Hemodynamic and neurohumoral profile in patients with different types of hypertension in pregnancy

Vitamin D Deficiency as a Risk Factor of Preeclampsia during Pregnancy

A balanced diet is achieved not only via the consumption of a variety of food products but also by ensuring that we take in sufficient quantities the micronutrients necessary for the adequate functioning of the human body, such as vitamins, an important one of which is vitamin D. Vitamin D has been closely linked to bone health. Vitamin D deficiency has often been associated with negative effects concerning several pregnancy adverse outcomes, the most important of which are the birth of SGA newborns, premature birth, and, finally, preeclampsia, which are discussed in this work. The aim of this review is to critically summarize and scrutinize whether the concentration of vitamin D in the blood serum of pregnant women in all its forms may be correlated with the risk of preeclampsia during pregnancy and whether vitamin D levels could act both as a protective agent or as a risk factor or even a prognostic measure of the disease. The association of vitamin D levels with the onset of preeclampsia was examined by searching the PubMed and Google Scholar databases. A total of 31 clinical trials were identified and included in this review, with the aim of summarizing the recent data concerning vitamin D levels and the risk of preeclampsia. Among them, 16 were published in the last five years, and 13 were published within the last a decade. Most studies showed a significant association between vitamin D deficiency and preeclampsia risk. It was also found that the higher the dose, the lower the risk of disease. Of the 31 articles, only 7 of them did not show a significant difference between vitamin D levels and preeclampsia regardless of comorbidity. The results of this review suggest that there is indeed an association between the concentration of vitamin D during pregnancy and the risk of preeclampsia; however, further studies are strongly recommended to derive conclusive evidence.

Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice

Hypertensive disorders of pregnancy (HDP) are the most common causes of maternal and perinatal morbidity and mortality. They are responsible for 16% of maternal deaths in high-income countries and approximately 25% in low- and middle-income countries. The impact of HDP can be lifelong as they are a recognized risk factor for future cardiovascular disease. During pregnancy, the cardiovascular system undergoes significant adaptive changes that ensure adequate uteroplacental blood flow and exchange of oxygen and nutrients to nurture and accommodate the developing fetus. Failure to achieve normal cardiovascular adaptation is associated with the development of HDP. Hemodynamic alterations in women with a history of HDP can persist for years and predispose to long-term cardiovascular morbidity and mortality. Therefore, pregnancy and the postpartum period are an opportunity to identify women with underlying, often unrecognized, cardiovascular risk factors. It is important to develop strategies with lifestyle and therapeutic interventions to reduce the risk of future cardiovascular disease in those who have a history of HDP.

Long-term consequences of previous preeclampsia and complicated pregnancy: analysis of echocardiographic aspects

AIM

To evaluated echocardiographic aspects in women with history of preeclampsia or preeclampsia-related complications in their previous pregnancies.

MATERIALS AND METHODS

Consecutive women receiving echocardiography during daily clinical echolab activity were studied using complete echocardiographic examination data and anamnestic data collection of hypertension, diabetes, dyslipidemia, and rheumatic diseases. Studied women should have at least one pregnancy in more than the 10 past years, and were subdivided into two groups according to the history of complicated or physiological pregnancy. Complicated pregnancies were defined by preeclampsia or preeclampsia-related complication, such as preterm delivery or small-for-gestational age newborn. Echocardiographic parameters and prevalence of hypertension, diabetes, dyslipidemia, and rheumatic disease were compared between the two groups of studied women.

RESULTS

From March 2016 to May 2020, 545 women were studied, of whom 218 had a history of complicated pregnancy (mean age 60.81 ± 11.109 years vs. 62.78 ± 9.758 years of not complicated pregnancy; P = 0.03). Compared with physiological pregnancy women, complicated pregnancy ones were shorter (159.97 ± 6.608 vs. 161.42 ± 6.427 cm; P = 0.012) with lower body surface area (1.678 ± 0.1937 vs. 1.715 ± 0.1662 m2; P = 0.02), had higher prevalence of diabetes (6.9 vs. 3.1%; P = 0.04; odds ratio = 2.34; CI 1.0323--5.3148) and rheumatic diseases (33 vs. 22.3%; P = 0.006; odds ratio = 1.72; CI 1.1688--2.5191), and showed a slight, not significant higher prevalence of hypertension. As for echocardiographic parameters, they showed significantly higher values of end-diastolic left ventricular posterior wall (LPWd) (P = 0.034), a trend toward a more concentric geometry, and a worse longitudinal systolic left and right ventricle performance, represented by lower tissue Doppler systolic waves (septal: 7.41 ± 1.255 vs. 7.69 ± 1.376 cm/s; P = 0.018; and tricuspidalic: 12.64 ± 2.377 vs. 13.32 ± 2.548 cm/s; P = 0.003).

CONCLUSION

Patients with previous preeclampsia present an increased risk of hypertension, diabetes, and rheumatic diseases, suggesting that these women could share a specific predisposition to a high-risk profile. Furthermore, they show a higher prevalence of classically considered echocardiographic hypertensive-derived cardiac damage, suggesting structural and functional left ventricular modifications as subclinical aspects of long-term worse cardiovascular prognosis for these women.

Nutraceuticals and Hypertensive Disorders in Pregnancy: The Available Clinical Evidence

The aim of the present critical review is to summarize the available clinical evidence supporting the use of some dietary supplements that have been shown to lower blood pressure in hypertensive pregnant women. A systematic search strategy was carried out to identify trials in MEDLINE (National Library of Medicine, Bethesda, Maryland, MD, USA; January 1980 to September 2019) and the Cochrane Register of Controlled Trials (The Cochrane Collaboration, Oxford, UK). The terms 'nutraceuticals', 'dietary supplements', 'pregnancy', 'pre-eclampsia', 'clinical trial', and 'human' were incorporated into an electronic search strategy. The references of the identified studies and review articles were reviewed to look for additional studies of interest. We preferably selected papers that reported recent comprehensive reviews or meta-analysis, or original clinical trials of substances with blood pressure-lowering or vascular protective effect in pregnancy. There is a relative body of evidence that supports the use of calcium, vitamin D, folic acid, and resveratrol in preventing the development of hypertensive disorders in pregnancy, and evidence supporting drug treatment too. Further clinical research is advisable to identify the dosage and timing of the supplementation, the group of women that might benefit the most from this approach, and the nutraceuticals with the best cost-effectiveness and risk-benefit ratio for widespread use in clinical practice.

Vitamin D supplementation and incident preeclampsia: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Maternal vitamin D deficiency has been associated with an increased risk for preeclampsia. Despite this, the current evidence regarding the efficacy of vitamin D supplementation in preventing preeclampsia is controversial. To assess the impact of vitamin D supplementation on the risk of preeclampsia, we performed a systematic review of the literature and a meta-analysis of the available randomized clinical trials (RCTs).

METHODS

The primary outcome was preeclampsia. Subgroup analyses were carried out considering the timing of the supplementation, type of intervention and the study design. Meta-regression analysis, including the amount of vitamin D and maternal age, were planned to explore heterogeneity (PROSPERO database registration number: CRD42019119207).

RESULTS

Data were pooled from 27 RCTs comprising 59 arms, which included overall 4777 participants, of whom 2487 were in the vitamin D-treated arm and 2290 in the control arm. Vitamin D administration in pregnancy was associated with a reduced risk of preeclampsia (odd ratio [OR] 0.37, 95% confidence interval [CI]: 0.26, 0.52; I² = 0%). If the vitamin D supplementation was started up to 20 weeks' gestation, the odds was a little lower (OR 0.35, 95% CI: 0.24, 0.50, p < 0.001). The effect was largely independent of the supplementation cessation (until delivery or not), type of intervention (vitamin D alone or in association with calcium), and study design. Increasing dose of vitamin D was associated with reduced incidence of preeclampsia (slope of log OR: -1.1, 95% CI: -1.73, -0.46; p < 0.001).

CONCLUSIONS

Results suggest that vitamin D supplementation may be useful in preventing preeclampsia. These data are especially useful for health-care providers who engage in the management of pregnant women at risk for preeclampsia. Our findings are a call for action to definitively address vitamin D supplementation as a possible intervention strategy in preventing preeclampsia in pregnancy.

Echocardiographic Structure and Function in Hypertensive Disorders of Pregnancy

Background—

Echocardiography is commonly used to direct the management of hypertensive disorders in medical patients, but its application in pregnancy is unclear. Our objective was to define the use of echocardiography in pregnancies complicated by gestational hypertension (GH) and preeclampsia.

Methods and Results—

We performed a systematic review of articles using an electronic search of databases from inception to March 2015, prospectively registered with PROSPERO (CRD42015015700). Eligible studies included pregnant women with GH or preeclampsia, evaluating left ventricular structure and function using echocardiography. The search strategy identified 36 studies, including 745 women with GH and 815 women with preeclampsia. The populations were heterogeneous with respect to clinical characteristics, parity, and risk of bias. Increased vascular resistance and left ventricular mass were the most consistent findings in GH and preeclampsia. Differentiating features from normal pregnancy were left ventricular wall thickness of ≥1.0 cm, exaggerated reduction in E/A, and lateral e′ of <14 cm/s. There was disagreement between studies with regard to cardiac output because of the timing of echocardiography, although reduced stroke volume was an indicator of adverse prognosis. Diastolic dysfunction and left ventricular remodeling are most marked in severe and early-onset preeclampsia, but are also markers of preeclampsia before clinical manifestation, and are associated with adverse outcomes.

Conclusions—

Echocardiography is a valuable tool to stratify risk and can guide management and counseling in the preclinical and clinical phases of GH and preeclampsia. Changes in cardiac function and morphology are recognizable at an asymptomatic early stage and correlate with disease severity and adverse outcomes.

Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding

In women with preexisting diabetes and nephropathy or microalbuminuria, it is important to deliver careful preconception counselling to assess the risk for the mother and the foetus, for optimizing glycaemic status and to adjust medical treatment. If serum creatinine is normal in early pregnancy, kidney function is often preserved during pregnancy, but complications such as severe preeclampsia and preterm delivery are still common. Perinatal mortality is now comparable with that in women with diabetes and normal kidney function. Besides strict glycaemic control before and during pregnancy, early and intensive antihypertensive treatment is important to optimize pregnancy outcomes. Methyldopa, labetalol, nifedipine and diltiazem are considered safe, whereas angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers should be stopped before or at confirmation of pregnancy. Supplementation with folic acid in early pregnancy and low-dose aspirin from 10 to 12 weeks reduces the risk of adverse pregnancy outcomes. During breastfeeding, several ACE inhibitors are considered safe.

Natriuretic peptide testing in high-risk pregnancy: a preventive opportunity?

Natriuretic peptide testing has been widely utilized in the heart failure and cardiac patient population, but there is limited utilization during pregnancy. Patients with hypertensive diseases of pregnancy have been shown to experience elevation of circulating natriuretic peptide levels compared to normal pregnancies, especially in the setting of preeclampsia. Natriuretic peptide testing can be utilized in patients presenting with signs and symptoms suspicious of heart failure in order to rule out underlying cardiac causes. Meanwhile, monitoring natriuretic peptide levels in those with established heart diseases (both congenital and acquired) may facilitate careful management of cardiac status during the course of pregnancy. Further investigations in the judicious use of selected medications (particularly loop diuretics) in the setting of elevated natriuretic peptide levels are warranted.

Post-partum evaluation of maternal cardiac function after severe preeclampsia

OBJECTIVE

To evaluate the post-partum maternal cardiac function in patients with history of severe preeclampsia.

METHODS

A series of women with previous singleton pregnancy complicated by severe preeclampsia underwent transthoracic echocardiography at 6-12 months from delivery. A group of women with previous uncomplicated pregnancy was selected as controls.

RESULTS

Sixteen women with history of severe preeclampsia were enrolled in the study group whereas 18 patients were selected as controls. In the study group systolic (p=0.002) and diastolic blood pressure (p=0.044) were significantly higher. Significant differences were observed in systolic left ventricular (LV) parameters, such as cardiac output (p=0.034), LV mass indexed to BSA (p=0.024) and longitudinal contraction, expressed by tissue Doppler (TD) S1 wave, which resulted relatively impaired in former preeclamptic women (p=0.049). As regards as diastolic parameters, pulsed Doppler A-wave velocity was increased (p=0.036). TD E-wave velocity was significantly lower in study group (p<0.001) and E/E1 ratio (E=peak early diastole transmitral wave velocity/E1=peak early diastolic velocity at mitral valve annulus at TD) was higher respect to controls (p<0.001).

CONCLUSIONS

LV contractility and diastolic function, although within normal reference ranges, show slight but significant impairment among women who experienced a severe preeclampsia. TD seems to be a sensible tool to identify these precocious signs of potential LV dysfunction.

Association of NT-proBNP with plasma renin activity and plasma aldosterone concentration in women with singleton pregnancy

OBJECTIVE

To determine the association of the N-terminal fragment of precursor protein brain-type natriuretic peptide (NT-proBNP) levels with plasma renin activity (PRA) and plasma aldosterone concentration (PAC) in singleton pregnancies.

DESIGN

Serum NT-proBNP levels, PRA and PAC were determined in 215 blood specimens from 139 women with singleton pregnancies, including 34 and 105 women who did and did not develop hypertensive disorders in pregnancy, respectively. Twenty-five blood specimens were obtained from 25 women who later developed hypertension (systolic BP⩾140mmHg and/or diastolic BP⩾90mmHg), but were normotensive at the time of blood sampling.

RESULTS

The serum NT-proBNP levels [pg/ml, median (range), 32 (5-142)] did not change in normotensive women, but increased significantly to 97 (23-436) after the development of hypertension (D/H). The PRA [ng/ml/h, median (range), 7.1 (1-20)] did not change in normotensive women, but decreased significantly to 1.9 (1-16) after D/H. PAC (pg/ml) increased significantly from 397 (94-1750) to 667 (123-2010) between the 2nd and 3rd trimesters in normotensive women. However, as PAC of hypertensive women did not change significantly before and after D/H, PAC [293 (116-1720)] after D/H was significantly lower than that [667 (123-2010)] of the 3rd trimester in the normotensive women. The serum levels of NT-proBNP were significantly and negatively correlated with both PRA and PAC.

CONCLUSIONS

The renin-angiotensin-aldosterone system is suppressed in pregnant women with cardiac conditions associated with higher NT-proBNP levels.

Effects of caesarean section on serum levels of NT-proBNP

OBJECTIVE

To determine the effects of delivery by caesarean on serum levels of N-terminal fragment of precursor protein brain-type natriuretic peptide (NT-proBNP).

METHODS

Serum NT-proBNP levels were determined longitudinally at 24 and 36 weeks of gestation (GW) and on post-partum day 3 and month 1 (PPD3 and PPM1, respectively) in 78 women with normotensive singleton pregnancies. Thirty-nine women underwent caesarean delivery. Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were determined on PPD3. Effects of maternal demographic characteristics on NT-proBNP levels were also analysed.

RESULTS

NT-proBNP levels (pg/ml) either in pregnancy or on PPM1 did not differ between women with vaginal and caesarean deliveries (44 ± 24 vs 41 ± 30, 24 GW; 37 ± 22 vs 29 ± 22, 36 GW; 43 ± 28 vs 39 ± 24, PPM1, respectively). Levels on PPD3 were significantly higher (94 ± 105 vs 247 ± 186, P < 0.0001) in women with caesarean delivery. Among women with caesarean delivery, a larger rise of NT-proBNP on PPD3 occurred in nulliparous than in multiparous women (319 ± 232 vs 185 ± 107, P = 0.023), while no rise occurred among multiparous women with vaginal delivery (108 ± 115 vs 47 ± 27). NT-proBNP levels on PPD3 were significantly and negatively correlated with PRA, PAC and maternal weight loss after childbirth on PPD3. These 3 variables on PPD3 were significantly lower in women undergoing caesarean than vaginal delivery (0.8 ± 0.4 vs 1.9 ± 1.4 ng/ml/h for PRA; 70 ± 38 vs 136 ± 88 pg/ml for PAC; 2.7 ± 1.2 vs 4.3 ± 1.1 kg for weight loss, each P < 0.0001).

CONCLUSIONS

The transient post-partum rise in serum NT-proBNP may reflect transient volume overload after parturition and is remarkable in nulliparous women, especially after caesarean section.

Obstetric nephrology: pregnancy in women with diabetic nephropathy--the role of antihypertensive treatment

This review highlights factors of importance for the clinical care of pregnant women with pregestational diabetes and microalbuminuria or diabetic nephropathy with particular focus on the role of intensive antihypertensive treatment during pregnancy. Most information in the literature comes from women with type 1 diabetes and diabetic nephropathy, but this is probably also valid for women with type 2 diabetes. Careful counseling of women with diabetic nephropathy before pregnancy with estimation of the risk for the mother and fetus is important. Pregnancy does not result in worsening of kidney function in women with diabetic nephropathy and normal serum creatinine, but pregnancy complications such as pre-eclampsia and preterm delivery are common. Intensive metabolic control before and during pregnancy, low-dose aspirin from 12 gestational weeks onward, and intensive antihypertensive treatment are important. Methyldopa, labetalol, and nifedipine are regarded safe in pregnancy, whereas angiotensin converting enzyme inhibitors, AngII antagonists, or statins should be paused before pregnancy. Case series and pathophysiological studies support the use of a stringent goal for BP and albumin excretion in pregnant women with diabetic nephropathy. Screening for diabetic retinopathy before and during pregnancy is mandatory and laser treatment should be performed if indicated. Pregnancy outcome in women with diabetic nephropathy has improved considerably with a take-home-baby rate of approximately 95%. Further research on the benefits and risks of intensive antihypertensive treatment in this population is needed.

Atrial Natriuretic Peptide (ANP) in early pregnancy is associated with development of preeclampsia in type 1 diabetes

The vasoactive markers of cardiac overload Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP) are elevated in preeclampsia. This study documents higher ANP concentrations as early as at 9 weeks in type 1 diabetic women subsequently developing preeclampsia suggesting that preeclampsia is associated with cardiovascular changes in early pregnancy.