Reduced pulmonary arterial compliance in hypertensive pregnancy

Increased pulmonary arterial pressure in children with nephrotic syndrome

AIMS

To evaluate the pulmonary arterial pressure in children with nephrotic syndrome (NS).

METHODS

Doppler echocardiography was performed in 40 children with NS (aged 1.5-13 years) at NS onset (n = 28) or relapse (n = 12), and 40 normal controls. Pulmonary pressure was estimated by: (1) measuring the systolic transtricuspid gradient from tricuspid regurgitation; and (2) measuring the time to peak velocity of pulmonary flow.

RESULTS

Thirty five of the 40 patients with NS had measurable tricuspid regurgitation with a pulmonary systolic pressure ranging from 21 to 48 mm Hg. Pulmonary systolic pressure was >40 mm Hg in seven patients. The pulmonary time to peak velocity was shortened and the ratio of time to peak velocity and right ventricular ejection time decreased compared with controls. The patients with increased pulmonary pressure had a longer time since onset of NS. One patient developed thrombus in the inferior vena cava during hospitalisation.

CONCLUSION

Pulmonary arterial pressure was increased in children with NS. Further work is needed to evaluate the aetiology and clinical implications of this abnormality.

Left ventricular mechanics in preeclampsia

Increased systemic vascular resistance and contracted blood volume are characteristic findings in preeclampsia. These alterations in cardiovascular hemodynamics can adversely affect ejection phase indices of left ventricular performance making it difficult to separate abnormalities resulting from changes in load from those caused by depressed myocardial contractility. To address this issue the contractility-sensitive, load-independent relationship between left ventricular end-systolic wall stress and rate-corrected velocity of fiber shortening was assessed in 10 nulliparous patients with preeclampsia. Comparisons were made with data obtained from 10 age-matched normotensive women with uncomplicated pregnancies (control subjects). Studies were performed by means of two-dimensionally targeted M-mode echocardiography and calibrated carotid pulse tracings during early labor, 1 day after delivery, and 4 weeks after delivery. During early labor and 1 day after delivery, patients with preeclampsia had elevated blood pressure and increased total systemic resistance. These parameters returned to normal by 4 weeks after delivery. Before delivery and 24 hours after delivery, the patients with preeclampsia had lower overall left ventricular performance (as measured by cardiac output and rate-corrected velocity of fiber shortening) and higher left ventricular afterload (as measured by left ventricular end-systolic wall stress) when compared with control subjects. These differences were no longer present 4 weeks after delivery. Despite the time-related intergroup differences in hemodynamics, left ventricular contractility was similar between normotensive and preeclamptic subjects at all stages of the study. Thus when load is eliminated as a confounding variable, the decrements in overall left ventricular performance measured in patients with preeclampsia reflect a mechanically appropriate response to increased afterload rather than an abnormality in the ventricular contractile state.

Haemodynamic changes in gestational proteinuric hypertension: the effects of rapid volume expansion and vasodilator therapy

Ten patients with gestational proteinuric hypertension were studied with a Swan-Ganz thermodilution haemodynamic catheter before, during and after plasma volume expansion. Five patients were treated with dihydralazine before volume expansion and five after volume expansion. Before treatment all patients had a low pulmonary capillary wedge pressure (PCWP), low cardiac index (CI) and high systemic vascular resistance (SVR). Following volume expansion the PCWP and CI increased, the SVR decreased but the blood pressure (BP) was unchanged. Administration of dihydralazine following volume expansion led to a decrease in PCWP, an increase in CI and a decrease in SVR and BP. Dihydralazine alone caused an increase in heart rate, PCWP, and CI, and a decrease in SVR and BP. Volume expansion, by increasing CI and decreasing SVR, may be of therapeutic benefit in the severely hypertensive pregnant patient with a low cardiac index.

Hemodynamic observations in severe pre-eclampsia with a flow-directed pulmonary artery catheter

Ten patients with severe pre-eclampsia were studied throughout labor and delivery and during the early puerperium with a flow-directed pulmonary artery catheter. Cardiac output was higher than previously described in normal patients. Pulmonary artery pressures were not significantly altered from the normal pregnant values. The usual increase in cardiac output occurring in the early puerperium was not observed in the patients with severe pre-eclampsia. Central venous pressure and pulmonary artery wedge pressure did not correlate in three of the nine patients studied. Left ventricular stroke work index was elevated in the patients with severe pre-eclampsia, suggesting a hyperdynamic state. The pulmonary artery catheter provided important new information in patients with severe pre-eclampsia and may be a useful clinical adjunct in patients with hemorrhage or oliguria and in patients needing a regional or general anesthetic.

Arterial blood gases in pre-eclampsia

Arterial blood gases, physiological dead space and percentage pulmonary venous admixture (physiological shunt) were measured in 31 patients with proteinuric pre-eclampsia. There was no difference in pulmonary function in 22 patients with moderate pre-eclampsia when compared with normal pregnancy, but in 9 patients with severe pre-eclampsia, there was a significant increase in alveolar-to-arterial PO2 difference and physiological shunt, indicating a degree of pulmonary ventilation/perfusion imbalance. There was no accompanying hypoxaemia, suggesting that the impairment was of no clinical importance.