Outcomes of pregnancy in patients with preexisting postural tachycardia syndrome

Female reproductive health impacts of Long COVID and associated illnesses including ME/CFS, POTS, and connective tissue disorders: a literature review

Long COVID disproportionately affects premenopausal women, but relatively few studies have examined Long COVID's impact on female reproductive health. We conduct a review of the literature documenting the female reproductive health impacts of Long COVID which may include disruptions to the menstrual cycle, gonadal function, ovarian sufficiency, menopause, and fertility, as well as symptom exacerbation around menstruation. Given limited research, we also review the reproductive health impacts of overlapping and associated illnesses including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), postural orthostatic tachycardia syndrome (POTS), connective tissue disorders like Ehlers-Danlos syndrome (EDS), and endometriosis, as these illnesses may help to elucidate reproductive health conditions in Long COVID. These associated illnesses, whose patients are 70%-80% women, have increased rates of dysmenorrhea, amenorrhea, oligomenorrhea, dyspareunia, endometriosis, infertility, vulvodynia, intermenstrual bleeding, ovarian cysts, uterine fibroids and bleeding, pelvic congestion syndrome, gynecological surgeries, and adverse pregnancy complications such as preeclampsia, maternal mortality, and premature birth. Additionally, in Long COVID and associated illnesses, symptoms can be impacted by the menstrual cycle, pregnancy, and menopause. We propose priorities for future research and reproductive healthcare in Long COVID based on a review of the literature. These include screening Long COVID patients for comorbid and associated conditions; studying the impacts of the menstrual cycle, pregnancy, and menopause on symptoms and illness progression; uncovering the role of sex differences and sex hormones in Long COVID and associated illnesses; and addressing historical research and healthcare inequities that have contributed to detrimental knowledge gaps for this patient population.

COVID-19 Induced Postural Orthostatic Tachycardia Syndrome (POTS): A Review

POTS (Postural Orthostatic Tachycardia Syndrome) is a multisystem disorder characterized by the abnormal autonomic response to an upright posture, causing orthostatic intolerance and excessive tachycardia without hypotension. Recent reports suggest that a significant percentage of COVID-19 survivors develop POTS within 6 to 8 months of infection. Prominent symptoms of POTS include fatigue, orthostatic intolerance, tachycardia, and cognitive impairment. The exact mechanisms of post-COVID-19 POTS are unclear. Still, different hypotheses have been given, including autoantibody production against autonomic nerve fibers, direct toxic effects of SARS-CoV-2, or sympathetic nervous system stimulation secondary to infection. Physicians should have a high suspicion of POTS in COVID-19 survival when presented with symptoms of autonomic dysfunction and should conduct diagnostic tests like the Tilt table and others to confirm it. The management of COVID-19-related POTS requires a comprehensive approach. Most patients respond to initial non-pharmacological options, but when the symptoms become more severe and they do not respond to the non-pharmacological approach, pharmacological options are considered. We have limited understanding and knowledge of post-COVID-19 POTS, and further research is warranted to improve our understanding and formulate a better management plan.

Symptoms of postural orthostatic tachycardia syndrome in pregnancy: a cross-sectional, community-based survey

OBJECTIVE

To evaluate the relationship between postural orthostatic tachycardia syndrome (POTS) and pregnancy.

DESIGN

Cross-sectional survey.

SETTING

International.

SAMPLE

A total of 8941 female patients with a diagnosis of POTS.

METHODS

Data from the survey were analysed using descriptive measures and stratified for comparisons.

MAIN OUTCOME MEASURES

Symptom course of POTS during pregnancy. Secondary outcomes included pregnancy loss, POTS onset during pregnancy and the impacts of a comorbid diagnosis of Ehlers-Danlos syndrome or an autoimmune disorder on symptoms during pregnancy.

RESULTS

Overall, 40.8% (n = 3652) of participants reported one or more pregnancies. Most participants experienced worsening of symptoms in the first (62.6%) and third (58.9%) trimesters and 3 months after pregnancy (58.7%), and 81.1% experienced worsening symptoms at any point in their pregnancy. Most participants with worsening symptoms in the first trimester also experienced worsening symptoms in the second (61.6%) and third (68.1%) trimesters, but if they improved in the first trimester then this improvement persisted in the second and third trimesters. Of participants who reported that POTS was triggered by a specific event (41.3%), 8.1% reported pregnancy as the trigger for the onset.

CONCLUSIONS

Postural orthostatic tachycardia syndrome symptoms in the first trimester of pregnancy may help predict symptom course throughout the duration of pregnancy. Some individuals may experience an initial onset of POTS during pregnancy. This novel information may guide clinicians in counselling patients with POTS who are planning pregnancy.

The prevalence of headache disorders in Postural Tachycardia Syndrome: A systematic review and meta-analysis of the literature

BACKGROUND

Headache is a common presentation of postural tachycardia syndrome, yet robust prevalence data is lacking.

OBJECTIVES

To undertake a systematic review and meta-analysis to estimate the prevalence of headache disorders in postural tachycardia syndrome, and to explore the potential shared pathophysiological mechanisms that underpin these conditions as well as treatment options.

METHODS

Three databases were searched for publications evaluating prevalence of migraine (primary outcome) and general and orthostatic headache (secondary outcomes) in patients with postural tachycardia syndrome. Two independent reviewers selected studies and extracted data. A random-effects meta-analysis calculated the pooled prevalence of migraine in postural tachycardia syndrome. A narrative literature review explored the pathophysiology and treatment options for concurrent headache disorders and postural tachycardia syndrome.

RESULTS

Twenty-three articles met inclusion criteria. Estimated pooled prevalence of migraine in postural tachycardia syndrome was 36.8% (95% CI 2.9-70.7%). Various shared pathophysiological pathways for these conditions, as well as proposed treatment strategies, were identified.Limitations: Heterogeneity of study design, populations, and methodology for identifying headache disorders and postural tachycardia syndrome limited the generalisability of results.

CONCLUSIONS

Migraine is a commonly reported comorbidity in POTS, however the true prevalence cannot be determined from the current literature. Further studies are required to assess this comorbidity and investigate the underlying mechanisms, as well as identify effective treatment strategies.

Obstetrics and gynecology in Ehlers-Danlos syndrome: A brief review and update

The Ehlers-Danlos syndromes (EDSs) are a group of hereditary disorders affecting collagen and connective tissue. Gynecologic and obstetric complications occur with increased frequency and severity due to these abnormalities. Recent studies suggest that some complications, including endometriosis and premature rupture of the membranes may occur less often than previously thought. In addition, having a known diagnosis allows anticipatory planning, resulting in lower morbidity from hemorrhage and tissue injury. With continued progress in understanding the underlying mechanisms of EDS, more effective treatments can be developed.

Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 3/5

Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.

Arrhythmias in Pregnancy

The prevalence of arrhythmias in pregnant women are rising, particularly among women with a history of structural heart disease or prior arrhythmia. The physiological changes of pregnancy increase the risk of both benign and pathologic arrhythmias, with atrial fibrillation representing the most common pathologic arrhythmia. While bradyarrhythmias rarely require treatment during pregnancy, pharmacotherapy is frequently required for tachyarrhythmias. Electrophysiological procedures including cardioversions, ablations, and device placement are occasionally required during pregnancy and can be performed safely with proper precautions. This chapter will discuss the diagnosis and management of a broad array of cardiac arrhythmias that may be encountered in pregnant women.

Postural orthostatic tachycardia syndrome is associated with platelet storage pool deficiency

Mechanisms have been postulated to explain postural orthostatic tachycardia syndrome (POTS), however, the etiology of this often debilitating disorder remains unknown. We conducted a retrospective case-control study of 181 POTS patients who exhibited/reported bleeding symptoms for a specific platelet (PL) dysfunction disorder, delta granule storage pool deficiency (δ-SPD).Patients were included only if results of blood tests for δ-SPD were available. Electron microscopy was utilized to diagnose δ-SPD. An ELISA assay was used to determine serotonin (5HT) concentration in PLs and medical record review was employed to collect patients' clinical symptoms.The most common bleeding symptom was easy bruising (71%) but frequent nose bleeds, heavy menstrual bleeding, and a family history of bleeding were also commonly reported. Of the patients studied, 81% were diagnosed with δ-SPD. Our investigation of 5HT concentration extracted from PLs revealed significantly lower levels of 5HT in POTS patients when compared to that of control subjects. Our data suggest that patients with POTS have significant comorbidities including bleeding symptoms and/or family bleeding histories, and have diminished PL 5HT levels supporting the hypothesis that POTS is a low 5HT level disorder. While we describe a significant relationship with POTS and δ-SPD, this finding does not constitute an etiology for POTS.Our results establish an additional comorbidity frequently seen in POTS that could explain a number of disparate symptoms often affecting the severity of POTS.

A Case Report and Review of Postural Orthostatic Tachycardia Syndrome in Pregnancy

Purpose Postural orthostatic tachycardia syndrome (POTS) is a form of orthostatic intolerance characterized by an increased heart rate upon transition from supine to standing, and head-up tilt without orthostatic hypotension. Its etiology is multifactorial, and no clear cause has been identified. Common symptoms include light-headedness, blurred vision, weakness, cognitive difficulties, and fatigue and are often accompanied by palpitations, shortness of breath, syncope, or gastrointestinal symptoms. Management includes volume expansion, physical counter maneuvers, and pharmacological agents such as fludrocortisone, midodrine, propranolol, and pyridostigmine. The course of POTS in pregnancy is variable and POTS has not been directly implicated in any adverse outcomes for the mother or fetus. Methods Two cases of POTS in pregnancy are presented, along with a review of the literature for reports of POTS in pregnancy. Results Along with our 2 cases, 10 other case reports were identified and included. Conclusion The course of POTS in pregnancy is variable, and not directly linked to increase perinatal morbidity or mortality. Women can safely undergo regional anesthesia, and vaginal delivery with close monitoring of hemodynamic changes.

Arrhythmias in pregnancy

Pregnant women have an increased risk of having the usual arrhythmias seen in women of childbearing age. Most of these are benign sinus tachycardias or bradycardias or atrial and ventricular ectopic beats. Women who have had sustained supraventricular or ventricular tachycardias before pregnancy frequently develop them during pregnancy. These arrhythmias often have enough hemodynamic significance to decrease uterine blood flow, which adds a sense of urgency for treatment. The management is similar to that of nonpregnant women, with nuances important for the protection of the developing fetus.

Postural orthostatic tachycardia syndrome complicating pregnancy: a case report with review of literature

Postural orthostatic tachycardia syndrome (POTS) affects women of child-bearing age. There are little reported data on the outcomes of pregnancy in women with POTS. The most common mode of delivery reported in the literature is the caesarean section. Here we describe a woman with POTS who delivered vaginally without any complications and present a comprehensive review of the literature on pregnancy in POTS.

Pregnancy in postural tachycardia syndrome: clinical course and maternal and fetal outcomes

OBJECTIVE

Postural tachycardia syndrome (POTS), a disorder of the autonomic nervous system, predominantly occurs in women of child-bearing age. We set out to determine the clinical course and maternal and fetal outcomes in pregnant women with pre-existing POTS.

METHODS

Participants were asked to complete a detailed questionnaire assessing the clinical course of POTS before, during and after pregnancy, as well as complications of pregnancy, labor and delivery and fetal outcomes.

RESULTS

Among 10 women with pre-existing POTS (pregnancy age 28 ± 7 years, range 16-39), with a total of 17 live births, two were complicated by pre-eclampsia, 14 were normal vaginal deliveries and three were C-sections. The rate of severe vomiting or hyperemesis gravidarum in the first trimester was 59%. There were no stillbirths or congenital abnormalities. The average birth weight was 3076 ± 733 grams, with two infants born premature. During pregnancy, POTS symptoms were either improved or stable in six of 10 women, and four of these six women utilized medications for POTS. Six months after delivery, POTS symptoms were improved in three, stable in two and worsened in five women compared to before pregnancy.

CONCLUSIONS

POTS may have a variable clinical course in pregnancy, with 60% of women reporting either improved or stable symptoms during pregnancy, and 50% of women reporting either improved or stable symptoms 6 months after delivery. There may be a higher rate of severe vomiting in the first trimester in women with POTS than in general population.

Effect of pregnancy on postural tachycardia syndrome

OBJECTIVES

To compare the clinical presentation, autonomic dysfunction, and pregnancy outcomes in parous and nulliparous women with postural tachycardia syndrome (POTS) and in women with POTS before and after pregnancy.

PATIENTS AND METHODS

This study consists of women who had at least 1 pregnancy during which time they met criteria for POTS between May 1993 and July 2009. All patients underwent standard autonomic testing. POTS was defined as a heart rate (HR) increase of greater than 30 beats/min on head-up tilt (HUT) with symptoms of orthostatic intolerance. Patients' charts were reviewed retrospectively to determine pregnancy outcomes.

RESULTS

Clinical characteristics related to POTS did not differ between parous and nulliparous women except for disease duration (parous, 3.7+/-2.6; nulliparous, 2.1+/-2.2; P<.001). Autonomic dysfunction did not differ between groups (change in HR on HUT: parous, 42.6+/-12.0 beats/min; nulliparous, 41.3+/-10.6 beats/min; P=.39). Of 116 total pregnancies, adverse pregnancy outcomes were reported in 9% and maternal complications in 1%. No complication was related to POTS. There was a trend toward modest improvement in autonomic dysfunction before and after pregnancy (change in HR on HUT: before pregnancy, 38.1+/-22.7 beats/min; after pregnancy, 21.9+/-14.9 beats/min; P=.07).

CONCLUSION

The long-term impact of pregnancy on POTS does not appear to be clinically important. However, there does appear to be a trend toward improvement in the short-term postpartum period. Adverse pregnancy events were similar to those seen in the general public and do not present a barrier to women with POTS who want to have children.

Comorbid health conditions in women with syncope

OBJECTIVE

We determine the comorbid conditions associated with syncope in women. In addition, we hypothesize a higher proportion of autonomic comorbid conditions during the female reproductive age.

METHODS

We identified a cohort of patients admitted to US hospitals with the principal diagnosis of syncope. We compare patient demographics stratified by gender as well as syncope associated comorbidities. We compared these comorbidities in female of reproductive age (15-45) to men as control.

RESULTS

From a total sample of 305,932, females constituted 56.7% (n = 173,434). Females were slightly older (mean age 70.9 +/- 17.9 vs. 66.7 +/- 17.3; P < 0.0001); with similar racial distribution (white 57.8 vs. 57.5%), and similar length of hospital stay (mean 2.66 +/- 2.63 vs. 2.68 +/- 2.72 days; P > 0.05). Females had higher proportion of migraine (1.65 vs. 1.29%; odds ratio 'OR' 1.29; 95% confidence interval 'CI' 1.21, 1.36); chronic fatigue syndrome (1.73 vs. 1.3%; OR 1.32; 95% CI 1.25, 1.4); gastroparesis (0.2 vs. 0.12%; OR 1.64; 95% CI 1.35, 1.98); interstitial cystitis (0.07 vs. 0.01%; OR 7.44; 95% CI 4.10, 13.5); and postural tachycardia syndrome (0.49 vs. 0.44%; OR 1.1; 95% CI 1.001, 1.23). Orthostatic hypotension was not different between the groups (P = 0.24). When the sample was stratified by age category, the odds ratio for gastroparesis, orthostatic hypotension, and postural tachycardia syndrome was increased (P < 0.05).

INTERPRETATION

A higher proportion of autonomic dysfunction was present in women compared to men. In addition, these comorbid autonomic conditions were especially prominent during the female reproductive age.

Perioperative care of an adolescent with postural orthostatic tachycardia syndrome

Postural orthostatic tachycardia syndrome (POTS) is a disorder characterized by postural tachycardia in combination with orthostatic symptoms without associated hypotension. Symptoms include light-headedness, palpitations, fatigue, confusion, and anxiety, which are brought on by assuming the upright position and usually relieved by sitting or lying down. Given the associated autonomic dysfunction that occurs with POTS, various perioperative concerns must be considered when providing anesthetic care for such patients. We present an adolescent with POTS who required anesthetic care during posterior spinal fusion for the treatment of scoliosis. The potential perioperative implications of this syndrome are discussed.

Postpartum postural orthostatic tachycardia syndrome in a patient with the joint hypermobility syndrome

Postural orthostatic tachycardia syndrome (POTS) commonly affects women of childbearing age. We report on a 37-year-old woman who developed symptoms of recurrent syncope in the postpartum period. Her head up tilt test and clinical presentation was consistent with POTS.