Cardiovascular Physiology of Pregnancy

Uteroplacental microvascular remodeling in health and disease

The microvascular system is essential for delivering oxygen and nutrients to tissues while removing metabolic waste. During pregnancy, the uteroplacental microvascular system undergoes extensive remodeling to meet the increased demands of the fetus. Key adaptations include vessel dilation and increases in vascular volume, density, and permeability, all of which ensure adequate placental perfusion while maintaining stable maternal blood pressure. Structural and functional abnormalities in the uteroplacental microvasculature are associated with various gestational complications, posing both immediate and long-term risks to the health of both mother and infant. In this review, we describe the changes in uteroplacental microvessels during pregnancy, discuss the pathogenic mechanisms underlying diseases such as preeclampsia, fetal growth restriction, and gestational diabetes, and summarize current clinical and research approaches for monitoring microvascular health. We also provide an update on research models for gestational microvascular complications and explore solutions to several unresolved challenges. With advancements in research techniques, we anticipate significant progress in understanding and managing these diseases, ultimately leading to new therapeutic strategies to improve maternal and fetal health.

Early Pregnancy Blood Pressure Trajectories and Hypertension Years After Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy (HDP) increase cardiovascular disease risk. Blood pressure (BP) trajectories ≤20 weeks' gestation predict HDP outcomes. We hypothesized that early-pregnancy BP patterns stratify risk of developing hypertension years after pregnancy.

METHODS

This prospective cohort of 174 774 women without prior hypertension, kidney, liver, or heart disease, or history of preeclampsia entered prenatal care ≤14 weeks and delivered a stillborn or live singleton birth at Kaiser Permanente Northern California hospitals (2009-2019). Electronic health records provided data, including HDP for each birth, longitudinal outpatient clinical BP measurements, International Classification of Diseases codes, and medication use to identify new-onset hypertension from 2 months through 14 years post-delivery (2009-2023). Latent class trajectory modeling identified 6 BP trajectory (BPT) groups capturing both BP levels and slopes from 0 to 20 weeks' gestation. Multivariable Cox regression models estimated the hazard ratio (95% CIs) of new-onset hypertension after pregnancy associated with early-pregnancy BP trajectories, with effect modification by HDP.

RESULTS

BP trajectories were associated with an increasing gradient of hypertension risk after pregnancy within each HDP group. Adjusted hazard ratios were higher among preeclampsia and gestational hypertension groups than for no HDP. From lowest to highest BPT groups, hazard ratios ranged from 2.91 to 27.31 for preeclampsia, 4.20 to 27.81 for gestational hypertension, and 2.92 to 10.96 for no HDP compared with lowest BP trajectories of the no HDP group (all reference 1.0).

CONCLUSIONS

Early-pregnancy BP trajectories are strongly associated with new-onset hypertension years after pregnancy. Combined with HDP, they may stratify risk for targeted surveillance and early interventions and improve the prediction of cardiovascular disease risk in women.

Cardiac remodelling, recognition memory deficits and accelerated ageing in a rat model of gestational diabetes

AIMS/HYPOTHESIS

Women with prior gestational diabetes mellitus (GDM) have higher incidence of age-associated diseases, including type 2 diabetes, CVD and cognitive impairment. Human studies cannot readily determine whether GDM causes these conditions or the underlying mechanisms. Here we used a well-validated rat model of GDM to address these questions.

METHODS

Rats with beta cell-specific expression of human amylin, a pancreatic hormone, were used as a GDM model. Five-month-old female rats were randomly assigned to no-pregnancy, one-pregnancy and two-pregnancies experimental groups. GTTs and transthoracic echocardiography were performed at baseline and during the postpartum period. At 18 months of age, the novel object recognition test was administered, followed by euthanasia and organ collection.

RESULTS

All female rats developed glucose intolerance and showed cardiac remodelling and impaired left ventricular relaxation with ageing. Glucose intolerance was exacerbated in rats with prior GDM pregnancies compared with nulliparous rats, with significant differences starting at 9 months of age. However, blood glucose levels were comparable in the three groups during the course of the study. Rats with two GDM-complicated pregnancies had increased left ventricular mass compared with the other groups following the second pregnancy and until the end of the study. At 18 months of age, rats with prior GDM pregnancies presented aggravated demyelination, particularly in the hippocampus and mid-brain region, oxidative stress and neuroinflammation, and had a lower recognition index in the novel object recognition test compared with nulliparous rats. Higher parity exacerbated these effects. Shorter telomeres and reduced mitochondrial DNA content, two hallmarks of biological ageing, were found in the brain, heart and pancreas of rats with prior GDM.

CONCLUSIONS/INTERPRETATION

These findings support the concept that GDM is a sex-specific risk factor for ageing-related diseases, and point to accelerated cellular ageing as a contributing mechanism.

DATA AVAILABILITY

Cardiac echocardiography and GTT data are available at Dataverse under the identifier https://doi.org/10.7910/DVN/R2HITG.

Mechanisms of altered hepatic drug disposition during pregnancy: small molecules

INTRODUCTION

Pregnancy alters the systemic exposure and clearance of many hepatically cleared drugs that are commonly used by obstetric patients. Understanding the molecular mechanisms underlying the changes in factors that affect hepatic drug clearance (blood flow, protein binding, and intrinsic clearance) is essential to more precisely predict systemic drug exposure and dose requirements in obstetric patients.

AREAS COVERED

This review (1) summarizes the anatomic, physiologic, and biochemical changes in maternal hepatic, cardiovascular, endocrine, and renal systems relevant to hepatic drug clearance and (2) reviews the molecular mechanisms underlying the altered hepatic metabolism and intrinsic clearance of drugs during pregnancy via a comprehensive PubMed search. It also identifies knowledge gaps in the molecular mechanisms and factors that modulate hepatic drug clearance during pregnancy.

EXPERT OPINION

Pharmacokinetic studies have shown that pregnancy alters systemic exposure, protein binding, and clearance of many drugs during gestation in part due to pregnancy-associated decreases in plasma albumin, increases in organ blood flow, and changes in the activity of drug-metabolizing enzymes (DMEs) and transporters. The changes in the activity of certain DMEs and transporters during pregnancy are likely driven by hormonal-changes that inhibit their activity or alter the expression of these proteins through activation of transcription factors.

Hospitalization for cardiovascular disease in the year after delivery of twin pregnancies

BACKGROUND AND AIMS

Increased cardiovascular demand in twin pregnancies, even those without hypertensive disease of pregnancy (HDP), may pose a greater risk for cardiovascular complications compared with singletons. In this study, the risk of cardiovascular disease (CVD)-related hospitalizations and mortality within the year following delivery in relation to HDP was compared between twin and singleton pregnancies.

METHODS

Using the Nationwide Readmissions Database of US hospitals from 2010 to 2020, the rates of CVD readmission in four exposure groups (twin deliveries with and without HDP and singleton deliveries with and without HDP) were estimated. Cox proportional hazard regression models were used to determine associations with singletons without HDP as the reference.

RESULTS

Of 36 million delivery hospitalizations, the rates of CVD readmission in twin and singleton pregnancies were 1105.4 and 734.1 per 100 000 delivery admissions, respectively. Compared with singletons without HDP, the adjusted hazard ratio (HR) of CVD readmission was highest for twins with HDP [HR 8.21, 95% confidence interval (CI) 7.48-9.01], followed by singletons with HDP (HR 5.89, 95% CI 5.70-6.08) and then twins without HDP (HR 1.95, 95% CI 1.75, 2.17).

CONCLUSIONS

Compared with singletons without HDP, twin pregnancies, even in the absence of HDP, are associated with increased risks for CVD complications in the first year post-partum. These findings highlight the increased strain twin pregnancies place on the maternal cardiovascular system. These findings advocate the need for appropriate pre-conception counselling for those with cardiovascular risk factors undergoing infertility treatment, which increase the risks of multi-foetal gestation, and increased post-partum surveillance in twin pregnancies.

Accuracy of the smartphone blood pressure measurement solution OptiBP to track blood pressure changes in pregnant women

INTRODUCTION

Hypertensive disorders present significant morbidity and mortality during pregnancy. Although ambulatory blood pressure measurement remains the standard of care for normotensive women, self-monitoring at home is increasingly prevalent. The widespread use of smartphones worldwide has sparked interest in mobile applications that leverage the built-in hardware for blood pressure estimation, yet few trials have assessed their accuracy.

METHODS

This prospective, longitudinal and monocentric study evaluated the accuracy of the OptiBP algorithm against standard oscillometric blood pressure measurements in a sample of pregnant women. Patients scheduled for elective caesarean sections were enrolled during the preoperative anesthesia consultations. Paired blood pressure measurements using OptiBP and the reference method were obtained at multiple time-points in late pregnancy and the postpartum period. Agreement between methods was assessed using the AAMI/ESH/ISO 81060-2:2018 standard thresholds of 5 ± 8 mmHg for mean ± standard deviation of the error (criterion 1) and patient-specific standard deviation of the mean error (criterion 2) and represented graphically by Bland-Altman scatterplots.

RESULTS

Forty-eight women were enrolled of which 32 completed the protocol, yielding 338 total valid measurement pairs. Mean and standard deviation of the error were -1.78 ± 7.94 and 1.19 ± 7.59, and the patient-specific standard deviation of the mean error was 4.68 and 4.52, for SBP and DBP, respectively.

CONCLUSION

Compared with blood pressure measurements taken with an oscillometric device, OptiBP's blood pressure estimates meet the AAMI/ESH/ISO 81060-2:2018 criteria.

Cardio obstetrics: Bridging heart and pregnancy health

Cardiovascular disease remains a major contributor to maternal morbidity and mortality in the United States. Cardio Obstetrics is a nascent field for which most cardiovascular clinicians have not received any formal training. This has resulted in knowledge and care gaps. In this review we provide principles to guide the care for the evaluation and management of pregnancy capable individuals, which should be considered the standard knowledge for all clinicians.

Hereditary Hemorrhagic Telangiectasia: Pregnancy and Delivery-Specific Considerations and Outcomes

Prior studies have evaluated maternal outcomes in patients with hereditary hemorrhagic telangiectasia (HHT), yet pregnancy- and delivery-specific data remain limited. This study aims to evaluate pregnancy and delivery outcomes in patients with HHT.This retrospective cohort study used the Nationwide Readmissions Database to identify patients with HHT diagnosis on delivery between 2010 and 2021. The primary outcome was severe maternal morbidity (SMM). Secondary outcomes included nontransfusion SMM, preterm birth, stillbirth, prelabor rupture of membranes or preterm prelabor rupture of membranes, cesarean delivery, respiratory bleeding, cerebrovascular complications, patient disposition, and length of stay. Trends in the prevalence of HHT at delivery were assessed with logistic regression. Logistic regression analyses, adjusting for age, payer, zip code income, hospital size, and teaching status, were also used to produce adjusted relationships between HHT status and outcomes.The cohort of 21,698,861 delivered pregnancies corresponded to a national estimate of 44,325,599. Of those, 612 (national estimate: 1,265; 2.8 per 100,000) had a diagnosis of HHT. A steady rise in the HHT diagnosis rate during pregnancy from 2010 to 2021 (1.7 per 100,000 in 2010, 3.8 per 100,000 in 2021, p < 0.001 for trend) was seen. Patients with HHT were significantly more likely to experience SMM compared with patients without HHT (7.8 vs. 1.7%, adjusted relative risk [aRR]: 4.49 [95% confidence interval, CI: 3.06, 6.58]). Rates of preterm birth (14.2 vs. 8.5%, aRR: 1.57 [95% CI: 1.22, 2.03]), cesarean delivery (41.0 vs. 32.9%, aRR: 1.23 [95% CI: 1.07, 1.41]), respiratory bleeding (2.1 vs. <0.1%, aRR: 94.44 [56.64, 157.46]), and cerebrovascular complications (0.9 vs. <0.1%, aRR: 22.89 [9.89, 52.96]) were higher in patients with HHT than non-HHT patients. There was no difference in stillbirth rates between groups.Patients with HHT have higher rates of SMM and adverse delivery outcomes when compared with the baseline population. · There was a steady rise in the rates of HHT during pregnancy from 2010 to 2021.. · Patients with HHT are more likely to experience SMM.. · Patients with HHT are more likely to have a preterm delivery and cesarean delivery..

Hematologic Complications of Pregnancy

Hematologic complications are common in pregnancy and can significantly impact both maternal and fetal health. Recognizing and treating these complications can be challenging due to the limited evidence available to guide clinical consultants. Iron deficiency anemia is the most prevalent hematologic issue in pregnancy and often occurs due to increased maternal blood volume and the nutritional demands of the growing fetus. Thrombocytopenia is the second most commonly occurring hematologic issue in pregnancy and can be associated with increased blood loss and complications during childbirth. However, the most common type of thrombocytopenia in pregnancy is gestational thrombocytopenia, which does not typically require clinical management. Thus, it is important to distinguish gestational thrombocytopenia from other etiologies of thrombocytopenia in pregnancy that require immediate treatment, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, preeclampsia, and HELLP (hemolysis, elevated liver enzyme levels, and low platelet levels) syndrome. Other important hematologic conditions in pregnancy include non-inherited anemias, such as autoimmune hemolytic anemia and aplastic anemia, as well as inherited anemias, such as sickle cell disease and thalassemia, which may require specialized management to optimize maternal and fetal outcomes. Additionally, bleeding disorders, such as von Willebrand disease and hemophilia, pose unique challenges in pregnancy, especially around the time of delivery, due to the risk of excessive bleeding. Lastly, thromboembolic disorders, such as venous thromboembolism (VTE), remain the leading cause of mortality in pregnancy in developed countries. Pregnancy-related hormonal changes, venous stasis, and hypercoagulability contribute to an increased thromboembolic risk, further exacerbated by additional risk factors such as obesity or a prior personal or family history of VTE. This review aims to summarize current guidelines and management of the most common hematologic disorders in pregnancy.

Pregnancy and postpartum dynamics revealed by millions of lab tests

Pregnancy and delivery involve dynamic alterations in many physiological systems. However, the physiological dynamics during pregnancy and after delivery have not been systematically analyzed at high temporal resolution in a large human population. Here, we present the dynamics of 76 lab tests based on a cross-sectional analysis of 44 million measurements from over 300,000 pregnancies. We analyzed each test at weekly intervals from 20 weeks preconception to 80 weeks postpartum, providing detailed temporal profiles. About half of the tests take 3 months to a year to return to baseline postpartum, highlighting the physiological load of childbirth. The precision of the data revealed effects of preconception supplements, overshoots after delivery and intricate temporal responses to changes in blood volume and renal filtration rate. Pregnancy complications-gestational diabetes, preeclampsia, and postpartum hemorrhage-showed distinct dynamical changes. These results provide a comprehensive dynamic portrait of the systems physiology of pregnancy.

Impact of pregnancy on the maternal brain in health and multiple sclerosis

Multiple sclerosis (MS) is a chronic immune-mediated demyelinating disease of the central nervous system characterised by inflammatory lesions and neurodegeneration. Diagnosis often occurs in women of childbearing age, and therefore pregnancy is frequently encountered in women with MS. However, the effect of pregnancy on the MS brain is not well understood, including the impact on inflammatory lesion activity and rate of brain atrophy. Determining the effect of pregnancy on the MS brain is complex due to several confounding factors, including dynamic changes in brain volumes in healthy physiological (non-MS) states and the impact of withdrawing disease-modifying therapies for pregnancy on inflammatory lesion activity. This review first provides an in-depth overview of the profound structural neuroplasticity that occurs during pregnancy in healthy women without neurological disease and its association with maternal caregiving behaviours and maternal-infant attachment measures. These findings are integrated with results of MRI studies in pregnant women with MS to provide a perspective on the multifold influences on brain volume changes in this context. This review also explores the increase in inflammatory lesions observed on postpartum MRI in women with MS, which likely accrue in the postpartum phase mirroring clinical relapse dynamics. Key knowledge gaps are identified, and future research pathways are proposed to improve our understanding of how pregnancy impacts the brain in both healthy and MS states.

Cardio-obstetrics in the Cardiac Intensive Care Unit: An Introductory Guide

The care of the cardio-obstetric population in the cardiac intensive care unit is challenging due to limited data in this patient population. Optimal care requires a broad multidisciplinary team of experts such that both maternal and fetal health are fully supported. A deep understanding of the interplay between the hemodynamics of pregnancy and the clinical manifestations of varied cardiac disease states is essential. The assessment, diagnostic testing, and treatment of patients who are pregnant require special consideration, especially as teams consider pharmacological and invasive therapies. Complex ethical decisions often arise and therapies may be limited by federal and state policy, which adds an additional layer of complexity. This review serves as an introductory guide to cardio-obstetric care in the cardiac intensive care unit.

Management of Valvular Heart Disease in Pregnancy: Challenges, Risk Stratification, and Multidisciplinary Approaches

Advancements in medicine and surgery have led to an increasing number of women with valvular heart disease (VHD) reaching reproductive age and pursuing pregnancy. VHD, which may be congenital or acquired, accounts for a significant proportion of heart diseases in pregnant women, with rheumatic heart disease being the predominant cause globally, especially in developing countries. Pregnancy-induced hemodynamic changes can exacerbate preexisting valvular conditions, leading to complications such as heart failure, arrhythmia, and adverse fetal outcomes. Management of pregnant women with VHD requires a comprehensive, multidisciplinary approach involving preconceptional counseling, risk stratification, and careful monitoring throughout pregnancy. Risk assessment models, including CARPREG II, ZAHARA II, mWHO, and the DEVI score, help identify high-risk patients and guide management strategies. Specific challenges arise in patients with mechanical prosthetic valves due to the need for anticoagulation therapy, which must be carefully managed to minimize risks to both mother and fetus. The delivery plan should be tailored to the severity of the valvular disease, with careful consideration of the mode of delivery and the need for anticoagulation management during labor and postpartum. Preconception counseling is crucial in informing women of the potential risks and helping guide family planning decisions. This paper highlights the importance of early diagnosis, tailored treatment, and a multidisciplinary approach to reduce maternal and fetal morbidity and mortality in pregnant women with valvular heart disease.

Effect of pregnancy on bioprosthetic structural valve degeneration

Background

Despite increasing frequency of pregnancies among patients with cardiac conditions, including the presence of prosthetic heart valves, data on the effects of physiological changes during pregnancy on the function of bioprosthetic valves remains scarce and shows conflicting results.

Objectives

This study was aimed to determine the effect of pregnancy on the rate of bioprosthetic structural valve degeneration.

Methods

We designed a retrospective matched cohort study of patients seen between June 2018 and February 2023. All pregnant patients with bioprosthetic valves were matched to non-pregnant controls with prior valve replacement based on bioprosthetic valve location, time since valve implantation, age of the patient at valve implantation and time between baseline and follow up echocardiograms. Echocardiograms of pregnant patients were evaluated for bioprosthetic structural valve degeneration grade based on a dedicated scale before and after pregnancy. Non-pregnant controls had echocardiogram scoring of structural valve degeneration over a similar time period.

Results

Thirty four pregnant patients with bioprosthetic valves in the pulmonary, aortic and mitral positions were matched with 71 non-pregnant controls with identical bioprosthetic valves locations. Over a median follow up period of 13.5 months that included the gestational period, 18 (53 %) pregnant patients had an increase in structural valve degeneration score as compared to 17 (26 %) of the non-pregnant patients in median follow up of 13.7 months (OR 3.87, p = 0.004). On multivariable analysis, pregnancy was the only variable associated with increased structural valve degeneration score.

Conclusions

Our results suggest that pregnancy is associated with increased bioprosthetic structural valve degeneration.

Evaluation of Cardiac Function in a Patient With Hypertrophic Cardiomyopathy Before and During Pregnancy to Predict Its Outcome: A Case Report

The risk of maternal and neonatal mortality in pregnant women with hypertrophic cardiomyopathy (HCM) is considered low, and prognostic methods have not yet been established. In this study, we evaluated several pregnancies in the same patient. In each case, we were able to assess the severity of the mother's cardiac disease and estimate the prognosis. By reviewing the severity of the disease over time and its actual course, we verified the kind of assessment that is important for predicting prognosis. We present the case of a patient who was diagnosed with HCM at 18 years of age and had her first spontaneous pregnancy at 25 years of age. The baby was born at 38 weeks and was healthy, but the mother's HCM worsened after the second trimester of pregnancy, and treatment in the intensive care unit was needed after delivery. After an implantable cardioverter-defibrillator (ICD) implantation, a second pregnancy was established. However, due to repeated arrhythmias requiring ICD activation, a termination of pregnancy was performed due to the risk of worsening maternal heart failure. After radical septal myectomy, a third pregnancy was achieved. In this case, the left ventricular outflow tract stenosis disappeared, the left ventricular outflow tract pressure gradient decreased, and the pregnancy progressed well with no maternal complications. The New York Heart Association (NYHA) and modified World Health Organization (WHO) scores before conceiving were not sufficient to predict pregnancy outcomes. Changes in the disease status during pregnancy were generally consistent with the Zwangerschap bij Aangeboren HARtAfwijkingen (ZAHARA) or pregnancy and congenital heart disease score, Cardiac Disease in Pregnancy Study II (CARPREG II) score, and modified WHO classification ratings, suggesting that they are suitable for assessing risk during pregnancy, and before and after delivery in patients with HCM.

Maternal shift work during pregnancy and cardiovascular health impacts on mother and offspring

Cardiovascular disease (CVD) is the leading cause of death for women worldwide. One of the risk factors for CVD in women is complications during pregnancy. Pregnancy complications include a wide arena of pathologies, including hypertension, preeclampsia, gestational diabetes, preterm delivery and miscarriage. Interestingly, increased evidence in recent years highlights a novel link between maternal shift work during pregnancy and increased risk for pregnancy complications, specifically hypertension and diabetes, while knowledge on other CVDs, such heart failure, atherosclerosis, ischemic heart disease, and stroke in pregnant shift working mothers is still scarce. Notably, shift work during pregnancy results in significant changes to the circadian rhythm of both the mother and fetus, therefore, engaging into shift work during pregnancy may adversely affect the cardiovascular health of both the mother and offspring, and carry into adulthood. Herein, we highlight the novel relationship between maternal shift work during pregnancy and the increased risk for pregnancy complications that may increase risk for CVD later in life. Furthermore, we provide mechanistic insights of the hemodynamic processes that are disrupted in response to maternal shift work and may explain the increased risk for cardiovascular disease. Understanding how shift work during pregnancy influences the prevalence for heart disease is of paramount clinical importance for minimizing the risk for cardiovascular disease for both the mother and offspring.

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.

Impact of Stress and Anxiety on Cardiovascular Health in Pregnancy: A Scoping Review

Complex biological processes that enable optimal foetal growth throughout pregnancy are linked to notable haemodynamic and metabolic changes in the mother's body. An inability to adapt to these changes can affect cardiovascular health. During pregnancy, women may experience mood swings, anxiety, and emotional ambivalence. These symptoms can lead to stress and harm the mental well-being of expectant mothers. It is crucial to know the aspects that can influence the development of cardiovascular problems among pregnant women. Effective management requires identifying risk factors. Applying the PRISMA ScR guidelines, we conducted a scoping review to explore and summarise the evidence regarding the impact of stress and anxiety on cardiovascular health in pregnant women. The following enquiries were looked into as research topics: What effects do anxiety and stress have on a pregnant woman's cardiovascular health? How is it quantifiable? It is essential to comprehend the physiological changes that the body undergoes throughout pregnancy in order to inform and assist both patients and medical professionals. This makes it possible for them to identify any pathological disorders or risk factors that could worsen the health of expectant mothers. Psychological and cardiovascular risk factor screening, either before or during pregnancy, may be able to uncover circumstances that require specific medical and psychological therapies in order to lower maternal morbidity and death from cardiovascular disease. Our findings underscore the need for systematic psychological and cardiovascular screening during prenatal care to mitigate adverse outcomes and improve maternal-foetal health.

Pregnancy-Related Cardiovascular Diseases: A Radiological Overview

Pregnancy induces significant hemodynamic changes, and cardiovascular diseases (CVDs) are one of the leading causes of non-obstetric maternal morbidity and mortality during pregnancy or the postpartum period in developed countries. The effective diagnosis and management of CVDs in pregnant women require a thorough evaluation that considers the health of both the mother and the fetus. Imaging plays a pivotal role in this evaluation, offering essential insights into the most significant pregnancy-related CVDs. However, due to concerns about fetal exposure, the use of contrast agents and radiation exposure must be carefully managed. Following to the principle of "As Low As Reasonably Achievable" (ALARA), strategies to minimize these risks are crucial for ensuring patient safety while maintaining diagnostic accuracy. This review highlights the contribution of cardiovascular imaging techniques, particularly computed tomography (CT) and magnetic resonance imaging (MRI), in the assessment of common pregnancy-related CVDs, and outlines strategies to reduce radiation exposure and limit contrast agent use when feasible, aiming to increase radiologists' awareness of this crucial topic.

Systematic Review and Meta-Analysis of 24-Hour Ambulatory Blood Pressure Monitoring in Pregnancy and Postpartum Periods

PURPOSE

Early detection and management of hypertensive disorders during pregnancy and postpartum are essential. This systematic review and meta analysis aimed: (1) to examine the state of 24-hour ambulatory blood pressure (ABP) use, and (2) in a subset of studies, evaluate 24-hour ABP parameters in the prediction and identification of Hypertensive Disorders of Pregnancy (HDP).

METHODS

A comprehensive literature search was conducted in March of 2022 for English language studies published after 2000. In a subset of studies in this review, we conducted a meta analysis summarizing 24-hour, day, and night standardized mean difference (hedge's g) in systolic and diastolic blood pressure during pregnancy for individuals later diagnosed with HDP and those without.

RESULTS

A total of 69 articles met all established criteria and were included in this systematic review, and a subgroup of studies that reported HDP outcomes (n=14) were included in the meta analysis. Out of the 69 studies, 31 (45.61%) used 24-hour ABP devices that are not validated for pregnant individuals. Birthing individuals diagnosed with HDP had elevated 24-hour, day, and night systolic and diastolic blood pressure during second and third trimesters of pregnancy.

CONCLUSION

A noticeable gap exists in the utilization of validated 24-hour ABP devices for pregnant and postpartum populations. Variations exist regarding the timing of 24-hour ABP measurements, particularly across trimesters.

IMPLICATIONS FOR PRACTICE

24-hour ABP monitoring could serve as one of the tools to identify and manage pregnant individuals at risk of HDP and ultimately reverse the current trend in maternal mortality.

Prevalence of metabolic syndrome among pregnant women: a systematic review and meta-analysis

PURPOSE

Metabolic syndrome (MetS) is a cluster of risk factors that increase the risk of cardiometabolic diseases. The prevalence of MetS and individual components across pregnancy has not been reviewed in the literature. This research was conducted to identify the prevalence of MetS and its components among pregnant women.

METHODS

The PubMed, EMBASE, CINAHL, Web of Science and Scopus databases were searched. The review protocol is registered in PROSPERO (CRD42023460729). Quality assessment was performed using the JBI critical appraisal checklist. The study selection, data extraction and data analyses were performed in accordance with the MOOSE guidelines.

RESULTS

The prevalence of MetS among pregnant women was 16.3%, (n = 3946). The prevalences for individual MetS components were: low HDL, 12.3% (n = 1108); high fasting glucose, 16.2% (n = 2333); high triglycerides, 48.5% (n = 2880); obesity, 42.7% (n = 5162) and high blood pressure 37.7% (n = 828). According to the definitions used to diagnose MetS, the prevalences were 18.2% according to the World Health Organization, 15.0% according to the International Diabetes Federation and 17.2% according to the National Cholesterol Education Program Adult Treatment Panel III. When stratified by gestational age at assessment, the prevalence of MetS was 9.9% before 16 weeks' and 24.1% after 20 weeks' of gestation.

CONCLUSION

This review demonstrates that MetS is detected in approximately one-fifth of pregnant women. Screening for MetS and its components during pregnancy may help identify young women at risk for future cardiovascular disease.

The microcirculation: master in normal pregnancy, puppet in preeclampsia

BACKGROUND

The microcirculation is studied sparsely in the field of maternal hemodynamics. With nailfold video capillaroscopy, further insight is possible in this interesting field within maternal hemodynamics.

OBJECTIVE

This study aimed to investigate the association between functional parameters of the microcirculation and the systemic cardiovascular system in pregnant women at risk for gestational hypertension disorders.

STUDY DESIGN

For this observational study, women with high cardiovascular risk according to maternal anthropometrics and obstetrical and medical history were recruited at random gestational ages, depending on the time of referral to the outpatient clinic for high-risk prenatal care at Ziekenhuis Oost-Limburg, Genk, Belgium. After birth, data on maternal and neonatal outcomes were obtained from hospital records, and only women with normal pregnancy (n=142) and preeclampsia (n=34) were included in this analysis. Nailfold video capillaroscopy measurements were performed in the first, second, and/or third trimesters. Video magnification of 200× was used for all fingers except the thumbs, and the stored images were analyzed offline. Capillary density was quantified (n/mm2), mean capillary diameter measured (μm), and capillary bed surface calculated as density × diameter. Cardiac output and total peripheral resistance were measured using impedance cardiography, together with sphygmomanometric blood pressure measurement. A linear mixed model for repeated measures was used to investigate the association between the microvascular and macrovascular parameters. No corrections for multiple testing were applied.

RESULTS

In normal pregnancies, a positive association was observed between the capillary bed surface and total vascular resistance (1.807; P=.01) and a negative association between capillary density and cardiac output (-0.269; P=.037). In preeclampsia, a negative association was observed between capillary density and mean arterial pressure (-0.5649; P=.010), and between capillary diameter and cardiac output (-0.165; P=.032).

CONCLUSION

The finding of a reduction in capillary density with an increase in blood pressure in preeclampsia is similar to observations in chronic hypertension. This is considered to be the result of capillary closure after the constriction of the precapillary arterioles. However, in normal pregnancy, the increase in capillary bed surface with rising vascular resistance can only be explained by the primary role of microcirculation in preventing capillary overflow via stimulation of arteriolar constriction. These observations elucidate the earliest hemodynamic origins of hypertension at the microcirculatory level in preeclampsia.

Pregnancy Complications and Long-Term Atherosclerotic Cardiovascular Disease Risk

PURPOSE OF REVIEW

Discuss the relationship between pregnancy complications and long-term atherosclerotic cardiovascular disease (ASCVD) risk.

RECENT FINDINGS

A large body of research confirms an association between pregnancy complications and increased short and long-term ASCVD risk and seeks to understand mechanisms for these associations. Social determinants of health continue to have a critical impact on the prevalence of adverse pregnancy outcomes (APOs) and long term ASCVD risk. Of the APOs, hypertensive disorders of pregnancy (HDP) are associated with the highest ASCVD risk. Additionally, recent research shows an association between APOs and microvascular coronary heart disease. APOs are associated with increased risk of ASCVD, however there is conflicting evidence on whether there is a causal relationship between APOs and ASCVD or if APOs are simply a marker of ASCVD risk. Current ASCVD risk models do not incorporate a history of APOs, therefore it is imperative that healthcare providers take a reproductive health history and account for pregnancy complications when counseling patients on long-term cardiovascular risk. Non-invasive modalities such as coronary artery calcium scoring can be considered as an adjunct, but further research is warranted to determine which patients would benefit most.

Cardiac Critical Care of the Cardio-Obstetric Patient

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States, with an incidence that has increased from 7.2 to 32.9 fatalities per 100,000 live births in the last 3 decades. This trend underscores the potential for an increase in the volume of admissions to cardiac intensive care units (CICUs) in the peripartum period. While congestive heart failure remains at the forefront of maternal morbidity, other life-threatening conditions include myocardial infarction (MI), hypertensive emergencies, fatal arrhythmias such as ventricular fibrillation, venous thromboembolism, aortopathies, valvular dysfunction, cardiac arrest, and cardiogenic shock. The lack of standardized guidelines to facilitate management of these conditions highlights the significant gap in medical knowledge while caring for acutely ill pregnant women. Through this comprehensive review, we highlight the most common cardiac pathologies encountered in the obstetric population and their diagnosis and contemporary management in the cardiac intensive care unit.

Considerations for Women with Congenital Heart Disease Undergoing Percutaneous Cardiovascular Procedures

The catheterization of women with congenital heart disease has unique considerations that must be taken into account. Hemodynamic changes secondary to pregnancy, anticoagulation strategies of women in child bearing years, and protection of a fetus during pregnancy require interventions and evidence of current therapies in the treatment of women continues to have more questions than answers in our current era. This review highlights some challenges in the catheterization of women with congenital heart disease.

Maternal heart exhibits metabolic and redox adaptations post-uncomplicated pregnancy

Pregnancy may be a challenging period for the maternal systems and has been regarded as a stress test, as imperceptible/mild dysfunctions eventually present may be exacerbated during this period. The cardiovascular system is no exception, and several morphological and functional adaptations accompanying pregnancy have been described. However, long-term pregnancy-induced cardiac molecular alterations remain highly unexplored. The postpartum is marked by reverse remodeling of the pregnancy-induced cardiovascular adaptations, representing a possible critical period for assessing future maternal cardiovascular health. The current study explored the molecular and metabolic alterations in the cardiac tissue eight weeks after a physiological uncomplicated pregnancy. Female Sprague-Dawley rats were fed a chow diet through pregnancy, lactation, and weaning and compared to their non-pregnant counterparts. Eight weeks postpartum, increased levels of the phosphorylated form of AMPKα (Thr172) and its ratio to total AMPKα indicated possible alterations in cardiac metabolic flexibility, accompanied by increased Pparα and Hif1α transcripts levels. Additionally, postpartum hearts exhibited higher mitochondrial ATP and NADH levels without major changes in mitochondrial respiratory function. Elevated Nrf2 levels in the cardiac tissue suggested potential implications for cardiac redox balance, further supported by increased levels or activity of proteins directly regulated by Nrf2. The findings herein reported suggest that at eight weeks postpartum, molecular alterations induced by pregnancy, especially regarding redox balance, are still observed in the mothers' heart. These alterations present at late postpartum may open new avenues to understand the different risk for cardiovascular complications development after normal pregnancies.

Untreated ALCAPA diagnosed in gestational ultrasonography

ALCAPA is a rare congenital anomaly that presents with left ventricular (LV) dysfunction and mitral valve regurgitation. The mortality rate is roughly 90% if the intracoronary collateral isn't significantly augmented. Malignant arrhythmias resulting in sudden death are common, affecting nearly 90% of patients with a mean age of 35 years. Especially during pregnancy, untreated ALCAPA can lead to high mortality and complications. Pregnant women with congenital heart disease have high risks for both themselves and their fetuses. Therefore, screening for congenital heart disease is very important in early diagnosis, counseling, and management. Most women born with congenital heart disease (CHD) will reach reproductive age. We report a case of a 30-year-old woman in her second trimester of pregnancy who presents with ALCAPA, preserved ejection fraction (EF), and mild LV dilation. An uncommon feature, in this case, is the origin of the left main (LM) coronary artery from the posterior to the right of the main pulmonary artery (MPA), which is very close to the ascending aorta, mimicking the normal origin of the LM from the aortic root in 2D transthoracic echocardiography. The patient also has preserved left ventricular function with endocardial fibroelastosis. Echocardiography should be performed every 4 weeks to assess the progression of the disease during pregnancy.

Pathways to maternal health inequities: Structural racism, sleep, and physiological stress

Racial inequities in health are vast and well-documented, particularly regarding maternal and infant health. Sleep health, including but not limited to duration and quality, is central to overall health and well-being. However, research has not adequately addressed how racism embedded in structures and systems, in addition to individual experiences, may affect maternal health by impacting sleep. In this critical review, we aim to 1) synthesize findings, emphasizing collaborative studies within our group, 2) highlight gaps in knowledge, and 3) propose a theoretical framework and methodological approach for moving the field forward. Specifically, we focus on findings and future directions linking perinatal sleep, cardiovascular and immune function, and racial disparities in maternal health. Because too few studies look beyond individual-level determinants of sleep deficiencies among Black Americans, we assert a critical need for research that bridges multiple levels of analysis (e.g., individual, community, society) and provides recommendations for specific health parameters that researchers in this area can target. Although the need to understand and address perinatal health disparities is clear, the goal of identifying multilevel mechanisms underlying how racism in one's environment and daily life may interact to affect health extends far beyond pregnancy research.

Unveiling an insidious diagnosis and its implications for clinical practice: Individual patient data systematic review of pregnancy-associated spontaneous coronary artery dissection

BACKGROUND

Pregnancy-Associated Spontaneous Coronary Artery Dissection (P-SCAD) is the most common cause of myocardial infarction in pregnancy and postpartum. Aim of this systematic review is to provide a descriptive picture of P-SCAD presentation, clinical course, management and outcomes.

METHODS

International databases were systematically screened up to November 2023 and all published P-SCAD case reports/series identified; additionally, we gathered four original cases, establishing a new database for the derived cohort.

RESULTS

253 studies (215 case reports, 38 case series) were included for the analysis, enrolling 316 patients admitted between 1952 and 2023. Median age was 34 (SD 5) years old, 64 (20.4 %) were prepartum, 249 (79.6 %) postpartum. Most common presentation was ST-elevation myocardial infarction (72.6 %). Cardiac arrest and cardiogenic shock occurred in 18.4 % and 16.1 %, respectively. Multivessel dissection was present in 45.2 % of cases, with left anterior descending artery being most frequently affected (74.4 %). Initial therapeutic strategy was medical therapy in 54.8 % while upfront revascularization was performed in 45.2 % of cases. Excluding autoptic studies, mortality rate was 4.1 %, without significant differences between pre and postpartum SCAD (p-value 0.6) or according to initial therapeutic approach (p-value 0.5). Recurrences after index event were registered in 74 patients (23.4 %), being more common after medical treatment than in case of immediate revascularization (30.8 versus 18.3 %, p-value 0.02).

CONCLUSIONS

P-SCAD is a complex clinical scenario: timely diagnosis is difficult, therapeutic management not well-defined, rate of recurrences not negligible. Additional observational studies and dedicated registries are necessary to enhance the management of this rare but severe condition.

Patient awareness of long-term cardiovascular and metabolic disease risks after hypertensive disorders of pregnancy in Japan

AIM

Given the increasing recognition of the importance of postpartum follow-up care for women with a history of hypertensive disorders of pregnancy (HDP) to mitigate their future risk of cardiovascular and metabolic diseases, here we aimed to evaluate the current status of postpartum follow-up care in Japan and explore the challenges to its implementation.

METHODS

A web-based survey was conducted using a smartphone application among postpartum women between March and May 2024 to assess their knowledge of HDP-related future risk and postpartum follow-up care.

RESULTS

A total of 880 valid responses were obtained, 73 (8.3%) of which were from women with a history of HDP. Of them, 56.2% were aware of the heightened risk of cardiovascular disease and even fewer knew about the risks of metabolic syndrome (37.0%) and the preventive use of low-dose aspirin (12.3%); in fact, 31.5% reported receiving no information about their risk or preventive measures from healthcare providers. Furthermore, 43.8% did not consult specialists or attend regular checkups after their 1-month checkup. Among women with a history of HDP, those who received information and guidance were more likely to implement behavioral changes than those who did not.

CONCLUSIONS

Patient awareness level of HDP-related risk was low and the information provided by their healthcare professionals was insufficient, indicating that postpartum follow-up care in Japan is not satisfactory. This study highlights the need for improved educational strategies and systematic follow-up protocols to ensure that women are adequately informed and supported in managing their long-term health risks.

Long-Term Impact of Pregnancy on Clinical Outcomes in Individuals With Hypertrophic Cardiomyopathy

Background

The effect of pregnancy on individuals with hypertrophic cardiomyopathy (HCM) is not well investigated.

Objectives

The purpose of this study was to assess the impact of pregnancy on all-cause mortality and clinical outcomes among individuals with HCM.

Methods

Using the TriNetX research network, we identified individuals within reproductive age (≥18-45 years) with a diagnosis of HCM between 2012 and 2022 (n = 10,936). Patients were stratified based on pregnancy history into 2 groups: 1) those with a history of pregnancy/high-risk pregnancy supervision; and 2) those without a history of pregnancy or subsequent antenatal/pregnancy supervision encounters throughout the study period. Propensity score matching resulted in 3,399 patients in each cohort. The primary outcome was all-cause mortality. Secondary outcomes include a composite of arrhythmic events (defined as sudden cardiac death, appropriate shocks, sustained ventricular tachycardia/ventricular fibrillation), major adverse cardiovascular events (MACE), and acute heart failure exacerbation during 10 years of follow-up.

Results

Pregnancy in patients with HCM was associated with a comparable risk of all-cause mortality (adjusted OR: 0.89; 95% CI: 0.7-1.14; P = 0.37) at 10-year follow-up. There was no difference in MACE (adjusted OR: 1.02; 95% CI: 0.85-1.22; P = 0.80) and arrhythmic events (adjusted OR: 0.93; 95% CI: 0.73-1.18; P = 0.55) between both groups. In subgroup analysis of obstructive HCM, the findings were similar between both pregnancy and no pregnancy groups.

Conclusions

Pregnancy in individuals with HCM was not associated with a higher risk of adverse outcomes at long-term follow-up. Further efforts are warranted to better understand the short-term outcomes in this high-risk population.

Electrocardiographic Changes in Pregnant Patients With Congenital Heart Disease

BACKGROUND

Electrocardiograms (EKGs) are routinely performed in pregnant patients with pre-existing cardiovascular disease. However, in pregnant patients with congenital heart disease (CHD), EKG changes during gestation have not been explored.

METHODS

We performed a retrospective study of pregnant patients with CHD enrolled in the STORCC initiative. Patients were included if they had at least two EKGs across the perinatal period and were grouped by specific conditions: atrial septal defect (ASD), tetralogy of Fallot, congenital pulmonary stenosis, coarctation of the aorta (CoA), bicuspid aortic valve (BAV), systemic right ventricle (SRV), and Fontan circulation. EKG parameters were measured in all available EKGs by two investigators, blinded to diagnosis and time of gestation.

RESULTS

One hundred and seventy pregnant patients were included. There was a statistically significant increase in HR from pre-pregnancy to third trimester in all groups except for those with Fontan and SRV. Patients with ASD and BAV had a statistically significant increase in their QTc (ASD:13 ms, p = 0.017; BAV:7 ms, p = 0.018) during pregnancy. QRS duration was shorter (4 ms) in the third trimester for patients with ASD (p = 0.033) and CoA (p = 0.014). Despite these individual findings, EKG parameters remained within normal limits and regressed to baseline in the postpartum period.

CONCLUSIONS

Patients with CHD have statistically significant EKG changes throughout pregnancy, but the values remain within normal limits. Like patients without heart disease, those with CHD increase their HR during pregnancy, except individuals with SRV and Fontan, who appear to lack capacity for physiologic HR augmentation.

Clinical approach to palpitations in pregnancy

Palpitations are common in pregnancy and warrant investigation. Palpitations may be caused by non-cardiac and cardiac causes. Patients with structural or functional abnormalities or inherited cardiovascular disease are more likely to develop arrhythmia, especially during pregnancy when the mother's body undergoes extensive physiological adaptations, which further contribute to an increased arrhythmia risk. While isolated ectopic beats do not require treatment, some heart rhythm disturbances can be life-threatening for mother and baby and mandate prompt intervention. Haemodynamically unstable patients should be electrically cardioverted. If the patient is stable, medical management is indicated, and early involvement of the pregnancy heart team can help facilitate appropriate treatment. In complex arrhythmia, consultation of an arrhythmia expert should be sought . Many anti-arrhythmics are safe in pregnancy, and it is important to reassure the pregnant patient of this.

Cardiac automaticity is modulated by IKACh in sinoatrial node during pregnancy

AIMS

Pregnant (P) women have a significantly elevated resting heart rate (HR), which makes cardiac arrhythmias more likely to occur. Although electrical remodelling of the sinoatrial node (SAN) has been documented, the underlying mechanism is not fully understood. The acetylcholine-activated potassium current (IKACh), one of the major repolarizing currents in the SAN, plays a critical role in HR control by hyperpolarizing the maximal diastolic potential (MDP) of the SAN action potential (AP), thereby reducing SAN automaticity and HR. Thus, considering its essential role in cardiac automaticity, this study aims to determine whether changes in IKACh are potentially involved in the increased HR associated with pregnancy.

METHODS AND RESULTS

Experiments were conducted on non-pregnant (NP) and pregnant (P; 17-18 days gestation) female CD-1 mice aged 2 to 4 months. IKACh was recorded on spontaneously beating SAN cells using the muscarinic agonist carbachol (CCh). Voltage-clamp data showed a reduction in IKACh density during pregnancy, which returned to control values shortly after delivery. The reduction in IKACh was explained by a decrease in protein expression of Kir3.1 channel subunit and the muscarinic type 2 receptor. In agreement with these findings, current-clamp data showed that the MDP of SAN cells from P mice were less hyperpolarized following CCh administration. Surface electrocardiograms (ECGs) recorded on anaesthetized mice revealed that the cholinergic antagonist atropine and the selective KACh channel blocker tertiapin-Q increased HR in NP mice and had only a minimal effect on P mice. AP and ECG data also showed that pregnancy is associated with a decrease in beating and HR variability, respectively.

CONCLUSION

IKACh function and expression are decreased in the mouse SAN during pregnancy, strongly suggesting that, in addition to other electrical remodelling of the SAN, reduced IKACh also plays an important role in the pregnancy-induced increased HR.

Anti-inflammatory diet mitigate cardiovascular risks due to particulate matter exposure in women during pregnancy: A perspective cohort study from China

BACKGROUND

Particulate matter (PM) exposure during pregnancy may increase cardiovascular risk (CVR). However, the specific time windows of exposure contributing to this association and the potential biological mechanisms underlying it remain unclear.

OBJECTIVE

To determine the sensitive time window for CVR related to PM exposure. We investigated whether levels of inflammatory biomarkers mediate the relationship between PM exposure and CVR, and examined the potential impact of an anti-inflammatory diet on this association.

METHODS

From 2015 to 2021, 9294 pregnant women from three Hefei hospitals were included. We used a 1 × 1 km satellite dataset to assess PM1, PM2.5, and PM10 exposure. High-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) were measured as inflammatory biomarkers. The empirical dietary inflammatory pattern (EDIP) score, based on a validated food frequency questionnaire. The CVR score was calculated using five clinical metrics based on American Heart Association criteria.

RESULTS

We found a significant association between PM exposure and increased CVR score, especially during the 2nd to 8th weeks of the first trimester. For every increase of 10-μg/m3 of PM1, PM2.5, and PM10, there was an associated increase in CVR of 0.51 (95%CI: 0.21, 082), 0.25 (95% CI: 0.11 to 0.39), and 0.29 (95% CI: 0.09 to 0.37), respectively. Mediation analysis revealed that the proportion of the association between PM1, PM2.5, and PM10 exposure and CVR mediated by inflammatory biomarkers was 24.3%, 22.4%, and 20.1%, respectively. Stratified analyses showed no positive correlation between PM exposure and CVR in the anti-inflammatory diet (low EDIP) group. The β coefficients were 0.52 for PM1 (95% CI: -0.06 to 1.11), 0.31 for PM2.5 (95% CI: -0.04 to 0.79), and 0.25 for PM10 (95% CI: -0.03 to 0.54).

CONCLUSIONS

PM exposure, particularly during weeks 2-8 of pregnancy, correlates with CVR, partly mediated by levels of inflammatory biomarkers. An anti-inflammatory diet mitigates CVR associated with PM exposure.

Treg cells promote decidual vascular remodeling and modulate uterine NK cells in pregnant mice

Regulatory T (Treg) cells are essential for maternal immune tolerance of the fetus and placenta. In preeclampsia, aberrant Treg cell tolerance is implicated, but how Treg cells affect the uterine vascular dysfunction thought to precede placental impairment and maternal vasculopathy is unclear. We used Foxp3-diphtheria toxin receptor mice to test the hypothesis that Treg cells are essential regulators of decidual spiral artery adaptation to pregnancy. Transient Treg cell depletion during early placental morphogenesis caused impaired remodeling of decidual spiral arteries, altered uterine artery function, and fewer Dolichos biflorus agglutinin+ uterine natural killer (uNK) cells, resulting in late-gestation fetal loss and fetal growth restriction. Replacing the Treg cells by transfer from wild-type donors mitigated the impact on uNK cells, vascular remodeling, and fetal loss. RNA sequencing of decidua revealed genes associated with NK cell function and placental extravillous trophoblasts were dysregulated after Treg cell depletion and normalized by Treg cell replacement. These data implicate Treg cells as essential upstream drivers of uterine vascular adaptation to pregnancy, through a mechanism likely involving phenotypic regulation of uNK cells and trophoblast invasion. The findings provide insight into mechanisms linking impaired adaptive immune tolerance and altered spiral artery remodeling, 2 hallmark features of preeclampsia.

Managing supraventricular tachyarrhythmia in pregnant patients within the emergency department

Background

Pregnancy increases the risk of supraventricular tachycardia (SVT) due to physiological changes. This study reviews the management of SVT in pregnant patients in the emergency department (ED).

Methods

We retrospectively analyzed 15 pregnant patients with SVT treated at Shenzhen Second People's Hospital ED from 2015 to 2023. Treatments included vagal nerve stimulation, pharmacotherapy, esophageal pacing, cardioversion, and radiofrequency ablation.

Results

The average patient age was 30.3 years. All presented with palpitations, and none had hemodynamic instability. Treatment success varied: 3 patients reverted spontaneously, 5 responded to vagal stimulation, and 4 to esophageal pacing. One required verapamil, and another responded to labetalol after failing vagal and pacing treatments.

Conclusion

When managing SVT during pregnancy, it is important to consider the patient's stability, the stage of pregnancy, and the safety of medications. For unstable patients, electrical cardioversion is the preferred option; for stable patients, vagus nerve stimulation (VNS) or other alternative treatments, such as adenosine, should be considered.

Evaluation of risk factors for postpartum cerebral venous sinus thrombosis, a multicenter retrospective observational study

The postpartum period is a well-defined risk factor for cerebral venous sinus thrombosis (CVST). However, it is unclear which patients are at risk for CVST in the postpartum period. Thus, determining some CVST risk factors in postpartum patients may be useful for preventing the disorder in this population. Previous studies have shown that preeclampsia (PE) is a risk factor for pulmonary thromboembolism and deep vein thrombosis, but whether it is related to postpartum CVST has not yet been evaluated. This study aimed to determine if this relationship exists. This study was a case-control study of retrospectively screened patients diagnosed with CVST between 2018 and 2023 at the Uludağ University Faculty of Medicine Department of Neurology, the Eskişehir Osmangazi University Faculty of Medicine and the Bursa City Hospital Health Sciences University Department of Neurology. All of the women who delivered between 2018 and 2023 at the Uludağ University Faculty of Medicine Department of Obstetrics and Gynaecology were included in the control group. In total, 57 out of 322 cases and 4299 out of 4452 controls were included in this study. A nonsignificant relationship was found between CVST and spinal anesthesia, but a significant relationship was found between PE and stillbirth. Women with PE who had recently delivered were found to be at increased risk of developing CVST. The primary limitation of this study is that it was retrospective, and the control group was hospital-based. We recommend that these findings be confirmed by multicenter prospective international studies.

Preemptive Use of a Left Microaxial Flow Pump in Peripartum Cardiomyopathy

Management of peripartum cardiomyopathy and cardiogenic shock often presents a significant clinical challenge. These patients are frequently best served at a specialized center with access to cardiac anesthesia, maternal-fetal medicine, and cardiac intensivists. Planning for delivery involves a plan for anesthesia and management of hemodynamic changes during the postoperative period. The use of temporary microaxial flow pumps for hemodynamic support allows for ventricular unloading and recovery without the use of catecholaminergic agents. We present a case of early left hemodynamic support with an Impella CP device (Abiomed) in the setting of cardiogenic shock during delivery.

Early Prediction of Hypertensive Disorders of Pregnancy Using Machine Learning and Medical Records from the First and Second Trimesters

Hypertensive disorders of pregnancy (HDPs) remain a major challenge in maternal health. Early prediction of HDPs is crucial for timely intervention. Most existing predictive machine learning (ML) models rely on costly methods like blood, urine, genetic tests, and ultrasound, often extracting features from data gathered throughout pregnancy, delaying intervention. This study developed an ML model to identify HDP risk before clinical onset using affordable methods. Features were extracted from blood pressure (BP) measurements, body mass index values (BMI) recorded during the first and second trimesters, and maternal demographic information. We employed a random forest classification model for its robustness and ability to handle complex datasets. Our dataset, gathered from large academic medical centers in Atlanta, Georgia, United States (2010-2022), comprised 1,190 patients with 1,216 records collected during the first and second trimesters. Despite the limited number of features, the model's performance demonstrated a strong ability to accurately predict HDPs. The model achieved an F1-score, accuracy, positive predictive value, and area under the receiver-operating characteristic curve of 0.76, 0.72, 0.75, and 0.78, respectively. In conclusion, the model was shown to be effective in capturing the relevant patterns in the feature set necessary for predicting HDPs. Moreover, it can be implemented using simple devices, such as BP monitors and weight scales, providing a practical solution for early HDPs prediction in low-resource settings with proper testing and validation. By improving the early detection of HDPs, this approach can potentially help with the management of adverse pregnancy outcomes.

Exercise Intervention to Mitigate the Cardiovascular Sequence of Pregnancy Complications

Pregnancy issues such as gestational hypertension, preeclampsia, and gestational diabetes mellitus (GDM) are significant contributors to long-term cardiovascular diseases (CVDs) in women. Recent research has proved the impact of exercise on improving cardiovascular outcomes, particularly in women with pregnancy-related disorders. This review explores the outcomes of various exercise interventions on cardiovascular health in pregnant women. Among these, aerobic exercise has been widely studied, with results from observational studies and randomized controlled trials (RCTs) showing its positive outcomes on cardiovascular health in pregnant women, especially with complications. It has been found that regular aerobic exercise has been associated with reduced hypertension and improved endothelial function, particularly in women with a history of preeclampsia. Evidently, aerobic exercise results in better blood pressure regulation and enhanced vascular health that directly attends to the risk of cardiovascular diseases associated with pregnancy complications. Another form of exercise is resistance training, which despite being studied less, has shown potential benefits as well. Some advantages of resistance exercise have been found to improve muscle strength and overall enhancement in metabolic control. This is important, especially in women with GDM whereby improvement in insulin sensitivity reduces the overall risk of type 2 diabetes and future CVDs. Combined exercise that incorporates both aerobic and resistance elements has been known to offer the most comprehensive benefits. Various studies suggest that a combinatory approach maximizes the positive cardiovascular effects. Practicing women have experienced better overall heart health, with improved blood pressure regulation, enhanced endothelial function, and reduced metabolic risks. However, despite these findings, there are challenges such as small sample sizes and limited follow-up durations that hinder the generalizability of current research. Importantly, previous studies targeting exercise interventions for women experiencing complications during pregnancy have been limited in evidence by small sample sizes, short follow-ups, and lack of diversity. Such broader, more diverse populations were needed to reflect the various health risks and responses to exercise. Future research must include multi-center RCTs, diverse exercise regimens, and digital health tools for monitoring exercise adherence. This warrants future large-scale, multicenter trials that are necessary to establish more definitive evidence. Additionally, clinicians should consider including tailored exercise programs in care plans for women with pregnancy complications to mitigate long-term cardiovascular risks.

Per- and polyfluoroalkyl substances (PFAS) and hypertensive disorders of Pregnancy- integration of epidemiological and mechanistic evidence

BACKGROUND

Hypertensive disorders of pregnancy (HDP) remain a significant global health burden despite medical advancements. HDP prevalence appears to be rising, leading to increased maternal and fetal complications, mortality, and substantial healthcare costs. The etiology of HDP are complex and multifaceted, influenced by factors like nutrition, obesity, stress, metabolic disorders, and genetics. Emerging evidence suggests environmental pollutants, particularly Per- and polyfluoroalkyl substances (PFAS), may contribute to HDP development.

OBJECTIVE

This review integrates epidemiological and mechanistic data to explore the intricate relationship between PFAS exposure and HDP.

EPIDEMIOLOGICAL EVIDENCE

Studies show varying degrees of association between PFAS exposure and HDP, with some demonstrating positive correlations, particularly with preeclampsia. Meta-analyses suggest potential fetal sex-specific differences in these associations.

MECHANISTIC INSIGHTS

Mechanistically, PFAS exposure appears to disrupt vascular hemodynamics, placental development, and critical processes like angiogenesis and sex steroid regulation. Experimental studies reveal alterations in the renin-angiotensin system, trophoblast invasion, oxidative stress, inflammation, and hormonal dysregulation - all of which contribute to HDP pathogenesis. Elucidating these mechanisms is crucial for developing preventive strategies.

THERAPEUTIC POTENTIAL

Targeted interventions such as AT2R agonists, caspase inhibitors, and modulation of specific microRNAs show promise in mitigating adverse outcomes associated with PFAS exposure during pregnancy.

KNOWLEDGE GAPS AND FUTURE DIRECTIONS

Further research is needed to comprehensively understand the full spectrum of PFAS-induced placental alterations and their long-term implications for maternal and fetal health. This knowledge will be instrumental in developing effective preventive and therapeutic strategies for HDP in a changing environmental landscape.

Antihypertensive medication prescription dispensation among pregnant women in the United States: A cohort study

IMPORTANCE

Hypertension is increasingly common in pregnancy capable individuals, yet there is limited data on antihypertensive medication dispensation in peripartum individuals.

OBJECTIVE

To describe antihypertensive medication dispensation from preconception through the first year postpartum.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Truven Health Market Scan administrative data from 2008 to 2014 to identify women in the United States with commercial or government health insurance, aged 15-54, free from heart disease, who experienced a pregnancy and filled at least 1 prescription for an antihypertensive medication between 3 months prior to conception and 12 months after the end of the pregnancy.

MAIN OUTCOMES AND MEASURES

We describe antihypertensive dispensation patterns (continuation, initiation, and discontinuation) by medication class during 5 time periods: preconception, first, second, and third trimesters, and the first year postpartum.

RESULTS

Of 1,058,521 pregnancies, 108,614 (10.3%) were exposed to at least 1 antihypertensive medication dispensation. The most commonly dispensed medications across all periods combined were adrenergic blockers, calcium channel blockers (CCBs), and diuretics. Renin-angiotensin-aldosterone system (RAAS) inhibitors were the third most dispensed medication class in the preconception period (26.4%), and fills decreased to 5.7% and 1.7% in the second and third trimesters, respectively. Of the women with chronic hypertension who filled at least 1 prescription prior to conception, 8.4% were not dispensed an antihypertensive medication during the first year after delivery.

CONCLUSIONS AND RELEVANCE

Antihypertensive prescription dispensation of both preferred and potentially harmful agents is common in pregnancy capable individuals. Patterns of dispensation suggest room for improvement in the treatment of chronic hypertension after a pregnancy.

RADIOGRAPHIC MEASUREMENT OF CARDIAC SIZE BY USING MULTIPLE SCALING SYSTEMS IN HEALTHY CAPTIVE AYE-AYES (DAUBENTONIA MADAGASCARIENSIS)

The aye-aye (Daubentonia madagascariensis) is an unusual lemur with a small population in human care. Cardiac pathologies, but not normal size parameters, have been reported in this species. This study aimed to determine whether radiographic cardiac scaling systems commonly used to evaluate heart size in domestic mammals have potential clinical application in aye-ayes. Selected cardiac silhouette, vertebral, and intrathoracic skeletal dimensions were measured retrospectively on paired sets of orthogonal thoracic radiographs collected during health examinations of aye-ayes maintained at three British zoos. Measurements from 21 healthy aye-ayes (10 males, 11 females) of varying ages were used to calculate reference intervals (RI) with 90% confidence intervals for vertebral heart scale in both right lateral (VHS-RLat) and ventrodorsal (VHS-VD) projections, a modified VHS (VHS-Mod), thoracic inlet heart size (TIHS), and cardiothoracic ratio (CTR). VHS-VD (9.49 ± 0.29) was slightly higher than VHS-RLat (9.32 ± 0.33; P = 0.08) and had the lowest coefficient of variation of the scaling indices; TIHS was 4.89 ± 0.36, VHS-Mod was 11.07 ± 0.49, and CTR was 0.53 ± 0.05. Thoracic depth-to-width ratio of aye-ayes ranged between 0.75 and 0.91, equivalent to an intermediate thoracic morphology in dogs. No scaling indices differed significantly by sex, age group, or thoracic morphology; however, VHS-Mod and CTR were significantly correlated with bodyweight (P = 0.0022 and P = 0.041, respectively) and CTR with age (P = 0.02). Summed cardiac dimensions demonstrated a near-linear relationship with bodyweight and T4 vertebral length (both P < 0.05), but not thoracic inlet length (P = 0.12). Analysis of measurements by using serial radiographs from hand-reared animals indicated potential utility of RI in aye-ayes >0.4 yr. Overall, results suggest VHS-VD and VHS-RLat are preferred cardiac scaling indices in aye-ayes. These data will aid zoo clinicians in the evaluation of cardiac size and identification of cardiomegaly in this endangered primate.

High-intensity interval training is an effective exercise mode to maintain normal blood pressure during pregnancy: a randomized control trial

Pregnant women are more susceptible to high blood pressure (BP) than the general adult population; therefore, all means of preventing this condition should be considered. High-intensity interval training (HIIT) is effective in this regard in the general population, but there is a lack of evidence of its effectiveness during pregnancy. This study aimed to compare an 8-week HIIT program to self-performed moderate-to-vigorous physical activity among pregnant women by evaluating changes in BP after a maximal progressive cardiorespiratory exercise test (CPET) performed at pre-intervention and post-intervention time points. A total of 54 Caucasian women in uncomplicated, singleton pregnancies (age 32 ± 4 years, 22 ± 4 weeks of gestation; M ± SD) with normal BP values completed the interventions. The experimental (HIIT) group (n = 34) completed an online supervised HIIT program consisting of three sessions per week and supplemented by an educational class once per week. Participants in the education (EDU) group (n = 20) attended an educational class once per week and were encouraged to perform moderate-to-vigorous physical activity (PA) on their own. Pre- and post-intervention, all women underwent a CPET on a cycle ergometer with a respiratory gas analyzer. On the day of the CPET, maternal systolic and diastolic BP (mmHg) was measured at rest (before the CPET) and approximately 60 min after the CPET using an electronic BP monitor. Identical CPET and BP measurement protocols were employed for both the HIIT and EDU groups at the pre- and post-intervention time points. Pre-intervention, the HIIT and EDU groups both showed a decrease in systolic and diastolic BP after the CPET, though only the change in systolic BP was statistically significant (HIIT group: p = 0.01; EDU group: p = 0.001). Post-intervention, there were no significant differences in either group between resting and post-CPET BP. There were significant post-intervention differences in VO2peak (p < 0.001) and HRmax (p = 0.002) between the HIIT and EDU groups. From pre- to post-intervention, the EDU and HIIT groups both showed decreases in resting systolic or diastolic BP; there was a significant difference in systolic BP in the EDU group (p = 0.005) and a significant difference in diastolic BP in the HIIT group (p = 0.03). Both groups maintained normal BP values throughout the experiment. However, HIIT, in addition to maintaining normotension, improved cardiorespiratory fitness in pregnant women. It seems that both supervised HIIT and self-performed moderate-to-vigorous PA can be recommended as strategies to prevent BP disorders during pregnancy. More studies are needed to confirm our findings.Trial registration The full study protocol was registered in ClinicalTrials.gov (NCT05009433).

Association of relationship satisfaction with blood pressure: a cross-sectional study of older adults in rural Burkina Faso

OBJECTIVES

The objective of this study is to examine the association between relationship satisfaction and blood pressure (BP) in a low-income setting and to screen for gender moderation in this context. Research conducted in high-income settings suggests that relationship satisfaction is associated with better physical and mental health outcomes.

DESIGN

A cross-sectional study design was employed, using both questionnaire and physical measurement data. Multiple linear regression models were calculated for systolic and diastolic BP and adjusted for age, gender, demographics/socioeconomics and other health-related variables. Gender moderation was tested using interaction terms in multivariable analyses.

SETTING

A household survey was conducted in 2018 in rural northwestern Burkina Faso.

PARTICIPANTS

Final analysis included 2114 participants aged over 40 who were not pregnant, reported being in a partnership and had valid BP readings.

MAIN OUTCOME MEASURES

Systolic and diastolic BP levels.

RESULTS

A significant positive association existed between relationship satisfaction (Couples Satisfaction Index-4 score) and systolic BP (B=0.23, 95% CI (0.02 to 0.45), p=0.03) when controlling for demographics/socioeconomics. Nevertheless, this relationship lost statistical significance when additional adjustments were made for health-related variables (B=0.21, 95% CI (-0.01 to 0.42), p=0.06). There was no significant association of relationship satisfaction and diastolic BP and no evidence of gender moderation.

CONCLUSION

In contrast to many higher-income settings, we found a positive association between relationship satisfaction and systolic BP in very low-income rural Burkina Faso. Our results add to the evidence regarding the contextual nature of the association between relationship satisfaction and health, as high relationship satisfaction may not act as a health promotor in this socioeconomic context.