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Alhuneafat L, Alrifai N, Amoateng R, Kyvernitakis A, Jabri A, Indaram M, Doyle M, Williams BA, Poornima IG. Echocardiographic Differences in Women Across Subtypes of Hypertensive Disorders of Pregnancy. JACC. ADVANCES 2024; 3:100725. [PMID: 38939814 PMCID: PMC11198092 DOI: 10.1016/j.jacadv.2023.100725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 07/27/2023] [Accepted: 08/26/2023] [Indexed: 06/29/2024]
Abstract
Background Hypertensive disorders of pregnancy (HDP) can be classified into gestational hypertension, preeclampsia (PRE), and chronic hypertension with superimposed preeclampsia (SPE). Objectives The purpose of this study was to retrospectively examine the echocardiographic differences in biventricular structure and function in 3 HDP groups of women in comparison to normotensive pregnant controls. Methods Women with an echocardiogram during or within the first year of pregnancy were identified within our integrated health network. Exclusion criteria included age <18 years, diagnosis of pulmonary embolism, malignancy, autoimmune disease, and structural heart disease. Results We identified a total of 706 subjects (cases: n = 427, normotensive controls: n = 279). Cases were divided into 3 groups: gestational hypertension (n = 57), PRE (n = 291), and SPE (n = 79). In adjusted analyses, echocardiographic parameters demonstrated a graded difference in left ventricular (LV) mass index, relative wall thickness, mitral inflow E, mitral inflow A, septal e', lateral e', E/e', left atrial volume index, tricuspid velocity, and lateral e' velocities with the most profound findings noted in the SPE group. Specifically, adjusted LV mass index (adjusted β = 14.45, 95% CI: 9.00-19.90) and E/e' (adjusted β = 2.97, 95% CI: 2.27-3.68) was highest in the SPE group in comparison to controls (P < 0.001). Conclusions LV remodeling and diastolic filling abnormalities are more common in HDP and are most evident in SPE and PRE. Echocardiography during or immediately after pregnancy may be useful in these high-risk women to identify these abnormalities. The long-term implications of these echocardiographic abnormalities require further study.
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Affiliation(s)
- Laith Alhuneafat
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
- Department of Cardiovascular Disease, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nada Alrifai
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Richard Amoateng
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Andreas Kyvernitakis
- Department of Cardiovascular Medicine, Unitypoint Health, Cedar Rapids, Iowa, USA
| | - Ahmad Jabri
- Heart and Vascular Institute, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mahathi Indaram
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Mark Doyle
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Brent A. Williams
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Indu G. Poornima
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Vasconcelos MMM, Ganan MCS, da Silveira MCFDSMP, Malagutte MKNDS, Poiati MPJR, Nunes MPHRDC, Martin MPLC, Bazan MPR, Borges MPVTM, Bazan SGZ. Evolution of myocardial hypertrophy associated with pregnancy in hypertensive women six months postpartum. Curr Probl Cardiol 2023; 48:101772. [PMID: 37121455 DOI: 10.1016/j.cpcardiol.2023.101772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Systemic arterial hypertension (SAH) is one of the principal risk factors for developing cardiovascular disease. When a hypertensive woman becomes pregnant, new hemodynamic condition is installed, with addition from chronic pressure overload to chronic volume overload. This new hemodynamic condition can provide greater myocardial hypertrophy(LVH), whose postpartum evolution has been little studied in the literature. OBJECTIVES To evaluate LVH in hypertensive women in the third trimester of pregnancy and six months postpartum and to establish which clinical variables are associated with elevated risk of LVH. METHODS Prospective longitudinal study including 41 pregnant women beyond 35 gestational weeks and with previous SAH. They were submitted to clinical and echocardiographic evaluation at the gestational period and six months postpartum. STATISTICAL ANALYSIS multivariate logistic regression with the exposures most strongly associated with maintenance of hypertrophy in univariate analysis. Significance level:p<0.05. RESULTS The mean age was 29±6.2 years. The majority of the women were white(85.4%). Before pregnancy 23(59%) women used anti-hypertensive drugs and 28(71.8%) used during pregnancy. At the end of gestation, all women presented LVH, 79% maintained hypertrophy six months postpartum. In multivariate analysis, exposures significantly associated with hypertrophy maintenance: systolic blood pressure(SBP) at the end of gestation, OR=1.16(1.03-1.30);p=0.013 and SBP increase at six months postpartum in relation to end of gestation, OR=22.9(1.8-294);p=0.016. CONCLUSIONS In hypertensive pregnant women, LVH frequency is elevated at the end of pregnancy, and recovery frequency of this hypertrophy, at six months postpartum, is very low. The increase of SBP six months postpartum was associated with maintenance of hypertrophy.
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Affiliation(s)
| | - Md Camilla Sousa Ganan
- Department of Internal Medicine, Botucatu Medical School - UNESP, São Paulo State University, Botucatu, Brazil
| | | | | | - Md PhD Juliane Rosa Poiati
- Department of Gynecology and Obstetrics, Botucatu Medical School - UNESP, São Paulo State University, Botucatu, Brazil
| | | | - Md PhD Luis Cuadrado Martin
- Department of Internal Medicine, Botucatu Medical School - UNESP, São Paulo State University, Botucatu, Brazil
| | - Md PhD Rodrigo Bazan
- Department of Internal Medicine, Botucatu Medical School - UNESP, São Paulo State University, Botucatu, Brazil
| | | | - Silméia Garcia Zanati Bazan
- Department of Internal Medicine, Botucatu Medical School - UNESP, São Paulo State University, Botucatu, Brazil
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3
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Curtis SL, Belham M, Bennett S, James R, Harkness A, Gamlin W, Thilaganathan B, Giorgione V, Douglas H, Carroll A, Kitt J, Colebourn C, Ribeiro I, Fairbairn S, Augustine DX, Robinson S, Thorne SA. Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society. Echo Res Pract 2023; 10:7. [PMID: 37076874 PMCID: PMC10116662 DOI: 10.1186/s44156-023-00019-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.
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Affiliation(s)
- Stephanie L Curtis
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK.
| | - Mark Belham
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sadie Bennett
- University Hospitals of North Midlands, Stoke-On-Trent, UK
| | - Rachael James
- University Hospitals Sussex NHS FT, Brighton, UK
- United Kingdom's Maternal Cardiology Society, London, UK
| | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - Wendy Gamlin
- North West Heart Centre, Wythenshawe Hospital, Manchester, UK
| | | | | | | | | | - Jamie Kitt
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Isabel Ribeiro
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Sarah Fairbairn
- University Hospitals Bristol and Weston NHS Trust, Bristol Heart Institute, Marlborough Street, Bristol, BS2 8HW, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | | | - Sara A Thorne
- University Health Network Toronto, Toronto General Hospital & Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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4
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Sedaghati F, Gleason RL. A mathematical model of vascular and hemodynamics changes in early and late forms of preeclampsia. Physiol Rep 2023; 11:e15661. [PMID: 37186372 PMCID: PMC10132946 DOI: 10.14814/phy2.15661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 05/17/2023] Open
Abstract
Preeclampsia-eclampsia syndrome is a leading cause of maternal mortality. The precise etiology of preeclampsia is still not well-defined and different forms exist, including early and late forms or preeclampsia, which may arise via distinctly different mechanisms. Low-dose aspirin administered at the end of the first trimester in women identified as high risk has been shown to reduce the incidence of early, but not late, preeclampsia; however, current risk factors show only fair predictive capability. There is a pressing need to develop accurate descriptions for the different forms of preeclampsia. This paper presents 1D fluid, solid, growth, and remodeling models for pregnancies complicated with early and late forms of preeclampsia. Simulations affirm a broad set of literature results that early forms of preeclampsia are characterized by elevated uterine artery pulsatility index (UA-PI) and total peripheral resistance (TPR) and lower cardiac output (CO), with modestly increased mean arterial blood pressure (MAP) in the first half of pregnancy, with elevation of TPR and MAP beginning at 20 weeks. Conversely, late forms of preeclampsia are characterized by only slightly elevated UA-PI and normal pre-term TPR, and slightly elevated MAP and CO throughout pregnancy, with increased TPR and MAP beginning after 34 weeks. Results suggest that preexisting arterial stiffness may be elevated in women that develop both early forms and late forms of preeclampsia; however, data that verify these results are lacking in the literature. Pulse wave velocity increases in early- and late-preeclampsia, coincident with increases in blood pressure; however, these increases are mainly due to the strain-stiffening response of larger arteries, rather than arterial remodeling-derived changes in material properties. These simulations affirm that early forms of preeclampsia may be associated with abnormal placentation, whereas late forms may be more closely associated with preexisting maternal cardiovascular factors; simulations also highlight several critical gaps in available data.
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Affiliation(s)
- Farbod Sedaghati
- The George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
| | - Rudolph L. Gleason
- The George W. Woodruff School of Mechanical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
- The Wallace H. Coulter Department of Biomedical EngineeringGeorgia Institute of TechnologyAtlantaGeorgiaUSA
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5
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Zaleski KL, Blazey MH, Carabuena JM, Economy KE, Valente AM, Nasr VG. Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review. J Cardiothorac Vasc Anesth 2022; 36:4483-4495. [PMID: 36195521 DOI: 10.1053/j.jvca.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022]
Abstract
Maternal congenital heart disease is increasingly prevalent, and has been associated with a significantly increased risk of maternal, obstetric, and neonatal complications. For patients with CHD who require cardiac interventions during pregnancy, there is little evidence-based guidance with regard to optimal perioperative management. The periprocedural management of pregnant patients with congenital heart disease requires extensive planning and a multidisciplinary teams-based approach. Anesthesia providers must not only be facile in the management of adult congenital heart disease, but cognizant of the normal, but significant, physiologic changes of pregnancy.
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Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care, and Pain Medicine-Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Jean M Carabuena
- Department of Anesthesiology, Perioperative and Pain Medicine-Brigham and Women's Hospital, Harvard Medical School, Boston MA
| | - Katherine E Economy
- Division of Maternal-Fetal Medicine, Brigham, and Women's Hospital, Harvard Medical School, Boston, MA
| | - Anne M Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care, and Pain Medicine-Boston Children's Hospital, Harvard Medical School, Boston, MA.
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6
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Ichii N, Kakinuma T, Fujikawa A, Takeda M, Ohta T, Kagimoto M, Kaneko A, Izumi R, Kakinuma K, Saito K, Maeyama A, Yanagida K, Takeshima N, Ohwada M. Diagnosed corrected transposition of great arteries after cesarean section: A case report. World J Clin Cases 2022; 10:9821-9827. [PMID: 36186208 PMCID: PMC9516933 DOI: 10.12998/wjcc.v10.i27.9821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/17/2022] [Accepted: 08/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Corrected transposition of the great arteries (cTGA) is a cardiac malformation in which the ventricular and arterial-ventricular positions in the heart are doubly reversed. In general, this defect puts a load on the systemic circulation and causes heart failure, resulting in a poor prognosis. This article reports a case of cTGA detected in a patient with post-caesarean pregnancy who had undergone elective caesarean section and was experiencing an episode of acute heart failure.
CASE SUMMARY This was the case of a 36-year-old gravida 3 para 1 woman. No problems were noted in the puerperal course following the previous pregnancy. The current pregnancy was also uneventful. An elective caesarean section was performed and the patient was discharged from the hospital 7 d after the operation. On postoperative day 18, the patient became aware of breathing difficulty and presented at a nearby clinic, where she was referred to our institution after bilateral pleural effusions were detected. She was then diagnosed with acute heart failure after noting the presence of a prominent pedal oedema and SpO2 91% (supine position and room air); the patient was promptly hospitalised for close examination and treatment. Although chest computed tomography revealed the presence of cTGA, no other cardiac malformations were observed. Owing to improvements in both the pedal oedema and pleural effusions, the patient was discharged on day 9.
CONCLUSION Close examination should be performed on the premise of congenital cardiac malformation when heart failure symptoms are noted during perinatal control.
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Affiliation(s)
- Naoki Ichii
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Toshiyuki Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Atsushi Fujikawa
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Morihiko Takeda
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Tomoyuki Ohta
- Department of Radiology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Masataka Kagimoto
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Ayaka Kaneko
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Ryo Izumi
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Kaoru Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Koyomi Saito
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Asako Maeyama
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Kaoru Yanagida
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Nobuhiro Takeshima
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
| | - Michitaka Ohwada
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Tochigi 329-2763, Japan
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7
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Tryfou ES, Kostakou PM, Kostopoulos VS, Olympios CD, Mihas C, Paraskevaidis I, Kouris NT. Pathophysiological alterations of left ventricular myocardial systolic function during normal pregnancy assessed by speckle tracking echocardiography: a prospective cohort echocardiography study. Int J Cardiovasc Imaging 2022; 38:2677-2686. [DOI: 10.1007/s10554-022-02682-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
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8
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A mathematical model of maternal vascular growth and remodeling and changes in maternal hemodynamics in uncomplicated pregnancy. Biomech Model Mechanobiol 2022; 21:647-669. [PMID: 35112224 DOI: 10.1007/s10237-021-01555-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 12/26/2021] [Indexed: 11/02/2022]
Abstract
The maternal vasculature undergoes tremendous growth and remodeling (G&R) that enables a > 15-fold increase in blood flow through the uterine vasculature from conception to term. Hemodynamic metrics (e.g., uterine artery pulsatility index, UA-PI) are useful for the prognosis of pregnancy complications; however, improved characterization of the maternal hemodynamics is necessary to improve prognosis. The goal of this paper is to develop a mathematical framework to characterize maternal vascular G&R and hemodynamics in uncomplicated human pregnancies. A validated 1D model of the human vascular tree from the literature was adapted and inlet blood flow waveforms at the ascending aorta at 4 week increments from 0 to 40 weeks of gestation were prescribed. Peripheral resistances of each terminal vessel were adjusted to achieve target flow rates and mean arterial pressure at each gestational age. Vessel growth was governed by wall shear stress (and axial lengthening in uterine vessels), and changes in vessel distensibility were related to vessel growth. Uterine artery velocity waveforms generated from this model closely resembled ultrasound results from the literature. The literature UA-PI values changed significantly across gestation, increasing in the first month of gestation, then dramatically decreasing from 4 to 20 weeks. Our results captured well the time-course of vessel geometry, material properties, and UA-PI. This 1D fluid-G&R model captured the salient hemodynamic features across a broad range of clinical reports and across gestation for uncomplicated human pregnancy. While results capture available data well, this study highlights significant gaps in available data required to better understand vascular remodeling in pregnancy.
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9
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Chang SA, Khakh P, Janzen M, Kiess M, Rychel V, Grewal J. Pregnancy related changes in Doppler gradients and left ventricular mechanics in women with sub-valvular or valvular aortic stenosis. Echocardiography 2021; 38:1754-1761. [PMID: 34672021 DOI: 10.1111/echo.15208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/14/2021] [Accepted: 08/22/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of our study was to characterize echocardiographic changes during pregnancy in women with known LVOT obstruction or AS compared to the healthy pregnancy controls, and to assess the relationship with pregnancy outcomes. METHODS We retrospectively studied 34 pregnant patients with congenital LVOT obstruction or AS with healthy age-matched pregnant controls. Patients with other significant valvular lesions, structural heart disease (LVEF < 40%), or prior valve surgery were excluded. All LVOTO/AS patients underwent a minimum of two consecutive echocardiograms between 1 year pre-conception and 1 year postpartum, with at least two studies during the pregnancy. Comprehensive echocardiographic evaluation was performed including speckle-tracking LV global longitudinal strain. RESULTS A total of 83 echocardiograms from the study group and 34 echocardiograms from the control group were evaluated. Over the range of LVOTO/AS, a significantly greater increase in the AV gradients and LV and LA volumes were observed as compared with the controls. In the sub-group of LVOTO/AS pregnant women with ≥ moderate (n = 8) versus < moderate LVOTO/AS (n = 26), averaged 2nd /3rd trimester LVEF was lower (51 ± 12)% versus (58 ± 4)%, (p = 0.02) and GLS was lower (-19.5 ± 2.8) versus (21.2 ± 2.4), (p = 0.06). Pregnancy was well tolerated despite these changes. CONCLUSION Among pregnant women with even milder forms of LVOTO/AS, increases in cardiac volumes and AV gradients can be expected over the course of pregnancy. Significant decreases in LV function and mechanics were only observed in women with moderate or greater LVOTO/AS, although still remained in normal range.
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Affiliation(s)
- Soohyun A Chang
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Parm Khakh
- University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Mikyla Janzen
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marla Kiess
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Valerie Rychel
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Jasmine Grewal
- Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Left ventricular trabeculations and noncompaction in pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Predictability of preoperative carotid artery-corrected flow time for hypotension after spinal anaesthesia in patients undergoing caesarean section: A prospective observational study. Eur J Anaesthesiol 2021; 38:394-401. [PMID: 33122575 DOI: 10.1097/eja.0000000000001376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Spinal anaesthesia-induced hypotension is frequently reported in patients undergoing caesarean section. Mechanistically, sympathetic blockade reduces the systemic vascular resistance and the left ventricular preload, causing hypotension, which is augmented by aortocaval compression. The corrected blood flow time (FTc) is affected by the preload and is inversely related to the afterload. OBJECTIVE We hypothesised that the preanaesthetic carotid artery FTc could predict hypotension after induction in patients undergoing a caesarean section with spinal anaesthesia. DESIGN A prospective observational study. SETTING A tertiary referral centre in South Korea from September 2018 to November 2019. PARTICIPANTS Thirty-eight parturients scheduled for elective caesarean section under spinal anaesthesia. INTERVENTIONS Using carotid ultrasonography, FTc was measured twice prior to inducing spinal anaesthesia. FTc was calculated using both Bazett's (B) and Wodey's (W) formulae. Hypotension was defined as an SBP decrease to less than 80 mmHg, or less than 75% of baseline, or if symptoms consistent with hypotension occurred from the time of injection of the spinal anaesthetic until delivery. MAIN OUTCOME MEASURES The primary endpoint was to determine the predictive value of preanaesthetic FTc for postspinal hypotension during caesarean delivery. RESULTS Among the 35 patients who completed this study, hypotension occurred in 21 (60%). The areas under the receiver-operating characteristic curves for FTc (B) and FTc (W) were 0.905 [95% confidence interval (CI), 0.757 to 0.978, P < 0.001] and 0.922 (95% CI, 0.779 to 0.985, P < 0.001), respectively. The optimal cut-off values for predicting hypotension were 346.4 and 326.9 ms, respectively. The grey zone for FTc (B) and FTc (W) included 40 and 14% of the patients, respectively. CONCLUSION Preanaesthetic carotid artery FTc was a reliable indicator of postspinal hypotension in parturients. Considering the grey zone, Wodey's formula is better than Bazett's formula. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03631329.
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12
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Silva-Jose C, Sánchez-Polán M, Diaz-Blanco Á, Coterón J, Barakat R, Refoyo I. Effectiveness of a Virtual Exercise Program During COVID-19 Confinement on Blood Pressure Control in Healthy Pregnant Women. Front Physiol 2021; 12:645136. [PMID: 33776798 PMCID: PMC7988209 DOI: 10.3389/fphys.2021.645136] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/17/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The situation caused by COVID-19 has led to movement restrictions for the majority of the population due to the confinement established by the health authorities. This new situation has changed people's habits and significantly affected the pregnant population. Decreased exercise and increased psychophysical stress are associated with excessive weight gain, diabetes, and gestational cardiovascular complications that affect the mother, fetus, and newborn. Recent research shows that the dynamics of maternal blood pressure is one of the most important control factors during pregnancy. Thus, prevention of these type of pathologies through interventions without maternal-fetal risks is important. OBJECTIVES To examine the influence of a virtual exercise program on maternal blood pressure during pregnancy. MATERIALS AND METHODS A randomized clinical trial design was used (NCT04563065). Data from 72 pregnant women without obstetric contraindications under confinement conditions in the Madrid area were collected. Women were randomly assigned to the intervention (IG) or control group (CG). They previously signed informed consent forms. A moderate exercise program was performed as an intervention from 8-10 to 38-39 weeks of pregnancy. Systolic (SBP) and diastolic (DBP) maternal blood pressure were measured during the first, second and third trimesters of pregnancy, as well as before and immediately after delivery in both study groups. RESULTS No differences in systolic and diastolic blood pressure during the first, second and third trimesters were found between groups. Significant differences in SBP were found immediately before delivery (IG = 119.83 ± 10.16 vs. CG = 125.6 ± 10.91; p = 0.047) and immediately after delivery (IG = 115.00 ± 11.18 vs. CG = 122.24 ± 15.71; p = 0.045). CONCLUSIONS Results show lower SBP values for the IG during delivery than CG. A virtual exercise program throughout pregnancy during COVID-19 confinement can help to control systolic blood pressure before and immediately after delivery in healthy pregnant women.
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Affiliation(s)
- Cristina Silva-Jose
- Actividad Físico-Deportiva en Poblaciones Específicas (AFIPE) Research Group, Facultad de Ciencias de la Actividad Física y el Deporte, Universidad Politécnica de Madrid, Madrid, Spain
| | - Miguel Sánchez-Polán
- Actividad Físico-Deportiva en Poblaciones Específicas (AFIPE) Research Group, Facultad de Ciencias de la Actividad Física y el Deporte, Universidad Politécnica de Madrid, Madrid, Spain
| | - Ángeles Diaz-Blanco
- Servicio de Obstetricia y Ginecología, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Javier Coterón
- Actividad Físico-Deportiva en Poblaciones Específicas (AFIPE) Research Group, Facultad de Ciencias de la Actividad Física y el Deporte, Universidad Politécnica de Madrid, Madrid, Spain
| | - Ruben Barakat
- Actividad Físico-Deportiva en Poblaciones Específicas (AFIPE) Research Group, Facultad de Ciencias de la Actividad Física y el Deporte, Universidad Politécnica de Madrid, Madrid, Spain
| | - Ignacio Refoyo
- Actividad Físico-Deportiva en Poblaciones Específicas (AFIPE) Research Group, Facultad de Ciencias de la Actividad Física y el Deporte, Universidad Politécnica de Madrid, Madrid, Spain
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Integration of physiological changes during the postpartum period into a PBPK framework and prediction of amoxicillin disposition before and shortly after delivery. J Pharmacokinet Pharmacodyn 2020; 47:341-359. [DOI: 10.1007/s10928-020-09706-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
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Aleksenko L, Quaye IK. Pregnancy-induced Cardiovascular Pathologies: Importance of Structural Components and Lipids. Am J Med Sci 2020; 360:447-466. [PMID: 32540145 DOI: 10.1016/j.amjms.2020.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 03/09/2020] [Accepted: 05/07/2020] [Indexed: 01/22/2023]
Abstract
Pregnancy leads to adaptations for maternal and fetal energy needs. The cardiovascular system bears the brunt of the adaptations as the heart and vessels enable nutrient supply to maternal organs facilitated by the placenta to the fetus. The components of the cardiovascular system are critical in the balance between maternal homeostatic and fetus driven homeorhetic regulation. Since lipids intersect maternal cardiovascular function and fetal needs with growth and in stress, factors affecting lipid deposition and mobilization impact risk outcomes. Here, the cardiovascular components and functional derangements associated with cardiovascular pathology in pregnancy, vis-à-vis lipid deposition, mobilization and maternal and/or cardiac and fetal energy needs are detailed. Most reports on the components and associated pathology in pregnancy, are on derangements affecting the extracellular matrix and epicardial fat, followed by the endothelium, vascular smooth muscle, pericytes and myocytes. Targeted studies on all cardiovascular components and pathological outcomes in pregnancy will enhance targeted interventions.
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Affiliation(s)
- Larysa Aleksenko
- Division of Obstetrics and Gynecology, Department of Clinical Sciences, Lund University, Lund, Sweden.
| | - Isaac K Quaye
- Regent University College of Science and Technology, Accra, Ghana
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15
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Ling HZ, Guy GP, Bisquera A, Poon LC, Nicolaides KH, Kametas NA. Maternal hemodynamics in screen-positive and screen-negative women of the ASPRE trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:51-57. [PMID: 30246326 DOI: 10.1002/uog.20125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/11/2018] [Accepted: 09/13/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To compare maternal hemodynamics and perinatal outcome, in pregnancies that do not develop pre-eclampsia (PE) or deliver a small-for-gestational-age (SGA) neonate, between those identified at 11-13 weeks' gestation as being screen positive or negative for preterm PE, by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, serum placental growth factor and pregnancy associated plasma protein-A. METHODS This was a prospective longitudinal cohort study of maternal cardiovascular function, assessed using a bioreactance method, in women undergoing first-trimester screening for PE. Maternal hemodynamics and perinatal outcome were compared between screen-positive and screen-negative women who did not have a medical comorbidity, did not develop PE or pregnancy-induced hypertension and delivered at term a live neonate with birth weight between the 5th and 95th percentiles. A multilevel linear mixed-effects model was used to compare the repeated measures of cardiac variables, controlling for maternal characteristics. RESULTS The screen-negative group (n = 926) had normal cardiac function changes across gestation, whereas the screen-positive group (n = 170) demonstrated static or reduced cardiac output and stroke volume and higher mean arterial pressure and peripheral vascular resistance with advancing gestation. In the screen-positive group, compared with screen-negative women, birth-weight Z-score was shifted toward lower values, with prevalence of delivery of a neonate below the 35th , 30th or 25th percentile being about 70% higher, and the rate of operative delivery for fetal distress in labor also being higher. CONCLUSION Women who were screen positive for impaired placentation, even though they did not develop PE or deliver a SGA neonate, had pathological cardiac adaptation in pregnancy and increased risk of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Z Ling
- Fetal Medicine Research Institute, King's College London, London, UK
| | - G P Guy
- Fetal Medicine Research Institute, King's College London, London, UK
| | - A Bisquera
- School of Population Health & Environmental Sciences, King's College London, London, UK
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - L C Poon
- Fetal Medicine Research Institute, King's College London, London, UK
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong, China
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College London, London, UK
| | - N A Kametas
- Fetal Medicine Research Institute, King's College London, London, UK
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Kodogo V, Azibani F, Sliwa K. Role of pregnancy hormones and hormonal interaction on the maternal cardiovascular system: a literature review. Clin Res Cardiol 2019; 108:831-846. [PMID: 30806769 DOI: 10.1007/s00392-019-01441-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 02/04/2019] [Indexed: 12/14/2022]
Abstract
Hormones have a vital duty in the conservation of physiological cardiovascular function during pregnancy. Alterations in oestrogen, progesterone and prolactin levels are associated with changes in the cardiovascular system to support the growing foetus and counteract pregnancy stresses. Pregnancy hormones are, however, also linked to numerous pathophysiological outcomes on the cardiovascular system. The expression and effects of the three main pregnancy hormones (oestrogen, prolactin and progesterone) vary depending on the gestation period. However, the reaction of a target cell also depends on the abundance of hormone receptors and impacts put forth by other hormones. Hormonal interaction may be synergistic, antagonistic or permissive. It is crucial to explore the cross talk of pregnancy hormones during gestation, as this may have a greater impact on the overall changes to the cardiovascular system.
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Affiliation(s)
- Vitaris Kodogo
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, 4th floor Chris Barnard Building, Observatory, Cape Town, 7935, South Africa
| | - Feriel Azibani
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, 4th floor Chris Barnard Building, Observatory, Cape Town, 7935, South Africa
| | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, 4th floor Chris Barnard Building, Observatory, Cape Town, 7935, South Africa.
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Martínez-Sellés M, Díez-Villanueva P, Álvarez Garcia J, Ferrero-Gregori A, Vives-Borrás M, Worner F, Bardají A, Delgado JF, Vázquez R, González-Juanatey JR, Fernández-Aviles F, Cinca J. Influence of sex and pregnancy on survival in patients admitted with heart failure: Data from a prospective multicenter registry. Clin Cardiol 2018; 41:924-930. [PMID: 29774566 DOI: 10.1002/clc.22979] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/09/2018] [Accepted: 05/14/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Female sex is an independent predictor of better survival in patients with heart failure (HF), but the mechanism of this association is unknown. On the other hand, pregnancies have a strong influence on the cardiovascular system. HYPOTHESIS Sex and previous gestations might have a prognostic impact on 1-year mortality in patients admitted with HF. METHODS We conducted an observational, prospective, consecutive, multicenter registry of 1831 patients (756 females [41.2%]) admitted with HF. RESULTS Females had a more advanced age (75.2 ±11.4 vs 70.4 ±12.2 years), less ischemic heart disease (167 [25.3%] vs 446 [47.3%]), and higher left ventricular ejection fraction (52.0% ±16.6% vs 41.1% ±17.0%) than did men (all P values <0.001). During 1-year follow-up, 373 (20.4%) patients died (151 females and 222 males). Female sex was an independent predictor for survival (hazard ratio: 0.79, 95% confidence interval: 0.64-0.98, P = 0.03). In 504 women (65.9%), the exact number of previous pregnancies could be determined; 62 women (12.3%) had no previous pregnancies, 288 (57.1%) women had 1 or 2 pregnancies, and 154 women (30.6%) had ≥3 pregnancies. We found an association between the number of previous gestations and better survival (hazard ratio: 0.878, 95% confidence interval: 0.773-0.997, P = 0.045). CONCLUSIONS In patients admitted with HF, female sex and the number of previous pregnancies are independently associated with better 1-year survival.
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Affiliation(s)
- Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Complutense, Madrid, Spain.,Universidad Europea, Madrid, Spain
| | | | - Jesús Álvarez Garcia
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andreu Ferrero-Gregori
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Miquel Vives-Borrás
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fernando Worner
- Cardiology Department, Hospital Universitari Arnau de Vilanova, Instituto de Investigación Biomédica de Lleida, Lleida (IRB LLEIDA), Spain
| | - Alfredo Bardají
- Cardiology Department, Hospital Universitario de Tarragona Joan XXIII, IISPV, Universidad Rovira Virgili, Tarragona, Spain
| | - Juan F Delgado
- Cardiology Department, Hospital General Universitario 12 de Octubre, Madrid, Spain
| | - Rafael Vázquez
- Cardiology Department, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - Francisco Fernández-Aviles
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Juan Cinca
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Cohen KM, Minehart RD, Leffert LR. Anesthetic Treatment of Cardiac Disease During Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:66. [PMID: 30019160 DOI: 10.1007/s11936-018-0657-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists. RECENT FINDINGS Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient's cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.
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Affiliation(s)
- Kate M Cohen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rebecca D Minehart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Umazume T, Yamada T, Yamada S, Ishikawa S, Furuta I, Iwano H, Murai D, Hayashi T, Okada K, Morikawa M, Yamada T, Ono K, Tsutsui H, Minakami H. Morphofunctional cardiac changes in pregnant women: associations with biomarkers. Open Heart 2018; 5:e000850. [PMID: 30057771 PMCID: PMC6059313 DOI: 10.1136/openhrt-2018-000850] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 05/30/2018] [Accepted: 06/13/2018] [Indexed: 11/03/2022] Open
Abstract
Objective This longitudinal study was performed to determine changes in echocardiography parameters in association with various biomarker levels in pregnancy/postpartum. Methods Fifty-one healthy pregnant women underwent echocardiography with simultaneous determination of blood levels of five biomarkers at each of the first, second and third trimesters of pregnancy, immediately postpartum within 1 week after childbirth and approximately 1 month postpartum. Data on 255 echocardiography scans (five times per woman) and biomarkers were analysed. Results Left ventricular end-diastolic dimension, left atrial (LA) volume index and left ventricular (LV) mass index increased with advancing gestation and reached the maximum immediately postpartum concomitant with the highest brain natriuretic peptide (BNP), N-terminal pro B-type natriuretic peptide (NT-proBNP), high-sensitivity troponin I (hs-TnI) and creatine kinase MB levels. The inferior vena cava diameter was significantly reduced in the third trimester compared with that in the first trimester and the peak occurred immediately after childbirth. In 255 paired measurements, hs-TnI level was significantly positively correlated with LA volume index and LV mass index; BNP and NT-proBNP were significantly positively correlated with LA volume index and estimated glomerular filtration rate (eGFR) was significantly positively correlated with the average of early diastolic septal and lateral mitral annular velocity (e'). Conclusions Maximal cardiac changes in morphology occurred postpartum within 1 week after childbirth, not during pregnancy. BNP/NT-proBNP, hs-TnI and eGFR reflected cardiac changes in pregnancy.
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Affiliation(s)
- Takeshi Umazume
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahiro Yamada
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Yamada
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Ishikawa
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Itsuko Furuta
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hiroyuki Iwano
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Daisuke Murai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Taichi Hayashi
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazunori Okada
- Faculty of Health Sciences, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Mamoru Morikawa
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takashi Yamada
- Department of Obstetrics and Gynecology, JCHO Hokkaido Hospital, Sapporo, Japan
| | - Kota Ono
- Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisanori Minakami
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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20
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Ventura NM, Li TY, Tse MY, Richard L, Tayade C, Jin AY, Andrew RD, Pang SC. Developmental origins of pregnancy-induced cardiac changes: establishment of a novel model using the atrial natriuretic peptide gene-disrupted mice. Mol Cell Biochem 2018; 449:227-236. [PMID: 29802597 DOI: 10.1007/s11010-018-3359-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 04/16/2018] [Indexed: 12/21/2022]
Abstract
Pregnancy evokes many challenges on the maternal cardiovascular system that may unmask predispositions for future disease. This is particularly evident for women who develop pregnancy-related disorders, for example, pre-eclampsia and gestational diabetes or hypertension. Such pregnancy-related syndromes increase the risk for cardiovascular disease (CVD) postpartum. As a result, pregnancy has been termed as a cardiovascular stress test and an indicator or marker to predict the development of CVD later in life. In addition, pregnancy-related disorders impact the development of offspring also placing them at a higher risk for disease. Utilizing pregnancy as a physiological stressor, the current investigation sought to determine whether the cardiovascular system of offspring exposed to gestational hypertension in utero would respond adversely to the stress of pregnancy. Heterozygous atrial natriuretic peptide gene-disrupted (ANP+/-) offspring were generated by either crossing male wildtype ANP+/+ with female knockout ANP-/- to produce ANP+/-KO mice or crossing female wildtype ANP+/+ with male knockout ANP-/- to produce ANP+/-WT mice. To study the cardiovascular stress induced by pregnancy, female ANP+/-WT and ANP+/-KO mice were mated with male wildtype ANP+/+ mice to initiate pregnancy. Cardiac size and molecular expression of the renin-angiotensin (RAS) and natriuretic peptide systems (NPS) were compared between offspring groups. Our data demonstrate that gestational hypertension and lack of maternal ANP did not significantly impact the progression and regression of pregnancy-induced cardiac hypertrophy over gestation and postpartum in ANP+/- offspring. Additionally, the molecular cardiac expression of the RAS and NPS did not differ between offspring groups. Future investigation should assess potential differences in cardiac function and the impact of fetal-programming on offspring cardiovascular adaptations during pregnancy in more severe models of pregnancy-related hypertensive syndrome such as angiotensin II or isoproterenol infusion.
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Affiliation(s)
- Nicole M Ventura
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
- Department of Anatomy and Cell Biology, Faculty of Medicine, McGill University, Room 1/54 Strathcona Anatomy Building, 3640 University St., Montreal, QC, H3A 0C7, Canada
| | - Terry Y Li
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
| | - M Yat Tse
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
| | - Logan Richard
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
| | - Chandrakant Tayade
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
| | - Albert Y Jin
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
- Department of Medicine (Neurology), Kingston General Hospital, 76 Stuart St. Kingston, Kingston, ON, K7L 2V7, Canada
| | - R David Andrew
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada
| | - Stephen C Pang
- Department of Biomedical and Molecular Sciences, Queen's University, Botterell Hall - 18 Stuart St., Kingston, ON, K7L 3N6, Canada.
- Department of Biomedical and Molecular Sciences, Queen's University, Rm 850 Botterell Hall, 18 Stuart St., Kingston, ON, K7L 3N6, Canada.
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Ambia AM, Morgan JL, Wells CE, Roberts SW, Sanghavi M, Nelson DB, Cunningham FG. Perinatal outcomes associated with abnormal cardiac remodeling in women with treated chronic hypertension. Am J Obstet Gynecol 2018; 218:519.e1-519.e7. [PMID: 29505770 DOI: 10.1016/j.ajog.2018.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/13/2018] [Accepted: 02/26/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Adverse maternal outcomes associated with chronic hypertension include accelerated hypertension and resultant target organ damage. One example is long-standing hypertension leading to maternal cardiac dysfunction. Our group has previously identified that features of such injury manifest as cardiac remodeling with left ventricular hypertrophy. Moreover, these features of cardiac remodeling identified in women with chronic hypertension during pregnancy were associated with adverse perinatal outcomes. Recent definitions of maternal cardiac remodeling using echocardiography have been expanded to include measurements of wall thickness. We hypothesized that these new features characterizing cardiac remodeling in women with chronic hypertension may also be associated with adverse perinatal outcomes. OBJECTIVE There were 3 aims in this study of women with treated chronic hypertension during pregnancy: to (1) apply the updated definitions of maternal cardiac remodeling; (2) elucidate whether these features of cardiac remodeling were associated with adverse perinatal outcomes; and (3) determine which, if any, of the newly defined cardiac remodeling strata were most damaging when compared to women with normal cardiac geometry. STUDY DESIGN This was a retrospective study of women with treated chronic hypertension during pregnancy delivered from January 2009 through January 2016. Cardiac remodeling was categorized by left ventricular mass index and relative wall thickness into 4 groups determined using the 2015 American Society of Echocardiography guidelines: normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Perinatal outcomes were analyzed according to each category of cardiac remodeling compared with outcomes in women with normal geometry. RESULTS A total of 314 women with treated chronic hypertension underwent echocardiography at a mean gestational age of 17.9 weeks. There were no differences between maternal age (P = .896), habitus (P = .36), or duration of chronic hypertension (P = .212) among the 4 groups. Abnormal cardiac remodeling was found in 51% and was significantly associated with increased rates of superimposed preeclampsia (P = .015), preterm birth (P < .001), and neonatal intensive care admission (P = .003). These outcomes reached the greatest significance when comparisons were made between eccentric hypertrophy and normal geometry. CONCLUSION Using current American Society of Echocardiography guidelines, 51% of women with treated chronic hypertension during pregnancy have some degree of abnormal cardiac remodeling. Any suggestion of maternal cardiac remodeling, regardless of subtype, was associated with increased risks for superimposed preeclampsia and preterm birth with its resultant perinatal sequelae. Eccentric ventricular hypertrophy, previously thought to mimic exercise physiology, appears to be the most associated with adverse perinatal outcomes. Despite evidence of cardiac remodeling, ejection fraction was preserved.
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Affiliation(s)
- Anne M Ambia
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Jamie L Morgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - C Edward Wells
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Scott W Roberts
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Monika Sanghavi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - David B Nelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - F Gary Cunningham
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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Hemodynamic and Electrocardiographic Aspects of Uncomplicated Singleton Pregnancy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:413-431. [PMID: 30051399 DOI: 10.1007/978-3-319-77932-4_26] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pregnancy is associated with significant changes in maternal hemodynamics, which are triggered by profound systemic vasodilation and mediated through the autonomic nervous system as well as the renin-angiotensin-aldosterone system. Vascular function changes to help accommodate an increase in intravascular volume due to blood volume expansion associated with pregnancy while maintaining the efficiency of ventricular-arterial coupling and diastolic perfusion pressure. The heart undergoes physiological (eccentric) hypertrophy due to increased volume load and cardiac stroke work, whereas the functional change of the left ventricle remains controversial. There are changes in cardiac electrical activity during pregnancy which can be detected in the electrocardiogram that are not related to disease. Sympathetic activation is a common phenomenon during uncomplicated pregnancy and may be a compensatory mechanism induced by profound systemic vasodilation and a decrease in mean arterial pressure. Despite marked sympathetic activation, vasoconstrictor responsiveness is blunted during uncomplicated pregnancy. There are race and ethnic differences in maternal hemodynamic adaptations to uncomplicated pregnancy, which may be attributed to differences in socioeconomic status or in prevalence rates of cardiovascular risk factors.
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Heart Function Analysis in Cardiac Patients with Focus on Sex-Specific Aspects. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1065:361-377. [DOI: 10.1007/978-3-319-77932-4_23] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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De Haas S, Ghossein-Doha C, Geerts L, van Kuijk SMJ, van Drongelen J, Spaanderman MEA. Cardiac remodeling in normotensive pregnancy and in pregnancy complicated by hypertension: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:683-696. [PMID: 28078751 DOI: 10.1002/uog.17410] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 12/27/2016] [Accepted: 01/03/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to describe comprehensively the pattern of cardiac remodeling during normotensive human singleton pregnancy and to compare it with that of pregnancy complicated by hypertension. METHODS We performed a meta-analysis of the current literature on cardiac remodeling during normotensive and complicated pregnancies. Literature was retrieved from PubMed (NCBI) and EMBASE (Ovid) databases. Included studies needed to report a reference measurement (matched non-pregnant control group, prepregnancy or postpartum) and measurements made during predetermined gestational-age intervals. Mean differences between reference and pregnancy data were calculated using the random-effects model described by DerSimonian and Laird. RESULTS Forty-eight studies were included in the meta-analysis, with publication dates ranging from 1977 to 2016. During normotensive pregnancy, most geometric indices started to increase in the second trimester. Left ventricular mass (LVM) increased by 28.36 (95% CI, 19.73-37.00) g (24%), and relative wall thickness (RWT) increased by 0.03 (95% CI, 0.02-0.05) (10%) compared with those in the reference group. During hypertensive pregnancy, LVM and RWT increased more than during normotensive pregnancy (92 (95% CI, 75.46-108.54) g (95%) and 0.14 (95% CI, 0.09-0.19) (56%), respectively). CONCLUSIONS During normotensive pregnancy, most cardiac geometric indices change from the second trimester onwards. Both LVM and RWT increase, by 20% and 10%, respectively, consistent with concentric rather than eccentric remodeling. Cardiac adaptation in hypertensive pregnancy deviates from that in healthy pregnancy by a greater change in LVM (95% increase from reference) and RWT (56% increase from reference). Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S De Haas
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - C Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - L Geerts
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - J van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - M E A Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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Corsini C, Cervi E, Migliavacca F, Schievano S, Hsia TY, Pennati G. Mathematical modelling of the maternal cardiovascular system in the three stages of pregnancy. Med Eng Phys 2017; 47:55-63. [PMID: 28694109 DOI: 10.1016/j.medengphy.2017.06.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/31/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
Abstract
In this study, a mathematical model of the female circulation during pregnancy is presented in order to investigate the hemodynamic response to the cardiovascular changes associated with each trimester of pregnancy. First, a preliminary lumped parameter model of the circulation of a non-pregnant female was developed, including the heart, the systemic circulation with a specific block for the uterine district and the pulmonary circulation. The model was first tested at rest; then heart rate and vascular resistances were individually varied to verify the correct response to parameter alterations characterising pregnancy. In order to simulate hemodynamics during pregnancy at each trimester, the main changes applied to the model consisted in reducing vascular resistances, and simultaneously increasing heart rate and ventricular wall volumes. Overall, reasonable agreement was found between model outputs and in vivo data, with the trends of the cardiac hemodynamic quantities suggesting correct response of the heart model throughout pregnancy. Results were reported for uterine hemodynamics, with flow tracings resembling typical Doppler velocity waveforms at each stage, including pulsatility indexes. Such a model may be used to explore the changes that happen during pregnancy in female with cardiovascular diseases.
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Affiliation(s)
- Chiara Corsini
- Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133 Milan, Italy.
| | - Elena Cervi
- UCL Institute of Cardiovascular Science and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133 Milan, Italy
| | - Silvia Schievano
- UCL Institute of Cardiovascular Science and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Tain-Yen Hsia
- UCL Institute of Cardiovascular Science and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Giancarlo Pennati
- Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133 Milan, Italy
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Abstract
OPINION STATEMENT Cardiovascular disease (CVD) is the leading cause of pregnancy-associated mortality, with an increasingly complex pregnant population. While our understanding of CVD in pregnancy continues to evolve, there remains a need to develop widely accessible tools to follow pregnant women both with and without preexisting disease with respect to cardiovascular risk, particularly for those presenting with symptoms suggestive of cardiovascular pathology. Thus, research is emerging with respect to the potential role of novel and established cardiac biomarkers in diagnosing and following CVD in pregnancy. Here, we review the normal hemodynamics of pregnancy and the behavior of various biomarkers in both normal and complicated pregnancies.
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Affiliation(s)
- Emily S Lau
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Amy Sarma
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Sengupta SP, Bansal M, Hofstra L, Sengupta PP, Narula J. Gestational changes in left ventricular myocardial contractile function: new insights from two-dimensional speckle tracking echocardiography. Int J Cardiovasc Imaging 2016; 33:69-82. [PMID: 27628530 DOI: 10.1007/s10554-016-0977-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 09/06/2016] [Indexed: 12/25/2022]
Abstract
The goal of this study was to evaluate the impact of pregnancy and labor on left ventricular (LV) myocardial mechanics using speckle tracking echocardiography (STE). Pregnancy is characterized by profound hormonal and hemodynamic alterations that directly or indirectly influence cardiac structure and function. However, the impact of these changes on left ventricular (LV) myocardial contractile function has not been fully elucidated. In this prospective, longitudinal study, 35 pregnant women underwent serial clinical and echocardiographic evaluation during each trimester and at labor. Two dimensional STE was performed to measure global LV longitudinal, circumferential and radial strain (GLS, GCS and GRS, respectively). Similar data obtained from 20 nulliparous, age-matched women were used as control. All strain values during pregnancy were adjusted for age and hemodynamic parameters. There was a progressive increase in heart rate, systolic and diastolic blood pressure, cardiac output and LV stroke-work during pregnancy. LV end-diastolic and end-systolic volumes also increased progressively but LV ejection fraction remained unaltered, except for slight reduction during the second trimester. Compared to the controls, GLS and GCS were reduced in the first trimester itself (GLS -22.39 ± 5.43 % vs. -18.66 ± 0.64 %, P 0.0002; GCS -20.84 ± 3.20 vs. -17.88 ± 0.09, P < 0.001) and remained so throughout the pregnancy and labor. In contrast, GRS showed an increase during pregnancy which peaked during the second trimester (24.18 ± 0.39 % vs. 18.06 ± 8.14 % in controls, P < 0.001). Alterations in loading conditions during pregnancy are associated with counterbalancing changes in the myocardial mechanics. LV longitudinal and circumferential strain are reduced whereas radial strain is increased. These counterbalancing changes serve to maintain overall LV ejection performance within a normal range and enable the maternal heart to meet the hemodynamic demands of pregnancy and labor.
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Affiliation(s)
| | | | | | | | - Jagat Narula
- Mount Sinai School of Medicine, New York, NY, USA
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Adeyeye VO, Balogun MO, Adebayo RA, Makinde ON, Akinwusi PO, Ajayi EA, Ogunyemi SA, Akintomide AO, Ajayi EO, Adeyeye AG, Ojo TO, Abiodun OO. Echocardiographic Assessment of Cardiac Changes During Normal Pregnancy Among Nigerians. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:157-62. [PMID: 27656092 PMCID: PMC5015814 DOI: 10.4137/cmc.s40191] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 06/25/2016] [Accepted: 06/26/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Pregnancy is a physiological process associated with an increased hemodynamic load and cardiac structural remodeling. Limited echocardiographic information exists on cardiac chambers, left ventricular (LV) systolic and diastolic functions, and LV mass during trimesters of normal pregnancy among African women. MATERIALS AND METHODS Echocardiography was done at the beginning of the second trimester, beginning of the third trimester, and middle of the third trimester for 100 normal pregnant women and at one visit for age-matched 100 nonpregnant women. The data were analyzed using the Statistical Package for Social Sciences (SPSS) version 17 software. Analysis of variance was used to compare within trimesters, and a P value of <0.05 was considered significant. RESULTS The mean (SD) ages of the patients and controls were 28.20 (±5.91) and 28.35 (±6.06) years, respectively (age range = 19–44 years, P = 0.86). Cardiac chambers, LV systolic function, and LV mass and its index increased significantly during pregnancy. A significant increase in A-wave velocity but slight increase in E-wave velocity and a reduction in tissue e′ velocity at the septal margin but a progressive increase in a′ velocity were also observed (P < 0.05). CONCLUSION Cardiac chamber dimensions, LV wall thickness, and mass, most indices of LV systolic and diastolic function, though within normal range, were significantly higher in pregnant than in nonpregnant Nigerian women.
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Affiliation(s)
- V O Adeyeye
- Department of Medicine, Babcock University Teaching Hospital, Ilishan-Remo, Ogun State, Nigeria
| | - M O Balogun
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - R A Adebayo
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - O N Makinde
- Department of Obstetrics, Gynaecology and Perinatology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - P O Akinwusi
- Department of Medicine, College of Health Sciences, Osun State University, Osogbo, Osun State, Nigeria
| | - E A Ajayi
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
| | - S A Ogunyemi
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - A O Akintomide
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - E O Ajayi
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - A G Adeyeye
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - T O Ojo
- Department of Community Health, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | - O O Abiodun
- Department of Medicine, Federal Medical Centre, Abuja, Nigeria
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Jongen GJLM, van der Hout-van der Jagt MB, van de Vosse FN, Oei SG, Bovendeerd PHM. A mathematical model to simulate the cardiotocogram during labor. Part B: Parameter estimation and simulation of variable decelerations. J Biomech 2016; 49:2474-80. [PMID: 26920511 DOI: 10.1016/j.jbiomech.2016.01.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/28/2016] [Indexed: 11/18/2022]
Abstract
During labor and delivery the cardiotocogram (CTG), the combined registration of fetal heart rate (FHR) and uterine contractions, is used to monitor fetal well-being. In part A of our study we introduced a new mathematical computer model for CTG simulation in order to gain insight into the complex relation between these signals. By reducing model complexity and by using physically more realistic descriptions, this model was improved with respect to our previous model. Aim of part B of this study is to gain insight into the cascade of events from uterine contractions causing combined uterine flow reduction and umbilical cord compression, resulting in blood and oxygen pressure variations, which lead to changes in FHR via the baro- and chemoreflex. In addition, we extensively describe and discuss the estimation of model parameter values. Simulation results are in good agreement with sheep data and show the ability of the model to describe variable decelerations. Despite reduced model complexity, parameter estimation still remains difficult due to limited clinical data.
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Affiliation(s)
- Germaine J L M Jongen
- Department of Biomedical Engineering, Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands; Department of Gynecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands.
| | - M Beatrijs van der Hout-van der Jagt
- Department of Biomedical Engineering, Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands; Department of Gynecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Frans N van de Vosse
- Department of Biomedical Engineering, Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands
| | - S Guid Oei
- Department of Gynecology and Obstetrics, Máxima Medical Center, Veldhoven, The Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Peter H M Bovendeerd
- Department of Biomedical Engineering, Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands
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Kim MJ, Seo J, Cho KI, Yoon SJ, Choi JH, Shin MS. Echocardiographic Assessment of Structural and Hemodynamic Changes in Hypertension-Related Pregnancy. J Cardiovasc Ultrasound 2016; 24:28-34. [PMID: 27081441 PMCID: PMC4828411 DOI: 10.4250/jcu.2016.24.1.28] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 10/01/2015] [Accepted: 02/01/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Pregnancy induces dramatic cardiovascular changes in order to meet the increasing metabolic needs. Adaptive change of left ventricle (LV) might be modified in pregnancy complicated by hypertension. METHODS Data from 193 consecutive pregnant women were analyzed. Clinical and echocardiographic data were compared in normotensive and hypertensive women. RESULTS Significantly higher LV mass indexed by height was observed in hypertensive women compared with normotensive women (84 ± 21 g/m vs. 97 ± 20 g/m, p = 0.001). Diastolic function measured by the ratio of peak velocity of early diastolic transmitral blood flow to early diastolic mitral annular velocity was impaired in hypertensive women (11.0 ± 3.0 vs. 9.2 ± 2.5, p < 0.001). Such change was more prominent in women with gestational hypertension (GH) than those with chronic hypertension (CH). Heavy maternal weight was an independent factor associated with LV hypertrophy (LVH) in both normotensive and hypertensive women. Overt eccentric LVH was more frequent than concentric remodeling/hypertrophy (24% vs. 8.4%) in GH, while the opposite result was observed in CH (14% vs. 23%). CONCLUSION Hypertensive pregnancy is associated with significant LVH and diastolic dysfunction. CH seems to induce different LV remodeling pattern from GH. Heavy maternal weight during pregnancy might intensify the unfavorable remodeling of LV, particularly in hypertensive pregnancy.
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Affiliation(s)
- Mi-Jeong Kim
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Jonggoo Seo
- Division of Cardiology, Department of Internal Medicine, Hallym Hospital, Incheon, Korea
| | - Kyoung-Im Cho
- Division of Cardiology, Department of Internal Medicine, Kosin University School of Medicine, Busan, Korea
| | - Se-Jung Yoon
- Division of Cardiology, Department of Internal Medicine, NHIC Ilsan Hospital, Goyang, Korea
| | - Jung-Hyun Choi
- Division of Cardiology, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University, Gil Medical Center, Incheon, Korea
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Khan SG, Melikian N, Mushemi-Blake S, Dennes W, Jouhra F, Monaghan M, Shah AM. Physiological Reduction in Left Ventricular Contractile Function in Healthy Postpartum Women: Potential Overlap with Peripartum Cardiomyopathy. PLoS One 2016; 11:e0147074. [PMID: 26859567 PMCID: PMC4747599 DOI: 10.1371/journal.pone.0147074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/27/2015] [Indexed: 01/04/2023] Open
Abstract
Aims Peripartum cardiomyopathy is a potentially life-threatening cause of heart failure, commoner in Afro-Caribbean than Caucasian women. Its diagnosis can be challenging due to physiological changes in cardiac function that also occur in healthy women during the early postpartum period. This study aimed to (i) establish the overlap between normal cardiac physiology in the immediate postpartum period and pathological changes in peripartum cardiomyopathy ii) identify any ethnicity-specific changes in cardiac function and cardiac biomarkers in healthy postpartum women. Methods and Results We conducted a cross-sectional study of 58 healthy postpartum women within 48 hours of delivery and 18 matched non-pregnant controls. Participants underwent cardiac assessment by echocardiography and strain analysis, including 3D echocardiography in 40 postpartum women. Results were compared with 12 retrospectively studied peripartum cardiomyopathy patients. Healthy postpartum women had significantly higher left ventricular volumes and mass, and lower ejection fraction and global longitudinal strain than non-pregnant controls. These parameters were significantly more impaired in peripartum cardiomyopathy patients but with overlapping ranges of values. Healthy postpartum women had higher levels of adrenomedullin, placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt1) compared to controls. The postpartum state, adrenomedullin, sFlt1 and the sFlt1:PlGF ratio were independent predictors of LV remodelling and function in healthy postpartum women. Conclusion Healthy postpartum women demonstrate several echocardiographic indicators of left ventricular remodelling and reduced function, which are associated with altered levels of angiogenic and cardiac biomarkers.
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MESH Headings
- Adult
- Biomarkers/metabolism
- Cardiomyopathy, Dilated/diagnostic imaging
- Cardiomyopathy, Dilated/metabolism
- Cardiomyopathy, Dilated/pathology
- Cardiomyopathy, Dilated/physiopathology
- Female
- Humans
- Myocardial Contraction
- Peripartum Period/metabolism
- Peripartum Period/physiology
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnostic imaging
- Pregnancy Complications, Cardiovascular/metabolism
- Pregnancy Complications, Cardiovascular/pathology
- Pregnancy Complications, Cardiovascular/physiopathology
- Retrospective Studies
- Stroke Volume
- Ultrasonography
- Ventricular Dysfunction, Left
- Ventricular Function, Left
- Ventricular Remodeling
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Affiliation(s)
- Sitara G. Khan
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Narbeh Melikian
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Sitali Mushemi-Blake
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - William Dennes
- Department of Obstetrics and Gynaecology, King’s College Hospital, London, United Kingdom
| | - Fadi Jouhra
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Mark Monaghan
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
| | - Ajay M. Shah
- Department of Cardiology, King’s College London British Heart Foundation Centre, London, United Kingdom
- Department of Cardiology, King’s College Hospital, London, United Kingdom
- * E-mail:
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Meah VL, Cockcroft JR, Backx K, Shave R, Stöhr EJ. Cardiac output and related haemodynamics during pregnancy: a series of meta-analyses. Heart 2016; 102:518-26. [PMID: 26794234 DOI: 10.1136/heartjnl-2015-308476] [Citation(s) in RCA: 195] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/11/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Cardiac output, a fundamental parameter of cardiovascular function, has consistently been shown to increase across healthy pregnancy; however, the time course and magnitude of adaptation remains equivocal within published literature. The aim of the present meta-analyses was to comprehensively describe the pattern of change in cardiac output during healthy pregnancy. METHOD A series of meta-analyses of previously published cardiac output data during healthy, singleton pregnancies was completed. PubMed and Scopus databases were searched for studies published between 1996 and 2014. Included studies reported absolute values during a predetermined gestational age (non-pregnant, late first trimester, early and late second trimester, early and late third trimester, early and late postpartum). Cardiac output was measured through echocardiography, impedance cardiography or inert gas rebreathing. Observational data were meta-analysed at each gestational age using a random-effects model. If reported, related haemodynamic variables were evaluated. RESULTS In total, 39 studies were eligible for inclusion, with pooled sample sizes ranging from 259 to 748. Cardiac output increased during pregnancy reaching its peak in the early third trimester, 1.5 L/min (31%) above non-pregnant values. The observed results from this study indicated a non-linear rise to this point. In the early postpartum, cardiac output had returned to non-pregnant values. CONCLUSION The present results suggest that cardiac output peaks in the early third trimester, following a non-linear pattern of adaptation; however, this must be confirmed using longitudinal studies. The findings provide new insight into the normal progression of cardiac output during pregnancy.
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Affiliation(s)
- Victoria L Meah
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | | | - Karianne Backx
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | - Rob Shave
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
| | - Eric J Stöhr
- Cardiff School of Sport, Cardiff Metropolitan University, Cardiff, UK
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Ventura NM, Li TY, Tse MY, Andrew RD, Tayade C, Jin AY, Pang SC. Onset and Regression of Pregnancy-Induced Cardiac Alterations in Gestationally Hypertensive Mice: The Role of the Natriuretic Peptide System1. Biol Reprod 2015; 93:142. [DOI: 10.1095/biolreprod.115.132696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/27/2015] [Indexed: 11/01/2022] Open
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Gongora MC, Wenger NK. Cardiovascular Complications of Pregnancy. Int J Mol Sci 2015; 16:23905-28. [PMID: 26473833 PMCID: PMC4632731 DOI: 10.3390/ijms161023905] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023] Open
Abstract
Pregnancy causes significant metabolic and hemodynamic changes in a woman's physiology to allow for fetal growth. The inability to adapt to these changes might result in the development of hypertensive disorders of pregnancy (hypertension, preeclampsia or eclampsia), gestational diabetes and preterm birth. Contrary to previous beliefs these complications are not limited to the pregnancy period and may leave permanent vascular and metabolic damage. There is in addition, a direct association between these disorders and increased risk of future cardiovascular disease (CVD, including hypertension, ischemic heart disease, heart failure and stroke) and diabetes mellitus. Despite abundant evidence of this association, women who present with these complications of pregnancy do not receive adequate postpartum follow up and counseling regarding their increased risk of future CVD. The postpartum period in these women represents a unique opportunity to intervene with lifestyle modifications designed to reduce the development of premature cardiovascular complications. In some cases it allows early diagnosis and treatment of chronic hypertension or diabetes mellitus. The awareness of this relationship is growing in the medical community, especially among obstetricians and primary care physicians, who play a pivotal role in detecting these complications and assuring appropriate follow up.
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Affiliation(s)
- Maria Carolina Gongora
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Nanette K Wenger
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Pijuan-Domènech A, Galian L, Goya M, Casellas M, Merced C, Ferreira-Gonzalez I, Marsal-Mora J, Dos-Subirà L, Subirana-Domènech M, Pedrosa V, Baró-Marine F, Manrique S, Casaldàliga-Ferrer J, Tornos P, Cabero L, Garcia-Dorado D. Cardiac complications during pregnancy are better predicted with the modified WHO risk score. Int J Cardiol 2015; 195:149-54. [DOI: 10.1016/j.ijcard.2015.05.076] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/06/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022]
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Hemnes AR, Kiely DG, Cockrill BA, Safdar Z, Wilson VJ, Al Hazmi M, Preston IR, MacLean MR, Lahm T. Statement on pregnancy in pulmonary hypertension from the Pulmonary Vascular Research Institute. Pulm Circ 2015; 5:435-65. [PMID: 26401246 PMCID: PMC4556496 DOI: 10.1086/682230] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 02/25/2015] [Indexed: 01/06/2023] Open
Abstract
Pregnancy outcomes in patients with pulmonary hypertension remain poor despite advanced therapies. Although consensus guidelines recommend against pregnancy in pulmonary hypertension, it may nonetheless occasionally occur. This guideline document sought to discuss the state of knowledge of pregnancy effects on pulmonary vascular disease and to define usual practice in avoidance of pregnancy and pregnancy management. This guideline is based on systematic review of peer-reviewed, published literature identified with MEDLINE. The strength of the literature was graded, and when it was inadequate to support high-level recommendations, consensus-based recommendations were formed according to prespecified criteria. There was no literature that met standards for high-level recommendations for pregnancy management in pulmonary hypertension. We drafted 38 consensus-based recommendations on pregnancy avoidance and management. Further, we identified the current state of knowledge on the effects of sex hormones during pregnancy on the pulmonary vasculature and right heart and suggested areas for future study. There is currently limited evidence-based knowledge about both the basic molecular effects of sex hormones and pregnancy on the pulmonary vasculature and the best practices in contraception and pregnancy management in pulmonary hypertension. We have drafted 38 consensus-based recommendations to guide clinicians in these challenging topics, but further research is needed in this area to define best practices and improve patient outcomes.
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Affiliation(s)
- Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - David G. Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, Sheffield, United Kingdom
| | - Barbara A. Cockrill
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, and Harvard University Medical School, Boston, Massachusetts, USA
| | - Zeenat Safdar
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Victoria J. Wilson
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Manal Al Hazmi
- Section of Pulmonary Diseases, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ioana R. Preston
- Pulmonary, Critical Care and Sleep Division, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mandy R. MacLean
- Institute of Cardiovascular and Medical Sciences, College of Medical and Veterinary Science, University of Glasgow, Glasgow, United Kingdom
| | - Tim Lahm
- Division of Pulmonary, Allergy, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine and Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
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Vårtun Å, Flo K, Wilsgaard T, Acharya G. Maternal functional hemodynamics in the second half of pregnancy: a longitudinal study. PLoS One 2015; 10:e0135300. [PMID: 26258418 PMCID: PMC4530890 DOI: 10.1371/journal.pone.0135300] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 07/20/2015] [Indexed: 01/04/2023] Open
Abstract
Objective Cardiovascular response to passive leg raising (PLR) is useful in assessing preload reserve, but it has not been studied longitudinally during pregnancy. We aimed to investigate gestational age associated serial changes in maternal functional hemodynamics and establish longitudinal reference ranges for the second half of pregnancy. Materials and Methods This was a prospective longitudinal study on 98 healthy pregnant women who were examined 3–5 times during 20–40 weeks of gestation (a total of 441 observations). Maternal cardiac function and systemic hemodynamics were assessed at baseline and 90 seconds after PLR using impedance cardiography (ICG). The main outcome measures were gestational age specific changes in ICG-derived variables of maternal cardiovascular function and functional hemodynamic response to PLR. Results Hemodynamic response to PLR varied during pregnancy. PLR led to an insignificant increase in stroke volume during 20+0 to 31+6 weeks, but later in gestation the stroke volume was slightly lower at PLR compared to baseline. PLR caused no significant change in cardiac output between 20+0 and 23+6 weeks and a significant decrease after 24+0 weeks. A decrease in heart rate, mean arterial pressure, and cardiac contractility was observed during PLR throughout the second half of pregnancy. Systemic vascular resistance was reduced by PLR up to 32+0 weeks, but increased slightly thereafter. Conclusion Healthy pregnant women appear to have limited preload reserve and reduced cardiac contractility, especially in the third trimester, which makes them vulnerable to fluid overload and cardiac failure.
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Affiliation(s)
- Åse Vårtun
- Women’s Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT- The Arctic University of Norway and Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
- * E-mail:
| | - Kari Flo
- Women’s Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT- The Arctic University of Norway and Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
| | - Tom Wilsgaard
- Department of Community Medicine, Faculty of Health Sciences, UiT- The Arctic University of Norway, Tromsø, Norway
| | - Ganesh Acharya
- Women’s Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT- The Arctic University of Norway and Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
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Barakat R, Perales M, Garatachea N, Ruiz JR, Lucia A. Exercise during pregnancy. A narrative review asking: what do we know? Br J Sports Med 2015; 49:1377-81. [DOI: 10.1136/bjsports-2015-094756] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2015] [Indexed: 12/16/2022]
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Patel H, Madanieh R, Kosmas CE, Vatti SK, Vittorio TJ. Reversible Cardiomyopathies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:7-14. [PMID: 26052233 PMCID: PMC4441366 DOI: 10.4137/cmc.s19703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/12/2015] [Accepted: 01/17/2015] [Indexed: 01/04/2023]
Abstract
Cardiomyopathies (CMs) have many etiological factors that can result in severe structural and functional dysregulation. Fortunately, there are several potentially reversible CMs that are known to improve when the root etiological factor is addressed. In this article, we discuss several of these reversible CMs, including tachycardia-induced, peripartum, inflammatory, hyperthyroidism, Takotsubo, and chronic illness-induced CMs. Our discussion also includes a review on their respective pathophysiology, as well as possible management solutions.
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Affiliation(s)
- Harsh Patel
- SUNY Downstate School of Medicine, Department of Internal Medicine, Brooklyn, NY, USA
| | - Raef Madanieh
- St. Francis Hospital - The Heart Center , Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | - Constantine E Kosmas
- Mount Sinai School of Medicine, Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, USA
| | - Satya K Vatti
- St. Francis Hospital - The Heart Center , Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
| | - Timothy J Vittorio
- St. Francis Hospital - The Heart Center , Center for Advanced Cardiac Therapeutics, Roslyn, NY, USA
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Marcolan Quitete CM, Marcolan Salvany A, de Andrade Martins W, Mesquita ET. Left ventricular remodeling and diastolic function in chronic hypertensive pregnant women. Pregnancy Hypertens 2015; 5:187-92. [PMID: 25943643 DOI: 10.1016/j.preghy.2015.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 10/28/2014] [Accepted: 01/15/2015] [Indexed: 10/24/2022]
Abstract
UNLABELLED Hypertension during pregnancy is a problem that impacts maternal morbidity and mortality. Dyspnea and edema are common symptoms, often secondary to physiological changes, but may raise doubts as to ventricular dysfunction. OBJECTIVE To evaluate the ventricular geometry pattern and diastolic function in chronic hypertensive pregnant women (HPW). METHODS Prospective, cross-sectional study on 62 pregnant women over a 29-month period, from March 2009 to July 2011, in Brazil was done. Thirty-one HPWs and 31 normotensive pregnant women (NPW) underwent clinical and cardiovascular evaluations, and were subjected to transthoracic echocardiogram. RESULTS LV mass (HPW: 220.9 ± 43.3 vs. NPW: 192.9 ± 39.8 g, p = 0.01), posterior wall thickness (HPW: 9.9 ± 1.1 vs. NPW: 9.2 ± 0.9 mm, p = 0.005), mitral flow A wave velocity (HPW: 0.60 ± 0.16 vs. NPW: 0.52 ± 0.10 m/s, p = 0.02), tissue Doppler A' wave velocity (HPW: 10 ± 2 vs. NPW: 8.9 ± 1cm/s, p=0.02), and E/E' ratio (HPW: 6.8 ± 2.2 vs. NPW: 5.5 ± 1.6, p = 0.01) were higher in HPWs. Septal and lateral walls E' wave velocities (HPW: 13 ± 2 vs. NPW: 15 ± 3 cm/s, p=0.001), and E'/A' ratio (HPW: 1.26 ± 0.38 vs. NPW: 1.77 ± 0.49, p = 0.00003) were lower in HPWs. There was a positive linear correlation between body mass index (BMI) and ventricular mass, A wave, systolic, diastolic blood pressures, and a negative correlation between BMI, E' wave and E'/A' ratio. CONCLUSION Ventricular remodeling showed a direct relationship with body weight, and both groups showed a predominant pattern of eccentric ventricular hypertrophy. The LV diastolic function was abnormal in HPWs.
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Affiliation(s)
| | - Aline Marcolan Salvany
- UNIFESO - Centro Universitário Serra dos Órgãos, Av. Alberto Torres 111-Alto, Teresópolis, RJ CEP 25964-004, Brazil
| | - Wolney de Andrade Martins
- Curso de Pós-Graduação em Ciências Cardiovasculares - Universidade Federal Fluminense (UFF), HUAP, Rua Marques do Paraná 303-Centro, Niterói, RJ CEP 24033-900, Brazil
| | - Evandro Tinoco Mesquita
- Curso de Pós-Graduação em Ciências Cardiovasculares - Universidade Federal Fluminense (UFF), HUAP, Rua Marques do Paraná 303-Centro, Niterói, RJ CEP 24033-900, Brazil
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Richartz BM, Nienaber CA. [Pregnancy-related cardiac problems]. Herz 2014; 39:605-18. [PMID: 25006077 DOI: 10.1007/s00059-014-4131-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
All women of child-bearing age suffering from congenital cardiac valve malformations or acquired valvular disease, pulmonary hypertension or arterial hypertension and who are at risk for coronary heart disease should receive early counseling and optimal treatment before pregnancy. They should be treated by an interdisciplinary team composed of gynecologists, cardiologists, geneticists and, if necessary, cardiac surgeons. This interdisciplinary approach should be used for all pregnant women with cardiac disease in order to minimize maternal and fetal mortality. As physicians will only rarely be confronted with such critically ill patients, guidelines and access to worldwide information from databanks are particularly important (http://www.safetus.com und http://www.emryotox.de).
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Sheppard R, Rajagopalan N, Safirstein J, Briller J. An update on treatments and outcomes in peripartum cardiomyopathy. Future Cardiol 2014; 10:435-47. [DOI: 10.2217/fca.14.23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
ABSTRACT: Peripartum cardiomyopathy (PPCM) is a well-established complication of pregnancy. Criteria include heart failure that presents with reduced left ventricular function, signs and symptoms of heart failure either late in pregnancy or early in the postpartum period. The incidence varies widely depending geography and ethnicity. The pathophysiology of PPCM is still an area of active investigation, but includes immune and inflammatory mechanisms, which are the subject of several investigations. Therapies for chronic heart failure from PPCM are similar to those patients with nonischemic cardiomyopathy from different etiologies, however novel therapies may include bromocriptine, pentoxifylline or other potential therapies influencing the immune system. The need for implantable defibrillators, left ventricular assist devices and cardiac transplant in women with PPCM is rare, and prognosis is better than other forms of nonischemic cardiomyopathy. Despite this, further information about the epidemiology, prognosis and potential therapies are required to better manage and diagnose PPCM in women with signs and symptoms of heart failure.
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Affiliation(s)
- Richard Sheppard
- Jewish General Hospital, McGill University, Montreal H3T1E2, Canada
| | - Navin Rajagopalan
- University of Kentucky, Division of Cardiovascular Medicine, KY, USA
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Vasapollo B, Novelli GP, Valensise H. Fetal growth restriction and maternal cardiac function. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.3.1.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Ducas RA, Elliott JE, Melnyk SF, Premecz S, daSilva M, Cleverley K, Wtorek P, Mackenzie GS, Helewa ME, Jassal DS. Cardiovascular magnetic resonance in pregnancy: insights from the cardiac hemodynamic imaging and remodeling in pregnancy (CHIRP) study. J Cardiovasc Magn Reson 2014; 16:1. [PMID: 24387349 PMCID: PMC3882291 DOI: 10.1186/1532-429x-16-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/11/2013] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cardiovascular disease in pregnancy is the leading cause of maternal mortality in North America. Although transthoracic echocardiography (TTE) is the most widely used imaging modality for the assessment of cardiovascular function during pregnancy, little is known on the role of cardiovascular magnetic resonance (CMR). The objective of the Cardiac Hemodynamic Imaging and Remodeling in Pregnancy (CHIRP) study was to compare TTE and CMR in the non-invasive assessment of maternal cardiac remodeling during the peripartum period. METHODS Between 2010-2012, healthy pregnant women aged 18 to 35 years were prospectively enrolled. All women underwent TTE and CMR during the third trimester and at least 3 months postpartum (surrogate for non-pregnant state). RESULTS The study population included a total of 34 women (mean age 29 ± 3 years). During the third trimester, TTE and CMR demonstrated an increase in left ventricular end-diastolic volume from 95 ± 11 mL to 115 ± 14 mL and 98 ± 6 mL to 125 ± 5 mL, respectively (p<0.05). By TTE and CMR, there was also an increase in left ventricular (LV) mass during pregnancy from 111 ± 10 g to 163 ± 11 g and 121 ± 5 g to 179 ± 5 g, respectively (p<0.05). Although there was good correlation between both imaging modalities for LV mass, stroke volume, and cardiac output, the values were consistently underestimated by TTE. CONCLUSION This CMR study provides reference values for cardiac indices during normal pregnancy and the postpartum state.
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Affiliation(s)
- Robin A Ducas
- Section of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Rm Y3531, Bergen Cardiac Care Centre, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada
| | - Jason E Elliott
- Department of Obstetrics, Gynecology & Reproductive Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven F Melnyk
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sheena Premecz
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Megan daSilva
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kelby Cleverley
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Piotr Wtorek
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - G Scott Mackenzie
- Section of Cardiac Anesthesia, Department of Anesthesia, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael E Helewa
- Department of Obstetrics, Gynecology & Reproductive Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Davinder S Jassal
- Section of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Rm Y3531, Bergen Cardiac Care Centre, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Radiology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Abstract
Healthy pregnancy is characterised by progressive physiological adaptation of the maternal cardiovascular (CV) system that facilitates optimal fetal development. The adaptations that constitute a healthy or normal progression are not always evident, and, in particular, CV adaptation to pregnancy is highly individualised. Some women develop pregnancy-related CV dysfunction such as pre-eclampsia (PE). Typically, PE is diagnosed by the development of hypertension and proteinuria after 20 weeks of pregnancy and is the leading cause of maternal and perinatal mortality and morbidity. Despite continued efforts to improve the understanding of the aetiology, pathophysiology and subsequently treatment for the disease, CV changes in PE are not well understood. PE before 34 weeks (early onset PE) is believed to differ in pathogenesis from late onset PE (>34 weeks) and can be characterised by a haemodynamic profile of increased systemic vascular resistance (SVR) and lower cardiac output (CO). Early onset PE is more often associated with uteroplacental insufficiency and significant adverse maternal and perinatal outcomes. In contrast, late onset PE (>34 weeks) involves an increased CO and lower SVR and is less likely to be associated with uteroplacental insufficiency and adverse perinatal outcomes. It is not known if PE develops secondary to the CV maladaptation in pregnancy or if a preexisting CV dysfunction predisposes some women to develop PE. Screening, diagnosis and disease management would be vastly improved if more were known about the onset of the maladaptive process associated with PE. To date, a combination of maternal factors including medical history, body mass index, age, parity and blood pressure (BP) have been used to predict the development of PE. In the first trimester, arterial stiffness is significantly increased in women who develop PE. Current hypotheses speculate that CV dysfunction is evident very early in pregnancy in PE and precedes the clinical manifestation at a later stage but whether CV dysfunction is present before pregnancy remains to be elucidated.
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Sakamoto A, Hosoya N, Kageyama S, Yoshizaki T, Takeuchi R, Murata K, Nawada R, Onodera T, Takizawa A, Nonaka Y, Fukasawa S. Peripartum cardiomyopathy with biventricular thrombus which led to massive cerebral embolism. J Cardiol Cases 2013; 9:71-74. [PMID: 30534300 DOI: 10.1016/j.jccase.2013.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 06/29/2013] [Accepted: 10/05/2013] [Indexed: 01/04/2023] Open
Abstract
A 37-year-old female who delivered her second child via a cesarean section 4 months previously presented to our hospital with gradual worsening of dyspnea on effort. Chest radiographic appearance showed cardiomegaly (cardiothoracic ratio 61%) and slight bilateral pulmonary congestion. Echocardiogram revealed diffuse hypokinesis of both left and right ventricles (left ventricular ejection fraction 29%) and large biventricular thrombus [left ventricular apex (28 mm × 21 mm, 22 mm × 14 mm) and right ventricular apex (16 mm × 11 mm)]. She was diagnosed as having peripartum cardiomyopathy (PPCM) and anticoagulation therapy was started. Surgical thrombectomy was not selected because of risk of complications. Massive cerebral infarction occurred 10 days after diagnosis. She was discharged with aphasia and right incomplete hemiplegia 65 days after admission. Biventricular thrombus is a rare complication of PPCM. If high risk of massive embolism is considered, surgical thrombectomy may be warranted even in cases with low cardiac function. <Learning objective: Biventricular thrombus is a rare complication of peripartum cardiomyopathy (PPCM). We report a case of biventricular thrombus secondary to PPCM. The decision to perform prophylactic surgical approach to ventricular thrombus is difficult in cases with low cardiac function.>.
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Affiliation(s)
- Atsushi Sakamoto
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Natsuko Hosoya
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Shigetaka Kageyama
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Toru Yoshizaki
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Ryosuke Takeuchi
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Tomoya Onodera
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Akinori Takizawa
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yuko Nonaka
- Department of Neurosurgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Seiji Fukasawa
- Department of Neurosurgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
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Egidy Assenza G, Cassater D, Landzberg M, Geva T, Schreier J, Graham D, Volpe M, Barker N, Economy K, Valente AM. The effects of pregnancy on right ventricular remodeling in women with repaired tetralogy of Fallot. Int J Cardiol 2013; 168:1847-52. [DOI: 10.1016/j.ijcard.2012.12.071] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 12/03/2012] [Accepted: 12/25/2012] [Indexed: 10/27/2022]
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