Adaptation of the maternal heart in pregnancy

Postpartum changes in maternal physiology and milk composition: a comprehensive database for developing lactation physiologically-based pharmacokinetic models

Introduction

Pharmacotherapy during lactation often lacks reliable drug safety data, resulting in delayed treatment or early cessation of breastfeeding. In silico tools, such as physiologically-based pharmacokinetic (PBPK) models, can help to bridge this knowledge gap. To increase the accuracy of these models, it is essential to account for the physiological changes that occur throughout the postpartum period.

Methods

This study aimed to collect and analyze data on the longitudinal changes in various physiological parameters that can affect drug distribution into breast milk during lactation. Following meta-analysis of the collated data, mathematical functions were fitted to the available data for each parameter. The best-performing functions were selected through numerical and visual diagnostics.

Results and Discussion

The literature search identified 230 studies, yielding a dataset of 36,689 data points from 20,801 postpartum women, covering data from immediately after childbirth to 12 months postpartum. Sufficient data were obtained to describe postpartum changes in maternal plasma volume, breast volume, cardiac output, glomerular filtration rate, haematocrit, human serum albumin, alpha-1-acid glycoprotein, milk pH, milk volume, milk fat, milk protein, milk water content, and daily infant milk intake. Although data beyond 7 months postpartum were limited for some parameters, mathematical functions were generated for all parameters. These functions can be integrated into lactation PBPK models to increase their predictive power and better inform medication efficacy and safety for breastfeeding women.

Maternal shift work during pregnancy and cardiovascular health impacts on mother and offspring

Cardiovascular disease (CVD) is the leading cause of death for women worldwide. One of the risk factors for CVD in women is complications during pregnancy. Pregnancy complications include a wide arena of pathologies, including hypertension, preeclampsia, gestational diabetes, preterm delivery and miscarriage. Interestingly, increased evidence in recent years highlights a novel link between maternal shift work during pregnancy and increased risk for pregnancy complications, specifically hypertension and diabetes, while knowledge on other CVDs, such heart failure, atherosclerosis, ischemic heart disease, and stroke in pregnant shift working mothers is still scarce. Notably, shift work during pregnancy results in significant changes to the circadian rhythm of both the mother and fetus, therefore, engaging into shift work during pregnancy may adversely affect the cardiovascular health of both the mother and offspring, and carry into adulthood. Herein, we highlight the novel relationship between maternal shift work during pregnancy and the increased risk for pregnancy complications that may increase risk for CVD later in life. Furthermore, we provide mechanistic insights of the hemodynamic processes that are disrupted in response to maternal shift work and may explain the increased risk for cardiovascular disease. Understanding how shift work during pregnancy influences the prevalence for heart disease is of paramount clinical importance for minimizing the risk for cardiovascular disease for both the mother and offspring.

Considerations for Women with Congenital Heart Disease Undergoing Percutaneous Cardiovascular Procedures

The catheterization of women with congenital heart disease has unique considerations that must be taken into account. Hemodynamic changes secondary to pregnancy, anticoagulation strategies of women in child bearing years, and protection of a fetus during pregnancy require interventions and evidence of current therapies in the treatment of women continues to have more questions than answers in our current era. This review highlights some challenges in the catheterization of women with congenital heart disease.

Impaired maternal central hemodynamics precede the onset of vascular disorders of pregnancy at high altitude

Hypertensive disorders of pregnancy represent an escalating global health concern with increasing incidence in low- to middle-income countries and high-income countries alike. The current lack of methods to detect the subclinical stages of preeclampsia (PE) and fetal growth restriction (FGR), two common vascular disorders of pregnancy, limits treatment options to minimize acute- and long-term adverse outcomes for both mother and child. To determine whether impaired maternal cardiovascular or uteroplacental vascular function precedes the onset of PE and/or FGR (PE-FGR), we used noninvasive techniques to obtain serial measurements of maternal cardiac output (CO), stroke volume (SV), systemic vascular resistance (SVR), and uterine and fetal arterial resistance at gestational weeks 10-16, 20-24, and 30-34 for 79 maternal-infant pairs in La Paz-El Alto, Bolivia (3,850 m), where the chronic hypoxia of high altitude increases the incidence of PE and FGR. Compared with controls (n = 55), PE-FGR cases (n = 24) had lower SV, higher SVR, and greater uterine artery resistance at 10-16 wk. In addition, fetuses of women with lower SV and higher SVR at 10-16 wk showed evidence of brain sparing at 30-34 wk and had lower birth weights, respectively. Although the trajectory of SV and SVR across pregnancy was similar between groups, PE-FGR cases had a comparatively blunted rise in CO from the first to the third visit. Impaired maternal central hemodynamics and increased uteroplacental resistance precede PE-FGR onset, highlighting the potential use of such measures for identifying high-risk pregnancies at high altitudes.NEW & NOTEWORTHY In this prospective study of maternal central hemodynamics at high altitude, pregnancies later affected by preeclampsia (PE) and/or fetal growth restriction (FGR) show elevated systemic and uterine vascular resistance and reduced stroke volume as early as 10-16 wk gestation. Maternal hemodynamic assessments could facilitate early detection of high-risk pregnancies, improving resource allocation and reducing adverse outcomes. We propose an integrated model linking maternal cardiovascular performance to placental insufficiency, enhancing the understanding of PE-FGR in high-altitude settings.

Cardiac automaticity is modulated by IKACh in sinoatrial node during pregnancy

AIMS

Pregnant (P) women have a significantly elevated resting heart rate (HR), which makes cardiac arrhythmias more likely to occur. Although electrical remodelling of the sinoatrial node (SAN) has been documented, the underlying mechanism is not fully understood. The acetylcholine-activated potassium current (IKACh), one of the major repolarizing currents in the SAN, plays a critical role in HR control by hyperpolarizing the maximal diastolic potential (MDP) of the SAN action potential (AP), thereby reducing SAN automaticity and HR. Thus, considering its essential role in cardiac automaticity, this study aims to determine whether changes in IKACh are potentially involved in the increased HR associated with pregnancy.

METHODS AND RESULTS

Experiments were conducted on non-pregnant (NP) and pregnant (P; 17-18 days gestation) female CD-1 mice aged 2 to 4 months. IKACh was recorded on spontaneously beating SAN cells using the muscarinic agonist carbachol (CCh). Voltage-clamp data showed a reduction in IKACh density during pregnancy, which returned to control values shortly after delivery. The reduction in IKACh was explained by a decrease in protein expression of Kir3.1 channel subunit and the muscarinic type 2 receptor. In agreement with these findings, current-clamp data showed that the MDP of SAN cells from P mice were less hyperpolarized following CCh administration. Surface electrocardiograms (ECGs) recorded on anaesthetized mice revealed that the cholinergic antagonist atropine and the selective KACh channel blocker tertiapin-Q increased HR in NP mice and had only a minimal effect on P mice. AP and ECG data also showed that pregnancy is associated with a decrease in beating and HR variability, respectively.

CONCLUSION

IKACh function and expression are decreased in the mouse SAN during pregnancy, strongly suggesting that, in addition to other electrical remodelling of the SAN, reduced IKACh also plays an important role in the pregnancy-induced increased HR.

Per- and polyfluoroalkyl substances (PFAS) and hypertensive disorders of Pregnancy- integration of epidemiological and mechanistic evidence

BACKGROUND

Hypertensive disorders of pregnancy (HDP) remain a significant global health burden despite medical advancements. HDP prevalence appears to be rising, leading to increased maternal and fetal complications, mortality, and substantial healthcare costs. The etiology of HDP are complex and multifaceted, influenced by factors like nutrition, obesity, stress, metabolic disorders, and genetics. Emerging evidence suggests environmental pollutants, particularly Per- and polyfluoroalkyl substances (PFAS), may contribute to HDP development.

OBJECTIVE

This review integrates epidemiological and mechanistic data to explore the intricate relationship between PFAS exposure and HDP.

EPIDEMIOLOGICAL EVIDENCE

Studies show varying degrees of association between PFAS exposure and HDP, with some demonstrating positive correlations, particularly with preeclampsia. Meta-analyses suggest potential fetal sex-specific differences in these associations.

MECHANISTIC INSIGHTS

Mechanistically, PFAS exposure appears to disrupt vascular hemodynamics, placental development, and critical processes like angiogenesis and sex steroid regulation. Experimental studies reveal alterations in the renin-angiotensin system, trophoblast invasion, oxidative stress, inflammation, and hormonal dysregulation - all of which contribute to HDP pathogenesis. Elucidating these mechanisms is crucial for developing preventive strategies.

THERAPEUTIC POTENTIAL

Targeted interventions such as AT2R agonists, caspase inhibitors, and modulation of specific microRNAs show promise in mitigating adverse outcomes associated with PFAS exposure during pregnancy.

KNOWLEDGE GAPS AND FUTURE DIRECTIONS

Further research is needed to comprehensively understand the full spectrum of PFAS-induced placental alterations and their long-term implications for maternal and fetal health. This knowledge will be instrumental in developing effective preventive and therapeutic strategies for HDP in a changing environmental landscape.

Cardiovascular effects of exercise training in pregnant people with a high body mass index: secondary results from a randomised controlled trial (ETIP)

Objectives

We aimed to determine the effectiveness of exercise training during pregnancy on peak oxygen uptake (V̇O2peak), cardiac function and flow-mediated dilatation (FMD) of the brachial artery throughout pregnancy and post partum in individuals with a prepregnancy body mass index (BMI) ≥28 kg/m2.

Trial design

Parallel-group randomised controlled trial (RCT).

Methods

The exercise group in the Exercise Training in Pregnancy (ETIP) RCT was offered 3 weekly supervised exercise sessions comprising 35 min of moderate-intensity treadmill walking followed by 25 min of strength exercises. The intervention started in gestational weeks 12-18 and continued throughout pregnancy. We measured V̇O2peak and FMD at baseline, in gestational weeks 34-37 and 3 months post partum and offered echocardiography in gestational weeks 14, 20, and 32, and 6-8 weeks postpartum.

Results

Of the 91 participants included in ETIP, 87 participants (age: 31.3±4.2 years, BMI: 34.6±4.3 kg/m2) provided data on V̇O2peak, cardiac function and/or FMD. There was no statistically significant effect of exercise training on V̇O2peak in gestational weeks 34-37, with an estimated effect of 1.7 mL/min/kg (95% CI -0.4 to 3.7, p=0.112) or post partum (1.6 mL/min/kg, 95% CI -0.2 to 3.4, p=0.079), compared with the control group. There were no statistically significant between-group differences in either FMD or any of the echocardiographic outcomes. Only 50% of the participants in the exercise group fulfilled our prespecified adherence criteria.

Conclusion

Offering pregnant individuals with BMI ≥28 kg/m2, a supervised exercise intervention did not improve cardiorespiratory fitness, cardiac function or FMD.

Trial registration number

NCT01243554.

Arrhythmogenic atrial remodeling during pregnancy in mice

BACKGROUND

Pregnancy is associated with greater vulnerability to supraventricular tachyarrhythmias.

OBJECTIVE

As the underlying mechanisms remain to be elucidated, we investigated whether pregnancy induces atrial remodeling that might contribute to this.

METHODS

Atrial electrophysiological and contractile properties were examined in nonpregnant and pregnant (P) mice. Cell shortening and Ca2+ imaging were measured on atrial myocytes. Atrial action potential and ionic currents were recorded using the patch-clamp technique. Atrial messenger RNA and protein expression were analyzed using quantitative polymerase chain reaction and Western blot.

RESULTS

The P-wave area on the electrocardiogram increased by 50% during pregnancy, suggesting atrial enlargement, confirmed by echocardiography. The atrial myocytes were longer in P mice, adding further evidence to the physiological hypertrophy associated with pregnancy. Echocardiography showed a 50% increase in atrial fractional area change during pregnancy, indicating much stronger contraction. A similar increase in cell shortening was observed in P mice and was associated with a decrease in sarcomere length and changes in myofilament protein phosphorylation. However, pregnancy did not affect L-type Ca2+ current, Ca2+ transients, and SR Ca2+ load. Myocytes from P mice showed twice as many spontaneous contractions and spontaneous diastolic Ca2+ releases. Moreover, pregnancy was associated with a 50% increase in action potential duration, linked to a reduction in the density of the Ca2+-independent transient outward K+ current and the underlying KV4.3 channel.

CONCLUSION

During pregnancy, atrial tissues undergo substantial remodeling, potentially contributing to the development of supraventricular tachyarrhythmias.

Physiologic changes of pregnancy and considerations for screening and diagnosis of sepsis

Obstetric sepsis is a significant cause of morbidity and mortality in pregnant people worldwide. Initial evaluation and timely intervention are crucial to improving outcomes for birthing persons and their newborns. While many of the therapies and interventions for peripartum sepsis are consistent with the general population, there are considerations unique to pregnancy. Stabilization of the septic pregnant or immediately postpartum patient requires an understanding of the physiologic changes of pregnancy, hemodynamic changes during labor, and infections specific to pregnancy. We will review the interaction between pregnant physiology and sepsis pathophysiology, and how this can guide screening and diagnosis.

The Fontan Circulation in Pregnancy: Hemodynamic Challenges and Anesthetic Considerations

Pregnancy in patients with Fontan physiology presents unique challenges due to altered cardiovascular dynamics inherent to both conditions. The Fontan procedure reroutes venous blood directly to the pulmonary arteries, bypassing the heart, and necessitating precise regulation of pulmonary venous resistance and systemic venous pressure to maintain effective cardiac output. The significant cardiovascular adaptations required during pregnancy to meet the metabolic demands of the mother and fetus can overburden the limited preload capacity and venous compliance in Fontan patients, predisposing them to a spectrum of potential complications, including arrhythmias, heart failure, thromboembolism, and obstetric and fetal risks. This review delineates the essential physiological adaptations during pregnancy and the challenges faced by Fontan patients, advocating for a comprehensive care approach involving multidisciplinary collaboration, vigilant monitoring, tailored anesthetic management, and postpartum care. Understanding the complex dynamics between Fontan physiology and pregnancy is crucial for anesthesiologists to develop and execute individualized management strategies to minimize risks and optimize outcomes for this high-risk population.

Cardiac physiology and pathophysiology in pregnancy

Cardiovascular disease is the leading indirect cause of maternal morbidity and mortality, accounting for nearly one third of maternal deaths during pregnancy. The burden of cardiovascular disease in pregnancy is increasing, as are the incidence of maternal morbidity and mortality. Normal physiologic adaptations to pregnancy, including increased cardiac output and plasma volume, may unmask cardiac conditions, exacerbate previously existing conditions, or create de novo complications. It is important for care providers to understand the normal physiologic changes of pregnancy and how they may impact the care of patients with cardiovascular disease. This review outlines the physiologic adaptions during pregnancy and their pathologic implications for some of the more common cardiovascular conditions in pregnancy.

The Influence of Pulmonary Arterial Hypertension In Pregnancy: A Review

Pulmonary arterial hypertension (PAH) is a severe condition characterized by increased pulmonary vascular resistance and right ventricular failure. This review examines the intersection of PAH and pregnancy, highlighting the significant physiological, hemodynamic, and hormonal changes that exacerbate PAH during gestation. Pregnancy is contraindicated in PAH patients due to high maternal and fetal morbidity and mortality rates. However, some patients choose to continue their pregnancies, necessitating a comprehensive understanding of the implications and management strategies. Effective management of PAH in pregnant patients involves individualized treatment plans. Prepartum management focuses on optimizing therapy and monitoring hemodynamic status. Prostacyclin analogs and phosphodiesterase inhibitors are commonly used, though their safety profiles require further investigation. Intrapartum management prioritizes preventing right ventricular failure, utilizing therapies such as intravenous epoprostenol, inhaled iloprost, and inhaled nitric oxide. Managing PAH in pregnancy requires careful planning, continuous monitoring, and tailored therapeutic strategies to navigate the complex interplay of physiological changes and mitigate risks. Future research should focus on elucidating the pathophysiology of PAH during pregnancy and developing safer, more effective treatments to improve maternal and fetal outcomes.

Biometrics of complete human pregnancy recorded by wearable devices

In the United States, normal-risk pregnancies are monitored with the recommended average of 14 prenatal visits. Check-ins every few weeks are the standard of care. This low time resolution and reliance on subjective feedback instead of direct physiological measurement, could be augmented by remote monitoring. To date, continuous physiological measurements have not been characterized across all of pregnancy, so there is little basis of comparison to support the development of the specific monitoring capabilities. Wearables have been shown to enable the detection and prediction of acute illness, often faster than subjective symptom reporting. Wearables have also been used for years to monitor chronic conditions, such as continuous glucose monitors. Here we perform a retrospective analysis on multimodal wearable device data (Oura Ring) generated across pregnancy within 120 individuals. These data reveal clear trajectories of pregnancy from cycling to conception through postpartum recovery. We assessed individuals in whom pregnancy did not progress past the first trimester, and found associated deviations, corroborating that continuous monitoring adds new information that could support decision-making even in the early stages of pregnancy. By contrast, we did not find significant deviations between full-term pregnancies of people younger than 35 and of people with "advanced maternal age", suggesting that analysis of continuous data within individuals can augment risk assessment beyond standard population comparisons. Our findings demonstrate that low-cost, high-resolution monitoring at all stages of pregnancy in real-world settings is feasible and that many studies into specific demographics, risks, etc., could be carried out using this newer technology.

Number of Pregnancies and Risk of Atherosclerotic Cardiovascular Disease in Postmenopausal Women: A Cross-Sectional Study of NHANES from 1999 to 2018

Background: Atherosclerotic cardiovascular disease (ASCVD) remains the most common cause of death in women. Pregnancy is an exposure unique to women leading to significant changes in maternal cardiovascular function. However, studies of the relationship between the number of pregnancies and ASCVD are rare. We aimed to clarify the association between the number of pregnancies and ASCVD. Methods: In this cross-sectional study, we used publicly available data from the National Health and Nutrition Examination Survey from 1999 to 2018. The number of pregnancies was divided into 0 (reference), 1, 2-3, 4-5, or ≥6, to create more stable estimates. A multiple logistic regression approach was used to examine the correlation between pregnancy and ASCVD in women aged 45 years or older who reported no menstruation in the past 12 months due to menopause, as well as in those aged 55 years or older, encompassing various age groups. We also separately estimated the association between the exposure of pregnancy and individual components of ASCVD. Results: In this study, age-adjusted data showed that women with six or more pregnancies had a doubled risk (odds ratio [OR]: 2.07) of ASCVD. The risk remained elevated at 1.69 times in women with four to five pregnancies and further increased to 1.90 times in women with six or more pregnancies, after adjusting for social factors. Similar patterns were observed when considering reproductive health and cardiovascular risk factors. Across the full population, every model that accounted for these variables consistently indicated that with an increasing number of pregnancies, we observed higher ORs for ASCVD risk (all p values <0.05). Conclusions: A higher number of pregnancies was associated with a higher risk of ASCVD after menopause, especially among women aged 45-64 years. Moreover, this association is particularly significant in the risk of stroke, cardiovascular heart disease, and heart attack.

Management of maternal pulse and blood pressure abnormalities during labour and childbirth: evidence-based algorithms for intrapartum care decision support

AIMS

To develop evidence-based clinical algorithms for assessment and management of abnormal maternal pulse and blood pressure during the intrapartum period.

POPULATION

Low risk singleton, term, pregnant women in labour.

SETTING

Institutional births in low- and middle-income countries.

SEARCH STRATEGY

A review of the literature was performed to retrieve evidence-based guidelines, systematic reviews, and papers on maternal pulse and blood pressure during labour. We searched a number of international clinical guidelines and PubMed using the corresponding key terms in November 2018 and updated the search in May 2020.

CASE SCENARIOS

Four common intrapartum case scenarios of abnormal pulse and blood pressure were identified for which algorithms were developed: hypertension, hypotension, tachycardia and bradycardia. Algorithms were constructed after reviewing guidelines and relevant papers, with input from a panel of experts. Thresholds for upper and lower limits of normal maternal pulse and blood pressure measurements are defined, evidence-based interventions for the initial management of abnormal parameters are described (resuscitation and monitoring) and guidance is provided on exploration of the potential causes for each case scenario, with links to pathways for their management.

CONCLUSIONS

Evidence-based algorithms to support the identification, and management of deviations in pulse and blood pressure during intrapartum care have been developed for hypertension, hypotension, tachycardia and bradycardia. The algorithms focus on initial resuscitation and monitoring, with an exploration of causes and early identification of underlying maternal conditions. These algorithms will help provide a standardised approach to investigation and management of these abnormal parameters to guide clinical practice.

TWEETABLE ABSTRACT

Algorithms for abnormal maternal pulse and blood pressure during labour allow standardised approach to early identification and management of complications.

TWEETABLE ABSTRACT

Guidelines for assessing maternal cardiovascular physiology during pregnancy and postpartum

Maternal mortality rates are at an all-time high across the world and are set to increase in subsequent years. Cardiovascular disease is the leading cause of death during pregnancy and postpartum, especially in the United States. Therefore, understanding the physiological changes in the cardiovascular system during normal pregnancy is necessary to understand disease-related pathology. Significant systemic and cardiovascular physiological changes occur during pregnancy that are essential for supporting the maternal-fetal dyad. The physiological impact of pregnancy on the cardiovascular system has been examined in both experimental animal models and in humans. However, there is a continued need in this field of study to provide increased rigor and reproducibility. Therefore, these guidelines aim to provide information regarding best practices and recommendations to accurately and rigorously measure cardiovascular physiology during normal and cardiovascular disease-complicated pregnancies in human and animal models.

Diuretics in pregnancy: Data from the ESC Registry of Pregnancy and Cardiac disease (ROPAC)

AIMS

Data on diuretic use in pregnancy are limited and inconsistent, and consequently it remains unclear whether they can be used safely. Our study aims to evaluate the perinatal outcomes after in-utero diuretic exposure.

METHODS AND RESULTS

The Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective, global registry of pregnancies in women with heart disease. Outcomes were compared between women who used diuretics during pregnancy versus those who did not. Multivariable regression analysis was used to assess the impact of diuretic use on the occurrence of congenital anomalies and foetal growth. Diuretics were used in 382 (6.7%) of the 5739 ROPAC pregnancies, most often furosemide (86%). Age >35 years (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-2.0), other cardiac medication use (OR 5.4, 95% CI 4.2-6.9), signs of heart failure (OR 1.7, 95% CI 1.2-2.2), estimated left ventricular ejection fraction <40% (OR 2.9, 95% CI 2.0-4.2), New York Heart Association class >II (OR 3.4, 95% CI 2.3-5.1), valvular heart disease (OR 6.3, 95% CI 4.7-8.3) and cardiomyopathy (OR 3.9, 95% CI 2.6-5.7) were associated with diuretic use during pregnancy. In multivariable analysis, diuretic use during the first trimester was not significantly associated with foetal or neonatal congenital anomalies (OR 1.3, 95% CI 0.7-2.6), and diuretic use during pregnancy was also not significantly associated with small for gestational age (OR 1.4, 95% CI 1.0-1.9).

CONCLUSIONS

Our study does not conclusively establish an association between diuretic use during pregnancy and adverse foetal outcomes. Given these findings, it is essential to assess the risk-benefit ratio on an individual basis to guide clinical decisions.

Vascular Remodeling During Late-Gestation Pregnancy: An In-Vitro Assessment of the Murine Ascending Thoracic Aorta

Maternal mortality due to cardiovascular disease is a rising concern in the U.S. Pregnancy triggers changes in the circulatory system, potentially influencing the structure of the central vasculature. Evidence suggests a link between a woman's pregnancy history and future cardiovascular health, but our understanding remains limited. To fill this gap, we examined the passive mechanics of the murine ascending thoracic aorta during late gestation. By performing biaxial mechanical testing on the ascending aorta, we were able to characterize the mechanical properties of both control and late-gestation tissues. By examining mechanical, structural, and geometric properties, we confirmed that remodeling of the aortic wall occurred. Morphological and mechanical properties of the tissue indicated an outward expansion of the tissue, as reflected in changes in wall thickness (∼12% increase) and luminal diameter (∼6% increase) at its physiologically loaded state in the pregnant group. With these geometric adaptations and despite increased hemodynamic loads, pregnancy did not induce significant changes in the tensile wall stress at the similar physiological pressure levels of the pregnant and control tissues. The alterations also included reduced intrinsic stiffness in the circumferential direction (∼18%) and reduced structural stiffness (∼26%) in the pregnant group. The observed vascular remodeling maintained the elastic stored energy of the aortic wall under systolic loads, indicating preservation of vascular function. Data from our study of pregnancy-related vascular remodeling will provide valuable insights for future investigations of maternal cardiovascular health.

Sub-Optimal Paternal Diet at the Time of Mating Disrupts Maternal Adaptations to Pregnancy in the Late Gestation Mouse

Pregnancy represents a stage during which maternal physiology and homeostatic regulation undergo dramatic change and adaptation. The fundamental purpose of these adaptations is to ensure the survival of her offspring through adequate nutrient provision and an environment that is tolerant to the semi-allogenic foetus. While poor maternal diet during pregnancy is associated with perturbed maternal adaptations during pregnancy, the influence of paternal diet on maternal well-being is less clearly defined. We fed C57BL/6 male mice either a control (CD), low protein diet (LPD), a high fat/sugar Western diet (WD) or the LPD or WD supplemented with methyl donors (MD-LPD and MD-WD, respectively) for a minimum of 8 weeks prior to mating with C57BL/6 females. Mated females were culled at day 17 of gestation for the analysis of maternal metabolic, gut, cardiac and bone health. Paternal diet had minimal influences on maternal serum and hepatic metabolite levels or gut microbiota diversity. However, analysis of the maternal hepatic transcriptome revealed distinct profiles of differential gene expression in response to the diet of the father. Paternal LPD and MD-LPD resulted in differential expression of genes associated with lipid metabolism, transcription, ubiquitin conjugation and immunity in dams, while paternal WD and MD-WD modified the expression of genes associated with ubiquitin conjugation and cardiac morphology. Finally, we observed changes in maternal femur length, volume of trabecular bone, trabecular connectivity, volume of the cortical medullar cavity and thickness of the cortical bone in response to the father's diets. Our current study demonstrates that poor paternal diet at the time of mating can influence the patterns of maternal metabolism and gestation-associated adaptations to her physiology.

Ophthalmic artery Doppler in women with hypertensive disorders of pregnancy: relationship to blood pressure control and renal dysfunction at 6-9 weeks postnatally

OBJECTIVES

To examine the postnatal course of ophthalmic artery (OA) Doppler in women with hypertensive disorders of pregnancy (HDP) and to evaluate the correlation between OA Doppler parameters and poor postnatal blood pressure control and renal dysfunction at 2-3 weeks and 6-9 weeks postnatally.

METHODS

This was a prospective cohort study of women with a singleton pregnancy and HDP seen at a tertiary pregnancy hypertension clinic between 2019 and 2021. Three visits were included: Visit 1, the last visit to the antenatal hypertension clinic within 2 weeks prior to delivery; Visit 2, at 2-3 weeks postnatally; and Visit 3, at 6-9 weeks postnatally. At each visit, maternal demographic characteristics, medical history, blood pressure and OA Doppler were obtained. In addition, fetal growth and fetal Dopplers were examined antenatally and, at 6-9 weeks postnatally, estimated glomerular filtration rate and proteinuria were quantified. Study participants were divided into four hypertension groups, according to longitudinal changes in blood pressure at the three visits. For the postnatal visits, hypertension was defined as systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg in the absence of antihypertensive medication, and SBP ≥ 130 mmHg and/or DBP ≥ 80 mmHg whilst taking antihypertensives. Group 1 was hypertensive at all three visits; Group 2 was hypertensive at Visits 1 and 2 but normotensive at Visit 3; Group 3 was hypertensive at Visits 1 and 3 but normotensive at Visit 2; and Group 4 was hypertensive at Visit 1 but normotensive at Visits 2 and 3. The longitudinal changes in mean arterial pressure (MAP), peak systolic velocity (PSV) 1, PSV2 and the ratio of PSV2/PSV1 over the three timepoints were examined by a repeated-measures, multilevel, linear mixed-effects analysis, controlling for maternal age, weight at presentation and use of antihypertensive medication. In addition, we examined the longitudinal change in OA Doppler parameters in women with different degrees of postnatal blood pressure control and in those with and those without renal dysfunction at 6-9 weeks postnatally.

RESULTS

A total of 108 women were recruited to the study, of whom 86 had new-onset hypertension and 22 had chronic hypertension. When controlling for maternal age, weight at presentation and use of antihypertensive medication, a significant decline in log10 MAP (P < 0.001), log10 PSV1 (P < 0.001) and log10 PSV2 (P = 0.01) was seen between Visits 1 and 3. Log10 PSVR did not change with time. When assessing OA Doppler against hypertension group, log10 PSV1 and log10 PSV2 did not differ between the hypertension groups, whilst Group 4 had a lower log10 PSVR compared with Group 1 (P < 0.01), Group 2 (P = 0.03) and Group 3 (P < 0.01). At 6-9 weeks postnatally, log10 PSVR was lower in those without compared to those with renal dysfunction (-0.021, P = 0.01), whilst log10 MAP, log10 PSV1 and log10 PSV2 values did not differ. Log10 PSVR did not change with time and remained at -0.12 (95% CI, -0.13 to -0.11) across the three visits.

CONCLUSIONS

In women with HDP, the OA-PSVR was significantly higher in those with labile or persistently raised blood pressure postnatally compared to women whose blood pressure normalized. Similarly, the OA-PSVR at 6-9 weeks postnatally was significantly higher in women with renal dysfunction vs those without dysfunction. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Challenges and opportunities in patients with adult congenital heart disease, a narrative review

Adult congenital heart disease Pregnancy Transition of care Challenges heart failure.

Preeclamptic heart failure - perioperative concerns and management: a narrative review

Preeclampsia is an important cause of heart failure during pregnancy and the postpartum period. The aim of this review is to elucidate the pathophysiology and clinical features of preeclamptic heart failure and describe the medical and anesthetic management of these high-risk parturients. This article reviews the current evidence base regarding preeclamptic heart failure and its pathophysiology, types, and clinical features. We also describe the medical and anesthetic management of these patients during the peripartum period. Heart failure due to preeclampsia can present as either systolic or diastolic dysfunction. The management strategies of systolic heart failure include dietary salt restriction, diuresis, and cautious use of beta-blockers and vasodilators. Diuretics are the mainstay in the treatment of diastolic heart failure. In the absence of obstetric indications, vaginal delivery is the safest mode of delivery in these high-risk patients, and the use of an early labor epidural for analgesia is recommended. These patients would require increased invasive monitoring during labor and vaginal delivery. Neuraxial and general anesthesia have been used successfully for cesarean section in these patients but require crucial modifications of the standard technique. Uterotonic drugs have significant cardiovascular and pulmonary effects, and a clear understanding of these is essential during the management of these patients. Preeclamptics with heart failure require individualized peripartum care, as cardiac decompensation is an important risk factor for maternal and neonatal morbidity and mortality. These high-risk parturients benefit from timely multidisciplinary team inputs and collaborated management.

Low dose aspirin prevents endothelial dysfunction in the aorta and foetal loss in pregnant mice infected with influenza A virus

Influenza A virus (IAV) infection in pregnancy resembles a preeclamptic phenotype characterised by vascular dysfunction and foetal growth retardation. Given that low dose aspirin (ASA) is safe in pregnancy and is used to prevent preeclampsia, we investigated whether ASA or NO-conjugated aspirin, NCX4016, resolve vascular inflammation and function to improve offspring outcomes following IAV infection in pregnant mice. Pregnant mice were intranasally infected with a mouse adapted IAV strain (Hkx31; 104 plaque forming units) and received daily treatments with either 200µg/kg ASA or NCX4016 via oral gavage. Mice were then culled and the maternal lungs and aortas collected for qPCR analysis, and wire myography was performed on aortic rings to assess endothelial and vascular smooth muscle functionality. Pup and placentas were weighed and pup growth rates and survival assessed. IAV infected mice had an impaired endothelial dependent relaxation response to ACh in the aorta, which was prevented by ASA and NCX4016 treatment. ASA and NCX4016 treatment prevented IAV dissemination and inflammation of the aorta as well as improving the pup placental ratios in utero, survival and growth rates at post-natal day 5. Low dose ASA is safe to use during pregnancy for preeclampsia and this study demonstrates that ASA may prove a promising treatment for averting the significant vascular complications associated with influenza infection during pregnancy.

Maternal hemodynamic evaluation in monochorionic twin pregnancy complicated by twin-to-twin transfusion syndrome treated with fetoscopic laser surgery

BACKGROUND

Maternal cardiovascular adaptations are amplified in twin pregnancies to support the metabolic request of the feto-placental unit. Few studies have evaluated the maternal hemodynamics changes after routine use of laser surgery in the treatment of twin-twin transfusion syndrome.

OBJECTIVE

The aim of our study was to evaluate hemodynamic changes in monochorionic twin pregnancies complicated by twin-twin transfusion syndrome before and after treatment with fetoscopic laser surgery.

STUDY DESIGN

A prospective observational study from 2020 to 2022, included monochorionic twin pregnancies complicated with twin-twin transfusion syndrome undergoing laser surgery between 16 and 26 weeks of gestation. To assess placental function and perfusion, uterine artery pulsatility index, hemoglobin, hematocrit, and soluble fms-like tyrosine kinase-1/placental growth factor ratio sampling prelaser and 24 hours postlaser were measured. Echocardiography by a single cardiologist evaluated maternal hemodynamics at presurgery, 24 hours, and 1 week postlaser. Those data were crosswise compared with cardiovascular indices of uncomplicated monochorionic pregnancies recruited at the same gestational age using nonparametric tests. Moreover, we fitted random-intercept linear regression models to investigate maternal hemodynamic changes according to the amount of amniotic fluid drained during laser surgery.

RESULTS

Forty-two twin-twin transfusion syndrome pregnancies with a median gestational age of 19.1 (17.4-20.9) weeks and 15 uncomplicated monochorionic pregnancies at the same gestational age were enrolled. Overall survival rate after laser was 72% with delivery at a median gestational age of 31.5 (27-34) weeks. Significant changes in blood chemistry and placental function were observed in the twin-twin transfusion syndrome group, along with alterations in arterial pressure, heart rate, cardiac output, and ventricular strain, eventually aligning with the uncomplicated group's values by 1 week postlaser. The amount of amniodrainage, with a 1000 ml cut-off, did not significantly impact hemodynamic parameters. Lastly, we detected a percentage of laser surgery complications in agreement with international literature and we did not record any maternal procedure-related problems.

CONCLUSION

Our analysis highlighted that maternal cardiovascular status in monochorionic twin pregnancy complicated by twin-twin transfusion syndrome was more dynamic and; 1 week after fetoscopic laser ablation of placental anastomosis completed by amniodrainage, maternal hemodynamic parameters restored to values similar to uncomplicated monochorionic twin pregnancies.

Maternal diabetes following gestational diabetes: Does multiple gestation multiply the risk?

OBJECTIVE

To assess whether the risk for future diabetes is higher among women diagnosed with gestational diabetes (GD) during twin versus singleton gestations.

METHOD

A retrospective cohort study was performed including all women who delivered at a tertiary medical center between the years 1991 and 2021 and had at least one GD diagnosis. The first GD diagnosis per women was defined as the index pregnancy. Women diagnosed with GD during multiple gestations were compared with women diagnosed with GD during singleton gestations. The outcomes included first hemoglobin A1C (Hba1C) level > 6.4 mg/dL post partum, and the highest level measured during the follow-up period of up to 30 years. Multivariable logistic and Cox proportional analysis were used to compare the risk between the two groups while adjusting for confounding variables.

RESULTS

The current study included 13 770 mothers, with 458 patients (3.3%) diagnosed with GD during twin gestations and 13 312 (96.7%) during singleton gestations. The mean follow-up was 12.25 ± 9.3 years. Mothers of both groups did not differ in age at index pregnancy; however, mothers of twins were more likely to conceive following fertility treatments. Incidence of diabetes and prediabetes (defined as Hba1C > 6.4 and >5.7, respectively) were lower among the twin-gestation group, both during the 6-month postpartum period (for diabetes: 15.5% vs 22.1%; odds ratio [OR], 0.65 [95% confidence interval (CI), 0.46-0.91]) and during the long-term follow-up (for diabetes: 31.8% vs 40.7%; OR, 0.68 [95% CI, 0.52-0.88]). These results remained significant in the multivariable analysis, while accounting for age, ethnicity, and fertility treatments.

CONCLUSION

GD diagnosis during multiple versus singleton gestations is associated with a lower risk for future diabetes.

Acute Myocardial Infarction in Pregnancy

Pregnancy-associated myocardial infarction is an overall uncommon event, but can be associated with significant maternal and fetal morbidity and mortality. In contrast to myocardial infarction in the general nonpregnant population, the mechanism of pregnancy-associated myocardial infarction is most commonly due to nonatherosclerotic mechanisms such as coronary dissection, vasospasm, or thromboembolism. The diagnosis of pregnancy-associated myocardial infarction can be challenging, requiring a high index of suspicion for prompt recognition and management. Furthermore, the management of pregnancy-associated myocardial infarction can be complex due to maternal and fetal considerations and may vary based on the specific underlying mechanism of the myocardial infarction. This review aims to review the recent literature on pregnancy-associated myocardial infarction and summarize the epidemiology, mechanisms, diagnosis, and treatment strategies for this uncommon entity.

Expert review: preeclampsia Type I and Type II

Pregnancy involves an interplay between maternal and fetal factors affecting changes to maternal anatomy and physiology to support the developing fetus and ensure the well-being of both the mother and offspring. A century of research has provided evidence of the imperative role of the placenta in the development of preeclampsia. Recently, a growing body of evidence has supported the adaptations of the maternal cardiovascular system during normal pregnancy and its maladaptation in preeclampsia. Debate surrounds the roles of the placenta vs the maternal cardiovascular system in the pathophysiology of preeclampsia. We proposed an integrated model of the maternal cardiac-placental-fetal array and the development of preeclampsia, which reconciles the disease phenotypes and their proposed origins, whether placenta-dominant or maternal cardiovascular system-dominant. These phenotypes are sufficiently diverse to define 2 distinct types: preeclampsia Type I and Type II. Type I preeclampsia may present earlier, characterized by placental dysfunction or malperfusion, shallow trophoblast invasion, inadequate spiral artery conversion, profound syncytiotrophoblast stress, elevated soluble fms-like tyrosine kinase-1 levels, reduced placental growth factor levels, high peripheral vascular resistance, and low cardiac output. Type I is more often accompanied by fetal growth restriction, and low placental growth factor levels have a measurable impact on maternal cardiac remodeling and function. Type II preeclampsia typically occurs in the later stages of pregnancy and entails an evolving maternal cardiovascular intolerance to the demands of pregnancy, with a moderately dysfunctional placenta and inadequate blood supply. The soluble fms-like tyrosine kinase-1-placental growth factor ratio may be normal or slightly disturbed, peripheral vascular resistance is low, and cardiac output is high, but these adaptations still fail to meet demand. Emergent placental dysfunction, coupled with an increasing inability to meet demand, more often appears with fetal macrosomia, multiple pregnancies, or prolonged pregnancy. Support for the notion of 2 types of preeclampsia observable on the molecular level is provided by single-cell transcriptomic survey of gene expression patterns across different cell classes. This revealed widespread dysregulation of gene expression across all cell types, and significant imbalance in fms-like tyrosine kinase-1 (FLT1) and placental growth factor, particularly marked in the syncytium of early preeclampsia cases. Classification of preeclampsia into Type I and Type II can inform future research to develop targeted screening, prevention, and treatment approaches.

The role of maternal hormones in regulating autonomic functions during pregnancy

Offspring development relies on numerous physiological changes that occur in a mother's body, with hormones driving many of these adaptations. Amongst these, the physiological functions controlled by the autonomic nervous system are required for the mother to survive and are adjusted to meet the demands of the growing foetus and to ensure a successful birth. The hormones oestrogen, progesterone, and lactogenic hormones rise significantly during pregnancy, suggesting they may also play a role in regulating the maternal adaptations linked to autonomic nervous system functions, including respiratory, cardiovascular, and thermoregulatory functions. Indeed, expression of pregnancy hormone receptors spans multiple brain regions known to regulate these physiological functions. This review examines how respiratory, cardiovascular, and thermoregulatory functions are controlled by these pregnancy hormones by focusing on their action on central nervous system circuits. Inadequate adaptations in these systems during pregnancy can give rise to several pregnancy complications, highlighting the importance in understanding the mechanistic underpinnings of these changes and potentially identifying ways to treat pregnancy-associated afflictions using hormones.

Pregnancy Considerations in Tetralogy of Fallot

The majority of women with repaired tetralogy of Fallot are able to tolerate pregnancy with a low risk of cardiovascular events. However, proactive contraceptive advice, prepregnancy counselling, and care by a pregnancy heart team with expertise in congenital heart disease are key to ensuring a good outcome for mother and baby. Maternal and fetal risks are increased in the presence of severe valvular stenosis, poorly tolerated arrhythmia, significant ventricular dysfunction, and cyanosis. It is unusual to see cyanotic adults with tetralogy of Fallot, whether unoperated or shunt palliated; pregnancy risks are greatly reduced by completing their repair before pregnancy is undertaken. The multidisciplinary pregnancy heart team should make a risk-stratified pregnancy care plan using a combination of published scoring systems and an individualized assessment of the patient's comorbidities. Low-risk patients may have the majority of their care and give birth in local units, whereas those at high risk should be managed and give birth in a tertiary centre with high-level expertise and intensive care facilities. Age-appropriate conversations about future childbearing and safe and reliable contraception should be part of routine follow-up from teenage years, so that women with tetralogy of Fallot can control their own fertility and make informed decisions about having children.

A Four-Dimensional Volumetric Quantification of the Left Ventricle in Healthy Pregnant Women in the Third Trimester

BACKGROUND

Hemodynamic load and heart structural remodeling rise during pregnancy because these changes are physiologically necessary. Adaptations in the mother's circulatory system may either initiate or aggravate the development of cardiovascular disease in the offspring. If the body is unable to adjust to these changes, it may develop heart conditions like cardiomyopathy. There is a lack of third-trimester echocardiographic data on left ventricular (LV) volume and function in healthy Iraqi women. To understand the cardiac alterations that occur during normal pregnancy, a precise tool that evaluates cardiac function is needed. In that regard, the four-dimensional echocardiography (4DE) technique has markedly improved the quality and accuracy of assessing the size and function of the left ventricle.

AIM

The present study aimed to assess LV volume and function in the third trimester of a healthy pregnancy using 4DE and to compare the results of LV assessment using 4DE with those of LV assessment using conventional two-dimensional (2D) echocardiography.

METHODS

The study was conducted on 75 healthy pregnant women (the case group) and 75 non-pregnant women (the control group). The participants attended Al-Fortat Teaching Hospital from April 1, 2022, to May 30, 2023, and had 2D and 4D echocardiographic studies performed on them.

RESULTS

The LV end-diastolic volume (EDV), end-systolic volume (ESV), and cardiac output (CO) were significantly increased in the case group compared to the control group (90.87 ± 18.03 ml vs. 62.64 ± 14.11 ml, P<0.001; 35.59 ± 6.52 ml vs. 22.42 ± 5.82 ml, P<0.001; and 4.87 ± 1.27 vs. 3.35 ± 0.87 L/m, P<0.001, respectively). In contrast, the LV ejection fraction (LVEF) was significantly decreased in the pregnant group compared to the control group (60.37 ± 5.42 % vs. 64.04 ± 4.99 %, P<0.01). Additionally, the study showed significant differences in EDV, ESV, ejection fraction (EF%), and CO (P<0.001) between 2D and 4D echocardiography, according to the Bland Altman test.

CONCLUSION

In healthy pregnant women in their third trimester, there is an increase in the indicators of preload (ventricular volume and CO) and a decrease in EF%. The 4DE provides detailed images and information about cardiac volumes and function, allowing for the early detection of any potential problems that may arise during pregnancy and thus improving the health outcomes of both the mother and the developing fetus.

Physiology of Health and Performance: Enabling Success of Women in Combat Arms Roles

INTRODUCTION

The modern female soldier has yet to be fully characterized as she steps up to fill new combat roles that have only recently been opened to women. Both U.S. and U.K. military operational research efforts are supporting a science-based evolution of physical training and standards for female warfighters. The increasing representation of women in all military occupations makes it possible to discover and document the limits of female physiological performance.

METHOD

An informal Delphi process was used to synthesize an integrated concept of current military female physiological research priorities and emerging findings using a panel of subject matter experts who presented their research and perspectives during the second Women in Combat Summit hosted by the TriService Nursing Research Program in February 2021.

RESULTS

The physical characteristics of the modern soldier are changing as women train for nontraditional military roles, and they are emerging as stronger and leaner. Capabilities and physique will likely continue to evolve in response to new Army standards and training programs designed around science-based sex-neutral requirements. Strong bones may be a feature of the female pioneers who successfully complete training and secure roles traditionally reserved for men. Injury risk can be reduced by smarter, targeted training and with attention directed to female-specific hormonal status, biomechanics, and musculoskeletal architecture. An "estrogen advantage" appears to metabolically support enhanced mental endurance in physically demanding high-stress field conditions; a healthy estrogen environment is also essential for musculoskeletal health. The performance of female soldiers can be further enhanced by attention to equipment that serves their needs with seemingly simple solutions such as a suitable sports bra and personal protective equipment that accommodates the female anatomy.

CONCLUSIONS

Female physiological limits and performance have yet to be adequately defined as women move into new roles that were previously developed and reserved for men. Emerging evidence indicates much greater physical capacity and physiological resilience than previously postulated.

Changes in Heart Rate, Heart Rate Variability, Breathing Rate, and Skin Temperature throughout Pregnancy and the Impact of Emotions-A Longitudinal Evaluation Using a Sensor Bracelet

(1) Background: Basic vital signs change during normal pregnancy as they reflect the adaptation of maternal physiology. Electronic wearables like fitness bracelets have the potential to provide vital signs continuously in the home environment of pregnant women. (2) Methods: We performed a prospective observational study from November 2019 to November 2020 including healthy pregnant women, who recorded their wrist skin temperature, heart rate, heart rate variability, and breathing rate using an electronic wearable. In addition, eight emotions were assessed weekly using five-point Likert scales. Descriptive statistics and a multivariate model were applied to correlate the physiological parameters with maternal emotions. (3) Results: We analyzed data from 23 women using the electronic wearable during pregnancy. We calculated standard curves for each physiological parameter, which partially differed from the literature. We showed a significant association of several emotions like feeling stressed, tired, or happy with the course of physiological parameters. (4) Conclusions: Our data indicate that electronic wearables are helpful for closely observing vital signs in pregnancy and to establish modern curves for the physiological course of these parameters. In addition to physiological adaptation mechanisms and pregnancy disorders, emotions have the potential to influence the course of physiological parameters in pregnancy.

Biomechanical remodeling of the murine descending thoracic aorta during late-gestation pregnancy

With the rise in maternal mortality rates and the growing body of epidemiological evidence linking pregnancy history to maternal cardiovascular health, it is essential to comprehend the vascular remodeling that occurs during gestation. The maternal body undergoes significant hemodynamic alterations which are believed to induce structural remodeling of the cardiovascular system. Yet, the effects of pregnancy on vascular structure and function have not been fully elucidated. Such a knowledge gap has limited our understanding of the etiology of pregnancy-induced cardiovascular disease. Towards bridging this gap, we measured the biaxial mechanical response of the murine descending thoracic aorta during a normotensive late-gestation pregnancy. Non-invasive hemodynamic measurements confirmed a 50% increase in cardiac output in the pregnant group, with no changes in peripheral blood pressure. Pregnancy was associated with significant wall thickening ( ∼14%), an increase in luminal diameter ( ∼6%), and material softening in both circumferential and axial directions. This expansive remodeling of the tissue resulted in a reduction in tensile wall stress and intrinsic tissue stiffness. Collectively, our data indicate that an increase in the geometry of the vessel may occur to accommodate for the increase in cardiac output and blood flow that occurs in pregnancy. Similarly, wall thickening accompanied by increased luminal diameter, without a change in blood pressure may be a necessary mechanism to decrease the tensile wall stress, and avoid pathophysiological events following late gestation.

Introducing and Implementing Genetic Assessment in Cardio-Obstetrics Clinical Practice: Clinical and Genetic Workup of Patients with Cardiomyopathy

Cardiovascular disease (CVD) during pregnancy varies significantly worldwide, influenced by factors such as access to healthcare, delayed diagnosis, causes, and risk factors. Our study sought to explore the spectrum of CVD present in pregnant women in the United Arab Emirates to better understand this population's unique needs and challenges. Central to our study is an emphasis on the importance of implementing a multidisciplinary approach that involves the collaboration of obstetricians, cardiologists, geneticists, and other healthcare professionals to ensure that patients receive comprehensive and coordinated care. This approach can also help identify high-risk patients and implement preventive measures to reduce the occurrence of adverse maternal outcomes. Furthermore, increasing awareness among women about the risk of CVD during pregnancy and obtaining detailed family histories can help in the early identification and management of these conditions. Genetic testing and family screening can also aid in identifying inherited CVD that can be passed down through families. To illustrate the significance of such an approach, we provide a comprehensive analysis of five women's cases from our retrospective study of 800 women. The findings from our study emphasize the importance of addressing maternal cardiac health in pregnancy and the need for targeted interventions and improvements in the existing healthcare system to reduce adverse maternal outcomes.

Twins versus singletons-Long-term health outcomes

INTRODUCTION

Multiple gestations are a risk factor for most pregnancy complications. The current study aimed to study whether offspring born after twin pregnancies are at increased risk for long-term health complications.

MATERIAL AND METHODS

A retrospective cohort study was conducted in a large medical center, including all offspring born between the years 1991-2021, which were followed-up until 18 years of age. Hospital-based diagnoses of the offspring were categorized into main groups of morbidities: cardiac, respiratory, infectious, neurological, malignancy, and metabolic. Incidence of hospitalization with diagnoses from each main group was compared between twins and singletons, as well as time to first hospitalization. Cox proportional hazard models were used to study the association between twins versus singletons and hospitalizations by grouped morbidities, while adjusting for maternal age, ethnicity and gender, besides maternal recurrence in the cohort.

RESULTS

A total of 369 478 offspring were included in the analysis; of these 11 986 (3.2%) were twins and 357 492 (96.8%) were singletons. Twins were more likely to be delivered preterm (odds ratio = 17.65, 95% CI: 16.74-18.60), by cesarean delivery and following infertility treatments. Incidence of hospitalizations with all morbidity groups was slightly, some significantly, higher among twins, including cardiac: 1.9% versus 1.5%, respiratory; 8.4% versus 7.1%, neurological: 7.7% versus 7.4%, infectious: 26.0% versus 24.1%, and malignancies: 0.7% versus 0.4%. The risk remained higher in the multivariable analyses (adjusted hazard ratios ranging between 1.09-1.75). When stratifying by gestational age at delivery, the risk for most morbidities was lower among twins versus singletons born in similar gestational ages.

CONCLUSIONS

Twins as compared to singletons are at increased risk for most morbidities due to their risk of being born earlier.

Reproductive Health in Congenital Heart Disease: Preconception, Pregnancy, and Postpartum

The prevalence of congenital heart disease (CHD) in pregnancy is rising due to the improved survival of patients with CHD into childbearing age. The profound physiological changes that occur during pregnancy may worsen or unmask CHD, affecting both mother and fetus. Successful management of CHD during pregnancy requires knowledge of both the physiological changes of pregnancy and the potential complications of congenital heart lesions. Care of the CHD patient should be based on a multidisciplinary team approach beginning with preconception counseling and continuing into conception, pregnancy, and postpartum periods. This review summarizes the published data, available guidelines and recommendations for the care of CHD during pregnancy.

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

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.

α/β- and β-Blocker Exposure in Pregnancy and the Risk of Neonatal Hypoglycemia and Small for Gestational Age

BACKGROUND

α/β- and β-blockers are essential in pregnant women's perinatal congenital heart disease management. Nevertheless, data on the effects of α/β- and β-blockers on pregnant women and fetuses are limited. We examined the risks of neonatal hypoglycemia and small for gestational age (SGA) associated with maternal exposure to α/β- and β-blockers.

METHODS AND RESULTS

All consecutive pregnant women with heart disease admitted to our hospital between January 2014 and October 2020 were included. Of 306 pregnancies (267 women), 32 were in the α/β-blocker group, 11 were in the β-blocker group, and 263 were in the control group. All 32 pregnancies in the α/β-blocker group were treated with carvedilol. In the β-blocker group, 4 women were treated with bisoprolol, 3 were treated with propranolol, 2 were treated with atenolol, 1 was treated with metoprolol, and 1 was treated nadolol. The incidence of neonatal hypoglycemia was higher in pregnant women taking carvedilol than in the control group (P=0.025). SGA was observed significantly more frequently in pregnant women taking β-blockers than in the carvedilol and control groups (P<0.001).

CONCLUSIONS

Carvedilol administration during pregnancy was associated with neonatal hypoglycemia; however, it did not occur in a time- or dose-dependent manner. Routine monitoring of blood glucose levels in newborns exposed to α/β- and β-blockers is essential.

Anesthesia during delivery in pregnant women with dilated cardiomyopathy

Emergency cesarean delivery in patients with heart failure increases maternal and fetal mortality. The present study aimed to identify the relationship between the use of anesthesia for delivery and progressive cardiac deterioration in women with dilated cardiomyopathy (DCM) and to examine its implications on maternal and fetal outcomes. Twenty-nine pregnancies in 25 women with DCM from the National Cerebral and Cardiovascular Center Hospital (Suita, Japan) were included in this retrospective longitudinal study. Fourteen of the patients (48.3%) delivered via cesarean section. Among these, 4 patients (13.8%) experienced heart failure within 42 days of delivery. The indication for cesarean delivery was heart failure in 3 patients and induction failure in 1 patient. The types of anesthesia used for these patients included general (n = 1), combined spinal-epidural (n = 2), and epidural (n = 1). Two of these cesarean deliveries were performed preterm. The left ventricular ejection fraction of patients with heart failure was ≤ 35% before 34 weeks gestation. Among the 25 patients without heart failure, 2 exhibited a left ventricular ejection fraction of ≤ 35% before 34 weeks gestation. Meanwhile, the types of anesthesia used for remaining 10 patients who did not experience heart failure included general (n = 1), combined spinal-epidural (n = 8), and epidural (n = 1). The rate of general anesthesia was 25% in patients who experienced heart failure and 4% in others. There was no incidence of maternal or fetal death. A preterm anesthetic evaluation may be warranted to optimize anesthetic management when the ejection fraction decreases to ≤ 35% before 34 weeks gestation in patients with DCM.

Pregnancy in Patients with Pulmonary Arterial Hypertension in Light of New ESC Guidelines on Pulmonary Hypertension

Pulmonary arterial hypertension (PAH) is defined as an elevated mean pulmonary artery pressure (mPAP) of >20 mmHg together with a pulmonary arterial wedge pressure (PAWP) of ≤15 mmHg and pulmonary vascular resistance (PVR) of>2 Wood units (WU). Although the total mortality of pregnant women with PAH has decreased significantly in recent years and is reported to be around 12% in some databases, total mortality is still at an unacceptably high percentage. Moreover, some subgroups, such as patients with Eisenmenger's syndrome, have a particularly high mortality rate of up to 36%. Pregnancy in patients with PAH is contraindicated; its appearance is an indication for a planned termination. Education of patients with PAH, including counseling on effective contraception, is essential. During pregnancy, blood volume, heart rate, and cardiac output increase, while PVR and systemic vascular resistance decrease. The hemostatic balance is shifted towards hypercoagulability. Among PAH-specific drugs, the use of inhaled or intravenous prostacyclins, phosphodiesterase inhibitors, and calcium channel blockers (in patients with preserved vasoreactivity) is acceptable. Endothelin receptor antagonists and riociguat are contraindicated. Childbirth can take place through either vaginal delivery or caesarean section; similarly, neuraxial and general anesthesia have proven indications. In a situation where all pharmacological options have been used in pregnant or postpartum patients in a serious condition, veno-arterial ECMO is a useful therapeutic option. For PAH patients who want to become mothers, an option that does not endanger their lives is adoption.

Effect of multidisciplinary team (MDT) centred on pregnant women with pulmonary hypertension on treatment and outcomes of pregnancy

BACKGROUND

The importance of multidisciplinary team (MDT) centred on pregnant women with pulmonary hypertension (PH) has been highlighted. However, rare studies have explored its effects on pregnancy outcomes. This study seeks to investigate whether and how the MDT has an effect on the treatment and outcomes of PH pregnant women.

METHODS

A pre- and post-intervention study was conducted based on an interrupted time series design to compare the treatment and outcomes of patients with PH before (pre-MDT) and after (post-MDT) implementation of the MDT. PH was defined as pulmonary artery systolic pressure (sPAP) ≥ 35 mmHg measured by echocardiography or right heart catheterization and sPAP at 35-60 mmHg and over 60 mmHg was defined as mild and severe PH, respectively. All results were analyzed by T-tests, Chi square tests or Fisher exact test and two-sided p value < 0.05 was set to be statistically significant.

RESULTS

149 pregnancies were found in 143 women with PH. Overall, 46 pregnancies were elective abortions, remaining 49 and 54 pregnancies completing delivery in the pre-MDT group and post-MDT group, respectively. Five (10.2%) mother and seven (8.6%) neonatal died in the former, while no maternal deaths but 1.9% neonatal death occurred in the latter. In subgroup analysis, maternal and fetal/neonatal complications were higher in patients with severe PH and World Health Organization functional class (WHO FC) III/IV and all maternal deaths occurred in class III/IV women. In pre-MDT and post-MDT groups, there were 8 and 22 pregnant women receiving the pulmonary-specific therapy and completing delivery, respectively. The percentage of heart failure and urgent cesarean of pre-MDT group was higher than the post-MDT group (30.6% vs. 12.9%, p = 0.02; 40.8% vs. 14.8%, p = 0.01, respectively).

CONCLUSION

Implementing the MDT decreased the rate of urgent caesarean section and heart failure in patients with PH and no maternal deaths occurred in the post-MDT group. Pregnant women with severe PH and WHO FC III/IV might have a poor prognosis, whereas the use of pulmonary-specific therapy might improve outcomes of pregnancy.

Rheumatic heart disease in pregnancy: Maternal and neonatal outcomes in the Top End of Australia

BACKGROUND

Women with rheumatic heart disease (RHD) can have a lower cardiac reserve to cope with pregnancy and labour, leading to increased obstetric and cardiac risks. The Northern Territory has been repeatedly reported to have the highest prevalence of RHD in Australia, yet evidence specific to pregnancy is scarce in the literature.

AIMS

The primary aim of this paper is to describe the baseline characteristics and maternal outcomes of pregnant women with RHD presenting to the largest obstetrics referral hospital in the Northern Territory. The secondary aim is to evaluate the current model of care in relation to their cardiac status.

METHODS

A retrospective observational study was conducted over a 9.5-year period. Demographics, cardiac, obstetrics and anaesthetics data were collected for analysis.

RESULTS

One hundred and twenty-nine pregnancies were included for analysis. All women were identified as Aboriginal or Torres Strait Islander, and 85% were of a RHD priority of 2 or 3. Of all 28 patients who had an emergency caesarean section, only one patient was indicated for cardiac reasons. There was no maternal or neonatal death reported. Three preterm births were induced secondary to maternal concerns related to RHD cardiac decompensation. There were no major adverse neonatal outcomes, including neonatal death, intraventricular haemorrhage or respiratory distress syndrome. Multidisciplinary care was also evaluated.

CONCLUSION

We observed a low rate of maternal and fetal morbidity and no mortality in a cohort of women with mild to severe RHD. These favourable outcomes have occurred in a multidisciplinary centre with significant experience in managing the medical and cultural complexities of this group.

Enhancing user awareness on inferences obtained from fitness trackers data

In the IoT era, sensitive and non-sensitive data are recorded and transmitted to multiple service providers and IoT platforms, aiming to improve the quality of our lives through the provision of high-quality services. However, in some cases these data may become available to interested third parties, who can analyse them with the intention to derive further knowledge and generate new insights about the users, that they can ultimately use for their own benefit. This predicament raises a crucial issue regarding the privacy of the users and their awareness on how their personal data are shared and potentially used. The immense increase in fitness trackers use has further increased the amount of user data generated, processed and possibly shared or sold to third parties, enabling the extraction of further insights about the users. In this work, we investigate if the analysis and exploitation of the data collected by fitness trackers can lead to the extraction of inferences about the owners routines, health status or other sensitive information. Based on the results, we utilise the PrivacyEnhAction privacy tool, a web application we implemented in a previous work through which the users can analyse data collected from their IoT devices, to educate the users about the possible risks and to enable them to set their user privacy preferences on their fitness trackers accordingly, contributing to the personalisation of the provided services, in respect of their personal data.

Association between the Change in Blood Pressure during Normotensive Pregnancy and the Development of Hypertension in Later Life

Introduction

Women who experience maternal complications, including pre-eclampsia, have a higher risk of cardiovascular disease development. Although the mechanism remains unclear, there is a hypothesis that pregnancy would be a stress test for cardiovascular disease. This study aimed to investigate whether changes in blood pressure during pregnancy would be associated with developing hypertension, which is a main risk of cardiovascular disease.

Methods

We conducted a retrospective study by collecting Maternity Health Record Books from 735 middle-aged women. Of these, 520 women were selected based on our criteria. 138 were defined as the hypertensive group according to the criteria of receiving antihypertensive medications or blood pressures of >140/90 mmHg at the survey. The rest 382 were defined as the normotensive group. We compared the blood pressures of the hypertensive group with those of the normotensive group during pregnancy and postpartum. Then, 520 women were divided into quartiles (Q1-Q4) according to their blood pressures during pregnancy. After the changes in blood pressure for each gestational month relative to nonpregnant measurements were calculated, the changes in blood pressure were compared among the four groups. Additionally, the rate of developing hypertension was evaluated among the four groups.

Results

The average age of the participants was 54.8 years (range: 40-85 years) at the time of the study and 25.9 years (range: 18-44 years) at delivery. There were significant differences in blood pressure during pregnancy between the hypertensive group and the normotensive group. Meanwhile, these two groups did not indicate any differences in blood pressure in postpartum. Higher mean blood pressure during pregnancy was associated with smaller changes in blood pressure during pregnancy. The rate of development of hypertension in each group of systolic blood pressure was 15.9% (Q1), 24.6% (Q2), 29.7% (Q3), and 29.7% (Q4). The rate of development of hypertension in each group of diastolic blood pressure (DBP) was 18.8% (Q1), 24.6% (Q2), 22.5% (Q3), and 34.1% (Q4).

Conclusions

Changes in blood pressure during pregnancy are small in women who have a higher risk of hypertension. Levels of blood pressure during pregnancy may be reflected in individual stiffness of blood vessels by the burden of pregnancy. If so, levels of blood pressure would be used to facilitate highly cost-effective screening and interventions for women with a high risk of cardiovascular diseases.

Cardiovascular Risk Assessment as a Quality Measure in the Pregnancy and Postpartum Period

Background

Cardiovascular disease (CVD) is the leading cause of maternal mortality in the United States, accounting for over one-third of all pregnancy-related deaths. Contributing factors such as lack of recognition and delayed diagnosis of CVD are primarily due to the overlap of signs and symptoms of a normal pregnancy with those of CVD.

Objectives

This study aimed to demonstrate the feasibility of introducing CVD risk assessment into clinical practice using the California Maternal Quality Care Collaborative algorithm to detect CVD during pregnancy and postpartum periods.

Methods

We implemented the CVD risk assessment algorithm into electronic health records at 3 large hospital networks serving over 14,000 patients at 23 sites. We determined the percentage of pregnant and/or postpartum patients who were screened for CVD risk and the follow-up rate for patients in whom the tool recommended a follow-up assessment. Rates were stratified according to clinical site characteristics. We obtained clinician feedback regarding the feasibility and acceptability of the tool.

Results

The rate of patients screened for CVD risk in the 3 hospital networks was 57.1%, 71.5%, and 98.7%. For those with a positive screen, follow-up rates were 65.8%, 72.5%, and 55.9% in the 3 networks. The rates of screening and follow-up varied based on the clinic size and specialty. Clinician-identified barriers were busy clinics, competing priorities, and the type of clinical practice.

Conclusions

This innovative population-based approach for universal CVD risk assessment during pregnancy is feasible and may be a helpful strategy to decrease CVD-related maternal morbidity and mortality.

Management of Complete Heart Block in a Pregnant Woman with Systemic Lupus Erythematosus-Associated Complications: Treatment Considerations and Pitfalls

We present a case of a pregnant woman with systemic lupus erythematosus (SLE) who was diagnosed with asymptomatic complete heart block (CHB) during pregnancy. To evaluate possible risks and benefits of pacemaker (PM) implantation, a multidisciplinary counselling board was held. Its recommendation was to perform PM implantation to prevent intra-uterine growth restriction from insufficient cardiac output using a fluoroscopic protective shield. The procedure was performed without complications and established permanent pacing on onwards ECG examinations. The patient subsequently gave birth to a healthy newborn. After a retrospective clinical case evaluation and review of relevant literature, a presumptive association between CHB and the primary diagnosis was proposed. Above that, pregnant women with SLE who develop hypertension are commonly treated with methyldopa, which may cause conduction abnormalities. Clinical recommendations for young female patients expecting pregnancy are lacking in this area. Careful diagnostic and treatment approaches should be used in the management of possible SLE-related complications in women of child-bearing age, focusing on preventable events.

Influenza Virus Infection during Pregnancy as a Trigger of Acute and Chronic Complications

Influenza A virus (IAV) infection during pregnancy disrupts maternal and fetal health through biological mechanisms, which are to date poorly characterised. During pregnancy, the viral clearance mechanisms from the lung are sub-optimal and involve hyperactive innate and adaptive immune responses that generate wide-spread inflammation. Pregnancy-related adaptations of the immune and the cardiovascular systems appear to result in delayed recovery post-viral infection, which in turn promotes a prolonged inflammatory phenotype, increasing disease severity, and causing maternal and fetal health problems. This has immediate and long-term consequences for the mother and fetus, with complications including acute cardiopulmonary distress syndrome in the mother that lead to perinatal complications such as intrauterine growth restriction (IUGR), and birth defects; cleft lip, cleft palate, neural tube defects and congenital heart defects. In addition, an increased risk of long-term neurological disorders including schizophrenia in the offspring is reported. In this review we discuss the pathophysiology of IAV infection during pregnancy and its striking similarity to other well-established complications of pregnancy such as preeclampsia. We discuss general features of vascular disease with a focus on vascular inflammation and define the "Vascular Storm" that is triggered by influenza infection during pregnancy, as a pivotal disease mechanism for short and long term cardiovascular complications.

Perioperative Anesthetic Management of the Pregnant Patient With Congenital Heart Disease Undergoing Cardiac Intervention: A Systematic Review

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.

Fetal and Neonatal Anesthesia

Anesthesia for fetal and neonatal surgery requires subspecialized knowledge and expertise. Attention to important anatomic, physiologic, and metabolic differences seen in pregnancy and at birth are essential for the optimal care of these patients. Thorough preoperative evaluations tailored intraoperative strategies and careful postoperative management are critical when devising the anesthetic approach for each of these cases.