Adaptations in autonomic nervous system regulation in normal and hypertensive pregnancy

Heart rate variability and perinatal depressive symptoms: A scoping review protocol

Objective

An emerging marker of depression in the perinatal period is represented by a reduction in the autonomic nervous system (ANS) activity, reflected by heart rate variability (HRV). This scoping review aims to map the association between HRV and depression during the perinatal period and to understand its potential clinical implications.

Introduction

Previous evidence associated ANS dysfunction and depressive symptomatology in the general population. Few observational and intervention studies investigated how HRV could be related to both pre- and post-partum depressive symptoms. However, high heterogeneity in the study designs and methods has been reported. Therefore, this scoping review plans to combine all these findings to build a starting point for future research.

Inclusion criteria

This scoping review will consider articles focusing on the association between HRV and depression in the peripartum and - when available - on the impact of interventions on HRV and how this correlates with changes in depressive symptoms. Studies will be included with no restrictions on participants' age, peripartum time points for the assessment, and HRV parameters collected.

Methods

We will perform a systematic search using the Medline (PubMed), PsychInfo, and Web of Science (WoS) databases. Two authors will independently screen titles, abstracts, and then full-text articles that meet the inclusion criteria. The review will include only journal articles published in English, with no time limitations. Data will be extracted and presented in tables and/or graphical representations to summarise and describe the results. Extracted data will be reported in a comprehensive summary.

Auriculotherapy for Labour Pain Management: a Systematic Review and Meta-Analysis

Importance

Labor pain presents significant challenges during childbirth, necessitating effective pain management strategies. Auriculotherapy, a non-pharmacological intervention targeting specific ear points, has been explored as a potential solution for alleviating labor pain.

Objective

This systematic review and meta-analysis aimed to evaluate the efficacy of auriculotherapy in reducing labor pain intensity and improving maternal satisfaction.

Data Resources

The electronic databases PubMed, Scopus, ScienceDirect, and Cochrane Library were searched from inception until December 2023 for randomized controlled trials (RCTs) investigating auriculotherapy as an intervention for labor pain management.

Study Selection

Two authors independently conducted literature selection based on predefined criteria (i.e., RCTs assessing auriculotherapy for labor pain management).

Data Extraction and Synthesis

Data extraction was performed independently by two authors, and a random-effects model was used for meta-analysis. The pooled mean difference (MD), with a 95% confidence interval (CI), was calculated to estimate the effect size.

Main Outcome(s) and Measure(s)

The primary outcome was labor pain intensity measured on the visual analog scale.

Results

Meta-analysis of five RCTs involving 451 patients revealed a significant reduction in labor pain following auriculotherapy compared with no treatment (MD, -1.78; 95% CI, -2.62 to -0.93). However, significant heterogeneity was observed among the included studies (I2, 87%; p < 0.01).

Conclusions and Relevance

Despite the observed heterogeneity, this meta-analysis suggests that auriculotherapy holds promise as a non-pharmacological intervention for alleviating labor pain. Further investigation is warranted to refine auriculotherapy protocols and assess its long-term effects, thereby enhancing its potential as a viable option for labor pain management.

Catheter ablation for focal atrial tachycardias during pregnancy: A systematic review

OBJECTIVE

Pregnancy can trigger maternal tachycardias, and the onset of recurrent or incessant focal atrial tachycardia (AT) can lead to tachycardia-induced cardiomyopathy. Medical interventions are commonly employed, but they carry potential fetal and maternal risks. Catheter ablation (CA), particularly with non-fluoroscopic navigation systems, may be considered as an alternative. This systematic review aims to explore the feasibility and outcomes of CA for focal AT during pregnancy.

METHODS

A thorough literature search was conducted until September 30th, 2023, on PubMed, Embase, and Cochrane databases. Included articles described maternal focal ATs diagnosed through electrophysiological studies and treated with CA. Data derived from these studies were organized into tables and subsequently analyzed.

RESULTS

Out of 278 papers reviewed, 15 articles involving 24 patients were retrieved. CA, utilizing radiofrequency energy achieved acute success in 95.8% of cases. Sixteen patients (66.7%) underwent complete fluoroless procedures, with two adverse events directly related to the procedure reported. Long-term follow-up revealed minimal AT recurrences, with a 0.06% arrhythmia burden in one case.

CONCLUSION

Focal ATs during pregnancy can be incessant and refractory to medical intervention, precipitating an acute decline in left ventricular ejection fraction. In this setting, CA emerges as an efficacious treatment modality, particularly in cases of tachycardia-induced cardiomyopathies. Whenever feasible, it is advisable to perform these procedures with minimal or no fluoroscopy guidance. Larger studies are needed to establish the safety and the efficacy of CA for focal ATs during pregnancy, as current research consists of case reports or small case series.

Multifractal analysis of heart rate variability in pregnancy during sleep

Understanding the complex dynamics of heart rate variability (HRV) during pregnancy is crucial for monitoring both maternal well-being and fetal health. In this study, we use the Multifractal Detrended Fluctuations Analysis approach to investigate HRV patterns in pregnant individuals during sleep based on RR interval maxima (MM fluctuations). In addition, we study the type of multifractality within MM fluctuations, that is, if it arises from a broad probability density function or from varying long-range correlations. Furthermore, to provide a comprehensive view of HRV changes during sleep in pregnancy, classical temporal and spectral HRV indices were calculated at quarterly intervals during sleep. Our study population consists of 21 recordings from nonpregnant women, 18 from the first trimester (early-pregnancy) and 18 from the second trimester (middle-pregnancy) of pregnancy. Results. There are statistically significant differences ( p -value < 0.05) in mean heart rate, rms heart rate, mean MM fluctuations, and standard deviation of MM fluctuations, particularly in the third and fourth quarter of sleep between pregnant and non-pregnant states. In addition, the early-pregnancy group shows significant differences ( p -value < 0.05) in spectral indices during the first and fourth quarter of sleep compared to the non-pregnancy group. Furthermore, the results of our research show striking similarities in the average multifractal structure of MM fluctuations between pregnant and non-pregnant states during normal sleep. These results highlight the influence of different long-range correlations within the MM fluctuations, which could be primarily associated with the emergence of sleep cycles on multifractality during sleep. Finally, we performed a separability analysis between groups using temporal and spectral HRV indices as features per sleep quarter. Employing only three features after Principal Component Analysis (PCA) to the original feature set, achieving complete separability among all groups appears feasible. Using multifractal analysis, our study provides a comprehensive understanding of the complex HRV patterns during pregnancy, which holds promise for maternal and fetal health monitoring. The separability analysis also provides valuable insights into the potential for group differentiation using simple measures such as mean heart rate, rms heart rate, and mean MM fluctuations or in the transformed feature space based on PCA.

Changes in Maternal Heart Rate Variability and Photoplethysmography Morphology after Corticosteroid Administration: A Prospective, Observational Study

Background: Owing to the association between dysfunctional maternal autonomic regulation and pregnancy complications, assessing non-invasive features reflecting autonomic activity-e.g., heart rate variability (HRV) and the morphology of the photoplethysmography (PPG) pulse wave-may aid in tracking maternal health. However, women with early pregnancy complications typically receive medication, such as corticosteroids, and the effect of corticosteroids on maternal HRV and PPG pulse wave morphology is not well-researched. Methods: We performed a prospective, observational study assessing the effect of betamethasone (a commonly used corticosteroid) on non-invasively assessed features of autonomic regulation. Sixty-one women with an indication for betamethasone were enrolled and wore a wrist-worn PPG device for at least four days, from which five-minute measurements were selected for analysis. A baseline measurement was selected either before betamethasone administration or sufficiently thereafter (i.e., three days after the last injection). Furthermore, measurements were selected 24, 48, and 72 h after betamethasone administration. HRV features in the time domain and frequency domain and describing heart rate (HR) complexity were calculated, along with PPG morphology features. These features were compared between the different days. Results: Maternal HR was significantly higher and HRV features linked to parasympathetic activity were significantly lower 24 h after betamethasone administration. Features linked to sympathetic activity remained stable. Furthermore, based on the PPG morphology features, betamethasone appears to have a vasoconstrictive effect. Conclusions: Our results suggest that administering betamethasone affects maternal autonomic regulation and cardiovasculature. Researchers assessing maternal HRV in complicated pregnancies should schedule measurements before or sufficiently after corticosteroid administration.

Impact of maternal obesity on resting muscle sympathetic nerve activity during uncomplicated pregnancy: a longitudinal assessment

Maternal obesity increases the risk of adverse pregnancy outcomes. The mechanisms that contribute to this elevated risk are unclear but may be related to greater activity of the sympathetic nervous system, which is associated with hypertensive disorders of pregnancy. We hypothesized that resting muscle sympathetic nerve activity (MSNA) would be greater in women with obesity during pregnancy when compared with normal-weight women. Blood pressure, heart rate, and MSNA were recorded during 5 min of supine rest in 14 normal-weight women [body mass index (BMI) 22.1 ± 2.1 (SD) kg/m2] and 14 women with obesity (BMI 33.9 ± 3.5 kg/m2) during (early and late) pregnancy and postpartum. All women had uncomplicated pregnancies. Resting MSNA burst frequency was not different between groups during early (normal weight 17 ± 10 vs. obesity 22 ± 15 bursts/min, P = 0.35) but was significantly greater in the obesity group during late pregnancy (23 ± 13 vs. 35 ± 15 bursts/min, P = 0.031) and not different postpartum (10 ± 6 vs. 9 ± 7 bursts/min, P = 0.74). These findings were also apparent when comparing burst incidence and total activity. Although still within the normotensive range, systolic blood pressure was greater in the obesity group across all time points (P = 0.002). Diastolic blood pressure was lower during pregnancy compared with postpartum (P < 0.001) and not different between groups (P = 0.488). Heart rate increased throughout pregnancy in both groups (P < 0.001). Our findings suggest that maternal obesity is associated with greater increases in sympathetic activity even during uncomplicated pregnancy. Future research is needed to determine if this is linked with an increased risk of adverse outcomes or is required to maintain homeostasis in pregnancy.NEW & NOTEWORTHY The impact of maternal obesity on resting muscle sympathetic nerve activity was examined during (early and late) and after uncomplicated pregnancy. Resting muscle sympathetic nerve activity is not different during early pregnancy or postpartum but is significantly elevated in women with obesity during late pregnancy when compared with normal-weight women. Future research is needed to determine if this is linked with an increased risk of adverse outcomes or is required to maintain homeostasis in pregnancy.

The impact of healthy pregnancy on features of heart rate variability and pulse wave morphology derived from wrist-worn photoplethysmography

Due to the association between dysfunctional maternal autonomic regulation and pregnancy complications, tracking non-invasive features of autonomic regulation derived from wrist-worn photoplethysmography (PPG) measurements may allow for the early detection of deteriorations in maternal health. However, even though a plethora of these features-specifically, features describing heart rate variability (HRV) and the morphology of the PPG waveform (morphological features)-exist in the literature, it is unclear which of these may be valuable for tracking maternal health. As an initial step towards clarity, we compute comprehensive sets of HRV and morphological features from nighttime PPG measurements. From these, using logistic regression and stepwise forward feature elimination, we identify the features that best differentiate healthy pregnant women from non-pregnant women, since these likely capture physiological adaptations necessary for sustaining healthy pregnancy. Overall, morphological features were more valuable for discriminating between pregnant and non-pregnant women than HRV features (area under the receiver operating characteristics curve of 0.825 and 0.74, respectively), with the systolic pulse wave deterioration being the most valuable single feature, followed by mean heart rate (HR). Additionally, we stratified the analysis by sleep stages and found that using features calculated only from periods of deep sleep enhanced the differences between the two groups. In conclusion, we postulate that in addition to HRV features, morphological features may also be useful in tracking maternal health and suggest specific features to be included in future research concerning maternal health.

Commentary on: Increased stiffness of omental arteries from late pregnant women at advanced maternal age

Worldwide, pregnancy at age 35 or older, termed 'advanced maternal age (AMA)', is increasing exponentially. As the incidence of pregnancy at AMA has increased, a growing body of evidence has suggested that AMA is also associated with increased risk for adverse maternal and fetal outcomes outside of genetic anomalies. Importantly, despite the mounting evidence and the increased global risk of adverse perinatal outcomes observed, few studies have examined the potential mechanisms underlying this elevated risk in pregnant people ≥35 years of age. Wooldridge and colleagues begin to address this gap in the literature. In their recent report, they examine vessel stiffness in omental resistance vessels obtained from pregnant individuals ≥35 years of age compared with pregnant individuals <35 years of age. Omental arteries were isolated and assessed via pressure myography (mechanical properties) and histological analysis for collagen and elastin content. Overall, the findings from this investigation report that maternal resistance arteries collected from women of AMA were less compliant and had less elastin than arteries obtained from women <35 years of age, suggesting that maternal resistance vessel stiffening in AMA may contribute to increased risk of adverse pregnancy outcomes. The authors should be commended for completing these studies in human resistance vessels, which now open new avenues for investigation and provoke a cascade of questions related to maternal cardiovascular adaptations to pregnancy in women ≥35 years of age.

Predicting postpartum depressive symptoms by evaluating self-report autonomic nervous system reactivity during pregnancy

OBJECTIVE

Altered self-reported autonomic reactivity is associated with worse mental health in the general population. Although dysfunctional changes in ANS during pregnancy have been investigated in relation to depressive symptoms, no studies addressed the relationship between self-report autonomic reactivity during pregnancy and depressive symptoms after the delivery. The present study aimed to assess the impact of prepartum self-reported autonomic reactivity on the development of postpartum depressive symptoms.

METHODS

In this longitudinal study, 170 women were assessed during pregnancy (i.e., second or third trimester) and after childbirth (i.e., one month after the delivery). Self-reported autonomic reactivity was assessed through the Body Perception Questionnaire - Short Form that evaluates the autonomic functions related to organs above (i.e., supradiaphragmatic reactivity) and below (i.e., subdiaphragmatic reactivity) the diaphragm. In addition, prepartum and postpartum depressive symptoms were evaluated using the Patient Health Questionnaire - 9.

RESULTS

Findings showed that higher prepartum supradiaphragmatic reactivity predicted higher depressive symptoms in the postpartum period (β = 0.112, p = 0.009) after controlling for prepartum depressive symptomatology and other potential covariates.

CONCLUSIONS

Evaluation of self-reported autonomic activity may be a useful tool to identify antenatally women at risk of postpartum depressive symptoms. Future studies are needed to evaluate the effectiveness of interventions aimed at reducing the threat-responsive autonomic reactivity at rest and improving adaptive autonomic regulation to prevent postpartum depression.

Maternal cardiorespiratory coupling: differences between pregnant and nonpregnant women are further amplified by sleep-stage stratification

Pregnancy complications are associated with abnormal maternal autonomic regulation. Subsequently, thoroughly understanding maternal autonomic regulation during healthy pregnancy may enable the earlier detection of complications, in turn allowing for the improved management thereof. Under healthy autonomic regulation, reciprocal interactions occur between the cardiac and respiratory systems, i.e., cardiorespiratory coupling (CRC). Here, we investigate, for the first time, the differences in CRC between healthy pregnant and nonpregnant women. We apply two algorithms, namely, synchrograms and bivariate phase-rectified signal averaging, to nighttime recordings of ECG and respiratory signals. We find that CRC is present in both groups. Significantly less (P < 0.01) cardiorespiratory synchronization occurs in pregnant women (11% vs. 15% in nonpregnant women). Moreover, there is a smaller response in the heart rate of pregnant women corresponding to respiratory inhalations and exhalations. In addition, we stratified these analyses by sleep stages. As each sleep stage is governed by different autonomic states, this stratification not only amplified some of the differences between groups but also brought out differences that remained hidden when analyzing the full-night recordings. Most notably, the known positive relationship between CRC and deep sleep is less prominent in pregnant women than in their nonpregnant counterparts. The decrease in CRC during healthy pregnancy may be attributable to decreased maternal parasympathetic activity, anatomical changes to the maternal respiratory system, and the increased physiological stress accompanying pregnancy. This work offers novel insight into the physiology of healthy pregnancy and forms part of the base knowledge needed to detect abnormalities in pregnancy.NEW & NOTEWORTHY We compare CRC, i.e., the reciprocal interaction between the cardiac and respiratory systems, between healthy pregnant and nonpregnant women for the first time. Although CRC is present in both groups, CRC is reduced during healthy pregnancy; there is less synchronization between maternal cardiac and respiratory activity and a smaller response in maternal heart rate to respiratory inhalations and exhalations. Stratifying this analysis by sleep stages reveals that differences are most prominent during deep sleep.

Alterations in Vessel Hemodynamics Across Uncomplicated Pregnancy

Pregnancy is marked by the onset of rapid hemodynamic alterations in order to accommodate the needs of the developing fetus. Arterial stiffness is an independent predictor of cardiovascular events and mortality, and its measurement in clinical practice has been recommended. It follows a U-shaped curve in uncomplicated pregnancy, decreasing to a nadir in mid-pregnancy and rising at term. Systemic vasodilation occurs due to elevated nitric oxide, prostacyclin, endothelium-derived hyperpolarizing factor, estrogen, progesterone, and relaxin. Vascular resistance decreases to a nadir in mid-pregnancy, while endothelial function is enhanced starting in the first trimester. Plasma volume increases by about 50%, and total red blood cell mass increases by up to 40%. Cardiac output increases by up to 45%, at first due primarily to elevated stroke volume, then mainly due to increased heart rate. Along with echocardiography, cardiac magnetic resonance imaging is safe for use in pregnancy. It may assess cardiac function more accurately than echocardiography, and may be indicated in specific clinical cases. Moreover, blood pressure decreases to a nadir in mid-pregnancy and rises to near preconception values postpartum. An appreciation of the vascular changes occurring in healthy pregnancy can aid in the prediction and diagnosis of pregnancy complications, such as preeclampsia and other hypertensive disorders of pregnancy, and inform treatment. In particular, noninvasive arterial stiffness/hemodynamics assessment provides unique clinical information beyond blood pressure and traditional maternal characteristics, and can signal a need for further testing, or be used in combination with other tests to predict or diagnose complications of pregnancy.

Muscle sympathetic nerve activity during pregnancy: A systematic review and meta-analysis

We conducted a systematic review and meta-analysis to quantify the impact of healthy and complex pregnancy on muscle sympathetic nerve activity (MSNA) at rest, and in response to stress. Structured searches of electronic databases were performed until February 23, 2022. All study designs (except reviews) were included: population (pregnant individuals); exposures (healthy and complicated pregnancy with direct measures of MSNA); comparator (individuals who were not pregnant, or with uncomplicated pregnancy); and outcomes (MSNA, BP, and heart rate). Twenty-seven studies (N = 807) were included. MSNA burst frequency was higher in pregnancy (n = 201) versus non-pregnant controls (n = 194) (Mean Differences [MD], MD: 10.6 bursts/min; 95% CI: 7.2, 14.0; I²  = 72%). Accounting for the normative increase in heart rate with gestation, burst incidence was also higher during pregnancy (Pregnant N = 189, non-pregnant N = 173; MD: 11 bpm; 95% CI: 8, 13 bpm; I²  = 47%; p < 0.0001). Meta-regression analyses confirmed that although sympathetic burst frequency and incidence are augmented during pregnancy, this was not significantly associated with gestational age. Compared to uncomplicated pregnancy, individuals with obesity, obstructive sleep apnea, and gestational hypertension exhibited sympathetic hyperactivity, while individuals with gestational diabetes mellitus or preeclampsia did not. Uncomplicated pregnancies exhibited a lesser response to head-up tilt, but an exaggerated sympathetic responsiveness to cold pressor stress compared to non-pregnant individuals. MSNA is higher in pregnant individuals and further increased with some, but not all pregnancy complications. PROSPERO registration number: CRD42022311590.

Posture-related changes in sympathetic baroreflex sensitivity during normal pregnancy

Normal pregnancy is associated with vast adjustments in cardiovascular autonomic control. Sympathetic baroreflex sensitivity has been reported to be attenuated during pregnancy in animal models, but most studies in humans are cross-sectional and findings from longitudinal case studies are inconclusive. It remains unclear how sympathetic baroreflex sensitivity is altered longitudinally during pregnancy within an individual in different body postures. Therefore, this study examined the impact of posture on sympathetic baroreflex sensitivity in 24 normal-weight normotensive pregnant women. Spontaneous sympathetic baroreflex sensitivity was assessed during early (6-11 weeks) and late (32-36 weeks) pregnancy and 6-10 weeks postpartum in the supine posture and graded head-up tilt (30° and 60°). In addition, data from the postpartum period were compared with (and no different to) 18 age-matched non-pregnant women to confirm that the postpartum period was reflective of a non-pregnant condition (online supplement). When compared with postpartum (-3.8 ± 0.4 bursts/100 heartbeats/mmHg), supine sympathetic baroreflex sensitivity was augmented during early pregnancy (-5.9 ± 0.4 bursts/100 heartbeats/mmHg, P < 0.001). However, sympathetic baroreflex sensitivity at 30° or 60° head-up tilt was not different between any phase of gestation (P > 0.05). When compared to supine, sympathetic baroreflex sensitivity at 60° head-up tilt was significantly blunted during early (Δ2.0 ± 0.7 bursts/100 heartbeats/mmHg, P = 0.024) and late (Δ1.5 ± 0.6 bursts/100 heartbeats/mmHg, P = 0.049) pregnancy but did not change postpartum (Δ0.4 ± 0.6 bursts/100 heartbeats/mmHg, P = 1.0). These data show that time-course changes in sympathetic baroreflex sensitivity are dependent on the posture it is examined in and provides a foundation of normal blood pressure regulation during pregnancy for future studies in women at risk for adverse pregnancy outcomes.

Characterizing the effect of demographics, cardiorespiratory factors, and inter-subject variation on maternal heart rate variability in pregnancy with statistical modeling: a retrospective observational analysis

Pregnancy complications are associated with insufficient adaptation of the maternal autonomic nervous system to the physiological demands of pregnancy. Consequently, assessing maternal heart rate variability (mHRV)-which reflects autonomic regulation-is a promising tool for detecting early deterioration in maternal health. However, before mHRV can be used to screen for complications, an understanding of the factors influencing mHRV during healthy pregnancy is needed. In this retrospective observational study, we develop regression models to unravel the effects of maternal demographics (age, body mass index (BMI), gestational age (GA), and parity), cardiorespiratory factors (heart rate and breathing rate), and inter-subject variation on mHRV. We develop these models using two datasets which are comprised of, respectively, single measurements in 290 healthy pregnant women and repeated measurements (median = 8) in 29 women with healthy pregnancies. Our most consequential finding is that between one-third and two-thirds of the variation in mHRV can be attributed to inter-subject variability. Additionally, median heart rate dominantly affects mHRV (p < 0.001), while BMI and parity have no effect. Moreover, we found that median breathing rate, age, and GA all impact mHRV (p < 0.05). These results suggest that personalized, long-term monitoring would be necessary for using mHRV for obstetric screening.

Central actions of insulin during pregnancy and lactation

Pregnancy and lactation are highly metabolically demanding states. Maternal glucose is a key fuel source for the growth and development of the fetus, as well as for the production of milk during lactation. Hence, the maternal body undergoes major adaptations in the systems regulating glucose homeostasis to cope with the increased demand for glucose. As part of these changes, insulin levels are elevated during pregnancy and lower in lactation. The increased insulin secretion during pregnancy plays a vital role in the periphery; however, the potential effects of increased insulin action in the brain have not been widely investigated. In this review, we consider the impact of pregnancy on brain access and brain levels of insulin. Moreover, we explore the hypothesis that pregnancy is associated with site-specific central insulin resistance that is adaptive, allowing for the increases in peripheral insulin secretion without the consequences of increased central and peripheral insulin functions, such as to stimulate glucose uptake into maternal tissues or to inhibit food intake. Conversely, the loss of central insulin actions may impair other functions, such as insulin control of the autonomic nervous system. The potential role of low insulin in facilitating adaptive responses to lactation, such as hyperphagia and suppression of reproductive function, are also discussed. We end the review with a list of key research questions requiring resolution.