Cardiovascular Physiology of Pregnancy

Association of Number of Live Births With Electrocardiographic and Cardiac Structural Changes

Background Pregnancy is a major life event unique to women and leads to significant hemodynamic, hormonal, and metabolic changes. The purpose of this study was to use the DHS (Dallas Heart Study), a multiethnic population-based cohort study of Dallas county adults, to evaluate the association between number of live births and cardiac magnetic resonance imaging and ECG parameters later in life. Methods and Results Women were included if they had data on self-reported live births and ECG or cardiac magnetic resonance imaging measurements. The 3014 women were stratified by number of live births: 0, 1, 2, 3, 4, and ≥5. Higher number of live births was associated with larger left ventricular (LV) end-diastolic volume (β, 1.31±0.41; P<0.01), LV end-systolic volume (β, 0.83±0.24; P<0.01), and LV mass (β, 1.13±0.49; P=0.02) and lower LV ejection fraction (β, -0.004±0.0014; P<0.01). Increasing parity was associated with longer PR intervals (β, 1.07±0.38; P<0.01). Subgroup analysis by race demonstrated that the association between number of live births and magnetic resonance imaging parameters (LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction) only remained significant in Black women (P value for interaction <0.05). Conclusions Increasing number of live births was associated with electrocardiographic and cardiac structural changes in a multiethnic population. When stratified by race and ethnicity, magnetic resonance imaging structural changes only remained significant in Black participants. Whether these changes are pathologic and increase the risk of heart failure or arrhythmias in multiparous women warrants further investigation.

COVID-19 associated liver injury: A general review with special consideration of pregnancy and obstetric outcomes

Liver injury is an increasingly recognized extra-pulmonary manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Coronavirus disease 2019 (COVID-19) associated liver injury (COVALI) is a clinical syndrome encompassing all patients with biochemical liver injury identified in the setting of SARS-CoV-2 infection. Despite profound clinical implications, its pathophysiology is poorly understood. Unfortunately, most information on COVALI is derived from the general population and may not be applicable to individuals under-represented in research, including pregnant individuals. This manuscript reviews: Clinical features of COVALI, leading theories of COVALI, and existing literature on COVALI during pregnancy, a topic not widely explored in the literature. Ultimately, we synthesized data from the general and perinatal populations that demonstrates COVALI to be a hepatocellular transaminitis that is likely induced by systemic inflammation and that is strongly associated with disease severity and poorer clinical outcome, and offered perspective on approaching transaminitis in the potentially COVID-19 positive patient in the obstetric setting.

Pathophysiology, Diagnosis and Treatment of Spontaneous Coronary Artery Dissection in Peripartum Women

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of nonobstructive ischemic heart disease in previously healthy young women and therefore is not usually considered in differential diagnoses. The overall incidence of SCAD in angiographic series is between 0.28 and 1.1%, with a clear predominance in young, healthy women (70%) of whom approximately 30% are in the postpartum period. In the United Kingdom, between 2008 and 2012, SCAD was the cause of 27% of acute myocardial infarctions during pregnancy, with a prevalence of 1.81 per 100,000 pregnancies. Regarding the mechanism of arterial obstruction, this may be due to the appearance of an intramural hematoma or to a tear in the intima of the arteries, both spontaneously. Although multiple diagnostic methods are available, it is suggested to include an appropriate anamnesis, an electrocardiogram in the first 10 min after admission to the service or the onset of symptoms, and subsequently, a CT angiography of the coronary arteries or urgent coronary angiography if the hemodynamic status of the patient allows it. Treatment should be individualized for each case; however, the appropriate approach is generally based on two fundamental pillars: conservative medical treatment with antiplatelet agents, beta-blockers, and nitrates, and invasive treatment with percutaneous coronary intervention for stent implantation or balloon angioplasty, if necessary.

An Evaluation of Exposure to 18 Toxic and/or Essential Trace Elements Exposure in Maternal and Cord Plasma during Pregnancy at Advanced Maternal Age

Pregnant women of advanced maternal age (AMA) are vulnerable to exposure to the surrounding environment. Assessment of trace elements in pregnant women living in specific areas is important for biomonitoring. However, exposure levels and variation patterns during pregnancy remains controversial and attracts extensive public concern. Therefore, we aimed to evaluate exposure of 18 toxic and/or essential trace elements in maternal plasma and in paired cord plasma during pregnancy at AMA. A total of 48 pregnant women of AMA were recruited in Peking University Third Hospital from 2018 to 2021. Eighteen elements found in maternal plasma during the 1st, 2nd, or 3rd trimester of pregnancy and paired cord plasma were measured by 7700x ICP-MS (Agilent Technologies, Palo Alto, CA, USA) and Elan DRC type II ICP-MS (The Perkin-Elmer Corporation, Waltham, MA USA). Concentrations of Pb, Se, Fe, Zn, and Mo all decreased during pregnancy, while Cu increased. Interestingly, concentrations of Rb decreased initially but then increased. Elements as Al, Co, Se, Cu, and Ni showed significantly lower levels in cord than in maternal plasma, while elements as Sr, Fe, Rb, Mn and Zn displayed significantly higher levels in cord than in maternal plasma. Moreover, positively- interacted clusters were found in Ni-Co-Cu-Al-Rb-Zn and Zn-Mn-Al-Pb in maternal blood. Similar positively-interacted clusters were found in Zn-Ni-Co, Zn-Ni-Fe, Mn-Al-Pb, Fe-Pb-Mn, Fe-Ni-Cu, and Rb-Cu-Sb-Fe-Mn in cord plasma. Furthermore, correlations between paired maternal and cord blood samples for As, Sr, and Mo were statistically significant, indicating that the fetus burden may reflect maternal exposure to some extent. Admittedly, levels of toxic and essential elements in our cohort study were comparatively lower than those in the scientific literature.

Spontaneous resolution of syringomyelia following pregnancy and parturition in a patient with type I chiari malformation: A case and systematic review

BACKGROUND

Spontaneous resolution of syringomyelia has rarely been reported in the literature. Rarer still are cases wherein this process is associated with pregnancy and parturition. We review theories on syringomyelia development and spontaneous resolution to better understand the role pregnancy and parturition may play in both processes.

METHODS

We present a 30-year-old female with MRI-confirmed spontaneous syrinx regression following caesarean delivery of a full-term pregnancy. We additionally review the literature to identify previously reported cases of spontaneous syrinx regression both independent of and associated with pregnancy.

RESULTS

Including the present case, 39 cases describing spontaneous regression of syringomyelia have been reported in the literature, of which only four are associated with pregnancy and parturition. 75% of all reported cases were associated with type I Chiari malformation, though several disorders of the craniocervical junction and spinal canal were implicated. Complete syrinx regression was achieved in 33.3% of cases and 5% of cases described recurrence of syringomyelia following the spontaneous resolution.

CONCLUSION

Syringomyelia likely develops due to disturbance of the physiologic flow of cerebrospinal fluid around the craniocervical junction and the obex. Several mechanisms including fissuring of the spinal cord parenchyma and reduction of subarachnoid scarring are likely involved in this process. In the setting of pregnancy, additional mechanisms surrounding the increased intraabdominal forces imparted by a growing fetus, Valsalva-like strain experienced during labor, and hemodynamic changes that occur to accommodate gestation are likely implicated. Nevertheless, patients should continue to be monitored periodically for syrinx recurrence.

Wave separation analysis-derived indexes obtained from radial and carotid tonometry in healthy pregnancy and pregnancy-associated hypertension: Comparison with pulse wave analysis-derived indexes

BACKGROUND

Increased wave reflections assessed by pulse wave analysis (PWA) was proposed as one of the potential culprits of hypertension seen in women with pregnancy-associated hypertension (PAH). However, this statement has never been confirmed with "Wave Separation Analysis" (WSA), a more sophisticated mathematical approach that analyzes the amplitude and interaction between forward and backward aortic pressure waveform components.

OBJECTIVE

To characterize potential changes in pressure wave components of PAH compared to healthy non-pregnant (NP) women and women with normal pregnancies (HP) by using WSA and compared these findings with PWA-derived indexes; secondarily, to evaluate differences in WSA-derived indexes between subgroups of PAH (i.e., preeclampsia [PE] and gestational hypertension [GH]).

METHODS

Using radial and carotid applanation tonometry, we quantified in HP (n = 10), PAH (n = 16), and NP (n = 401): (i) PWA-derived indexes; (ii) WSA-derived indexes: forward (Pf) and backward (Pb) waveform components, backward component arrival time (PbAT), reflection magnitude (RM = Pb/Pf) and index [RIx = Pb/(Pf + Pb)].

RESULTS

While PAH was associated with a higher Pf compared to HP and NP, Pb and PbAT were similar between the groups. Both GH and PE showed a higher Pf compared to HP, but only PE had a trend of presenting with higher Pb and lower PbAT compared to the other groups. Finally, PAH showed a trend of having lower RM and RIx compared to NP and HP, with no differences between GH and PE.

CONCLUSION

PAH was associated with higher Pf, but not higher Pb, compared to NP and HP, although PE also demonstrated a trend of higher Pb.

Patterns of physical activity and sedentary behavior before and during pregnancy and cardiometabolic outcomes

OBJECTIVE

To assess how physical activity and sedentary behavior change from pre-pregnancy to pregnancy, and if pre-pregnancy and pregnancy physical activity and sedentary behavior are related to gestational weight gain, blood pressure, or blood glucose across pregnancy.

DESIGN

Secondary analysis of two prospective cohort studies.

SETTING

Prenatal research centers in Pittsburgh, PA and Iowa City, IA.

PARTICIPANTS

Pregnant individuals (n=131), 18-45 years old, of any BMI, with no medical condition limiting physical activity or use of hypertension/diabetes medications.

METHODS

Participants self-reported physical activity and sedentary behavior pre-pregnancy and in each trimester using validated questionnaires. Blood pressure, blood glucose, and weight were obtained from study visits and/or electronic medical records. Multivariable regression examined associations between pre-pregnancy, trimester-specific, and changes in physical activity and sedentary behavior with weight gain and blood pressure outcomes in each trimester, and blood glucose in the second trimester.

RESULTS

Compared to pre-pregnancy, physical activity was lower in each trimester, and sedentary behavior was higher in each trimester (p<0.05). Increasing physical activity from pre-pregnancy levels was associated with lower first trimester SBP (p<0.05). Unexpectedly, higher pre-pregnancy physical activity was associated with higher SBP in the first trimester (p=0.02) and higher weight gain in the third trimester (p=0.02). Higher and increasing sedentary behavior was associated with greater weight gain in the third trimester (p=0.03).

CONCLUSION

Future research should investigate the opportune time (before or during pregnancy) to deliver behavior modification interventions that could prevent excessive gestational weight gain or elevated blood pressure to improve maternal health outcomes.

COVID-19 Pregnancies with Heart Disease: Challenges of Delivery

This case series of four cases of pregnancy with rheumatic heart disease with COVD-19 disease reports on the management of delivery and complications of heart disease with COVID-19, high-lighting the presentation, severity, delivery concerns, and clinical management with the maternal and fetal outcomes. Of the four full-term deliveries, one delivered normally, one instrumental delivery and two by cesarean section. All four required oxygen support post-delivery, 2/4 (50%) were transferred for intensive care unit (ICU) care, 1/4 (25%) required mechanical ventilation, 1/4 (25%) had postpartum hemorrhage, 1/4 (25%) had COVID related sepsis and received convalescent plasma therapy, and 2/4 (50%) received antiviral remdesivir. The most severe disease (COVID sepsis and ICU stay) was seen in patient of heart disease with COVID with preclampsia. All neonates tested SARS-CoV-2 negative, with one early neonatal death. All four mothers were discharged in stable condition of COVID and heart status. COVID-19 in cardiac disease pregnancies has increased rates of complications, oxygen, and ICU requirements than other pregnancies with COVID, requiring multidisciplinary team for intensive monitoring of intrapartum and postpartum period.

Association of age at first birth and risk of non-alcoholic fatty liver disease in women: evidence from the NHANES

BACKGROUND

Numerous studies have suggested that age at first birth (AFB) is inversely associated with metabolic diseases, but positively associated with liver cancer in women. Non-alcoholic fatty liver disease (NAFLD) is a canonical example of metabolic dysfunction and inflammation-based liver disease, while the association between AFB and the risk of NAFLD remains unclear. We aimed to investigate the association between AFB and the odds of NAFLD in women.

METHODS

Women older than 20 years at the time of the survey were analyzed using National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2018 in the US. AFB was obtained with self-administered questionnaires. NAFLD was diagnosed as fatty liver index (FLI) ≥ 60. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression models.

RESULTS

Of the 12,188 women included in this study, 5670 (46.5%) had NAFLD. Compared to individuals with AFB of 30-32 years old (reference group), the fully adjusted ORs and 95% CI in women with AFB < 18, 18-20, 21-23, and 24-26 years were 1.52 (95% CI 1.14, 2.03), 1.60 (95% CI 1.21, 2.11), 1.40 (95% CI 1.06, 1.84), and 1.33 (95% CI 1.01-1.76), respectively. Yet there was no significant difference between AFB of 27-29, 33-35, or > 35 years compared to the reference group.

CONCLUSIONS

Women with younger AFB have higher odds of NAFLD in later life. Policymakers should consider focusing on those with earlier AFB for screening and prevention of NAFLD.

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.

Modeling renal autoregulation in a hemodynamic, first-trimester gestational model

The maternal cardiovascular system, led by renal volume regulatory responses, changes during pregnancy to ensure an adequate circulation for fetal development and growth. Circulatory maladjustment predisposes to hypertensive complications during pregnancy. Mathematical models can be used to gain insight in the gestational cardiovascular physiology. In this study, we developed an accurate, robust, and transparent model for renal autoregulation implemented in an existing circulatory gestational model. This renal autoregulation model aims to maintain steady glomerular pressure by the myogenic response, and glomerular filtration rate by tubuloglomerular feedback, both by inducing a change in the radius, and thus resistance, of the afferent arteriole. The modeled response of renal blood flow and the afferent arteriole following blood pressure increase were compared to published observations in rats. With solely the myogenic response, our model had a maximum deviation of 7% in change in renal blood flow and 7% in renal vascular resistance. When both the myogenic response and tubuloglomerular feedback were concurrently activated, the maximum deviation was 7% in change in renal blood flow and 5% in renal vascular resistance. These results show that our model is able to represent renal autoregulatory behavior comparable to empirical data. Further studies should focus on extending the model with other regulatory mechanisms to understand the hemodynamic changes in healthy and complicated pregnancy.

Iron Deficiency in the United States: Limitations in Guidelines, Data, and Monitoring of Disparities

Iron deficiency and the more severe sequela, iron deficiency anemia, are public health problems associated with morbidity and mortality, particularly among pregnant women and younger children. The 1998 Centers for Disease Control and Prevention recommendations for prevention and control of iron deficiency in the United States is old and does not reflect recent evidence but is a foundational reference for many federal, clinical, and program guidelines. Surveillance data for iron deficiency are sparse at all levels, with critical gaps for pregnant women and younger children. Anemia, iron deficiency, and iron deficiency anemia are often conflated but should not be. Clinical guidelines for anemia, iron deficiency, and iron deficiency anemia give inconsistent recommendations, causing nonsystematic assessment of iron deficiency. Screening for iron deficiency typically relies on identifying anemia, despite anemia's low sensitivity for iron deficiency. In the National Health and Nutrition Examination Survey, more than 70% of iron deficiency is missed among pregnant women and children by relying on hemoglobin for iron deficiency screening. To improve assessment and diagnosis and strengthen surveillance, better and more complete data and updated foundational guidance on iron deficiency and anemia are needed that consider new evidence for measuring and interpreting laboratory results. (Am J Public Health. 2022;112(S8):S826-S835. https://doi.org/10.2105/AJPH.2022.306998).

Maternal pregnancy outcomes in women with cardiomyopathy: a systematic review and meta-analysis

OBJECTIVE

This study aimed to systematically assess the impact of cardiomyopathy on maternal pregnancy outcomes.

DATA SOURCES

PubMed, Ovid Embase, Ovid MEDLINE, Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to April 24, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, case-control, and case-cohort studies in human populations were included if they reported predefined maternal outcomes for pregnant women with cardiomyopathy (any subtype) and for an appropriate control population (pregnant women with no known heart disease or pregnant women with noncardiomyopathy heart disease).

METHODS

Two reviewers independently assessed the articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Data were extracted and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analyses of Observational Studies in Epidemiology guidelines.

RESULTS

A total of 14 studies (n=57,539,306 pregnancies) were eligible for inclusion. Women with cardiomyopathy were more likely to deliver by cesarean delivery than women with no heart disease (odds ratio, 2.96; 95% confidence interval, 2.47-3.55; I2=95%; P≤.00001) or women with noncardiomyopathy heart disease (odds ratio, 1.90; 95% confidence interval, 1.62-2.22; I2=91%; P<.00001). Having cardiomyopathy conferred a greater risk for experiencing severe maternal adverse cardiovascular events during pregnancy when compared with not having any heart disease (odds ratio, 206.64; 95% confidence interval, 192.09-222.28; I2=73%; P<.0001) or having noncardiomyopathy heart disease (odds ratio, 7.09; 95% confidence interval; 6.08-8.27; I2=88%; P<.00001). In-hospital mortality was significantly higher among women with cardiomyopathy than among women with no heart disease (odds ratio, 126.67; 95% confidence interval, 43.01-373.07; I2=87%; P<.00001) or among women with noncardiomyopathy heart disease (odds ratio, 4.30; 95% confidence interval, 3.42-5.40; I2=0%; P<.00001).

CONCLUSION

Pregnant women with cardiomyopathy have increased risks for adverse maternal outcomes, including maternal death, when compared with both women with no heart disease and women with noncardiomyopathy heart disease. Our results highlight the importance of preconception risk assessments to allow for informed decision-making before pregnancy. Pregnancies affected by cardiomyopathy are high risk and should be managed by expert, multidisciplinary obstetrical and cardiology teams.

Maternal body weight and estimated circulating blood volume: a non-linear approach

Postpartum haemorrhage continues to be a leading cause of morbidity and mortality in the obstetric population worldwide, especially in patients at extremes of body weight. Quantification of blood loss has been considered extensively in the literature. However, these volumes must be contextualised to appreciate the consequences of blood loss for individual parturients. Knowledge of a patient's peripartum circulating blood volume is essential to allow accurate interpretation of the significance of haemorrhage and appropriate resuscitation. Greater body weight in obesity can lead to overestimation of blood volume, resulting in inappropriately high thresholds for blood product transfusion and delays in treatment. The most recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) surveillance report demonstrated the risk to this population, with more than half of all maternal mortality recorded in parturients who were either overweight or obese. Current linear calculations used to estimate circulating blood volumes based on patients' weights could be contributing to this phenomenon, as blood volume increases at a disproportional rate to body composition. In this review, we summarise the relevant physiology and explore the existing literature on the estimation of circulating blood volume, both during pregnancy and in obesity. Building on key works and principal findings, we present a practical, nonlinear approach to the adjustment of estimated blood volume with increasing body mass. This clinical tool aims to reduce the clinical bias influencing the management of obstetric haemorrhage in a population already at increased risk of morbidity and mortality. Discussion of the limitations of this approach and the call for further research within this field completes this review.

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Purpose of Review

The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.

Recent Findings

A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.

Summary

Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

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.

Diagnosing Arterial Stiffness in Pregnancy and Its Implications in the Cardio-Renal-Metabolic Chain

Cardio-renal and metabolic modifications during gestation are crucial determinants of foetal and maternal health in the short and long term. The cardio-renal metabolic syndrome is a vicious circle that starts in the presence of risk factors such as obesity, hypertension, diabetes, kidney disease and ageing, all predisposing to a status dominated by increased arterial stiffness and alteration of the vascular wall, which eventually damages the target organs, such as the heart and kidneys. The literature is scarce regarding cardio-renal metabolic syndrome in pregnancy cohorts. The present paper exposes the current state of the art and emphasises the most important findings of this entity, particularly in pregnant women. The early assessment of arterial function can lead to proper and individualised measures for women predisposed to hypertension, pre-eclampsia, eclampsia, and diabetes mellitus. This review focuses on available information regarding the assessment of arterial function during gestation, possible cut-off values, the possible predictive role for future events and modalities to reverse or control its dysfunction, a fact of crucial importance with excellent outcomes at meagre costs.

Maternal Left Ventricular Function in Uncomplicated Twin Pregnancies: A Speckle-Tracking Imaging Longitudinal Study

Objective: The knowledge of maternal cardiovascular hemodynamic adaptation in twin pregnancies is incomplete. We aimed to longitudinally investigate maternal left ventricular (LV) function in uncomplicated twin pregnancies. Methods: 30 healthy and uncomplicated twin pregnant women and 30 controls with normal singleton pregnancies were prospectively enrolled to undergo transthoracic echocardiography at 10–15 week’s gestation (w) (T1), 19–26 w (T2) and 30–38 w (T3). LV dimensions and volumes, as well as LV ejection fraction (LVEF), mass (LVM) and diastolic parameters (at transmitral pulsed wave Doppler and mitral annular plane tissue Doppler), were calculated. Speckle-tracking imaging was also applied to evaluate LV global longitudinal (GLS), radial and circumferential 2D strains. Results: During twin pregnancy, maternal LV dimensions, volumes and LVM had an increasing trend from T1 to T3, similar to singletons, while LVEF remained stable. There was LV remodeling/hypertrophy in 50% of women at T2 and T3 in both groups. Diastolic function had a worsening trend from T1 to T3 with no differences between twins and singletons, except for higher LV filling pressure (i.e., E/E′) at T2 in twins. Two-dimensional strains did not vary during gestation in either group, except for a linear trend to increase (i.e., worsen) GLS in singletons. Radial and circumferential 2D strains were impaired in about half of the women at each trimester, while GLS was altered in one-fourth/one-third of them in both groups. Conclusion: Maternal LV geometry, dimensions and function are significantly impaired during twin pregnancies, in particular in the second half of gestation, with no significant differences compared to singletons.

Clinical significance of unexplained persistent sinus tachycardia in women with structurally normal heart during the peripartum period

Background

Persistent sinus tachycardia (ST) is frequently encountered during pregnancy and peripartum period and its etiology often remains elusive. We sought to examine the possible association between unexplained persistent ST and obstetric outcomes.

Methods

A case control study was conducted using chart review of women admitted in labor to one of 7 hospitals of Northwell Health between January 2015 to June 2021. After excluding women with structurally abnormal hearts, we identified patients with persistent ST during the peripartum period, defined as a heart rate of more than 100 bpm for more than 48 h. A control group was created by randomly subsampling those who did not meet the inclusion criteria for sinus tachycardia. Obstetric outcomes were measured as mother’s length of stay (LOS), pre-term labor (PTL), admission to the neonatal ICU (NICU), and whether she received cesarean-section (CS).

Results

Seventy-eight patients with persistent ST were identified, out of 141,769 women admitted for labor throughout the Northwell Health system. 23 patients with ST attributable to infection or hypovolemia from anemia requiring transfusion and 55 with unclear etiology were identified. After adjusting for age and parity, pregnant mothers with ST were 2.35 times more likely to have a CS than those without (95% CI: 1.46–3.81, p = 0.0005) and had 1.38 times the LOS (1.21- 1.56, p < 0.0001). Among mothers with ST, those with unexplained ST were 2.14 times more likely to have a CS (1.22–3.75, p = 0.008).

Conclusion

Among pregnant patients, patients with ST have higher rates of CS.This association is unclear, however potential mechanisms include catecholamine surge, indolent infection, hormonal fluctuations, and medications. More studies are needed to explore the mechanism of ST in pregnant woman to determine the clinical significance and appropriate management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05012-3.

Obstetric Disorders and Critical Illness

In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.

Association Between Sex-Specific Risk Factors and Risk of New-Onset Atrial Fibrillation Among Women

IMPORTANCE

Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide, with different epidemiological and pathophysiological processes for women vs men and a poorer prognosis for women. Further investigation of sex-specific risk factors associated with AF development in women is warranted.

OBJECTIVE

To investigate the linear and potential nonlinear associations between sex-specific risk factors and the risk of new-onset AF in women.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study obtained data from the 2006 to 2010 UK Biobank study, a cohort of more than 500 000 participants aged 40 to 69 years. Participants were women without AF and history of hysterectomy and/or bilateral oophorectomy at baseline. Median follow-up period for AF onset was 11.6 years, and follow-up ended on October 3, 2020.

EXPOSURES

Self-reported, sex-specific risk factors, including age at menarche, history of irregular menstrual cycle, menopause status, age at menopause, years after menopause, age at first live birth, years after last birth, history of spontaneous miscarriages, history of stillbirths, number of live births, and total reproductive years.

MAIN OUTCOMES AND MEASURES

The primary outcome was new-onset AF, which was defined by the use of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code I48.

RESULTS

A total of 235 191 women (mean [SD] age, 55.7 [8.1] years) were included in the present study. During follow-up, 4629 (2.0%) women experienced new-onset AF. In multivariable-adjusted models, history of irregular menstrual cycle was associated with higher AF risk (hazard ratio [HR], 1.34; 95% CI, 1.01-1.79). Both early menarche (age 7-11 years; HR, 1.10 [95% CI, 1.00-1.21]) and late menarche (age 13-18 years; HR, 1.08 [95% CI, 1.00-1.17]) were associated with AF incidence. Early menopause (age 35-44 years; HR, 1.24 [95% CI, 1.10-1.39]) and delayed menopause (age ≥60 years; HR, 1.34 [95% CI, 1.10-1.78]) were associated with higher risk of AF. Compared with women with 1 to 2 live births, those with 0 live births (HR, 1.13; 95% CI, 1.04-1.24) or 7 or more live births (HR, 1.67; 95% CI, 1.03-2.70) both had significantly higher AF risk.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that irregular menstrual cycles, nulliparity, and multiparity were associated with higher risk of new-onset AF among women. The results highlight the importance of taking into account the reproductive history of women in devising screening strategies for AF prevention.

Management of the Critically Ill Patient with Pulmonary Arterial Hypertension and Right Heart Failure

Right ventricular (RV) failure is a recognized complication of pulmonary hypertension (PH). Pregnancy and surgery represent unique challenges to the patient with PH and require input from an interprofessional team. Approach to treatment must embrace sound physiologic principles that are based on optimization of RV preload, contractility, and afterload to improve cardiac function and tissue perfusion before the onset of multiorgan dysfunction. Failure of medical therapy needs to be recognized before the onset of irreversible shock. When appropriate, eligible patients should be considered for mechanical circulatory support as a bridge to recovery or transplantation.

Effects of aerobic, strength, and combined training during pregnancy in the blood pressure: A systematic review and meta-analysis

Gestational hypertension can lead to fetal complications, and, if untreated, high blood pressure during pregnancy may cause eclampsia and even death in the mother and fetus. Exercise is a strategy for preventing blood pressure disorders. There is little knowledge about the physiological impacts of different physical types of training on blood pressure during pregnancy. For that, this meta-analysis aimed to compare the effects of different physical exercise modalities (i.e., aerobic training-AT, strength training-ST, and combined training-AT + ST) on systolic blood pressure (SBP) and diastolic blood pressure (DBP) of pregnant women. A search was performed on PUBMED, LILACS, CINAHL, Sport discus, EMBASE, SCOPUS, and Cochrane Central Register of Controlled Trials to identify researchers. From 3,450 studies, 20 and 19 were included in the qualitative and quantitative analyses. AT studies presented a medium effect size (ES) on SBP [-0.29 (-2.95 to 2.36) p = 0.83], with substantial heterogeneity (I2 = 64%), and had a large impact on DBP [-1.34 (-2.98 to 0.30) p = 0.11], with moderate heterogeneity (I2 = 30%). ST researchers showed a large ES on SBP [-1.09 (-3.66 to 1.49) p = 0.41], with a reduced heterogeneity (I2 = 0%), and a medium ES on DBP [-0.26 (-2.77 to 2.19) p = 0.83] with moderate heterogeneity (I2 = 38%). AT + ST studies had a large ES on SBP [-1.69 (-3.88 to 0.49) p = 0.13] and DBP [-01.29 (-2.26 to 0.31) p = 0.01] with considerable (I2 = 83%) and moderate heterogeneity (I2 = 47%), respectively. These findings are essential for developing new research protocols to avoid gestational hypertension and preeclampsia. AT + ST had a large impact on the SBP and DBP reduction; however, there is a need for more similar procedures to reduce heterogeneity between studies, promoting consensual results. Systematic Review Registration: [PROSPERO], identifier [CRD42021256509].

Postnatal cardiovascular morbidity following preterm pre-eclampsia: An observational study

OBJECTIVE

To explore the nature of postnatal cardiovascular morbidity following pregnancies complicated by preterm pre-eclampsia and investigate associations between pregnancy characteristics and maternal postnatal cardiovascular function.

STUDY DESIGN

This was an observational sub-study of a single-centre feasibility randomised double-blind placebo-controlled trial (https://www.

CLINICALTRIALS

gov; NCT03466333), involving women with preterm pre-eclampsia, delivering before 37 weeks. Eligible women underwent echocardiography, arteriography and blood pressure monitoring within three days of birth, six weeks and six months postpartum. Correlations between pregnancy and cardiovascular characteristics were assessed using Spearman's correlation.

MAIN OUTCOME MEASURES

The prevalence of cardiovascular dysfunction and remodelling six months following preterm pre-eclampsia.

RESULTS

Forty-four women completed the study. At six months, 27 (61 %) had diastolic dysfunction, 33 (75 %) had raised total vascular resistance (TVR) and 18 (41 %) had left ventricular remodelling. Sixteen (46 %) women had de novo hypertension by six months and only two (5 %) women had a completely normal echocardiogram. Echocardiography did not change significantly from six weeks to six months. Earlier gestation at delivery and lower birthweight centile were associated with worse six-month diastolic dysfunction (E/E': rho = -0.39, p = 0.001 & rho = -0.42, p = 0.005) and TVR (rho = -0.34, p = 0.02 & rho = -0.37, p = 0.01).

CONCLUSIONS

Preterm pre-eclampsia is associated with persistent cardiovascular morbidity-six months postpartum in the majority of women. These cardiovascular changes have significant implications for long-term cardiovascular health. The graded severity of diastolic dysfunction and TVR with worsening pre-eclampsia phenotype suggests a dose-effect. However, the mechanistic link remains uncertain.

Pregnancy Considerations in the Multidisciplinary Care of Patients with Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is a vasoconstrictive disease of the distal pulmonary vasculature resulting in adverse right heart remodeling. Pregnancy in PAH patients is associated with high maternal morbidity and mortality as well as neonatal and fetal complications. Pregnancy-associated changes in the cardiovascular, pulmonary, hormonal, and thrombotic systems challenge the complex PAH physiology. Due to the high risks, patients with PAH are currently counseled against pregnancy based on international consensus guidelines, but there are promising signs of improving outcomes, particularly for patients with mild disease. For patients who become pregnant, multidisciplinary care at a PAH specialist center is needed for peripartum monitoring, medication management, delivery, postpartum care, and complication management. Patients with PAH also require disease-specific counseling on contraception and breastfeeding. In this review, we detail the considerations for reproductive planning, pregnancy, and delivery for the multidisciplinary care of a patient with PAH.

Two-dimensional speckle tracking echocardiography in assessing the subclinical myocardial dysfunction in patients with gestational diabetes mellitus

Background

Gestational diabetes mellitus (GDM) may increase the risk of cardiovascular disease and accompany asymptomatic deterioration of the myocardial function. This study aims to identify the subclinical impact of GDM on maternal left ventricular function by two-dimensional speckle tracking echocardiography (2D-STE).

Methods

We prospectively recruited 47 women with GDM and 62 healthy pregnant women who underwent transthoracic echocardiography (TTE) at 24 to 28 weeks of pregnancy. GDM diagnosis agreed with the IADPSG criteria. TTE was performed according to the criteria of the American Society of Echocardiography. Conventional echocardiographic data and 2D-STE parameters were compared between the two groups.

Results

Age, gestational weeks, heart rate, and conventional echocardiographic parameters had no difference between the two groups. The average LV global longitudinal strain (LV-GLS) of GDM patients was lower than controls (18.14 ± 2.53 vs. 22.36 ± 6.33, p < 0.001), and 31 patients (66%) in our study had an absolute LV-GLS less than 20%. The LA reservoir and conduit strain in patients with GDM were also significantly reduced (32.71 ± 6.64 vs. 38.00 ± 7.06, 20.41 ± 5.69 vs. 25.56 ± 5.73, p < 0.001). However, there was no significant difference in LA contractile function between the two groups. In multiple regression analysis, LV-GLS and LA conduit strain independently associated with GDM.

Conclusions

2D-STE could detect the subclinical myocardial dysfunction more sensitively than conventional echocardiography, with LV-GLS and LA conduit strain as independent indicators of the GDM impact on maternal cardiac function during pregnancy.

Cardiovascular Imaging in Pregnancy: Valvulopathy, Hypertrophic Cardiomyopathy, and Aortopathy

Pregnancy is associated with profound hemodynamic changes that are particularly impactful in patients with underlying cardiovascular disease. Management of pregnant women with cardiovascular disease requires careful evaluation that considers the well-being of both the woman and the developing fetus. Clinical assessment begins before pregnancy and continues throughout gestation into the post-partum period and is supplemented by cardiac imaging. This review discusses the role of imaging, specifically echocardiography, cardiac MRI, and cardiac CT, in pregnant women with valvular diseases, hypertrophic cardiomyopathy, and aortic pathology.

Pulmonary hypertension in pregnancy and its effects on the fetus

Pulmonary hypertension (PH) is an important and potentially lethal diagnosis for pregnant patients. Although pregnancy is usually contraindicated in this condition and there is no standard algorithm for the treatment of pregnant patients with PH, studies in recent years have shown improvement in maternal outcomes for those with PH. Many factors have likely contributed to the improved outcomes, including earlier treatment by multidisciplinary teams. Pregnant patients with PH require specialized management throughout pregnancy, especially in the early post-partum period. Echocardiography is an important diagnostic tool to follow cardiac function in these patients. PH and its treatment during pregnancy has significant implications on maternal as well as fetal outcomes. In this review, PH management during pregnancy and the fetal implications are summarized.

Birth, love, and fear: Physiological networks from pregnancy to parenthood

Pregnancy and childbirth are among the most dramatic physiological and emotional transformations of a lifetime. Despite their central importance to human survival, many gaps remain in our understanding of the temporal progression of and mechanisms underlying the transition to new parenthood. The goal of this paper is to outline the physiological and emotional development of the maternal-infant dyad from late pregnancy to the postpartum period, and to provide a framework to investigate this development using non-invasive timeseries. We focus on the interaction among neuroendocrine, emotional, and autonomic outputs in the context of late pregnancy, parturition, and post-partum. We then propose that coupled dynamics in these outputs can be leveraged to map both physiologic and pathologic pregnancy, parturition, and parenthood. This approach could address gaps in our knowledge and enable early detection or prediction of problems, with both personalized depth and broad population scale.

Role of MRI and CT in the Evaluation of Headache in Pregnancy and the Postpartum Period

Approximately 35% of acute headaches in pregnant women are secondary to an underlying condition. Headaches are also common in the postpartum period where they occur in 30% to 40% of patients. The majority of secondary headaches are due to hypertensive disorders: preeclampsia-eclampsia, posterior reversible encephalopathy syndrome, and acute arterial hypertension. Other causes include reversible cerebral vasoconstriction syndrome and pituitary apoplexy, as well as life-threatening conditions such as cerebral venous thrombosis. In this article, we review general recommendations for imaging the pregnant patients and discuss the imaging findings of common causes of headaches in pregnancy and the postpartum period.

Acute Myocardial Infarction in Pregnancy

Cardiovascular disease, and particularly ischemic heart disease, is a leading cause of maternal morbidity and mortality in high-income countries. The incidence of acute myocardial infarction (AMI) has been rising over the past two decades due to increasing maternal age and a higher prevalence of cardiovascular risk factors in the pregnant population. Causes of AMI in pregnancy are diverse and may require specific considerations for their diagnosis and management. In this narrative review, we provide an overview of physiologic changes, risk factors, and etiologies leading to AMI in pregnancy, as well as diagnostic tools, reperfusion strategies, and pharmacological treatments for this complex population. In addition, we outline considerations for labor and delivery planning and long-term follow-up of patients with AMI in pregnancy.

Analysis of Retinal Blood Vessel Diameters in Pregnant Women Practicing Yoga: A Feasibility Study

Studies have shown that practicing yoga during pregnancy beneficially affects maternal and neonatal outcomes. The objective of this study was to determine the effect of prenatal yoga on the microvascular circulatory system via non-invasive measurements of retinal blood vessels. We included 29 women who practiced prenatal yoga in the study. There were no statistically significant differences in arteriolar and venular diameters pre- vs. post-90 min yoga practice (150.5 ± 11.4 μm pre- vs. 151.2 ± 10.2 μm post-yoga; p = 0.53 for arteriolar and 221.8 ± 16.1 μm pre- vs. 223.2 ± 15.7 μm post-yoga; p = 0.51 for venular diameters). The current study demonstrated the feasibility of the setup. More extensive studies are needed to determine the potential microvascular effects of practicing yoga throughout pregnancy.

Haemolysis Detection in MicroRNA-Seq from Clinical Plasma Samples

The abundance of cell-free microRNA (miRNA) has been measured in blood plasma and proposed as a source of novel, minimally invasive biomarkers for several diseases. Despite improvements in quantification methods, there is no consensus regarding how haemolysis affects plasma miRNA content. We propose a method for haemolysis detection in miRNA high-throughput sequencing (HTS) data from libraries prepared using human plasma. To establish a miRNA haemolysis signature we tested differential miRNA abundance between plasma samples with known haemolysis status. Using these miRNAs with statistically significant higher abundance in our haemolysed group, we further refined the set to reveal high-confidence haemolysis association. Given our specific context, i.e., women of reproductive age, we also tested for significant differences between pregnant and non-pregnant groups. We report a novel 20-miRNA signature used to identify the presence of haemolysis in silico in HTS miRNA-sequencing data. Further, we validated the signature set using firstly an all-male cohort (prostate cancer) and secondly a mixed male and female cohort (radiographic knee osteoarthritis). Conclusion: Given the potential for haemolysis contamination, we recommend that assays for haemolysis detection become standard pre-analytical practice and provide here a simple method for haemolysis detection.

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 PFOS exposure during rat pregnancy causes hypersensitivity to angiotensin II and attenuation of endothelium-dependent vasodilation in the uterine arteries

Epidemiological studies show a strong association between environmental exposure to perfluorooctane sulfonic acid (PFOS) and preeclampsia and fetal growth restriction; however, the underlying mechanisms are unclear. We tested the hypothesis that gestational PFOS exposure leads to pregnancy complications via alterations in uterine vascular endothelium-independent angiotensin II-related mechanisms and endothelium-derived factors such as nitric oxide. Pregnant Sprague Dawley rats were exposed to PFOS 0.005, 0.05, 0.5, 5, 10, and 50 μg/mL through drinking water from gestational day 4 to 20, and dams with PFOS 50 μg/mL were used to assess mechanisms. PFOS exposure dose-dependently increased maternal blood pressure but decreased fetal weights. Uterine artery blood flow was lower and resistance index was higher in the PFOS dams. In PFOS dams, uterine artery contractile responses to angiotensin II were significantly greater, whereas contractile responses to K+ depolarization and phenylephrine were unaffected. Plasma angiotensin II levels were not significantly different between control and PFOS dams; however, PFOS exposure significantly increased AGTR1 and decreased AGTR2 protein levels in uterine arteries. Endothelium-dependent relaxation response to acetylcholine was significantly reduced with decreased endothelial nitric oxide synthase expression in the uterine arteries of PFOS dams. Left ventricular hypertrophy and fibrosis were observed, along with increased ejection fraction and fractional shortening in PFOS dams. These results suggest that elevated maternal PFOS levels decrease uterine blood flow and increase vascular resistance via heightened angiotensin II-mediated vasoconstriction and impaired endothelium-dependent vasodilation, which provides a molecular mechanism linking elevated maternal PFOS levels with gestational hypertension and fetal growth restriction.

Reproductive Issues in Patients With the Fontan Operation

Patients with the Fontan operation have a unique circulation, with a limited ability to increase cardiac output, and high central venous pressure. They may have diastolic and/or systolic ventricular dysfunction, arrhythmias, thromboembolic complications, or multiorgan dysfunction. All of these factors contribute to reproductive issues, including menstrual irregularities, infertility, recurrent miscarriage, and complications during pregnancy. Although atrial arrhythmias are the most common cardiac complications during pregnancy, patients can develop heart failure and thromboembolic events. Obstetric bleeding, including postpartum hemorrhage, is common. In addition to maternal complications, adverse fetal and neonatal events, such as prematurity and low birthweight, are very common. Counselling about these reproductive issues should begin early. For those who become pregnant, care should be provided by a multidisciplinary cardio-obstetric team familiar with the specific issues and needs of the Fontan population. In this review, we discuss infertility, contraception, and pregnancy in patients with the Fontan operation.

Cardio-Obstetrics: the Next Frontier in Cardiovascular Disease Prevention

PURPOSE OF REVIEW

Internationally, cardiovascular disease (CVD) is the leading cause of death in women. With risk factors for CVD continuing to rise, early identification and management of chronic diseases such as hypertension, diabetes, and obstructive sleep apnea is necessary for prevention. Pregnancy is a natural stress test for women with risk factors who may be predisposed to CVD and offers a unique opportunity to not only recognize disease but also implement effective and long-lasting strategies for prevention.

RECENT FINDINGS

Prevention begins before pregnancy, as preconception screening, counseling, and optimization of chronic diseases can improve maternal and fetal outcomes. Throughout pregnancy, women should maintain close follow-up, continued reevaluation of risk factors, with counseling when necessary. Continued healthcare engagement during the "fourth trimester," 3 months following delivery, allows clinicians to continue monitoring the evolution of chronic diseases, encourage ongoing lifestyle counseling, and connect women with primary care and appropriate specialists if needed. Unfortunately, this postpartum period represents a major care gap, as a significant proportion of most women do not attend their scheduled visits. Social determinants of health including decreased access to care and economic instability lead to increased risk factors throughout pregnancy but particularly play a role in poor compliance with postpartum follow-up. The use of telemedicine clinics and remote monitoring may prove to be effective interventions, bridging the gap between physicians and patients and improving follow-up for at-risk women. While many clinicians are beginning to understand the impact of CVD on women, screening and prevention strategies are not often implemented until much later in life. Pregnancy creates an opportunity to begin engaging women in cardiovascular protective strategies before the development of the disease.

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

Out-of-hospital cardiac arrest in pregnant women: a 55-patient French cohort study

AIM

To describe a cohort of pregnant women having suffered an out-of-hospital cardiac arrest (OHCA) and to compare them with nonpregnant women of childbearing age having suffered OHCA.

METHODS

Study data were extracted from the French National OHCA Registry between 2011 and 2021. We compared patients in terms of characteristics, care and survival.

RESULTS

We included 3,645 women of childbearing age (15-44) who had suffered an OHCA; 55 of the women were pregnant. Pregnant women were younger than nonpregnant victims (30 vs. 35 years, p=0.006) and were more likely to have a medical history (76.4% vs. 50.5%, p<0.001) and a medical cause of the OHCA (85.5% vs. 57.2%, p<0.001). Advanced Life Support was more frequently administered to pregnant women (98.2%, vs. 72.0%; p<0.001). In pregnant women, the median time of MICU arrival was 20 minutes for the Medical Intensive Care Unit with no difference with nonpregnant women. Survival rate on admission to hospital was higher among pregnant women (43.6% vs. 27.3%; p=0.009). There was no difference in 30-day survival between pregnant and nonpregnant groups (14.5% vs. 7.3%; p=0.061). Fetal survival was only observed for OHCAs that occurred during the pregnancy second or third trimester (survival rates: 10.0% and 23.5%, respectively).

CONCLUSIONS

Our results show that resuscitation performance does not meet European Resuscitation Council's specific guidelines on OHCA in pregnant women. Although OHCA in pregnancy is rare, the associated prognosis is poor for both woman and fetus. Preventive measures should be reinforced, especially when pregnant women have medical history.

Maternal left ventricular function and adverse neonatal outcomes in women with cardiac disease

Purpose

To evaluate the relationship between maternal left ventricular systolic function, utero-placental circulation, and risk of adverse neonatal outcomes in women with cardiac disease.

Methods

119 women managed in the pregnancy heart clinic (2019–2021) were identified. Women were classified by their primary cardiac condition. Adverse neonatal outcomes were: low birth weight (< 2500 g), small-for-gestational-age (< 10th birth-weight centile), pre-term delivery (< 37 weeks’ gestation), and fetal demise (> 20 weeks’ gestation). Parameters of left ventricular systolic function (global longitudinal strain, radial strain, ejection fraction, average S’, and cardiac output) were calculated and pulsatility index was recorded from last growth scan.

Results

Adverse neonatal outcomes occurred in 28 neonates (24%); most frequently in valvular heart disease (n = 8) and cardiomyopathy (n = 7). Small-for-gestational-age neonates were most common in women with cardiomyopathy (p = 0.016). Early pregnancy average S’ (p = 0.03), late pregnancy average S’ (p = 0.02), and late pregnancy cardiac output (p = 0.008) were significantly lower in women with adverse neonatal outcomes than in those with healthy neonates. There was a significant association between neonatal birth-weight centile and global longitudinal strain (p = 0.04) and cardiac output (p = 0.0002) in late pregnancy. Pulsatility index was highest in women with cardiomyopathy (p = 0.007), and correlated with average S’ (p < 0.0001) and global longitudinal strain (p = 0.03) in late pregnancy.

Conclusion

Women with cardiac disease may not tolerate cardiovascular adaptations required during pregnancy to support fetal growth. Adverse neonatal outcomes were associated with reduced left ventricular systolic function and higher pulsatility index. The association between impaired systolic function and reduced fetal growth is supported by insufficient utero-placental circulation.

The effect of impedance cardiography directed antihypertensive therapy on fetal growth restriction rates and perinatal mortality in women with chronic hypertension

OBJECTIVES

We sought to determine the effect of impedance cardiography directed medical antihypertensive therapy on fetal growth restriction and perinatal mortality in women with chronic hypertension.

STUDY DESIGN

A retrospective study was conducted on 958 women referred to the Maternal Hypertension Center at Cabell Huntington Hospital between 2005 and 2014 for the indication of chronic hypertension.

MAIN OUTCOME MEASURES

Serial assessments of maternal hemodynamics were obtained using non-invasive impedance cardiography. Vasodilators were initiated for increased systemic vascular resistance. Elevated cardiac output was treated with beta blockade.

RESULTS

Blood pressure at initial visit was used to stratify patients into five groups. Initial blood pressure of <130 systolic or <80 diastolic had 24 cases of growth restriction (6.8%) and 6 perinatal deaths (1.7%), 130-139 systolic or 80-89 diastolic resulted in 29 cases of growth restriction (9.3%) and 9 perinatal deaths (2.9%), 140-149 systolic or 90-99 diastolic 14 cases of growth restriction (6.5%) and 3 perinatal deaths (1.4%), 150-159 systolic or 100-109 diastolic had 5 cases of growth restriction (8.6%) and 4 perinatal deaths (6.89%), and >160 systolic or >110 diastolic 3 cases of growth restriction (13%) with no perinatal deaths. There were no differences in growth restriction (p = .59) or perinatal death (p = .15) between the groups.

CONCLUSION

The rates of IUGR and perinatal mortality did not increase even with increasing severity of maternal hypertension. This low cost and non-invasive test should be considered for optimizing rates of growth restriction and perinatal mortality in pregnancies complicated by chronic hypertension.

Cardiac remodelling - Part 2: Clinical, imaging and laboratory findings. A review from the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology

In patients with heart failure, the beneficial effects of drug and device therapies counteract to some extent ongoing cardiac damage. According to the net balance between these two factors, cardiac geometry and function may improve (reverse remodelling, RR) and even completely normalize (remission), or vice versa progressively deteriorate (adverse remodelling, AR). RR or remission predict a better prognosis, while AR has been associated with worsening clinical status and outcomes. The remodelling process ultimately involves all cardiac chambers, but has been traditionally evaluated in terms of left ventricular volumes and ejection fraction. This is the second part of a review paper by the Study Group on Biomarkers of the Heart Failure Association of the European Society of Cardiology dedicated to ventricular remodelling. This document examines the proposed criteria to diagnose RR and AR, their prevalence and prognostic value, and the variables predicting remodelling in patients managed according to current guidelines. Much attention will be devoted to RR in patients with heart failure with reduced ejection fraction because most studies on cardiac remodelling focused on this setting.

ZFP36L2 suppresses mTORc1 through a P53-dependent pathway to prevent peripartum cardiomyopathy in mice

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.

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.

Cardiac disease in pregnancy

In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. The cardiovascular system is not only significantly challenged by physiological alterations in pregnancy but also by obstetric medication. Depending upon the severity of the underlying condition, pregnant women with cardiovascular disease should be managed by a multidisciplinary heart team in which anaesthesiologists play an important role. Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.

Feasibility of continuous distal body temperature for passive, early pregnancy detection

Most American women become aware of pregnancy ~3-7 weeks after conceptive sex, and all must seek testing to confirm their pregnant status. The delay between conceptive sex and pregnancy awareness is often a time in which contraindicated behaviors take place. However, there is long standing evidence that passive, early pregnancy detection may be possible using body temperature. To address this possibility, we analyzed 30 individuals' continuous distal body temperature (DBT) in the 180 days surrounding self-reported conceptive sex in comparison to self-reported pregnancy confirmation. Features of DBT nightly maxima changed rapidly following conceptive sex, reaching uniquely elevated values after a median of 5.5 ± 3.5 days, whereas individuals reported a positive pregnancy test result at a median of 14.5 ± 4.2 days. Together, we were able to generate a retrospective, hypothetical alert a median of 9 ± 3.9 days prior to the date at which individuals received a positive pregnancy test. Continuous temperature-derived features can provide early, passive indication of pregnancy onset. We propose these features for testing and refinement in clinical settings, and for exploration in large, diverse cohorts. The development of pregnancy detection using DBT may reduce the delay from conception to awareness and increase the agency of pregnant individuals.

Preventing hemorrhoids during pregnancy: a multicenter, randomized clinical trial

Background

To compare specific dietary and behavioral recommendations for hemorrhoids prevention during pregnancy.

Methods

This was a randomized, single-blind, multicenter trial conducted in three different clinical centers. Patients were randomly allocated into two groups in a ratio of 1:1. Intervention consisted of specific dietary and behavioral counseling. The primary outcome of this study was the rate of hemorrhoids at the time of discharge from the obstetrics unit. Categorical variables were compared by the Chi-Squared or Fisher exact tests, as appropriate. Continuous variables were compared using either the Student's t-test or the Mann–Whitney U test. Binary logistic regression model was used to identify independent predictors of hemorrhoids after delivery. This analysis was performed on factors with a p-value < 0.10 in univariate analysis. Statistical analysis was performed using IBM SPSS 23.0 and GraphPad Prism 9 software. A P-value of less than 0.05 was considered significant for all tests.

Results

We observed a significantly lower hemorrhoids rate in the intervention group at the time of discharge from the obstetrics unit after delivery (intention-to-treat (ITT) (the relative risk (RR) 0.38; 95% the confidence interval (CI) 0.24–0.59; p < 0.001) per-protocol (PP) (RR 0.42; 95% CI 0.27–0.64; p < 0.001). There was no significant difference in spontaneous miscarriage rate between the groups for both ITT and PP analysis. Additional binary logistic regression analysis revealed that the intervention applied in this study was the only protective factor. Both, the history of hemorrhoids before pregnancy and the increase of newborn height was associated with a higher risk of hemorrhoids.

Conclusions

Our suggested intervention, aimed to modify dietary and behavioral habits, significantly reduces the rate of hemorrhoids after pregnancy and can be safely recommended to pregnant women.

Trial registration

Date of registration: 2016–05-09; Date of initial patient enrollment: 2016–06-02; Trial registration number: 158200–16-843–357; Trial registration site URL: https://www.mf.vu.lt/mokslas/vilniaus-regioninis-biomedicininiu-39tyrimu-etikos-komitetas#isduoti40vrbtek-leidimai. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04688-x.