Myocardial performance index in hypertensive disorders of pregnancy: The relationship between blood pressures and angiogenic factors

Metabolic theory of preeclampsia: implications for maternal cardiovascular health

Preeclampsia (PE) is a multisystemic disorder of pregnancy that not only causes perinatal mortality and morbidity but also has a long-term toll on the maternal and fetal cardiovascular system. Women diagnosed with PE are at greater risk for the subsequent development of hypertension, ischemic heart disease, cardiomyopathy, cerebral edema, seizures, and end-stage renal disease. Although PE is considered heterogeneous, inefficient extravillous trophoblast (EVT) migration leading to deficient spiral artery remodeling and increased uteroplacental vascular resistance is the likely initiation of the disease. The principal pathophysiology is placental hypoxia, causing subsequent oxidative stress, leading to mitochondrial dysfunction, mitophagy, and immunological imbalance. The damage imposed on the placenta in turn results in the "stress response" categorized by the dysfunctional release of vasoactive components including oxidative stressors, proinflammatory factors, and cytokines into the maternal circulation. These bioactive factors have deleterious effects on systemic endothelial cells and coagulation leading to generalized vascular dysfunction and hypercoagulability. A better understanding of these metabolic factors may lead to novel therapeutic approaches to prevent and treat this multisystemic disorder. In this review, we connect the hypoxic-oxidative stress and inflammation involved in the pathophysiology of PE to the resulting persistent cardiovascular complications in patients with preeclampsia.

A STUDY ON THE CORRELATION BETWEEN THE ENDOTHELIN-1, NITRIC OXIDE FUNCTION AND THE RENAL HEMODYNAMICS IN PATIENTS WITH HYPERTENSIVE DISORDERS IN PREGNANCY IN HUBEI

Objective: To analyze the correlation between the vascular endothelial function (characterized by endothelin-1 and nitric oxide) and the renal hemodynamics in patients with hypertensive disorders in pregnancy (HDP) by color Doppler ultrasound.

Method: Depending on the severity of the disease, 76 HDP patients were divided into three groups, namely, pregnancy-induced hypertension (PIH) group ([Formula: see text]), mild preeclampsia (PE) group ([Formula: see text]), and severe PE group ([Formula: see text]). In the meantime, 28 healthy pregnant women were selected as controls. Color Doppler ultrasound was performed to determine the following parameters in the interlobar arteries of the kidney: Resistance index (RI), peak end-diastolic velocity (EDV), pulsatility index (PI), peak systolic velocity (PSV), and S/D ratio. The correlations of these parameters with the serum levels of ET-1 and NO were then analyzed.

Result: (1) In the interlobar arteries of the kidney, RI, S/D, PI were positively significantly correlated to the serum level of ET-1 in HDP patients (All [Formula: see text]) and negatively to the serum level of NO (All [Formula: see text]). (2) RI, S/D, PI of the mild and severe PE groups were significantly higher than those of the control group (All [Formula: see text]). However, EDV of the mild and severe PE groups was significantly lower than that of the control group (All [Formula: see text]). (3) The serum level of ET-1 was significantly higher in the HDP patients than in the control group ([Formula: see text]). However, the serum level of NO was significantly lower in the former than in the latter ([Formula: see text]). As HDP became more severe, there was an elevation in the serum level of ET-1 and a decrease in NO.

Conclusion: Indicators of renal hemodynamics measured by color Doppler ultrasound were correlated to the serum levels of ET-1 and NO characterizing the vascular endothelial function. They were sensitive indicators reflecting hemodynamic changes and renal impairment in HDP patients.

Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension

Patients with a history of hypertensive disorders of pregnancy (HDP) suffer higher rates of long-term cardiovascular events including heart failure, coronary artery disease, and stroke. Cardiovascular changes during pregnancy can act as a natural stress test, subsequently unmasking latent cardiovascular disease in the form of HDP. Because HDP now affect 10% of pregnancies in the United States, the American Heart Association has called for physicians who provide peripartum care to promote early identification and cardiovascular risk reduction. In this review, we discuss the epidemiology, pathophysiology, and outcomes of HDP-associated cardiovascular disease. In addition, we propose a multi-pronged approach to support cardiovascular risk reduction for women with a history of HDP. Additional research is warranted to define appropriate blood pressure targets in the postpartum period, optimize the use of pregnancy history in risk stratification tools, and clarify the effectiveness of preventive interventions. The highest rates of HDP are in populations with poor access to resources and quality health care, making it a major risk for inequity of care. Interventions to decrease long-term cardiovascular disease risk in women following HDP must also target disparity reduction.

Association between changes in gestational blood pressure and vanadium exposure in China

OBJECTIVE

To investigate the association between urinary vanadium concentrations and blood pressure (BP) changes in Chinese pregnant women.

METHODS

This longitudinal study included 716 pregnant women who visited our hospital in Wuhan, China, from 2014 to 2016. Urinary sample collection and BP measurements were performed at 9-15, 21-27, and 34-40 weeks of gestation. Outcomes were repeated BP measurements (systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse pressure [PP], and mean arterial pressure [MAP]) during pregnancy.

RESULTS

The geometric mean of urinary vanadium concentrations was 0.65 μg/g creatinine. After adjusting for potential confounders, each threefold increase in urinary vanadium concentration was observed to be associated with a 1.06 mmHg decrease in SBP (95 % confidence interval [CI]: -1.80, -0.32), a 0.68 mmHg decrease in DBP (95 % CI: -1.32, -0.04), and a 0.81 mmHg decrease in MAP (95 % CI: -1.42, -0.19). Cross-sectional analysis showed a negative association between urinary vanadium concentrations and BP in the third trimester. Specifically, each threefold increase in urinary vanadium concentration in the second trimester was associated with decreases in SBP, DBP, PP, and MAP by 2.72 mmHg (95 % CI: -4.02, -1.41), 1.57 mmHg (95 % CI: -2.72, -0.42), 1.14 mmHg (95 % CI: -2.15, -0.14), and 1.95 mmHg (95 % CI: -3.06, -0.85), respectively, in the third trimester.

CONCLUSION

To the best of our knowledge, this is the first longitudinal study that suggests the negative association between vanadium exposure and BP among pregnant women in China.

Cardiac maladaptation in obese pregnant women at term

OBJECTIVE

Obesity is an increasing problem worldwide, with well recognized detrimental effects on cardiovascular health; however, very little is known about the effect of obesity on cardiovascular adaptation to pregnancy. The aim of the present study was to compare biventricular cardiac function at term between obese pregnant women and pregnant women with normal body weight, utilizing conventional echocardiography and speckle-tracking assessment.

METHODS

This was a prospective case-control study of 40 obese, but otherwise healthy, pregnant women with a body mass index (BMI) of ≥ 35 kg/m² and 40 healthy pregnant women with a BMI of ≤ 30 kg/m² . All women underwent a comprehensive echocardiographic examination and speckle-tracking assessment at term.

RESULTS

Obese pregnant women, compared with controls, had significantly higher systolic blood pressure (117 vs 109 mmHg; P = 0.002), cardiac output (6.73 vs 4.90 L/min; P < 0.001), left ventricular (LV) mass index (74 vs 64 g/m² ; P < 0.001) and relative wall thickness (0.43 vs 0.37; P < 0.001). Diastolic dysfunction was present in five (12.5%) controls and 16 (40%) obese women (P = 0.004). In obese women, compared with controls, LV global longitudinal strain (-15.59 vs -17.61%; P < 0.001), LV endocardial (-17.30 vs -19.84%; P < 0.001) and epicardial (-13.10 vs -15.73%; P < 0.001) global longitudinal strain as well as LV early diastolic strain rate (1.05 vs 1.24 /s; P = 0.006) were all significantly reduced. No differences were observed in the degree of LV twist and torsion between the two groups.

CONCLUSIONS

Morbidly obese, but otherwise healthy, pregnant women at term had significant LV hypertrophy with evidence of diastolic dysfunction and impaired deformation indices compared with pregnant women of normal weight. These findings are likely to represent a maladaptive response of the heart to volume overload in obese pregnancy. The impact of theses changes on pregnancy outcome and long-term maternal outcome is unclear. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare, often dilated, cardiomyopathy with systolic dysfunction that presents in late pregnancy or, more commonly, the early postpartum period. Although the condition is prevalent worldwide, women with black ancestry seem to be at greatest risk, and the condition has a particularly high incidence in Nigeria and Haiti. Other risk factors include pre-eclampsia, advanced maternal age, and multiple gestation pregnancy. Although the complete pathophysiology of peripartum cardiomyopathy remains unclear, research over the past decade suggests the importance of vasculo-hormonal pathways in women with underlying susceptibility. At least some women with the condition harbor an underlying sarcomere gene mutation. More than half of affected women recover systolic function, although some are left with a chronic cardiomyopathy, and a minority requires mechanical support or cardiac transplantation (or both). Other potential complications include thromboembolism and arrhythmia. Currently, management entails standard treatments for heart failure with reduced ejection fraction, with attention to minimizing potential adverse effects on the fetus in women who are still pregnant. Bromocriptine is one potential disease specific treatment under investigation. In this review, we summarize the current literature on peripartum cardiomyopathy, as well as gaps in the understanding of this condition and future research directions.

Cardiovascular origins of preeclampsia

PURPOSE OF REVIEW

To review the current data on maternal cardiovascular adaptation in normal pregnancy and preeclampsia.

RECENT FINDINGS

Defective placentation causes early-onset preeclampsia, a disease entity that is considered more or less distinct from late-onset preeclampsia. The latter has been attributed as 'maternal' preeclampsia. There are inconsistencies with the placental origins hypothesis, especially when considering the lack of a causative association with abnormal placental histology or impaired fetal growth. An alternative explanation is that placental dysfunction is secondary to maternal cardiovascular maladaptation in pregnancy. The concept that placental dysfunction is secondary to a maternal disorder is not new when one considers the clinical similarities between preeclampsia and gestational diabetes - both pregnancy-specific conditions that are cured by birth. It is accepted that gestational diabetes develops when the maternal pancreas is unable to manage the increasing glucose load of pregnancy. It is now apparent that pregnancy presents a substantial cardiovascular load on the maternal heart, and that cardiovascular dysfunction precedes the disorder, predominates in the clinical syndrome and persists for several decades postpartum. It is time to consider the evidence that failure of the maternal cardiovascular system to adapt to pregnancy may well be the primary mechanism leading to secondary placental dysfunction in preeclampsia.

SUMMARY

Many of the existing paradoxes of preeclampsia challenge the placental origin hypothesis and are explained if one considered preeclampsia to be a cardiovascular syndrome.

Hypertensive disorders of pregnancy and future heart failure risk: A nationwide population-based retrospective cohort study

OBJECTIVE

To assess whether hypertensive disorders of pregnancy (HDP) increased the risk of subsequent heart failure (HF) and identify possible risk factors.

STUDY DESIGN

A nationwide population-based retrospective cohort study.

MAIN OUTCOME MEASURES

Incidence of heart failure.

RESULTS

Among the 23.3 million individuals registered in the National Health Insurance Research Database in Taiwan, 29,186 patients with HDP and 116,744 matched controls were identified. The overall incidence of HF was greater in the HDP group than it was in the control group (9.83 vs. 1.67 per 10,000 person-years), with a significant incidence rate ratio (IRR = 5.88, 95% confidence interval [CI] 5.84-5.92, p < 0.0001). When stratified by age, parity, gestational age, gestational number, and follow-up years, the IRR for subsequent HF remained significantly higher in the HDP group in all stratifications. Additionally, the Kaplan-Meier analysis indicated that the cumulative incidence rate of HF was higher in the HDP group than it was in the control group. The Cox proportional-hazard model analysis showed that in addition to HDP, single parity, preterm and hypertension were independent risk factors for developing HF. Moreover, HF was more likely to develop within 5 years post-partum. Among patients with a history of HDP, the Cox proportional-hazard model showed that severe forms of HDP and increased HDP occurrences were independently associated with the subsequent development of HF.

CONCLUSIONS

Patients who have experienced HDP presented an increased risk for developing HF later in life. Moreover, among individuals with a history of HDP, those with severe forms of HDP or recurrent HDP displayed an increased subsequent risk of HF.

Abnormal mid-trimester cardiac strain in women with chronic hypertension predates superimposed preeclampsia

BACKGROUND

Chronic hypertension (cHTN) affects 7% of all pregnancies. We hypothesized that cHTN during pregnancy would be associated with abnormal myocardial strain patterns and adverse perinatal outcomes.

METHODS

This was a retrospective cohort study of patients seen in a high-risk obstetrics clinic with cHTN. Parturients with a singleton pregnancy who had undergone an echocardiogram as part of routine clinical care were eligible. Clinical and demographic information was collected from medical records. Global peak longitudinal strain (GLS) was measured using automated software from stored echocardiographic images.

RESULTS

60 patients were included in this analysis, of which 48 (80.0%) were African American. The median BMI was 40.6, age was 34 years, and the gestational age was 20.4 weeks at the time of the echo and 37.9 weeks at delivery. Thirty-four patients (56.7%) demonstrated abnormal strain, defined as a GLS <= -19%. Patients with abnormal strain were similar in age and BMI to patients with normal cardiac function. When compared to women with normal strain, those with abnormal strain had lower stroke volume (69.0 ml vs 81.5 ml; p = .001) and ejection fraction (49.6% vs 57.5%; p < .0001). Rates of superimposed preeclampsia were higher (38.2% vs 11.5%, p-value = .02) and a higher proportion of patients in the abnormal strain group delivered before 37 weeks (44.1% vs 19.2%; p = .04).

CONCLUSION

In a population of parturients with cHTN, we found that more than one-half demonstrated subclinical abnormal cardiac function. The presence of abnormal cardiac strain predates superimposed preeclampsia and preterm delivery. Further studies are needed to validate these findings.