Immune Markers, Blood Pressure Severity, and Cardiac Remodeling 1 to 2 Years After Hypertensive Disorders of Pregnancy

Background Cardiovascular dysfunction and hypertension can persist postpartum following hypertensive disorders of pregnancy (HDPs). This study hypothesized that activin A, proinflammatory markers and concentric remodeling by echo would be higher 1-2 years postpartum following HDP with persistent hypertension compared to HDP with normalized blood pressure (BP). We further hypothesized correlations between biomarkers with BP and echocardiographic indices. Methods and Results This study enrolled participants with HDPs but no prepregnancy hypertension followed 1 to 2 years after delivery. Activin A and inflammatory cytokines, BP, and echocardiograms were obtained. Biomarker concentrations and echocardiographic parameters were compared between HDP with and without persistent hypertension. Individuals with persistent hypertension at a mean of 1.6 years postpartum had significantly higher activin A concentrations (median[interquartile range 25-75] 230.6 [196.0-260.9] versus 175.3 pg/mL [164.3-188.4]; P<0.01), more concentric left ventricular concentric remodeling (relative wall thickness >0.42, 48% versus 7%; P<0.01), and worse peak left atrial strain (33.4% versus 39.3%; P<0.05) as compared with those whose BP normalized. Higher activin A and interleukin-6 concentrations correlated with higher systolic (activin A: r=0.43, P=0.01) and diastolic BP (activin A: r=0.58, P<0.01; interleukin-6: r=0.36; P<0.05), as well as greater left ventricular thickness (activin A and interventricular septal thickness: r=0.41, interleukin-6 and interventricular septal thickness: r=0.36; both P<0.05). Conclusions Individuals with HDPs and persistent hypertension had significantly higher activin A and greater concentric remodeling compared with those with HDPs and normalized BP at 1 to 2 years postpartum. Activin A was positively correlated with both BP and echocardiographic indices (left ventricular thickness), suggesting overlapping processes between persistent hypertension and cardiac remodeling.

Infective Endocarditis in Pregnancy: A Contemporary Cohort

OBJECTIVE

 Pregnancy-related infective endocarditis (IE) caries a high risk of morbidity and mortality. With increasing intravenous drug abuse (IVDA) amid the opioid epidemic, the risk factor profile may be shifting. In this case series, we aimed to describe risk factors and outcomes for peripartum IE in a contemporary cohort.

STUDY DESIGN

 We identified patients with IE diagnosed during pregnancy or up to 6 weeks' postpartum from 2015 through 2018 at a single tertiary care center. We abstracted detailed medical history and clinical outcome measures from the electronic medical record. The diagnosis of IE was supported by the modified Duke Criteria.

RESULTS

 Nine patients had peripartum IE: eight (89%) with a history of IVDA, one with an indwelling central venous catheter (11%), and one with prior IE (11%). None had preexisting congenital or valvular heart disease. Six (67%) had comorbid hepatitis C. Eight cases (89%) had gram-positive cocci with vegetations involving the tricuspid valve (56%) and both mitral and tricuspid valves (22%). Major complications included shock (33%), mechanical ventilation (44%), septic emboli (67%), and noncardiac abscesses (33%). Two patients underwent valve surgery, and there were two cases of postpartum maternal mortality (22%), one from septic shock and one from intracerebral hemorrhage. While four patients (44%) delivered preterm (average gestational age 35 weeks), most delivered vaginally (89%) with only one requiring an emergent caesarean section. There was no fetal mortality, although three newborns (43%) required admission to the neonatal intensive care unit. Two patients were initiated on medication-assisted treatment for opioid use disorder. Consultants included infectious disease, cardiology, cardiac surgery, maternal-fetal medicine, and psychiatry.

CONCLUSION

 These findings confirm that IVDA is a growing risk factor for pregnancy-related IE. Peripartum IE carries a high risk of complications, including maternal mortality, and warrants management with a multidisciplinary care team at a tertiary center.

KEY POINTS

· Intravenous drug use was the most common risk factor for IE in pregnancy.. · IE in pregnancy carries a high morbidity and mortality with complications including septic emboli, septic shock, and need for mechanical ventilation.. · A multidisciplinary team approach can assure the best possible maternal and fetal outcomes..

Association of Hypertensive Disorders of Pregnancy With Left Ventricular Remodeling Later in Life

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with short-term cardiac structure and function abnormalities, but later life changes are not well studied.

OBJECTIVES

This study aimed to determine if HDP history is associated with echocardiographic differences 8 to 10 years after delivery, and if subgroups with placental maternal vascular malperfusion (MVM) lesions or current hypertension may be particularly affected.

METHODS

Women with pregnancies delivered from 2008 to 2009 were selected from a clinical cohort with abstracted pregnancy and placental pathology data to undergo transthoracic echocardiography (2017 to 2020). Medical history, blood pressure, and weight were measured at the study visit.

RESULTS

The authors enrolled 132 women (10 ± 1 years post-delivery, age 38 ± 6 years): 102 with normotensive pregnancies and 30 with HDP: pre-eclampsia (n = 21) or gestational hypertension (n = 9). Compared with women with normotensive pregnancies, those with HDP history were more likely to have current hypertension (63% vs. 26%; p < 0.001). After adjusting for age, race, MVM lesions, body mass index, current hypertension, and hemoglobin A1c, women with HDP history had higher interventricular septal thickness (β = 0.08; p = 0.04) and relative wall thickness (β = 0.04; p = 0.04). In subgroup analyses, those with both HDP history and current hypertension had a higher proportion of left ventricular remodeling (79.0%) compared with all other groups (only HDP [36.4%; p = 0.01], only current hypertension [46.2%; p = 0.02], and neither HDP nor hypertension [38.2%; p < 0.001]), and lower mitral inflow E/A and annular e'. Accounting for placental MVM lesions did not impact results.

CONCLUSIONS

Women with both HDP history and current hypertension have pronounced differences in left ventricular structure and function a decade after pregnancy, warranting continued surveillance and targeted therapies for cardiovascular disease prevention.

Maternal focal atrial tachycardia during pregnancy: A systematic review

INTRODUCTION

The presentation and optimal management of maternal focal atrial tachycardia (AT) during pregnancy are unknown. The objective of this study is to conduct a comprehensive summary of the existing evidence.

METHODS AND RESULTS

A systematic review of all reported cases of maternal focal AT during pregnancy was performed. The primary search queried PubMed using the MeSH terms "supraventricular tachycardia" and "pregnancy." A stepwise ancillary search included article bibliographies, citations listed by the Google internet search engine, and PubMed using the MeSH terms "atrial tachycardia" and "pregnancy." In total, 28 citations that described 32 patients were retrieved. A case from our institution was added. Detailed information was available for 30 patients. Clinical characteristics at presentation included a mean ± standard deviation of 28.3 ± 5.7 years for maternal age and 24.6 ± 7.7 weeks for gestation age. Suspected tachycardia-induced cardiomyopathy was present in 20 of 30 (67%) patients and left ventricular ejection fraction improved in 15 of 15 (100%) patients with follow-up measurements. Medication failure was common. Focal AT resolved spontaneously after delivery in eight of nine (89%) patients treated with only medications. Automaticity was suggested by discrete electrograms at sites of origin and lack of reported inducibility and termination with programmed stimulation in all patients who underwent electrophysiology studies. There were nine cases of successful catheter ablation with zero fluoroscopy since 2010.

CONCLUSIONS

Automaticity is the dominant mechanism for patients with maternal focal AT during pregnancy. Catheter ablation with zero fluoroscopy is an emerging therapy for medically refractory cases.