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Müller LM, Eveslage M, Köster HA, Willy K, Möllers M, Schmitz R, Oelmeier K, Willy D. The Role of Hypertension for Maternal Outcomes of Women with HELLP Syndrome - a Retrospective Study from a Tertiary Obstetric Center. Geburtshilfe Frauenheilkd 2024; 84:635-645. [PMID: 38993801 PMCID: PMC11233203 DOI: 10.1055/a-2308-9698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 04/17/2024] [Indexed: 07/13/2024] Open
Abstract
Introduction HELLP syndrome is a serious disorder that can occur in pregnancy; it has many possible complications and is associated with adverse maternal outcome. Due to the lack of predictive parameters for HELLP syndrome, finding the right time for delivery is challenging. In contrast to preeclampsia, hypertension is not an essential part of the diagnosis; nevertheless, many women with HELLP syndrome are hypertensive. The role and possible implications of hypertension in HELLP syndrome are not fully understood. Material and Methods In this retrospective cohort study, we analyzed the maternal outcomes of 59 patients diagnosed with HELLP syndrome. The patients were divided into three groups according to their blood pressure levels during their stay in hospital. These three groups were compared in terms of patient characteristics and maternal outcomes. A combined endpoint for adverse maternal outcome was defined which included blood pressure and antihypertensive medication at discharge from hospital, severe postpartum anemia, and eclampsia. Results Women with hypertensive crises had an unfavorable outcome compared to women with lower blood pressure levels. Patients with higher blood pressure during pregnancy were more likely to be hypertensive at discharge and needed a combination of antihypertensive agents significantly more often. The risk of an adverse maternal outcome increased with the severity of hypertension. An increase in systolic blood pressure by 10 mmHg raised the risk of an adverse outcome by 74% (95% CI: 1.22-2.66). Conclusion Hypertension not only plays an important role in preeclampsia but also affects the outcomes of patients with HELLP syndrome. These patients need to be identified quickly and treated accordingly as they are at risk of cardiovascular impairment. Patients should be followed up closely after delivery to reduce cardiovascular morbidity.
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Affiliation(s)
- Linda-Marie Müller
- Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Helen Ann Köster
- Clinic for Gynecology and Obstetrics, Frauenarztpraxis am Mexikoplatz, Berlin, Germany
| | - Kevin Willy
- Department of Cardiology, University Hospital Münster, Münster, Germany
| | - Mareike Möllers
- Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
| | - Ralf Schmitz
- Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
| | - Kathrin Oelmeier
- Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
| | - Daniela Willy
- Department of Obstetrics and Gynecology, University Hospital Münster, Münster, Germany
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Vasapollo B, Zullino S, Novelli GP, Farsetti D, Ottanelli S, Clemenza S, Micaglio M, Ferrazzi E, Di Martino DD, Ghi T, Di Pasquo E, Orabona R, Corbella P, Frigo MG, Prefumo F, Stampalija T, Giannubilo SR, Valensise H, Mecacci F. Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine. Am J Perinatol 2024. [PMID: 38350640 DOI: 10.1055/a-2267-3994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
OBJECTIVE The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art. STUDY DESIGN AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version. RESULTS More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life. CONCLUSION Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications. KEY POINTS · Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..
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Affiliation(s)
- Barbara Vasapollo
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Gian Paolo Novelli
- Department of Integrated Care Services, Prehospitalization Unit, Policlinico di Tor Vergata, Rome, Italy
| | - Daniele Farsetti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Serena Ottanelli
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Sara Clemenza
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Unit of Obstetric and Gynecologic Anesthesia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Tullio Ghi
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elvira Di Pasquo
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rossana Orabona
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paola Corbella
- Maternal Infant Department SC, Obstetrics and Gynecology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Grazia Frigo
- Department of Anesthesia and Resuscitation in Obstetrics, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | - Federico Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Stefano Raffaele Giannubilo
- Department of Obstetrics and Gynecology, Marche Polytechnic University, Ancona, Italy
- Department of Clinical Sciences, Polytechnic University of Marche Salesi Hospital, Ancona, Italy
| | - Herbert Valensise
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Federico Mecacci
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
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Cutler HR, Barr L, Sattwika PD, Frost A, Alkhodari M, Kitt J, Lapidaire W, Lewandowski AJ, Leeson P. Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review. Eur J Prev Cardiol 2024; 31:77-99. [PMID: 37607255 PMCID: PMC10767256 DOI: 10.1093/eurjpc/zwad275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 08/24/2023]
Abstract
AIMS Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum. METHODS AND RESULTS Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum. CONCLUSION The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.
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Affiliation(s)
- Hannah Rebecca Cutler
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Logan Barr
- Department of Biomedical and Molecular Sciences, Queens University, Barrie St, Kingston, Canada
| | - Prenali Dwisthi Sattwika
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Bulaksumur, Caturtunggal, Kec, Kabupaten Sleman, Indonesia
| | - Annabelle Frost
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Mohanad Alkhodari
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
- Healthcare Engineering Innovation Center, Department of Biomedical Engineering, Khalifa University, Abu Dhabi, Shakhbout Bin Sultan St, Hadbat Al Za'faranah, United Arab Emirates
| | - Jamie Kitt
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Winok Lapidaire
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Adam James Lewandowski
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
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Barr LC, Liblik K, Johri AM, Smith GN. Maternal Cardiovascular Function Following a Pregnancy Complicated by Preeclampsia. Am J Perinatol 2022; 39:1055-1064. [PMID: 33321533 DOI: 10.1055/s-0040-1721694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preeclampsia is a hypertensive pregnancy complication with an unknown etiology and high maternal burden worldwide. Burgeoning research has linked preeclampsia to adverse maternal health outcomes remote from pregnancy; however, the intermediary mechanisms responsible for this association have not been sufficiently established. In the present narrative review, we summarize leading evidence of structural and functional cardiovascular changes associated with prior preeclampsia, and how these changes may be linked to future maternal disease. KEY POINTS: · Prior preeclampsia is associated with subclinical structural and functional vascular changes remote from pregnancy.. · Maternal cardiac adaptations to preeclampsia may have long-term implications on cardiovascular health.. · Clinicians have an opportunity to minimize maternal disease risk following preeclampsia..
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Affiliation(s)
- Logan C Barr
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Kiera Liblik
- Cardiovascular Imaging Network at Queen's, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Cardiovascular Imaging Network at Queen's, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Graeme N Smith
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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Noninvasive Cardiac Imaging in Formerly Preeclamptic Women for Early Detection of Subclinical Myocardial Abnormalities: A 2022 Update. Biomolecules 2022; 12:biom12030415. [PMID: 35327607 PMCID: PMC8946283 DOI: 10.3390/biom12030415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Preeclampsia is a maternal hypertensive disease, complicating 2–8% of all pregnancies. It has been linked to a 2–7-fold increased risk for the development of cardiovascular disease, including heart failure, later in life. A total of 40% of formerly preeclamptic women develop preclinical heart failure, which may further deteriorate into clinical heart failure. Noninvasive cardiac imaging could assist in the early detection of myocardial abnormalities, especially in the preclinical stage, when these changes are likely to be reversible. Moreover, imaging studies can improve our insights into the relationship between preeclampsia and heart failure and can be used for monitoring. Cardiac ultrasound is used to assess quantitative changes, including the left ventricular cavity volume and wall thickness, myocardial mass, systolic and diastolic function, and strain. Cardiac magnetic resonance imaging may be of additional diagnostic value to assess diffuse and focal fibrosis and perfusion. After preeclampsia, sustained elevated myocardial mass along with reduced myocardial circumferential and longitudinal strain and decreased diastolic function is reported. These findings are consistent with the early phases of heart failure, referred to as preclinical (asymptomatic) or B-stage heart failure. In this review, we will provide an up-to-date overview of the potential of cardiac magnetic resonance imaging and echocardiography in identifying formerly preeclamptic women who are at high risk for developing heart failure. The potential contribution to early cardiac screening of women with a history of preeclampsia and the pros and cons of these imaging modalities are outlined. Finally, recommendations for future research are presented.
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Inappropriate left ventricular mass after HELLP syndrome inappropriate LVM after HELLP syndrome. Pregnancy Hypertens 2021; 27:16-22. [PMID: 34844072 DOI: 10.1016/j.preghy.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Excessive left ventricular mass (LVM) results in inefficient LV work with energy waste leading to a negative prognostic effect. We aimed at investigating the presence of inappropriate LVM and calculating the myocardial mechano-energetic efficiency index (MEEi) in former pre-eclamptic (PE) women (with or without HELLP syndrome) compared to women who experienced HELLP syndrome without PE. STUDY DESIGN In this cross-sectional study, women with a history of normotensive HELLP (n = 32), PE without HELLP (n = 59), and PE with HELLP (n = 101) underwent echocardiography as part of the clinical CV work-up after their complicated pregnancies from 6 months to 4 years postpartum. We excluded women with comorbidities, including chronic hypertension, hypercholesterolemia, and obesity. MAIN OUTCOME MEASURES LVM excess was calculated as the ratio between observed LVM and predicted LVM (by sex, stroke work and height), while MEEi was considered as the ratio between stroke work and "double product" (to approximate energy consumption), indexed to LVM. RESULTS LV hypertrophy was present in 8-14% and concentric remodeling in 31-42% of women, without intergroup difference. LVM was inappropriate in one-third of normotensive former HELLP and in about one-half of PE with or without HELLP, with no difference among groups. Accordingly, without nominal difference, MEEi showed a tendency towards lower values in former pre-eclamptic individuals. CONCLUSIONS Women with a history of HELLP syndrome, independently from the presence/absence of PE, showed inappropriate LVM in the first 4 years after delivery, which may partially explain the elevated CV risk in these women compared to the general female population.
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Sciatti E, Mohseni Z, Orabona R, Mulder EG, Prefumo F, Lorusso R, Frusca T, Ghossein-Doha C, Spaanderman ME. Maternal myocardial dysfunction after hemolysis, elevated liver enzymes, and low platelets syndrome: a speckle-tracking study. J Hypertens 2021; 39:1956-1963. [PMID: 34173798 PMCID: PMC10231931 DOI: 10.1097/hjh.0000000000002901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/10/2021] [Accepted: 04/29/2021] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Pregnancy complicated by pre-eclampsia (PE) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is associated with an increased risk of cardiovascular (CV) diseases later in life. Subclinical cardiac alterations precede eminent CV diseases. Speckle-tracking echocardiography (STE) is an effective method to assess subclinical myocardial dysfunction. We performed a myocardial speckle tracking study to investigate the prevalence of subclinical myocardial dysfunction in former PE patients (with and without HELLP syndrome) compared to normotensive women affected by HELLP syndrome. METHODS In this cross-sectional retrospective study, women with a history of normotensive HELLP (n = 32), PE without HELLP (n = 59), and PE with HELLP (n = 101) underwent conventional and STE as part of the clinical CV work-up after their complicated pregnancies from 6 months to 4 years postpartum. We excluded women with comorbidities, including chronic hypertension, hypercholesterolemia, and obesity. RESULTS Women with a history of PE with HELLP syndrome were characterized by a higher prevalence of altered left ventricular circumferential and global longitudinal two-dimensional (2D) strain (74 and 20%, respectively), altered right ventricular longitudinal 2D strain (37%), and left atrial (LA) 2D strain (57%). Moreover, a higher proportion of alterations of biventricular and LA strains was also present in former PE without HELLP as well as in the normotensive HELLP group. CONCLUSIONS In the first years after a pregnancy complicated by HELLP syndrome, irrespective of whether there was concomitant PE, a higher rate of abnormal STE myocardial function is observed. Therefore, these women may benefit from CV risk management.
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Affiliation(s)
- Edoardo Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Center (MUMC), The Netherlands
| | - Zenab Mohseni
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), The Netherlands
| | - Rossana Orabona
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), The Netherlands
- Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Eva G. Mulder
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), The Netherlands
| | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Center (MUMC), The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Tiziana Frusca
- Department of Clinical and Experimental Sciences, University of Brescia, Italy
- Department of Obstetrics and Gynecology, University of Parma, Italy
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), The Netherlands
- Department of Cardiology, Heart & Vascular Centre, Maastricht University Medical Center (MUMC), The Netherlands
| | - Marc E.A. Spaanderman
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), The Netherlands
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Countouris ME, Villanueva FS, Berlacher KL, Cavalcante JL, Parks WT, Catov JM. Association of Hypertensive Disorders of Pregnancy With Left Ventricular Remodeling Later in Life. J Am Coll Cardiol 2021; 77:1057-1068. [PMID: 33632480 PMCID: PMC10544734 DOI: 10.1016/j.jacc.2020.12.051] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are associated with short-term cardiac structure and function abnormalities, but later life changes are not well studied. OBJECTIVES This study aimed to determine if HDP history is associated with echocardiographic differences 8 to 10 years after delivery, and if subgroups with placental maternal vascular malperfusion (MVM) lesions or current hypertension may be particularly affected. METHODS Women with pregnancies delivered from 2008 to 2009 were selected from a clinical cohort with abstracted pregnancy and placental pathology data to undergo transthoracic echocardiography (2017 to 2020). Medical history, blood pressure, and weight were measured at the study visit. RESULTS The authors enrolled 132 women (10 ± 1 years post-delivery, age 38 ± 6 years): 102 with normotensive pregnancies and 30 with HDP: pre-eclampsia (n = 21) or gestational hypertension (n = 9). Compared with women with normotensive pregnancies, those with HDP history were more likely to have current hypertension (63% vs. 26%; p < 0.001). After adjusting for age, race, MVM lesions, body mass index, current hypertension, and hemoglobin A1c, women with HDP history had higher interventricular septal thickness (β = 0.08; p = 0.04) and relative wall thickness (β = 0.04; p = 0.04). In subgroup analyses, those with both HDP history and current hypertension had a higher proportion of left ventricular remodeling (79.0%) compared with all other groups (only HDP [36.4%; p = 0.01], only current hypertension [46.2%; p = 0.02], and neither HDP nor hypertension [38.2%; p < 0.001]), and lower mitral inflow E/A and annular e'. Accounting for placental MVM lesions did not impact results. CONCLUSIONS Women with both HDP history and current hypertension have pronounced differences in left ventricular structure and function a decade after pregnancy, warranting continued surveillance and targeted therapies for cardiovascular disease prevention.
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Affiliation(s)
- Malamo E Countouris
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA.
| | - Flordeliza S Villanueva
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - Kathryn L Berlacher
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania, USA
| | - João L Cavalcante
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - W Tony Parks
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Janet M Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences and Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Sciatti E, Orabona R, Prefumo F, Vizzardi E, Bonadei I, Valcamonico A, Metra M, Frusca T. Elastic properties of ascending aorta and ventricular-arterial coupling in women with previous pregnancy complicated by HELLP syndrome. J Hypertens 2020; 37:356-364. [PMID: 30234780 DOI: 10.1097/hjh.0000000000001888] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To compare the elastic properties of the ascending aorta and ventricular-arterial coupling (VAC) in women with a previous pregnancy complicated by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, women who experienced preeclampsia, and healthy controls. METHODS Women with a history of preeclampsia (n = 60) or HELLP syndrome (n = 49) and matched healthy controls (n = 60) underwent transthoracic echocardiography at 6 months to 4 years after delivery. Aortic M-mode and tissue Doppler imaging (TDI) parameters were measured. Aortic diameters were assessed at end-diastole at four levels: Valsalva sinuses, sinotubular junction, tubular tract, and aortic arch. Aortic compliance, distensibility, stiffness index, Peterson's elastic modulus, pulse-wave velocity, and M-mode strain were calculated using standard formulae. Aortic expansion velocity, early and late diastolic retraction velocities, and peak systolic tissue strain (TDI-ε) were determined. VAC was defined as the ratio between aortic elastance (Ea) and left ventricular end-systolic elastance (Ees). All women were free from cardiovascular risk factors. RESULTS Women with a history of HELLP syndrome showed larger aortas than those with previous preeclampsia or controls, probably related to a higher blood pressure. Aortic elastic properties, including Ea, were similar between HELLP and preeclampsia groups, even comparing cases with early-onset preeclampsia and HELLP. In contrast, Ees was more impaired in the HELLP group than in the other two. Consequently, about one-quarter of women who experienced HELLP syndrome had a pathological VAC, whereas only 5% of previously preeclamptic patients did. Multivariate analysis confirmed the association between HELLP syndrome and VAC, whereas other parameters including aortic compliance, distensibility, stiffness index, and elastic modulus are linked only to gestational age at preeclampsia onset, ad also Ea and Ees did. CONCLUSIONS We found a significant overlap between the aortic elastic properties in women with a history of preeclampsia and those with a previous HELLP syndrome, suggesting a common pathophysiologic pathway. However, women who experienced HELLP syndrome showed a higher blood pressure than other cases and controls, probably determining larger aortas. In addition, VAC was more altered in the HELLP group than in the others because of a higher Ea and a lower Ees.
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Affiliation(s)
- Edoardo Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health
| | - Rossana Orabona
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia
| | - Federico Prefumo
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia
| | - Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health
| | - Ivano Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health
| | - Adriana Valcamonico
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia
| | - Marco Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health
| | - Tiziana Frusca
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia.,Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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Melchiorre K, Thilaganathan B, Giorgione V, Ridder A, Memmo A, Khalil A. Hypertensive Disorders of Pregnancy and Future Cardiovascular Health. Front Cardiovasc Med 2020; 7:59. [PMID: 32351977 PMCID: PMC7174679 DOI: 10.3389/fcvm.2020.00059] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/24/2020] [Indexed: 12/24/2022] Open
Abstract
Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations. These women are known to have higher cardiovascular morbidity and mortality later in life in comparison with parous controls who had normotensive pregnancies. Several studies have demonstrated that women with preeclampsia present in a state of segmental impaired myocardial function, biventricular chamber dysfunction, adverse biventricular remodeling, and hypertrophy, a compromised hemodynamic state and indirect echocardiographic signs of localized myocardial ischemia and fibrosis. These cardiac functional and geometric changes are known to have strong predictive value for cardiovascular disease in non-pregnant subjects. A "dose effect" response seems to regulate this relationship with severe HDP, early-onset HDP, coexistence of fetal growth disorders, and recurrence of HDP resulting in poorer cardiovascular measures. The mechanism underlying the relationship between HDP in younger women and cardiovascular disease later in life is unclear but could be explained by sharing of pre-pregnancy cardiovascular risk factors or due to a direct impact of HDP on the maternal cardiovascular system conferring a state of increased susceptibility to future metabolic or hemodynamic insults. If so, the prevention of HDP itself would become all the more urgent. Shortly after delivery, women who experienced HDP express an increased risk of classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile, and diabetes with higher frequency than controls. Within one or two decades after delivery, this group of women are more likely to experience premature cardiovascular events, such as symptomatic heart failure, myocardial ischemia, and cerebral vascular disease. Although there is general agreement that women who suffered from HDP should undertake early screening for cardiovascular risk factors in order to allow for appropriate prevention, the exact timing and modality of screening has not been standardized yet. Our findings suggest that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, stop smoking, healthy diet, and daily exercise which are well-established and cost-effective prevention strategies.
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Affiliation(s)
- Karen Melchiorre
- Department of Obstetrics and Gynecology, Spirito Santo Hospital of Pescara, Pescara, Italy
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Veronica Giorgione
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Anna Ridder
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Alessia Memmo
- Department of Obstetrics and Gynecology, Spirito Santo Hospital of Pescara, Pescara, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
- *Correspondence: Asma Khalil
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11
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Sciatti E, Orabona R, Prefumo F, Frusca T. Ultrasound evaluation of left ventricular and aortic fibrosis after HELLP syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:839-840. [PMID: 31432565 DOI: 10.1002/uog.20847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 08/04/2019] [Accepted: 08/09/2019] [Indexed: 06/10/2023]
Affiliation(s)
- E Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - R Orabona
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - F Prefumo
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - T Frusca
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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12
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Reddy M, Wright L, Rolnik DL, Li W, Mol BW, La Gerche A, da SilvaCosta F, Wallace EM, Palmer K. Evaluation of Cardiac Function in Women With a History of Preeclampsia: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2019; 8:e013545. [PMID: 31698969 PMCID: PMC6915290 DOI: 10.1161/jaha.119.013545] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Women with a history of preeclampsia are at increased risk of cardiovascular morbidity and mortality. However, the underlying mechanisms of disease association, and the ideal method of monitoring this high‐risk group, remains unclear. This review aims to determine whether women with a history of preeclampsia show clinical or subclinical cardiac changes when evaluated with an echocardiogram. Methods and Results A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify studies that examined cardiac function in women with a history of preeclampsia, in comparison with those with normotensive pregnancies. In the 27 included studies, we found no significant differences between preeclampsia and nonpreeclampsia women with regard to left ventricular ejection fraction, isovolumetric relaxation time, or deceleration time. Women with a history of preeclampsia demonstrated a higher left ventricular mass index and relative wall thickness with a mean difference of 4.25 g/m2 (95% CI, 2.08, 6.42) and 0.03 (95% CI, 0.01, 0.05), respectively. In comparison with the nonpreeclampsia population, they also demonstrated a lower E/A and a higher E/e′ ratio with a mean difference of −0.08 (95% CI, −0.15, −0.01) and 0.84 (95% CI, 0.41, 1.27), respectively. Conclusions In comparison with women who had a normotensive pregnancy, women with a history of preeclampsia demonstrated a trend toward altered cardiac structure and function. Further studies with larger sample sizes and consistent echocardiogram reporting with the use of sensitive preclinical markers are required to assess the role of echocardiography in monitoring this high‐risk population group.
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Affiliation(s)
- Maya Reddy
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
| | - Leah Wright
- Baker Heart and Diabetes Institute Melbourne Victoria Australia
| | - Daniel Lorber Rolnik
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Department of Cardiology St Vincent's Hospital Melbourne Victoria Australia
| | - Fabricio da SilvaCosta
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Department of Gynecology and Obstetrics Ribeirão Preto Medical School University of São Paulo Ribeirão Preto Brazil
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Kirsten Palmer
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
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13
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Cavazzana I, Piantoni S, Sciatti E, Fredi M, Taraborelli M, Bonadei I, Airò P, Metra M, Tincani A, Franceschini F, Vizzardi E. Relationship between endothelial dysfunction, videocapillaroscopy and circulating CD3+CD31+CXCR4+ lymphocytes in systemic lupus erythematosus without cardiovascular risk factors. Lupus 2019; 28:210-216. [PMID: 30608206 DOI: 10.1177/0961203318821161] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The objective of this paper is to analyse whether digital capillary morphology, analysed by nailfold videocapillaroscopy (NVC), and the number of circulating CD3 + CD31 + CXCR4 + lymphocytes (angiogenic T cells) could be markers of endothelial dysfunction (ED) in systemic lupus erythematosus (SLE) without cardiovascular disease (CVD) and CV risk factors. METHODS Nineteen consecutive SLE patients, according to Systemic Lupus International Collaborating Clinics Classification Criteria, with a disease duration less than five years, low disease activity, without CVD and CV risk factors (diabetes, chronic renal disease, uncontrolled systemic arterial hypertension, smoking, hypercholesterolemia, obesity), statin or beta-blocker use were enrolled. Each patient and sex- and age-matched healthy control (HC) underwent Doppler echocardiogram, an endothelial function study by peripheral arterial tonometry technique, NVC and peripheral blood immunophenotyping. RESULTS SLE ED+ more frequently showed NVC abnormalities compared with HCs ( p < 0.0001) in terms of minor alterations ( p = 0.017), lower capillary numbers ( p = 0.0035) and major alterations. SLE ED + showed a higher rate of CD3 + CD31 + CXCR4 + lymphocytes compared with SLE ED- and with HCs. NVC + SLE showed a significantly reduced rate of total CD3 + cells, but a higher rate and absolute number of CD3 + CD31 + CXCR4 + , compared with NVC- SLE. CONCLUSION NVC alterations are frequent in SLE without any CV risk factors and CVD. They are associated with ED and increased circulating CD3 + CD31 + CXCR4 + lymphocytes. These findings demonstrate a clear microvascular perturbation in patients with short disease duration, low disease activity and no CV risk factors.
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Affiliation(s)
- I Cavazzana
- 1 Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - S Piantoni
- 1 Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy.,2 Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - E Sciatti
- 3 Cardiology Unit, ASST-Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - M Fredi
- 1 Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy.,2 Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - M Taraborelli
- 4 Internal Medicine Unit, ASST Franciacorta, Chiari (Brescia), Italy
| | - I Bonadei
- 3 Cardiology Unit, ASST-Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - P Airò
- 1 Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy
| | - M Metra
- 3 Cardiology Unit, ASST-Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - A Tincani
- 1 Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy.,2 Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - F Franceschini
- 1 Rheumatology and Clinical Immunology Unit, ASST-Spedali Civili of Brescia, Brescia, Italy.,2 Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - E Vizzardi
- 3 Cardiology Unit, ASST-Spedali Civili of Brescia, University of Brescia, Brescia, Italy
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14
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Orabona R, Sciatti E, Vizzardi E, Prefumo F, Bonadei I, Valcamonico A, Metra M, Lorusso R, Ghossein-Doha C, Spaanderman MEA, Frusca T. Inappropriate left ventricular mass after preeclampsia: another piece of the puzzle Inappropriate LVM and PE. Hypertens Res 2018; 42:522-529. [PMID: 30552407 DOI: 10.1038/s41440-018-0163-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/27/2018] [Accepted: 09/12/2018] [Indexed: 01/25/2023]
Abstract
Excessive left ventricular (LV) mass (LVM) increase results in inefficient LV work with high energy waste and a negative prognostic effect. We aimed to investigate the presence of inappropriate LVM and to calculate the myocardial mechanoenergetic efficiency index (MEEi) in asymptomatic women with a history of early-onset (EO) or late-onset (LO) pre-eclampsia (PE). Among all women diagnosed with PE in the years 2009-2013, after applying inclusion/exclusion criteria and cost-effectiveness analysis, we randomly selected thirty women who experienced EO-PE, thirty with a previous LO-PE and thirty healthy controls to undergo echocardiography from 6 months to 4 years after delivery. Data regarding gestational age (GA) and mean uterine artery (UtA) pulsatility index (PI) at PE onset were collected from medical records. All women were free from cardiovascular risk factors. LVM excess was calculated as the ratio between observed LVM and predicted LVM (by sex, stroke work and height), while MEEi was calculated as the ratio between stroke work and "double product" (to approximate energy consumption), indexed to LVM. Concentric remodeling was present in 60% of EO-PE and 53% of LO-PE. LVM excess was significantly more often present in the EO-PE group than in the control group. LVM was inappropriate in 52% of EO-PE and 17% of LO-PE. MEEi showed a tendency towards lower values in the EO-PE group. Multivariate regression analysis showed that both LVM excess and MEEi were independently associated with lower GA and higher mean UtA PI at PE onset. Inappropriate LVM with a tendency towards reduced MEEi in the first 4 years after delivery may partially explain the elevated cardiovascular risk in former pre-eclamptic women compared to the general population.
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Affiliation(s)
- Rossana Orabona
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy. .,Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands.
| | - Edoardo Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Ivano Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Adriana Valcamonico
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - Marco Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
| | - Tiziana Frusca
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy.,Department of Obstetrics and Gynecology, University of Parma, Brescia, Italy
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15
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Hieda M, Yoo JK, Sun DD, Okada Y, Parker RS, Roberts-Reeves MA, Adams-Huet B, Nelson DB, Levine BD, Fu Q. Time course of changes in maternal left ventricular function during subsequent pregnancy in women with a history of gestational hypertensive disorders. Am J Physiol Regul Integr Comp Physiol 2018; 315:R587-R594. [PMID: 29897820 PMCID: PMC6230888 DOI: 10.1152/ajpregu.00040.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/29/2018] [Accepted: 06/11/2018] [Indexed: 01/04/2023]
Abstract
Women with a history of gestational hypertensive disorders (GHD) are at increased risk for developing perinatal cardiovascular complications (e.g., gestational hypertension, preeclampsia, etc.) in subsequent pregnancies. The underlying mechanisms remain uncertain, but impaired maternal left ventricular function may be one contributing factor for these complications. We evaluated the time course of changes in left ventricular function before, during, and after pregnancy in women with prior GHD. Sixteen women with a history of GHD (the high-risk group) and 25 women without such a history (controls) were enrolled. Resting hemodynamic and echocardiographic measurements were longitudinally performed before pregnancy, during early pregnancy (4-8 wk of gestation), during late pregnancy (32-36 wk of gestation), and postpartum (6-10 wk after delivery). Pregnancy outcomes were obtained after delivery. At prepregnancy, there was no difference in blood pressure and heart rate between the groups. Corrected isovolumic relaxation time was longer, E/ e' was larger, and Tei index was greater in the high-risk group than controls. Moreover, the rate of GHD during the study was significantly greater in the high-risk group than controls [odds ratio = 8.94 (95% confidence interval: 1.55-51.5), P = 0.007]. Multiple logistic regression analysis adjusted for age demonstrated that prepregnancy E/ e' was an independent predictor for GHD ( P = 0.017). Thus, women with a history of GHD have modestly impaired cardiac function prepregnancy compared with controls, which identifies an increased susceptibility to developing cardiovascular complications during a subsequent pregnancy.
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Affiliation(s)
- Michinari Hieda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeung-Ki Yoo
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dan-Dan Sun
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yoshiyuki Okada
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rosemary S Parker
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Monique A Roberts-Reeves
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Beverley Adams-Huet
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
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16
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Taraborelli M, Sciatti E, Bonadei I, Terlizzi V, Fredi M, Zani R, Cancarini G, Tincani A, Franceschini F, Vizzardi E, Cavazzana I. Endothelial Dysfunction in Early Systemic Lupus Erythematosus Patients and Controls Without Previous Cardiovascular Events. Arthritis Care Res (Hoboken) 2018; 70:1277-1283. [DOI: 10.1002/acr.23495] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 12/05/2017] [Indexed: 01/30/2023]
Affiliation(s)
- Mara Taraborelli
- Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Edoardo Sciatti
- University of Brescia and Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Ivano Bonadei
- University of Brescia and Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Vincenzo Terlizzi
- University of Brescia and Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Micaela Fredi
- Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Roberta Zani
- Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Giovanni Cancarini
- University of Brescia and Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Angela Tincani
- University of Brescia and Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Franco Franceschini
- Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Enrico Vizzardi
- University of Brescia and Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
| | - Ilaria Cavazzana
- Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia; Brescia Italy
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17
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Parikh P, Blauwet L. Peripartum Cardiomyopathy and Preeclampsia: Overlapping Diseases of Pregnancy. Curr Hypertens Rep 2018; 20:69. [PMID: 29971645 DOI: 10.1007/s11906-018-0868-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Hypertensive disorders of pregnancy (HDP) often result in cardiac dysfunction and have been variably included as a risk factor for peripartum cardiomyopathy (PPCM). However, there is debate regarding the relationship between the two entities. RECENT FINDINGS Diastolic dysfunction appears to be more predominant among gravidas with HDP, while systolic dysfunction predominates in PPCM. However, this finding is not consistent in all studies. Recent examinations of mortality and morbidity associated with PPCM in the setting of HDP do not demonstrate a predominant pattern with a mixture of results. Further, right ventricular dysfunction is identified to be a common theme in both populations. From a basic science perspective, there is evidence to demonstrate a predominantly anti-angiogenic milieu in both PPCM and HDP. PPCM and HDP associated cardiomyopathy overlap significantly. As such, unifying theories for their pathophysiology should be investigated.
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Affiliation(s)
- Pavan Parikh
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mayo Clinic, 200 1st Street South West, Rochester, MN, 55905, USA.
| | - Lori Blauwet
- Department of Cardiovascular Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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18
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Sava RI, March KL, Pepine CJ. Hypertension in pregnancy: Taking cues from pathophysiology for clinical practice. Clin Cardiol 2018; 41:220-227. [PMID: 29485737 PMCID: PMC6490052 DOI: 10.1002/clc.22892] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 01/05/2018] [Indexed: 12/19/2022] Open
Abstract
Pregnancy-related hypertension (PHTN) syndromes are a frequent and potentially deadly complication of pregnancy, while also negatively impacting the lifelong health of the mother and child. PHTN appears in women likely to develop hypertension later in life, with the stress of pregnancy unmasking a subclinical hypertensive phenotype. However, distinguishing between PHTN and chronic hypertension is essential for optimal management. Preeclampsia (PE) is linked to potentially severe outcomes and lacks effective treatments due to poorly understood mechanisms. Inadequate remodeling of spiral uterine arteries (SUAs), the cornerstone of PE pathophysiology, leads to hypoperfusion of the developing placenta. In normal pregnancies, extravillous trophoblast (EVT) cells assume an invasive phenotype and invade SUAs, transforming them into large conduits. Decidual natural killer cells play an essential role, mediating materno-fetal immune tolerance, inducing early SUA remodeling and regulating EVT invasiveness. Notch signaling is important in EVT phenotypic switch and is dysregulated in PE. The hypoxic placenta releases antiangiogenic and proinflammatory factors that converge upon maternal endothelium, inducing endothelial dysfunction, hypertension, and organ damage. Hypoxia-inducible factor 1-α is upstream of such molecules, whereas endothelin-1 is a major effector. We also describe important genetic links and evidence of incomplete materno-fetal immune tolerance, with PE patients presenting with autoantibodies, lower Treg , and higher Th 17 cells. Thus, PE manifestations arise as a consequence of mal-placentation or/and because of a predisposition of the maternal vascular bed to excessively react to pathogenic molecules. From this pathophysiological basis, we provide current and propose future therapeutic directions for PE.
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Affiliation(s)
- Ruxandra I. Sava
- Center for Regenerative MedicineUniversity of FloridaGainesvilleFlorida
- “Elias” Emergency University Hospital“Carol Davila” University of Medicine and PharmacyBucharestRomania
- Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleFlorida
| | - Keith L. March
- Center for Regenerative MedicineUniversity of FloridaGainesvilleFlorida
- Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleFlorida
| | - Carl J. Pepine
- Center for Regenerative MedicineUniversity of FloridaGainesvilleFlorida
- Division of Cardiovascular MedicineUniversity of Florida College of MedicineGainesvilleFlorida
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19
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Orabona R, Sciatti E, Vizzardi E, Bonadei I, Prefumo F, Valcamonico A, Metra M, Frusca T. Maternal endothelial function and vascular stiffness after HELLP syndrome: a case-control study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:596-602. [PMID: 28004456 DOI: 10.1002/uog.17394] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/13/2016] [Accepted: 12/16/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To assess endothelial function and arterial stiffness in women with a previous pregnancy complicated by pre-eclampsia (PE) with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, and to compare these findings to those in women with previous PE but no HELLP and to those in controls with previous uncomplicated pregnancy, in order to investigate the influence of HELLP syndrome on subsequent cardiovascular impairment. METHODS In this prospective single-center case-control study, we performed peripheral arterial tonometry (PAT) (using the EndoPAT method) and pulse-wave velocity (PWV) assessment in 109 women who had had a singleton pregnancy complicated by PE with (n = 49) or without (n = 60) HELLP syndrome, as well as in 60 controls with previous uncomplicated pregnancy, between 6 months and 4 years after delivery. The following EndoPAT and PWV indices were compared between groups: reactive hyperemia index (RHI), as an indication of endothelial function, and peripheral and aortic heart-rate-corrected augmentation indices (AIx) standardized for a heart rate of 75 bpm (AIx@75) and carotid-femoral pulse-wave velocity (cfPWV), as indications of arterial stiffness. RESULTS PAT and arterial stiffness indices were significantly different between PE cases, with or without previous HELLP, and controls, except for carotid-femoral PWV. There were no significant differences among PE groups: women who had experienced HELLP and those with a history of PE without HELLP showed similar rates of RHI ≤ 1.67 (28.6% vs 18.3%, P = 0.254) and RHI ≤ 2.00 (61.2% vs 41.7%, P = 0.055), peripheral AIx@75 ≥ 17% (38.8% vs 30.0%, P = 0.417), aortic AIx@75 ≥ 35% (29.2% vs 20.0%, P = 0.461) and cfPWV × 0.8 > 9.6 m/s, which occurred in only three women, all in the group without previous HELLP (0% vs 5.0%, P = 0.251). On multivariate regression analysis, HELLP syndrome, intrauterine growth restriction (IUGR) and early-onset PE independently predicted endothelial dysfunction at 6 months to 4 years postpartum, after correcting for uterine artery pulsatility index, birth-weight percentile, and maternal blood pressure, age and body mass index. Women with both previous HELLP and early-onset IUGR had a significantly higher prevalence of endothelial dysfunction (P = 0.001). CONCLUSION Similar vascular abnormalities were found in women previously affected by HELLP syndrome and those with previous PE without HELLP. However, a history of HELLP syndrome, IUGR and early-onset PE seems to identify a subgroup of women with a higher risk for future development of endothelial dysfunction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Orabona
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - E Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - E Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - I Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - F Prefumo
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - A Valcamonico
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - M Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - T Frusca
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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