Are Gestational and Essential Hypertension Similar? Left Ventricular Geometry and Diastolic Function

Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine

OBJECTIVE

 The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art.

STUDY DESIGN

 AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

RESULTS

 More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life.

CONCLUSION

 Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications.

KEY POINTS

· Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..

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

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

Comparison of echocardiographic findings in women with late preeclampsia and healthy pregnant women: a case-control study

BACKGROUND

Preeclampsia is one of the most common types of pregnancy disorders, and it is essential to know its cardiovascular complications. Therefore, we aimed to compare echocardiographic findings in women with late preeclampsia and healthy pregnant women.

METHOD

In this case-control study, 80 women with late preeclampsia and 80 healthy pregnant women were randomly selected and echocardiographic findings were determined and compared in the two groups.

RESULTS

Evaluating the relationship between late preeclampsia and echocardiographic variables in pregnant women showed a significant relationship between diastolic disorder (15% in the case group vs. 5% in the control group) (p = .035), systolic artery pressure (p = .002), and TR gradient (p = .003) with late preeclampsia; However, this relationship was not observed with other echocardiographic variables (p > .05).

CONCLUSION

Since the role of transthoracic echocardiography in the management of women with preeclampsia has been emphasized by international groups, the results of this study suggest that increased TR Gradient and diastolic dysfunction are the most important echocardiography findings in patients with late preeclampsia.

A more accurate prediction to rule in and rule out pre-eclampsia using the sFlt-1/PlGF ratio and NT-proBNP as biomarkers

Background The management of potential pre-eclamptic patients using the soluble FMS-like tyrosine kinase 1 (sFlt-1)/ placental growth factor (PlGF) ratio is characterised by frequent false-positive results. Methods A retrospective cohort study was conducted to identify and validate cut-off values, obtained using a machine learning model, for the sFlt-1/PlGF ratio and NT-proBNP that would be predictive of the absence or presence of early-onset pre-eclampsia (PE) in singleton pregnancies presenting at 24 to 33 + 6 weeks of gestation. Results For the development cohort, we defined two sFlt-1/PlGF ratio cut-off values of 23 and 45 to rule out and rule in early-onset PE at any time between 24 and 33 + 6 weeks of gestation. Using an sFlt-1/PlGF ratio cut-off value of 23, the negative predictive value (NPV) for the development of early-onset PE was 100% (95% confidence interval [CI]: 99.5-100). The positive predictive value (PPV) of an sFlt-1/PlGF ratio >45 for a diagnosis of early-onset PE was 49.5% (95% CI: 45.8-55.6). When an NT-proBNP value >174 was combined with an sFlt-1/PlGF ratio >45, the PPV was 86% (95% CI: 79.2-92.6). In the validation cohort, the negative and positive values were very similar to those found for the development cohort. Conclusions An sFlt-1/PlGF ratio <23 rules out early-onset PE between 24 and 33 + 6 weeks of gestation at any time, with an NPV of 100%. An sFlt-1/PlGF ratio >45 with an NT-proBNP value >174 significantly enhances the probability of developing early-onset PE.

NT-proBNP levels in preeclampsia, intrauterine growth restriction as well as in the prediction on an imminent delivery

OBJECTIVES

Studies of cardiovascular function in pregnancy have shown inconsistent and, in some cases, contradictory results, particularly regarding cardiac output. While some studies report preeclampsia associated with high cardiac output, other studies suggest that preeclampsia should be further subdivided into women with high or low cardiac output. This study was conducted to examine the NT-proBNP levels in preeclampsia, intrauterine growth restriction, and hypertensive pregnancies without preeclampsia. We also examined N-terminal pro-B natriuretic peptide (NT-proBNP) levels three to four months after delivery, in preeclamptic women as well as the prediction of delivery within 10 days. In a reduced number of preeclamptic women and controls we performed echocardiograms to study their diastolic function.

METHODS

We investigated the NT-proBNP levels in 213 subjects with preeclampsia only, 73 with intrauterine growth restriction, 44 with preeclampsia and intrauterine growth restriction, 211 who were hypertensive and 662 unaffected pregnancies (controls). We also performed echocardiograms on 36 preeclampsia and 19 controls before delivery and three to five months after delivery.

RESULTS

NT-proBNP levels are higher in early onset preeclampsia than in late onset preeclampsia. Intrauterine growth restriction pregnancies showed a NT-proBNP levels similar to hypertensive and unaffected pregnancies. Compared with healthy pregnancies, women with preterm preeclampsia (<37 gestational weeks) had altered left atrial segments.

CONCLUSIONS

We observed that NT-proBNP levels are higher in early onset preeclampsia than in late onset. Moreover, diastolic dysfunction is higher in early onset than in late-onset term preeclampsia. An NT-proBNP value >136 pg/mL has a high positive predictive value for an imminent delivery within 10 days.

The Use of Echocardiography and Advanced Cardiac Ultrasonography During Pregnancy

PURPOSE OF REVIEW

Pregnancy is a time of significant cardiovascular change. Echocardiography is the primary imaging modality used to assess cardiovascular anatomy and physiology during pregnancy. Both two-dimensional (2D) echocardiography and advanced cardiac ultrasound modalities play pivotal roles in identifying and monitoring these changes, especially in women with preexisting or new cardiac disease. This paper reviews the role of echocardiography and advanced cardiac ultrasound during normal pregnancy and pregnancy complicated by hypertensive disorders, valvular disorders, and cardiomyopathy. It also examines the role of echocardiography in guiding decisions about delivery.

RECENT FINDINGS

The data establishing normal echo parameters during pregnancy are inconsistent. In addition, there is limited research exploring the role of advanced cardiac ultrasound modalities, such as tissue Doppler imaging or speckle tracking echocardiography, in assessing cardiac function during pregnancy. What data there are suggest that these advanced modalities can be used to identify subclinical changes before traditional echocardiography can, and thus have clear utility in identifying early abnormal cardiac responses to pregnancy. Echocardiography is the modality of choice for imaging the heart in pregnant women. Advanced ultrasound modalities increasingly play a role in identifying abnormal adaptations to pregnancy and detecting subclinical changes. This, in turn, can help promote a healthy pregnancy for both mother and fetus.

Can brain natriuretic peptide predict cardiovascular complications in severe preeclampsia? A case-control study

Background

Preeclampsia is one of the most common pregnancy complications, which is one of the major causes of fetal and maternal mortality.

Objective

To compare the serum Brain Natriuretic Peptide (BNP) level in patients with severe preeclampsia and normal pregnancy and investigate associated cardiovascular complications.

Materials and Methods

This case-control study was performed on 94 women with a singleton pregnancy (severe preeclampsia and normal pregnancy) at Imam Reza Hospital in Mashhad, Iran. The venous blood samples were collected to evaluate the serum BNP level. All patients were subjected to echocardiography performed by a single cardiologist.

Results

The mean pro-BNP levels were 480.36 ± 754.52 and 67.46 ± 106.24 pg/dL in the severe preeclampsia and normal pregnancy patients, respectively (p < 0.001). However, adjusted BNP for maternal and gestational age was not different in the two groups (ANCOVA, p = 0.69). Furthermore, the two study groups showed no significant difference in terms of the cardiac parameters, including ejection fraction (EF), left ventricle end-diastolic and -systolic diameters (LVEDD and LVESD, respectively), tricuspid annular plane systolic excursion (TAPSE), and ratio of the early transmitral flow velocity to the early diastolic tissue velocity (E/Em). However, the serum BNP level showed a significant correlation with EF (r = -0.39, p = 0.008), TAPSE (r = -0.47, p = 0.001), and E/Em ratio (r = 0.48, p = 0.001) in patients with severe preeclampsia.

Conclusion

It seems that BNP can be used as a predictor for some of the main cardiac functional indices (i.e., E/Em, EF, and TAPSE) in severe preeclampsia patients.

Maternal Cardiac Adaptations to a Physical Exercise Program during Pregnancy

INTRODUCTION

Scarce evidence exists regarding the effects of regular pregnancy exercise on maternal cardiovascular health. We aimed to study, using a randomized controlled trial design, the effects of pregnancy exercise on echocardiographic indicators of hemodynamics, cardiac remodeling, left ventricular (LV) function, and cardiovascular disease (CVD) risk factors.

METHODS

Two hundred forty-one healthy pregnant women were assigned to a control (standard care) or intervention (exercise) group (initial n = 121/120). The intervention (weeks 9-11 to 38-39) included three supervised sessions per week (55-60 min, with light-moderate intensity aerobic and strength exercises).

RESULTS

The main findings were as follows: (i) the proportion of women with excessive weight gain at end pregnancy was lower in the exercise group compared with controls (18% vs 40%, P = 0.005), and (ii) there was a tendency toward lower prevalence of depression at end pregnancy in the former (P = 0.029, threshold P value set at 0.013). No significant exercise training effect was essentially found for echocardiographic variables, CVD risk factors, type/duration of labor, or newborn's outcomes (weight, height, head circumference, Apgar scores, and umbilical cord pH).

CONCLUSIONS

Light-moderate intensity supervised exercise is safe for healthy pregnant women and does not impose an additional cardiac overload beyond gestation or affect the main pregnancy outcomes. Such intervention might help decrease, at least partly, the risk of two CVD-associated conditions, excessive weight gain and depression.

Echocardiographic Structure and Function in Hypertensive Disorders of Pregnancy

Background—

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

Methods and Results—

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

Conclusions—

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

Impact of gestational risk factors on maternal cardiovascular system

BACKGROUND

Scarce evidence is available on the potential cardiovascular abnormalities associated with some common gestational complications. We aimed to analyze the potential maternal cardiac alterations related to gestational complications, including body mass index (BMI) >25 kg/m(2), gaining excessive weight, or developing antenatal depression.

METHODS

The design of this study was a secondary analysis of a randomized controlled trial. Echocardiography was performed to assess cardiovascular indicators of maternal hemodynamic, cardiac remodeling and left ventricular (LV) function in 59 sedentary pregnant women at 20 and 34 weeks of gestation.

RESULTS

Starting pregnancy with a BMI >25 kg/m(2), gaining excessive weight, and developing antenatal depression had no cardiovascular impact on maternal health (P value >0.002). Depressed women were more likely to exceed weight gain recommendations than non-depressed women (P value <0.002).

CONCLUSIONS

The evaluated gestational complications seem not to induce cardiovascular alterations in hemodynamic, remodeling and LV function indicators. However, developing antenatal depression increases the risk of an excessive weight gain. This finding is potentially important because excessive weight gain during pregnancy associates with a higher risk of cardiovascular diseases (CVD) later in life.

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

Hypertension in pregnancy is a frequent disorder that includes a spectrum of conditions. We aimed at comparatively evaluating the hemodynamic, echocardiographic and biohumoral profile of a sample of pregnant Caucasian women with different form of pregnancy-related hypertension. We enrolled 39 non-hypertensive pregnant women (NP), 26 with Chronic HBP in pregnancy (CH), 24 with gestational hypertension (G-PIH), and 33 with pre-eclampsia. We recorded and compared blood pressure (BP), echocardiographic parameters, resting plasma renin activity (PRA) and plasma aldosterone (PA), Plasma levels of atrial (ANP) and brain natriuretic peptide (BNP). PE patients had a significantly higher BP than either G-PIH or NP patients. PE patients had also significantly lower cardiac output than NP, G-PIH and CH. In comparison to NP patients, the total peripheral vascular resistance was 61% higher in PE women and 38% higher in CH patients. All echographic parameters were significantly more altered in PE patients when compared with NP, in respect to any other form of hypertension. Either ANP (+35%) and BNP (+40%) were significantly higher in PE patients than in controls. The PRA was reduced in PE and CH patients when compared either with NP (-38 and -35%, respectively) or G-PIH (-47 and -43%, respectively). On the basis of our data, we can conclude that PE is the gestation associated hypertension with the largest anatomical, functional and biohumoral involvement, and so it has to be involved in a more intensive monitoring and evaluation.

Impact of gestational hypertension on left ventricular function and geometric pattern

BACKGROUND

The effect of gestational hypertension on left ventricular (LV) function in previously normotensive young women has not been evaluated.

METHODS AND RESULTS

A total of 106 gestational hypertensive women (GHW, 32.3 ± 4.2 years) and 93 normotensive pregnant women (NPW, 30.2 ± 4.4 years) were enrolled. Transthoracic echocardiography, including 2-dimensional strain echocardiography, was done and myocardial performance (Tei index), LV mass index (LVMI), and relative wall thickness (RWT) were analyzed. GHW had significantly increased wall thickness (interventricular septum, 9.5 ± 0.9 mm vs. 8.8 ± 1.0 mm, P < 0.001; posterior wall, 9.0 ± 1.1 mm vs. 8.5 ± 1.1 mm, P = 0.007; and RWT, 0.39 ± 0.06 vs. 0.35 ± 0.05, P = 0.02), higher LVMI (95.6 ± 17.3g/m² vs. 86.1 ± 14.5g/m², P = 0.03), longer isovolumetric relaxation time (117.7 ± 18.2 ms vs. 82.3 ± 12.6 ms, P = 0.003), lower E/A ratio (1.00 ± 0.29 vs. 1.27 ± 0.33, P = 0.002), and higher Tei index (0.48 ± 0.23 vs. 0.33 ± 0.13, P = 0.003) compared to NPW. Global longitudinal LV strain, representing LV systolic function, was also significantly reduced in GHW compared with NPW (-17.6 ± 2.95% vs. -21.2 ± 2.14%, P = 0.02). A total of 62% of GHW (n = 66) had abnormal geometry, of whom, 42 (40%) had eccentric hypertrophy (EH). A total of 93% of NPW (n = 86) had normal geometry, and only 7 NPW (7%) had abnormal geometry.

CONCLUSIONS

GHW had aggravated diastolic and longitudinal systolic dysfunction. GHW had increased LVMI with the abnormal geometric pattern of EH. The reversibility of these morphological and functional impairments after delivery needs to be clarified.

Pregnancy as the prodrome to vascular dysfunction and cardiovascular risk

In previously apparently healthy women, glucose intolerance and high blood pressure during pregnancy are common and frequently occur together. This article reviews the role of these gestational disorders as markers of vascular dysfunction and its pathophysiology. Mechanisms include alterations to function of large arteries and resistance vessels and to capillary blood flow. Much of the vessel pathology is seen in both gestational diabetes and hypertension. In women who have had transient diabetes during pregnancy and later redeveloped overt diabetes, cardiovascular risk is already elevated nearly fourfold before diagnosis, which is almost as high as the average risk after a clinical diagnosis of diabetes is made. This key finding suggests that vascular risk in such women is at least partly independent of overt hyperglycemia.