Ophthalmic artery Doppler for prediction of pre-eclampsia: systematic review and meta-analysis

Relationship of maternal ophthalmic artery Doppler with uterine artery Doppler, hemodynamic indices and gestational age: prospective MATERA study

OBJECTIVES

To examine the relationship of ophthalmic artery (OA) Doppler indices with uterine artery (UtA) Doppler indices, selected maternal hemodynamic parameters and gestational age, and to evaluate the intraobserver reproducibility of OA Doppler indices.

METHODS

This was a prospective cohort study of women recruited between 11 + 0 and 23 + 6 weeks' gestation using a stratified and random sampling approach to ensure adequate distribution across the gestational-age range. OA pulsatility index (PI), first peak systolic velocity (PSV1), second peak systolic velocity (PSV2) and peak systolic velocity ratio (PSV ratio), calculated as PSV2/PSV1, were measured twice in each eye by the same observer. UtA-PI was also measured twice on each side by the same observer. Maternal hemodynamic assessment was undertaken using an ultrasonic cardiac output monitor (USCOM 1A). Pearson's and Spearman's rank correlation coefficients were used to assess the correlations between variables, and Bland-Altman plots were used to evaluate the intraobserver reproducibility of OA Doppler indices.

RESULTS

Of 194 women invited to participate in the study, 169 were eligible for inclusion, of whom 16 were excluded following an obstetric ultrasound scan and a further three owing to inadequate or incomplete OA or UtA Doppler assessment, leaving 150 women in the final analysis. Log UtA-PI had a weak correlation with both OA-PI (r = -0.19 (95% CI, -0.34 to -0.03), P = 0.021) and OA-PSV ratio (r = 0.31 (95% CI, 0.15-0.45), P < 0.001). The correlation between gestational age and OA-PI was non-significant (r = 0.14 (95% CI, -0.03 to 0.29), P = 0.097), and that between gestational age and OA-PSV ratio was weak (r = -0.23 (95% CI, -0.38 to -0.07), P = 0.004), as opposed to the strong correlation between gestational age and UtA-PI (r = -0.68 (95% CI, -0.76 to -0.58), P < 0.001). No strong correlations were observed between OA-PI or OA-PSV ratio and maternal hemodynamic indices. The correlations were unaltered by adjustment for maternal age and body mass index. The intraobserver reproducibility of OA-PI and OA-PSV ratio in the same eye was high. The correlation between the right and left eyes was moderate for OA-PI (r = 0.63 (95% CI, 0.53-0.72), P < 0.001) and strong for OA-PSV ratio (r = 0.81 (95% CI, 0.75-0.86), P < 0.001).

CONCLUSIONS

OA-PI and OA-PSV ratio had a weak or no correlation with UtA-PI and maternal hemodynamic parameters, meaning that they can be used as independent predictors for pre-eclampsia. Gestational age had no clinically relevant effect on OA-PI and OA-PSV ratio, suggesting that these indices could be measured without adjustment at any time between 11 and 23 weeks' gestation. OA Doppler indices had high intraobserver reproducibility and were strongly correlated between the right and left eyes. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of Ophthalmic Artery Doppler Parameters in Preeclamptic and Normotensive Pregnant Women

OBJECTIVE

 Preeclampsia, whose pathophysiology is still not fully elucidated today, is a pregnancy-specific disease that affects most organ systems in pregnant women, including the central nervous system. In this context, we aimed to investigate the effects of preeclampsia on blood flow in the ophthalmic artery of the eye, which is considered a part of the central nervous system.

MATERIALS AND METHODS

 This prospective, non-interventional cohort study was conducted between February 2022 and June 2022 at Umraniye Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey. Forty-six normotensive healthy pregnant women constituted the control group and 46 preeclamptic pregnant women constituted the preeclampsia group. Prenatal follow-up and delivery of the participants were carried out in our clinic. First, an obstetric ultrasound was performed on all participants with the same ultrasound device and the same clinician. Then, Doppler measurements of the ophthalmic artery of both eyes were made by the same clinician using the linear probe of the same ultrasound. Both groups were compared in terms of the first peak of systolic velocity (PSV), second PSV, pulsatility index (PI), PSV ratio, end-diastolic velocity (EDV), resistance index (RI), and systolic/diastolic ratio (S/D) measurements of the ophthalmic artery. RESULTS : The first PSV, second PSV, PSV ratio, and EDV were significantly higher in the preeclampsia group than in the control group (p=0.001, p<0.001, p=0.019, p<0.001, respectively). According to the receiver operating characteristic analysis, the second PSV with a cut-off value of 43.75 cm/s was the most powerful ophthalmic artery Doppler parameter in detecting preeclampsia with 63% sensitivity and 63% specificity. No significant difference was found between the early and late onset or mild and severe preeclampsia groups in terms of ophthalmic artery Doppler parameters.

CONCLUSION

 Although the number of participants was too small to draw a definitive conclusion, the second PSV seems to be the most powerful parameter for the detection of preeclampsia. Studies with larger series are needed to determine the usability of ophthalmic artery Doppler parameters in the routine clinical diagnosis of preeclampsia and follow-up of the disease.

Feto-maternal indicators of cardiac dysfunction as a justification for the cardiac origins for pre-eclampsia

While the pathophysiology of pre-eclampsia has been postulated as being secondary to placental dysfunction, a cardiac origin has more recently been proposed. Although an association between fetal congenital cardiovascular disease and pre-eclampsia has been demonstrated, no precise pathophysiologic mechanism for this association has been described. This review highlights the current biophysical (including echocardiography and Doppler indices) and biochemical (including proteomic, metabolomic and genetic/transcriptomic) markers of cardiac dysfunction that have been investigated in maternal and fetal cardiac disease and their overlap with predictors of pre-eclampsia.   Common pathways of inflammatory and anti-angiogenesis imbalance, endothelial damage, and oxidative stress have been demonstrated in both cardiovascular disease and pre-eclampsia and further investigation into these pathways could help to elucidate the common pathophysiologic mechanisms linking these disorders.

Analysis of Ophthalmic Artery Doppler in Normotensive, Preeclamptic, and Eclamptic Pregnancies in Correlation With Clinical Parameters in a Tertiary Care Hospital in India

Preeclampsia occurs in hypertensive pregnant women beyond 20 weeks of gestation and is accompanied by proteinuria. Hypertensive retinopathy is the most prevalent sign of preeclampsia, and eclampsia and it needs to be addressed at the earliest opportunity. This study was intended to gauge and assess the ophthalmic artery Doppler indices such as mean enveloped velocity, the pulsatility index (PI), and the resistivity index (RI) in normotensive, preeclamptic, and eclamptic pregnancies with their respective correlations. We also saw correlations with serum creatinine and platelets with the PI and RI. Methods A prospective case-control study was conducted among 70 subjects in the Department of Radiodiagnosis of Sri Devaraj Urs Medical College, Tamaka, Karnataka, India. We carried out ultrasound and Doppler examinations of the right ophthalmic artery. Doppler indices including mean enveloped velocity, PI, and RI were assessed in normotensive as well as preeclamptic pregnancies. Results The mean ages of cases and controls were 28.26 and 26.74 years, respectively. The mean RIs in controls and cases were 0.86 and 0.69, respectively (preeclampsia and eclampsia were 0.73 and 0.65, respectively), whereas the mean PIs in controls and cases were 1.96 and 1.17, respectively (preeclampsia and eclampsia were 1.31 and 1.06, respectively). The mean enveloped velocities in preeclampsia and eclampsia were 28.82 cm/sec and 20.43 cm/sec, respectively. Conclusion We found a definite reduction in the PI, RI, and mean enveloped velocity flow levels in preeclampsia and eclampsia patients in comparison to that amongst normal subjects. Therefore, it is important to assess and manage such conditions at the earliest stage to achieve a better prognosis while providing adequate treatment to the patient.

Ophthalmic artery Doppler in women with hypertensive disorders of pregnancy: relationship to blood pressure control and renal dysfunction at 6-9 weeks postnatally

OBJECTIVES

To examine the postnatal course of ophthalmic artery (OA) Doppler in women with hypertensive disorders of pregnancy (HDP) and to evaluate the correlation between OA Doppler parameters and poor postnatal blood pressure control and renal dysfunction at 2-3 weeks and 6-9 weeks postnatally.

METHODS

This was a prospective cohort study of women with a singleton pregnancy and HDP seen at a tertiary pregnancy hypertension clinic between 2019 and 2021. Three visits were included: Visit 1, the last visit to the antenatal hypertension clinic within 2 weeks prior to delivery; Visit 2, at 2-3 weeks postnatally; and Visit 3, at 6-9 weeks postnatally. At each visit, maternal demographic characteristics, medical history, blood pressure and OA Doppler were obtained. In addition, fetal growth and fetal Dopplers were examined antenatally and, at 6-9 weeks postnatally, estimated glomerular filtration rate and proteinuria were quantified. Study participants were divided into four hypertension groups, according to longitudinal changes in blood pressure at the three visits. For the postnatal visits, hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg in the absence of antihypertensive medication, and SBP ≥ 130 mmHg and/or DBP ≥ 80 mmHg whilst taking antihypertensives. Group 1 was hypertensive at all three visits; Group 2 was hypertensive at Visits 1 and 2 but normotensive at Visit 3; Group 3 was hypertensive at Visits 1 and 3 but normotensive at Visit 2; and Group 4 was hypertensive at Visit 1 but normotensive at Visits 2 and 3. The longitudinal changes in mean arterial pressure (MAP), peak systolic velocity (PSV) 1, PSV2 and the ratio of PSV2/PSV1 over the three timepoints were examined by a repeated-measures, multilevel, linear mixed-effects analysis, controlling for maternal age, weight at presentation and use of antihypertensive medication. In addition, we examined the longitudinal change in OA Doppler parameters in women with different degrees of postnatal blood pressure control and in those with and those without renal dysfunction at 6-9 weeks postnatally.

RESULTS

A total of 108 women were recruited to the study, of whom 86 had new-onset hypertension and 22 had chronic hypertension. When controlling for maternal age, weight at presentation and use of antihypertensive medication, a significant decline in log10 MAP (P < 0.001), log10 PSV1 (P < 0.001) and log10 PSV2 (P = 0.01) was seen between Visits 1 and 3. Log10 PSVR did not change with time. When assessing OA Doppler against hypertension group, log10 PSV1 and log10 PSV2 did not differ between the hypertension groups, whilst Group 4 had a lower log10 PSVR compared with Group 1 (P < 0.01), Group 2 (P = 0.03) and Group 3 (P < 0.01). At 6-9 weeks postnatally, log10 PSVR was lower in those without compared to those with renal dysfunction (-0.021, P = 0.01), whilst log10 MAP, log10 PSV1 and log10 PSV2 values did not differ. Log10 PSVR did not change with time and remained at -0.12 (95% CI, -0.13 to -0.11) across the three visits.

CONCLUSIONS

In women with HDP, the OA-PSVR was significantly higher in those with labile or persistently raised blood pressure postnatally compared to women whose blood pressure normalized. Similarly, the OA-PSVR at 6-9 weeks postnatally was significantly higher in women with renal dysfunction vs those without dysfunction. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Acid hydrolysis of Solanum tuberosum periderm for accumulation of polyhydroxyalkanoates in Pseudomonas putida MTCC 2475

Polyhydroxyalkanoates are a class of biodegradable, biocompatible polymers composed of polyesters of R-hydroxyalkanoic acids and deposited intracellularly by a variety of microorganisms which have potential to serve as alternative to commercial plastic. Bioplastics are gaining attention due to sustainability, biodegradability, biocompatibility, and lower carbon footprint. Nevertheless, the commercialization of PHA is predominantly hindered by the elevated production expenses arising primarily from the use of a pure sugar substrate. Our study has established a feasible method for bioplastic formation applying Pseudomonas putida MTCC 2475 and Solanum tuberosum periderm as a carbon source. To optimize the sugar yield response surface methodology was used, which released 69.34% ± 0.25% reducing sugar. PHA production experiments were performed in hydrolysate containing media as well as commercial sugar containing mineral salt media. After 48 h of fermentation of using this sugar, a biomass concentration of 2.19 gL-1, with a PHA production of 0.60 gL-1 (28.71% ± 0.55%) was obtained which was comparatively similar with synthetic media (2.56 gL-1 cell dry weight and 29.97% ± 0.45% PHA). Furthermore, the monomers of PHA produced by hydrolysate were characterized using Gas chromatography-mass spectrometry, Fourier transform infrared spectroscopy, differential scanning calorimetry, and nuclear magnetic resonance. This investigation has identified three distinct monomers of medium-chain PHAs, namely, methyl 3-Hydroxydodecanoate, 3-Hydroxytetradecanoate, and Hexadecanoic acid 3-Hydroxy methyl esters. Hence this study concludes a sustainable production of bioplastics from S. tuberosum periderm waste.

Risk of bias assessments in individual participant data meta-analyses of test accuracy and prediction models: a review shows improvements are needed

OBJECTIVES

Risk of bias assessments are important in meta-analyses of both aggregate and individual participant data (IPD). There is limited evidence on whether and how risk of bias of included studies or datasets in IPD meta-analyses (IPDMAs) is assessed. We review how risk of bias is currently assessed, reported, and incorporated in IPDMAs of test accuracy and clinical prediction model studies and provide recommendations for improvement.

STUDY DESIGN AND SETTING

We searched PubMed (January 2018-May 2020) to identify IPDMAs of test accuracy and prediction models, then elicited whether each IPDMA assessed risk of bias of included studies and, if so, how assessments were reported and subsequently incorporated into the IPDMAs.

RESULTS

Forty-nine IPDMAs were included. Nineteen of 27 (70%) test accuracy IPDMAs assessed risk of bias, compared to 5 of 22 (23%) prediction model IPDMAs. Seventeen of 19 (89%) test accuracy IPDMAs used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2), but no tool was used consistently among prediction model IPDMAs. Of IPDMAs assessing risk of bias, 7 (37%) test accuracy IPDMAs and 1 (20%) prediction model IPDMA provided details on the information sources (e.g., the original manuscript, IPD, primary investigators) used to inform judgments, and 4 (21%) test accuracy IPDMAs and 1 (20%) prediction model IPDMA provided information or whether assessments were done before or after obtaining the IPD of the included studies or datasets. Of all included IPDMAs, only seven test accuracy IPDMAs (26%) and one prediction model IPDMA (5%) incorporated risk of bias assessments into their meta-analyses. For future IPDMA projects, we provide guidance on how to adapt tools such as Prediction model Risk Of Bias ASsessment Tool (for prediction models) and QUADAS-2 (for test accuracy) to assess risk of bias of included primary studies and their IPD.

CONCLUSION

Risk of bias assessments and their reporting need to be improved in IPDMAs of test accuracy and, especially, prediction model studies. Using recommended tools, both before and after IPD are obtained, will address this.

Uterine Arteries Resistance in Pregnant Women with Gestational Diabetes Mellitus, Diabetes Mellitus Type 1, Diabetes Mellitus Type 2, and Uncomplicated Pregnancies

BACKGROUND

The examination of the uterine arteries using Doppler in the first trimester of pregnancy serves as a valuable tool for evaluating the uteroplacental circulation. Diabetes mellitus is associated with altered placental implantation and pregnancy-related pathologies, such as preeclampsia. The aim of this study was to compare the uterine arteries' pulsatility indices (UtA PI) in women with diabetes mellitus type 1 (DM1), diabetes mellitus type 2 (DM2), gestational diabetes mellitus (GDM), and uncomplicated pregnancies.

METHODS

This was a retrospective case-control trial including pregnant women with DM1, DM2, GDM, and uncomplicated pregnancies, presenting for first-trimester ultrasound screening in two tertiary university hospitals between 2013 and 2023. The first-trimester UtA pulsatility index (PI), expressed in multiples of medians (MoMs), was compared between the four groups.

RESULTS

Out of 15,638 pregnant women, 58 women with DM1, 67 women with DM2, 65 women with GDM, and 65 women with uncomplicated pregnancies were included. The mean UtA PI were 1.00 ± 0.26 MoMs, 1.04 ± 0.32 MoMs, 1.02 ± 0.31 MoMs, and 1.08 ± 0.33 MoMs in pregnant women with DM1, DM2, GDM, and uncomplicated pregnancies, respectively (p > 0.05).

CONCLUSIONS

Potential alterations in the implantation of the placenta in pregnant women with diabetes were not displayed in the first-trimester pulsatility indices of the uterine arteries, as there were no changes between the groups.

Obstetric vascular Doppler velocimetry: clinical applications and overuses

A safe and non-intrusive assessment of fetal health is not only crucial in low-risk gestations, but it is also the standard of care in high-risk pregnancies. Therefore, measuring blood flow across different vessels with non-invasive ultrasound methods has been accurately and painstakingly studied and published. Amongst these state-of-the-art techniques, umbilical artery (blood flow) Doppler velocimetry (UADV) has allowed for fetal well-being follow-ups and assess uteroplacental function, which obtains a more complete and clearer picture; particularly in regard to complicated pregnancies. Additionally, there are other modalities with diverse clinical applications that have emerged, including their clinical and research utilization in conditions such as fetal growth restriction (FGR), preeclampsia, fetal anemia, monochorionic twins vascular blood flow mismatch such as is in twin-to-twin transfusion syndrome, twin anemia polycythemia sequence, and twin reverse arterial perfusion sequence. Nevertheless, their applications regarding various other maternal-fetal diagnoses in the same way as premature births and/or multiple gestation surveillance have not been reported to hold strong clinical evidence. With that in regard, the purpose of this unique study was to give update of the multiple clinical applications of this very important obstetrical tool. Additionally, to review the pathophysiology as well as revisit their reported significant valid uses and occasional overuses. We also delved into quality control measures as related to the application of Doppler in obstetrics. Lastly, it is essential to look through and reflect on the future developments of this valuable, non-invasive, high-risk marvelous modern device.

Performance of HDP-Gestosis Score and Ophthalmic Artery Doppler in Prediction of Pre-eclampsia

Purpose of Study

To study the predictive accuracy of maternal characteristics, mean arterial pressure, uterine artery doppler and maternal ophthalmic artery doppler in second trimester for subsequent development of pre-eclampsia.

Methods

A prospective cohort study of 440 women at 19-24 weeks' gestation. It included recording of maternal demographic characteristics and calculation of HDP Gestosis Score, measurement of MAP and ultrasound evaluation for fetal anatomy, Uterine artery doppler and maternal ophthalmic artery doppler. The mean Peak Systolic Velocity ratio was obtained by taking two sets of reading from both eyes. The statistical analysis was done using independent t-test for quantitative variables and chi-square test, Fisher's exact test for qualitative variables and Area Under Curve was obtained at 10% False Positive Rate.

Results

Among 440 pregnant women, 43(10.8%) developed Hypertensive Disorder of Pregnancy (8 early onset PE, 16 late onset PE and 19 GHTN) and 42 were lost to follow up, with an incidence rate of 10.8%. Combination of Gestosis Score + OAD PSV Ratio had highest AUC of 0.73. Whereas combination of Gestosis Score + MAP + UtAPI + OAD-PSV Ratio had highest sensitivity of 97.67%. The OAD PSV ratio improved detection rate of Gestosis Score (from 90 to 100%) for prediction of development of PE, especially Preterm PE at 10% FPR.

Conclusion

Maternal Ophthalmic artery doppler study significantly improved prediction of development of PE at 19-24 weeks' gestation, both independently as well as in combination with HDP-Gestosis Score, MAP and uterine artery doppler.

A Correlational Study of Ophthalmic Artery Doppler Parameters and Maternal Blood Pressure in Normotensive and Pre-eclamptic Pregnancies at a Tertiary Care Hospital

Background Hypertensive disorders are one of the most common complications of pregnancy. This study aimed to investigate the relationship between ophthalmic artery Doppler indices and preeclampsia development and evaluate differences in these indices between normotensive and hypertensive pregnancies. Methods A hospital-based cross-sectional observational study was conducted involving a sample size of 80 pregnant women: 40 normotensive and 40 preeclamptic. The participants' ophthalmic artery Doppler parameters were evaluated using ultrasonography. Various clinical and demographic factors were also collected for analysis. Results Significant differences in the pulsatility index (PI) and end-diastolic volume (EDV) of the ophthalmic arteries were found between the normotensive and preeclamptic participants (p < 0.05). An inverse correlation was observed between the ophthalmic artery PI (OAPI) and mean maternal arterial pressure, suggesting reduced orbital vascular resistance and increased orbital flow. Moreover, the decrease in PI was more significant in severely preeclamptic women than in mildly preeclamptic and normotensive women. The findings indicated a significant correlation between ophthalmic artery Doppler parameters and the development of preeclampsia. The decrease in OAPI was particularly profound in women with severe preeclampsia. However, the study was limited by its small sample size and the lack of matching of participants based on maternal age, gestational age, and other factors. Conclusions The study results suggest that ophthalmic artery Doppler parameters, mainly PI and EDV, could serve as reliable indicators for the development of preeclampsia. Given their safety, cost-effectiveness, and accessibility, these parameters can help differentiate between preeclamptic and normotensive pregnancies in late gestation. Further research with larger sample sizes and matched participant groups is recommended for more conclusive results.

Ophthalmic artery Doppler for pre-eclampsia prediction at the first trimester: a Bayesian survival-time model

OBJECTIVE

To develop a Bayesian survival-time model for the prediction of pre-eclampsia (PE) at the first trimester using a combination of established biomarkers including maternal characteristics and history, mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI), and Placental Growth Factor (PlGF)) with an ophthalmic artery Doppler peak ratio (PR) analysis.

METHODS

The receiving operator curve (ROC) analysis was used to determine the area under the curve (AUC), detection rate (DR), and positive screening cut-off value of the model in predicting the occurrence of early-onset PE (< 34 weeks' gestation) and preterm PE (< 37 weeks' gestation).

RESULTS

Of the 946 eligible participants, 71 (7.49%) subjects were affected by PE. The incidences of early-onset and preterm PE were 1% and 2.2%, respectively. At a 10% false-positive rate, using the high-risk cut-off 1:49, with AUC 0.981 and 95%CI 0.965-0.998, this model had an 100% of DR in predicting early-onset PE. The DR of this model in predicting preterm PE is 71% when using 1:13 as the cut-off, with AUC 0.919 and 95%CI 0.875-0.963.

CONCLUSION

Combination ophthalmic artery Doppler PR with the previously established biomarkers could improve the accuracy of early and preterm PE prediction at the first trimester screening.

Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition

Preeclampsia accounts for one of the most common documented gestational complications, with a prevalence of approximately 2 to 15% of all pregnancies. Defined as gestational hypertension after 20 weeks of pregnancy and coexisting proteinuria or generalized edema, and certain forms of organ damage, it is life-threatening for both the mother and the fetus, in terms of increasing the rate of mortality and morbidity. Preeclamptic pregnancies are strongly associated with significantly higher medical costs. The maternal costs are related to the extra utility of the healthcare system, more resources used during hospitalization, and likely more surgical spending due to an elevated rate of cesarean deliveries. The infant costs also contribute to a large percentage of the expenses as the babies are prone to preterm deliveries and relevant or causative adverse events. Preeclampsia imposes a considerable financial burden on our societies. It is important for healthcare providers and policy-makers to recognize this phenomenon and allocate enough economic budgets and medical and social resources accordingly. The true cellular and molecular mechanisms underlying preeclampsia remain largely unexplained, which is assumed to be a two-stage process of impaired uteroplacental perfusion with or without prior defective trophoblast invasion (stage 1), followed by general endothelial dysfunction and vascular inflammation that lead to systemic organ damages (stage 2). Risk factors for preeclampsia including race, advanced maternal age, obesity, nulliparity, multi-fetal pregnancy, and co-existing medical disorders, can serve as warnings or markers that call for enhanced surveillance of maternal and fetal well-being. Doppler ultrasonography and biomarkers including the mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), and serum pregnancy-associated plasma protein A (PAPP-A) can be used for the prediction of preeclampsia. For women perceived as high-risk individuals for developing preeclampsia, the administration of low-dose aspirin on a daily basis since early pregnancy has proven to be the most effective way to prevent preeclampsia. For preeclamptic females, relevant information, counseling, and suggestions should be provided to facilitate timely intervention or specialty referral. In pregnancies complicated with preeclampsia, closer monitoring and antepartum surveillance including the Doppler ultrasound blood flow study, biophysical profile, non-stress test, and oxytocin challenge test can be arranged. If the results are unfavorable, early intervention and aggressive therapy should be considered. Affected females should have access to higher levels of obstetric units and neonatal institutes. Before, during, and after delivery, monitoring and preparation should be intensified for affected gravidas to avoid serious complications of preeclampsia. In severe cases, delivery of the fetus and the placenta is the ultimate solution to treat preeclampsia. The current review is a summary of recent advances regarding the knowledge of preeclampsia. However, the detailed etiology, pathophysiology, and effect of preeclampsia seem complicated, and further research to address the primary etiology and pathophysiology underlying the clinical manifestations and outcomes is warranted.

An update on maternal cardiac hemodynamics in fetal growth restriction and pre-eclampsia

Pre-eclampsia and fetal growth restriction (FGR) have been long related to primary placental dysfunction, caused by abnormal trophoblast invasion. Nevertheless, emerging evidence has led to a new hypothesis for the origin of pre-eclampsia and FGR. Suboptimal maternal cardiovascular adaptation has been shown to result in uteroplacental hypoperfusion, ultimately leading to placental hypoxic damage with secondary dysfunction. In this review, we summarize current evidence on maternal cardiac hemodynamics in FGR and pre-eclampsia. We also discuss the different approaches for antihypertensive treatment according to the hemodynamic phenotype observed in pre-eclampsia and FGR.

Two-Dimensional Ultrasound and Triplane Tissue Doppler Ultrasound of Patients with Severe Preeclampsia

This study was to investigate the cardiac function characteristics under two-dimensional ultrasound and triplane tissue Doppler imaging (TDI) of patients with severe preeclampsia (SPE). 28 SPE patients with singleton pregnancy from January 2018 to December 2020 were included in the SPE group. 25 healthy nonpregnant women of reproductive age were taken as the control group (Ctrl group), and 26 normal pregnant women with singleton pregnancy were selected as the normal group (Norm group); all the research objects underwent ultrasonography. The morphological and functional indexes of left and right ventricles were compared among the cases in different groups. The results showed that the left ventricular end-diastolic period diameter (LVEDd), left ventricular relative wall thickness (LV-RWT), left ventricular mass index (LVMi), left anterior descending (LAd), left ventricular $E/e$ and $e/a$ values, right ventricular diameter (RV-D), right ventricular anterior wall thickness (RVAW), $a$ value, right atrial septum (RA-S), pulmonary artery systolic pressure (PASP), left ventricular end-systolic period diameter (LVEds), interventricular septal thickness (IVSd), posterior wall thickness (PWd), end-diastolic period volume (EVD), end-systolic period volume (ESV), relative wall thickness (RWT), sphericity index (SpI), left atrium volume index (LAVi), and $E/e$ value of patients in the SPE group were higher than those in the Ctrl group and the Norm group ( $P<0.05$ ). The mitral annular plane systolic excursion (MAPSE), $s$ value, tricuspid annual plane systolic excursion (TAPSE), ratio of early diastolic blood flow velocity to late diastolic blood flow velocity ( $E/A$ ), ratio of peak early diastolic velocity to peak late diastolic velocity ( $e/a$ ), peak early diastolic velocity ( $e$ ), and ejection fraction (EF) of the SPE group were lower than those of the Ctrl group and the Norm group ( $P<0.05$ ). The ratio of mitral valve early diastolic blood flow velocity to peak early diastolic velocity ( $E/e$ ) of the Norm group was higher than that of the Ctrl group ( $P<0.05$ ). In two-dimensional ultrasound of the SPE group, the maximum difference in time from the start to the peak of systole (Ts) of the right ventricle between the basal and middle segments of the lateral wall and that of interventricular septum (RV-Ts-max) was $31.56\pm 0.39\%$ . The maximum difference in time to peak of early diastole (Te) under the same condition (RV-Te-max) was $47.16\pm 0.19\%$ . Left ventricular LV-Ts-max and LV-Te-max were $9.83\pm 0.80\%$ and $8.37\pm 0.68\%$ , respectively, in triplane TDI, which were considerably higher than those in the Ctrl and Norm groups ( $P<0.05$ ). It suggested that two-dimensional ultrasound and triplane TDI could reflect the ventricular morphology as well as diastolic and systolic function injury in patients, which offered a reference basis for the diagnosis of SPE.

Alternatives of Risk Prediction Models for Preeclampsia in a Low Middle-Income Setting

Abstract Objectives:  To  develop prediction models for the first-trimester prediction of PE (PE) using the established biomarkers including maternal characteristics and history, mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI ), and Placental Growth Factor (PlGF)) in combination with Ophthalmic artery Doppler peak ratio (PR). Methods:  This was a  prospective observational study in women attending a first-trimester screening at 11-14 weeks’  gestation. Maternal characteristics and history, measurement of MAP, ultrasound examination for UtA-PI measurement, maternal ophthalmic PR Doppler measurement, and serum  PlGF collection were performed during the visit. Logistic regression  analysis was used to determine if the maternal factor had a significant contribution in predicting PE. The Receiving Operator Curve (ROC) analysis was used to determine the area under the curve  (AUC), positive predictive value  (PPV), negative prefictive value (NPV) and positive screening cut-off in predicting the occurrence of PE at any gestational age.   Results: Of the 946 eligible participants, 71 (7,49%) subjects were affected by PE. Based on the ROC curves, optimal high-risk cutoff value for prediction of preeclampsia at any gestational age for model 2 (primary care model) in this Indonesia study population were 63% with the sensitivity and specificity of 71.8% and 71.2%, respectively. Both sensitivity and specificity for model 3 (complete model) were 70.4% and 74.9%, respectively for the cutoff value 58%. The area under the curve of model 2, model 3 was 0.7651 (95% CI: 0.7023-0.8279)) and 0.7911 (95% CI: 0.7312-0.8511), respectively, for predicting PE. In addition, PPV and NPV for model 2 were 16.8% and 96.9%, respectively. PPV and NPV for model 3 were 18.55 and 96.9%, respectively.   Conclusion: The prediction models of preeclampsia vary depending upon healthcare resource. Complete model is clinically superior to primary care model but it is not statistically significant.  Prognostic models should be easy to use, informative and low cost with great potential to improve maternal and neonatal health in Low Middle Income Country settings. 

Cardiovascular determinants of impaired placental function in women with cardiac dysfunction

Female heart disease has for a long time been an underrecognized problem in the field of cardiology. With an ever-growing number of these patients getting pregnant, cardiac dysfunction during pregnancy is an increasingly large medical problem. Previous work has shown that maternal heart disease may have an adverse effect on pregnancy outcome in both mother and child. The placenta forms the connection and it is postulated that cardiac dysfunction negatively affects the placenta, and consequently, neonatal outcome. Given the paucity of data in this field, more research on the influence of cardiac (mal)function on placental (mal)function is needed. The present review describes placental function in women with various types of cardiac dysfunction, thereby aiming to provide more insight into possible underlying mechanisms of placental malfunction. Organ dysfunction in patients with heart failure is for an important part based on reduced perfusion and venous congestion. This has been shown in other organs such as kidneys, liver and brain. In pregnant women with cardiac dysfunction, placental dysfunction may follow similar patterns. Moreover, other factors, such as pre-existing hypertension and chronic hypoxia may lead to further impairment of placental function, through abnormal vascular remodeling of the uterine spiral arteries. The pathophysiology of placental dysfunction in pregnant women with cardiac dysfunction may thus be multifactorial. It is therefore important to monitor closely cardiac and placental function in such high-risk pregnancies. Gaining a better understanding of the underlying pathophysiological mechanisms may have important clinical implications in terms of pregnancy counseling, monitoring and outcome.

The placenta and preeclampsia: villain or victim?

Preeclampsia is a disease whose characterization has not changed in the 150 years since the cluster of signs associated with the disorder were first described. Although our understanding of the pathophysiology of preeclampsia has advanced considerably since then, there is still little consensus regarding the true etiology of preeclampsia. As a consequence, preeclampsia has earned the moniker "disease of theories," predominantly because the underlying biological mechanisms linking clinical epidemiologic findings to observed organ dysfunction in preeclampsia are far from clear. Despite the lack of cohesive evidence, expert consensus favors the hypothesis that preeclampsia is a primary placental disorder. However, there is now emerging evidence that suboptimal maternal cardiovascular performance resulting in uteroplacental hypoperfusion is more likely to be the cause of secondary placental dysfunction in preeclampsia. Preeclampsia and cardiovascular disease share the same risk factors, preexisting cardiovascular disease is the strongest risk factor (chronic hypertension, congenital heart disease) for developing preeclampsia, and there are now abundant data from maternal echocardiography and angiogenic marker studies that cardiovascular dysfunction precedes the development of preeclampsia by several weeks or months. Importantly, cardiovascular signs and symptoms (hypertension, cerebral edema, cardiac dysfunction) predominate in preeclampsia at clinical presentation and persist into the postnatal period with a 30% risk of chronic hypertension in the decade after birth. Placental malperfusion caused by suboptimal maternal cardiovascular performance may lead to preeclampsia, thereby explaining the preponderance of cardiovascular drugs (aspirin, calcium, statins, metformin, and antihypertensives) in preeclampsia prevention strategies. Despite the seriousness of the maternal and fetal consequences, we are still developing sensitive screening, reliable diagnostic, effective therapeutic, or improvement strategies for postpartum maternal cardiovascular legacy in preeclampsia. The latter will only become clear with an acceptance and understanding of the cardiovascular etiology of preeclampsia.

Performance of ophthalmic artery Doppler velocimetry in the complementary diagnosis of preeclampsia

OBJECTIVES

To calculate the accuracy (A) and establish the best cutoff value for ophthalmic artery (OA) Doppler velocimetry indexes in patients diagnosed with preeclampsia (PE), compared with healthy pregnant women.

METHODS

This prospective experimental study enrolled 268 women: 133 with PE and 135 healthy pregnant women. All patients were evaluated by OA Doppler sonography, bilaterally, to assess their pulsatility index (PI), resistance index (RI), peak systolic velocity (PVS), second peak systolic velocity (P2), end-diastolic velocity (EDV), and peak ratio (PR). Means were compared using Student's T-test. Receiver Operating Characteristics (ROC) curve was used to establish the cutoff value and estimate the sensitivity (S), specificity (Sp), accuracy (A) of all variables, and a significance of 95% was adopted.

RESULTS

ROC curve analysis showed that P2 and PR were superior to the other parameters for PE diagnosis. We tested two cutoff values: (1) using PR ≥0.70, obtained A: 88.72%, S: 81.95%, and Sp: 95.48% and (2) using PR ≥0.75, and A: 86.24%, S: 74.43%, and Sp: 99.24%. By adopting P2 ≥ 21.5 cm/s, we obtained A: 87.59%, S: 84.96%, and Sp: 90.22% and when the cutoff point was P2 ≥ 22 cm/s, there was a slight decrease in A to 86.46% and S to 81.20%, with Sp: 91.89.3%.

CONCLUSION

Ophthalmic artery Doppler demonstrated to be an effective and high-performance imaging method for the diagnosis of PE and the indexes P2 and PR demonstrated superior accuracy to the other Doppler parameters assessed. Higher performance occurred when the cutoff values with greater specificity were adopted, PR ≥ 0.75 and P2 ≥ 22 cm/s, considering that the proposed OA Doppler is to be a complementary method for preeclampsia.

Case-control study on ocular changes and ophthalmic Doppler velocimetric indices among preeclamptic and normotensive pregnant women in Ibadan, Nigeria

Objective

To compare the ocular changes and Doppler velocimetric indices in preeclamptic and normotensive pregnant women.

Methods and analysis

This was a case-control study of 71 preeclamptic women and 72 parity-matched normotensive pregnant women conducted at the University College Hospital, Ibadan, Nigeria. Demographic data were obtained using questionnaires. All participants had visual acuity assessment, funduscopy, intraocular pressure measurement and orbital Doppler ultrasonography. The differences in parameters between the two groups were tested using Student’s t-test for quantitative variables and χ² tests for categorical variables.

Results

There were no significant differences between cases and controls with respect to sociodemographic variables. The mean pulsatility index was 1.35±0.46 in cases and 2.1±0.4 in controls (p<0.001); the resistivity index was 0.7±0.18 in cases and 0.83±0.27 among the controls (p=0.01). A similar pattern was observed in the peak systolic velocity (p<0.001) and the peak ratio (p<0.001). There was no significant difference between the groups concerning end-diastolic velocity (p=0.535). Three preeclampsia patients (5.2%) had abnormalities on funduscopy compared with none of the controls. Preeclamptic women had significantly higher intraocular pressures in both eyes at baseline and at 24 hours post delivery.

Conclusion

This study demonstrated lower Doppler velocimetry and impedance parameters and higher intraocular pressure among preeclampsia cases compared with controls. Abnormal funduscopic findings were observed in a few preeclamptic women and none among the controls. Ophthalmic artery Doppler parameters could be useful in identifying those women who are likely to suffer preeclampsia and its complications.

What Is the Role of the Maternal Ophthalmic and Cervical Internal Carotid Arteries in Predicting Maternal Adverse Outcomes in Preeclampsia?

OBJECTIVES

We aimed to investigate the efficacy of maternal ophthalmic artery (OA) and cervical internal carotid artery (CICA) in predicting adverse maternal outcomes and gestational age at birth in preeclampsia (PE).

METHODS

The study was performed at the Zeynep Kamil Women and Children's Diseases Training and Research Hospital. Measurements were made in 2 groups consisting of 50 pregnant women with PE and 50 healthy pregnant women. The peak systolic velocity (PSV), end-diastolic velocity, PI, RI, first diastolic peak velocity, systolic/diastolic (S/D) ratio, and peak ratio of the maternal OA were measured by a transorbital Doppler ultrasound (US) scan. The PSV, end-diastolic velocity, PI, RI, and S/D ratio of the CICA were measured. The differences of Doppler indices between groups with P < .05 were considered statistically significant. Cutoff values were calculated, which could be used to predict adverse maternal outcomes and gestational age at birth.

RESULTS

The RI and PI values of the OA were lower, and the first diastolic peak velocity, PSV, and peak ratio values were higher among the PE group. The RI and S/D values of the CICA were significantly lower in the PE group compared to the healthy group. The OA RI was determined to be the strongest US variable in predicting adverse maternal outcomes and gestational age at birth, with a cutoff value of 0.72, 76% sensitivity, and 76% specificity.

CONCLUSIONS

Maternal OA Doppler indices can be used as US markers to predict adverse maternal outcomes.

Preeclampsia: a gestational cardiorenal syndrome

It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.

Preeclampsia: The Relationship between Uterine Artery Blood Flow and Trophoblast Function

Maternal uterine artery blood flow is critical to maintaining the intrauterine environment, permitting normal placental function, and supporting fetal growth. It has long been believed that inadequate transformation of the maternal uterine vasculature is a consequence of primary defective trophoblast invasion and leads to the development of preeclampsia. That early pregnancy maternal uterine artery perfusion is strongly associated with placental cellular function and behaviour has always been interpreted in this context. Consistently observed changes in pre-conceptual maternal and uterine artery blood flow, abdominal pregnancy implantation, and late pregnancy have been challenging this concept, and suggest that abnormal placental perfusion may result in trophoblast impairment, rather than the other way round. This review focuses on evidence that maternal cardiovascular function plays a significant role in the pathophysiology of preeclampsia.

Correlation between central and uterine hemodynamics in hypertensive disorders of pregnancy

OBJECTIVE

Pregnancies affected by a hypertensive disorder (HDP) have increased uterine artery pulsatility index (UtA-PI) compared with that in healthy pregnancies. Women with HDP are also known to have lower cardiac output and increased systemic vascular resistance. The aim of this study was to investigate the relationship between central and uterine hemodynamics in HDP and uncomplicated pregnancy.

METHODS

This was a prospective study of HDP and normotensive control singleton pregnancies presenting at a tertiary referral hospital between January 2012 and December 2017. Paired measurements of maternal hemodynamics, using a non-invasive device (USCOM-1A®), and UtA-PI were performed in the third trimester. HDP pregnancies were divided into preterm (onset < 37 weeks' gestation) and term (onset ≥ 37 weeks). Spearman's rank coefficient was used to assess the correlation between the central and uteroplacental hemodynamics. Regression analysis was performed to assess the association of UtA-PI with independent variables.

RESULTS

We included 231 women with HDP (152 with preterm and 79 with term HDP) and 378 controls with normotensive pregnancy. Compared with controls, women with preterm HDP had significantly lower cardiac output (median (interquartile range (IQR)), 6.0 (5.1-7.2) vs 6.6 (5.8-7.5) L/min; P < 0.001) and significantly higher systemic vascular resistance (median (IQR), 1394 (1189-1670) vs 1063 (915-1222) dynes × s/cm⁵ ; P < 0.001) and UtA-PI (median (IQR), 1.0 (0.75-1.4) vs 0.67 (0.58-0.83); P < 0.001). Conversely, in women with term HDP, there were no significant differences in heart rate, cardiac output or UtA-PI compared with controls (all P > 0.05), while systemic vascular resistance was significantly higher (median (IQR), 1315 (1099-1527) vs 1063 (915-1222) dynes × s/cm⁵ ; P < 0.001). On multiple regression analysis, heart rate, mean arterial pressure and stroke volume were associated significantly with mean UtA-PI (all P < 0.001).

CONCLUSIONS

Differences observed between HDP and normotensive pregnancies in third-trimester UtA resistance are mirrored in the central maternal hemodynamic parameters. Late pregnancy differences in the uteroplacental circulation in preterm and term HDP are an index of maternal cardiovascular function rather than being related to inadequate spiral artery remodeling and impaired placentation. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Current Resources for Evidence-Based Practice, March 2019

A review of new resources to support the provision of evidence-based care for women and infants.