Abnormal Endothelium-Dependent Microvascular Reactivity in Recently Preeclamptic Women

Association of Hypertensive Disorders of Pregnancy With Coronary Microvascular Dysfunction 8 to 10 Years After Delivery

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with subsequent adverse cardiac remodeling and cardiovascular disease. The role of myocardial microvascular disease among individuals with HDP and left ventricular (LV) remodeling as a potential link to cardiovascular disease is unknown. We aimed to determine whether individuals with HDP history have coronary microvascular dysfunction measured by coronary flow reserve 8 to 10 years after delivery and whether microvascular dysfunction correlates with LV remodeling.

METHODS

Individuals with pregnancies delivered from 2008 to 2010 underwent burst-replenishment myocardial contrast echocardiography (2017-2020) to quantify myocardial perfusion at rest and during dobutamine stress. Video intensity versus time data were used to derive β, the rate of rise of video intensity, a correlate for myocardial blood flow. Coronary flow reserve was calculated as the ratio of β at peak stress to β at rest, averaged across LV myocardial regions of interest.

RESULTS

We studied 91 individuals (aged 38±6 and 9.1±0.9 years postdelivery) and 19 with a history of HDP. Individuals with coronary microvascular dysfunction (coronary flow reserve <2.0; n=13) had a higher proportion of HDP (46.2% versus 16.7%; P=0.026) and higher prepregnancy body mass index, baseline heart rate, and hemoglobin A1c compared with those without microvascular dysfunction. The association of coronary flow reserve and HDP was attenuated after adjusting for cardiometabolic factors (P=0.133). In exploratory subgroup analyses, individuals with both LV remodeling (relative wall thickness >0.42) and HDP (n=12) had the highest proportion of microvascular dysfunction (41.7% versus +HDP-LV remodeling [n=7] 14.3%; -HDP+LV remodeling [n=26] 7.7%; P=0.0498).

CONCLUSIONS

In this small study, HDP history is associated with coronary microvascular dysfunction 1 decade after delivery, findings that may, in part, be driven by metabolic factors including obesity and diabetes. Microvascular dysfunction may contribute to cardiovascular disease among individuals with a history of HDP.

The Risk of Persistent Hypertension and Chronic Kidney Disease in Early- and Late-Onset Preeclampsia: A Report From Developing Country

BACKGROUND AND OBJECTIVE

Preeclampsia (PE) has been disproportionately prevalent in developing countries and constitutes a leading cause of maternal mortality, and also has long-term impacts, including renal consequences. This study aimed to explore the risk of persistent hypertension and kidney failure in early-onset PE (EOP) and late-onset PE (LOP) in the five years after delivery.

METHODS

This retrospective cohort study included women with a prior history of severe PE or normotensive pregnancy admitted to tertiary hospitals in Indonesia. The blood pressure, body mass index (BMI), urea, creatinine serum, and protein urine were analyzed, and the risk of chronic kidney disease (CKD) after five years was performed using the Kidney Disease Improvement Global Outcomes (KDIGO) classification.

RESULTS

Twenty-seven EOP, 35 LOP, and 30 normotensive cases were included. Mean blood pressure after five years was recorded as 115.6 ± 14.25 mmHg in the normotensive group, 131.82 ± 19.34 mmHg in the LOP group, and 154.96 ± 23.48 mmHg in the EOP group. According to the KDIGO classification, the normotensive group had an average 10% risk of CKD, but severe PE had a risk of CKD greater than 90%. In the severe PE group, the risk of CKD was 20.94 times higher compared to normotensive women (OR 20.94; 95% CI 2.67-163.72, p = 0.004). The risk of CKD in the EOP group was 6.75 times higher than in the LOP group (OR 6.75; 95% CI 2.19-20.76, p = 0.001), whereas persistent hypertension in the EOP group was 5.78 times higher than in the LOP group (OR 5.78; 95% CI 1.91-17.395, p = 0.002).

CONCLUSIONS

PE women have a higher risk of CKD than normotensive women. Women with a history of EOP are more likely to develop persistent hypertension and CKD than women with a prior LOP history.

Maternal Immune Cell and Cytokine Profiles to Predict Cardiovascular Risk Six Months after Preeclampsia

Women who develop preeclampsia (PE) are at high risk for cardiovascular disease (CVD). Early identification of women with PE who may benefit the most from early cardiovascular risk screening and interventions remains challenging. Our objective was to assess whether cytokine and immune cell profiles after PE are helpful in distinguishing women at low and high CVD risk at 6-months postpartum. Individuals who developed PE were followed for immune cell phenotyping and plasma cytokine quantification at delivery, at 3-months, and at 6-months postpartum. Lifetime CVD risk was assessed at 6-months postpartum, and the immune cell and cytokine profiles were compared between risk groups at each time point. Among 31 participants, 18 (58.1%) exhibited high CVD-risk profiles at 6-months postpartum. The proportion of circulating NK-cells was significantly lower in high-risk participants at delivery (p = 0.04). At 3-months postpartum, high-risk participants exhibited a lower proportion of FoxP3⁺ regulatory T-cells (p = 0.01), a greater proportion of CD8⁺ T cells (p = 0.02) and a lower CD4⁺:CD8⁺ ratio (p = 0.02). There were no differences in immune cell populations at 6-months postpartum. There were no differences in plasma cytokines levels between risk groups at any time point. Subtle differences in immune cell profiles may help distinguish individuals at low and high CVD risk in the early postpartum period and warrants further investigation.

Maternal Cardiovascular Function Following a Pregnancy Complicated by Preeclampsia

Preeclampsia is a hypertensive pregnancy complication with an unknown etiology and high maternal burden worldwide. Burgeoning research has linked preeclampsia to adverse maternal health outcomes remote from pregnancy; however, the intermediary mechanisms responsible for this association have not been sufficiently established. In the present narrative review, we summarize leading evidence of structural and functional cardiovascular changes associated with prior preeclampsia, and how these changes may be linked to future maternal disease. KEY POINTS: · Prior preeclampsia is associated with subclinical structural and functional vascular changes remote from pregnancy.. · Maternal cardiac adaptations to preeclampsia may have long-term implications on cardiovascular health.. · Clinicians have an opportunity to minimize maternal disease risk following preeclampsia..

Postpartum microvascular functional alterations following severe preeclampsia

Preeclampsia is associated with adverse maternal health outcomes later in life. Vascular endothelial dysfunction has been previously described following preeclampsia. We hypothesized that microvascular endothelial dysfunction associated with preeclampsia persists postpartum and may identify those at greatest risk of future cardiovascular disease. The objective of this study was to examine postpartum microvascular endothelial function in women after a pregnancy complicated by preeclampsia. Women with previous preeclampsia (n = 30) and normotensive controls (n = 30) between 6 mo and 5 yr postpartum were recruited. Severity of preeclampsia [severe (n = 16) and mild (n = 14)] was determined by standardized chart review. Microvascular reactivity in the forearm was measured with laser speckle contrast imaging, coupled with iontophoresis; endothelium-dependent and endothelium-independent vasodilation was induced with 1% acetylcholine and sodium nitroprusside solutions, respectively. A postocclusive reactive hyperemia test assessed vasodilatory response following three minutes of suprasystolic (200 mmHg) occlusion with a mechanized cuff. Women with prior severe preeclampsia exhibited significantly higher vasodilation to acetylcholine and sodium nitroprusside compared to controls (P < 0.01; P = 0.03) and prior mild preeclampsia (P = 0.03; P < 0.01). Neither the degree of postocclusive reactive hyperemia (P = 0.98), nor time to return halfway to baseline [OR = 1.026 (0.612, 1.72); P = 0.92], differed between preeclampsia and controls. In conclusion, severe preeclampsia is associated with heightened postpartum microvascular endothelium-dependent and endothelium-independent vasoreactivity. These changes, or a common antecedent, may be linked to postpartum alterations in vascular function that predispose women to disease after preeclampsia. Further investigation should identify the contributing mechanism and the degree to which it could be amenable to medical intervention.NEW & NOTEWORTHY We examine maternal microvascular function after preeclampsia, identifying heightened endothelium-dependent and endothelium-independent microvascular reactivity following severe disease. Our study represents a noteworthy addition to the existing literature with the use of a novel imaging modality, vascular perturbation, postpartum time point, and patient population with differentiation of preeclampsia into severe and nonsevere subtypes. These results represent a novel addition to the growing clinical and academic understanding of maternal health outcomes following preeclampsia.

Preeclampsia Increases the Incidence of Postpartum Cerebrovascular Disease in Korean Population

BACKGROUND

Multiple studies have been reported regarding preeclampsia as a possible risk factor of cerebrovascular disease (CVD). However, the correlation of preeclampsia and CVD, whether it is a cause-effect relationship or they are sharing common predisposing condition, is not well understood. Therefore, the aim of this study was to investigate the association between the preeclampsia during pregnancy and development of postpartum CVD.

METHODS

A total of 1,384,550 Korean women who had a delivery between January 1, 2010 and December 31, 2012, were enrolled. Women with the risk of CVD within 1 year prior to pregnancy were excluded based on the Charlson comorbidity index. Primary endpoint was the event of CVD within a year from delivery. After exclusion, 1,075,061 women were analyzed.

RESULTS

During the follow-up of 1 year postpartum, there were 25,577 preeclampsia out of 1,072,041 women without postpartum CVD (2.39%), and 121 of 3,020 women with postpartum CVD had preeclampsia before delivery (4.01%). In multivariate logistic regression analysis, women who had preeclampsia during pregnancy showed a higher risk for postpartum CVD (odds ratio, 1.64; 95% confidence interval, 1.37-1.98).

CONCLUSION

The incidence of CVD after delivery was higher in women who had preeclampsia during pregnancy.

Marked regional endothelial dysfunction in mottled skin area in patients with severe infections

Background

Mottling around the knee, reflecting a reduced skin blood flow, is predictive of mortality in patients with septic shock. However, the causative pathophysiology of mottling remains unknown. We hypothesized that the cutaneous hypoperfusion observed in the mottled area is related to regional endothelial dysfunction.

Methods

This was a prospective, observational study in a medical ICU in a tertiary teaching hospital. Consecutive adult patients with sepsis admitted to ICU were included. After resuscitation, endothelium-dependent vasodilation in the skin circulation was measured before and after iontophoresis of acetylcholine (Ach) in the forearm and the knee area. We analyzed the patterns of induced vasodilatation according to the presence or absence of mottling and vital status at 14 days.

Results

We evaluated 37 septic patients, including 11 without and 26 with septic shock. Overall 14-day mortality was 22%. Ten patients had mottling around the knee (10/37, 27%). In the knee area, the increased skin blood flow following iontophoresis of Ach was lower in patients with mottled skin as compared to patients without mottled skin (area under curve (AUC) 3280 (2643–6440) vs. 7980 (4233–19,707), both P < 0.05). In the forearm area, the increased skin blood flow following iontophoresis of Ach was similar in patients with and without mottled skin. Among patients with septic shock, the increased skin blood flow following iontophoresis of Ach in the knee area was significantly lower in non-survivors as compared to survivors at 14 days (AUC 3256 (2600–4426) vs. 7704 (4539–15,011), P < 0.01). In patients with septic shock, the increased skin blood flow in the forearm area following iontophoresis of Ach was similar in survivors and non-survivors at 14 days.

Conclusion

Mottling is associated with regional endothelial dysfunction in patients with septic shock. Endothelial dysfunction in the knee skin area was more pronounced in non-survivors than in survivors.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1742-x) contains supplementary material, which is available to authorized users.

Maternal microcirculation and sidestream dark field imaging: a prospective assessment of the association between labour pain and analgesia on the microcirculation of pregnant women

BACKGROUND

Pregnancy places significant demands on the cardiovascular system leading to measurable changes in the macrocirculation and potentially the microcirculation. During labour, both uterine contractions and labour pain can further impact cardiovascular status. The objective of this observational study was to compare sublingual microcirculation in labouring parturients before and after epidural analgesia.

METHODS

Healthy pregnant, labouring women requesting epidural analgesia were approached to participate. Participants with cardiovascular disease, diabetes, obesity, smoking or caffeine intake were excluded. The sidestream dark field device was applied to the sublingual mucosa obtaining images of at least 20 seconds in 5 visual fields before and after epidural analgesia. Video clips were analyzed randomly and blindly. The primary outcome was mean microvascular flow index (MFI).

RESULTS

Twelve participants completed this study. The results demonstrate no statistically significant difference in the MFI during labour pain (2.9±0.1) compared to after epidural analgesia (3.0±0.04, p = 0.31). Furthermore, there were no statistically significant differences in any secondary outcomes.

CONCLUSION

Our findings indicate that epidural analgesia may not impact sublingual microcirculation in labouring women. This agrees with literature supporting epidural analgesia as a safe, appropriate method of pain relief during labour with limited impact on peripheral macro or microcirculation.

Postpartum Vascular Dysfunction in the Reduced Uteroplacental Perfusion Model of Preeclampsia

Preeclampsia is a disorder affecting 2–8% of all pregnancies, characterized by gestational hypertension (≥ 140/90 mmHg) and proteinuria (≥300 mg over 24 hours) diagnosed following the 20^th week of pregnancy, and for which there is currently no available treatment. While the precise cause of preeclampsia is unknown, placental ischemia/hypoxia resulting from abnormal trophoblast invasion and maternal endothelial dysfunction are central characteristics. Preeclampsia is a major cause of both maternal and fetal morbidity and mortality in the perinatal period. In addition, women who have experienced preeclampsia are more likely to suffer cardiovascular disease later in life. The cause of this elevation in cardiovascular risk postpartum, however, is unknown. We hypothesize that there may be lasting vascular dysfunction following exposure to reduced uteroplacental perfusion during pregnancy that may contribute to increased cardiovascular risk postpartum. Using the rat reduced utero-placental perfusion pressure (RUPP) model of preeclampsia, blood pressure was assessed in dams at gestational day 20, one and three months postpartum. Mesenteric artery and aortic function were assessed using wire myography. We demonstrated hypertension and increased mesenteric artery responses to phenylephrine at gestational day 20, with the latter due to a decreased contribution of nitric oxide without any change in methylcholine-induced relaxation. At one month postpartum, we demonstrated a small but significant vasoconstrictive phenotype that was due to an underlying loss of basal nitric oxide contribution. At three months postpartum, endothelium-dependent relaxation of the aorta demonstrated sensitivity to oxLDL and mesenteric arteries demonstrated decreased nitric oxide bioavailability with impaired methylcholine-induced relaxation; indicative of an early development of endothelial dysfunction. In summary, we have demonstrated impaired vascular function following exposure to a RUPP pregnancy that continued into the postpartum period; suggesting that a pregnancy complicated by preeclampsia may predispose women to later life cardiovascular disease via ongoing vascular dysfunction.

No Hypertensive Disorder of Pregnancy; No Preeclampsia-eclampsia; No Gestational Hypertension; No Hellp Syndrome. Vascular Disorder of Pregnancy Speaks for All

Hypertensive disorders complicate 5%-10% of pregnancies with increasing incidence mainly due to upward trends in obesity globally. In the last century, several terminologies have been introduced to describe the spectrum of this disease. The current and widely used classification of hypertensive pregnancy disorders was introduced in 1972 and in 1982, but has not been free of controversy and confusion. Unlike other diseases, the existing terminology combines signs and symptoms, but does not describe the underlying pathology of the disease itself. In this commentary, a detailed account is given to vascular disorder of pregnancy (VDP) as an inclusive terminology taking into account the underlying pathology of the disease on affected organs and systems. A simple and uniform classification scheme for VDP is proposed.

Does high-density lipoprotein protect vascular function in healthy pregnancy?

The maternal adaptation to pregnancy includes hyperlipidaemia, oxidative stress and chronic inflammation. In non-pregnant individuals, these processes are usually associated with poor vascular function. However, maternal vascular function is enhanced in pregnancy. It is not understood how this is achieved in the face of the adverse metabolic and inflammatory environment. Research into cardiovascular disease demonstrates that plasma HDL (high-density lipoprotein), by merit of its functionality rather than its plasma concentration, exerts protective effects on the vascular endothelium. HDL has vasodilatory, antioxidant, anti-thrombotic and anti-inflammatory effects, and can protect against endothelial cell damage. In pregnancy, the plasma HDL concentration starts to rise at 10 weeks of gestation, peaking at 20 weeks. The initial rise in plasma HDL occurs around the time of the establishment of the feto-placental circulation, a time when the trophoblast plugs in the maternal spiral arteries are released, generating oxidative stress. Thus there is the intriguing possibility that new HDL of improved function is synthesized around the time of the establishment of the feto-placental circulation. In obese pregnancy and, to a greater extent, in pre-eclampsia, plasma HDL levels are significantly decreased and maternal vascular function is reduced. Wire myography studies have shown an association between the plasma content of apolipoprotein AI, the major protein constituent of HDL, and blood vessel relaxation. These observations lead us to hypothesize that HDL concentration, and function, increases in pregnancy in order to protect the maternal vascular endothelium and that in pre-eclampsia this fails to occur.

Alterations to the maternal circulating proteome after preeclampsia

OBJECTIVE

The long-term maternal cardiovascular and metabolic implications associated with preeclampsia (PE) include risk of hypertension, heart disease, and metabolic syndrome. The objective of this study was to investigate if a recent history of PE was associated with detectable alterations in the circulating maternal proteome.

STUDY DESIGN

Six-month postpartum plasma from women with a history of PE (n = 12) and women with uncomplicated obstetrical history (n = 12) were used for analysis. Depleted maternal plasma was analyzed by label-free liquid chromatography-mass spectrometry assay. Identified peptides were searched against the International Protein Index human database version 3.87. Exponentially modified protein abundance indices were used for comparison. Results were analyzed using pathway analysis software.

RESULTS

A total of 126 eligible peptides were identified for analysis; 3 peptides were differentially expressed in the PE proteome, and an additional 5 peptides were unique to control subjects and 7 to PE subjects. PE peptide profiles were more strongly associated with markers of coagulation and complement activation compared to controls and mapped more significantly to cardiovascular disease (CVD) functions. Stratification of subjects by low (<39%) and high (≥39%) lifetime risk of CVD rather than by diagnosis produced similar findings. Comparison of controls (n = 6) to PE subjects (n = 6) without traditional cardiovascular risk factors found that while similar for body mass indices, blood pressure, and fasting lipid profiles at 6 months postpartum, PE peptide profiles continued to display stronger associations for coagulation and CVD functions. Global network analysis found that unique peptides to low-risk PE subjects were associated with cardiac infarction, CVD, and organismal injury and abnormalities.

CONCLUSION

Markers of CVD risk and progression are evident in the maternal circulating proteome 6 months postpartum after PE. Augmentations in circulating peptide profiles occur in patients with previous PE who otherwise do not have clinically measurable cardiovascular risk factors. Our data highlight the need for the implementation of postpartum prevention programs in the PE population and identifies molecules that may be targeted for screening or therapeutic benefit.

Increased microvascular vasodilation and cardiovascular risk following a pre-eclamptic pregnancy

Women who develop pre-eclampsia are at high-risk for premature cardiovascular disease and death. The aim of this study was to assess microvascular function and cardiovascular risk in the early postpartum period for women who did/did not have a pregnancy complicated by pre-eclampsia. Peripheral microvascular function was assessed in women in the third trimester of uncomplicated pregnancies, with re-evaluation at 2 and 6 months postpartum. The effect of pre-eclampsia on postpartum microvascular function was assessed 2 and 6 months after delivery. Never-pregnant, naturally cycling women served for comparison. Cutaneous microvascular reactivity to acetylcholine and sodium nitroprusside, delivered locally by iontophoresis, was measured by laser Doppler flowmetry. 30-year and lifetime risk estimates for cardiovascular disease were established. Acetylcholine-mediated vasodilation was enhanced by normotensive pregnancy, and declined to nonpregnant levels by 6 months postpartum. Acetylcholine-mediated vasodilation remained high in pre-eclamptic subjects from 2 to 6 months postpartum compared to normotensive and never-pregnant controls. Pre-eclamptic subjects exhibited elevated 30-year and lifetime risk at 6 months postpartum. This study provides in vivo evidence of microvascular and cardiovascular risk implications of pre-eclampsia as early as 6 months postpartum, and suggests that the development of pre-eclampsia may be used to identify women at risk and eligible for risk screening and intervention.

Involvement of the Heme Oxygenase System in the Development of Preeclampsia and as a Possible Therapeutic Target

The enzyme heme oxygenase (HO) is an important regulatory molecule present in most nucleated mammalian cells which functions to break down the pro-oxidant molecule heme into three products, carbon monoxide (CO), biliverdin and free iron. The HO system has been associated with many physiologic functions, including vascular tone, regulation of inflammation and apoptosis, angiogenesis and antioxidant capabilities. Deficiencies in HO are associated with several pregnancy disorders, including preeclampsia. With no present cure, this disorder continues to affect 5–7% of all pregnancies worldwide, leading to maternal and fetal morbidity and mortality. Researchers continue to strive for therapeutic potentials and this review will outline the possible use of the HO/CO system as a target treatment/prevention of preeclampsia in the future.

Endothelial dysfunction after pregnancy-induced hypertension

OBJECTIVE

To carry out long-term analysis of the presence of endothelial dysfunction after the development of pregnancy-induced hypertension (PIH).

METHODS

In a retrospective cohort study, data were analyzed from 60 women who delivered at a tertiary maternity hospital in Fortaleza, Ceara, Brazil, between 1992 and 2002. Thirty women had a history of PIH and 30 had no history of complications. Anthropometric and laboratory data were collected, and endothelial function was evaluated by flow-mediated dilatation of the brachial artery. Continuous variables were analyzed via Student t test, and Mann-Whitney test was used to compare means. Clinical and metabolic measures were categorized according to cardiovascular risk by cutoff points determined by national consensus; χ2 and Fisher exact tests were used to compare the groups. Relative risk was calculated for variables that were statistically significant (P<0.05).

RESULTS

Women with a history of PIH had higher body mass index (P=0.03), systolic blood pressure (P=0.03), low-density lipoprotein cholesterol (P=0.02), and fasting glucose (P=0.02) compared with women with no pregnancy complications. The frequency of endothelial dysfunction was 60% among all women, with a significant difference between the 2 groups (P=0.01).

CONCLUSION

Women with a history of PIH were found to have a higher frequency of long-term endothelial dysfunction.

An observational assessment of the sublingual microcirculation of pregnant and non-pregnant women

BACKGROUND

The microcirculation is responsible for distribution of blood within tissues, delivery of oxygen and other nutrients, and regulation of blood pressure. The objective of this study was to compare the sublingual microcirculation of pregnant participants to that of comparable non-pregnant volunteers.

METHODS

Two groups of participants were recruited: a group of pregnant, non-laboring women with singleton pregnancies at term gestation and a control group of age-comparable non-pregnant volunteers. A sidestream dark field imaging device was applied to the sublingual mucosal surface obtaining a steady image for at least 20 s duration, in five visual fields. The resultant five video clips per participant were analyzed blindly and at random to prevent coupling between images. The mean microvascular flow index values for each group were compared using a paired t-test.

RESULTS

Thirty-seven participants were recruited (19 pregnant, 18 non-pregnant); a single pregnant participant was withdrawn because of technical issues. Baseline characteristics were similar with the exception of weight and body mass index. The mean microvascular flow index was significantly higher in the pregnant group 2.7 ± 0.2 compared to the non-pregnant group 2.5 ± 0.3 (P = 0.021), while the perfused vessel density and proportion of perfused vessels were not significantly different (P = 0.707 and 0.403, respectively).

CONCLUSION

The microvascular flow index of pregnant women is higher than a comparable non-pregnant group, which appears to correlate with the physiological changes of pregnancy.

From preeclampsia to renal disease: a role of angiogenic factors and the renin-angiotensin aldosterone system?

Complicating up to 8% of pregnancies, preeclampsia is the most common glomerular disease worldwide and remains a leading cause of infant and maternal morbidity and mortality. Although the exact pathogenesis of this syndrome of hypertension and proteinuria is still incomplete, a consistent line of evidence has identified an imbalance of proangiogenic and anti-angiogenic proteins as a key factor in the development of preeclampsia. Furthermore, more attention has been recently addressed to the renin-angiotensin aldosterone system (RAAS), to provide understanding on the hypertension of preeclampsia. The imbalance of the RAAS and the imbalance between angiogenic and anti-angiogenic factors, which may be both common to preeclampsia and chronic kidney disease (CKD), might explain why a history of preeclampsia predisposes women to develop CKD. In this review, we briefly describe the characteristics of preeclampsia with a focus on the mechanisms of angiogenesis and the RAAS and its role in the pathogenesis of preeclampsia. Our main focus will be on the intriguing association between preeclampsia and the subsequent increased risk of developing CKD and on the potential mechanisms by which the risk of CKD is elevated in women with a history of preeclampsia.

Prevention of vascular dysfunction after preeclampsia: a potential long-term outcome measure and an emerging goal for treatment

Preeclampsia is increasingly being recognised as more than an isolated disease of pregnancy. In particular, preeclampsia has emerged as an independent risk factor for maternal cardiovascular disease and has recently been recognised as a risk factor for cardiovascular disease in children exposed in utero. Preeclampsia and cardiovascular disease may share important pathophysiological and molecular mechanisms and further investigation into these is likely to offer insight into the origins of both conditions. This paper considers the links between cardiovascular disease and preeclampsia and the implication of these findings for refinement of the management of patients whose care is complicated by preeclampsia.

Decreased arterial elasticity in formerly early-onset preeclamptic women

OBJECTIVE

Preeclampsia is associated with cardiovascular atherosclerotic events later in life. Impaired arterial elasticity is considered to be a marker of vascular (endothelial) dysfunction and to be involved in the atherosclerotic process. We investigated whether previously preeclamptic women have lower arterial elasticity indices in comparison with controls.

DESIGN

Case-control study.

SETTING

University Medical Center Groningen, the Netherlands.

SAMPLE

14 non-pregnant women with a history of early-onset preeclampsia (cases) and 16 non-pregnant women (controls) with an uncomplicated pregnancy in 2003-2004.

METHODS

Measurement of radial artery elasticity indices combined with the brachial blood pressure using pulse wave contour analysis. The assessment of traditional risk factors for cardiovascular diseases (CVD) including body mass index, serum high-sensitivity C-reactive protein (hsCRP), serum insulin and plasma homocysteine.

MEAN OUTCOME MEASURES

Arterial elasticity indices and traditional risk factors for CVD in cases and controls.

RESULTS

Arterial elasticity was impaired in cases as compared with controls. Body mass index, blood pressure, pulse pressure, hsCRP and triglycerides were significantly higher in cases.

CONCLUSION

Arterial elasticity indices are reduced in formerly preeclamptic women, indicating vascular dysfunction. This and the more established risk factors for CVD are likely to contribute to a higher risk of CVD in women with a history of early-onset preeclampsia.

Preeclampsia and Stroke: Risks during and after Pregnancy

Preeclampsia and stroke are significantly related, both pathologically and temporally (across the life span) in women. Cerebrovascular events can complicate preeclampsia, and can also manifest later in life. A history of preeclampsia is associated with long-term risk for hypertension, stroke, and heart disease. Cerebrovascular complications occur in only a small proportion of women with severe preeclampsia, but with high morbidity and mortality. Endothelial dysfunction and impaired cerebral autoregulation, and severe hypertension in the setting of preeclampsia are likely the cause of many strokes during pregnancy. The relationship between preeclampsia and stroke involves shared risk factors for both disorders, including chronic endothelial dysfunction and increased risk for long-term hypertension following preeclampsia (one of the major risk factors for stroke). This overlap provides insights into underlying pathophysiology and potential preventive strategies for both preeclampsia and stroke. For example, aspirin may prevent both disorders. The current review will describe the current data regarding these relationships and suggest future research to investigate remaining knowledge gaps. These are important topics for neurologists, who are likely to be involved with the care of severely ill preeclamptic patients with neurologic complications, as well as women at increased risk of stroke due to a history of preeclampsia.

Thrombophilia mediates lowering cardiovascular risk factors in women with a history of preeclampsia

OBJECTIVE

Preeclampsia is associated with increased risk of cardiovascular disease. The aim of this pilot study was to assess whether the presence of thrombophilia results in a greater tendency to develop endothelial dysfunction and cardiovascular diseases.

METHODS

Ten women with thrombophilia were matched with 10 women without thrombophilia for a history of hypertensive disorders during pregnancy. Laboratory measurements: blood pressure, insulin sensitivity, and micro- and macrovascular function were determined.

RESULTS

Women with thrombophilia had significant lower total- and low-density cholesterol, were more insulin sensitive, and had better microvascular function.

CONCLUSION

This study suggests that thrombophilia "mediates" in lowering of cardiovascular risk factors in women with a history of preeclampsia.

Long-term maternal cardiovascular function in a mouse model of sFlt-1-induced preeclampsia

Our aim was to evaluate the long-term effects of preeclampsia on vascular function in a mouse model induced by sFlt-1 overexpression. CD-1 mice at day 8 of gestation were injected via the tail vein with adenovirus carrying sFlt1 (AdsFlt1), adenovirus carrying the murine IgG2alpha Fc fragment as the adenovirus control (AdmFc), or saline. Vascular function in the mothers was investigated 6-8 mo after delivery by recording blood pressure (BP) by telemetry (AdsFlt1 n = 8, AdmFc n = 6, saline n = 4) and exploring carotid artery reactivity in a wire myograph (AdsFlt1 n = 6, AdmFc n = 8, saline n = 4). sFlt-1 blood levels at 6-8 mo postpartum had returned to low levels and were comparable between the three groups (P = 0.808). There was no statistically significant difference in BP (P = 0.067) or vascular reactivity between the three groups of postpartum mice (phenylephrine P = 0.079, thromboxane P = 0.979, serotonin P = 0.659, acetylcholine P = 0.795, sodium nitroprusside P = 0.728, isoproterenol P = 0.370). Our results indicate that in a mouse model overexpression of sFlt-1 does not lead to increased in BP and altered vascular function in the absence of the pregnancy and has no long-term effect on BP and vascular function in the postpartum mothers. Our findings favor the hypothesis that increased cardiovascular diseases in women with history of preeclampsia are likely the result of preexisting risk factors common to preeclampsia and cardiovascular diseases.

No effects of bosentan on microvasculature in patients with limited cutaneous systemic sclerosis

The endothelium-derived vasoconstrictor molecule endothelin-1 (ET-1) has been suggested to play a role in the pathogenesis of Raynaud’s phenomenon (RP) and systemic sclerosis (SSc). We studied the effect of bosentan on microvascular structure and function in patients with RP secondary to limited cutaneous SSc in a mechanistic pilot study. In this single center, open study, 15 patients with limited cutaneous SSc were treated with bosentan for 16 weeks with a follow-up period of 4 weeks. Changes in microvascular structure and function were studied with assessment of vasodilatory microvascular responses using laser Doppler fluxmetry combined with iontophoresis, capillary permeability using fluorescence videomicroscopy, nailfold capillary microscopy, and serological markers of endothelial activation. No significant changes were seen in vasodilator responses to acetylcholine and sodium nitroprusside following bosentan treatment. No effect was noted on capillary permeability during treatment. The number of nailfold capillaries remained unchanged. The endothelial activation marker vascular cell adhesion molecule did not change during treatment, but levels of thrombomodulin significantly decreased after 12 weeks of treatment. Bosentan did not induce significant changes in vasodilator responses, capillary permeability, and capillary density during treatment, so no evidence was obtained for structural improvement of microvascular structure and function in this short-time mechanistic pilot study in patients with lcSSc.

Vascular responsiveness in the microcirculation of patients with systemic lupus erythematosus is not impaired

As endothelial dysfunction is one of the earliest signs of atherosclerosis, which is accelerated in systemic lupus erythematosus (SLE), we assessed whether vascular responses of the cutaneous microcirculation are disturbed in SLE patients and influenced by Raynaud's phenomenon (RP). Laser Doppler fluxmetry (LDF) was used in combination with iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP), an endothelium-dependent and endothelium-independent vasodilator respectively. 42 SLE patients with inactive disease, 12 of whom had RP and 19 age- and sex-matched controls were included. Furthermore, traditional and non-traditional risk factors for cardiovascular disease (CVD) were assessed, and markers of inflammation and endothelial activation were measured. Vascular responses of SLE patients without RP did not differ from controls. However, SLE patients with RP exhibited decreased vasodilatation compared with controls. SLE patients with RP also had longer arrival times of ACh and SNP than controls. Markers of inflammation and von Willebrand factor were increased in SLE patients. Smoking, the presence of SLE and RP were negatively associated with vascular responses in univariate analysis. In multivariate analyses, the only independent variable of vascular responses to ACh and SNP was the presence of RP. Despite signs of endothelial activation, SLE patients with inactive disease do not have altered vascular responses in the microcirculation compared with controls. In SLE patients with RP, cutaneous vascular responses to both ACh and SNP are impaired. Therefore, LDF of the microcirculation seems not to be the appropriate method to distinguish those SLE patients with an increased risk to develop CVD.

Abnormal endothelium-dependent microvascular dilator reactivity in pregnancies complicated by normotensive intrauterine growth restriction

OBJECTIVE

Normotensive intrauterine growth restriction and preeclampsia share a similar placenta pathophysiology, whereas maternal clinical manifestations differ. Clinical symptoms of preeclampsia are partly attributed to vascular endothelial dysfunction, but it is unclear whether this phenomenon plays a role in intrauterine growth restriction. Therefore, we investigated microvascular endothelial function in women with intrauterine growth restriction.

STUDY DESIGN

Laser Doppler fluxmetry was used combined with iontophoresis of acetylcholine and sodium nitroprusside, namely, endothelium-dependent and endothelium-independent vasodilators. We studied 12 women with intrauterine growth restriction and 16 controls in the third trimester of pregnancy. All women had prepregnancy body mass indexes < 26.

RESULTS

Acetylcholine-mediated vasodilatation was significantly increased in women with intrauterine growth restriction compared with controls (743% +/- 120% vs 390% +/- 67%, P = .01); sodium nitroprusside-mediated vasodilatation was not different (360% +/- 55% vs 363% +/- 65%, P > .99).

CONCLUSION

Nonobese women with normotensive intrauterine growth restriction show abnormal endothelium-dependent microvascular vasodilatation, suggesting endothelial dysfunction as in preeclampsia. Obviously, for the clinical manifestation of preeclampsia additional factors are required, and a role of metabolic syndrome and obesity has been suggested.

Configuration of the microcirculation in pre-eclampsia: possible role of the venular system

OBJECTIVE

To test the hypothesis that during pre-eclampsia microvascular function and structure are disturbed, which contributes to raised venular resistance.

METHODS

The microcirculation of the skin and bulbar conjunctiva was studied in 11 women with preeclampsia and nine parous controls, both in the third trimester and 3 months postpartum. Using intravital videomicroscopy, arteriolar and venular diameters were determined in the conjunctiva. In addition, skin capillary densities and morphology were determined.

RESULTS

Conjunctival venular diameters were 30% smaller in pre-eclampsia compared with controls, both during pregnancy (P < 0.01) and postpartum (P = 0.045). Arteriolar diameters also tended to be smaller; however, this difference was not statistically significant. In women with pre-eclampsia we found a higher percentage of tortuous/dilated skin capillaries (5%) compared with controls (0%; P < 0.05). Three months postpartum, this difference had disappeared. Skin capillary densities did not differ between the groups.

CONCLUSION

Women with severe pre-eclampsia have narrow venules, both during manifest disease and postpartum. Possibly, these narrow venules raise venular resistance and with it, hydrostatic pressure in the capillary bed. The latter, in turn, may explain the higher number of tortuous/dilated capillaries in women with preeclampsia. These findings support an important role of the venous system in the pathogenesis of pre-eclampsia.

Periodontal disease increases the risk of severe pre-eclampsia among pregnant women

AIM

To evaluate the possible link between the severity of periodontal disease and pre-eclampsia and to correlate this link to clinical periodontal parameters and interleukin (IL)-1beta, tumour necrosis factor-alpha (TNF-alpha), and prostaglandins (PGE(2)) levels in both gingival crevicular fluid (GCF) and serum.

MATERIAL AND METHODS

Fifty-nine pregnant women (20 mild pre-eclampsia, 18 severe pre-eclampsia, and 21 healthy pregnant women) were included in the study. Dental and periodontal recordings as well as GCF and blood samples were obtained within 48 h preceding delivery.

RESULTS

The results of multivariate logistic regression showed a highly significant association between mild to severe pre-eclampsia and severe periodontal disease (p<0.001). After adjusting for potential confounders (smoking, body weight, socioeconomic status, education level, and age), severe pre-eclamptic women were 3.78 (1.77-12.74) times more likely to present severe periodontal disease than normotensive pregnant women. This odds ratio (OR) was 2.43 (1.13-8.19) for mild pre-eclamptic women. IL-1beta, TNF-alpha, and PGE(2) levels in both serum and GCF were also significantly higher in the pre-eclamptic groups than the normotensive women.

CONCLUSIONS

These results indicate that the presence and severity of periodontal disease seems to increase the risk for not only the occurrence but also the severity of pre-eclampsia in pregnant women.

Women with a recent history of early-onset pre-eclampsia have a worse periodontal condition

OBJECTIVE

Pre-eclampsia is a complication of pregnancy characterized by systemic vascular dysfunction and pathological changes in placental arteries. Growing evidence of chronic infection as an aetiological factor in vascular diseases prompted us to study maternal periodontal disease in subjects with early-onset pre-eclampsia (<34 weeks).

METHODS

A case-control study was carried out on 17 early-onset pre-eclamptic women and 35 controls with uncomplicated pregnancies in a period of 3-28 months postpartum. All were Caucasians. Full-mouth periodontal examinations were performed to determine the periodontal condition. Subgingival-plaque samples were analysed by anaerobic culture techniques for the presence of seven bacterial periodontal pathogens. Potential confounders as age, smoking, educational level and body mass index were determined.

RESULTS

Severe periodontal disease was found in 82% of the pre-eclamptic and in 37% of the control group (p=0.009). After adjusting for age, smoking and educational level, the odds ratio was 7.9 (95% CI: 1.9-32.8). The periodontopathic microorganism Micromonas micros was more prevalent in the case group (p=0.040) while Campylobacter rectus was more prevalent in the control group (p=0.047).

CONCLUSION

These results indicate that Caucasian women with a recent history of early-onset pre-eclampsia have a worse periodontal condition, as compared with women with uncomplicated deliveries.

Diffusion model for iontophoresis measured by laser-Doppler perfusion flowmetry, applied to normal and preeclamptic pregnancies

We present a physical model to describe iontophoresis time recordings. The model is a combination of monodimensional material diffusion and decay, probably due to transport by blood flow. It has four adjustable parameters, the diffusion coefficient, the decay constant, the height of the response, and the shot saturation constant, a parameter representing the relative importance of subsequent shots (in case of saturation). We test the model with measurements of blood perfusion in the capillary bed of the fingers of women who recently had preeclampsia and in women with a history of normal pregnancy. From the fits to the measurements, we conclude that the model provides a useful physical description of the iontophoresis process.

Organ systems dependent on nitric oxide and the potential for nitric oxide-targeted therapies in related diseases

Nitric oxide (NO) is a universal messenger molecule that plays diverse and essential physiologic roles in multiple organ systems, including the vasculature, bone, muscle, heart, kidney, liver, and central nervous system. NO is produced by 3 known isoforms-endothelial, neuronal, and inducible NO synthase-each of which perform distinct functions. Impairment of NO bioactivity may be an important factor in the pathogenesis of a wide range of conditions, including preeclampsia, osteoporosis, nephropathy, liver disease, and neurodegenerative diseases. Although increased levels of NO synthase or NO bioactivity have been associated with some of these disease states, research increasingly suggests that preservation or promotion of normal NO bioactivity may be beneficial in reducing the risks and perhaps reversing the underlying pathophysiology. Based on this rationale, studies investigating the use of NO-donating or NO-promoting agents in some of these diseases have produced positive results, at least to some degree, in either animal or human studies. Further investigation of NO-targeted therapies in these diverse diseases is clearly mandated.

Pregnancy as the prodrome to vascular dysfunction and cardiovascular risk

In previously apparently healthy women, glucose intolerance and high blood pressure during pregnancy are common and frequently occur together. This article reviews the role of these gestational disorders as markers of vascular dysfunction and its pathophysiology. Mechanisms include alterations to function of large arteries and resistance vessels and to capillary blood flow. Much of the vessel pathology is seen in both gestational diabetes and hypertension. In women who have had transient diabetes during pregnancy and later redeveloped overt diabetes, cardiovascular risk is already elevated nearly fourfold before diagnosis, which is almost as high as the average risk after a clinical diagnosis of diabetes is made. This key finding suggests that vascular risk in such women is at least partly independent of overt hyperglycemia.

Three-dimensional assessment of the morphology of the umbilical artery in normal and pre-eclamptic placentas

AIM

Pre-eclampsia is one of the main causes of intrauterine growth retardation. Although there are many studies performed in this setting showing the course of the umbilical vessels within the umbilical cord along with its structural changes, studies are lacking with regard to intraplacental vasculature and its structural changes.

METHODS

We investigated whether the vascular pattern differed in preeclamptic placentas in terms of intraplacental course and morphometry of the umbilical artery by using vascular corrosion cast technique. Furthermore, cross-sections taken from umbilical artery branches at different levels within the placenta, were examined with both light and scanning electron microscopy (SEM).

RESULTS

Vascular corrosion casts generated in both pregnancy groups should be defined with the main umbilical artery divided into 2-4 primary branches. No significant difference was seen between normal and pre-eclamptic groups regarding the diameters of primary and secondary branches and the number of cotyledons contained (P > 0.05). However, microscopic studies demonstrated expanded intervillous spaces in the placentas of pre-eclamptic pregnancies. Under SEM, distortion on the endothelial surface of the umbilical artery and an increase in vessel diameter and wall thickness have been determined in pre-eclamptic placentas. Furthermore, the branching pattern and changes affecting the endothelial surface of the umbilical artery have been shown three-dimensionally in pre-eclamptic placentas, using corrosion cast technique and SEM, respectively.

CONCLUSION

While microscopic findings were consistent with the Doppler ultrasonography findings, namely higher systole/diastole ratio and increased resistance (RI) and pulsatile (PI) index in the umbilical artery, no clear morphometric change has been observed.

Skin autofluorescence, a marker of advanced glycation end products and oxidative stress, is increased in recently preeclamptic women

OBJECTIVE

Advanced glycation end-products are considered to be markers of oxidative stress and to be involved in the atherosclerotic process. We investigated skin autofluorescence, which reflected advanced glycation end-product accumulation, in recently preeclamptic women and its relationship with intima-media thickness, which is a marker of atherosclerosis.

STUDY DESIGN

Skin autofluorescence of the arm and leg was measured in 26 preeclamptic women and 17 control subjects at 3 to 13 months after delivery. Lipid profiles, smoking habits, and intima-media thickness of 5 carotid and femoral artery segments were recorded.

RESULTS

The preeclampsia group was younger and had higher values for blood pressure, insulin resistance, common femoral artery intima-media thickness, and skin autofluorescence of the leg. With the use of linear regression analysis, the difference in leg autofluorescence was explained only by preeclampsia. In the preeclampsia group, skin autofluorescence of the leg correlated with smoking and common femoral artery intima-media thickness.

CONCLUSION

These results support the hypothesis of accelerated atherosclerosis in recently preeclamptic women and the possible involvement of advanced glycation end-product accumulation.

Increased Intima-Media Thickness After Early-Onset Preeclampsia

OBJECTIVE

Preeclampsia is associated with cardiovascular atherosclerotic events later in life. However, little is known about earlier subclinical signs of atherosclerosis. We aimed to investigate whether women who recently had preeclampsia show increased intima-media thickness (IMT), as marker of early atherosclerosis, compared with women with normal pregnancies or nulliparous women.

METHODS

Intima-media thickness of carotid and femoral arteries measured by ultrasonography, and possible confounding risk factors as body mass index, blood pressure, serum lipids, smoking status, and family history of cardiovascular disease were compared among 22 nulliparous women, 22 primiparous women with normal pregnancy, and 22 primiparous women with early-onset preeclampsia at least 3 months postpartum and 6 weeks after ending lactation

RESULTS

Except for slightly higher values for blood pressure, triglycerides, and homocysteine in the formerly preeclamptic women, no other clinical or biochemical differences were observed. The preeclampsia group showed an increased IMT (mean +/- standard deviation, 0.63 +/- 0.14 mm) of the common femoral artery compared with the normal pregnancy group (0.55 +/- 0.06 mm, P = .005) and to the nulliparous group (0.52 +/- 0.06 mm, P < .001). These differences remained significant after correction for possible confounders by multiple linear regression analyses. An increase in IMT of the common carotid artery between the normal pregnancy and the nulliparous group was observed, which became significant after adjustment for confounders.

CONCLUSION

Preeclampsia and, to a lesser degree, normal pregnancy are associated with increased IMT. The association between increased IMT and (preeclamptic) pregnancy leads to the question of which comes first, which should be addressed in follow-up studies.

LEVEL OF EVIDENCE

II-2.

Noninvasive monitoring of peripheral perfusion

BACKGROUND

Early hemodynamic assessment of global parameters in critically ill patients fails to provide adequate information on tissue perfusion. It requires invasive monitoring and may represent a late intervention initiated mainly in the intensive care unit. Noninvasive monitoring of peripheral perfusion can be a complementary approach that allows very early application throughout the hospital. In addition, as peripheral tissues are sensitive to alterations in perfusion, monitoring of the periphery could be an early marker of tissue hypoperfusion. This review discusses noninvasive methods for monitoring perfusion in peripheral tissues based on clinical signs, body temperature gradient, optical monitoring, transcutaneous oximetry, and sublingual capnometry.

DISCUSSION

Clinical signs of poor peripheral perfusion consist of a cold, pale, clammy, and mottled skin, associated with an increase in capillary refill time. The temperature gradients peripheral-to-ambient, central-to-peripheral and forearm-to-fingertip skin are validated methods to estimate dynamic variations in skin blood flow. Commonly used optical methods for peripheral monitoring are perfusion index, near-infrared spectroscopy, laser Doppler flowmetry and orthogonal polarization spectroscopy. Continuous noninvasive transcutaneous measurement of oxygen and carbon dioxide tensions can be used to estimate cutaneous blood flow. Sublingual capnometry is a noninvasive alternative for gastric tonometry.