that HDP associated with SGA is characterized by impaired placental growth and perfusion as soon as in the first trimester of pregnancy. The role of PQ, isolated or in association with other biophysical parameters, to predict HDP with fetal growth impairment remains to be evaluated.
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Affiliation(s)
- Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Mariachiara Quadrifoglio
- Unit of Fetal Medicine and Prenatal Diagnosis, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Daniela Casati
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Valeria Maggi
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Daniela Di Martino
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Eleonora Rosti
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Cristina Mastroianni
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Valentina Signorelli
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Pro- and Anti-Angiogenic Markers as Clinical Tools for Suspected Preeclampsia with and without FGR near Delivery—A Secondary Analysis. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2010003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective—the objective of this study was to assess the accuracy of placental growth factor (PlGF), soluble Fms-like Tyrosine Kinase 1 (sFlt-1), and endoglin (sEng) in the diagnosis of suspected preeclampsia (PE) with and without fetal growth restriction (FGR) near delivery. Methods—this is a secondary analysis of a dataset of 125 pregnant women presenting at the high risk pregnancy clinic with suspected PE, FGR or PE + FGR in the University Medical Center of Slovenia. The dataset included 31 PE cases, 16 FGR cases, 42 PE + FGR cases, 15 cases who developed with unrelated complications before 37 weeks (wks) (PTD), and 21 unaffected controls who delivered a healthy baby at term. We also analyzed a sub-group of women who delivered early (<34 wks) including 10 PE, 12 FGR, 28 PE + FGR, and six PTD. Clinical management adhered to hospital guidelines. Marker levels were extracted from the dataset and were used to develop Receiver Operating Characteristic (ROC) curves and to calculate the area under the curve (AUC), the detection rates (DRs), and the false positive rates (FPRs). Previously published marker cutoffs for yes/no admission to hospital wards were extracted from the literature. Negative and positive predictive values (NPVs and PPVs) were evaluated for their value in determining whether hospital admission was required. Non-parametric tests were applied for statistical analysis; p < 0.05 was considered significant. Results—near delivery, all the pro-and anti-angiogenic markers provided diagnostic (ROC = 1.00) accuracy for the early (<34 wks) group of FGR. Diagnostic or near diagnostic (ROC = 0.95) accuracy was achieved by all marker for early PE + FGR but lower accuracy was achieved for early PE. For all cases, all markers, especially PlGF reached diagnostic or near diagnostic accuracy for FGR and PE + FGR. At this accuracy level, they can contribute to the clinical management of FGR, and PE + FGR. All the markers were less accurate for all PE cases. The use of published cutoffs was adequate for clinical management of FGR, whether early or for all cases, using an NPV > 90%. For PE + FGR, the PPV value approached 100%, especially for early cases, and can thus be implemented in clinical management. Neither NPV nor PPV were high enough for managing all cases of PE. There was no added value in measuring the PlGF/(sFlt-1 + sEng) ratio. Conclusion—This is the first study on a Slovenian population. It shows that near-delivery angiogenic biomarkers tests may be useful for confirming the diseases in cases where there is a diagnostic doubt. However, the clinical use of the biomarkers needs to be weighed against resources available and degree of certainty of the diagnosis made with and without them for managing suspected FGR and PE + FGR requiring delivery <34 wks, where they are very accurate, and furthermore in the management of all cases of FGR and FGR+PE. The markers were less accurate for the clinical diagnosis of PE.
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Dobrowolski P, Kosinski P, Prejbisz A, Szczepkowska A, Klisiewicz A, Januszewicz M, Wielgos M, Januszewicz A, Hoffman P. Longitudinal changes in maternal left atrial volume index and uterine artery pulsatility indices in uncomplicated pregnancy. Am J Obstet Gynecol 2021; 224:221.e1-221.e15. [PMID: 32717256 DOI: 10.1016/j.ajog.2020.07.042] [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: 06/01/2020] [Revised: 07/10/2020] [Accepted: 07/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data on the relationship between longitudinal changes in maternal volume-dependent echocardiographic parameters and placentation in uncomplicated pregnancy are limited. OBJECTIVE This study aimed to evaluate changes in volume-dependent echocardiographic parameters in uncomplicated pregnancy to test the hypothesis of the existence of an association between volume-dependent echocardiographic parameters and Doppler ultrasound parameters of fetal circulation and the uterine artery in uncomplicated pregnancy and to establish which of the volume-dependent echocardiographic parameters best depicts volume changes and correlates best with Doppler ultrasound of fetal circulation and the uterine artery in healthy pregnancy. STUDY DESIGN Data from 60 healthy pregnant women were analyzed. A complete echocardiographic study was performed at 11 to 13, 20 to 22, and 30 to 32 weeks' gestation: left ventricular end-diastolic volume, early diastolic peak flow velocity, late diastolic peak flow velocity, left atrial area, and left atrial volume index were assessed. Obstetrical assessment was performed including fetal growth and uterine artery pulsatility index. Fetal well-being was assessed by umbilical and middle cerebral artery blood flow. Serum pregnancy-associated plasma protein A and free β-human chorionic gonadotropin were assessed during the routine first-trimester scan (11-13 weeks' gestation). RESULTS Left ventricular end-diastolic volume and left atrial area increased significantly between 11 to 13 and 20 to 22 weeks' gestation but not between 20 to 22 and 30 to 32 weeks' gestation. Left atrial volume index measured at 30 to 32 weeks' gestation correlated with uterine artery pulsatility indices in 3 trimesters. Changes in the left atrial volume index between the third and first trimesters correlated significantly with the uterine artery pulsatility index measured at 20 to 22 weeks' gestation (r=-0.345; P=.020) and at 30 to 32 weeks' gestation (r=-0.452; P=.002). Changes in the left atrial volume index between the second and first trimesters significantly correlated with the uterine artery pulsatility index measured in the first trimester (r=-0.316; P=.025). CONCLUSION Our study showed that in an uncomplicated pregnancy, among volume-dependent echocardiographic parameters, left atrial volume index increased between both the first and second trimesters and the second and third trimesters and correlated with parameters of Doppler ultrasound of the fetal circulation and the uterine artery. Our results expand on the previous observation on the relationship between maternal cardiovascular adaptation and placentation in women with heart diseases to the population of healthy women with uncomplicated pregnancy.
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Golinska-Grzybala K, Wiechec M, Golinski B, Rostoff P, Szlósarczyk B, Gackowski A, Nessler J, Konduracka E. Subclinical cardiac performance in obese and overweight women as a potential risk factor of preeclampsia. Pregnancy Hypertens 2020; 23:131-135. [PMID: 33348313 DOI: 10.1016/j.preghy.2020.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/22/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Failure to increase cardiac output owing to suboptimal cardiac performance in obese women may contribute to placental hypoperfusion, and therefore subsequently to the abnormal placental development. The aim of this study was to evaluate the relationship between left ventricle (LV) function in overweight and obese pregnant women and parameters of blood flow in uterine arteries. STUDY DESIGN AND MAIN OUTCOME MEASURES We conducted a prospective cohort study, which included consecutive 87 women with singleton pregnancy - 56 women with normal weight and 31 overweight and obese women. During pregnancy blood pressure, echocardiography and the assessment of blood flow in uterine arteries - pulsatility index (PI) and resistance index (RI) were assessed on two visits (V): V1 between 10 and 14 weeks and V2 between 25 and 30 weeks of gestation. A stepwise logistic regression analysis was performed to determine the independent predictors of upper quartile of RI and PI during V2 in the study population. RESULTS The multivariate logistic regression analysis showed that LVCI and LV mass measured on V1 were the only independent predictors of upper quartile of RI during V2, whereas LVCI was the only independent predictor of upper quartile of PI during V2. CONCLUSIONS Subclinical left ventricle dysfunction in obese and overweight women, present from the first trimester, may contribute to placental hypoperfusion and higher resistance in uterine arteries later during pregnancy. This may lead in some women to preeclampsia.
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Affiliation(s)
- Karolina Golinska-Grzybala
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Prądnicka 80 Street, 31-202, Kraków, Poland; Multimed Medical Center, Outpatient Clinic, W. Jagielly Street 15, 32-800, Brzesko, Poland
| | - Marcin Wiechec
- Department of Gynaecology and Obstetrics, University Hospital, M. Kopernika Street, 31-501, Krakow, Poland
| | - Bogdan Golinski
- Multimed Medical Center, Outpatient Clinic, W. Jagielly Street 15, 32-800, Brzesko, Poland
| | - Pawel Rostoff
- Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka 80 Street, 31-202, Krakow, Poland
| | - Barbara Szlósarczyk
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Prądnicka 80 Street, 31-202, Kraków, Poland; Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka 80 Street, 31-202, Krakow, Poland
| | - Andrzej Gackowski
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Prądnicka 80 Street, 31-202, Kraków, Poland; Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka 80 Street, 31-202, Krakow, Poland
| | - Jadwiga Nessler
- Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka 80 Street, 31-202, Krakow, Poland
| | - Ewa Konduracka
- Department of Coronary Disease and Heart Failure, Jagiellonian University Medical College, John Paul II Hospital, Prądnicka 80 Street, 31-202, Krakow, Poland
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Lanssens D, Thijs IM, Gyselaers W. Design of the Pregnancy REmote MOnitoring II study (PREMOM II): a multicenter, randomized controlled trial of remote monitoring for gestational hypertensive disorders. BMC Pregnancy Childbirth 2020; 20:626. [PMID: 33059633 PMCID: PMC7565319 DOI: 10.1186/s12884-020-03291-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/27/2020] [Indexed: 12/24/2022] Open
Abstract
Background Observational data from the retrospective, non-randomized Pregnancy REmote MOnitoring I (PREMOM I) study showed that remote monitoring (RM) may be beneficial for prenatal observation of women at risk for gestational hypertensive disorders (GHD) in terms of clinical outcomes, health economics, and stakeholder perceptions. PREMOM II is a prospective, randomized, multicenter follow-up study that was performed to explore these promising results. Methods After providing written consent, 3922 pregnant women aged ≥18 years who are at increased risk of developing GHD will be randomized (1:1:1 ratio) to (a) conventional care (control group), (b) a patient self-monitoring group, and (c) a midwife-assisted RM group. The women in each group will be further divided (1:1 ratio) to evaluate the outcomes of targeted or non-targeted (conventional) antihypertensive medication. Women will be recruited in five hospitals in Flanders, Belgium: Ziekenhuis Oost-Limburg, Universitaire Ziekenhuis Antwerpen, Universitaire Ziekenhuis Leuven, AZ Sint Jan Brugge–Oostende, and AZ Sint Lucas Brugge. The primary outcomes are: (1) numbers and types of prenatal visits; (2) maternal outcomes; (3) neonatal outcomes; (4) the applicability and performance of RM; and (5) compliance with RM and self-monitoring. The secondary outcomes are: (1) cost-effectiveness and willingness to pay; (2) patient-reported outcome measures (PROMS) questionnaires on the experiences of the participants; and (3) the maternal and perinatal outcomes according to the type of antihypertensive medication. Demographic, and maternal and neonatal outcomes are collected from the patients’ electronic records. Blood pressure and compliance rate will be obtained from an online digital coordination platform for remote data handling. Information about the healthcare-related costs will be obtained from the National Coordination Committee of Belgian Health Insurance Companies (Intermutualistisch Agentschap). PROMS will be assessed using validated questionnaires. Discussion To our knowledge, this is the first randomized trial comparing midwife-assisted RM and self-monitoring of prenatal blood pressure versus conventional management among women at increased risk of GHD. Positive results of this study may lead to a practical framework for caregivers, hospital management, and payers to introduce RM into the prenatal care programs of high-risk pregnancies. Trial registration This study was registered on clinicaltrials.gov, identification number NCT04031430. Registered 24 July 2019, https://clinicaltrials.gov/ct2/show/NCT04031430?cond=premom+ii&draw=2&rank=1.
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Affiliation(s)
- Dorien Lanssens
- Ziekenhuis Oost-Limburg, Future Health Department, Limburg Clinical Research Center/Mobile Health Unit, Genk, Belgium. .,Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium. .,Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health, UnitUHasselt - ZOL, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium.
| | - Inge M Thijs
- Ziekenhuis Oost-Limburg, Future Health Department, Limburg Clinical Research Center/Mobile Health Unit, Genk, Belgium.,Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health, UnitUHasselt - ZOL, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Wilfried Gyselaers
- Department of Obstetrics and Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Faculty of Medicine and Life Sciences, Limburg Clinical Research Center/Mobile Health, UnitUHasselt - ZOL, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
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Gyselaers W, Lozada MJ, Pacheco LD, Tayebi S, Malbrain MLNG. Intra-abdominal pressure as an ignored parameter in the pathophysiology of preeclampsia. Acta Obstet Gynecol Scand 2020; 99:963-965. [PMID: 32683680 DOI: 10.1111/aogs.13898] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/03/2023]
Affiliation(s)
- Wilfried Gyselaers
- Department of Physiology, Hasselt University, Hasselt, Belgium.,Department of Obstetrics and Gynecology, Ziekenhuis Oost Limburg, Genk, Belgium
| | - M James Lozada
- Division of Obstetric Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Luis D Pacheco
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Texas Medical Branch at Galveston, Galveston, TX, USA.,Division of Critical Care Medicine, Department of Anesthesiology, University of Texas Medical Branch at Galveston, Galveston, TX, USA
| | - Salar Tayebi
- Department of Biomedical Engineering, Vrije Universiteit Brussel, Brussels, Belgium
| | - Manu L N G Malbrain
- Intensive Care Unit, University Hospital Brussels, Jette, Belgium.,Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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Sarno L, Morlando M, Giudicepietro A, Carlea A, Sidhu S, Campanile M, Maruotti GM, Martinelli P, Guida M. The impact of obesity on haemodynamic profiles of pregnant women beyond 34 weeks' gestation. Pregnancy Hypertens 2020; 22:191-195. [PMID: 33065481 DOI: 10.1016/j.preghy.2020.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/10/2020] [Accepted: 10/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We aimed to compare the haemodynamic profiles of obese and non-obese pregnant women, alongside describing the haemodynamic changes that occur in hypertensive disorders of pregnancies with an Appropriate for Gestational Age Fetus (HDP-AGA) beyond 34 weeks' gestation. STUDY DESIGN In this prospective case-control study, maternal haemodynamic assessment was carried out by a trained operator using an UltraSonic Cardiac Output Monitor during a routine clinical assessment after 34 weeks of gestation. Indexed and non-indexed parameters were evaluated. MAIN OUTCOME MEASURES Maternal hemodynamic parameters. RESULTS Obese and non-obese women did not differ for non-indexed parameters (Cardiac Output, Stroke Volume, Systemic Vascular Resistance). Using indexed parameters, corrected for Body Surface Area, obese women presented significantly lower Cardiac Index z-score (-0.23 ± 0.5 vs 0.26 ± 1.2; p = 0.004), Stroke Volume Index z-score (-0.27 ± 0.8 vs 0.31 ± 1.0; p < 0.0001) and significantly higher Systemic Vascular Resistance Index (0.16 ± 0.8 vs -0.36 ± 0.7; p < 0.0001). In obese women, HDP-AGA (n = 19) had significantly higher Systemic Vascular Resistance Index z-score (1.26 ± 1.7 vs 0.16 ± 0.8; P = 0.009) and significantly lower Stroke Volume Index (-0.68 ± 0.8 vs -0.27 ± 0.8; 0.049). CONCLUSION Using indexed parameters, differences in haemodynamic profiles between obese and non obese women can be highlighted. Obese women seem to present a cardiac maladapation to the pregnancy (reduced cardiac index and stroke volume and increased vascular resistance) that could explain the increased risk of complications in this subgroup.
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Affiliation(s)
- Laura Sarno
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy.
| | - Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonia Giudicepietro
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Annunziata Carlea
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Supreet Sidhu
- Institute of Medical and Biomedical Education (IMBE), St. George's, University of London, Cranmer Terrace, Tooting, London SW17 0RE, United Kingdom
| | - Marta Campanile
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Giuseppe Maria Maruotti
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Pasquale Martinelli
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
| | - Maurizio Guida
- Department of Neurosciences, Reproductive Science and Dentistry, University of Naples Federico II, Via Pansini 5, 80131 Naples, Italy
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Vasapollo B, Novelli GP, Gagliardi G, Farsetti D, Valensise H. Pregnancy complications in chronic hypertensive patients are linked to pre-pregnancy maternal cardiac function and structure. Am J Obstet Gynecol 2020; 223:425.e1-425.e13. [PMID: 32142824 DOI: 10.1016/j.ajog.2020.02.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 12/19/2022]
Abstract
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.
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Gyselaers W. Preeclampsia Is a Syndrome with a Cascade of Pathophysiologic Events. J Clin Med 2020; 9:jcm9072245. [PMID: 32679789 PMCID: PMC7409017 DOI: 10.3390/jcm9072245] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/05/2020] [Accepted: 07/13/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Wilfried Gyselaers
- Department Obstetrics, Ziekenhuis Oost Limburg, B3600 Genk, Belgium; ; Tel.: +32-89-306420
- Department Physiology, Hasselt University, B3590 Diepenbeek, Belgium
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Perry H, Gutierrez J, Binder J, Thilaganathan B, Khalil A. Maternal arterial stiffness in hypertensive pregnancies with and without small-for-gestational-age neonate. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:44-50. [PMID: 31613410 DOI: 10.1002/uog.21893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/21/2019] [Accepted: 10/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Pregnancies complicated by pre-eclampsia with a small-for-gestational-age (SGA) neonate have poorer maternal hemodynamic function compared to those with hypertensive disorders of pregnancy (HDP) and an appropriately grown neonate. Arterial stiffness is a recognized prognostic marker of cardiovascular disease in the general population. The aim of this study was to compare maternal arterial stiffness between hypertensive pregnancies with, and those without, a SGA neonate and normotensive control pregnancies. METHODS This was a prospective cohort study of pregnancies complicated by pre-eclampsia or gestational hypertension and healthy normotensive control pregnancies, presenting to a tertiary referral hospital between January 2012 and May 2018. Maternal arterial stiffness was assessed by aortic pulse-wave velocity (PWV) and aortic augmentation index (AIx), which were recorded using a non-invasive device (Arteriograph®). Maternal and hemodynamic factors were adjusted for using linear regression analysis. Pregnancies with HDP were divided into those that delivered a SGA (birth weight < 10th percentile) neonate (HDP + SGA group) and those that delivered an appropriately grown neonate (HDP-only group). Comparisons between groups were carried out using the Mann-Whitney U-test for continuous variables and the chi-square (or Fisher's exact) test for categorical variables. RESULTS Included in the analysis were 69 patients with HDP who delivered a SGA neonate, 129 with HDP who delivered a normally grown neonate and 220 healthy controls. Maternal age, weight, height and heart rate were associated significantly with brachial and aortic AIx. Maternal weight, height, mean arterial pressure, heart rate and gestational age were significant predictors of aortic PWV. Adjusted aortic AIx was significantly higher in both the HDP + SGA and HDP-only groups, compared with in controls (12.5% and 10.0% vs 7.6%; both P < 0.01), and was significantly different between the two HDP groups (P = 0.002). Adjusted PWV was significantly higher in the HDP-only group compared with in controls and the HDP + SGA group (7.7 m/s vs 7.1 m/s and 7.1 m/s; both P < 0.001). Conversely, unadjusted PWV was not significantly different between the two HDP groups (P = 0.414). CONCLUSIONS Pregnancies complicated by HDP with, and those without, a SGA neonate have significantly higher aortic AIx compared with uncomplicated normotensive pregnancies. Aortic AIx was highest in those pregnancies complicated by HDP with a SGA neonate, reflecting a progression in severity of arterial stiffness abnormality with a worsening clinical picture. These findings most likely reflect systemic reduced vascular compliance and increased systemic vascular resistance in pregnancy complicated by HDP. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - J Gutierrez
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - J Binder
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Moresi S, Martino C, Salvi S, Del Sordo G, Fruci S, Garofalo S, Lanzone A, De Carolis S, Ferrazzani S. Perinatal outcome in gestational hypertension: Which role for developing preeclampsia. A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2020; 251:218-222. [PMID: 32559606 DOI: 10.1016/j.ejogrb.2020.05.064] [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: 02/15/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To analyze perinatal outcome in singleton pregnancies complicated by gestational hypertension (GH), to investigate the rate of women developing preeclampsia (PE) and to describe maternal features associated with progression to PE. STUDY DESIGN This is a population-based retrospective cohort-study involving 514 singleton pregnancies with a diagnosis of GH at admission. RESULTS In pregnancies with GH, a poorer pregnancy outcome in comparison to healthy controls was observed in terms of gestational age at delivery, birthweight and birthweight percentile. The observed overall rate of developing PE was 11.7 %. Of all pregnancies with GH at admission, two different groups were identified based on the diagnosis at delivery: GHPE, i.e. women who developed PE (60/514; 11.7 %), and GHnoPE, i.e. women who did not develop PE (454/514; 88.3 %). In the GHPE group it was observed that the 62 % of the women with diagnosis of GH earlier than 28 weeks developed PE while only 2% developed PE if the diagnosis of GH was performed later than 36 weeks. The observed rate of developing PE was 14.7 % in pharmacologically treated hypertensive women, whereas the diagnosis of PE has been made in only 3% of non-treated women. CONCLUSION Pregnant women with raised blood pressure are at risk of having a less favourable perinatal outcome. The risk is mainly associated with the progression to PE. Major determinants of the risk of developing PE are the earlier gestational age at diagnosis of GH, the necessity of treatment and the number of anti-hypertensive drugs needed for controlling blood pressure.
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Affiliation(s)
- Sascia Moresi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Carmelinda Martino
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Silvia Salvi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Gelsomina Del Sordo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Stefano Fruci
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Serafina Garofalo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Antonio Lanzone
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Sara De Carolis
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Sergio Ferrazzani
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
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Ling HZ, Gallardo-Arozena M, Company-Calabuig AM, Nicolaides KH, Kametas NA. Clinical validation of bioreactance for the measurement of cardiac output in pregnancy. Anaesthesia 2020; 75:1307-1313. [PMID: 32469423 DOI: 10.1111/anae.15110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 11/27/2022]
Abstract
Maternal cardiac dysfunction is associated with pre-eclampsia, fetal growth restriction and haemodynamic instability during obstetric anaesthesia. There is growing interest in the use of non-invasive cardiac output monitoring to guide antihypertensive and fluid therapies in obstetrics. The aim of this study was to validate thoracic bioreactance using the NICOM® instrument against transthoracic echocardiography in pregnant women, and to assess the effects of maternal characteristics on the absolute difference of stroke volume, cardiac output and heart rate. We performed a prospective study involving women with singleton pregnancies in each trimester. We recruited 56 women who were between 11 and 14 weeks gestation, 57 between 20 and 23 weeks, and 53 between 35 and 37 weeks. Cardiac output was assessed repeatedly and simultaneously over 5 min in the left lateral position with NICOM and echocardiography. The performance of NICOM was assessed by calculating bias, 95% limits of agreement and mean percentage difference relative to echocardiography. Multivariate regression analysis evaluated the effect of maternal characteristics on the absolute difference between echocardiography and NICOM. The mean percentage difference of cardiac output measurements between the two methods was ±17%, with mean bias of -0.13 l.min-1 and limits of agreement of -1.1 to 0.84; stroke volume measurements had a mean percentage difference of ±15%, with a mean bias of -0.8 ml (-10.9 to 12.6); and heart rate measurements had a mean percentage difference of ±6%, with a mean bias of -2.4 beats.min-1 (-6.9 to 2.0). Similar results were found when the analyses were confined to each individual trimester. The absolute difference between NICOM and echocardiography was not affected by maternal age, weight, height, race, systolic or diastolic blood pressure. In conclusion, NICOM demonstrated good agreement with echocardiography, and can be used in pregnancy for the measurement of cardiac function.
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Affiliation(s)
- H Z Ling
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - M Gallardo-Arozena
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - A M Company-Calabuig
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - K H Nicolaides
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
| | - N A Kametas
- Department of Maternal-Fetal Medicine, Fetal Medicine Research Institute, King's College London, UK
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Perry H, Binder J, Gutierrez J, Thilaganathan B, Khalil A. Maternal haemodynamic function differs in pre-eclampsia when it is associated with a small-for-gestational-age newborn: a prospective cohort study. BJOG 2020; 128:167-175. [PMID: 32314535 DOI: 10.1111/1471-0528.16269] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To describe maternal haemodynamic differences in gestational hypertension with small-for-gestational-age babies (HDP + SGA), gestational hypertension with appropriate-for-gestational-age babies (HDP-only) and control pregnancies. DESIGN Prospective cohort study. SETTING Tertiary Hospital, UK. POPULATION Women with gestational hypertension and healthy pregnant women. METHODS Maternal haemodynamic indices were measured using a non-invasive Ultrasound Cardiac Output Monitor (USCOM-1A® ) and corrected for gestational age and maternal characteristics using device-specific reference ranges. MAIN OUTCOME MEASURES Maternal cardiac output, stroke volume, systemic vascular resistance. RESULTS We included 114 HDP + SGA, 202 HDP-only and 401 control pregnancies at 26-41 weeks of gestation. There was no significant difference in the mean arterial blood pressure (110 versus 107 mmHg, P = 0.445) between the two HDP groups at presentation. Pregnancies complicated by HDP + SGA had significantly lower median heart rate (76 versus 85 bpm versus 83 bpm), lower cardiac output (0.85 versus 0.98 versus 0.97 MoM) and higher systemic vascular resistance (1.4 versus 1.0 versus 1.2 MoM) compared with control and HDP-only pregnancies, respectively (all P < 0.05). CONCLUSION Women with HDP + SGA present with more severe haemodynamic dysfunction than HDP-only. Even HDP-only pregnancies exhibit impaired haemodynamic indices compared with normal pregnancies, supporting a role of the maternal cardiovascular system in gestational hypertension irrespective of fetal size. Central haemodynamic changes may play a role in the pathogenesis of pre-eclampsia and should be considered alongside placental aetiology. TWEETABLE ABSTRACT Hypertensive disorders of pregnancy are associated with worse maternal haemodynamic function when associated with small-for-gestational-age birth.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Binder
- Department of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - J Gutierrez
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
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Kalapotharakos G, Salehi D, Steding-Ehrenborg K, Andersson MEV, Arheden H, Hansson SR, Hedström E. Cardiovascular effects of severe late-onset preeclampsia are reversed within six months postpartum. Pregnancy Hypertens 2020; 19:18-24. [PMID: 31864208 DOI: 10.1016/j.preghy.2019.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Preeclampsia (PE) is a common pregnancy-related disorder associated with cardiovascular long-term disease. Eighty percent are late-onset PE, occurring after 34 gestational weeks, and can present with severe symptoms. Magnitude and reversibility rate of maternal cardiovascular changes after severe late-onset PE have not been characterized. This study therefore evaluated longitudinal dynamics of maternal cardiovascular changes after severe late-onset PE. STUDY DESIGN Six previously normotensive women with severe late-onset PE and eight pregnant controls were included. Severe PE was defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 110 mmHg and proteinuria with/without evidence of end-organ dysfunction, or SBP ≥ 140 mmHg or DBP ≥ 90 mmHg with/without proteinuria and with evidence of end-organ dysfunction. Cardiovascular function was assessed by magnetic resonance imaging at 1-3 days, one week and six months postpartum. RESULTS Left ventricular mass at 1-3 days postpartum was higher after severe late-onset PE (57 g/m2) compared to after normal pregnancy (48 g/m2; p = 0.01). Pulse wave velocity (PWV) decreased between 1 and 3 days and six months postpartum after PE (6.1 to 5.0 m/s; p = 0.028). There was no difference in PWV 1-3 days postpartum after severe PE compared after normal pregnancy (6.1 versus 5.6 m/s; p = 0.175). Blood pressure normalized within six months in all but one patient. CONCLUSIONS Cardiac effects after severe late-onset PE were small and transient. This indicates that left ventricular hypertrophy after severe late-onset PE may be a secondary physiologic response to increased peripheral resistance in PE. Vascular mechanisms rather than persistent cardiac hypertrophy postpartum may be the culprit for increased long-term cardiovascular risk after PE.
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Affiliation(s)
- Grigorios Kalapotharakos
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Obstetrics and Gynaecology, Lund, Sweden
| | - Daniel Salehi
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - Katarina Steding-Ehrenborg
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden; Lund University, Skåne University Hospital, Department of Health Sciences, Physiotherapy, Lund, Sweden
| | - Maria E V Andersson
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Obstetrics and Gynaecology, Lund, Sweden
| | - Håkan Arheden
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - Stefan R Hansson
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Obstetrics and Gynaecology, Lund, Sweden
| | - Erik Hedström
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden; Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Diagnostic Radiology, Lund, Sweden.
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Dreesen P, Schoutteten MK, Vande Velde N, Kaminski I, Heylen L, De Moor B, Malbrain ML, Gyselaers W. Increased Intra-Abdominal Pressure During Laparoscopic Pneumoperitoneum Enhances Albuminuria via Renal Venous Congestion, Illustrating Pathophysiological Aspects of High Output Preeclampsia. J Clin Med 2020; 9:jcm9020487. [PMID: 32054051 PMCID: PMC7074134 DOI: 10.3390/jcm9020487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/13/2020] [Accepted: 02/09/2020] [Indexed: 01/31/2023] Open
Abstract
Intra-abdominal hypertension (IAH) causes severe organ dysfunction. Our aim is to evaluate the effect of increased intra-abdominal pressure (IAP) on renal function, hypothesizing that venous congestion may increase proteinuria and fluid retention without endothelial dysfunction. Three urine samples were collected from 32 non-pregnant women undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) and from 10 controls placed in Trendelenburg position for 60 min. Urine sampling was done before (PRE), during or immediately after (PER), and two hours after (POST) the procedure. Urinary albumin, protein and creatinine concentrations were measured in each sample, and ratios were calculated and compared within and between groups. During LAVH, the albumin/creatinine ratio (ACR) increased and persisted POST-procedure, which was not observed in controls. A positive correlation existed between the LAVH duration and the relative change in both ACR and protein/creatinine ratio (PCR) PER- and POST-procedure. Iatrogenic IAH increases urinary ACR and PCR in non-pregnant women via a process of venous congestion. This mechanism might explain the presentation of one specific subtype of late-onset preeclampsia, where no drop of maternal cardiac output is observed.
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Affiliation(s)
- Pauline Dreesen
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Melanie K. Schoutteten
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
- Department of Nephrology, Catharina Ziekenhuis, 5623 EJ Eindhoven, The Netherlands
| | - Nele Vande Velde
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
| | - Iris Kaminski
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
| | - Line Heylen
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Department of Nephrology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
| | - Bart De Moor
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Department of Nephrology, Jessa Ziekenhuis, 3500 Hasselt, Belgium
| | - Manu L.N.G. Malbrain
- Department of Intensive Care, Universitair Ziekenhuis Brussel, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - Wilfried Gyselaers
- UHasselt—Hasselt University, Faculty of Medicine and Life Sciences, Department of Physiology, Limburg Clinical Research Center, 3590 Diepenbeek, Belgium
- Department of Obstetrics & Gynecology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
- Correspondence: ; Tel.: +32-89327524
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Woods A, Afshar Y, Yin O, Jones WM, Kwan L, Zhang H, Koos BJ, DeVore G. Maternal Central Blood Pressure Is Associated with Fetal Middle Cerebral Artery Dopplers. Reprod Sci 2020; 27:655-661. [PMID: 32046428 DOI: 10.1007/s43032-019-00069-6] [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: 03/25/2019] [Accepted: 07/23/2019] [Indexed: 11/26/2022]
Abstract
Cardiovascular adaptations to pregnancy involve physiological mechanisms that increase cardiac output, decrease total vascular resistance, and decrease both systolic and diastolic blood pressure (BP). These maternal hemodynamic changes modulate uteroplacental blood flow and fetal-placental Doppler indices. Our objective was to create maternal cardiac profiles of pregnant women using non-invasive measurements of central BP to identify changes in maternal-fetal hemodynamics as a surrogate to fetal status. This was a prospective cohort study of all singleton pregnancies in a perinatal referral center between January and April 2018. Central BP was measured non-invasively using the BP+ device. The BP+ device is a supra-systolic oscillometric central BP device, which measures BP waveforms peripherally and calculates central BP. We compared various BP+ values for peripheral BP with central BP and stratified by gestational age. We investigated the correlations between peripheral BP, central BP, estimated fetal weight (EFW), and the pulsatility indices (PI) of Doppler velocimetry and demonstrate that both central systolic and diastolic BP correlated to peripheral systolic and diastolic BP. Linear regression analysis confirmed that central BP predicts the middle cerebral artery (MCA) PI. The MCA PI correlated with EFW, specifically higher central systolic BP is associated with a lower MCA PI, implying a possible etiology of fetal brain shunting with poor placental perfusion. Future studies using predictors and markers of fetal outcomes from maternal cardiac parameters should consider maternal cardiovascular measurements to peripheral arterial BP.
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Affiliation(s)
- Allison Woods
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA, 90095-1740, USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA, 90095-1740, USA.
| | - Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA, 90095-1740, USA
| | - William M Jones
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA, 90095-1740, USA
| | - Lorna Kwan
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Haoyue Zhang
- Department of Urology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Brian J Koos
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA, 90095-1740, USA
| | - Greggory DeVore
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA, 90095-1740, USA
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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: 0.6] [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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Di Pasquo E, Ghi T, Dall'Asta A, Angeli L, Fieni S, Pedrazzi G, Frusca T. Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms. Am J Obstet Gynecol 2019; 221:633.e1-633.e9. [PMID: 31226294 DOI: 10.1016/j.ajog.2019.06.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/02/2019] [Accepted: 06/12/2019] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Elvira Di Pasquo
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy.
| | - Andrea Dall'Asta
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Laura Angeli
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Stefania Fieni
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | | | - Tiziana Frusca
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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Sharabi-Nov A, Kumar K, Fabjan Vodušek V, Premru Sršen T, Tul N, Fabjan T, Meiri H, Nicolaides KH, Osredkar J. Establishing a Differential Marker Profile for Pregnancy Complications Near Delivery. Fetal Diagn Ther 2019; 47:471-484. [PMID: 31778996 DOI: 10.1159/000502177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/16/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this work was to define a differential marker profile for pregnancy complications near delivery. METHODS We enrolled pregnant women who were referred to the outpatient pregnancy clinic of the University Medical Center, Ljubljana, Slovenia, due to symptoms of pregnancy complications and women with a history of pregnancy complications attending the high-risk hospital clinic for close surveillance. They were evaluated for prior risk and were tested for biophysical and biochemical markers at the time of enrolment. Biochemical markers included the pro- and anti-angiogenic markers, along with additional previously reported markers of potential value, all tested by various formats of immuno-diagnostics. Biophysical markers included blood pressure, sonographic markers, and EndoPAT. Statistical differences were determined with Kruskal-Wallis and Mann-Whitney tests for continuous parameters, and Pearson χ2 for categorical values. p < 0.05 was considered significant. RESULTS The cohort included 125 pregnant patients, 31 developed preeclampsia (PE) alone (13 were <34 weeks' gestation), 16 had intrauterine growth restriction (IUGR) alone (12 were <34 weeks), 42 had both IUGR and PE (22 were <34 weeks), and 15 had an iatrogenic preterm delivery (PTD; 6 were <34 weeks). Twenty-one were unaffected and delivered a healthy baby at term. Mean arterial blood pressure and proteinuria were significantly higher in PE and PE+IUGR but not in pure IUGR or PTD. In PE, IUGR, and PE+IUGR, the levels of soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin (sEng) were significantly higher, while placental growth factor (PlGF) was very low compared to unaffected controls and PTD. PE, IUGR, and PE+IUGR also had a high anti-angiogenic ratio (sFlt-1/PlGF) and a low proangiogenic ratio of PlGF/(sFlt-1+Eng). Levels of inhibin A were significantly higher in pure PE across subgroups but had many extreme values, which made it a poor differentiator. Higher uterine artery Doppler pulsatility indexes were detected in PE, IUGR, and PE+IUGR, with similar resistance indexes and peaks of systolic velocity. A significantly different marker level between PE and IUGR was found using arterial stiffness that was 10 times higher in PE; concurrently with an increase of the reactive hyperemia index, both were accompanied by a slight increase in placental protein 13. Higher tumor necrosis factor alpha (TNFα) differentially identified iatrogenic very early PTD (<34 weeks). CONCLUSION Arterial stiffness can serve as a major marker to differentiate PE (with/without IUGR) from pure IUGR near delivery. TNFα can differentiate iatrogenic early PTD from other complications of pregnancy and term IUGR.
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Affiliation(s)
| | - Kristina Kumar
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Vesna Fabjan Vodušek
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Tanja Premru Sršen
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Nataša Tul
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.,Women's Hospital Postojna, Postojna, Slovenia
| | - Teja Fabjan
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | | | - Kypros H Nicolaides
- The Fetal Medicine Institute and Fetal Medicine Foundation, London, United Kingdom
| | - Joško Osredkar
- Institute of Clinical Chemistry and Biochemistry, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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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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48
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Bijl RC, Cornette JMJ, van den Bosch AE, Duvekot JJ, Molinger J, Willemsen SP, Koning AHJ, Roos-Hesselink JW, Franx A, Steegers-Theunissen RPM, Koster MPH. Study protocol for a prospective cohort study to investigate Hemodynamic Adaptation to Pregnancy and Placenta-related Outcome: the HAPPO study. BMJ Open 2019; 9:e033083. [PMID: 31712350 PMCID: PMC6858161 DOI: 10.1136/bmjopen-2019-033083] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The importance of cardiovascular health in relation to pregnancy outcome is increasingly acknowledged. Women who develop certain pregnancy complications, in particular preeclampsia, are at higher risk for future cardiovascular disease. Independent of its outcome, pregnancy requires a substantial adaptive response of the maternal cardiovascular system. In the Hemodynamic Adaptation to Pregnancy and Placenta-related Outcome (HAPPO) study, we aim to examine longitudinal maternal haemodynamic adaptation to pregnancy from the preconception period onwards. We hypothesise that women who will develop adverse pregnancy outcomes have impaired cardiovascular health before conception, leading to haemodynamic maladaptation to pregnancy and diminished uteroplacental vascular development. METHODS AND ANALYSIS In this prospective cohort study embedded in the Rotterdam periconception cohort, 200 women with a history of placenta-related pregnancy complications (high-risk group) and 100 women with an uncomplicated obstetric history (low-risk group) will be included. At five moments (preconception, first, second and third trimester and postdelivery), women will undergo an extensive examination of the macrocirculatory and microcirculatory system and uteroplacental vascular development. The main outcome measures are differences in maternal haemodynamic adaptation to pregnancy between women with and without placenta-related pregnancy complications. In a multivariate linear mixed model, the relationship between maternal haemodynamic adaptive parameters, (utero)placental vascularisation indices and clinical outcomes (occurrence of pregnancy complications, embryonic and fetal growth trajectories, miscarriage rate, gestational age at delivery, birth weight) will be studied. Subgroup analysis will be performed to study baseline and trajectory differences between high-risk and low-risk women, independent of subsequent pregnancy outcome. ETHICS AND DISSEMINATION This study protocol was approved by the Medical Ethics Committee of the Erasmus MC, Rotterdam, the Netherlands (MEC 2018-150). Results will be disseminated to the medical community by publications in peer-reviewed journals and presentations at scientific congresses. Also, patient associations will be informed and the public will be informed by dissemination through (social) media. TRIAL REGISTRATION NUMBER NL7394 (www.trialregister.nl).
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Affiliation(s)
- Rianne C Bijl
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
| | - Jérôme M J Cornette
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
| | - Jeroen Molinger
- Department of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands
- Department of Anesthesiology & Intensive Care Medicine, Human Physiology and Pharmacology Lab (HPPL), Duke Medicine, Durham, North Carolina, USA
| | - Sten P Willemsen
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
| | | | | | - Arie Franx
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Maria P H Koster
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
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Vonck S, Lanssens D, Staelens AS, Tomsin K, Oben J, Bruckers L, Gyselaers W. Obesity in pregnancy causes a volume overload in third trimester. Eur J Clin Invest 2019; 49:e13173. [PMID: 31545513 DOI: 10.1111/eci.13173] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 07/06/2019] [Accepted: 09/18/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Obesity is a major risk factor for cardiovascular diseases. In this study, we aimed to investigate the maternal circulatory differences during pregnancy between obese and normal weight women. MATERIALS AND METHODS The functioning of the maternal circulation (arteries, veins, heart and body fluid) was assessed by ECG-Doppler ultrasound, impedance cardiography (ICG) and bio-impedance during pregnancy in obese women (BMI ≥30 kg/m2 ) and normal weight, nonobese women (BMI 20-25 kg/m2 ). In this observational study, 232 assessments were performed in the obese group, whereas 919 assessments were performed in the nonobese group. RESULTS Relative to nonobese women, the overall cardiovascular function in obese women during first and second trimester is consistent with a high volume/low-resistance circulation. In third trimester, cardiac output of obese women decreases from 9.2 (8.2-10.7) L/min to 8.5 (7.6-9.6) L/min (P = .037) whereas this is not true in the nonobese women (from 7.8 (7-8.5) L/min to 7.8 (6.8-8.9) L/min, P = .536). Simultaneously, the persistently lower peripheral vascular resistance in obese vs nonobese women disappears (880 (761-1060) dyn.sec/cm5 vs 928 (780-1067). CONCLUSIONS The circulatory gestational adaptations between nonobese and obese women were generally similar. The findings in the third trimester suggest that a pregnancy in obese women start as a state of high volume/low resistance, gradually shifting to a volume overload with decrease of cardiac output and disappearance of low vascular resistance. This evolution makes obese women vulnerable for gestational hypertensive diseases.
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Affiliation(s)
- Sharona Vonck
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, Diepenbeek, Belgium.,Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dorien Lanssens
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, Diepenbeek, Belgium.,Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Kathleen Tomsin
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jolien Oben
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Liesbeth Bruckers
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Gyselaers
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, Diepenbeek, Belgium.,Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department Physiology, Hasselt University, Diepenbeek, Belgium
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50
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Perry H, Stirrup O, Gutierrez J, Vinayagam D, Thilaganathan B, Khalil A. Influence of maternal characteristics and gestational age on hemodynamic indices: NICOM device-specific reference ranges. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:670-675. [PMID: 30548496 DOI: 10.1002/uog.20179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/04/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To construct reference ranges for stroke volume, cardiac output and systemic vascular resistance (SVR) in normal pregnancy for the NICOM® device, and to explore associations between maternal characteristics and these hemodynamic variables. METHODS This was a prospective cohort study of healthy singleton pregnancies between 10 and 40 weeks' gestation attending a tertiary referral hospital between September 2012 and May 2018. Measurements of stroke volume, cardiac output and SVR were obtained throughout pregnancy using NICOM, a non-invasive device based on bioreactance technology. NICOM device-specific reference ranges were created with respect to gestational age and maternal characteristics. Once the distribution of the data had been determined with respect to the gestational age, patient characteristics were added to the model to test whether they provided a significant improvement in prediction of the median value. The effect was assessed of maternal weight, height, smoking status, conception using assisted reproductive technology, nulliparity and ethnicity. RESULTS We included 411 women in this study. The relationships between cardiac variables and gestational age observed in the NICOM-specific reference ranges are consistent with previous findings, with increasing cardiac output values until around 35 weeks and a decrease thereafter until term, and decreasing SVR until around 36 weeks, followed by an increase towards 40 weeks. Stroke volume showed a small linear increase across gestation with lower variability in observations close to term. Maternal weight, height and age were associated with cardiac output (all P < 0.05) and SVR (all P < 0.01), whilst maternal weight and height were associated with stroke volume (both P < 0.001). Ethnicity was significantly associated with stroke volume (P = 0.001) but not with cardiac output or SVR. CONCLUSIONS This study presents device-specific reference ranges for stroke volume, cardiac output and SVR for the NICOM device in healthy pregnancy and describes the maternal characteristics that are associated with the values of these hemodynamic measurements. Studies using NICOM in pregnancy can use these ranges in order to evaluate observations relative to those expected in uncomplicated pregnancy conditional on maternal characteristics. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - O Stirrup
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
| | - J Gutierrez
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - D Vinayagam
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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