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Aimo A, Morfino P, Arzilli C, Vergaro G, Spini V, Fabiani I, Castiglione V, Rapezzi C, Emdin M. Disease features and management of cardiomyopathies in women. Heart Fail Rev 2024; 29:663-674. [PMID: 38308002 PMCID: PMC11035404 DOI: 10.1007/s10741-024-10386-x] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
Over the last years, there has been a growing interest in the clinical manifestations and outcomes of cardiomyopathies in women. Peripartum cardiomyopathy is the only women-specific cardiomyopathy. In cardiomyopathies with X-linked transmission, women are not simply healthy carriers of the disorder, but can show a wide spectrum of clinical manifestations ranging from mild to severe manifestations because of heterogeneous patterns of X-chromosome inactivation. In mitochondrial disorders with a matrilinear transmission, cardiomyopathy is part of a systemic disorder affecting both men and women. Even some inherited cardiomyopathies with autosomal transmission display phenotypic and prognostic differences between men and women. Notably, female hormones seem to exert a protective role in hypertrophic cardiomyopathy (HCM) and variant transthyretin amyloidosis until the menopausal period. Women with cardiomyopathies holding high-risk features should be referred to a third-level center and evaluated on an individual basis. Cardiomyopathies can have a detrimental impact on pregnancy and childbirth because of the associated hemodynamic derangements. Genetic counselling and a tailored cardiological evaluation are essential to evaluate the likelihood of transmitting the disease to the children and the possibility of a prenatal or early post-natal diagnosis, as well as to estimate the risk associated with pregnancy and delivery, and the optimal management strategies.
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Affiliation(s)
- Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | | | - Chiara Arzilli
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Valentina Spini
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Rapezzi
- Cardiologic Centre, University of Ferrara, Ferrara, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola (Ravenna), Ravenna, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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2
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Crea F. New light shed on Anderson-Fabry, peripartum, and early-onset cardiomyopathies. Eur Heart J 2024; 45:1379-1383. [PMID: 38643479 DOI: 10.1093/eurheartj/ehae226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2024] Open
Affiliation(s)
- Filippo Crea
- Centre of Excellence of Cardiovascular Sciences, Gemelli Isola Hospital, Rome, Italy
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3
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Elendu C, Okoye OK. Peripartum cardiomyopathy: A case report of decompensated heart failure in a hypertensive patient. Medicine (Baltimore) 2024; 103:e37600. [PMID: 38552076 PMCID: PMC10977545 DOI: 10.1097/md.0000000000037600] [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: 11/20/2023] [Accepted: 02/23/2024] [Indexed: 04/02/2024] Open
Abstract
RATIONALE Peripartum cardiomyopathy (PPCM) occurring in the context of hypertension presents a unique clinical challenge. This case contributes to the medical literature by highlighting the complexities of managing heart failure in postpartum women with pre-existing hypertensive disorders, particularly when complicated by a history of preeclampsia. PATIENT CONCERNS Mrs. O.O., a 34-year-old hypertensive woman, presented with progressive dyspnea, bilateral leg swelling, and orthopnea. Notably, she had a history of previous preeclampsia and exhibited worsening symptoms over several months. DIAGNOSES The patient was diagnosed with decompensated heart failure secondary to PPCM, exacerbated by hypertension and anemia. INTERVENTIONS Therapeutic interventions included diuretics, angiotensin receptor-neprilysin inhibitors, digoxin, and anticoagulation. Additionally, lifestyle modifications and dietary restrictions were implemented. OUTCOMES Following treatment adjustments, the patient demonstrated significant improvement in symptoms, exercise tolerance, and cardiac function. The transition from NYHA class III to class II heart failure indicated successful management. LESSONS This case underscores the importance of a comprehensive approach to managing PPCM in hypertensive patients, with attention to cardiovascular and obstetric factors. It highlights the effectiveness of multidisciplinary care in achieving positive outcomes and emphasizes the need for heightened vigilance in postpartum women with cardiovascular risk factors.
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Affiliation(s)
- Chukwuka Elendu
- Department of Internal medicine, University of California, Santa Cruz, CA
| | - Osinachi K. Okoye
- Department of Internal medicine, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Awka, Nigeria
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4
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Shapiro H, Alshawabkeh L. Valvular Heart Disease in Pregnancy. Methodist Debakey Cardiovasc J 2024; 20:13-23. [PMID: 38495658 PMCID: PMC10941694 DOI: 10.14797/mdcvj.1323] [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: 11/29/2023] [Accepted: 01/20/2024] [Indexed: 03/19/2024] Open
Abstract
Valvular heart disease is a common cause of peripartum cardiovascular morbidity and mortality. The hemodynamic changes of pregnancy and their impact on preexisting valvular lesions are described in this paper. Tools for calculation of maternal and fetal risk during pregnancy are also discussed. The pathophysiology and management of valvular lesions, both obstructive and regurgitant, are then described, followed by discussion of mechanical and bioprosthetic valve complications during pregnancy.
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Affiliation(s)
- Hilary Shapiro
- University of California, San Diego, San Diego, California, US
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Rajpal S, Rodriguez CP. High-Risk Congenital Heart Disease in Pregnancy. Methodist Debakey Cardiovasc J 2024; 20:24-35. [PMID: 38495662 PMCID: PMC10941697 DOI: 10.14797/mdcvj.1306] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/03/2024] [Indexed: 03/19/2024] Open
Abstract
High-risk congenital heart disease (CHD) in pregnancy presents a complex clinical challenge. With improved medical care and increased survival rates, a growing population of adults with complex CHD are surviving to adulthood, including women of reproductive age. This chapter focuses on risk stratification and management of pregnant women with high-risk CHD, emphasizing the importance of considering both anatomical and physiological complexity. Maternal physiological changes, such as blood volume increase, cardiac output changes, and alterations in vascular resistance, can significantly impact high-risk CHD patients. Management of high-risk CHD in pregnancy necessitates a multidisciplinary approach and individualized care.
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Affiliation(s)
- Saurabh Rajpal
- The Ohio State University Wexner Medical Center, Columbus, Ohio, US
- Nationwide Children’s Hospital, Columbus, Ohio, US
| | - Carla P. Rodriguez
- Nationwide Children’s Hospital, Columbus, Ohio, US
- Boston Children’s Hospital and Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, US
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6
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Ejim EC, Karaye KM, Antia S, Isiguzo GC, Njoku PO. Peripartum cardiomyopathy in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102476. [PMID: 38395024 DOI: 10.1016/j.bpobgyn.2024.102476] [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: 09/30/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Peripartum cardiomyopathy (PPCM) causes pregnancy-associated heart failure, typically during the last month of pregnancy, and up to 6 months post-partum, in women without known cardiovascular disease. PPCM is a global disease, but with a significant geographical variability within and between countries. Its true incidence in Africa is still unknown because of the lack of a PPCM population-based study. The variability in the epidemiology of PPCM between and within countries could be due to differences in the prevalence of both genetic and non-genetic risk factors. Several risk factors have been implicated in the aetiopathogenesis of PPCM over the years. Majority of patients with PPCM present with symptoms and signs of congestive cardiac failure. Diagnostic work up in PPCM is prompted by strong clinical suspicion, but Echocardiography is the main imaging technique for diagnosis. The management of PPCM involves multiple disciplines - cardiologists, anaesthetists, intensivists, obstetricians, neonatologists, and the prognosis varies widely.
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Affiliation(s)
- Emmanuel C Ejim
- Department of Medicine, University of Nigeria Ituku-Ozalla Campus, Enugu, Nigeria.
| | - Kamilu M Karaye
- Bayero University & Aminu Kano Teaching Hospital Kano, Nigeria.
| | - Samuel Antia
- Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
| | - Godsent C Isiguzo
- Department of Medicine, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Nigeria.
| | - Paschal O Njoku
- Department of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.
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7
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Sliwa K, van der Meer P, Viljoen C, Jackson AM, Petrie MC, Mebazaa A, Hilfiker-Kleiner D, Maggioni AP, Laroche C, Regitz-Zagrosek V, Tavazzi L, Roos-Hesselink JW, Hamdan R, Frogoudaki A, Ibrahim B, Farhan HAF, Mbakwem A, Seferovic P, Böhm M, Pieske B, Johnson MR, Bauersachs J. Socio-economic factors determine maternal and neonatal outcomes in women with peripartum cardiomyopathy: A study of the ESC EORP PPCM registry. Int J Cardiol 2024; 398:131596. [PMID: 37979788 DOI: 10.1016/j.ijcard.2023.131596] [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: 05/19/2023] [Revised: 09/20/2023] [Accepted: 11/14/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is a global disease with substantial morbidity and mortality. The aim of this study was to analyze to what extent socioeconomic factors were associated with maternal and neonatal outcomes. METHODS In 2011, >100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global PPCM registry, under the auspices of the ESC EORP Programme. We investigated the characteristics and outcomes of women with PPCM and their babies according to individual and country-level sociodemographic factors (Gini index coefficient [GINI index], health expenditure [HE] and human developmental index [HDI]). RESULTS 739 women from 49 countries (Europe [33%], Africa [29%], Asia-Pacific [15%], Middle East [22%]) were enrolled. Low HDI was associated with greater left ventricular (LV) dilatation at time of diagnosis. However, baseline LV ejection fraction did not differ according to sociodemographic factors. Countries with low HE prescribed guideline-directed heart failure therapy less frequently. Six-month mortality was higher in countries with low HE; and LV non-recovery in those with low HDI, low HE and lower levels of education. Maternal outcome (death, re-hospitalization, or persistent LV dysfunction) was independently associated with income. Neonatal death was significantly more common in countries with low HE and low HDI, but was not influenced by maternal income or education attainment. CONCLUSIONS Maternal and neonatal outcomes depend on country-specific socioeconomic characteristics. Attempts should therefore be made to allocate adequate resources to health and education, to improve maternal and fetal outcomes in PPCM.
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Affiliation(s)
- Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Charle Viljoen
- Cape Heart Institute, Department of Medicine and Cardiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Alice M Jackson
- Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, United Kingdom
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, United Kingdom
| | - Alexandre Mebazaa
- Department of Anaesthesia and Critical Care, University Hospitals Saint Louis-Lariboisière Paris, University Paris Diderot, Paris, France
| | | | - Aldo P Maggioni
- ANMCO Research Centre, Firenze, Italy; EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France
| | - Cecile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France
| | - Vera Regitz-Zagrosek
- Berlin Institute of Gender in Medicine (GiM), Charité - Universitätsmedizin, Berlin, Germany
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Righab Hamdan
- Cardiology Department, Al Qassimi Hospital, Sharjah, United Arab Emirates
| | | | | | - Hasan Ali Farhan Farhan
- Iraqi Board for Medical Specializations, Scientific Council of Cardiology, College of Medicine, University of Baghdad, Baghdad Heart Center, Baghdad, Iraq
| | - Amam Mbakwem
- Department of Medicine, College of Medicine and Lagos University Teaching Hospital, Lagos, Nigeria
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade, Serbia
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Burkert Pieske
- Department of Cardiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Mark R Johnson
- Department of Obstetrics, Imperial College School of Medicine, Chelsea and Westminster Hospital, London, United Kingdom
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Medical School Hannover, Hannover, Germany
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8
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Margaretha RE, George YWH, Hidayat J. Guyton perspective in managing peripartum cardiomyopathy patient with pulmonary edema: a case report. J Med Case Rep 2024; 18:87. [PMID: 38342904 PMCID: PMC10860229 DOI: 10.1186/s13256-024-04398-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/19/2024] [Indexed: 02/13/2024] Open
Abstract
BACKGROUND Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-related condition characterized by left ventricular dysfunction and heart failure, typically occurring in the peripartum period. Individuals with a history of preeclampsia and hypertension are particularly prone to developing PPCM. Recent research suggests that the condition may be triggered by vascular dysfunction influenced by maternal hormones in the late stages of gestation. The onset of left heart failure results in decreased cardiac output, leading to insufficient perfusion, which in turn, contributes to pulmonary edema and exacerbates tissue hypoxia. This cardiovascular response activates the neurohumoral system, causing peripheral vasoconstriction and elevating both mean capillary filling pressure (MCFP) and central venous pressure (CVP). Early administration of furosemide reduces volume overload due to negative cumulative fluid balance gaining and vasodilation, which increases the velocity of intravascular refilling and causes interstitial edema to resolve. This will decrease interstitial fluid pressure, resulting in decreased mechanical compression to systemic capillary and systemic vein pressure, thus decreasing MCFP and CVP subsequently. Reduced CVP also contributes to increased venous return by decreasing the gradient pressure between MCFP and CVP, resulting in increased cardiac output (CO) and improved tissue oxygenation. CASE A 33-year-old Asian woman, para 3 at full term pregnancy, admitted to the intensive care unit (ICU) after c-section and tubectomy due to shortness of breath and palpitation. Based on history taking, physical examination and echocardiography the patient fulfilled the criteria of PPCM which was also complicated by pulmonary edema. Despite impending respiratory failure, the patient rejected intubation and continuous positive airway pressure (CPAP), and was given oxygen supplementation through nasal cannula. Furosemide was given rapidly continued by maintenance dose and CVP was monitored. Antihypertensive drug, anticoagulants, and bromocriptine were also administered. After achieving negative cumulative fluid balance the patient's symptoms resolved and was discharged one week later. CONCLUSION There is a correlation between negative cumulative fluid balance and reduced central venous pressure after early furosemide therapy. Suspicion for PPCM should not be lowered in the presence of preeclampsia, it could delay appropriate treatment and increase the mortality.
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Affiliation(s)
- Ruth Evlin Margaretha
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.
- Semen Padang Hospital, Jl. Raya By Pass Km. 7, Kecamatan Pauh, West Sumatera, Indonesia.
| | - Yohanes W H George
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Jefferson Hidayat
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Indonesia-Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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9
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Muñoz-Ortiz E, Miranda-Arboleda AF, Saavedra-González YA, Gándara-Ricardo JA, Velásquez-Penagos J, Giraldo-Ardila N, Zapata-Montoya M, Holguín-Gonzalez E, Villegas-García F, Senior-Sanchez JM. Characterization of cardiac arrhythmias and maternal-fetal outcomes in pregnant women: A prospective cohort study. Rev Port Cardiol 2024; 43:67-74. [PMID: 37923244 DOI: 10.1016/j.repc.2023.08.003] [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: 02/05/2023] [Revised: 08/13/2023] [Accepted: 08/21/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Cardiovascular disease is a common cause of morbidity and mortality in pregnant women. Arrhythmias are common complications during pregnancy; however, the data are limited. Our goal was to characterize the epidemiology, clinical presentation, and impact of cardiac arrhythmias on maternal-fetal outcomes. METHODS A prospective cohort study from the Colombian Registry of Pregnancy and Cardiovascular Disease was carried out from 2016 to 2019. All patients with tachyarrhythmia or bradyarrhythmia and a minimum follow-up of six months after delivery were included. The primary outcome was a composite of cardiac events defined as pulmonary edema, symptomatic sustained arrhythmia requiring specific therapy, stroke, cardiac arrest, or maternal death. Secondary outcomes were other cardiac, neonatal, and obstetric events. RESULTS Arrhythmias were the most common cause of referral to our dedicated cardio-obstetric clinic. A total of 92 patients were included, mean age 27±6 years; 8.7% had previous structural heart disease, and cardiology consultation was delayed in 79.4%. The most common arrhythmias were premature ventricular contractions (33%) and paroxysmal reentrant supraventricular tachycardias (15%); 11 patients (12%) had cardiac implantable electronic devices. Cardiac events occurred in 18.4% of patients, obstetric events occurred in 6.5%, and one caesarean was indicated in the context of symptomatic severe mitral stenosis. Adverse neonatal outcomes were observed in 24.3% of newborns. CONCLUSIONS Arrhythmias were the most common cause of referral to a dedicated cardio-obstetric clinic; most had a benign course. Adverse maternal cardiovascular outcomes were significant and there was a high rate of obstetric and neonatal adverse events, underlining the importance of multidisciplinary care.
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Affiliation(s)
- Edison Muñoz-Ortiz
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia; Sección de Cardiología, Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Antioquia, Colombia; Grupo Para el Estudio de las Enfermedades Cardiovasculares - GEEC, Universidad de Antioquia, Medellín, Antioquia, Colombia.
| | | | | | - Jairo Alfonso Gándara-Ricardo
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia; Sección de Cardiología, Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Antioquia, Colombia; Grupo Para el Estudio de las Enfermedades Cardiovasculares - GEEC, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Jesús Velásquez-Penagos
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia; Departamento de Ginecología y Obstetricia, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | | | - Magnolia Zapata-Montoya
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia
| | - Erica Holguín-Gonzalez
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia
| | - Francisco Villegas-García
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia; Servicio de Cardiología, Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia
| | - Juan Manuel Senior-Sanchez
- Clínica Cardio-obstétrica, Hospital Universitario de San Vicente Fundación, Medellín, Antioquia, Colombia; Sección de Cardiología, Departamento de Medicina Interna, Universidad de Antioquia, Medellín, Antioquia, Colombia; Grupo Para el Estudio de las Enfermedades Cardiovasculares - GEEC, Universidad de Antioquia, Medellín, Antioquia, Colombia
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10
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Ardissino M, Halliday BP, de Marvao A. The global landscape of peripartum cardiomyopathy: Morbidity, mortality, recovery and inequity. Eur J Heart Fail 2024; 26:43-45. [PMID: 38013247 DOI: 10.1002/ejhf.3097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 11/23/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Maddalena Ardissino
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- National Heart and Lung Institute, Imperial College London, London, UK
- Medical Research Council Laboratory of Medical Sciences, Imperial College London, London, UK
- Department of Women and Children's Health, King's College London, London, UK
| | - Brian P Halliday
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Antonio de Marvao
- Medical Research Council Laboratory of Medical Sciences, Imperial College London, London, UK
- Department of Women and Children's Health, King's College London, London, UK
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
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11
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Vinsard PA, Arendt KW, Sharpe EE. Care for the Obstetric Patient with Complex Cardiac Disease. Adv Anesth 2023; 41:53-69. [PMID: 38251622 DOI: 10.1016/j.aan.2023.05.004] [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] [Indexed: 01/23/2024]
Abstract
The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.
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Affiliation(s)
- Patrice A Vinsard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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12
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Orita Y, Uebo S, Arai K, Hamada T, Niihara Y, Kobayashi H. Successful Management and Birth After Perimortem Cesarean Delivery and Stillbirth Due to Anaphylaxis. Kurume Med J 2023; 69:115-117. [PMID: 37544749 DOI: 10.2739/kurumemedj.ms6912005] [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] [Indexed: 08/08/2023]
Abstract
Perimortem cesarean delivery is an effective procedure for cardiopulmonary resuscitation during pregnancy. However, there are no reports documenting long-term outcomes in perimortem cesarean delivery survivors. This may be the first report of a successful live birth, occurring two years after perimortem cesarean delivery. A 29-year-old primipara was transferred to the emergency center on account of cardiopulmonary arrest, at 33 weeks of gestation. She was resuscitated 47 min after cardiopulmonary arrest by perimortem cesarean delivery amongst other treatment modalities, although the fetus died. Two months later, she was discharged with a preserved uterus, and no neurological damage. The couple suffered from posttraumatic stress disorder, which they overcame with the support of the multidisciplinary team, then gave birth to a healthy baby 2 years later. To overcome cardiopulmonary arrest during pregnancy, a seamless approach by a multidisciplinary team is essential for a good patient outcome.
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Affiliation(s)
- Yuji Orita
- Department of Obstetrics and Gynecology Faculty of Medicine, Kagoshima University
| | - Shota Uebo
- Department of Cardiovascular medicine and Hypertension, Graduate School of Medicine and Dental sciences, Kagoshima University
| | - Kaoru Arai
- Department of Psychiatry, Kagoshima University Graduate School of Medicine and Dental sciences
| | - Tomonori Hamada
- Department of Obstetrics and Gynecology Faculty of Medicine, Kagoshima University
| | - Yuichiro Niihara
- Department of Obstetrics and Gynecology Faculty of Medicine, Kagoshima University
| | - Hiroaki Kobayashi
- Department of Obstetrics and Gynecology Faculty of Medicine, Kagoshima University
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13
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Bala R, Mehta S, Roy VC, Kaur G, de Marvao A. Peripartum cardiomyopathy: A review. Rev Port Cardiol 2023; 42:917-924. [PMID: 37414337 DOI: 10.1016/j.repc.2023.01.029] [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: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 07/08/2023] Open
Abstract
Peripartum cardiomyopathy is a rare type of heart failure manifesting towards the end of pregnancy or in the months following delivery, in the absence of any other cause of heart failure. There is a wide range of incidence across countries reflecting different population demographics, uncertainty over definitions and under-reporting. Race, ethnicity, multiparity and advanced maternal age are considered important risk factors for the disease. Its etiopathogenesis is incompletely understood and is likely multifactorial, including hemodynamic stresses of pregnancy, vasculo-hormonal factors, inflammation, immunology and genetics. Affected women present with heart failure secondary to reduced left ventricular systolic function (LVEF <45%) and often with associated phenotypes such as LV dilatation, biatrial dilatation, reduced systolic function, impaired diastolic function, and increased pulmonary pressure. Electrocardiography, echocardiography, magnetic resonance imaging, endomyocardial biopsy, and certain blood biomarkers aid in diagnosis and management. Treatment for peripartum cardiomyopathy depends on the stage of pregnancy or postpartum, disease severity and whether the woman is breastfeeding. It includes standard pharmacological therapies for heart failure, within the safety restrictions for pregnancy and lactation. Targeted therapies such as bromocriptine have shown promise in early, small studies, with large definitive trials currently underway. Failure of medical interventions may require mechanical support and transplantation in severe cases. Peripartum cardiomyopathy carries a high mortality rate of up to 10% and a high risk of relapse in subsequent pregnancies, but over half of women present normalization of LV function within a year of diagnosis.
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Affiliation(s)
- Rajni Bala
- Department of Biotechnology, Punjabi University, Patiala, India; Adduct Healthcare Pvt. Ltd., Mohali, India
| | - Sakshi Mehta
- Adduct Healthcare Pvt. Ltd., Mohali, India; Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Vikas C Roy
- Department of Pharmacy, Global College of Pharmacy, Kahanpur, Punjab, India
| | - Geetika Kaur
- Integrative Biosciences Center, Wayne State University, Detroit, MI 48202, USA; Department of Ophthalmology, Visual and Anatomical Sciences, School of Medicine, Wayne State University, Detroit, MI 48202, USA
| | - Antonio de Marvao
- Department of Women and Children's Health, King's College London, London, United Kingdom; British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
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14
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Lovell JP, Bermea K, Yu J, Rousseau S, Cohen CD, Bhalodia A, Zita MD, Head RD, Blumenthal RS, Alharethi R, Damp J, Boehmer J, Alexis J, McNamara DM, Sharma G, Adamo L. Serum Proteomic Analysis of Peripartum Cardiomyopathy Reveals Distinctive Dysregulation of Inflammatory and Cholesterol Metabolism Pathways. JACC Heart Fail 2023; 11:1231-1242. [PMID: 37542511 DOI: 10.1016/j.jchf.2023.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The pathophysiology of peripartum cardiomyopathy (PPCM) and its distinctive biological features remain incompletely understood. High-throughput serum proteomic profiling, a powerful tool to gain insights into the pathophysiology of diseases at a systems biology level, has never been used to investigate PPCM relative to nonischemic cardiomyopathy. OBJECTIVES The aim of this study was to characterize the pathophysiology of PPCM through serum proteomic analysis. METHODS Aptamer-based proteomic analysis (SomaScan 7K) was performed on serum samples from women with PPCM (n = 67), women with nonischemic nonperipartum cardiomyopathy (NPCM) (n = 31), and age-matched healthy peripartum and nonperipartum women (n = 10 each). Serum samples were obtained from the IPAC (Investigation of Pregnancy-Associated Cardiomyopathy) and IMAC2 (Intervention in Myocarditis and Acute Cardiomyopathy) studies. RESULTS Principal component analysis revealed unique clustering of each patient group (P for difference <0.001). Biological pathway analyses of differentially measured proteins in PPCM relative to NPCM, before and after normalization to pertinent healthy controls, highlighted specific dysregulation of inflammatory pathways in PPCM, including the upregulation of the cholesterol metabolism-related anti-inflammatory pathway liver-X receptor/retinoid-X receptor (LXR/RXR) (P < 0.01, Z-score 1.9-2.1). Cardiac recovery by 12 months in PPCM was associated with the downregulation of pro-inflammatory pathways and the upregulation of LXR/RXR, and an additional RXR-dependent pathway involved in the regulation of inflammation and metabolism, peroxisome proliferator-activated receptor α/RXRα signaling. CONCLUSIONS Serum proteomic profiling of PPCM relative to NPCM and healthy controls indicated that PPCM is a distinct disease entity characterized by the unique dysregulation of inflammation-related pathways and cholesterol metabolism-related anti-inflammatory pathways. These findings provide insight into the pathophysiology of PPCM and point to novel potential therapeutic targets.
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Affiliation(s)
- Jana P Lovell
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin Bermea
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jinsheng Yu
- Department of Genetics, McDonnell Genome Institute, Washington University, St. Louis, Missouri, USA
| | - Sylvie Rousseau
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles D Cohen
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aashik Bhalodia
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcelle Dina Zita
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard D Head
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Roger S Blumenthal
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Julie Damp
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Boehmer
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jeffrey Alexis
- Division of Cardiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Dennis M McNamara
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, Maryland, USA. https://twitter.com/GarimaVSharmaMD
| | - Luigi Adamo
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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15
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Wolff J, Breuer F, von Kottwitz K, Poloczek S, Röschel T, Dahmen J. [Prehospital perimortem cesarean section during cardiopulmonary resuscitation for traumatic cardiac arrest : Case report and lessons learned]. Unfallchirurgie (Heidelb) 2023; 126:727-735. [PMID: 35947175 PMCID: PMC10449654 DOI: 10.1007/s00113-022-01220-w] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 06/15/2023]
Abstract
The following case report discusses the resuscitation of a pregnant woman in traumatic cardiac arrest after a fall from a height with consecutive resuscitative hysterotomy for maternal and fetal salvage. The report illustrates all lessons learned from critical appraisal amid new guideline recommendations and gives an overview of the published literature on the matter. Despite extensive resuscitation efforts, ultimately both the mother and the newborn were pronounced life extinct at the scene. Prehospital treatment of (traumatic) cardiac arrest in a pregnant patient as well as performing a perimortem cesarean section remain infrequent but challenging scenarios.
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Affiliation(s)
- Justus Wolff
- Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Florian Breuer
- Ärztliche Leitung Rettungsdienst Rheinisch-Bergischer Kreis, Amt für Feuerschutz und Rettungswesen, Bergisch Gladbach, Deutschland
| | | | - Stefan Poloczek
- Ärztliche Leitung Rettungsdienst Berlin, Berliner Feuerwehr, Berlin, Deutschland
| | - Tom Röschel
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, Unfallkrankenhaus Berlin, Berlin, Deutschland
| | - Janosch Dahmen
- Ärztliche Leitung Rettungsdienst Berlin, Berliner Feuerwehr, Berlin, Deutschland.
- Fakultät für Gesundheit, Department Humanmedizin, Universität Witten/Herdecke, Witten/Herdecke, Deutschland.
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16
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Misra A, Porras MP, Rajendran A, Contreras J, Scott NS. Cardio-Obstetrics: A Focused Review. Curr Cardiol Rep 2023; 25:1065-1073. [PMID: 37540401 DOI: 10.1007/s11886-023-01928-0] [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] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease is the leading cause of maternal mortality in the USA. All cardiovascular care providers should have a foundational knowledge on the management of pregnant individuals with heart disease. This focused review touches on several key cardio-obstetric themes. RECENT FINDINGS Many individuals with cardiovascular disease can safely undergo pregnancy, but should have counseling preconception to optimize cardiac status. There are several cardiovascular conditions that are high risk for maternal mortality and morbidity. These individuals should be adequately counseled preconception and offered reliable birth control. The approach to a high-risk pregnant patient with cardiac disease is best managed by a multidisciplinary team to address potential maternal and fetal complications. Identification of at risk individuals can be estimated preconception with several risk scores. The development of risk scores to stratify and identify those at elevated risk during pregnancy is an area of continued research and development.
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Affiliation(s)
- Amrit Misra
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Aardra Rajendran
- Department of Internal Medicine, John Hopkins University, Baltimore, MD, USA
| | - Johanna Contreras
- Department of Cardiology, Division of Advanced Heart Failure and Transplant, Icahn School of Medicine, Mount Sinai, New York City, NY, USA
| | - Nandita S Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Yawkey 5B, Boston, MA, 02114, USA.
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17
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Abdelnabi M, Almaghraby A, Abdelgawad H, Saleh Y. Socioeconomic disparities in peripartum cardiomyopathy. Eur Heart J 2023; 44:2795-2796. [PMID: 37313596 DOI: 10.1093/eurheartj/ehad385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/12/2023] [Accepted: 05/26/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
- Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Abdallah Almaghraby
- Cardiology Department, Ibrahim Bin Hamad Hospital, Al Nakheel, Ras Al Khaimah, 10190, UAE
| | - Hoda Abdelgawad
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Cardiology Department, King's college hospital NHS Trust, London, UK
| | - Yehia Saleh
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Cardiology Department, Houston Methodist DeBakey Cardiology Associates, Houston, TX, USA
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18
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Cameron NA, Yee LM, Dolan BM, O'Brien MJ, Greenland P, Khan SS. Trends in Cardiovascular Health Counseling Among Postpartum Individuals. JAMA 2023; 330:359-367. [PMID: 37490084 PMCID: PMC10369213 DOI: 10.1001/jama.2023.11210] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/06/2023] [Indexed: 07/26/2023]
Abstract
Importance Poor prepregnancy cardiovascular health (CVH) and adverse pregnancy outcomes (APOs) are key risk factors for subsequent cardiovascular disease (CVD) in birthing adults. The postpartum visit offers an opportunity to promote CVH among at-risk individuals. Objective To determine prevalence, predictors, and trends in self-reported CVH counseling during the postpartum visit. Design, Setting, and Participants Serial, cross-sectional analysis of data from 2016-2020 from the Pregnancy Risk Assessment Monitoring System (PRAMS), a nationally representative, population-based survey. The primary analysis included individuals who attended a postpartum visit 4 to 6 weeks after delivery with available data on receipt of CVH counseling, self-reported prepregnancy CVD risk factors (obesity, diabetes, and hypertension), and APOs (gestational diabetes, hypertensive disorders of pregnancy, and preterm birth) (N = 167 705 [weighted N = 8 714 459]). Exposures Total number of CVD risk factors (0, 1, or ≥2 prepregnancy risk factors or APOs). Main Outcomes and Measures Annual, age-adjusted prevalence of self-reported postpartum CVH counseling per 100 individuals, defined as receipt of counseling for healthy eating, exercise, and losing weight gained during pregnancy, was calculated overall and by number of CVD risk factors. Average annual percent change (APC) assessed trends in CVH counseling from 2016 through 2020. Data were pooled to calculate rate ratios (RRs) for counseling that compared individuals with and without CVD risk factors after adjustment for age, education, postpartum insurance, and delivery year. Results From 2016 through 2020, prevalence of self-reported postpartum CVH counseling declined from 56.2 to 52.8 per 100 individuals among those with no CVD risk factors (APC, -1.4% [95% CI, -1.8% to -1.0%/y]), from 58.5 to 57.3 per 100 individuals among those with 1 risk factor (APC, -0.7% [95% CI, -1.3% to -0.1%/y]), and from 61.9 to 59.8 per 100 individuals among those with 2 or more risk factors (APC, -0.8% [95% CI, -1.3% to -0.3%/y]). Reporting receipt of counseling was modestly higher among individuals with 1 risk factor (RR, 1.05 [95% CI, 1.04 to 1.07]) and with 2 or more risk factors (RR, 1.11 [95% CI, 1.09 to 1.13]) compared with those who had no risk factors. Conclusions and Relevance Approximately 60% of individuals with CVD risk factors or APOs reported receiving CVH counseling at their postpartum visit. Prevalence of reporting CVH counseling decreased modestly over 5 years.
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Affiliation(s)
- Natalie A Cameron
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Lynn M Yee
- Feinberg School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Northwestern University, Chicago, Illinois
| | - Brigid M Dolan
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Matthew J O'Brien
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine, Northwestern University, Chicago, Illinois
| | - Philip Greenland
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Sadiya S Khan
- Feinberg School of Medicine, Department of Preventive Medicine, Northwestern University, Chicago, Illinois
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, Illinois
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19
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Harris E. Cardiac Arrest Rates in Pregnancy Might Be Higher Than Expected. JAMA 2023; 329:1143. [PMID: 36947077 DOI: 10.1001/jama.2023.4007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
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20
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Prickett MA, Howell CM. A patient with untreated preeclampsia and peripartum cardiomyopathy. JAAPA 2023; 36:25-27. [PMID: 36815845 DOI: 10.1097/01.jaa.0000911224.29850.f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
ABSTRACT The pathophysiologic process of peripartum cardiomyopathy, a rare and potentially life-threatening condition, is not completely understood. One theory is a possible link between the development of preeclampsia and peripartum cardiomyopathy. These two conditions have been linked to significant mortality in peripartum or postpartum patients. Clinicians must be able to identify the two, their differences, and start appropriate therapies immediately.
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Affiliation(s)
- Mara A Prickett
- Mara A. Prickett is principal faculty in the PA program at Mount St. Joseph University and practices in emergency medicine at Qualified Emergency Specialists Inc., both in Cincinnati, Ohio. Christopher M. Howell is an associate clinical professor and program director at Miami University in Oxford, Ohio, and practices in emergency, family, and addiction medicine in Ohio and Indiana. The authors have disclosed no potential conflicts of interest, financial or otherwise
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21
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Sawyer JM, Moridzadeh N, Bavolek RA. Cardiovascular Complications of Pregnancy. Emerg Med Clin North Am 2023; 41:247-258. [PMID: 37024161 DOI: 10.1016/j.emc.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The physiologic changes in pregnancy predispose the pregnant patient to a variety of potential cardiovascular complications. In this article, we discuss the major cardiovascular disorders of pregnancy and their management, highlight specific diagnostic challenges, and discuss new developments in the field. Topics covered in this article include venous thromboembolism, acute myocardial infarction, peripartum cardiomyopathy, and aortic dissection.
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Affiliation(s)
- John Mark Sawyer
- UCLA Ronald Reagan, Olive View Emergency Medicine Residency, 1100 Glendon Avenue, Suite 1200, Los Angeles, CA 90024, USA.
| | | | - Rebecca A Bavolek
- UCLA Ronald Reagan, Olive View Emergency Medicine Residency, 1100 Glendon Avenue, Suite 1200, Los Angeles, CA 90024, USA
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22
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Velásquez-Penagos J, Muñoz-Ortiz E, Toro-Lugo C, Henao-Parra DA, Correa-Vásquez M, Gándara-Ricardo JA, Zapata-Montoya AM, Holguín-Gonzalez E, Giraldo-Ardila N, Milena-Campo S, Múnera-García M, Senior-Sánchez JM. Maternal and neonatal outcomes in pregnant women with heart disease with single evaluation vs. semi-structured evaluation by a cardio-obstetric team. Arch Cardiol Mex 2023; 93:300-307. [PMID: 37553104 PMCID: PMC10406487 DOI: 10.24875/acm.22000057] [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: 02/14/2022] [Accepted: 08/16/2022] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION Cardiovascular diseases in pregnant women are challenging, with high maternal and perinatal morbidity and mortality, so a cardio-obstetric team is recommended for their care. Even so, little data evaluates the impact of these teams. Therefore, the present study aims to compare the obstetric, maternal, and neonatal outcomes of semi-structured follow-up (SSF) in a Cardio-obstetric clinic concerning regular or unstructured follow-up (USF) in pregnant women with heart disease. METHODS A prospective registry of pregnant women with heart disease was carried out. Patients with SSF by a cardio-obstetric team were compared with those with single evaluation or USF. The risk of events was calculated according to the modified World Health Organization (mWHO) classification and the CARPREG-II scale, and cardiac, obstetric, and neonatal outcomes were evaluated. RESULTS One hundred sixty-eight patients were evaluated, 37 with SSF and 131 with single evaluation (USF). The primary diagnoses were congenital heart disease, arrhythmias, and valve disease. The average CARPREG-II in USF patients was 2.48 (SD 2.3); in SSF patients, it was 3.37 (SD 2.45; p = 0.041). The average of the mWHO in patients with USF was 2.1 (SD 1.6), and with SSF, it was 2.65 (SD 0.95; p = 0.0052). There were no significant differences in primary cardiac outcomes (13.8% in USF vs. 5.4% in SSF; p = 0.134), secondary cardiac (5.3% in USF vs. 2.7% in SSF; p = 0.410), obstetric (10% in USF vs. 16.2% in SSF; p = 0.253) and neonatal (35.9% in USF and 40.5% in SSF; p = 0.486) even though patients with SSF had a higher risk than patients with USF according to the mWHO and CARPREG-II scales. CONCLUSIONS In pregnant women with heart disease, an SSF compared with a USF by a cardio-obstetric team did not show statistically significant differences in cardiovascular, obstetric, and neonatal outcomes. However, patients with SSF had a significantly higher risk of adverse outcomes due to the mWHO and CARPREG-II scales. This result suggests that the SSF achieves at least equal outcomes despite the higher risk of adverse events that patients in this group had.
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Affiliation(s)
- Jesús Velásquez-Penagos
- Departamento de Ginecología y Obstetricia, Universidad de Antioquia
- Clínica Cardio-Obstétrica, Hospital Universitario San Vicente Fundación
| | - Edison Muñoz-Ortiz
- Clínica Cardio-Obstétrica, Hospital Universitario San Vicente Fundación
- Sección de Cardiología, Departamento de Medicina Interna, Universidad de Antioquia
| | | | | | | | - Jairo A. Gándara-Ricardo
- Clínica Cardio-Obstétrica, Hospital Universitario San Vicente Fundación
- Sección de Cardiología, Departamento de Medicina Interna, Universidad de Antioquia
- Grupo para el Estudio de las Enfermedades Cardiovasculares, Universidad de Antioquia
| | | | - Erica Holguín-Gonzalez
- Clínica Cardio-Obstétrica, Hospital Universitario San Vicente Fundación
- Unidad Funcional de Cirugía y Trauma, Hospital Universitario San Vicente Fundación
| | | | - Sandra Milena-Campo
- Departamento de Medicina Interna, Universidad de Antioquia. Medellín, Colombia
| | | | - Juan M. Senior-Sánchez
- Clínica Cardio-Obstétrica, Hospital Universitario San Vicente Fundación
- Sección de Cardiología, Departamento de Medicina Interna, Universidad de Antioquia
- Grupo para el Estudio de las Enfermedades Cardiovasculares, Universidad de Antioquia
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23
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Parrini I, Lucà F, Favilli S, Domenicucci S, Russo MG, Sarubbi B, Gelsomino S, Colivicchi F, Gulizia MM. [Pregnancy and heart disease: the role of the Pregnancy Heart Team]. G Ital Cardiol (Rome) 2022; 23:631-644. [PMID: 36169143 DOI: 10.1714/3856.38394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
A significant risk of maternal and fetal morbidity and mortality has been shown to be associated with congenital heart disease or heart disease occurring during pregnancy. Given the increasing number of patients with corrected congenital heart disease who reach fertile age and the more and more common advanced maternal age associated with preexisting or intercurrent comorbidities, a higher incidence of cardiac complications in pregnancy has been reported in the last decades. Improvement in maternal and neonatal outcomes is influenced by a multidisciplinary strategy. The purpose of this review is to assess the role of the Pregnancy Heart Team which should ensure careful pre-pregnancy counseling, pregnancy monitoring, and delivery planning for both congenital heart disease and other cardiac or metabolic disorders.
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Affiliation(s)
- Iris Parrini
- Divisione di Cardiologia, Ospedale Mauriziano, Torino
| | - Fabiana Lucà
- U.O. Cardiologia, UTIC, Grande Ospedale Metropolitano, Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria
| | - Silvia Favilli
- S.O.C. Cardiologia Pediatrica e della Transizione, AOU Meyer, Firenze
| | | | - Maria Giovanna Russo
- U.O.C. Cardiologia Pediatrica e U.O.S.D. Cardiopatie Congenite dell'Adulto, Università della Campania "L. Vanvitelli", Ospedale Monaldi, Napoli
| | - Berardo Sarubbi
- U.O.C. Cardiologia Pediatrica e U.O.S.D. Cardiopatie Congenite dell'Adulto, Università della Campania "L. Vanvitelli", Ospedale Monaldi, Napoli
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht - CARIM, University of Maastricht, Maastricht, Olanda
| | - Furio Colivicchi
- U.O.C. Cardiologia Clinica e Riabilitativa, Dipartimento di Emergenza e Accettazione, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma
| | - Michele Massimo Gulizia
- Divisione di Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione "Garibaldi", Catania - Fondazione per il Tuo cuore - Heart Care Foundation, Firenze
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24
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Chien P. Hypertension during pregnancy. BJOG 2022; 129:1229-1230. [PMID: 35722962 DOI: 10.1111/1471-0528.17243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Fernandez Campos BA, Silversides CK. Marfan syndrome and pregnancy-related aortic complications: contemporary outcomes from two Spanish Marfan units. Rev Esp Cardiol (Engl Ed) 2022; 75:542-544. [PMID: 35339410 DOI: 10.1016/j.rec.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Beatriz Aldara Fernandez Campos
- University of Toronto, Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Candice K Silversides
- University of Toronto, Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, University Health Network and Mount Sinai Hospital, Toronto, Canada.
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26
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Wang HY, Bao ZL, Yang D, Li YN, Bu L, Ding WW, Zhang J. [Clinical characteristics and pregnancy outcomes of pregnant women with left ventricular non-compaction]. Zhonghua Fu Chan Ke Za Zhi 2022; 57:332-338. [PMID: 35658323 DOI: 10.3760/cma.j.cn112141-20220126-00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective: To investigate the clinical characteristics and pregnancy outcomes in pregnant women with left ventricular non-compaction (LVNC). Methods: The clinical data of seven pregnant women with LVNC from January 2011 to December 2021 in Beijing Anzhen Hospital,Capital Medical University were retrospectively analyzed, including age, gestational age of symptom first occured, LVNC history, clinical symptoms, New York Heart Association (NYHA) cardiac function class, echocardiography, blood brain natriuretic peptide (BNP), treatment and the maternal and fetal outcomes. Results: Five cases were diagnosed before pregnancy, of which there were three women with medication; one case diagnosed in the month of pregnancy; one case diagnosed at 36 weeks of gestation. NYHA cardiac function was grade Ⅰ in four cases and grade Ⅱ in three cases before or during the first trimester of pregnancy. Of the five pregnant women who underwent echocardiography, there were one case of left ventricular insufficiency, three cases of mild left ventricular dysfunction and one case of normal left ventricular function before or during the first trimester of pregnancy. Of the five pregnant women to the second and third trimester of pregnancy, there were one case of grade Ⅳ, one case of grade Ⅲ, two cases of grade Ⅱ-Ⅲ and one case of grade Ⅱ in NYHA class ; three cases of left ventricular insufficiency, two cases of normal left ventricular function by echocardiography four cases had cardiac symptoms at 15-24 weeks of gestation and were treated with medication. In four cases, blood BNP increased to 214-1 197 ng/L during pregnancy, and were 89-106 ng/L after termination of pregnancy. There were 4 cases with arrhythmia. Indications for termination of pregnancy: LVNC complicated with heart failure in two cases, LVNC complicated with decreased cardiac function and threatened preterm birth in one case, complicated with pregnancy at full term in two cases, LVNC complicated with severe pulmonary hypertension in one case, and left ventricular dysfunction in one case. Cesarean section in four cases in the third-trimester, in one case in the second-trimester, and forceps curettage in two cases were taken. Two full-term infants,two preterm infants were born without LVNC. Conclusions: Women diagnosed with LVNC and low left ventricular ejection fraction before pregnancy are more prone to decreased cardiac function during pregnancy. Carrying out pregnancy risk assessment and strengthening the multi-disciplinary team management of high risk factors in pregnancy are conducive to achieve good pregnancy outcomes.
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Affiliation(s)
- H Y Wang
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, Obstetrics and Gynecology Center for Severe Cardiovascular Diseases, Beijing 100029, China
| | - Z L Bao
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, Obstetrics and Gynecology Center for Severe Cardiovascular Diseases, Beijing 100029, China
| | - D Yang
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, Obstetrics and Gynecology Center for Severe Cardiovascular Diseases, Beijing 100029, China
| | - Y N Li
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, Obstetrics and Gynecology Center for Severe Cardiovascular Diseases, Beijing 100029, China
| | - L Bu
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, Obstetrics and Gynecology Center for Severe Cardiovascular Diseases, Beijing 100029, China
| | - W W Ding
- Pediatric Cardiology Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - J Zhang
- Department of Obstetrics and Gynecology, Beijing Anzhen Hospital, Capital Medical University, Obstetrics and Gynecology Center for Severe Cardiovascular Diseases, Beijing 100029, China
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27
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Kouzu H, Tatekoshi Y, Chang HC, Shapiro JS, McGee WA, De Jesus A, Ben-Sahra I, Arany Z, Leor J, Chen C, Blackshear PJ, Ardehali H. ZFP36L2 suppresses mTORc1 through a P53-dependent pathway to prevent peripartum cardiomyopathy in mice. J Clin Invest 2022; 132:e154491. [PMID: 35316214 PMCID: PMC9106345 DOI: 10.1172/jci154491] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/17/2022] [Indexed: 01/13/2023] Open
Abstract
Pregnancy is associated with substantial physiological changes of the heart, and disruptions in these processes can lead to peripartum cardiomyopathy (PPCM). The molecular processes that cause physiological and pathological changes in the heart during pregnancy are not well characterized. Here, we show that mTORc1 was activated in pregnancy to facilitate cardiac enlargement that was reversed after delivery in mice. mTORc1 activation in pregnancy was negatively regulated by the mRNA-destabilizing protein ZFP36L2 through its degradation of Mdm2 mRNA and P53 stabilization, leading to increased SESN2 and REDD1 expression. This pathway impeded uncontrolled cardiomyocyte hypertrophy during pregnancy, and mice with cardiac-specific Zfp36l2 deletion developed rapid cardiac dysfunction after delivery, while prenatal treatment of these mice with rapamycin improved postpartum cardiac function. Collectively, these data provide what we believe to be a novel pathway for the regulation of mTORc1 through mRNA stabilization of a P53 ubiquitin ligase. This pathway was critical for normal cardiac growth during pregnancy, and its reduction led to PPCM-like adverse remodeling in mice.
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Affiliation(s)
- Hidemichi Kouzu
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
| | - Yuki Tatekoshi
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
| | - Hsiang-Chun Chang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
| | - Jason S. Shapiro
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
| | - Warren A. McGee
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Adam De Jesus
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
| | - Issam Ben-Sahra
- Department of Biochemistry, Northwestern University, Chicago, Illinois, USA
| | - Zoltan Arany
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan Leor
- Cardiovascular Research Institute, Tel Aviv University and Sheba Medical Center, Tel Aviv, Israel
| | - Chunlei Chen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
| | - Perry J. Blackshear
- Signal Transduction Laboratory, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
| | - Hossein Ardehali
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Feinberg Cardiovascular and Renal Research Institute and
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28
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Bukhari S, Fatima S, Barakat AF, Fogerty AE, Weinberg I, Elgendy IY. Venous thromboembolism during pregnancy and postpartum period. Eur J Intern Med 2022; 97:8-17. [PMID: 34949492 DOI: 10.1016/j.ejim.2021.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 08/17/2021] [Revised: 11/11/2021] [Accepted: 12/15/2021] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE) is one of the leading causes of maternal mortality. Rates of VTE during pregnancy and the postpartum period have not decreased over the past two decades and pregnancyassociated VTE continues to pose a significant health challenge. Pregnant and postpartum women are at a higher risk for VTE owing to many factors. There are hormonally mediated and pregnancy-specific alterations of coagulation that favor thrombosis, including increased production of clotting factors. There are physiologic and anatomic mechanisms that also contribute, including a decreased rate of venous blood flow from the lower extemities as pregnancy progresses. Cesarean delivery also introduces VTE risk. In addition, studies have demonstrated that pregnancy-associated complications such as pre-eclampsia or peri-partum infections are associated with increased VTE rates. In this review, we discuss the recent epidemiological studies, pathogenesis, risk factors and clinical presentation as well as therapeutic options for VTE during pregnancy and the postpartum period. We also provide proposed diagnostic algorithms for diagnosis and management of VTE during pregnancy and the postpartum period based on updated evidence. Finally, we highlight knowledge gaps to guide future research.
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Affiliation(s)
- Syed Bukhari
- Department of Medicine, Temple University, Philadelphia, PA
| | - Shumail Fatima
- Department of Medicine, University of Pittsburgh Medical Center McKeesport Hospital, McKeesport, PA
| | - Amr F Barakat
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Annemarie E Fogerty
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ido Weinberg
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.
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29
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Collins A, Memtsa M, Kirk E, Othman M, Abdul Kadir R. The risk of venous thromboembolism in early pregnancy loss: Review of the literature and current guidelines and the need for guidance - Communication from the SSC on Women's Health Issues for thrombosis and haemostasis. J Thromb Haemost 2022; 20:767-776. [PMID: 34897975 DOI: 10.1111/jth.15621] [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: 05/14/2021] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thromboembolic disease is one of the major causes of mortality and morbidity in pregnancy and the puerperium, with 1 death per 100 000 births attributed to venous thromboembolism (VTE). Factors associated with development of thrombosis are all present in pregnancy, with some of these changes seen from conception. OBJECTIVE Given how common early pregnancy loss is, the aim of this review is to evaluate the uncertainty surrounding the risk of VTE following early pregnancy loss and termination of pregnancy. METHODS A structured literature search was conducted to identify existing evidence as well as international pregnancy-specific guidelines regarding assessment and prevention of VTE risk in pregnant women. This review was reviewed, critiqued, and approved by all members of the International Society on Thrombosis and Haemostasis subcommittee for Women's Health Issues in Thrombosis and Haemostasis. RESULTS Four published original research studies, one clinical comment paper, and six guidelines were reviewed. Despite clear evidence of the increased risk of VTE in pregnancy, there is a lack of guidance regarding evaluation and management after early pregnancy loss. CONCLUSION International collaborative research to determine the risk of VTE and its prevention in women undergoing surgical termination of pregnancy or following surgical management of early pregnancy loss is urgently needed. Pregnancy-specific risk assessment taking into account preexisting risk factors is advocated. Education of health care professionals involved in early pregnancy care and guidance on management, albeit based on limited existing evidence, are necessary to highlight the need for individualized care.
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Affiliation(s)
| | - Maria Memtsa
- Institute for Women's Health, University College London, London, UK
| | - Emma Kirk
- The Royal Free NHS Foundation Hospital, London, UK
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Institute for Women's Health, University College London, London, UK
- The Royal Free NHS Foundation Hospital, London, UK
- Katharine Dormandy Haemophilia and Thrombosis Centre, Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, UK
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30
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Ornaghi S, Crippa I, Di Nicola S, Giardini V, La Milia L, Locatelli L, Corso R, Roncaglia N, Vergani P. Splenic artery aneurysm in obstetric patients: a series of four cases with different clinical presentation and outcome. Int J Gynaecol Obstet 2022; 159:474-479. [PMID: 35122689 DOI: 10.1002/ijgo.14133] [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: 09/03/2021] [Revised: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe four consecutive cases of splenic artery aneurysm with different clinical patterns of presentation among obstetric patients. METHOD A series of four cases of splenic artery aneurysm diagnosed in pregnant or post-partum women at our University center between January 1998 and December 2020. Clinical and radiological data were retrospectively obtained by reviewing paper and electronic medical records after acquiring patient's consent. RESULTS One case was completely asymptomatic and incidentally identified at the beginning of pregnancy, thus allowing for multidisciplinary treatment. The other three cases were unknown: two manifested with maternal collapse due to aneurysm rupture in the third trimester of gestation, whereas one presented with acute abdominal pain during the post-partum period and was successfully managed before rupture occurred. CONCLUSION Although being extremely rare, SAA rupture in obstetric patients can be associated with dramatic consequences. Since early suspicion and prompt intervention are essential to avoid fatal outcomes, promotion of knowledge of all the potential clinical patterns of presentation of SAA rupture among obstetric patients is mandatory.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Isabella Crippa
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
| | - Sara Di Nicola
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Valentina Giardini
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
| | - Laura La Milia
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Luca Locatelli
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Rocco Corso
- Department of Radiology, San Gerardo Hospital, Monza, Italy
| | - Nadia Roncaglia
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
| | - Patrizia Vergani
- Department of Obstetrics, MBBM Foundation at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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31
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Jonathan Pfeffer T, Berliner D, Bauersachs J. Peripartum Cardiomyopathy is Missing. Dtsch Arztebl Int 2022; 119:57. [PMID: 35410671 PMCID: PMC9017778 DOI: 10.3238/arztebl.m2022.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
| | - Dominik Berliner
- *Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Germany
| | - Johann Bauersachs
- *Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Germany
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32
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Skeith L. Prevention and management of venous thromboembolism in pregnancy: cutting through the practice variation. Hematology Am Soc Hematol Educ Program 2021; 2021:559-569. [PMID: 34889418 PMCID: PMC8791179 DOI: 10.1182/hematology.2021000291] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
There is clinical practice variation in the area of prevention and management of venous thromboembolism (VTE) in pregnancy. There are limited data and differing recommendations across major clinical practice guidelines, especially relating to the role of postpartum low-molecular-weight heparin (LMWH) for patients with mild inherited thrombophilia and those with pregnancy-related VTE risk factors. This chapter explores the issues of practice variation and related data for postpartum VTE prevention. Controversial topics of VTE management in pregnancy are also reviewed and include LMWH dosing and the role of anti-Xa level monitoring, as well as peripartum anticoagulation management around labor and delivery.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, Foothills Medical Centre, University of Calgary, Calgary, Canada
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33
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Vecchio M, Guenot C, Staubli S, Gavillet M, Alberio L, Mazzolai L, Alatri A. [Venous thromboembolic disease during pregnancy : diagnosis, treatment and follow-up]. Rev Med Suisse 2021; 17:2135-2138. [PMID: 34878742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Venous thromboembolism is a leading cause of maternal morbidity and mortality with an overall incidence of 1-2 cases per 1000 pregnancies. The purpose of this article is to summarize more recent recommendations for the management of venous thromboembolism during pregnancy and post-partum period.
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Affiliation(s)
- Matteo Vecchio
- Service d'angiologie, Département cœur-vaisseaux, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Cécile Guenot
- Service d'obstétrique, Département femme-mère-enfant, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Samuel Staubli
- Service d'angiologie, Département cœur-vaisseaux, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Mathilde Gavillet
- Service et Laboratoire central d'hématologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Lorenzo Alberio
- Service et Laboratoire central d'hématologie, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Lucia Mazzolai
- Service d'angiologie, Département cœur-vaisseaux, Centre hospitalier universitaire vaudois, 1011 Lausanne
| | - Adriano Alatri
- Service d'angiologie, Département cœur-vaisseaux, Centre hospitalier universitaire vaudois, 1011 Lausanne
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34
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Cupido B, Zühlke L, Osman A, van Dyk D, Sliwa K. Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach. Can J Cardiol 2021; 37:2045-2055. [PMID: 34571164 DOI: 10.1016/j.cjca.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 10/20/2022] Open
Abstract
Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.
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Affiliation(s)
- Blanche Cupido
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Liesl Zühlke
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Red Cross Children's Hospital, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa; The Deanery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Ayesha Osman
- Department of Obstetrics and Gynaecology: Maternal Fetal Medicine Unit, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Dominique van Dyk
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Cape Heart Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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35
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Affiliation(s)
- Andrea Girnius
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH
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36
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Soar J, Becker LB, Berg KM, Einav S, Ma Q, Olasveengen TM, Paal P, Parr MJA. Cardiopulmonary resuscitation in special circumstances. Lancet 2021; 398:1257-1268. [PMID: 34454688 DOI: 10.1016/s0140-6736(21)01257-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/13/2021] [Accepted: 05/24/2021] [Indexed: 12/21/2022]
Abstract
Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.
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Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Lance B Becker
- Emergency Medicine, Zucker School of Medicine at Hofstra-Northwell, Northwell Health, New Hyde Park, NY, USA
| | | | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Qingbian Ma
- Emergency Medicine, Peking University Third Hospital, Beijing, China
| | | | - Peter Paal
- Anaesthesiology and Intensive Care, St John of God Hospital, Paracelsus, Salzburg, Austria
| | - Michael J A Parr
- Intensive Care, Liverpool University Hospital, University of New South Wales, Sydney, NSW, Australia; Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
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37
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Abstract
Pregnancy-related acute myocardial infarction is a rare and potentially life-threatening cardiovascular event, the incidence of which is growing due to the heightened prevalence of several risk factors, including increased maternal age. Its main aetiology is spontaneous coronary artery dissection, which particularly occurs in pregnancy and may engender severe clinical scenarios. Therefore, despite frequently atypical and deceptive presentations, early recognition of such a dangerous complication of gestation is paramount. Notwithstanding diagnostic and therapeutic improvements, pregnancy-related acute myocardial infarction often carries unfavourable outcomes, as emergent management is difficult owing to significant limitations in the use of ionising radiation-e.g. during coronary angiography, potentially harmful to the foetus even at low doses. Notably, however, maternal mortality has steadily decreased in recent decades, indicating enhanced awareness and major medical advances in this field. In our paper, we review the recent literature on pregnancy-related acute myocardial infarction and highlight the key points in its management.
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Affiliation(s)
- Andrea Carlo Merlo
- Department of Internal Medicine and Medical Specialties (DIMI), Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialties (DIMI), Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy
- Cardiology Unit, DICATOV-Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI), Chair of Cardiovascular Diseases, University of Genoa, Genoa, Italy.
- Cardiology Unit, DICATOV-Cardiothoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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38
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Elgendy IY, Gad MM, Mansoor H, Mahmoud AN, Elbadawi A, Saad A, Saad M, Elkaryoni A, Secemsky EA, Mamas MA, Monreal M, Weinberg I, Pepine CJ. Acute Pulmonary Embolism During Pregnancy and Puerperium: National Trends and In-Hospital Outcomes. Mayo Clin Proc 2021; 96:2102-2113. [PMID: 34144802 DOI: 10.1016/j.mayocp.2021.01.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 12/28/2020] [Accepted: 01/07/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To investigate the trend and outcomes of acute pulmonary embolism (PE) during pregnancy and puerperium using a large national database. PATIENTS AND METHODS The National Inpatient Sample was queried to identify pregnancy-related hospitalizations in the United States from January 1, 2007, through September 30, 2015. Temporal trends in the rates of acute PE and in-hospital mortality rates were extracted. RESULTS Among 37,524,314 hospitalizations, 6,333 patients (0.02%) had acute PE. The prevalence of comorbidities and risk factors such as hypertension, obesity, and smoking increased, but rates of acute PE did not change significantly (18.01 in 2007 vs 19.36 in 2015, per 100,000 hospitalizations, Ptrends=.21). Advanced therapies were used in a small number of women (systemic thrombolysis: 2.4%, surgical pulmonary embolectomy: 0.5%, and inferior vena cava filter in 8.3%). Rates of in-hospital mortality were almost 200-fold higher among those who had acute PE (29.3 vs 0.13, per 1000 pregnancy-related, P<.001). The rate of in-hospital mortality did not change among women with acute PE (2.6% in 2007 vs 2.5% in 2015, Ptrends=.74). CONCLUSION In this contemporary analysis of pregnancy-related hospitalizations, acute PE was uncommon, but rates have not decreased over the past decade. Acute PE during pregnancy and puerperium was associated with high maternal mortality, and the rates of in-hospital mortality have not improved. Future studies to improve prevention and management of acute PE during pregnancy and puerperium are warranted.
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Affiliation(s)
- Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar.
| | - Mohamed M Gad
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Hend Mansoor
- College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Ahmed N Mahmoud
- Division of Cardiology, Case Western Reserve University, School of Medicine and Harrington Heart and Vascular Institute, Cleveland, OH
| | - Ayman Elbadawi
- Department of Cardiology, University of Texas Medical Branch, Galveston, TX
| | - Anas Saad
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Marwan Saad
- Division of Cardiology, The Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Ahmed Elkaryoni
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL
| | - Eric A Secemsky
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ido Weinberg
- Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
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Millington S, Edwards S, Clark RA, Dekker GA, Arstall M. The association between guidelines adherence and clinical outcomes during pregnancy in a cohort of women with cardiac co-morbidities. PLoS One 2021; 16:e0255070. [PMID: 34297761 PMCID: PMC8301645 DOI: 10.1371/journal.pone.0255070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
Background/Aims Maternal and infant morbidities associated with pregnant women with cardiac conditions are a global issue contingent upon appropriate care. This study aimed to describe the clinical variables and their association with the adherence scores to perinatal guidelines for pregnant women with cardiac conditions. The clinical variables included cardiac, perinatal, and neonatal outcomes and complications. Methods Using a retrospective cross-sectional medical record audit, data were abstracted and categorised as cardiac, obstetric, and neonatal predictors. Linear regression modelling was used to find the mean difference (MD) in adherence scores for each predictor, including a 95% confidence interval (CI) and a significance value for all the three categories’ clinical outcomes. Results This maternal cohort’s (n = 261) cardiac complications were primarily arrhythmias requiring treatment (29.9%), particularly SVT (28%), a new diagnosis of valvular heart disease and congenital heart disease (24%) and decompensated heart failure (HF) (16%). Women with HF had associated increased adherence scores (MD = 3.546, 95% CI: 1.689, 5.403) compared to those without HF. Elective LSCS mode of delivery was associated with a higher adherence score (MD = 5.197, 95% CI: 3.584, 6.811) than non-elective LSCS subgroups. Babies admitted to intensive /special care had greater adherence to the guidelines (MD = 3.581, 95% CI: 1.822, 5.340) than those not requiring the same care. Conclusions Some pregnancy associated complications and morbidities were associated with higher adherence scores, reflecting that a diagnosis, identification of morbidities or risk factors, initiation of appropriate multidisciplinary involvement and adherence to guidelines were associated. Conversely, potentially avoidable major complications such as sepsis were associated with a low adherence score. Trial registration ACTRN12617000417381.
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Affiliation(s)
- Sandra Millington
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- * E-mail:
| | - Suzanne Edwards
- Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Robyn A. Clark
- College of Nursing and Health Science, Flinders University, Adelaide, South Australia, Australia
| | - Gustaaf A. Dekker
- Women’s and Children’s Division Northern Adelaide Health Local Network (NAHLN) and Obstetrics and Gynaecology, University of Adelaide, Adelaide, South Australia, Australia
| | - Margaret Arstall
- Cardiology Unit NAHLN, University of Adelaide, Adelaide, South Australia, Australia
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Morikawa M, Adachi T, Itakura A, Nii M, Nakabayashi Y, Kobayashi T. A retrospective cohort study using a national surveillance questionnaire to investigate the characteristics of maternal venous thromboembolism in Japan in 2018. BMC Pregnancy Childbirth 2021; 21:514. [PMID: 34273959 PMCID: PMC8286571 DOI: 10.1186/s12884-021-03993-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 07/02/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In Japan, the numbers of deliveries by women of older maternal age and women with overweight or obesity have recently increased. Since 2008, the guidelines and practices to prevent the maternal venous thromboembolism (VTE) have been recommended antepartum and postpartum thromboprophylaxis for each risk level of VTE. This study aimed to clarify the incidence and characteristics (type of VTE and thromboprophylaxis) of VTE in pregnant women in Japan to reduce the rate of mortality from VTE METHODS: Of 2299 institutions sent the surveillance questionnaire, 666 (29.0%) responded, and data from 295,961 women who gave birth in those institutions in 2018 were analyzed. We calculated the incidence and characteristics of VTE before and after the deliveries. RESULTS At the responding institutions, 243 women (0.082%) had VTE in 2018. In 2018, deep vein thrombosis was significantly more common (0.0053%) than pulmonary thromboembolism (0.0019%; p < 0.0001). The incidence of antepartum VTE (0.0055%) was significantly higher than that of postpartum VTE (0.0026%; p < 0.0001). The incidence of VTE after cesarean Sect. (0.0074%) was significantly higher than that after vaginal delivery (0.0012%; p < 0.0001). Of the women with VTE, 4 (1.6%) died. CONCLUSIONS Among the women thought to have a low risk of VTE during the antepartum period, and especially women who had a vaginal delivery, the actual incidence of VTE might have increased in Japan.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics and Gynecology, Kansai Medical University, Shinmachi 2-5-1, Hirakata City, Osaka, 573-1010, Japan.
| | - Tomoko Adachi
- Department of Obstetrics and Gynecology, Aiiku Hospital, Tokyo, Japan
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Tsu, Japan
| | | | - Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Hamamatsu, Japan
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Hussey H, Hussey P, Meng ML. Peripartum considerations for women with cardiac disease. Curr Opin Anaesthesiol 2021; 34:218-225. [PMID: 33935168 PMCID: PMC8610034 DOI: 10.1097/aco.0000000000000992] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this review of cardiac disease in pregnancy is to delineate current best practices and highlight emerging themes in the literature. RECENT FINDINGS Cardiovascular disease is the leading cause of death among pregnant women in the United States. Many clinicians and institutions have developed care pathways to approach care in these high-risk patients including highly coordinated multidisciplinary teams. The diagnosis of pulmonary hypertension is the greatest risk factor for an adverse event in pregnant women. Vaginal delivery, with good neuraxial anesthesia, is usually the preferred mode of delivery in women with cardiac disease, although the rate of cesarean delivery is higher among women with heart disease. SUMMARY The leading cause of morbidity and mortality in pregnant women is cardiac disease. Preconception counseling is useful for optimizing patients for pregnancy and setting appropriate expectations about care and outcomes. Ensuring that women are cared for in centers with appropriate multidisciplinary resources is key for improving outcomes for cardio-obstetric patients.
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Affiliation(s)
- Hanna Hussey
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick Hussey
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
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Davis MB, Arendt K, Bello NA, Brown H, Briller J, Epps K, Hollier L, Langen E, Park K, Walsh MN, Williams D, Wood M, Silversides CK, Lindley KJ. Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5. J Am Coll Cardiol 2021; 77:1763-1777. [PMID: 33832604 DOI: 10.1016/j.jacc.2021.02.033] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 01/10/2023]
Abstract
The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.
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Affiliation(s)
- Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Katherine Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Haywood Brown
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Florida, USA
| | - Joan Briller
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kelly Epps
- Division of Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - Lisa Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth Langen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Mary Norine Walsh
- Division of Cardiology, St. Vincent Heart Center, Indianapolis, Indiana, USA
| | - Dominique Williams
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Malissa Wood
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Candice K Silversides
- Division of Cardiology, Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Duncker D, Pfeffer TJ, Bauersachs J, Veltmann C. ECG and arrhythmias in peripartum cardiomyopathy. Herzschrittmacherther Elektrophysiol 2021; 32:207-213. [PMID: 33791817 DOI: 10.1007/s00399-021-00760-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 01/18/2021] [Accepted: 03/19/2021] [Indexed: 01/24/2023]
Abstract
Peripartum cardiomyopathy (PPCM) is a rare but life-threatening heart disease, with onset in the last month of pregnancy or in the first months after delivery. Extensive studies on the burden of supraventricular and ventricular arrhythmias are lacking. Patients with PPCM present with electrocardiographic findings typical in acute heart failure. Management of arrhythmias in PPCM depends on the severity and the onset (during pregnancy or after delivery). Studies on the use of the wearable cardioverter-defibrillator in patients with PPCM show a substantial burden of ventricular tachyarrhythmias and sudden death in patients with severely reduced left ventricular function. The aim of the present article is to summarize actual knowledge on electrocardiogram findings, arrhythmias, and sudden cardiac death in patients with PPCM.
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Affiliation(s)
- David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Tobias J Pfeffer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 691] [Impact Index Per Article: 230.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
Peripartum cardiomyopathy is now increasingly recognized as a cause of heart failure in the later months of pregnancy and early postpartum period. Clinical diagnosis may be challenging as it closely resembles several common medical and obstetric complications. Complex pathogenesis, unpredictable onset, staggered recovery, and unanticipated fetomaternal risks pose unique challenge to clinicians. Prevalence seems to vary with race, geographic location, and diagnostic criteria. The presence of multiple risk factors substantially elevates the risk of PPCM. Transthoracic echocardiographic examination can exclude the majority of the mimickers. Symptomatic presentation is initially limited to, varying grades of low cardiac output syndrome. Rarely, PPCM begins with decompensated heart failure and cardiovascular collapse. Guideline-directed medical therapy involves graded initiation and titration of heart failure medications while ensuring the fetal and neonatal safety. Anesthetic and obstetric management should be individualized to improve fetomaternal outcomes. However, emergent cesarean delivery may be required in women with decompensated heart failure and cardiovascular collapse. An early institution of mechanical circulatory support has shown to improve outcome. Bromocriptine and other experimental drugs designed to target pathogenic pathway have yielded mixed results. A further change in approach to management requires a comprehensive understanding of pathophysiology and fetomaternal safety profiles of heart failure medications.
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Affiliation(s)
- Nivedita Jha
- Department of Obstetrics and Gynaecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Cardiothoracic Division, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
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Xie F, Hao J, Richard SA, Yang Y, Zou W, Liu HB, Deng M, Zhang C. Awake endovascular coiling of a dissected intracranial aneurysm in a third-trimester twin pregnancy: A case report. Medicine (Baltimore) 2021; 100:e24239. [PMID: 33429826 PMCID: PMC7793342 DOI: 10.1097/md.0000000000024239] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/17/2020] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Subarachnoid hemorrhages (SAHs) from ruptured intracranial aneurysms are very rare during pregnancy. Management of ruptured intracranial aneurysms with SAH in pregnancy is often challenging because of the risks to the fetus and the mother. We present the first successful awake endovascular coiling of a dissected intracranial aneurysm in a third trimester twin pregnancy. PATIENT CONCERNS A 28 years' old pregnant woman was admitted at the obstetric department of our hospital on account of very severe headaches associated with nausea and vomiting. DIAGNOSIS Emergency obstetric ultrasound scan done confirmed 32 weeks' twin gestation, whereas magnetic resonance imaging established hemorrhage in the suprasellar cistern and the subarachnoid space. Magnetic resonance angiography revealed a dissected aneurysm in the ophthalmic segment of the left internal carotid artery. INTERVENTIONS Awake cerebral angiography as well as embolization of the aneurysm with coils was done via the transarterial route and the twins were delivered via caesarean section at 37 weeks' gestation. OUTCOMES Two years' follow-up indicated no complications and children as well as their mother are healthy. LESIONS Awake endovascular coiling was very beneficial in our case because we avoided general anesthesia and the use of osmotic diuretics which are potentially hazardous during pregnancy.
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Affiliation(s)
| | | | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
- Department of Medicine, Princefield University, Ho-Volta Region, Ghana West Africa
| | - Yuanli Yang
- Department of Obstetrics and Gynecology, Ziyang First People's Hospital, Ziyang
| | - Wuchun Zou
- Department of Obstetrics and Gynecology, Ziyang First People's Hospital, Ziyang
| | | | - Min Deng
- Department of Obstetrics and Gynecology, Ziyang First People's Hospital, Ziyang
| | - Changwei Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, P. R. China
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Benmessaoud FA, Bendagha N, Soufiani A, Konaté L, Fellat N, Benani R, Haitam NE, Fellat R. Dilatation mitrale percutanée des rétrécissements mitraux en hypertention pulmonaire importante au cours de la grossesse. Pan Afr Med J 2021; 40:265. [PMID: 35251459 PMCID: PMC8856978 DOI: 10.11604/pamj.2021.40.265.11297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/03/2017] [Indexed: 11/11/2022] Open
Abstract
Le rétrécissement mitral (RM) rhumatismal est la valvulopathie organique la plus fréquente dans les pays en voie de développement. La grossesse constitue l´une des circonstances de décompensation de cette valvulopathie. Nous rapportons notre expérience dans la dilatation mitrale percutanée des rétrécissements mitraux en hypertension pulmonaire importante au cours de la grossesse. La commissurotomie mitrale percutanée (CMP) a été réalisée chez deux cent vingt-trois parturientes entre janvier 2009 et décembre 2015. Quarante trois soit 19% de ces patientes avaient une hypertension pulmonaire importante (PAPS > 70 mmHg). Toutes les parturientes de notre série sont porteuses d´un RM très serré symptomatique malgré un traitement médical bien conduit. La CMP a été un succès chez l´ensemble des patientes de l´étude, toutes les patientes se sont améliorées sur le plan clinique. L´insuffisance mitrale a progressé d´un grade chez deux patientes. Une patiente a présenté une tamponnade avec une évolution favorable après ponction péricardique. Aucun avortement n´est survenu après procédure et deux accouchements prématurés ont été rapportés. La prise en charge d´un RM serré durant la grossesse doit être multidisciplinaire et faire intervenir le gynécologue-obstétricien, l´anesthésiste et le cardiologue. La CMP constitue actuellement le traitement de référence du RM au cours de la grossesse.
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Affiliation(s)
- Fatima Azzahra Benmessaoud
- Service de Cardiologie B, CHU Ibn Sina, Rabat, Maroc
- Auteur correspondant: Fatima Azzahra Benmessaoud, Service de Cardiologie B, CHU Ibn Sina, Rabat, Maroc.
| | | | - Aida Soufiani
- Service de Cardiologie A, CHU Ibn Sina, Rabat, Maroc
| | | | - Nadia Fellat
- Service de Cardiologie A, CHU Ibn Sina, Rabat, Maroc
| | - Rajae Benani
- Service de Cardiologie A, CHU Ibn Sina, Rabat, Maroc
| | | | - Roukia Fellat
- Service de Cardiologie A, CHU Ibn Sina, Rabat, Maroc
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Balgobin CA, Zhang X, Lima FV, Avila C, Parikh PB, Yang J, Stergiopoulos K. Risk Factors and Timing of Acute Myocardial Infarction Associated With Pregnancy: Insights From the National Inpatient Sample. J Am Heart Assoc 2020; 9:e016623. [PMID: 33106090 PMCID: PMC7763409 DOI: 10.1161/jaha.120.016623] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Pregnancy increases the risk of acute myocardial infarction (AMI). The purpose of this study was to examine timing and risk factors for AMI in pregnancy and poor outcome. Methods and Results National Inpatient Sample (2003–2015) was screened in pregnancy, labor and delivery, and postpartum. There were 11 297 849 records extracted with 913 instances of AMI (0.008%). One hundred eleven (12.2%) women experienced AMI during labor and delivery, 338 (37.0%) during pregnancy and most during the postpartum period (464; 50.8%). The prevalence of AMI in pregnancy has increased (P=0.0005). Most major adverse cardiovascular and cerebrovascular events occurred in the postpartum period (63.5%). Inpatient mortality was 4.5%. Predictors of AMI include known coronary artery disease (odds ratio [OR], 517.4; 95% CI, 420.8–636.2), heart failure (OR, 8.2; 95% CI, 1.9–35.2), prior valve replacement (OR, 6.4; 95% CI, 2.4–17.1), and atrial fibrillation (OR, 2.7; CI, 1.5–4.7; P<0.001). Risk factors of traditional atherosclerosis including hyperlipidemia, obesity, tobacco history, substance abuse, and thrombophilia were identified (P<0.001). Gestational hypertensive disorders (eclampsia OR, 6.0; 95% CI, 3.3–10.8; preeclampsia OR, 3.2; 95% CI, 2.5–4.2) were significant risk factors in predicting AMI. Risk factors associated with major adverse cardiovascular and cerebrovascular events included prior percutaneous coronary intervention (OR, 6.6; 95% CI, 1.4–31.2) and pre‐eclampsia (OR, 2.3; 95% CI, 1.3–3.9). Conclusions AMI is associated with modifiable, nonmodifiable, and obstetric risk factors. These risk factors can lead to devastating adverse outcomes and highlight the need for risk factor modification and public health resource initiatives toward the goal of decreasing AMI in the pregnant population.
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Affiliation(s)
- Courtney A. Balgobin
- Division of Cardiovascular MedicineDepartment of MedicineState University of New YorkStony Brook University Medical CenterRenaissance School of MedicineStony BrookNY
| | - Xiaoyue Zhang
- Department of Family, Population and Preventative MedicineStony Brook University Medical CenterStony BrookNY
| | - Fabio V. Lima
- Division of CardiologyWarren Alpert Medical School of Brown University and Lifespan Cardiovascular InstituteProvidenceRI
| | - Cecilia Avila
- Department of Obstetrics, Gynecology and Reproductive MedicineStony Brook University Medical CenterStony BrookNY
| | - Puja B. Parikh
- Division of Cardiovascular MedicineDepartment of MedicineState University of New YorkStony Brook University Medical CenterRenaissance School of MedicineStony BrookNY
| | - Jie Yang
- Department of Family, Population and Preventative MedicineStony Brook University Medical CenterStony BrookNY
| | - Kathleen Stergiopoulos
- Division of Cardiovascular MedicineDepartment of MedicineState University of New YorkStony Brook University Medical CenterRenaissance School of MedicineStony BrookNY
- St. Francis Hospital – The Heart CenterRoslynNY
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Yuliyanti S, Utarini A, Trisnantoro L. A protocol study of participatory action research: integrated care pathway for pregnant women with heart disease in Indonesia. BMC Health Serv Res 2020; 20:932. [PMID: 33036607 PMCID: PMC7547524 DOI: 10.1186/s12913-020-05769-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/28/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Heart diseases are increasingly identified as an important indirect cause of maternal mortality in several cities in Indonesia. The management of pregnancy with heart diseases requires a multidisciplinary approach, and interprofessional collaboration practice (IPCP) is critical to improving the quality of patient care. To enable the effective implementation of IPCP, integrated care pathways (ICPs) are needed to define the roles and responsibilities of the health professionals involved. This study aims to examine the obstacles and enabling factors of IPCP, to develop and use ICPs in the implementation of IPCP in health care services for pregnant women with heart diseases. METHODS A participatory action study consisting of four stages (diagnostic, planning, implementation, and evaluation) will take approximately 2 years after consensus of ICPs are made. The primary data collection process will employ consensus, observations, focus group discussions, and in-depth interviews throughout the four stages, while secondary data from referral documents and medical records will be collected mainly during the diagnostic and evaluation stages. The findings are being analysed and will then be used to develop an ICPs through consensus building at the planning stage to be applied in the implementation stage. Finally, the implementation outcome, including acceptability, adoption, appropriateness, and feasibility of IPCP, will be assessed in the evaluation stage. All qualitative data will be analysed thematically by two coders using NVIVO 12 software. DISCUSSION This research aims to assess the needs of IPCP, develop and use the ICPs in the implementation of IPCP in health care services for pregnant women with heart diseases. Findings from this study will be used for health service planning and policy making to strengthen practice of IPCP during the referral process. As a result, pregnant women with heart disease will have better access to high-quality services at every health care facility to reduce maternal mortality. TRIAL REGISTRATION Retrospectively registered in the ISRCTN registry with study ID ISRCTN82300061 on Feb 6, 2019.
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Affiliation(s)
- Suryani Yuliyanti
- Public Health Department, Faculty of Medicine, Universitas Islam Sultan Agung, Jl. Kaligawe Raya km 4, Semarang, 50122 Indonesia
- Doctoral Study Programme, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, Sinduadi, Mlati, Special Region of Yogyakarta 55281 Indonesia
| | - Adi Utarini
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, Sinduadi, Mlati, Special Region of Yogyakarta 55281 Indonesia
| | - Laksono Trisnantoro
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, Sinduadi, Mlati, Special Region of Yogyakarta 55281 Indonesia
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50
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Sisakian HS, Shahnazaryan S, Pepoyan S. Severe peripartum cardiomyopathy: A case report of successful recovery with personalized treatment approach. Hellenic J Cardiol 2020; 62:394-395. [PMID: 32992007 DOI: 10.1016/j.hjc.2020.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/10/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hamayak S Sisakian
- Clinic of General and Invasive Cardiology, University Hospital #1, Yerevan State Medical University, Armenia.
| | - Syuzanna Shahnazaryan
- Clinic of General and Invasive Cardiology, University Hospital #1, Yerevan State Medical University, Armenia.
| | - Sergey Pepoyan
- Clinic of General and Invasive Cardiology, University Hospital #1, Yerevan State Medical University, Armenia.
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