Adaptation of the maternal heart in pregnancy

Sport and exercise recommendations for pregnant athletes: a systematic scoping review

Objectives

To analyse the available evidence and identify gaps in current knowledge regarding physical activity volume and intensity and their effects on pregnancy outcomes in female athletes.

Design

Scoping review.

Data sources

A structured literature search of three electronic databases (Embase, PubMed and Web of Science) was conducted on 25 February 2022, and a rerun search was conducted on 8 September 2022.

Eligibility criteria

Studies were eligible if they contained information on the relevant population (ie, elite or competitive amateur female athletes), intervention/exposure (ie, minimum of 10 hours of sport per week) and fetal and maternal outcomes. Eligible comparators included female recreational athletes and pregnant non-exercisers.

Risk of bias

The risk of bias was evaluated with the National Institutes of Health (National Heart, Lung and Blood Institute) quality assessment tool.

Results

The results revealed a discrepancy between the number of original research papers and the number of reviews and recommendations derived from them. The identified studies focused primarily on pregnant recreational athletes. Sixteen clinical studies met the inclusion criteria. No adverse effects on maternal or fetal outcomes were reported. Only during performance tests involving acute intensive exercise with the mother exercising at more than 90% of her maximal heart rate did some fetuses experience decelerations in heart rate.

Summary/conclusion

A lack of high-quality studies and direct evidence on pregnant elite and competitive amateur female athletes is evident. Further prospective observational cohort studies are needed using new monitoring methods (eg, non-invasive, wireless monitoring systems) aiming to gain a broader understanding of the stress tolerance of pregnant athletes and fetuses during exercise. Following that, interventional studies with stress tests in laboratory settings should be conducted. Therefore, technology plays a decisive role in gaining new knowledge and providing evidence-based recommendations on this topic.

PROSPERO registration number

CRD42022309541.

Acute heart failure associated with toxic shock syndrome due to methicillin-susceptible Staphylococcus aureus during the postpartum period: case report and systematic literature review

BACKGROUND

Toxic shock syndrome (TSS) caused by Staphylococcus aureus in the postpartum period is a rare but life-threatening disease. We present a case of acute heart failure as the initial presentation of TSS due to methicillin-susceptible Staphylococcus aureus (MSSA) and describe its clinical characteristics with a systematic literature review.

CASE PRESENTATION

A 34-year-old woman, 8 days after a normal vaginal delivery presented to our hospital with dyspnea and fever. She had jugular venous distension, bilateral leg edema, and erythema. Laboratory examinations revealed elevated NT-pro-BNP level of 3,233 pg/mL. Transthoracic echocardiography showed elevated tricuspid regurgitation peak gradient, with decreased respiratory variability of the inferior vena cava diameter and bilateral pleural effusions. The patient was hospitalized with suspicion of congestive heart failure. MSSA positive for toxic shock syndrome exotoxin-1 was detected in the culture of the perineal incision wound, and we diagnosed TSS caused by MSSA. Intravenous diuretics were administered, along with eventual cefazolin plus clindamycin. After 2 weeks of antimicrobial therapy, the patient showed improvement and was discharged. No recurrence was observed at the 24-month follow-up.

CONCLUSION

This is a rare case report of acute heart failure being the initial manifestation of TSS due to MSSA in the postpartum period. Clinicians should consider TSS as a possibility in postpartum patients with acute heart failure. This systematic review provides insights into its clinical features, treatment regimens, and prognosis of TSS by S. aureus in the postpartum period. TSS requires an appropriate, prompt diagnosis, because delayed treatment can be fatal.

Anatomical Changes of the Vulva Due to Childbirth and Aging

The female reproductive system consists of several structures. These organs are constantly undergoing changes throughout the lifetime of a woman. Most of these occur due to changes in estrogen and progesterone levels at key transitions in life such as puberty, pregnancy, and menopause. Laxity and atrophy occur during pregnancy and menopause, respectively, can cause significant symptomology for women. Although some women do have return to normal anatomy following pregnancy, many do not and develop pelvic organ prolapse that worsens over their lifetime. Symptoms are often underreported, but for those who do have symptoms, surgical intervention may be warranted.

The role of angiotensin II and relaxin in vascular adaptation to pregnancy

In brief

There is a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular function and can be maintained postpartum. This review outlines the cardiovascular changes that occur in a healthy human and rodent pregnancy, as well as different pathways that are activated by angiotensin II and relaxin that result in blood vessel dilation.

Abstract

During pregnancy, systemic and uteroplacental blood flow increase to ensure an adequate blood supply that carries oxygen and nutrients from the mother to the fetus. This results in changes to the function of the maternal cardiovascular system. There is also a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular health/function. Additionally, there is evidence that the effects of maternal vascular vasodilation are maintained post-partum, which may reduce the risk of developing high blood pressure in the next pregnancy and reduce cardiovascular risk later in life. At both non-pregnant and pregnant stages, vascular endothelial cells produce a number of vasodilators and vasoconstrictors, which transduce signals to the contractile vascular smooth muscle cells to control the dilation and constriction of blood vessels. These vascular cells are also targets of other vasoactive factors, including angiotensin II (Ang II) and relaxin. The binding of Ang II to its receptors activates different pathways to regulate the blood vessel vasoconstriction/vasodilation, and relaxin can interact with some of these pathways to induce vasodilation. Based on the available literature, this review outlines the cardiovascular changes that occur in a healthy human pregnancy, supplemented by studies in rodents. A specific focus is placed on vasodilation of blood vessels during pregnancy; the role of endothelial cells and endothelium-derived vasodilators will also be discussed. Additionally, different pathways that are activated by Ang II and relaxin that result in blood vessel dilation will also be reviewed.

Maternal Right Ventricular and Left Atrial Function in Uncomplicated Twin Pregnancies: A Longitudinal Study

Objective: The knowledge regarding maternal cardiovascular hemodynamic adaptation in twin pregnancies is incomplete. We performed a longitudinal investigation of maternal right ventricular (RV) and left atrial (LA) function in a cohort of uncomplicated twin pregnancies compared to singleton pregnancies. Study design: Healthy women with uncomplicated twin pregnancies were prospectively enrolled and assessed by transthoracic echocardiography at 10−15 weeks’ (w) gestation (T1), 19-26 w gestation (T2), and 30−38 w gestation (T3). Subjects with uneventful singleton pregnancies were selected as controls at the same gestational ages. Cardiac findings were compared to those of women with uneventful singleton gestations. RV systolic and diastolic functions were assessed by conventional echocardiography (FAC, TAPSE, sPAP, E, A, DT) and tissue Doppler imaging (TDI) (E’, A’, S’, IVA, IVCT, IVRT, ET, MPI), and LA dimensions were calculated. Speckle-tracking imaging was also applied to evaluate RV global longitudinal strain and LA 2D strains (at LV end-systole (LAS) and at atrial contraction (LAA)). Results: Overall, 30 uncomplicated twin and 30 uncomplicated singleton pregnancies were included. Regarding maternal RV function in twins, all the parameters (FAC, TAPSE, sPAP, E, A, E/A, DT, E/E’, IVA, IVCT, MPI and 2D longitudinal strain) were almost stable throughout gestation, with the exception of the TDI findings (E’ decreased from T1 to T3 (p = 0.03), while E’/A’ increased from T1 to T2 and then decreased (p = 0.01); A’ and basal S’ increased (p = 0.04 and p = 0.03, respectively), while IVRT and ET significantly decreased (p = 0.009 and p = 0.007, respectively)). These findings were similar to those found for singleton pregnancies. LA dimensions significantly increased throughout gestation in both twins and singletons (p < 0.001), without intergroup difference. LA strains did not vary during either twin or singleton pregnancies, except for LAA in T1, which was higher among twins than among singletons. Conclusion: Maternal RV and LA function in uncomplicated twin pregnancies does not seem to undergo more significant changes than in singletons, being characterized by similar findings in RV systolic and diastolic functions, as well as LA dimensions and strains.

Multiscale model of heart growth during pregnancy: integrating mechanical and hormonal signaling

Pregnancy stands at the interface of mechanics and biology. The growing fetus continuously loads the maternal organs as circulating hormone levels surge, leading to significant changes in mechanical and hormonal cues during pregnancy. In response, maternal soft tissues undergo remarkable growth and remodeling to support the mother and baby for a healthy pregnancy. We focus on the maternal left ventricle, which increases its cardiac output and mass during pregnancy. This study develops a multiscale cardiac growth model for pregnancy to understand how mechanical and hormonal cues interact to drive this growth process. We coupled a cell signaling network model that predicts cell-level hypertrophy in response to hormones and stretch to a compartmental model of the rat heart and circulation that predicts organ-level growth in response to hemodynamic changes. We calibrated this multiscale model to data from experimental volume overload and hormonal infusions of angiotensin 2 (AngII), estrogen (E2), and progesterone (P4). We then validated the model's ability to capture interactions between inputs by comparing model predictions against published observations for the combinations of VO + E2 and AngII + E2. Finally, we simulated pregnancy-induced changes in hormones and hemodynamics to predict heart growth during pregnancy. Our model produced growth consistent with experimental data. Overall, our analysis suggests that the rise in P4 during the first half of gestation is an important contributor to heart growth during pregnancy. We conclude with suggestions for future experimental studies that will provide a better understanding of how hormonal and mechanical cues interact to drive pregnancy-induced heart growth.

Electrocardiographic findings in pregnant women in Angola

BACKGROUND

Studies on the electrocardiogram findings in African pregnant women are limited. There is no information available in the literature on the electrocardiographic parameters of pregnant Angolan women.

OBJECTIVES

The aim of this study was to describe electrocardiographic findings in women with normal pregnancies in Bengo Province, Angola.

METHODS

This is a community-based study with a cross-sectional design conducted between September 2013 and March 2014 in Bengo. The study involved 114 black pregnant women, compared with a paired control group comprising of 120 black non-pregnant women, aged 15 to 42 years. A 12-lead electrocardiogram and a rhythm strip were recorded for all participants.

RESULTS

In this study, the mean age was 26.2 ± 7.3 years. Comparing pregnant women vs. non-pregnant, we found the following mean values: Heart rate (83 bpm vs. 74 bpm, p < .001), PR interval (146 ms vs. 151 ms, p = .034), QT interval (360 ms vs. 378 ms, p < .001), QTIc Fridericia (398 ms vs. 403, p = .017), QTIc Framingham (399 ms vs. 404 ms, p = .013) and T-wave axis (34⁰ vs. 41⁰ , p = .001).The main electrocardiographic changes found were: Sinus tachycardia (4.4% vs. 2.5%), T-wave inversion (14.9% vs. 1.7%), Minor ST segment depression (4.5% vs. 0%) and left ventricular hypertrophy (11.4% vs. 11.7%, p = .726).

CONCLUSIONS

Pregnant Angolan women compared with controls, had several significantly higher values for heart rate, and significantly lower values of systolic blood pressure and diastolic blood pressure, PR interval, QT interval, QTc interval by Fridericia and Framingham and T-wave axis. Sinus tachycardia, T-wave inversion, and left ventricular hypertrophy, were the main electrocardiographic changes found.

Maternal hemodynamics and computerized cardiotocography during labor with epidural analgesia

PURPOSE

To analyze the mechanisms involved in the fetal heart rate (FHR) abnormalities after the epidural analgesia in labor.

METHODS

A prospective unblinded single-center observational study on 55 term singleton pregnant women with spontaneous labor. All women recruited underwent serial bedside measurements of the main hemodynamic parameters using a non-invasive ultrasound system (USCOM-1A). Total vascular resistances (TVR), heart rate (HR), stroke volume (SV), cardiac output (CO) and arterial blood pressure were measured before epidural administration (T0), after 5 min 5 (T1) from epidural bolus and at the end of the first stage of labor (T2). FHR was continuously recorded through computerized cardiotocography before and after the procedure.

RESULTS

The starting CO was significantly higher in a subgroup of women with low TVR than in women with high-TVR group. After the bolus of epidural analgesia in the low-TVR group there was a significant reduction in CO and then increased again at the end of the first stage, in the high-TVR group the CO increased insignificantly after the anesthesia bolus, while it increased significantly in the remaining part of the first stage of labor. On the other hand, CO was inversely correlated with the number of decelerations detected on cCTG in the 1 hour after the epidural bolus while the short-term variation was significantly lower in the group with high-TVR.

CONCLUSION

Maternal hemodynamic status at the onset of labor can make a difference in fetal response to the administration of epidural analgesia.

Metabolic Signatures of Pregnancy-Induced Cardiac Growth

The goal of this study was to develop an atlas of the metabolic, transcriptional, and proteomic changes that occur with pregnancy in the maternal heart. Timed pregnancy studies in FVB/NJ mice revealed significant increases in heart size by day 8 of pregnancy (mid-pregnancy; MP), which was sustained throughout the rest of the term compared with non-pregnant controls. Cardiac hypertrophy and myocyte cross-sectional area were highest 7 d after birth (post-birth; PB) and were associated with significant increases in end-diastolic and end-systolic left ventricular volumes and cardiac output. Metabolomics analyses revealed that, by day 16 of pregnancy (late pregnancy; LP), metabolites associated with nitric oxide production as well as acylcholines, sphingomyelins, and fatty acid species were elevated, which coincided with a lower activation state of phosphofructokinase and higher levels of pyruvate dehydrogenase kinase 4 (Pdk4). In the postpartum period, urea cycle metabolites, polyamines, and phospholipid levels were markedly elevated in the maternal heart. Cardiac transcriptomics in LP revealed significant increases in not only Pdk4, but also genes that regulate glutamate and ketone body oxidation, which were preceded in MP by higher expression of transcripts controlling cell proliferation and angiogenesis. Proteomics analysis of the maternal heart in LP and PB revealed significant reductions in several contractile filaments and mitochondrial complex subunits. Collectively, these findings describe the coordinated molecular changes that occur in the maternal heart during and after pregnancy.

Pregnancy in women with dilated cardiomyopathy

Only a few studies describe the pathophysiology and outcomes of dilated cardiomyopathy (DCM) in pregnancy, which the authors aim to review here. DCM causes enlargement of the ventricles and reduced systolic function. Fluid overload and raised cardiac output in pregnancy may contribute to cardiac complications that lead to cardiac remodeling and heart failure, a common cause of maternal mortality. The risk of cardiac complications is higher in women with New York Heart Association class III and IV. Fetal and neonatal complications are common with coexisting obstetric risk factors. Hence, prepregnancy counseling and a multi-disciplinary approach are essential. Renin-angiotensin-aldosterone system blockers prevent cardiac remodeling but are teratogenic. Drugs, such as β-blockers to control cardiac remodeling, thiazide diuretics to reduce preload, hydralazine and nitrates to reduce afterload and digoxin to increase inotropy, are safe and should be used to manage DCM in pregnancy.

Recurrent births (multiparity) lead to permanent changes in cardiac structure

AIM

Although the effects of pregnancy on the cardiovascular system have been covered by many studies, permanent changes in the hearts of multiparous women have not been investigated. This study therefore aimed to examine the permanent structural changes in the cardiac structure of multiparous women via transthoracic echocardiography (TTE).

METHOD

This case-control study included 366 females who had given birth to 1-21 children, and 218 females with no previous deliveries. Anamnesis, physical examination, electrocardiography (ECG), TTE, and exercise stress tests were used to determine whether the cases had additional systemic pathologies. The structural cardiac parameters of all cases were recorded with TTE.

RESULTS

The study revealed that LV mass, LV mass index, left ventricular end diastolic volume (LVEDV), left ventricular end diastolic volume index (LVEDVI) were observed higher in women with five or more deliveries when compared to nulliparous women. On the other hand, ejection fraction (EF) was significantly lower in the same group. Receiver operating curve (ROC) analysis demonstrated that the prediction sensitivity for the presence of eccentric hypertrophy was 74% among women who had given >10.5 births, and its specificity was 97.8% (AUC: 0.949, 95% CI 0.905-0.993; p < 0.0001).

CONCLUSION

The results showed that women with recurrent births had increased left ventricular end diastolic volume, left ventricular total mass in myocardium and decreased EF due to increased end diastolic volume. The results also showed delivering at frequent intervals (especially the birth of 11 or more) may be one of the causes of eccentric hypertrophy, in women of the low-to-middle income countries.

Peripartum echocardiographic changes in women with hypertensive disorders of pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) are associated with significant myocardial dysfunction on echocardiography. The impact of hemodynamic changes related to volume redistribution following delivery on myocardial function in women with HDP has not been evaluated systematically. The aim of this study was to compare echocardiographic findings immediately before and after delivery in women with HDP.

METHODS

This was a prospective longitudinal study including 30 women with a diagnosis of HDP who underwent two consecutive transthoracic echocardiographic (TTE) examinations, before delivery and in the early postpartum period. Paired comparisons of the findings from the two assessments were performed.

RESULTS

Left-ventricular (LV) concentric remodeling or hypertrophy was detected in 21 (70%) patients. There was no significant difference in cardiac morphology indices such as LV mass index (78.9 ± 16.3 g/m² vs 77.9 ± 15.4 g/m² ; P = 0.611) or relative wall thickness (0.45 ± 0.1 vs 0.44 ± 0.1; P = 0.453) before vs after delivery. LV diastolic function did not demonstrate any peripartum variation, with similar left-atrial volume (52.4 ± 15.3 mL vs 51.0 ± 15.6 mL; P = 0.433), lateral E' (0.12 ± 0.03 m/s vs 0.12 ± 0.03 m/s; P = 0.307) and E/E' ratio (7.9 ± 2.2 vs 7.9 ± 1.7; P = 0.934) before vs after delivery. Systolic function indices, such as LV ejection fraction (57.5 ± 3.4% vs 56.4 ± 2.1%; P = 0.295) and global longitudinal strain (-15.3 ± 2.6% vs -15.1 ± 3.1%; P = 0.582), also remained unchanged between before vs after delivery.

CONCLUSIONS

Maternal hemodynamic changes associated with delivery did not influence significantly peripartum TTE indices in women with HDP. Suboptimal maternal echocardiographic findings in HDP are likely to be the consequence of chronic pregnancy cardiovascular load changes or pre-existing maternal cardiovascular impairment. Severity and persistence of myocardial dysfunction in the postpartum period may be related to the long-term maternal cardiovascular disease legacy of HDP. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic de l’embolie pulmonaire dans le contexte de la grossesse

Les problématiques posées par la prise en charge de la femme enceinte suspecte d’embolie pulmonaire (EP) aux urgences sont multiples. Les modifications physiologiques au cours de la grossesse majorent les sollicitations médicales pour des tableaux de douleur thoracique, de dyspnée, de malaise… En parallèle, ces manifestations aux cours de la grossesse peuvent se confondre avec les éléments évocateurs d’une EP et interférer sur nos capacités d’appréciation de sa probabilité. Enfin, l’élévation physiologique des D-dimères et le taux d’imageries thoraciques non conclusives complexifient la démarche diagnostique. C’est pourtant dans le contexte de la grossesse qu’il est particulièrement souhaitable de ne pas manquer un diagnostic d’EP, tout en évitant d’exposer inutilement la patiente et son foetus à l’imagerie thoracique. Pour aider dans les prises de décision, deux stratégies ont été validées dans le contexte de la grossesse. La première repose sur le score de Genève, incluant la réalisation d’une échographie de compression proximale chez les patientes à probabilité forte ou ayant un D-dimère supérieur à 500 μg/L. La seconde repose sur l’algorithme YEARS, avec réalisation d’une échographie uniquement chez les patientes ayant des symptômes évocateurs d’une thrombose veineuse des membres inférieurs associée, puis un dosage des D-dimères avec un seuil à 500 ou 1 000 μg/L en fonction de la probabilité clinique. La fiabilité de ces deux stratégies a été démontrée. La première stratégie présente l’avantage de ne reposer que sur des données objectives, et la deuxième de reposer le seuil décisionnel à 1 000 μg/L chez les patientes n’ayant aucun des critères YEARS.

Successful management of a pregnant woman of lower-limb arteriovenous malformation with chronic cardiac failure

The clinical features of extracranial arteriovenous malformations (AVM) vary from stages I (quiescence) with few symptoms to IV (decompensation) with overt symptoms of cardiac failure. Although the maternal outcomes of pregnant women with extracranial AVM is understudied due to its rarity, previous studies suggested the difficulty in the management of recurrent hemorrhage due to AVM progression during perinatal period; thus, pregnant case of extracranial AVM complicated with cardiac failure were considered challenging. We have reported a woman of stage IV extracranial AVM in the right lower limb with a history of below-the-knee amputation, in which two pregnancies and vaginal deliveries under epidural anesthesia were managed successfully. Cardiac failure did not exacerbate throughout the gestational or postpartum periods. Ulceration gradually worsened, with no massive hemorrhage. It is ideal to assess abnormal vascularity, especially in the lower abdomen, vagina, and epidural and subdural spaces, through magnetic resonance imaging to ensure safe delivery.

An integrated model of preeclampsia: a multifaceted syndrome of the maternal cardiovascular-placental-fetal array

Maternal tolerance of the semiallogenic fetus necessitates conciliation of competing interests. Viviparity evolved with a placenta to mediate the needs of the fetus and maternal adaptation to the demands of pregnancy and to ensure optimal survival for both entities. The maternal-fetal interface is imagined as a 2-dimensional porous barrier between the mother and fetus, when in fact it is an intricate multidimensional array of tissues and resident and circulating factors at play, encompassing the developing fetus, the growing placenta, the changing decidua, and the dynamic maternal cardiovascular system. Pregnancy triggers dramatic changes to maternal hemodynamics to meet the growing demands of the developing fetus. Nearly a century of extensive research into the development and function of the placenta has revealed the role of placental dysfunction in the great obstetrical syndromes, among them preeclampsia. Recently, a debate has arisen questioning the primacy of the placenta in the etiology of preeclampsia, asserting that the maternal cardiovascular system is the instigator of the disorder. It was the clinical observation of the high rate of preeclampsia in hydatidiform mole that initiated the focus on the placenta in the etiology of the disease. Over many years of research, shallow trophoblast invasion with deficient remodeling of the maternal spiral arteries into vessels of higher capacitance and lower resistance has been recognized as hallmarks of the preeclamptic milieu. The lack of the normal decrease in uterine artery resistance is likewise predictive of preeclampsia. In abdominal pregnancies, however, an extrauterine pregnancy develops without remodeling of the spiral arteries, yet there is reduced resistance in the uterine arteries and distant vessels, such as the maternal ophthalmic arteries. Proponents of the maternal cardiovascular model of preeclampsia point to the observed maternal hemodynamic adaptations to pregnancy and maladaptation in gestational hypertension and preeclampsia and how the latter resembles the changes associated with cardiac disease states. Recognition of the importance of the angiogenic-antiangiogenic balance between placental-derived growth factor and its receptor soluble fms-like tyrosine kinase-1 and disturbance in this balance by an excess of a circulating isoform, soluble fms-like tyrosine kinase-1, which competes for and disrupts the proangiogenic receptor binding of the vascular endothelial growth factor and placental-derived growth factor, opened new avenues of research into the pathways to normal adaptation of the maternal cardiovascular and other systems to pregnancy and maladaptation in preeclampsia. The significance of the "placenta vs heart" debate goes beyond the academic: understanding the mutuality of placental and maternal cardiac etiologies of preeclampsia has far-reaching clinical implications for designing prevention strategies, such as aspirin therapy, prediction and surveillance through maternal hemodynamic studies or serum placental-derived growth factor and soluble fms-like tyrosine kinase-1 testing, and possible treatments to attenuate the effects of insipient preeclampsia on women and their fetuses, such as RNAi therapy to counteract excess soluble fms-like tyrosine kinase-1 produced by the placenta. In this review, we will present an integrated model of the maternal-placental-fetal array that delineates the commensality among the constituent parts, showing how a disruption in any component or nexus may lead to the multifaceted syndrome of preeclampsia.

[Percutaneous dilation of mitral stenosis in patients with severe pulmonary hypertension during pregnancy]

Rheumatic mitral stenosis is the most common organic valvular heart disease in developing countries. These patients are at risk of decompensation during pregnancy. We here describe our experience with percutaneous dilation of mitral stenosis in patients with severe pulmonary hypertension during pregnancy. Percutaneous balloon mitral valve commissurotomy was performed in two hundred and twenty-three pregnant women between January 2009 and December 2015. Forty-three (19%) of these patients had severe pulmonary hypertension (SPAP > 70 mmHg). All pregnant women in our study had very severe symptomatic rheumatic mitral stenosis despite well-performed medical treatment. All patients had clinical improvement after percutaneous balloon mitral valve commissurotomy. The severity of mitral insufficiency progressed by one grade in two patients. One patient had tamponade with favorable outcome after a pericardial puncture. No abortion occurred after the procedure and two preterm deliveries were reported. Patients with severe rheumatic mitral stenosis during pregnancy should receive multidisciplinary care involving an obstetrician, anesthetist and cardiologist. Percutaneous balloon mitral valve commissurotomy is currently the standard treatment for rheumatic mitral stenosis during pregnancy.

Diagnosis and management of arrhythmias in pregnancy

Arrhythmias are the most common cardiac complications occurring in pregnancy. Although the majority of palpitations in pregnancy may be explained by atrial or ventricular premature complexes, the full spectrum of arrhythmias can occur. In this article, we establish a systematic approach to the evaluation and management of arrhythmias in pregnancy. Haemodynamically unstable arrhythmias warrant urgent cardioversion. For mild cases of benign arrhythmia, treatment is usually not needed. Symptomatic but haemodynamically stable arrhythmic patients should first undergo a thorough evaluation to establish the type of arrhythmia and the presence or absence of structural heart disease. This will ultimately determine the necessity for treatment given the potential risks of anti-arrhythmic pharmacotherapy in pregnancy. We will discuss the main catalogue of anti-arrhythmic medications, which have some established evidence of safety in pregnancy. Based on our appraisal, we provide a treatment algorithm for the tachyarrhythmic pregnant patient.

Continuous transthoracic echocardiographic monitoring for changes in maternal cardiac hemodynamics during cesarean section under combined epidural-spinal anesthesia: a prospective, observational study

The change in maternal hemodynamics during cesarean section has not been well studied. Continuous transthoracic echocardiography can monitor cardiac function continuously. This study aimed to evaluate the effectiveness of maternal hemodynamic parameters monitoring during cesarean section using continuous transthoracic echocardiography. In this prospective, observational study, women with an uncomplicated singleton pregnancy scheduled for elective cesarean section at term under combined spinal-epidural anesthesia were enrolled. Maternal hemodynamic parameters were assessed by continuous transthoracic echocardiography at 11 pre-set time points. The image quality of continuous transthoracic echocardiography was evaluated before measurement was performed. Totally, one hundred parturients were recruited, and transthoracic echocardiography images with sufficient quality for further analysis were obtained in 72 women. Following anesthesia, maternal heart rate decreased by 11.18% and cardiac output decreased by 7.82%, but stroke volume remained stable. After delivery of the neonate and placenta, stroke volume and cardiac output increased by 21.09% and 22.33%, respectively. End-diastolic volume also increased significantly after delivery of the neonate, but end-systolic volume was unchanged. Following delivery of the neonate, fractional shortening increased till the end of the cesarean section while total peripheral resistance decreased significantly. In conclusion, continuous transthoracic echocardiographic monitoring revealed that there were significant changes in hemodynamic parameters during cesarean section after delivery of the newborn and placenta, which warranted further investigation.

Echocardiographic Assessments for Peripartum Cardiac Events in Pregnant Women with Low-Risk Congenital Heart Disease

This retrospective cohort study aimed to explore the relationship between temporal changes in the cardiac function and peripartum cardiac events in pregnant women with low-risk congenital heart disease.We performed echocardiography at early and late pregnancy and postpartum in 76 pregnant women with low-risk congenital heart disease, and compared echocardiographic parameters between subjects with and without peripartum cardiac events. Median age at delivery was 27 (range, 24-31) years. The ZAHARA and CARPREG II scores suggested that most women were found to be at low-risk for pregnancy. Fifteen subjects had cardiac events that included heart failure in 10, arrhythmia in 4, and pulmonary hypertension in one subject. The left ventricular and atrial volumes significantly increased from early pregnancy toward late pregnancy, and the E/A ratio and global longitudinal strain significantly decreased from early pregnancy toward late pregnancy. The left atrial volume (67 [53-79] versus 45 [35-55] mL, P = 0.002) and plasma brain natriuretic peptide level (58 [36-123] versus 34 [18-48] pg/mL, P = 0.026) at late pregnancy were significantly higher in subjects with cardiac events than in those without cardiac events.An increase in the left atrial volume followed by mild left ventricular diastolic dysfunction is related to peripartum cardiac events in women with congenital heart disease who are at low risk for cardiac events during pregnancy.

Links Between Maternal Cardiovascular Disease and the Health of Offspring

Maternal cardiovascular disease (CVD) during pregnancy is on the rise worldwide, as both more women with congenital heart disease are reaching childbearing age, and conditions such as diabetes, hypertension, and obesity are becoming more prevalent. However, the extent to which maternal CVD influences offspring health, as a neonate and later in childhood and adolescence, remains to be fully understood. The thrifty phenotype hypothesis, by which a fetus adapts to maternal and placental changes to survive a nutrient-starved environment, may provide an answer to the mechanism of maternal CVD and its impact on the offspring. In this narrative review, we aim to provide a review of the literature pertaining to the impact of maternal cardiovascular and hypertensive disease on the health of neonates, children, and adolescents. This review demonstrates that maternal CVD leads to higher rates of complications among neonates. Ultimately, our review supports the hypothesis that maternal CVD leads to intrauterine growth restriction (IUGR), which, through the thrifty phenotype hypothesis and vascular remodelling, can have health repercussions, including an impact on CVD risk, both in the immediate newborn period as well as later throughout the life of the offspring. Further research remains crucial in elucidating the mechanism of maternal CVD long-term effects on offspring, as further understanding could lead to preventive measures to optimise offspring health, including modifiable lifestyle changes. Potential treatments for this at-risk offspring group could mitigate risk, but further studies to provide evidence are needed.

The Canadian Women’s Heart Health Alliance Atlas on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women — Chapter 4: Sex- and Gender-Unique Disparities: CVD Across the Lifespan of a Woman

Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman’s risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman’s lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment.

Pregnancy-Associated Myocardial Infarction: A Review of Current Practices and Guidelines

PURPOSE OF REVIEW

Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy.

RECENT FINDINGS

Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.

Uteroplacental Circulation in Normal Pregnancy and Preeclampsia: Functional Adaptation and Maladaptation

Uteroplacental blood flow increases as pregnancy advances. Adequate supply of nutrients and oxygen carried by uteroplacental blood flow is essential for the well-being of the mother and growth/development of the fetus. The uteroplacental hemodynamic change is accomplished primarily through uterine vascular adaptation, involving hormonal regulation of myogenic tone, vasoreactivity, release of vasoactive factors and others, in addition to the remodeling of spiral arteries. In preeclampsia, hormonal and angiogenic imbalance, proinflammatory cytokines and autoantibodies cause dysfunction of both endothelium and vascular smooth muscle cells of the uteroplacental vasculature. Consequently, the vascular dysfunction leads to increased vascular resistance and reduced blood flow in the uteroplacental circulation. In this article, the (mal)adaptation of uteroplacental vascular function in normal pregnancy and preeclampsia and underlying mechanisms are reviewed.

Maternal Heart Failure

Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.

Comparison of maternal third trimester hemodynamics between singleton pregnancy and twin pregnancy

OBJECTIVES

The impedance cardiography (ICG) technique measures the variation of impedance in the thorax due to the physical contractile activity of the heart. Twin pregnancy is characterized by greater maternal hemodynamic changes than a singleton pregnancy.

METHODS

In a study on 121 pregnant women in the last trimester we performed ICG, evaluating the following hemodynamic parameters: stroke volume, heart rate, cardiac output, ventricular ejection time, left ventricular ejection time, thoracic impedance, and systemic vascular resistance.

RESULTS

The study included singleton and twin pregnancies. Heart rate values in women with single fetus was lower than in those carrying twins (85 vs. 100 beats/min, p=0.021) as were the stroke volume values (64 vs. 83 mL, p=0.010) and the cardiac output (p<0.0001). Systemic vascular resistance decreased in twin pregnancies compared to singleton pregnancy (p=0.023).

CONCLUSIONS

ICG studies are rare, and the validation of their results is an ongoing process. However, the ICG technique is applicable in the third trimester of pregnancy and can yield important information regarding the hemodynamic profile of singleton and twin pregnancies, revealing maternal heart changes specific to twin pregnancies.

Walking Cadence during Moderate-Intensity Physical Activity in Pregnant Women

Evidence has established that a cadence of 100 steps/min is indicative of the moderate intensity threshold of 3 metabolic equivalents (METs), but this has only been described in non-pregnant individuals. As metabolic alterations are well established during pregnancy, the purpose of this study was to determine if the walking cadence equivalent to 3 METs in pregnant women is similar to non-pregnant populations. Pregnant females (n = 29; age = 30.3 ± 3.2 years, gestational age = 23.9 ± 6.6 weeks) in their second or third trimester (>12 weeks gestation) completed three stages of treadmill walking for 5 min at different standardized walking speeds: 2.5, 3.0, and 3.5 miles per hour (mph). Oxygen consumption (VO2) and heart rate (HR) were measured each minute and METs were calculated for each stage. Real-time continuous monitoring of walking cadence was evaluated by an OptoGait gait analysis system. Following the three standardized speed stages, participants completed an additional stage walking at a speed that elicited 100 steps/min; VO2 and HR were also collected. A one-sample t-test was used to compare MET values at each stage to the heuristic 3 MET cutoff, and Pearson correlation coefficient was calculated to evaluate the relationship between cadence and METs. Mean cadence increased linearly across the three stages (2.5 mph = 103.7 ± 4.5, 3.0 mph = 112.5 ± 5.3, and 3.5 mph = 120.4 ± 6.2 steps/min), as did METs (2.5 mph = 2.7 ± 1.7, 3.0 mph = 3.2 ± 0.8, and 3.5 mph = 4.3 ± 1.8 METs) regardless of trimester. The average treadmill speed at which women walked at 100 steps/min was 2.4 ± 0.4 mph which elicited an oxygen consumption of 9.5 mL•kg⁻¹•min⁻¹, or 2.7 ± 0.7 METs. There was no significant difference between METs at 3.0 mph and the conventional 3 MET cut point for moderate-intensity PA (p < 0.05). There was a moderate and significant relationship between METs and cadence (2nd trimester: r = 0.51; 3rd trimester: r = 0.42). Current data indicate for the first time that the traditionally used 3 MET cutoff for moderate-intensity activity is appropriate for pregnant women despite metabolic alterations associated with pregnancy. This may have important implications for exercise prescription in pregnant populations.

Pregnancy in the FONTAN palliation: physiology, management and new insights from bioengineering

Fontan palliation for the single ventricle results in a challenging and delicate physiological state. At rest, the body adapts to a low cardiac output and high systemic venous pressure. However, when physiological demands increase, such as in the case of exercise or pregnancy, this delicate physiology struggles to adapt due to the inability of the heart to pump blood into the lungs and the consequent lack of augmentation of the cardiac output.

Due to the advances in paediatric cardiology, surgery and intensive care, today most patients born with congenital heart disease reach adulthood. Consequently, many women with a Fontan circulation are becoming pregnant and so far data suggest that, although maternal risk is not high, the outcomes are poor for the foetus. Little is known about the reasons for this disparity and how the Fontan circulation adapts to the physiological demands of pregnancy.

Here we review current knowledge about pregnancy in Fontan patients and explore the potential role of computational modelling as a means of better understanding this complex physiology in order to potentially improve outcomes, particularly for the foetus.

A case report of pregnancy in untreated alkaptonuria - Focus on urinary tissue remodelling markers

A 34-year old woman with alkaptonuria had an elective pregnancy, during which she collected urine samples over the duration of her pregnancy until parturition. She had been attending the National Alkaptonuria Centre from the age of 31 years and continued to attend after delivery for a further three annual visits. Data from her NAC visits as well as urine samples collected during pregnancy were analysed. Urine CTX-1/urine creatinine, urine αCTX-I/ urine creatinine, urine CTX-II/ urine creatinine, and urine C3M/urine creatinine all showed a rapid increase early in pregnancy, returning to baseline before increasing in late pregnancy, indicating significant remodelling of bone, subchondral bone, cartilage and other organs and connective tissue rich in collagens I, II and III. The pattern of tissue remodelling in AKU pregnancy has been described for the very first time. Further research is needed to understand pregnancy in AKU.

Pulmonary Hypertension Complicating Pregnancy

Purpose of review

This study aims to describe the pathophysiology of pregnancy in pulmonary hypertension (PH) and review recent literature on maternal and fetal outcomes.

Recent findings

There is an increasing number of pregnant women with PH. Maternal mortality in pulmonary arterial hypertension (PAH) ranges from 9 to 25%, most commonly from heart failure and arrythmias. The highest risk of death is peri-partum and post-partum. Fetal/neonatal morbidity and mortality are also substantial. There are high rates of prematurity, intrauterine growth retardation, and preeclampsia. Women should be referred to expert centers for management. Combination PAH therapy with parenteral prostacyclin and a phosphodiesterase type V inhibitor is recommended. Induced vaginal delivery is preferred, except in cases of severe heart failure or obstetric indications for cesarean section.

Summary

Despite advances in management, pregnancy in PAH remains a high-risk condition and should be prevented.

Use of Ballistocardiography to Monitor Cardiovascular Hemodynamics in Preeclampsia

Objective: Pregnancy requires a complex physiological adaptation of the maternal cardiovascular system, which is disrupted in women with pregnancies complicated by preeclampsia, putting them at higher risk of future cardiovascular events. The measurement of body movements in response to cardiac ejection via ballistocardiogram (BCG) can be used to assess cardiovascular hemodynamics noninvasively in women with preeclampsia.

Methods: Using a previously validated, modified weighing scale for assessment of cardiovascular hemodynamics through measurement of BCG and electrocardiogram (ECG) signals, we collected serial measurements throughout pregnancy and postpartum and analyzed data in 30 women with preeclampsia and 23 normotensive controls. Using BCG and ECG signals, we extracted measures of cardiac output, J-wave amplitude × heart rate (J-amp × HR). Mixed-effect models with repeated measures were used to compare J-amp × HRs between groups at different time points in pregnancy and postpartum.

Results: In normotensive controls, the J-amp × HR was significantly lower early postpartum (E-PP) compared with the second trimester (T2; p = 0.016) and third trimester (T3; p = 0.001). Women with preeclampsia had a significantly lower J-amp × HR compared with normotensive controls during the first trimester (T1; p = 0.026). In the preeclampsia group, there was a trend toward an increase in J-amp × HR from T1 to T2 and then a drop in J-amp × HR at T3 and further drop at E-PP.

Conclusions: We observe cardiac hemodynamic changes consistent with those reported using well-validated tools. In pregnancies complicated by preeclampsia, the maximal force of contraction is lower, suggesting lower cardiac output and a trend in hemodynamics consistent with the hyperdynamic disease model of preeclampsia.

Atrial fibrillation during pregnancy: a 9-month period with limited options

Pregnancy is a physiological condition with reversible hemodynamic, neurohormonal and coagulation changes to the maternal body during this 9‑month period. The occurrence of atrial fibrillation (AF) is altogether rare among pregnant women, but necessitates immediate treatment und further work-up. Despite numerous pharmacological and invasive therapeutic modalities for AF in non-pregnant patients, very few options are considered safe enough for the fetus and the mother during pregnancy. Commonly used medications such as beta blockers, calcium channel antagonists, antiarrhythmic drugs and anticoagulation therapy must be carefully individualized according to the week of gestation and possible underlying comorbidities of the mother, thus highlighting the importance of an interdisciplinary evaluation by a cardiologist and a gynecologist. The current review summarizes the existing knowledge and treatment options for AF in pregnancy and suggests a simplified algorithm for this clinical constellation.

Pregnancy-induced increased heart rate is independent of thyroid hormones

Background

The heart rate increases by 10–20 beats per minute (bpm) throughout pregnancy in women, reaching maximum heart rate in the third trimester. During pregnancy, important changes in thyroid hormones also occur, with increases of up to 50% in the levels of triiodothyronine (T₃), the biological active thyroid hormone. In addition, T₃ has been shown to regulate cardiac electrophysiology.

Objective

Thus, in the present study the potential contribution of T₃ in pregnancy-induced increased heart rate was explored.

Methods

We compared the heart rate between nonpregnant and pregnant mice under control conditions and after altering thyroid hormone levels with T₃ and propylthiouracil (PTU, an antithyroid drug) treatments.

Results

Consistent with the clinical data, we found a 58% rise in T₃ levels during pregnancy in mice. Although pregnant mice had a higher baseline heart rate (607 ± 8 bpm, P = .004) and higher T₃ levels (1.9 ± 0.4 nM, P = .0005) than nonpregnant mice (heart rate: 546 ± 16 bpm; T₃ levels: 1.2 ± 0.1 nM), their heart rate responded similarly to T₃ treatment as nonpregnant mice (nonpregnant: Δ130 ± 22 bpm; pregnant: Δ126 ± 17 bpm, P = .858). Additionally, the heart rate remained significantly elevated (607 ± 11 bpm, P = .038) and comparable to untreated pregnant mice, after the use of the antithyroid drug PTU, although T₃ levels (1.3 ± 0.2 nM, P = .559) returned to nonpregnant values.

Conclusion

Based on these results, it is unlikely that T₃ contributes significantly to the pregnancy-induced increased heart rate.

Early N-terminal pro-B-type natriuretic peptide is associated with cardiac complications and function during pregnancy in congenital heart disease

Background

Elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at 20 weeks’ gestation predict adverse cardiovascular (CV) complications during pregnancy in women with congenital heart disease (CHD). To improve early risk assessment in these women, we investigated the predictive value of first-trimester NT-proBNP for CV complications and its association with ventricular function during pregnancy.

Methods

Pregnant women with CHD, previously enrolled in a prospective national study or evaluated by an identical protocol, were included. Clinical data, echocardiographic evaluation and NT-proBNP measurements were obtained at 12, 20 and 32 weeks’ gestation. Elevated NT-proBNP was defined as > 235 pg/ml (95th percentile reference value of healthy pregnant women in the literature).

Results

We examined 126 females (mean age 29 years). Elevated NT-proBNP at 12 weeks was associated with CV complications (n = 7, 5.6%, odds ratio 10.9, p = 0.004). Arrhythmias were the most common complication (71%). The negative predictive value of low NT-proBNP to exclude CV complications was 97.2%. In women with CV complications, NT-proBNP levels remained high throughout pregnancy, while a decrease was seen in women without CV complications (p < 0.001 for interaction between group and time). At 12 weeks, higher NT-proBNP levels were associated with impaired subpulmonary ventricular function (p < 0.001) and also with a decline in subpulmonary ventricular function later in pregnancy (p = 0.012).

Conclusions

In this study, first-trimester NT-proBNP levels were associated with adverse CV complications and a decline in subpulmonary ventricular function later in pregnancy in women with CHD. Early NT-proBNP evaluation is useful for tailored care in pregnant women with CHD.

Computational models of cardiac hypertrophy

Cardiac hypertrophy, defined as an increase in mass of the heart, is a complex process driven by simultaneous changes in hemodynamics, mechanical stimuli, and hormonal inputs. It occurs not only during pre- and post-natal development but also in adults in response to exercise, pregnancy, and a range of cardiovascular diseases. One of the most exciting recent developments in the field of cardiac biomechanics is the advent of computational models that are able to accurately predict patterns of heart growth in many of these settings, particularly in cases where changes in mechanical loading of the heart play an import role. These emerging models may soon be capable of making patient-specific growth predictions that can be used to guide clinical interventions. Here, we review the history and current state of cardiac growth models and highlight three main limitations of current approaches with regard to future clinical application: their inability to predict the regression of heart growth after removal of a mechanical overload, inability to account for evolving hemodynamics, and inability to incorporate known growth effects of drugs and hormones on heart growth. Next, we outline growth mechanics approaches used in other fields of biomechanics and highlight some potential lessons for cardiac growth modeling. Finally, we propose a multiscale modeling approach for future studies that blends tissue-level growth models with cell-level signaling models to incorporate the effects of hormones in the context of pregnancy-induced heart growth.

Continuous Maternal Hemodynamics Monitoring at Delivery Using a Novel, Noninvasive, Wireless,PPG-Based Sensor

Objective: To evaluate continuous monitoring of maternal hemodynamics during labor and delivery utilizing an innovative, noninvasive, reflective photoplethysmography-based device. Study design: The Biobeat Monitoring Platform includes a wearable wristwatch monitor that automatically samples cardiac output (CO), blood pressure (BP), stroke volume (SV), systemic vascular resistance (SVR), heart rate (HR) every 5 s and uploads all data to a smartphone-based app and to a data cloud, enabling remote patient monitoring and analysis of data. Low-risk parturients at term, carrying singletons pregnancies, were recruited at early delivery prior to the active phase. Big data analysis of the collected data was performed using the Power BI analysis tool (Microsoft). Next, data were normalized to visual presentation using Excel Data Analysis and the regression tool. Average measurements were compared before and after rupture of membranes, epidural anesthesia, fetal delivery, and placental expulsion. Results: Eighty-one parturients entered analysis. Epidural anesthesia was associated with a slight elevation in CO (5.5 vs. 5.6, L/min, 10 min before and after EA, p < 0.05) attributed to a non-significant increase in both HR and SV. BP remained stable as of counter decrease in SVR (1361 vs. 1319 mmHg⋅min⋅mL⁻¹, 10 min before and after EA, p < 0.05). Fetal delivery was associated with a peak in CO after which it rapidly declined (6.0 vs. 7.2 vs. 6.1 L/min, 30 min before vs. point of delivery vs. after delivery, p < 0.05). The mean BP remained stable throughout delivery with a slight increase at fetal delivery (92 vs. 95 vs. 92.1 mmHg, p < 0.05), reflecting the increase in CO and decrease in SVR (1284 vs. 1112 vs. 1280 mmHg⋅min⋅mL⁻¹, p < 0.05)with delivery. Placental expulsion was associated with a second peak in CO and decrease in SVR. Conclusions: We presented a novel application of noninvasive hemodynamic maternal monitoring throughout labor and delivery for both research and clinical use.

Minimally Invasive Hemodynamic Assessment during Obstetric Hysterectomy for Invasive Placentation with Epidural Anesthesia

Background

The present study aimed to describe the evolution of hemodynamic parameters over time of patients with invasive placentation during their third trimester who were delivered via cesarean section and subsequently underwent obstetric hysterectomy under epidural anesthesia.

Methods

A prospective, descriptive, longitudinal, 11-month cohort study of 43 patients aged between 18 and 37 years who presented with invasive placentation. Minimal invasive monitoring was placed before the administration of epidural anesthesia for hemodynamic parameter tracking during the cesarean section. After delivery, the patients underwent an obstetric hysterectomy. Blood loss, hemodynamic parameters, and coagulation were managed via goal-directed therapy. Parameters were compared via repeated measures ANOVA and effect size estimation (Cohen's d).

Results

The mean age of the patients was 29.2 ± 3.4 years and was moderately overweight. They had minor cardiac index variance (P=NS, no significance), vascular systemic resistance index (NS), heart rate (P=NS), and median arterial pressure (P=NS). Differences were observed in the stroke volume index (P=0.015) due to moderately higher values (d = 0.3, P=0.016) in the middle of the surgery. Patients had lower cardiac index (d = -0.36, NS) and cardiac workload requirements (d = -0.29, P=0.034) toward the completion of surgery.

Conclusion

Patients who are in their third trimester and who subsequently underwent obstetric hysterectomy under epidural anesthesia had modest surgical hemodynamic variance and reduced cardiac workload requirements toward the end of the surgery.

Drug Development and the Use of Induced Pluripotent Stem Cell-Derived Cardiomyocytes for Disease Modeling and Drug Toxicity Screening

: Over the years, numerous groups have employed human induced pluripotent stem cell-derived cardiomyocytes (iPSC-CMs) as a superb human-compatible model for investigating the function and dysfunction of cardiomyocytes, drug screening and toxicity, disease modeling and for the development of novel drugs for heart diseases. In this review, we discuss the broad use of iPSC-CMs for drug development and disease modeling, in two related themes. In the first theme-drug development, adverse drug reactions, mechanisms of cardiotoxicity and the need for efficient drug screening protocols-we discuss the critical need to screen old and new drugs, the process of drug development, marketing and Adverse Drug reactions (ADRs), drug-induced cardiotoxicity, safety screening during drug development, drug development and patient-specific effect and different mechanisms of ADRs. In the second theme-using iPSC-CMs for disease modeling and developing novel drugs for heart diseases-we discuss the rationale for using iPSC-CMs and modeling acquired and inherited heart diseases with iPSC-CMs.

Physical activity and gestational weight gain predict physiological and perceptual responses to exercise during pregnancy

BACKGROUND

Exercise is known to improve the health of the pregnant woman and her child. Studies that have evaluated physiological parameters during prenatal exercise have conflicting results. Better understanding of these physiological responses can modify exercise prescriptions, safety, and monitoring strategies. We examined the association between age, prepregnancy body mass index (BMI), gestational weight gain (GWG), and physical activity (PA) levels, factors that may influence a change in physiological (HR, VO₂ responses) and perceptual (RPE) responses to acute exercise throughout pregnancy.

METHODS

Twenty-two healthy pregnant women (31.4 ± 3.7 years) performed a Submaximal incremental Walking Exercise Test (SWET). Early- (13-18 weeks), mid- (24-28 weeks), and late-pregnancy (34-37 weeks) were compared. VO₂ (L/min; ml/kg/min), HR (bpm), and RPE were collected at the end of each test stage. PA was determined by accelerometry. We associated PA levels, GWG, prepregnancy BMI, and age with HR, RPE, and VO₂ responses.

RESULTS

HR, RPE, and absolute VO₂ were higher in late-pregnancy compared to earlier time points (p < .05; η² = 0.299-0.525). Regression models were built for HR (all time points), RPE (early- and late-pregnancy), and VO₂ (L/min; late-pregnancy). HR (late-pregnancy) was predicted by time in vigorous PA, GWG, age, and prepregnancy BMI (r² = 0.645; SEE = 5.84). RPE (late-pregnancy) was predicted by sedentary time, GWG, prepregnancy BMI, and age (r² = 0.662; SEE = 1.21).

CONCLUSION

Physiological/perceptual responses were higher in late-pregnancy compared to other time points and associated with combined PA, GWG, prepregnancy BMI, and age. These findings can be used to modify exercise prescriptions and designs for future PA interventions in pregnant women.

Oscillatory fluid-induced mechanobiology in heart valves with parallels to the vasculature

Forces generated by blood flow are known to contribute to cardiovascular development and remodeling. These hemodynamic forces induce molecular signals that are communicated from the endothelium to various cell types. The cardiovascular system consists of the heart and the vasculature, and together they deliver nutrients throughout the body. While heart valves and blood vessels experience different environmental forces and differ in morphology as well as cell types, they both can undergo pathological remodeling and become susceptible to calcification. In addition, while the plaque morphology is similar in valvular and vascular diseases, therapeutic targets available for the latter condition are not effective in the management of heart valve calcification. Therefore, research in valvular and vascular pathologies and treatments have largely remained independent. Nonetheless, understanding the similarities and differences in development, calcific/fibrous pathologies and healthy remodeling events between the valvular and vascular systems can help us better identify future treatments for both types of tissues, particularly for heart valve pathologies which have been understudied in comparison to arterial diseases.

Tricuspid Stenosis in Pregnancy: A Valve-in-Valve Conundrum

Redo tricuspid valve replacement has high surgical operative mortality. Transcatheter valve-in-valve provides a viable option for valve replacement. We discuss the decision-making process involved in performing transcatheter tricuspid valve-in-valve replacement in a 23-week pregnant woman with multiple comorbidities and symptomatic severe bioprosthetic stenosis. (Level of Difficulty: Intermediate.)

Contribution of estrogen to the pregnancy-induced increase in cardiac automaticity

BACKGROUND

The heart rate progressively increases throughout pregnancy, reaching a maximum in the third trimester. This elevated heart rate is also present in pregnant mice and is associated with accelerated automaticity, higher density of the pacemaker current I_f and changes in Ca²⁺ homeostasis in sinoatrial node (SAN) cells. Strong evidence has also been provided showing that 17β-estradiol (E₂) and estrogen receptor α (ERα) regulate heart rate. Accordingly, we sought to determine whether E₂ levels found in late pregnancy cause the increased cardiac automaticity associated with pregnancy.

METHODS AND RESULTS

Voltage- and current-clamp experiments were carried out on SAN cells isolated from female mice lacking estrogen receptor alpha (ERKOα) or beta (ERKOβ) receiving chronic E₂ treatment mimicking late pregnancy concentrations. E₂ treatment significantly increased the action potential rate (284 ± 24 bpm, +E₂ 354 ± 23 bpm, p = 0.040) and the density of I_f (+52%) in SAN cells from ERKOβ mice. However, I_f density remains unchanged in SAN cells from E₂-treated ERKOα mice. Additionally, E₂ also increased I_f density (+67%) in nodal-like human-induced pluripotent stem cell-derived cardiomyocytes (N-hiPSC-CM), recapitulating in a human SAN cell model the effect produced in mice. However, the L-type calcium current (I_CaL) and Ca²⁺ transients, examined using N-hiPSC-CM and SAN cells respectively, were not affected by E₂, indicating that other mechanisms contribute to changes observed in these parameters during pregnancy.

CONCLUSION

The accelerated SAN automaticity observed in E₂-treated ERKOβ mice is explained by an increased I_f density mediated by ERα, demonstrating that E₂ plays a major role in regulating SAN function during pregnancy.

Postpartum Hypertension

PURPOSE OF REVIEW

Hypertension affects approximately 10% of pregnancies and may persist in the postpartum period. Furthermore, de novo hypertension may present after delivery, but its exact prevalence is not verified. Both types of hypertension expose the mother to eventually severe complications like eclampsia, stroke, pulmonary edema, and HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome.

RECENT FINDINGS

Until today, there are limited data regarding the risk factors, pathogenesis, and pathophysiology of postpartum hypertensive disorders. However, there is certain evidence that preeclampsia may in large part be responsible. Women who experienced preeclampsia during pregnancy, although considered cured after delivery and elimination of the placenta, continue to present endothelial and renal dysfunction in the postpartum period. The brain and kidneys are particularly sensitive to this pathological vascular condition, and severe complications may result from their involvement. Large randomized trials are needed to give us the evidence that will allow a timely diagnosis and treatment. Until then, medical providers should increase their knowledge regarding hypertension after delivery because many times there is an underestimation of the complications that can ensue after a misdiagnosed or undertreated postpartum hypertension.

Anatomical and physiological alterations of pregnancy

The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.

Continuous 7-Month Internet of Things-Based Monitoring of Health Parameters of Pregnant and Postpartum Women: Prospective Observational Feasibility Study

BACKGROUND

Monitoring during pregnancy is vital to ensure the mother's and infant's health. Remote continuous monitoring provides health care professionals with significant opportunities to observe health-related parameters in their patients and to detect any pathological signs at an early stage of pregnancy, and may thus partially replace traditional appointments.

OBJECTIVE

This study aimed to evaluate the feasibility of continuously monitoring the health parameters (physical activity, sleep, and heart rate) of nulliparous women throughout pregnancy and until 1 month postpartum, with a smart wristband and an Internet of Things (IoT)-based monitoring system.

METHODS

This prospective observational feasibility study used a convenience sample of 20 nulliparous women from the Hospital District of Southwest Finland. Continuous monitoring of physical activity/step counts, sleep, and heart rate was performed with a smart wristband for 24 hours a day, 7 days a week over 7 months (6 months during pregnancy and 1 month postpartum). The smart wristband was connected to a cloud server. The total number of possible monitoring days during pregnancy weeks 13 to 42 was 203 days and 28 days in the postpartum period.

RESULTS

Valid physical activity data were available for a median of 144 (range 13-188) days (75% of possible monitoring days), and valid sleep data were available for a median of 137 (range 0-184) days (72% of possible monitoring days) per participant during pregnancy. During the postpartum period, a median of 15 (range 0-25) days (54% of possible monitoring days) of valid physical activity data and 16 (range 0-27) days (57% of possible monitoring days) of valid sleep data were available. Physical activity decreased from the second trimester to the third trimester by a mean of 1793 (95% CI 1039-2548) steps per day (P<.001). The decrease continued by a mean of 1339 (95% CI 474-2205) steps to the postpartum period (P=.004). Sleep during pregnancy also decreased from the second trimester to the third trimester by a mean of 20 minutes (95% CI -0.7 to 42 minutes; P=.06) and sleep time shortened an additional 1 hour (95% CI 39 minutes to 1.5 hours) after delivery (P<.001). The mean resting heart rate increased toward the third trimester and returned to the early pregnancy level during the postpartum period.

CONCLUSIONS

The smart wristband with IoT technology was a feasible system for collecting representative data on continuous variables of health parameters during pregnancy. Continuous monitoring provides real-time information between scheduled appointments and thus may help target and tailor pregnancy follow-up.