The use of pulse wave velocity in predicting pre-eclampsia in high-risk women

Increase of augmentation index (AIx@75): a promising tool for screening hypertensive pregnancy disorders

BACKGROUND

Screening tools in the first trimester of pregnancy for hypertensive pregnancy disorders need to be determined.

OBJECTIVES

To compare cardiovascular parameters between pregnant (PG) and non-pregnant women (NPG) and to evaluate the sensitivity and specificity of arterial stiffness indices in screening for hypertensive pregnancy disorders and their possible association with the mean uterine artery pulsatility index (MUA-PI).

METHODS

This study included 77 pregnant women (11-13.6 gestational weeks) and 77 age-matched non-pregnant women. Cardiovascular parameters were non-invasively measured using Mobil- O-Graph®, a cuff-based oscillometric device. The Doppler Ultrasonographic was used to evaluate the MUA-PI.

RESULTS

Augmentation index (AIx@75) was significantly higher in PG compared to NPG. ROC curve of AIx@75 showed area under curve (AUC): 0.7303, Sensitivity: 74.03% and Specificity: 64.94% and Cutoff: 22.50%. The systolic volume index was lower and the heart rate was higher in PG compared to NPG. Of the 77 pregnant women, 12 had an unfavorable outcome with hypertensive changes. Central systolic blood pressure (109.1 ± 8.84mmHg) and AIx@75 (31.97 ± 5.47%) were significantly higher in the group of pregnant women with outcome compared to the group without outcome (103.0 ± 8.53mmHg and 26.80 ± 8.71%). ROC curve showed better performance of the AIx@75 [AUC: 0.7179, Sensitivity: 83.33% and Specificity: 60.00%, Cutoff: 27.67%] compared to MUA-PI [AUC: 0.5098, Sensitivity: 8.333% and Specificity 98.44%].

CONCLUSIONS

AIx@75 was significantly higher in PG compared to NPG. We compared the AIx@75 of PG with and without outcomes. ROC curve analysis showed that this index could discriminate between PG with and without an outcome. Differently, the MUA-PI did not differ between PG with and without outcome, suggesting the superiority of AIx@75 in relation to MUA-PI as a method of screening in the first trimester for hypertensive disease of pregnancy. AIx@75 did not assotiate with MUA-PI. Prospective studies will be needed to confirm these findings.

Vascular health and exercise in females throughout the lifespan: Exploring puberty, pregnancy and menopause

This narrative review highlights the impact of exercise on vascular health in females over the lifespan with an emphasis on puberty, pregnancy and menopause. These events encompass substantial changes in sex hormone levels, particularly oestrogens and progesterone. They are also accompanied by distinct adaptations of the central, peripheral and cerebral vasculature. Regular exercise is an effective mechanism to reduce vascular risk in females of all ages, especially for those at higher risk for vascular disorders. However, there are large variabilities in the vascular adaptations to exercise in females that may be related to circulating sex hormone levels. In addition, exogenous hormones, such as oral contraceptives taken after puberty or hormonal replacement therapy taken to mitigate symptoms of menopause, may interact with exercise-induced changes in vascular function. We highlight how more research is needed to understand the optimal exercise interventions to promote vascular health in females across the lifespan, especially during times of hormonal transition.

The association between pulse wave velocity and pregnancy-associated diseases: A systematic review and meta-analysis

Background

Maintaining healthy vascular structure and function is important for a healthy pregnancy. Obesity is a well-known predictor for poor postoperative outcomes of vascular surgery. However, the association between pulse wave velocity (PWV), a well-recognized parameter for arterial stiffness assessment, and pregnancy-associated diseases is still unclear. Therefore, we conducted this systematic review, and a meta-analysis was performed to assess the relevant associations.

Methods

We systematically searched the Web of Science and PubMed databases to obtain articles on PWV and pregnancy-associated diseases published before April 2023. The mean with standard deviation was used to assess the differences in PWV in pregnant women with or without relevant diseases. Subgroup analysis was conducted according to specific types of PWV. The Newcastle‒Ottawa Scale was used to evaluate the quality of the enrolled studies.

Results

A total of 6488 individuals from 21 studies were included. All enrolled studies were high-quality. Overall, the PWV was elevated in pregnant women who suffered from preeclampsia (mean difference (MD) = 0.67, 95 % confidence interval (CI): 0.51,0.83, P < 0.00001), hypertension (MD = 1.04, 95 % CI: 1.00,1.08, P < 0.00001), gestational diabetes mellitus (MD = 0.34, 95%CI: 0.19,0.48, P < 0.00001), and diabetes (MD = 0.49, 95%CI: 0.27,0.70, P < 0.00001). Subgroup analysis based on specific types of PWV showed similar results.

Conclusion

In our study, PWV is elevated in pregnancy-associated diseases, including preeclampsia, hypertension, and diabetes. The PWV assessment should be regarded as a clinical routine for pregnant women to prevent and manage cardiovascular diseases during pregnancy.

Maternal vascular indices at 36 weeks' gestation in the prediction of preeclampsia

BACKGROUND

Epidemiological studies have shown that women with preeclampsia (PE) are at increased long term cardiovascular risk. This risk might be associated with accelerated vascular ageing process but data on vascular abnormalities in women with PE are scarce.

OBJECTIVE

This study aimed to identify the most discriminatory maternal vascular index in the prediction of PE at 35 to 37 weeks' gestation and to examine the performance of screening for PE by combinations of maternal risk factors and biophysical and biochemical markers at 35 to 37 weeks' gestation.

STUDY DESIGN

This was a prospective observational nonintervention study in women attending a routine hospital visit at 35 0/7 to 36 6/7 weeks' gestation. The visit included recording of maternal demographic characteristics and medical history, vascular indices, and hemodynamic parameters obtained by a noninvasive operator-independent device (pulse wave velocity, augmentation index, cardiac output, stroke volume, central systolic and diastolic blood pressures, total peripheral resistance, and fetal heart rate), mean arterial pressure, uterine artery pulsatility index, and serum concentration of placental growth factor and soluble fms-like tyrosine kinase-1. The performance of screening for delivery with PE at any time and at <3 weeks from assessment using a combination of maternal risk factors and various combinations of biomarkers was determined.

RESULTS

The study population consisted of 6746 women with singleton pregnancies, including 176 women (2.6%) who subsequently developed PE. There were 3 main findings. First, in women who developed PE, compared with those who did not, there were higher central systolic and diastolic blood pressures, pulse wave velocity, peripheral vascular resistance, and augmentation index. Second, the most discriminatory indices were systolic and diastolic blood pressures and pulse wave velocity, with poor prediction from the other indices. However, the performance of screening by a combination of maternal risk factors plus mean arterial pressure was at least as high as that of a combination of maternal risk factors plus central systolic and diastolic blood pressures; consequently, in screening for PE, pulse wave velocity, mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 were used. Third, in screening for both PE within 3 weeks and PE at any time from assessment, the detection rate at a false-positive rate of 10% of a biophysical test consisting of maternal risk factors plus mean arterial pressure, uterine artery pulsatility index, and pulse wave velocity (PE within 3 weeks: 85.2%; 95% confidence interval, 75.6%-92.1%; PE at any time: 69.9%; 95% confidence interval, 62.5%-76.6%) was not significantly different from a biochemical test using the competing risks model to combine maternal risk factors with placental growth factor and soluble fms-like tyrosine kinase-1 (PE within 3 weeks: 80.2%; 95% confidence interval, 69.9%-88.3%; PE at any time: 64.2%; 95% confidence interval, 56.6%-71.3%), and they were both superior to screening by low placental growth factor concentration (PE within 3 weeks: 53.1%; 95% confidence interval, 41.7%-64.3%; PE at any time: 44.3; 95% confidence interval, 36.8%-52.0%) or high soluble fms-like tyrosine kinase-1-to-placental growth factor concentration ratio (PE within 3 weeks: 65.4%; 95% confidence interval, 54.0%-75.7%; PE at any time: 53.4%; 95% confidence interval, 45.8%-60.9%).

CONCLUSION

First, increased maternal arterial stiffness preceded the clinical onset of PE. Second, maternal pulse wave velocity at 35 to 37 weeks' gestation in combination with mean arterial pressure and uterine artery pulsatility index provided effective prediction of subsequent development of preeclampsia.

Highlighting the Mechanistic Relationship Between Perinatal Depression and Preeclampsia: A Scoping Review

Background

Although there is scientific literature supporting an association between depression and preeclampsia (PE), little is known about the underlying mechanistic pathways that may explain these observed associations. Thus, this study aimed to outline the relationship between depression and PE, and to highlight the underlying cardiovascular and metabolic risk factors that are common to both.

Methods

A scoping review of the literature was conducted in Medline, Scopus, and Web of Science.

Results

From 706 articles initially identified, 23 articles met the inclusion criteria and were included in this review. Although some studies reported a positive association between PE and postpartum depressive symptoms, challenges comparing different methodologies, measurement instruments and when measurements were administered, and patient populations do not permit a decisive conclusion. In addition, very few studies addressed potential underlying mechanisms that may be contributing to observed associations; thus, a secondary search was conducted to identify cardiovascular and metabolic risk factors that are common to both depression and PE.

Conclusion

The cardiovascular and metabolic risk factors (i.e., increased inflammation and oxidative stress and decreased vascular and endothelial function) common to both depression and PE suggest that these factors may contribute as underlying mechanisms in both conditions. These similarities underscore the importance to better understand these mechanisms so preventative and therapeutic strategies could be developed to improve maternal health.

Diagnosing Arterial Stiffness in Pregnancy and Its Implications in the Cardio-Renal-Metabolic Chain

Cardio-renal and metabolic modifications during gestation are crucial determinants of foetal and maternal health in the short and long term. The cardio-renal metabolic syndrome is a vicious circle that starts in the presence of risk factors such as obesity, hypertension, diabetes, kidney disease and ageing, all predisposing to a status dominated by increased arterial stiffness and alteration of the vascular wall, which eventually damages the target organs, such as the heart and kidneys. The literature is scarce regarding cardio-renal metabolic syndrome in pregnancy cohorts. The present paper exposes the current state of the art and emphasises the most important findings of this entity, particularly in pregnant women. The early assessment of arterial function can lead to proper and individualised measures for women predisposed to hypertension, pre-eclampsia, eclampsia, and diabetes mellitus. This review focuses on available information regarding the assessment of arterial function during gestation, possible cut-off values, the possible predictive role for future events and modalities to reverse or control its dysfunction, a fact of crucial importance with excellent outcomes at meagre costs.

Vascular Age, Metabolic Panel, Cardiovascular Risk and Inflammaging in Patients With Rheumatoid Arthritis Compared With Patients With Osteoarthritis

Introduction

The risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) is 1.5–2 times higher than the general population. The fundamental risk factor for CVD is age, related to alterations at the arterial level. The aim of the study was to compare vascular age (VA) in RA patients under a strict treat-to-target (T2T) strategy with Osteoarthritis (OA) patients without strict follow up and to assess the influence of inflammaging (chronic, sterile, low-grade inflammation related to aging) and metabolic markers on VA.

Materials and Methods

This was an analytical cross-sectional study. Patients with RA (under a strict a T2T strategy) and OA patients without strict clinical follow-up were included. Patients with a history of uncontrolled hypertension, CVD, and/or current smoking were excluded. Sociodemographic, physical activity, and toxic exposure data were obtained. Waist-hip ratio and body mass index (BMI) were measured. DAS-28 (RA) and inflammatory markers, lipid profile, and glycaemia were analyzed. Pulse wave velocity (PWV) was measured (oscillometric method, Arteriograph-TensioMed®). VA was calculated based on PWV. Eleven components of inflammaging [six interleukins, three metalloproteinases (MMP), and two tissue inhibitors of metalloproteinases (TIMP)] were evaluated (Luminex® system). Univariate and bivariate analyzes (Mann Whitney U and chi-square) and correlations (Spearmans Rho) were done to compare the two groups.

Results

A total of 106 patients (74% women) were included, 52/RA and 54/OA. The mean age was 57 (Interquartile range - IQR 9 years). The BMI, waist circumference, and weight were higher in patients with OA (p &lt; 0.001). RA patients had low disease activity (DAS-28-CRP). There were no differences in VA, inflammaging nor in PWV between the two groups. VA had a positive, but weak correlation, with age and LDL. In group of RA, VA was higher in those who did not receive methotrexate (p = 0.013). LDL levels correlated with MMP1, TIMP1, and TIMP2.

Conclusions

When comparing RA patients with low levels of disease activity with OA patients with poor metabolic control, there are no differences in VA. Furthermore, methotrexate also influences VA in RA patients. This shows that implemented therapies may have an impact on not only the inflammatory state of the joint but also CVD risk.

Preeclampsia has two phenotypes which require different treatment strategies

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.

Personalising cardiovascular network models in pregnancy: A two-tiered parameter estimation approach

Uterine artery Doppler waveforms are often studied to determine whether a patient is at risk of developing pathologies such as pre-eclampsia. Many uterine waveform indices have been developed, which attempt to relate characteristics of the waveform with the physiological adaptation of the maternal cardiovascular system, and are often suggested to be an indicator of increased placenta resistance and arterial stiffness. Doppler waveforms of four patients, two of whom developed pre-eclampsia, are compared with a comprehensive closed-loop model of pregnancy. The closed-loop model has been previously validated but has been extended to include an improved parameter estimation technique that utilises systolic and diastolic blood pressure, cardiac output, heart rate, and pulse wave velocity measurements to adapt model resistances, compliances, blood volume, and the mean vessel areas in the main systemic arteries. The shape of the model-predicted uterine artery velocity waveforms showed good agreement with the characteristics observed in the patient Doppler waveforms. The personalised models obtained now allow a prediction of the uterine pressure waveforms in addition to the uterine velocity. This allows for a more detailed mechanistic analysis of the waveforms, eg, wave intensity analysis, to study existing clinical indices. The findings indicate that to accurately estimate arterial stiffness, both pulse pressure and pulse wave velocities are required. In addition, the results predict that patients who developed pre-eclampsia later in pregnancy have larger vessel areas in the main systemic arteries compared with the two patients who had normal pregnancy outcomes.

A longitudinal analysis of arterial stiffness and wave reflection in preeclampsia: Identification of changepoints

PURPOSE

Preeclampsia (PrE) is a leading complication of pregnancy characterized by vascular dysfunction. Characterizing the longitudinal changes in vascular function prior to PrE onset is critical to the identification of optimal timepoints for vascular assessment and the development of effective early screening strategies.

METHODS

In this prospective longitudinal study of women with singleton high-risk pregnancies, arterial stiffness and wave reflection parameters were assessed using applanation tonometry at 10-13 weeks' gestation and repeated every 4 weeks throughout pregnancy. Changepoints in carotid-femoral pulse wave velocity (cfPWV), carotid-radial PWV (crPWV), augmentation index (AIx), time to wave reflection (T_1R), pulse pressure amplification (PPA), and subendocardial viability ratio (SEVR) were compared between women who did and did not subsequently develop PrE.

RESULTS

A changepoint in cfPWV and crPWV was detected at 14-17 weeks' gestation. cfPWV then increased in women who went on to develop PrE but decreased in women who did not; a 1.2 m/s difference in cfPWV between the groups was observed at 22-25 weeks' gestation. Conversely, crPWV converged in the two groups from a baseline difference of 1.05 m/s (95% credible interval: 0.37, 1.72). Women who subsequently developed PrE demonstrated an increase in AIx at 18-21 weeks' gestation that was not seen in women who did not develop PrE until 30-33 weeks. No differences in T_1R, PPA, or SEVR were observed between the groups.

CONCLUSIONS

Altered vascular adaptations were detected using measures of arterial stiffness and wave reflection in the early second trimester of pregnant women who developed PrE compared to those who did not. These findings demonstrate the potential clinical utility of arterial stiffness and wave reflection parameters as an early screening tool for PrE, which can be used to inform clinical management of high-risk pregnancies.

CHANGES IN GAUSSIAN MODELING PARAMETERS OF PPG PULSE DURING HEALTHY PREGNANCY

We used Gaussian modeling to depict the changes in finger photoplethysmographic (PPG) pulse during pregnancy in healthy women. We enrolled 70 healthy pregnant women and recorded their PPG pulses in 11–13 gestational weeks, 20–22 gestational weeks, and 37–39 gestational weeks. Three independent positive Gaussian functions were utilized to decompose the pulses, and each Gaussian function extracted three key parameters: the peak amplitude ([Formula: see text]), the peak position ([Formula: see text]), and the half-width ([Formula: see text]). The method of ANOVA and post-hoc multiple comparisons of mathematical statistics were utilized to study the differences of these parameters between the three trimesters. We found that in the first trimester [Formula: see text] increased significantly ([Formula: see text]: [Formula: see text] versus [Formula: see text], [Formula: see text]). [Formula: see text] and [Formula: see text] increased in the first trimester ([Formula: see text]: [Formula: see text] versus [Formula: see text], [Formula: see text]; [Formula: see text]: [Formula: see text] versus [Formula: see text], [Formula: see text]), then decreased significantly ([Formula: see text]: [Formula: see text] versus [Formula: see text], [Formula: see text]: [Formula: see text] versus [Formula: see text], [Formula: see text]). [Formula: see text] is associated with cardiac output, and [Formula: see text] and [Formula: see text] are associated with peripheral vascular resistance. The results of this study were consistent with the conclusion that healthy pregnant women exhibited high flow state of the cardiovascular system and their peripheral vascular resistance decreased first and then gradually recovered during pregnancy. This study indicated that PPG pulse could also reflect the changes in the maternal cardiovascular system during pregnancy.

Endometrial preparation for frozen-thawed embryo transfer cycles: a systematic review and network meta-analysis

PURPOSE

To compare the effects of different endometrial preparation protocols for frozen-thawed embryo transfer (FET) cycles and present treatment hierarchy.

METHODS

Systematic review with meta-analysis was performed by electronic searching of MEDLINE, the Cochrane Library, Embase, ClinicalTrials.gov and Google Scholar up to Dec 26, 2020. Randomised controlled trials (RCTs) or observational studies comparing 7 treatment options (natural cycle with or without human chorionic gonadotrophin trigger (mNC or tNC), artificial cycle with or without gonadotropin-releasing hormone agonist suppression (AC+GnRH or AC), aromatase inhibitor, clomiphene citrate, gonadotropin or follicle stimulating hormone) in FET cycles were included. Meta-analyses were performed within random effects models. Primary outcome was live birth presented as odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

Twenty-six RCTs and 113 cohort studies were included in the meta-analyses. In a network meta-analysis, AC ranked last in effectiveness, with lower live birth rates when compared with other endometrial preparation protocols. In pairwise meta-analyses of observational studies, AC was associated with significant lower live birth rates compared with tNC (OR 0.81, 0.70 to 0.93) and mNC (OR 0.85, 0.77 to 0.93). Women who achieved pregnancy after AC were at an increased risk of pregnancy-induced hypertension (OR 1.82, 1.37 to 2.38), postpartum haemorrhage (OR 2.08, 1.61 to 2.78) and very preterm birth (OR 2.08, 1.45 to 2.94) compared with those after tNC.

CONCLUSION

Natural cycle treatment has a higher chance of live birth and lower risks of PIH, PPH and VPTB than AC for endometrial preparation in women receiving FET cycles.

Role of arterial impairment in preeclampsia: should the paradigm shift?

Preeclampsia is a worldwide pregnancy complication with serious short- and long-term maternal and neonatal consequences. Our understanding of preeclampsia pathophysiology has significantly evolved over the last decades with the recognition that impaired arterial function and structure may occur early in the course of pregnancy, preceding the clinic-humoral syndrome and driving long-term cardiovascular disease risk in the future of these patients. Although an early abnormal placentation may be the inciting event for a large proportion of cases, there is growing evidence that challenges the placental hypothesis in all affected women, since placental histopathology lesions thought to be characteristic are neither sensitive nor specific markers for the disorder. Recent hemodynamic investigations and studies on left ventricular function and structure in women with preeclampsia further challenge this universal paradigm and propose that placental dysfunction could be secondary to a maternal cardiovascular maladaptation to pregnancy in certain patients. Supporting this hypothesis, certain vascular features, which are characteristically enhanced in normal pregnancy allowing a healthy vascular adaptation, are absent in preeclampsia and comparable to the nonpregnant population. However, arterial biomechanics in preeclampsia may only not cope with hemodynamic demands of pregnancy but also impose additional detrimental loads to the maternal heart ("impaired left-ventricle-aorta coupling") and transmit pressure and flow disturbances into the fetoplacental circulation ("impaired large arteries-microcirculation coupling"). In this review, we analyze the major role of the arterial dysfunction in the cardiovascular maladaptation hypothesis of preeclampsia, shed light on its potential etiopathogenic link, and discuss the complementary nature of the placental and cardiovascular theories.

Maternal Vascular Health in Pregnancy and Postpartum After Assisted Reproduction

Although most pregnancies after assisted reproduction are associated with a favorable outcome for the mother and infant, reports of abnormal vascular adaptation in early pregnancy and emerging maternal and perinatal pathology warrant further investigations. Herein we extended our previous work and further examined whether perturbations of blood pressure and endothelial function during the first trimester in conceptions with nonphysiological corpus luteum (CL) numbers would persist through the third trimester of pregnancy and into the postpartum period. We investigated both maternal and perinatal outcomes. Participants were grouped according to CL number and method of conception: 0 CL (programmed autologous frozen-thawed embryo transfer, N=10-18); 1 CL (spontaneous conception [N=16] and natural cycle frozen-thawed embryo transfer [N=12]); or >3 CL associated with autologous fresh embryo transfer [N=8-12]. Augmentation index was higher during the third trimester in the absence of a CL compared to 1 CL (P=0.03) and in frozen-thawed embryo transfer in a programmed compared to a natural cycle (P=0.02). Moreover, baseline pulse-wave amplitude was higher in >3 CL conceptions at all time points (all P<0.05). The incidence of preeclampsia and preeclampsia with severe features was significantly higher in the absence of a CL compared to the presence of one or >3 CL (P=0.045 and P=0.03). Infants from conceptions with >3 CL had lower birth weights (P=0.02) and a higher rate of low birth weight offspring (P=0.008). Deficient vascular adaptation during early gestation in conceptions with nonphysiological CL numbers might predispose women to adverse pregnancy outcomes, for example, preeclampsia.

Frozen-thawed embryo transfer: the potential importance of the corpus luteum in preventing obstetrical complications

The use of frozen-thawed embryo transfer (FET) has increased over the past decade with improvements in technology and increasing live birth rates. FET facilitates elective single-embryo transfer, reduces ovarian hyperstimulation syndrome, optimizes endometrial receptivity, allows time for preimplantation genetics testing, and facilitates fertility preservation. FET cycles have been associated, however, with an increased risk of hypertensive disorders of pregnancy for reasons that are not clear. Recent evidence suggests that absence of the corpus luteum (CL) could be at least partly responsible for this increased risk. In a recent prospective cohort study, programmed FET cycles (no CL) were associated with higher rates of preeclampsia and preeclampsia with severe features compared with modified natural FET cycles. FET cycles are commonly performed in the context of a programmed cycle in which the endometrium is prepared with the use of exogenous E2 and P. In these cycles, ovulation is suppressed and therefore the CL is absent. The CL produces not only E2 and P, but also vasoactive products, such as relaxin and vascular endothelial growth factor, which are not replaced in a programmed FET cycle and which are hypothesized to be important for initial placentation. Emerging evidence has also revealed other adverse obstetrical and perinatal outcomes, including postpartum hemorrhage, macrosomia, and post-term birth specifically in programmed FET cycles compared with natural FET cycles. Despite the widespread use of FET, the optimal protocol with respect to live birth rate, maternal health, and perinatal outcomes has yet to be determined. Future practice regarding FET should be based on high-quality evidence, including rigorous controlled trials.

A Systematic Review of Vascular Structure and Function in Pre-eclampsia: Non-invasive Assessment and Mechanistic Links

Hypertensive disorders of pregnancy, such as pre-eclampsia, are known to be independently associated with the development of premature cardiovascular disease (CVD) in women. In pre-eclampsia, the placenta secretes excess anti-angiogenic factors into the maternal circulation, leading to widespread endothelial damage, and inflammation. This endothelial damage is evidenced to persist beyond the acute illness. However, whether it is permanent and responsible for the elevated rates of premature CVD seen in this at-risk group remains unclear. A systematic review of the available literature with respect to vascular structure and function prior to, during and after a pregnancy complicated by pre-eclampsia was performed. Studies non-invasively assessing vascular structure using carotid intima-media thickness (CIMT), retinal microvasculature caliber, CT coronary angiogram, or coronary calcium scores were included. Vascular function was assessed using brachial flow-mediated dilation (FMD), pulse wave analysis (PWA), and peripheral arterial tonometry (PAT). In total 59 articles were included (13 CIMT, 5 CTCA/Ca score, five retinal microvasculature, 27 FMD, 7 PAT, and 14 PWV/PWA), consisting of prospective and retrospective cohort, and case-control studies. Change in vascular structure was evidenced with significant increases in CIMT by 73-180 μm greater than that of non-affected women. This is tempered by other studies reporting resolution of structural changes postpartum, highlighting the need for further research. Accelerated coronary calcification and plaque deposition was identified, with greater rates of increased calcium scores and subclinical coronary artery disease shown by CTCA in women with a history of pre-eclampsia at 30 years postpartum. Impaired endothelial function was consistently reported prior to, during and immediately after pregnancy as evidenced by differences in FMD of 1.7-12.2% less than non-affected women, an increase in PWV by 13.2-26%, and reduced retinal microvascular caliber and arterial elasticity indices. The evidence was less conclusive for the persistence of long-term endothelial dysfunction. Understanding the underlying mechanistic links between pre-eclampsia and CVD is a key step to identifying targeted therapies aimed at "repairing the endothelium" and attenuating risk. This review has highlighted the need for a greater understanding of vascular structure and function following pre-eclampsia through high quality studies with large sample sizes, particularly in the longer postpartum period when clinical CVD disease starts to manifest.

A Systematic Review of Vascular Structure and Function in Pre-eclampsia: Non-invasive Assessment and Mechanistic Links

Hypertensive disorders of pregnancy, such as pre-eclampsia, are known to be independently associated with the development of premature cardiovascular disease (CVD) in women. In pre-eclampsia, the placenta secretes excess anti-angiogenic factors into the maternal circulation, leading to widespread endothelial damage, and inflammation. This endothelial damage is evidenced to persist beyond the acute illness. However, whether it is permanent and responsible for the elevated rates of premature CVD seen in this at-risk group remains unclear. A systematic review of the available literature with respect to vascular structure and function prior to, during and after a pregnancy complicated by pre-eclampsia was performed. Studies non-invasively assessing vascular structure using carotid intima-media thickness (CIMT), retinal microvasculature caliber, CT coronary angiogram, or coronary calcium scores were included. Vascular function was assessed using brachial flow-mediated dilation (FMD), pulse wave analysis (PWA), and peripheral arterial tonometry (PAT). In total 59 articles were included (13 CIMT, 5 CTCA/Ca score, five retinal microvasculature, 27 FMD, 7 PAT, and 14 PWV/PWA), consisting of prospective and retrospective cohort, and case-control studies. Change in vascular structure was evidenced with significant increases in CIMT by 73–180 μm greater than that of non-affected women. This is tempered by other studies reporting resolution of structural changes postpartum, highlighting the need for further research. Accelerated coronary calcification and plaque deposition was identified, with greater rates of increased calcium scores and subclinical coronary artery disease shown by CTCA in women with a history of pre-eclampsia at 30 years postpartum. Impaired endothelial function was consistently reported prior to, during and immediately after pregnancy as evidenced by differences in FMD of 1.7–12.2% less than non-affected women, an increase in PWV by 13.2–26%, and reduced retinal microvascular caliber and arterial elasticity indices. The evidence was less conclusive for the persistence of long-term endothelial dysfunction. Understanding the underlying mechanistic links between pre-eclampsia and CVD is a key step to identifying targeted therapies aimed at “repairing the endothelium” and attenuating risk. This review has highlighted the need for a greater understanding of vascular structure and function following pre-eclampsia through high quality studies with large sample sizes, particularly in the longer postpartum period when clinical CVD disease starts to manifest.

Increased Preeclampsia Risk and Reduced Aortic Compliance With In Vitro Fertilization Cycles in the Absence of a Corpus Luteum

In vitro fertilization involving frozen embryo transfer and donor oocytes increases preeclampsia risk. These in vitro fertilization protocols typically yield pregnancies without a corpus luteum (CL), which secretes vasoactive hormones. We investigated whether in vitro fertilization pregnancies without a CL disrupt maternal circulatory adaptations and increase preeclampsia risk. Women with 0 (n=26), 1 (n=23), or >1 (n=22) CL were serially evaluated before, during, and after pregnancy. Because increasing arterial compliance is a major physiological adaptation in pregnancy, we assessed carotid-femoral pulse wave velocity and transit time. In a parallel prospective cohort study, obstetric outcomes for singleton livebirths achieved with autologous oocytes were compared between groups by CL number (n=683). The expected decline in carotid-femoral pulse wave velocity and rise in carotid-femoral transit time during the first trimester were attenuated in the 0-CL compared with combined single/multiple-CL cohorts, which were similar (group-time interaction: P=0.06 and 0.03, respectively). The blunted changes of carotid-femoral pulse wave velocity and carotid-femoral transit time from prepregnancy in the 0-CL cohort were most striking at 10 to 12 weeks of gestation ( P=0.01 and 0.006, respectively, versus 1 and >1 CL). Zero CL was predictive of preeclampsia (adjusted odds ratio, 2.73; 95% CI, 1.14-6.49) and preeclampsia with severe features (6.45; 95% CI, 1.94-25.09) compared with 1 CL. Programmed frozen embryo transfer cycles (0 CL) were associated with higher rates of preeclampsia (12.8% versus 3.9%; P=0.02) and preeclampsia with severe features (9.6% versus 0.8%; P=0.002) compared with modified natural frozen embryo transfer cycles (1 CL). In common in vitro fertilization protocols, absence of the CL perturbed the maternal circulation in early pregnancy and increased the incidence of preeclampsia.

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

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

Gaussian Modelling Characteristics of Peripheral Arterial Pulse: Difference between Measurements from the Three Trimesters of Healthy Pregnancy

Arterial pulse wave analysis has been attempted to monitor the maternal physiological changes of circulatory system during pregnancy. This study aimed to quantify the difference of Gaussian modelling characteristics derived from radial pulses measured from the three trimesters of healthy pregnant women. Radial pulses were recorded from seventy pregnant women between gestational week 11–13, week 20–22, and then week 37–39. They were then normalized and decomposed into three independent Gaussian waves for deriving four key modelling characteristic parameters: including the peak time interval (T) and peak amplitude ratio (R) between the first and second Gaussian waves (T_1,2 and R_1,2), and their corresponding values between the first and third Gaussian waves (T_1,3 and R_1,3). Post hoc multiple comparisons after analysis of variance was then applied to study the within-subject differences in Gaussian modelling characteristics between the three trimesters. The key results were that T_1,2 and T_1,3 increased significantly (T_1,2: 12.8 ± 1.3 vs 13.2 ± 1.3, p < 0.05; T_1,3: 39.5 ± 4.3 vs 45.4 ± 5.1, p < 0.001), and R_1,3 decreased significantly from the first to second trimester (0.60 ± 0.15 vs 0.53 ± 0.11, p < 0.001). From the second to third trimester, T_1,2 decreased significantly (13.2 ± 1.3 vs 12.8 ± 1.2, p < 0.01), and T_1,3 and R_1,3 decreased slightly but nonsignificantly. Since larger T_1,2 and T_1,3 and smaller R_1,3 are associated with more compliant peripheral arteries, our results indicated that peripheral arteries become more compliant from the first to second trimester and then have a tendency of returning to baseline during normal pregnancy. In conclusion, this study has quantitatively demonstrated significant changes of Gaussian modelling characteristics derived from radial pulses at the three trimesters of normal pregnant women, suggesting that these modelling characteristics could be used as parameters in monitoring maternal physiological changes during normal pregnancy.

Preeclampsia biomarkers: An assessment of maternal cardiometabolic health

Preeclampsia is a serious pregnancy condition defined as new-onset hypertension and proteinuria, commonly characterized as either early, 'placental', or late onset, 'maternal', using a cut-off of 34 weeks gestation. However, it may be more useful to differentiate between the vascular remodelling and placental invasion vs. inflammation and metabolic pathophysiology that underlie these forms of preeclampsia. Due to rising rates of obesity, the late-onset, maternal form is increasingly occurring earlier in pregnancy. Predictive tests for preeclampsia typically include biophysical markers such as maternal body mass index and mean arterial pressure, indicating the importance of cardiovascular and metabolic health in its pathophysiology. In contrast, the placental, inflammatory, endothelial and/or metabolic biomarkers used in these tests are generally thought to indicate an abnormal response to placentation and predict the disease. However, many of these non-placental biomarkers are known to predict impaired metabolic health in non-pregnant subjects with obesity (metabolically unhealthy obesity) and coronary artery disease or stroke in people at risk for cardiovascular events. Similarities between the performance of these markers in the prediction of cardiovascular and metabolic health outside of pregnancy suggests that they may be more indicative of maternal health than predictive for preeclampsia. This paper reviews the biophysical and biochemical markers in preeclampsia prediction and compares their performance to tests assessing metabolic health and risk of cardiovascular disease, particularly in the obese population.

Preeclampsia and Vascular Function: A Window to Future Cardiovascular Disease Risk

Preeclampsia affects ∼3%-7% of all pregnancies and is the third leading cause of maternal mortality globally. Growing evidence indicates that preeclampsia results from vascular dysfunction, which also increases the risk for future cardiovascular events. Until recently, preeclampsia was considered a disorder limited to pregnancy, which fully resolved with the delivery of the placenta; however, it is now clear that women with a history of preeclampsia have approximately double the risk of future cardiovascular events compared to women with normotensive pregnancies. The aims of this review were to describe the hemodynamic and vascular changes that occur in normal and preeclamptic pregnancies, to review noninvasive methods to test vascular function, and to discuss the associated increased cardiovascular disease risk related to preeclampsia.

Combination of serum angiopoietin-2 and uterine artery Doppler for prediction of preeclampsia

The aim of this study was to determine the predictive value of the combination of serum angiopoietin-2 (Ang-2) levels and uterine artery Doppler for the detection of preeclampsia in women at 16-18 weeks of gestation and to identify other pregnancy complications that could be predicted with these combined tests. Maternal serum Ang-2 levels were measured, and uterine artery Doppler was performed in 400 pregnant women. The main outcome was preeclampsia. The predictive values of this combination were calculated. Twenty-five women (6.3%) developed preeclampsia. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of uterine artery Doppler combined with serum Ang-2 levels for the prediction of preeclampsia were 24.0%, 94.4%, 22.2% and 94.9%, respectively. For the prediction of early-onset preeclampsia, the sensitivity, specificity, PPV and NPV were 57.1%, 94.1%, 14.8% and 99.2%, respectively. Patients with abnormal uterine artery Doppler and abnormal serum Ang-2 levels (above 19.5 ng ml(-1)) were at higher risk for preterm delivery (relative risk=2.7, 95% confidence interval 1.2-5.8). Our findings revealed that the combination of uterine artery Doppler and serum Ang-2 levels at 16-18 weeks of gestation can be used to predict early-onset preeclampsia but not overall preeclampsia. Thus, this combination may be a useful early second trimester screening test for the prediction of early-onset preeclampsia.