Artery wall layer dimensions during normal pregnancy: a longitudinal study using noninvasive high-frequency ultrasound

Women and Ischemic Stroke

Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.

Obesity in adolescents associated with vascular aging - a study using ultra-high-resolution ultrasound

BACKGROUND

Obesity in adolescents is increasing worldwide and associated with an elevated cardiovascular risk later in life. In a group-comparative study, we investigated the association between adiposity in adolescents and signs of vascular aging and inflammation.

METHODS

Thirty-nine adolescents (10-18 years old), 19 with obesity and 20 with normal weight, were enrolled. The intima thickness and intima/media thickness ratio (I/M) were assessed using high-resolution ultrasound in the common carotid artery (center frequency 22 MHz) and the distal radial artery (RA; 50 MHz). Increased intima and high I/M are signs of vascular aging. Body characteristics, high-sensitivity C-reactive protein (hs-CRP), plasma lipids, and glycemic parameters were measured.

RESULTS

Adolescents with obesity, compared to normal-weight peers, had elevated plasma lipid, insulin c-peptide, and hs-CRP levels, the latter increasing exponentially with increasing adiposity. Obese adolescents had a thicker RA intima layer [0.005 mm; 95% confidence intervals (0.000, 0.009); P = 0.043] and a higher RA I/M [0.10; (0.040, 0.147); P < 0.0007]. Group differences for the RA I/M remained significant after adjustment for age, sex, fasting plasma insulin, and body mass index, both separately and together (P = 0.032). The RA I/M was correlated with hs-CRP, and both were correlated with the analyzed cardiovascular risk factors. Receiver operating curve c-values for RA I/M (0.86) and hs-CRP (0.90) strongly indicated correct placement in the obese or non-obese group.

CONCLUSIONS

Adolescents with obesity had significantly more extensive vascular aging in the muscular RA, than normal-weight peers. The findings support an inflammatory link between obesity and vascular aging in adolescents.

Postpartum Reversible Cerebral Vasoconstriction Syndrome Presenting with Radiological Plethora

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinicoradiological syndrome characterized by segmental vasoconstriction of cerebral arteries with resolution in most patients within 1 to 3 months. It has been known to be a benign uniphasic reversible illness but cases of fulminant RCVS with mortality have also been reported. The symptoms can be varied with presentations like transient ischemic attack (TIA), ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and posterior reversible encephalopathy syndrome (PRES). We report a postpartum female with RCVS with radiological features of ICH, SAH, atypical PRES, and atypical clinical presentation as well. RCVS can be frequently missed unless there is a high index of suspicion. Hence clinicians should be aware of the typical and the atypical presentation of RCVS along with the radiological findings with the potential complications. Early suspicion and detection in the emergency help in recovery and reducing morbidity.

Dimethylarginines correlate to common carotid artery wall layer dimensions and cardiovascular risk factors in pregnant women with/without preeclampsia: A group comparative study

OBJECTIVES

Asymmetric- and symmetric dimethylarginines (ADMA, SDMA) are elevated in cardiovascular disease (CVD). Preeclampsia is a pregnancy-specific syndrome and is an independent risk factor for subsequent CVD. Aims were to investigate whether ADMA, SDMA levels and l-arginine/ADMA and l-arginine/SDMA ratios during pregnancy and their changes from pregnancy to postpartum are associated to arterial wall layer dimensions and cardiovascular risk factors in women with and without preeclampsia.

STUDY DESIGN

Dimethylarginines were analyzed by LC-MS, and the common-carotid-artery (CCA) intima and media thicknesses were estimated using 22-MHz non-invasive ultrasonography in women with preeclampsia (cases = 48) and normal pregnancies (controls = 58) in similar gestational age, with reassessment one-year postpartum. A thick intima, thin media and high intima/media ratio (I/M) indicates a less healthy arterial wall.

RESULTS

The median age of cases and controls was 30 years. During pregnancy, women with preeclampsia had higher plasma ADMA, SDMA and lower l-arginine/ADMA and l-arginine/SDMA (all p < 0.01) than women with normal pregnancies. Further, ADMA, SDMA, l-arginine/ADMA and l-arginine/SDMA correlated to intima thickness (r_s = 0.33/0.33/-0.33/-0.35 and p < 0.01), I/M (r_s = 0.26/0.28/-0.22/-0.26 and p < 0.05) and mean arterial pressure (MAP) (r_s = 0.43/0.42/-0.39/-0.40 and p < 0.0001). Changes in ADMA, SDMA and l-arginine/SDMA from pregnancy to postpartum correlated to changes in intima thickness (r_s = 0.22/0.32/-0.21 and p < 0.05/<0.01/<0.05), I/M (r_s = 0.22/0.31/0.08 and p < 0.05/<0.01/=0.43) and MAP (r_s = 0.31/0.53/-0.25 and p < 0.01/<0.001/<0.05). No correlations were found for conventional CCA intima-media-thickness.

CONCLUSIONS

Dimethylarginines were associated to signs of adverse effects on arterial wall layer dimensions and cardiovascular risk factors in women with and without preeclampsia, during pregnancy and to their changes from pregnancy up to one-year postpartum.

Association between neutrophil to lymphocyte ratio and carotid artery wall thickness in healthy pregnant women

OBJECTIVE

Pregnancy may elicit a state of mild inflammation that might affect, either directly or indirectly, haematological parameters associated with systemic inflammation. In particular, both Neutrophil-to-lymphocyte ratio (NLR) and Red blood cells Distribution Width (RDW) have been found to be elevated in complicated pregnancy. However, data regarding the association of these haematological parameters with common carotid artery (CCA) intima-media thickness (IMT) in healthy pregnancy are scanty. Aim of this study was to evaluate possible changes in CCA-IMT during normal pregnancy and in the postpartum period, and to correlate these changes with NLR and RDW.

STUDY DESIGN

Between October 2019 and February 2020, a prospective study was carried out on 73 consecutive healthy pregnant women (32.8 ± 4.9 yrs/old). Women underwent obstetric assessment, complete blood cell counts with calculation of NLR and RDW, two-dimensional transthoracic echocardiography and carotid Doppler ultrasonography.

RESULTS

During normal pregnancy, both NLR and RDW progressively increased (p < 0.0001); likewise, parameters of carotid dimensions also significantly increased (p < 0.0001). Hematological and morphological changes all decreased in postpartum period. By univariable logistic regression, the variables which showed the greatest independent association with CCA-IMT (defined as CCA-IMT ≥0.55 mm) were: age (HR 1.33, 95% CI 1.15-1.53, p < 0.0001), pre-pregnant BMI (HR 2.75, 95% CI 1.72-4.41, p < 0.0001), third trimester E/e' ratio (HR 1.64, 95% CI 1.34-2.02, p < 0.0001), and third trimester NLR (HR 3.00, 95% CI 1.64-5.50, p < 0.0001). Multivariable logistic regression analysis demonstrated that third trimester NLR was the only variable that retained statistical significance (HR 2.49, 95% CI 1.35-4.59, p = 0.003). An NLR ≥ 2 reached 83% of sensitivity and 99% of specificity in identifying a CCA-IMT ≥0.55 mm (AUC = 0.95). A strong linear correlation of both third trimester NLR and RDW with CCA-IMT was observed (r = 0.89 and 0.83, respectively).

CONCLUSIONS

Pregnancy is a state of chronic mild inflammation and the progressive increase in NLR and RDW during normal pregnancy is significantly associated with CCA intimal-medial thickening.

Evaluation of Left Atrial Functions by 2-dimensional Speckle-Tracking Echocardiography During Healthy Pregnancy

OBJECTIVES

We aimed to determine the effects of normal pregnancy on left atrial (LA) mechanics using 2-dimensional speckle-tracking echocardiography.

METHODS

A total of 47 healthy women with singleton pregnancies were prospectively enrolled in this study. A total of 4 visits, including each trimester and postpartum at 6 months, were planned. Echocardiographic studies were performed with a Vivid 7 device equipped with a 2.5-MHz transducer (GE Vingmed Ultrasound AS, Horten, Norway).

RESULTS

Although the LA reservoir phase strain showed a gradual decrease from the first trimester to the third trimester during pregnancy, the measurements in the postpartum period were found to return to initial levels (mean ± SD: first trimester, 40.3% ± 11.7%; second trimester, 37.5% ± 12.9%; third trimester, 33.5% ± 9.0%; postpartum, 42.1% ± 11.1%; P < .001). The LA pump function strain was also parallel to the LA reservoir strain and gradually decreased from the first trimester to the third trimester during pregnancy, and it was observed that rose to the initial level in the postpartum period (first trimester, 16.7% ± 7.4%; second trimester, 14.8% ± 5.5%; third trimester, 12.7% ± 4.3%; postpartum, 15.8% ± 5.5%; P < .001).

CONCLUSIONS

We prospectively determined normal reference values for LA deformation parameters using speckle-tracking echocardiography in each trimester and the postpartum period in healthy pregnancy. These reference values may help identify subclinical LA dysfunction in several cardiovascular or systemic conditions. According to this study, these parameters decreased toward the third trimester during pregnancy and recovered in the postpartum period.

Sub-clinical atherosclerosis in the common carotid artery in women with/without previous pre-eclampsia: A seven-year follow-up

BACKGROUND AND AIMS

Pre-eclampsia is associated with increased risk of cardiovascular disease and premature death. However, conventional common carotid artery intima-media thickness (CCA-IMT) measurement does not reflect this. In contrast, measurement of the individual CCA intima and media thicknesses clearly indicates increased vascular risk both at diagnosis and about one year after pre-eclampsia. This study examined whether individual CCA wall layers, risk factors for cardiovascular disease, and markers of endothelial dysfunction had normalized or remained unfavorable seven years after pre-eclampsia.

METHODS

The individual CCA intima and media thicknesses were measured using 22 MHz ultrasound. Conventional cardiovascular risk factors were recorded. A thick intima, thin media and high intima/media thickness ratio (I/M) are signs of sub-clinical atherosclerosis.

RESULTS

The median age of women with previous pre-eclampsia (cases = 23) or normal pregnancies (controls = 35) was 39/37 years. At follow-up (median about seven years), the intima remained thicker and the I/M was higher in cases than in controls [all p < 0.0001; p < 0.001 after adjustment for time to follow-up, body mass index (BMI), and mean arterial pressure (MAP)], whereas the CCA-IMT was illogically thinner. Further, BMI, MAP, hip circumference, abdominal height, serum endostatin and apolipoprotein B levels were higher in cases (all p < 0.05). Intima and I/M measurements were correlated with age, MAP, endostatin and apolipoprotein B, whereas no logical correlations were found for CCA-IMT.

CONCLUSIONS

The arteries in cases but not controls were still adversely affected after seven years. Measuring intima thickness and I/M appears preferable to measuring CCA-IMT for demonstrating vascular risk after pre-eclampsia.

Common carotid artery intima-media thickness increases throughout the pregnancy cycle: a prospective cohort study

Background

High parity is associated with greater cardiovascular disease (CVD) among mid-life and older women. Prospective studies of arterial change throughout pregnancy are needed to provide insight into potential mechanisms. This study assessed vascular adaptation across pregnancy in healthy first-time pregnant women.

Methods

The Maternal Vascular Adaptation to Healthy Pregnancy Study (Pittsburgh, PA, 2010–2015) assessed 37 primigravid women each trimester, 6–8 weeks after delivery and 1–5 years postpartum, with B-mode ultrasound imaging of common carotid artery (CCA) intima-media thickness (IMT) and inter-adventitial diameter (IAD) to assess associations with physical and cardiometabolic measures.

Results

Thirty-seven women (age 28.2 ± 4.5 years, pre-pregnant BMI 24.4 ± 3.2 kg/m²) experienced uncomplicated pregnancies. After adjustment for age and pre-pregnancy BMI, mean (SE) IAD (mm) increased each trimester, from 6.38 (0.08) in the 1st trimester to 6.92 (0.09) in the 3rd trimester, and then returned to 1st trimester levels postpartum (6.35 [0.07], P <  0.001). In contrast, mean (SE) CCA IMT (mm) increased from the 2nd trimester (i.e., 0.546 [0.01]) onward, and remained higher at an average of 2.7 years postpartum (0.581 [0.02], P = 0.03). Weight partially explained changes in IAD.

Conclusions

In uncomplicated first pregnancies, IAD increased and returned to 1st trimester levels postpartum. In contrast, CCA IMT remained increased 2 years postpartum. Maternal weight explained vascular changes better than did metabolic changes. Increased postpartum CCA IMT may persist and contribute to long-term CVD risk.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1841-y) contains supplementary material, which is available to authorized users.

Cerebral haemodynamics in early puerperium: A prospective study

AIM

Prospective study on 900 consecutive puerperae to assess normal values and range of the blood flow velocity in the middle cerebral artery in both hemispheres.

MATERIAL AND METHOD

M1 and M2 segments of both middle cerebral arteries were assessed in all subjects within 96 hours of delivery. Mean flow velocity was recorded after adjusting for insonation angle. Lindegaard index (LI = middle cerebral artery-Internal Carotid Artery mean flow velocity ratio) was calculated whenever the mean flow velocity exceeded 100 cm/second. Asymmetry indexes were calculated inter hemispherically for M1 and M2 segments separately.

RESULTS

Mean flow velocities were 74 ± 17 and 72 ± 17 in right and 73 ± 17 and 72 ± 17 cm/second in the left M1 and M2, respectively. A total of 136 subjects (12.1%) exceeded the threshold of 100 cm/second, but LI was consistently <3 in all of them. Mean flow velocity was inversely and independently correlated to haemoglobin levels and to parity. Mean asymmetry indexes were 0.25 ± 23 in M1 and 0.45 ± 25 in M2.

CONCLUSION

Mean flow velocity in the middle cerebral artery of healthy subjects in early puerperium is higher than in age-matched non-puerperal women and may exceed the threshold of 100 cm/second with no evidence of intracranial spasm, because of blood loss during delivery. Mean flow velocity is independently correlated with parity. Right-to-left mean flow velocity asymmetry may reach 50% as a consequence of a transient imbalance in vascular tone regulation.

Reversible cerebral vasoconstriction syndrome in puerperium: A prospective study

BACKGROUND AND AIM OF THE STUDY

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe "thunderclap" headache, with or without associated neurological symptoms and neuroimaging findings of reversible vasoconstriction of cerebral arteries. Puerperium is a recognized precipitant, but the incidence of puerperal RCVS is unknown. We conducted a prospective study to assess incidence, risk factors and clinical features of RCVS.

MATERIAL AND METHOD

Nine-hundred consecutive puerperae were prospectively enrolled within three days of delivery. Past medical history, basal demographic, anthropometric and biological variables were recorded. Transcranial Colour Coded Sonography (TCCS) was performed to assess early signs of vasospasm in brain vessels. A structured telephone interview was planned in all subjects one month postdelivery.

RESULTS

Thunderclap headache was recorded in 8 subjects (0.9%) on the first visit. At the one month follow-up interview 27 more patients reported having had at least one episode of thunderclap headache. In these 33 (3.8%) patients the course was spontaneously benign. One patient presented to the Emergency ward with throbbing thunderclap headache three weeks after delivery. Diagnostic work-up ended up in the diagnosis of RCVS, the outcome was favourable CONCLUSION: In normally coursing pregnancies and after uncomplicated delivery the risk of puerperal RCVS is negligible (0.1%). On the other way thunderclap headache may occur in a measurable proportion of (3.4%), although in the vast majority of cases (33/34=97%) it is of benign course. Transcranial Doppler sonography may be helpful to pick up those cases in whom further neuroradiological investigation is warranted.

Postpartum reversible cerebral vasoconstriction syndrome: Review and analysis of the current data

Postpartum reversible cerebral vasoconstriction syndrome (PPRCVS) is a rare but serious cause of headache that occurs in the early postpartum period. The rarity of this disorder has limited the current literature to single case reports and small, observational case series. The lack of familiarity with PPRCVS may contribute to mismanagement of these unique patients and lead to poor outcomes. To address current gaps in the understanding of PPRCVS, this review and data analysis characterizes the demographics, presentation, clinical course, management and prognosis of PPRCVS and provides a general review of the epidemiology, pathophysiology and diagnosis to assist clinicians who may care for patients with this rare disorder.

Follow up of intima-media thickness after severe early-onset preeclampsia

OBJECTIVE

Early-onset preeclampsia is associated with premature cardiovascular disease. We previously demonstrated that femoral intima-media thickness (IMT) and markers of cardiovascular disease were increased in women 1 year after early-onset preeclampsia. The current study measured (progression of) IMT, cardiovascular disease risk factors and markers of endothelial cell dysfunction 4-5 years postpartum in the same women.

STUDY DESIGN

Case-control study.

POPULATION

Formerly preeclamptic women.

METHODS

IMT of carotid and femoral arteries was measured by ultrasound, as a marker of subclinical atherosclerosis. Various conventional cardiovascular risk factors were determined, as well as serum markers of endothelial cell activation and inflammation. Values were compared with those 1 year after the first (preeclamptic) pregnancy.

MAIN OUTCOME MEASURES IMT RESULTS

We included 17 formerly preeclamptic women (cases) and 16 controls. Mean interval between index delivery and day of investigation was 4.7 years for the cases and 4.3 years for the controls. Neither differences nor progression of IMT was observed between the cases and the controls. Increased blood pressure, body mass index, serum triglycerides and inflammatory markers were found in the cases compared with the controls.

CONCLUSION

IMT was not increased in women with an almost 5-year history of severe preeclampsia as an indicator of increased cardiovascular risk. This study suggests a transient adaptive response of the arteries in formerly preeclamptic women. The persistence of cardiovascular risk factors in this group emphasizes the need for long-term follow-up.

Thicknesses of individual layers of artery wall indicate increased cardiovascular risk in severe pre-eclampsia

OBJECTIVE

To assess whether thicknesses of the intima and media in the common carotid artery (CCA) and the intima/media ratio (I/M) indicate an increased cardiovascular risk in non-pregnant women with a history of previous severe pre-eclampsia.

METHODS

Thicknesses of the CCA intima and media layers were measured using non-invasive high-frequency (22 MHz) ultrasound in 42 women with a history of severe pre-eclampsia and 44 women with previous normal pregnancy.

RESULTS

Women with a history of severe pre-eclampsia had a thicker CCA intima and a higher I/M than had women with previous normal pregnancy, also after adjustment for mean arterial pressure, body mass index and CCA intima-media thickness (IMT) (all P < 0.0001). CCA-IMT did not differ significantly between groups. In receiver-operating characteristics curve analysis, intima thickness and I/M clearly discriminated between women with and those without previous pre-eclampsia (area under the receiver-operating characteristics curve (AUC), 0.98 and 0.93), whereas CCA-IMT did not (AUC, 0.52).

CONCLUSIONS

CCA individual intima and media thicknesses as well as I/M, but not CCA-IMT, reflect the known increased long-term cardiovascular risk of pre-eclampsia. Estimation of individual CCA layers using high-frequency ultrasound appears preferable to measuring CCA-IMT for investigating arterial effects and the increased cardiovascular risk in women with a history of severe pre-eclampsia.

Individual common carotid artery wall layer dimensions, but not carotid intima-media thickness, indicate increased cardiovascular risk in women with preeclampsia: an investigation using noninvasive high-frequency ultrasound

BACKGROUND

Preeclampsia (PE) is associated with increased risk of cardiovascular disease later in life. Ultrasound assessment of the common carotid artery intima-media thickness (IMT) during or after PE has not indicated any increased cardiovascular risk.

METHODS AND RESULTS

We used high-frequency ultrasound (22 MHz) to estimate the individual common carotid artery IMTs in 55 women at PE diagnosis and in 64 women with normal pregnancies at a similar stage. All were re-examined about 1 year postpartum. A thick intima, thin media, and high intima/media (I/M) ratio are signs of a less healthy artery wall. PE was associated with a significantly thicker mean common carotid artery intima, thinner media, and higher I/M ratio than in normal pregnancy (mean I/M difference, 0.21; 95% confidence interval, 0.17-0.25; P<0.0001). After adjustment for first trimester body mass index and mean arterial pressure, differences in intima thickness and I/M remained significant. About 1 year postpartum, these values had improved in both groups, but group differences remained significant (all adjusted P<0.0001). There were no significant differences in IMT between groups. In receiver-operating characteristic curve analysis, intima thickness and I/M were strongly predictive of prevalent PE (area under the curve, ≈0.95), whereas IMT was not (area under the curve, 0.49).

CONCLUSIONS

The arteries of women with PE were negatively affected during pregnancy and 1 year postpartum compared with women with normal pregnancies, indicating increased cardiovascular risk. Estimation of intima thickness and I/M ratio seem preferable to estimation of common carotid artery IMT in imaging cardiovascular risk in PE. Results from this pilot study warrant further confirmation.