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Buddeberg BS, Seeberger E, Bläsi C, Dutilh G, Steiner LA, Bandschapp O, Palanisamy A, Girard T. Is crystalloid co-loading necessary to prevent spinal hypotension during elective cesarean delivery? A randomized double-blind trial. Int J Obstet Anesth 2024; 58:103968. [PMID: 38485584 DOI: 10.1016/j.ijoa.2023.103968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 05/07/2024]
Abstract
BACKGROUND Hypotension is common during spinal anesthesia for cesarean delivery. Preventive strategies include fluid loading and phenylephrine. We hypothesized that if prophylactic phenylephrine infusion is used, omission of fluid loading would be non-inferior to fluid co-loading in maintaining cardiac output. We assumed that if there was a difference, the increase in cardiac output would be greater in the no-loading than in the co-loading group. METHODS Term pregnant women scheduled for elective cesarean delivery were randomized to receive 1 L crystalloid co-loading or maintenance fluids only. Phenylephrine was titrated to maintain blood pressure. Changes in cardiac output following spinal anesthesia were the primary outcome. The study was powered as a non-inferiority trial, allowing the no-loading arm to have a 50% greater change in cardiac output. Heart rate, dose of phenylephrine, occurrence of nausea and vomiting, Apgar scores and neonatal acid base status were secondary outcomes. RESULTS Data from 63 women were analyzed. In contrast to our hypothesis, there was 33% less increase in cardiac output with no loading (ratio 0.67, 95% CI 0.15 to 1.36), and 60% greater reduction of cardiac output with no loading (ratio 1.6, 95% CI 1.0 to 2.7). Total dose of phenylephrine was higher in the no-loading group. There may be a less favorable neonatal acid base status without volume loading. CONCLUSION Omission of crystalloid co-loading leads to a decrease in cardiac output which has a potentially unfavorable impact on neonatal acid base status. We conclude that crystalloid co-loading may be useful in the presence of phenylephrine infusion.
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Affiliation(s)
- B S Buddeberg
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland.
| | - E Seeberger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - C Bläsi
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - G Dutilh
- Department of Clinical Research, University of Basel, Switzerland
| | - L A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - O Bandschapp
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - A Palanisamy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - T Girard
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
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Florio KL, Williams EM, White D, Daming T, Hostetter S, Schrufer-Poland T, Gray R, Schmidt L, Grodzinsky A, Lee J, Rader V, Swearingen K, Nelson L, Patel N, Magalski A, Gosch K, Jones P, Fu Z, Spertus JA. Validation of a noninvasive cardiac output monitor in maternal cardiac disease: comparison of NICOM and transthoracic echocardiogram. Am J Obstet Gynecol MFM 2024; 6:101312. [PMID: 38342307 DOI: 10.1016/j.ajogmf.2024.101312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND The physiological changes to the cardiovascular system during pregnancy are considerable and are more pronounced in those with cardiac disease. In the general population, noninvasive hemodynamic monitoring is a valid alternative to pulmonary artery catheterization, which poses risk in the pregnant population. There is limited data on noninvasive cardiac output monitoring in pregnancy as an alternative to pulmonary artery catheterization. OBJECTIVE We sought to compare transthoracic echocardiography with a noninvasive cardiac output monitor (NICOM, Cheetah Medical) in pregnant patients with and without cardiac disease. STUDY DESIGN This was a prospective, open-label validation study that compared 2-dimensional transthoracic echocardiography with NICOM estimations of cardiac output in each trimester of pregnancy and the postpartum period. Participants with and without cardiac disease with a singleton gestation were included. NICOM estimations of cardiac output were derived from thoracic bioreactance and compared with 2-dimensional transthoracic echocardiography for both precision and accuracy. A mean percentage difference of ±30% between the 2 devices was considered acceptable agreement between the 2 measurement techniques. RESULTS A total of 58 subjects were enrolled; 36 did not have cardiac disease and 22 had cardiac disease. Heart rate measurements between the 2 devices were strongly correlated in both groups, whereas stroke volume and cardiac output measurements showed weak correlation. When comparing the techniques, the NICOM device overestimated cardiac output in the control group in all trimesters and the postpartum period (mean percentage differences were 50.3%, 52.7%, 48.1%, and 51.0% in the first, second, and third trimesters and the postpartum period, respectively). In the group with cardiac disease, the mean percentage differences were 31.9%, 29.7%, 19.6%, and 35.2% for the respective timepoints. CONCLUSION The NICOM device consistently overestimated cardiac output when compared with 2-dimensional transthoracic echocardiography at all timepoints in the control group and in the first trimester and postpartum period for the cardiovascular disease group. The physiological changes of pregnancy, specifically the mean chest circumference and total body water, may alter the accuracy of the cardiac output measurement by the NICOM device as they are currently estimated. Although NICOM has been validated for use in the critical care setting, there is insufficient data to support its use in pregnancy.
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Affiliation(s)
- Karen L Florio
- Department of Obstetrics and Gynecology, University of Missouri, Columbia MO (Dr Florio); Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson).
| | - Emily M Williams
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel)
| | - Darcy White
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Tara Daming
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Department of Maternal-Fetal Medicine, Mercy Hospital of Saint Louis, Saint Louis, MO (Dr Daming)
| | - Sarah Hostetter
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Department of Maternal Fetal Medicine, Mercy Hospital of Springfield, Springfield, MO (Dr Hostetter)
| | - Tabitha Schrufer-Poland
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); AdventHealth High Risk Pregnancy Consultants, Orlando, FL (Dr Schrufer-Poland)
| | - Rebecca Gray
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Laura Schmidt
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Anna Grodzinsky
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - John Lee
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Valerie Rader
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Kathleen Swearingen
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Lynne Nelson
- Division of Women's and Children's, Saint Luke's Hospital of Kansas City, Kansas City, MO (Dr Florio, Ms White, Ms Gray, Ms Swearingen, and Ms Nelson)
| | - Neil Patel
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO (Drs Florio, Williams, Daming, Hostetter, Schrufer-Poland, and Patel); Department of Obstetrics and Gynecology, University of Kentucky, Lexington KY (Dr Patel)
| | - Anthony Magalski
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
| | - Kensey Gosch
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus)
| | - Philip Jones
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus)
| | - Zhuxuan Fu
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus)
| | - John A Spertus
- Mid-America Heart Institute, Saint Luke's Hospital of Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, and Magalski, Ms Gosch, Mr Jones, and Drs Fu and Spertus); Department of Cardiology, University of Missouri-Kansas City, Kansas City, MO (Drs Schmidt, Grodzinsky, Lee, Rader, Magalski, and Spertus)
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DeVore GR, Polanco B. Assessing maternal cardiac function by obstetricians: technique and reference ranges. Am J Obstet Gynecol 2023:S0002-9378(23)00006-6. [PMID: 36627073 DOI: 10.1016/j.ajog.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND A strong body of evidence has now coalesced indicating that some obstetrical syndromes may result from maladaptive responses of the maternal cardiovascular system. Longitudinal studies have shown that these changes are complex and present before the clinical recognition of preeclampsia and fetal growth restriction, suggesting that hemodynamic maladaptation may play an etiologic role in obstetrical complications. Chronic hypertension is one of the most frequent complications of pregnancy, and recent evidence suggests that control of mild hypertension in early pregnancy improves outcome. The management of chronic hypertension can be improved by understanding specific cardiovascular hemodynamic abnormalities such as increased cardiac output or increased systemic vascular resistance, which can respond to either beta or calcium channel blockers, depending on the hemodynamic findings. Evaluation of maternal cardiac function has not been previously available to obstetrical healthcare providers using diagnostic ultrasound equipment used for fetal evaluation. OBJECTIVE Obstetrical ultrasound machines may be configured for various probes (endovaginal, abdominal, 3D/4D, and cardiac). This study used a cardiac probe placed in the suprasternal notch to image and measure the descending aorta diameter and the velocity time integral using pulsed and continuous wave Doppler ultrasound in normal pregnant women between 11 and 39 weeks of gestation. These measurements were followed by computation of maternal left ventricular preload, afterload, contractility, and blood flow. STUDY DESIGN This was a prospective cross-sectional study. A total of 400 pregnant women were recruited between 11 and 39 weeks of gestation. Imaging of the maternal aortic arch was performed by placing a cardiac probe in the suprasternal notch to identify the aortic arch using 2D and color Doppler ultrasound. The end-systolic diameter of the aorta was measured at the junction of the left subclavian artery with the descending aorta, which was followed by insonation of the descending aorta to obtain the Doppler waveform. Following insonation of the descending aorta, measurements of the aortic diameter, velocity time integral, ejection time, mean pressure gradient, heart rate, maternal weight and height, and systolic and diastolic blood pressures were entered into an Excel spreadsheet to compute the following: (1) preload measurements of stroke volume, stroke volume index, and stroke work index; (2) afterload measurements of systemic vascular resistance and the potential-to-kinetic energy ratio; (3) contractility measurements of inotropy and the Smith-Madigan inotropy index; and (4) blood flow measurements of cardiac output and the cardiac output index. Fractional polynomial regression analysis was performed for each of the above measurements using gestational age as the independent variable. RESULTS The diastolic and mean arterial blood pressure decreased from 11 to 18 weeks of gestation and then increased until term. The afterload measurements demonstrated similar characteristics, as all values decreased from 11 weeks until the mid and late second trimester, after which all values increased until term. Changes in contractility demonstrated an increase from 11 weeks to 25 to 28 weeks, followed by a decline until term. Changes in blood flow demonstrated an increase from 11 to 27 weeks and then declined until term. The continuous wave Doppler values were greater than the pulsed Doppler values except for the contractility measurements. Examples of abnormal cardiac measurements were identified in pregnant patients with hypertension and fetal growth restriction. An Excel calculator was created to provide quick computation of z-score measurements and their corresponding centiles described in this study. CONCLUSION The technique for evaluation of maternal cardiac function described in this study would allow screening of maternal left ventricular preload, afterload, contractility, and blood flow in the obstetrical clinical milieu once a cardiac probe is acquired for obstetrical ultrasound machines used for fetal evaluation. The above measurements would allow the clinician to select appropriate hypertensive medication on the basis of the results of the evaluation of the maternal left ventricle.
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Gyselaers W. Hemodynamic pathways of gestational hypertension and preeclampsia. Am J Obstet Gynecol 2022; 226:S988-S1005. [PMID: 35177225 DOI: 10.1016/j.ajog.2021.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 12/01/2022]
Abstract
Gestational hypertension and preeclampsia are the 2 main types of hypertensive disorders in pregnancy. Noninvasive maternal cardiovascular function assessment, which helps obtain information from all the components of circulation, has shown that venous hemodynamic dysfunction is a feature of preeclampsia but not of gestational hypertension. Venous congestion is a known cause of organ dysfunction, but its potential role in the pathophysiology of preeclampsia is currently poorly investigated. Body water volume expansion occurs in both gestational hypertension and preeclampsia, and this is associated with the common feature of new-onset hypertension after 20 weeks of gestation. Blood pressure, by definition, is the product of intravascular volume load and vascular resistance (Ohm's law). Fundamentally, hypertension may present as a spectrum of cardiovascular states varying between 2 extremes: one with a predominance of raised cardiac output and the other with a predominance of increased total peripheral resistance. In clinical practice, however, this bipolar nature of hypertension is rarely considered, despite the important implications for screening, prevention, management, and monitoring of disease. This review summarizes the evidence of type-specific hemodynamic profiles in the latent and clinical stages of hypertensive disorders in pregnancy. Gestational volume expansion superimposed on an early gestational closed circulatory circuit in a pressure- or volume-overloaded condition predisposes a patient to the gradual deterioration of overall circulatory function, finally presenting as gestational hypertension or preeclampsia-the latter when venous dysfunction is involved. The eventual phenotype of hypertensive disorder is already predictable from early gestation onward, on the condition of including information from all the major components of circulation into the maternal cardiovascular assessment: the heart, central and peripheral arteries, conductive and capacitance veins, and body water content. The relevance of this approach, outlined in this review, openly invites for more in-depth research into the fundamental hemodynamics of gestational hypertensive disorders, not only from the perspective of the physiologist or the scientist, but also in assistance of clinicians toward understanding and managing effectively these severe complications of pregnancy.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost-Limburg, Genk, Belgium; and Faculty of Medicine and Life Sciences, Department Physiology, Hasselt University, Belgium.
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Di Pasquo E, Ghi T, Dall'Asta A, Angeli L, Ciavarella S, Armano G, Sesenna V, Di Peri A, Frusca T. Hemodynamic findings in normotensive women with small-for-gestational-age and growth-restricted fetuses. Acta Obstet Gynecol Scand 2020; 100:876-883. [PMID: 33084031 DOI: 10.1111/aogs.14026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Fetal growth restriction (FGR) in most instances is a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational-age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome. MATERIAL AND METHODS An observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria, and pregnant women underwent hemodynamic assessment using a cardiac output monitor. A group of women with singleton uncomplicated pregnancies ar ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume, and heart rate were measured and compared among the three groups (controls vs FGR vs SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis. RESULTS A total of 51 women with fetal smallness were assessed at 34.8 ± 2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5 ± 0.8 weeks of gestation. Women with FGR had a lower cardiac output Z-score (respectively, -1.3 ± 1.2 vs -0.4 ± 0.8 vs -0.2 ± 1.0; P < .001) and a higher systemic vascular resistance Z-score (respectively, 1.2 ± 1.2 vs 0.2 ± 1.1 vs -0.02 ± 1.2; P < .001) compared with both SGA and controls, whereas no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of neonatal intensive care unit admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; P = .13), but FGR fetuses had a longer hospitalization compared with SGA fetuses (14.2 ± 17.7 vs 4.5 ± 1.6 days; P = .02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (P = .012) and the birthweight Z-score (P = .007) were independent predictors of the length of neonatal hospitalization. CONCLUSIONS Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization.
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Affiliation(s)
- Elvira Di Pasquo
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Laura Angeli
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Sara Ciavarella
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Giulia Armano
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Veronica Sesenna
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Antonio Di Peri
- Department of Neonatology, University of Parma, Parma, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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Hong NT, Minh Duc N, Hoang L, Duyet PT, Thien DH, Mai NTT, Tram HTN, Xuan NM, Huy HQ. Reference values for ductus venosus doppler indices of normal gestation at 22-37 weeks: A Vietnamese cohort study. Pediatr Rep 2020; 12:8535. [PMID: 32922711 PMCID: PMC7461642 DOI: 10.4081/pr.2020.8535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/13/2020] [Indexed: 11/23/2022] Open
Abstract
Prenatal doppler ultrasound of the ductus venosus plays an important role in the evaluation of fetal circulation and fetal heart function. We aimed to establish the percentile of Resistivity Index (RI) and Pulsatility Index (PI) of the Ductus Venosus (DV) among normal Vietnamese fetuses with a gestation from 22 to 37 weeks in a cohort study. Normal Vietnamese fetuses with a gestation ranging from 22 to 37 weeks were examined in a cohort study. The PI and RI were recorded from the DV. We analyzed 640 participants who all fulfilled the inclusion and exclusion criteria of our study. Results: There was a significant correlation between RI, PI and gestational age as shown with the equations y = 0.077x - 0.003x2 + 3.493e - 5x3 (r=0.97) and y = 0.106x - 0.004x2 + 4.5e - 5x3 (r=0.94), respectively. A centile module was constructed for the DV RI and PI indices among normal Vietnamese fetuses with gestation from 22 to 37 weeks.
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Affiliation(s)
- Nguyen Thi Hong
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen
| | | | - Le Hoang
- National Hospital of Obstetrics and Gynecology, Ha Noi, Vietnam
| | | | - Dang Hong Thien
- National Hospital of Obstetrics and Gynecology, Ha Noi, Vietnam
| | | | | | - Ngo Minh Xuan
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City
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Di Pasquo E, Ghi T, Dall'Asta A, Angeli L, Fieni S, Pedrazzi G, Frusca T. Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms. Am J Obstet Gynecol 2019; 221:633.e1-633.e9. [PMID: 31226294 DOI: 10.1016/j.ajog.2019.06.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/02/2019] [Accepted: 06/12/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND A primary role of maternal heart dysfunction in the pathophysiology of preeclampsia had been previously advocated although if contradictory results have been reported. OBJECTIVES The objectives of the study were to describe maternal hemodynamic parameters according to 2 main preeclampsia phenotypes and to investigate whether cardiac findings may be helpful in characterizing the severity and the progression of the disease. STUDY DESIGN This was a prospective cohort study. We used an ultrasonic cardiac output monitor system to compare the hemodynamic parameters of women with preeclampsia with a group of healthy normotensive women enrolled as controls with a ratio of 1:2. Cardiac output, systemic vascular resistance, and stroke volume were compared among controls and preeclamptic women who were grouped in accordance to the following characteristics: early preeclampsia (<34 weeks' gestation) vs late preeclampsia onset (≥34 weeks' gestation); preeclampsia associated with appropriate for gestational age or small-for-gestational-age newborns. Hemodynamic characteristics were also compared between preeclamptic women with a mild form vs those who progressed toward a severe form. RESULTS A total of 38 preeclamptic women and 61 normotensive women were included in the study. Both cases of preeclampsia associated with small-for-gestational-age neonates as those with normal-sized ones showed higher systemic vascular resistance compared with the control group (respectively, 1580.6 ± 483.2 vs 1479.1 ± 433.3 vs 1105.3 ± 293.1; P < .0001), while a lower cardiac output was reported only for preeclamptic women with small-for-gestational-age neonates compared with controls (5.7 ± 1.5 vs 6.5 ± 1.3; P = .02). Maternal cardiac parameters were comparable between these 2 groups of preeclamptic women (small-for-gestational-age vs appropriate-for-gestational-age preeclampsia) with the exception of a lower stroke volume in the former one (64.8 ± 24.4 vs 75.2 ± 17.8; P = .04). Similarly, women with both early and late preeclampsia showed higher systemic vascular resistance compared with controls (1559.5 ± 528.3 vs 1488.5 ± 292.9 vs 1105.3 ± 293.1, respectively; P < .001), while a lower cardiac output was noted only in the early-onset group compared with controls (5.5 ± 1.2 P = .02). Maternal cardiac findings were similar between women with early vs late-onset preeclampsia. Hemodynamic parameters are significantly different between those women with mild preeclampsia who remained stable compared with those who progressed toward a severe disease. Cardiac output Z-score, systemic vascular resistance Z-score, and uterine arteries' pulsatility index Z-score showed similar sensitivity (80% vs 75% vs 80%, respectively) and specificity (73% vs. 73% vs 74%, respectively), while the association of systemic vascular resistance Z-score and uterine arteries pulsatility index Z-score showed a sensitivity of 95% and a specificity of 80% (area under the curve, 0.90) in predicting evolution toward severe forms. CONCLUSION Evaluation of maternal cardiovascular system could help clinician in defining a subset of preeclamptic patients with more profound placental impairment and might predict the likelihood of progression toward a severe condition in cases with a mild preeclampsia at clinical onset.
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Affiliation(s)
- Elvira Di Pasquo
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy.
| | - Andrea Dall'Asta
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Laura Angeli
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - Stefania Fieni
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
| | | | - Tiziana Frusca
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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Perry H, Stirrup O, Gutierrez J, Vinayagam D, Thilaganathan B, Khalil A. Influence of maternal characteristics and gestational age on hemodynamic indices: NICOM device-specific reference ranges. Ultrasound Obstet Gynecol 2019; 54:670-675. [PMID: 30548496 DOI: 10.1002/uog.20179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 11/04/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To construct reference ranges for stroke volume, cardiac output and systemic vascular resistance (SVR) in normal pregnancy for the NICOM® device, and to explore associations between maternal characteristics and these hemodynamic variables. METHODS This was a prospective cohort study of healthy singleton pregnancies between 10 and 40 weeks' gestation attending a tertiary referral hospital between September 2012 and May 2018. Measurements of stroke volume, cardiac output and SVR were obtained throughout pregnancy using NICOM, a non-invasive device based on bioreactance technology. NICOM device-specific reference ranges were created with respect to gestational age and maternal characteristics. Once the distribution of the data had been determined with respect to the gestational age, patient characteristics were added to the model to test whether they provided a significant improvement in prediction of the median value. The effect was assessed of maternal weight, height, smoking status, conception using assisted reproductive technology, nulliparity and ethnicity. RESULTS We included 411 women in this study. The relationships between cardiac variables and gestational age observed in the NICOM-specific reference ranges are consistent with previous findings, with increasing cardiac output values until around 35 weeks and a decrease thereafter until term, and decreasing SVR until around 36 weeks, followed by an increase towards 40 weeks. Stroke volume showed a small linear increase across gestation with lower variability in observations close to term. Maternal weight, height and age were associated with cardiac output (all P < 0.05) and SVR (all P < 0.01), whilst maternal weight and height were associated with stroke volume (both P < 0.001). Ethnicity was significantly associated with stroke volume (P = 0.001) but not with cardiac output or SVR. CONCLUSIONS This study presents device-specific reference ranges for stroke volume, cardiac output and SVR for the NICOM device in healthy pregnancy and describes the maternal characteristics that are associated with the values of these hemodynamic measurements. Studies using NICOM in pregnancy can use these ranges in order to evaluate observations relative to those expected in uncomplicated pregnancy conditional on maternal characteristics. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - O Stirrup
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
| | - J Gutierrez
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - D Vinayagam
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Gutierrez J, Perry H, Columb M, Bampoe S, Thilaganathan B, Khalil A. Cardiac output measurements during high-risk Cesarean section using electrical bioreactance or arterial waveform analysis: assessment of agreement. Ultrasound Obstet Gynecol 2019; 54:232-238. [PMID: 30302868 DOI: 10.1002/uog.20142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/28/2018] [Accepted: 10/02/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Maternal hemodynamics change significantly during Cesarean section complicated by massive hemorrhage or severe hypertensive disease. Cardiac output (CO) monitoring aids early, goal-directed hemodynamic therapy. The aim of this study was to record hemodynamic changes observed during Cesarean section in pregnancies at high risk of hemodynamic instability, using invasive (LiDCOrapid™) and non-invasive (NICOM®) devices, and to assess agreement between the two devices in measuring CO. METHODS Simultaneous intraoperative hemodynamic measurements were taken using the LiDCOrapid and NICOM devices, following standardized techniques, in women at high risk of hemodynamic instability undergoing Cesarean section. Agreement in CO measurements between the two devices was assessed using Bland-Altman plots and the agreement:tolerability index (ATI). Agreement analyses were performed for repeated measures in subjects, using centiles. RESULTS From 10 women, 307 paired measurements were analyzed. Mean bias (defined as the mean difference in CO measurements between the LiDCOrapid and NICOM devices) was 3.05 (95% CI, 1.89 to 4.21) L/min. Limits of agreement ranged from -1.58 (95% CI, -4.47 to -0.14) to 7.68 (95% CI, 6.24 to 10.56) L/min. The resulting agreement interval was 9.26 L/min which returned an ATI of 2.3. CONCLUSIONS There are large mean differences between CO measurements obtained during Cesarean section using the LiDCOrapid and NICOM hemodynamic monitors in pregnant women at high risk of hemodynamic instability, indicating that they should not be considered interchangeable clinically. There is an unacceptably low level of agreement (ATI > 2) in CO measurements between the devices, conferring a high risk of clinical misclassification during massive hemorrhage. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Gutierrez
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - H Perry
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - M Columb
- Manchester University Hospitals NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - S Bampoe
- Centre for Anaesthesia and Perioperative Medicine, University College London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Vonck S, Staelens AS, Lanssens D, Tomsin K, Oben J, Bruckers L, Gyselaers W. Development of a biophysical screening model for gestational hypertensive diseases. J Biomed Sci 2019; 26:38. [PMID: 31109316 PMCID: PMC6528347 DOI: 10.1186/s12929-019-0530-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 05/05/2019] [Indexed: 02/08/2023] Open
Abstract
Background To investigate the possibility of using maternal biophysical parameters only in screening for the different types of gestational hypertensive diseases. Methods A total of 969 pregnant women were randomly screened in first and second trimester, of which 8 developed Early-onset Preeclampsia, 29 Late-onset Preeclampsia, 35 Gestational Hypertension and 897 women had a normal outcome. An observational maternal hemodynamics assessment was done via standardized electrocardiogram-Doppler ultrasonography, Impedance Cardiography and bio-impedance, acquiring functional information on heart, arteries, veins and body fluid. Preliminary prediction models were developed to test the screening potential for early preeclampsia, late preeclampsia and gestational hypertension using a Partial Least Square Discriminant Analysis. Results A combined model using maternal characteristics with cardiovascular parameters in first and second trimester offers high screening performance with Area Under the Curve of 99,9% for Early-onset Preeclampsia, 95,3% for Late-onset Preeclampsia and 94% for Gestational Hypertension. Conclusions Using biophysical parameters as fundament for a new prediction model, without the need of biochemical parameters, seems feasible. However, validation in a large prospective study will reveal its true potential.
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Affiliation(s)
- Sharona Vonck
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium. .,Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Anneleen S Staelens
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Dorien Lanssens
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium.,Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Kathleen Tomsin
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Jolien Oben
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Liesbeth Bruckers
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium
| | - Wilfried Gyselaers
- Faculty of Medicine and Life Sciences, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium.,Department Physiology, Hasselt University, Agoralaan, 3590, Diepenbeek, Belgium
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McHugh A, El-Khuffash A, Bussmann N, Doherty A, Franklin O, Breathnach F. Hyperoxygenation in pregnancy exerts a more profound effect on cardiovascular hemodynamics than is observed in the nonpregnant state. Am J Obstet Gynecol 2019; 220:397.e1-397.e8. [PMID: 30849354 DOI: 10.1016/j.ajog.2019.02.059] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/31/2019] [Accepted: 02/27/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Supplemental oxygen is administered to pregnant women in many different clinical scenarios in obstetric practice. Despite the accepted uses for maternal hyperoxygenation, the impact of hyperoxia on maternal hemodynamic indices has not been evaluated. As a result, there is a paucity of data in the literature in relation to the physiological changes to the maternal circulation in response to supplemental oxygen. OBJECTIVE The hemodynamic effects of oxygen therapy are under-recognized and the impact of hyperoxygenation on maternal hemodynamics is currently unknown. Using noninvasive cardiac output monitoring which employs transthoracic bioreactance, we examined the effect of brief hyperoxygenation on cardiac index, systemic vascular resistance, blood pressure, stroke volume, and heart rate in pregnant mothers during the third trimester, compared with those effects observed in a nonpregnant population subjected to the same period of hyperoxygenation. STUDY DESIGN Hemodynamic monitoring was performed in a continuous manner over a 30-minute period using noninvasive cardiac output monitoring. Hyperoxygenation (O2 100% v/v inhalational gas) was carried out at a rate of 12 L/min via a partial non-rebreather mask for 10-minutes. Cardiac index, systemic vascular resistance, stroke volume, heart rate, and blood pressure were recorded before hyperoxygenation, at completion of hyperoxygenation, and 10 minutes after the cessation of hyperoxygenation. Two-way analysis of variance with repeated measures was used to assess the change in hemodynamic indices over time and the differences between the 2 groups. RESULTS Forty-six pregnant and 20 nonpregnant women with a median age of 33 years (interquartile range, 26-38 years) and 32 years (interquartile range, 28-37 years) were recruited prospectively, respectively (P=.82). The median gestational age was 35 weeks (33-37 weeks). In the pregnant group, there was a fall in cardiac index during the hyperoxygenation exposure period (P=.009) coupled with a rise in systemic vascular resistance with no recovery at 10 minutes after cessation of hyperoxygenation (P=.02). Heart rate decreased after hyperoxygenation exposure and returned to baseline by 10 minutes after cessation of therapy. There was a decrease in stroke volume over the exposure period, with no change in systolic or diastolic blood pressure. In the nonpregnant group, there was no significant change in the cardiac index, systemic vascular resistance, stroke volume, heart rate, or systolic or diastolic blood pressure during the course of exposure to hyperoxygenation. CONCLUSION Hyperoxygenation during the third trimester is associated with a fall in maternal cardiac index and a rise in systemic vascular resistance without recovery to baseline levels at 10 minutes after cessation of hyperoxygenation. The hemodynamic changes that were observed in this study in response to hyperoxygenation therapy during pregnancy could counteract any intended increase in oxygen delivery. The observed maternal effects of hyperoxygenation call for a reevaluation of the role of hyperoxygenation treatment in the nonhypoxemic pregnant patient.
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Affiliation(s)
- Ann McHugh
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland.
| | - Afif El-Khuffash
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Anne Doherty
- Department of Anaesthesia, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Fionnuala Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda, Hospital, Dublin, Ireland
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McLaughlin K, Wright SP, Kingdom JC, Parker JD. Clinical Validation of Non-Invasive Cardiac Output Monitoring in Healthy Pregnant Women. Journal of Obstetrics and Gynaecology Canada 2017; 39:1008-1014. [DOI: 10.1016/j.jogc.2017.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 01/30/2023]
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13
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Zieleskiewicz L, Noel A, Duclos G, Haddam M, Delmas A, Bechis C, Loundou A, Blanc J, Mignon A, Bouvet L, Einav S, Bourgoin A, Leone M. Can point-of-care ultrasound predict spinal hypotension during caesarean section? A prospective observational study. Anaesthesia 2017; 73:15-22. [PMID: 28986931 DOI: 10.1111/anae.14063] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2017] [Indexed: 12/18/2022]
Abstract
Spinal anaesthesia for elective caesarean section is associated with maternal hypotension, secondary to alteration of sympathetic tone and hypovolemia, in up to 70% of cases. Measurement of the subaortic variation in the velocity time integral (VTI) after passive leg raising allows prediction of fluid responsiveness. Our objective, in this prospective single-centre observational study, was to assess the ability of change in VTI after 45° passive leg raising to predict hypotension after spinal anaesthesia. Ultrasound measurements were performed just before elective caesarean section. Anaesthesia, intravenous coloading and prophylactic vasopressor treatment were standardised according to current guidelines. We studied 40 women. Hypotension occurred in 17 (45%) women. The area (95%CI) under the receiver operating characteristics (ROC) curve for the prediction of spinal hypotension was 0.8 (0.6-0.9; p = 0.0001). Seventeen women had a change in VTI with leg elevation ≤ 8%, which was predictive for not developing hypotension, and 11 had a change ≥ 21%, predictive for hypotension. The grey zone between 8% and 21%, with inconclusive values, included 12 women. We suggest that cardiac ultrasound provides characterisation of the risk of hypotension following spinal anaesthesia at elective caesarean section, and therefore may allow individualised strategies for prevention and management.
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Affiliation(s)
- L Zieleskiewicz
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - A Noel
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - G Duclos
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - M Haddam
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - A Delmas
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - C Bechis
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - A Loundou
- Epidemiology and Methodology Department, Aix Marseille University, Marseille, France
| | - J Blanc
- Department of Obstetrics and Gynecology, Aix Marseille University, Marseille, France
| | - A Mignon
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - L Bouvet
- Department of Anaesthesia and Intensive Care Medicine, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - S Einav
- General Intensive Care, Shaare Zedek Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - A Bourgoin
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France
| | - M Leone
- Department of Anaesthesia and Intensive Care Medicine, University Hospital of Marseille, Marseille, France.,Centre d'Investigation Clinique 1409, AP-HM, Aix Marseille University, Marseille, France
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