Maternal Cardiovascular Impairment in Pregnancies Complicated by Severe Fetal Growth Restriction

The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia

Preeclampsia remains the leading cause of maternal morbidity and mortality and is associated with abnormal body fluid homeostasis and cardiovascular dysfunction. Moreover, 2 distinct hemodynamic phenotypes have been described in preeclampsia, which might require different therapeutic approaches. Fluid restriction is mandatory in women at risk of pulmonary edema, whereas additional fluid administration may be required to correct tissue hypoperfusion in women with intravascular volume depletion. As clinical examination alone cannot discriminate among different hemodynamic patterns, optimal management of women with preeclampsia remains challenging. Noninvasive bedside ultrasound has become an important diagnostic and monitoring tool in critically ill patients, and it has been demonstrated that it can also be used in the monitoring of women with preeclampsia. Echocardiography in combination with lung ultrasound provides information on hemodynamic status, cardiac function, lung congestion, and fluid responsiveness and, therefore, could help clinicians identify women at higher risk of life-threatening complications. This review describes the cardiovascular changes in preeclampsia and provides an overview of the ultrasound methodologies that could be efficiently used for better hemodynamic assessment and management of women with preeclampsia.

Impact of adverse pregnancy outcomes on brain vascular health and cognition

A State of the Art lecture titled "Impact of Adverse Pregnancy Outcomes on Brain Vascular Health and Cognition" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Adverse pregnancy outcomes, encompassing conditions such as gestational hypertension, eclampsia, preeclampsia, preterm birth, fetal growth restriction, stillbirth, and gestational diabetes, may form part of an underrecognized pathway from early adulthood reproductive health factors to later-life vascular cognitive impairment and dementia in women. Adverse pregnancy outcomes are caused by dysregulated vascular and metabolic adaptations during pregnancy, and these pathophysiological changes may persist after delivery. Adverse pregnancy outcomes may contribute to the increased risk of cognitive impairment and dementia directly through vascular and metabolic dysregulation and subsequent development of cardiovascular diseases, or other biological processes may be at play, such as shared maternal risk factors. Extensive epidemiologic evidence has shown that many cognitive impairment and dementia cases may be prevented or delayed by strategies targeting midlife cardiovascular health. Despite the recognized importance of adverse pregnancy outcomes for cardiovascular health, the literature on associated long-term health outcomes is limited. In this State of the Art review article, we summarize the current epidemiologic evidence on the relationship between adverse pregnancy outcomes and cognitive impairment and dementia and provide an overview of the potential pathophysiological mechanisms. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.

The prediction of hypertensive disorders by maternal hemodynamic assessment in the first trimester of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy and fetal growth restriction share common etiopathological origins and could be caused by maternal hemodynamic maladaptation to pregnancy.

OBJECTIVE

The aim of our study is to evaluate if there is a correlation between maternal hemodynamic detected by UltraSonic Cardiac Output Monitor (USCOM^®) during the first trimester and the pregnancy outcome.

STUDY DESIGN

We recruited a nonconsecutive series of women in the first trimester of pregnancy with no previous history of hypertensive disorders. We measured the pulsatility index uterine arteries and performed a hemodynamic evaluation by USCOM^® device. After delivery, we reported the development of hypertensive disorders or intrauterine fetal growth restriction later during gestation.

RESULTS

A total of 187 women were enrolled during the first trimester; 17 (9%) developed gestational hypertension or preeclampsia while 11 (6%) delivered a restricted growth fetus. Mean uterine artery pulsatility index above the 95th percentile was significantly more frequent in both women who developed hypertension and those with fetal growth restriction compared to controls. Hemodynamic parameters (reduced cardiac output and increased total vascular resistance) were significantly different in the group that developed hypertensive disorders, compared to uncomplicated pregnancy. ROC curves demonstrated the usefulness of uterine artery pulsatility index in the prediction of fetal growth restriction, while hemodynamic parameters were significantly associated to the development of hypertensive disorders.

CONCLUSIONS

Hemodynamic maladaptation to pregnancy may predispose to the development of hypertension, while we demonstrated a significative relationship between growth restriction and mean uterine pulsatility index. Further studies are needed to assess the value of hemodynamics evaluation in screening protocols of preeclampsia.

Placental syndromes and maternal cardiovascular health

The placental syndromes gestational hypertension, preeclampsia and intrauterine growth restriction are associated with an increased cardiovascular risk to the mother later in life. In this review, we argue that a woman's pre-conception cardiovascular health drives both the development of placental syndromes and long-term cardiovascular risk but acknowledge that placental syndromes can also contribute to future cardiovascular risk independent of pre-conception health. We describe how preclinical studies in models of preeclampsia inform our understanding of the links with later cardiovascular disease, and how current pre-pregnancy studies may explain relative contributions of both pre-conception factors and the occurrence of placental syndromes to long-term cardiovascular disease.

A mathematical model of vascular and hemodynamics changes in early and late forms of preeclampsia

Preeclampsia-eclampsia syndrome is a leading cause of maternal mortality. The precise etiology of preeclampsia is still not well-defined and different forms exist, including early and late forms or preeclampsia, which may arise via distinctly different mechanisms. Low-dose aspirin administered at the end of the first trimester in women identified as high risk has been shown to reduce the incidence of early, but not late, preeclampsia; however, current risk factors show only fair predictive capability. There is a pressing need to develop accurate descriptions for the different forms of preeclampsia. This paper presents 1D fluid, solid, growth, and remodeling models for pregnancies complicated with early and late forms of preeclampsia. Simulations affirm a broad set of literature results that early forms of preeclampsia are characterized by elevated uterine artery pulsatility index (UA-PI) and total peripheral resistance (TPR) and lower cardiac output (CO), with modestly increased mean arterial blood pressure (MAP) in the first half of pregnancy, with elevation of TPR and MAP beginning at 20 weeks. Conversely, late forms of preeclampsia are characterized by only slightly elevated UA-PI and normal pre-term TPR, and slightly elevated MAP and CO throughout pregnancy, with increased TPR and MAP beginning after 34 weeks. Results suggest that preexisting arterial stiffness may be elevated in women that develop both early forms and late forms of preeclampsia; however, data that verify these results are lacking in the literature. Pulse wave velocity increases in early- and late-preeclampsia, coincident with increases in blood pressure; however, these increases are mainly due to the strain-stiffening response of larger arteries, rather than arterial remodeling-derived changes in material properties. These simulations affirm that early forms of preeclampsia may be associated with abnormal placentation, whereas late forms may be more closely associated with preexisting maternal cardiovascular factors; simulations also highlight several critical gaps in available data.

Maternal hemodynamic profile during pregnancy and in the post-partum in hypertensive disorders of pregnancy and fetal growth restriction

BACKGROUND

Maternal cardiovascular changes, occurring since the beginning of pregnancy, are necessary for normal placentation and regular evolution of pregnancy.

OBJECTIVE

This study aimed to compare the hemodynamic profiles and cardiac remodeling of women with hypertensive disorders of pregnancy and either appropriate for gestational age fetuses or growth-restricted fetuses, women with normotensive pregnancies complicated by fetal growth restriction, and women with uncomplicated pregnancies, during pregnancy and the postpartum period.

STUDY DESIGN

A prospective longitudinal case-control design was used for this study. Over the study period, 220 eligible women with singleton pregnancies were selected for the analysis and divided into 4 groups: (1) hypertensive disorders of pregnancy with appropriate for gestational age fetuses; (2) hypertensive disorders of pregnancy with fetal growth restriction; (3) normotensive fetal growth restriction; and (4) controls. Ultrasound fetal biometry and fetoplacental Doppler velocimetry were performed at recruitment. Maternal hemodynamic assessment using transthoracic echocardiography was performed at the time of recruitment by a dedicated cardiologist blinded to maternal clinical data. The same assessments were performed in 104 patients at 32 weeks (interquartile range, 24-40) after delivery by the same cardiologist.

RESULTS

During pregnancy, women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction group showed significantly lower cardiac output and increased compared with those in the control group. These values were associated with concentric remodeling of the left ventricle owing to relatively increased wall thickness, which was not accompanied by an increase in left ventricular mass. Isolated fetal growth restriction presented similar but less important hemodynamic changes; however, there was no change in relative wall thickness. At postpartum follow-up, the hemodynamic parameters of women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and isolated-fetal-growth-restriction groups reverted to values similar to those of the control group. Only 8.3% of women in these groups experienced hypertension even in the postpartum period, and asymptomatic stage-B cardiac failure was observed for 17% at echocardiography. In the group of women with hypertensive disorders of pregnancy and appropriate for gestational age fetuses, cardiac output increased as in normal pregnancies, but total vascular resistance was significantly higher; hypertension then occurred, along with ventricular concentric hypertrophy and diastolic dysfunction. At postpartum follow-up, women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed significantly higher mean arterial pressure, total vascular resistance, and left ventricular mass compared with those in the control group. Persistent hypertension and asymptomatic stage-B cardiac failure were observed in 39.1% and 13% of women in the former group, respectively.

CONCLUSION

Pregnancies with hypertensive disorders of pregnancy and fetal growth restriction and normotensive pregnancies with fetal growth restriction were associated with the hemodynamic profile of lower heart rate and cardiac output, most likely because of abnormal adaptation to pregnancy, as confirmed by abnormal changes from pregnancy to the postpartum period. The heart rates and cardiac output of women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed changes opposite to those observed in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and fetal-growth-restriction groups. Obesity and other metabolic risk factors, significantly prevalent in women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group, predispose to hypertension and cardiovascular diseases during pregnancy and the postpartum period, potentially offering a window for personalized prevention. Such preventive strategies could differ in women with hypertensive disorders of pregnancy and fetal growth restriction characterized by poor early placental development.

Pregnancy-Related Complications and Incidence of Atrial Fibrillation: A Systematic Review

Pregnancy-related complications are associated with a higher risk of various incident cardiovascular diseases, but their specific potential relationship with incident atrial fibrillation (AF) is less clear. This systematic review summarises the available evidence from observational studies which have examined associations between pregnancy-related complications and the risk of AF. MEDLINE and EMBASE (Ovid) were searched for studies between 1990 to 10 February 2022. Pregnancy-related complications examined included hypertensive disorders of pregnancy (HDP), gestational diabetes, placental abruption, preterm birth, small-for-gestational-age and stillbirth. Study selection, data extraction and quality assessment were completed independently by two reviewers. Narrative synthesis was used to evaluate the results of the included studies. Nine observational studies were included, with eight eligible for narrative synthesis. Sample sizes ranged from 1839 to 2,359,386. Median follow-up ranged from 2 to 36 years. Six studies reported that pregnancy-related complications were associated with a significantly increased risk of incident AF. Hazard ratios (HRs) (95% confidence intervals) for the four studies that evaluated HDP ranged from 1.1 (0.8-1.6) to 1.9 (1.4-2.7). For the four studies that evaluated pre-eclampsia, HRs ranged from 1.2 (0.9-1.6) to 1.9 (1.7-2.2). Current evidence from observational studies suggests pregnancy-related complications are associated with a significantly higher risk of incident AF. However, only a small number of studies examining each pregnancy-related complication were identified, and considerable statistical heterogeneity was observed. Further large-scale prospective studies are required to confirm the association between pregnancy-related complications and incident AF.

An update on maternal cardiac hemodynamics in fetal growth restriction and pre-eclampsia

Pre-eclampsia and fetal growth restriction (FGR) have been long related to primary placental dysfunction, caused by abnormal trophoblast invasion. Nevertheless, emerging evidence has led to a new hypothesis for the origin of pre-eclampsia and FGR. Suboptimal maternal cardiovascular adaptation has been shown to result in uteroplacental hypoperfusion, ultimately leading to placental hypoxic damage with secondary dysfunction. In this review, we summarize current evidence on maternal cardiac hemodynamics in FGR and pre-eclampsia. We also discuss the different approaches for antihypertensive treatment according to the hemodynamic phenotype observed in pre-eclampsia and FGR.

Sex differences in heart failure with preserved ejection fraction: From traditional risk factors to sex-specific risk factors

Heart failure with preserved ejection fraction has a higher prevalence in women versus men. There are several proposed mechanisms to explain this sex discrepancy including differences in cardiovascular adaptation to comorbidities and potential underlying etiologic mechanisms. In this review, we summarize sex differences in traditional risk factors, such as obesity, diabetes, hypertension, and coronary artery disease, which contribute to the development of heart failure with preserved ejection fraction in women. Furthermore, we explore female-specific risk factors, such as sex hormones, adverse pregnancy outcomes, and other reproductive factors, which may explain the predominance of heart failure with preserved ejection fraction in women. Beyond sex differences in risk factors, there are also significant sex differences in outcomes with women reporting lower quality of life but overall better survival versus men. Finally, while treatment options for patients with heart failure with preserved ejection fraction are still limited, sex differences have also been reported for the available therapies, with suggestion of preferential benefit of specific heart failure with preserved ejection fraction therapies in women. Further work is required to better understand sex differences in heart failure with preserved ejection fraction, including deeper understanding of pathophysiological mechanisms, derivation of more accurate risk stratification models, and increased representation of women in clinical trials.

Is high normotension a norm or a risk factor for perinatal complications: prospective cohort study

Aim. Comparative assessment of the effect of high normotension and hypertension 12nd stage on the risk of gestational and perinatal complications. Materials and methods. A prospective cohort study (n=110) assessing the effect of high normotension on the risk of gestational complications and pregnancy outcomes was conducted. The main group (n=70) included 30 patients with high normotension subgroup A, and 40 patients with hypertension 12nd stage subgroup B. The comparison group included 40 patients with "white coat hypertension". Results. The most frequent complications in the 2nd and 3rd trimesters of pregnancy were toxaemia, threatened miscarriage, edema (detected in more than half of patients with high normotension and hypertension 12nd stage) and well as threatened preterm labor (p0.05). The frequency of pre-eclampsia development in subgroups A and B did not differ significantly, however, in patients with high normotension in the 3rd trimester during a test of endothelium-dependent vasodilation were detected signs of endothelial dysfunction, which may be one of the mechanisms for the subsequent formation of hypertension in these patients. Placental insufficiency of varying severity was detected only in subgroups A and B. Placental insufficiency, along with intrauterine fetal hypoxia of different etiologies, were the most frequent causes of emergency caesarean section, occurring only in the main group 3 (75.0%) in subgroup A and 6 (66.67%) in subgroup B and associated with blood pressure above 130/85 mm Hg. Conclusion. The importance of preventing blood pressure increase to high normal rate is explained by the development of endothelial dysfunction at late gestation, which can serve as the mechanisms of hypertension formation in this category of pregnant women.

Preeclampsia: Maternal cardiovascular function and optimising outcomes

Preeclampsia is associated with cardiac dysfunction, not only during the clinical phase of the disease, but also after delivery, with long term implications for both maternal and neonatal cardiovascular health. An abnormal cardiovascular phenotype also precedes conception, indicating that pre-existing cardiovascular dysfunction is associated with the development of preeclampsia. This review summarises the changes in cardiovascular function in preeclampsia, examining the evidence for when cardiovascular dysfunction develops and presenting the evidence for two phenotypes - one associated with fetal growth restriction, low cardiac output and high peripheral resistance, and a second associated with normal fetal growth, high cardiac output and low peripheral resistance. The presence of a cardiovascular phenotype that precedes conception demonstrates the potential for prevention of preeclampsia through cardiovascular optimisation at this stage. The two phenotypes mean therapy can be targeted to optimising cardiovascular function. The prevention and effective treatment of preeclampsia are essential aspects of improving maternal and neonatal cardiovascular health in the long term.

[Short stature due to intrauterine growth retardation. Clinical and hormonal-metabolic features, possibilities of growth-stimulating therapy]

The article presents data about short stature due to intrauterine development delay. This type of short stature - separate nosology, unites children born small for gestation age. The majority of them in the first years of life have accelerated growth rates, allowing the child to normalize their weight-growth indicators and catch up in the development of peers. In the absence of an accelerated growth rates, children have a high risk of lagging behind in physical development throughout childhood, achieving low final growth and becoming short adults. In addition, the fact of birth with small body sizes is associated with a number of hormonal and metabolic features, a risk of metabolic syndrome in adult years.It is assumed that the absence of postnatal growth acceleration is due to various damages to the GH-IGF1 axis (partial GH deficiency, partial resistance to GH, partial resistance to IGF1). Growth hormone therapy, initiated early in life, is able to normalize growth rates in childhood and ultimately significantly improve or normalize the final growth of short stature children born small for gestational age.

Non-invasive Maternal Hemodynamic Assessment to Classify High-Risk Pregnancies Complicated by Fetal Growth Restriction

Objectives

To verify whether the use of the temporal criterion of 32 weeks’ gestation is effective in identifying maternal hemodynamic differences between early- and late-onset fetal growth restriction (FGR), and to test the statistical performance of a classificatory algorithm for FGR.

Materials and methods

A prospective multicenter study conducted at three centers over 17 months. Singleton pregnant women with a diagnosis of FGR based on the international Delphi survey consensus at ≥ 20 weeks of gestation were included. FGR was classified as early-onset if diagnosed <32 weeks’ gestation and as late-onset if ≥32 weeks. Hemodynamic assessment was performed by USCOM-1A at the time of FGR diagnosis. Comparisons between early- and late-onset FGR among the entire study cohort, FGR associated with hypertensive disorders of pregnancy (HDP-FGR), and isolated FGR (i-FGR) were performed. In addition, HDP-FGR cases were compared to i-FGR, regardless of the temporal cut-off of 32 weeks’ gestation. Finally, a classificatory analysis based on the Random Forest model was performed to identify significant variables with the ability to differentiate FGR phenotypes.

Results

During the study period, 146 pregnant women fulfilled the inclusion criteria. In 44 cases, FGR was not confirmed at birth, thus limiting the final study population to 102 patients. In 49 (48.1%) women, FGR was associated to HDP. Fifty-nine (57.8%) cases were classified as early-onset. Comparison of the maternal hemodynamics between early- and late-onset FGR did not show any difference. Similarly, non-significant findings were observed in sensitivity analyses performed for HDP-FGR and for i-FGR. In turn, comparison between pregnant women with FGR and hypertension and women with i-FGR, independently of the gestational age at FGR diagnosis, revealed substantial differences, with the former showing higher vascular peripheral resistances and lower cardiac output, among other significant parameters. The classificatory analysis identified both phenotypic and hemodynamic variables as relevant in distinguishing HDP-FGR from i-FGR (p=0.009).

Conclusions

Our data show that HDP, rather than gestational age at FGR diagnosis, allows to appreciate specific maternal hemodynamic patterns and to accurately distinguish two different FGR phenotypes. In addition, maternal hemodynamics, alongside phenotypic characteristics, play a central role in classifying these high-risk pregnancies.

Maternal echocardiographic changes in twin pregnancies with and without pre-eclampsia

OBJECTIVE

Twin pregnancies are at increased risk of developing hypertensive disorders of pregnancy (HDP) compared with singleton pregnancies, resulting in a substantially higher rate of maternal and perinatal complications. The strain caused by twin pregnancy on the maternal cardiovascular system has not been studied extensively. The objective of this study was to evaluate the changes in maternal cardiac morphology and diastolic function in a cohort of women with normotensive and those with hypertensive twin pregnancies.

METHODS

This was a cross-sectional study conducted at a tertiary referral university center. Women with singleton or twin pregnancy were enrolled prospectively to undergo maternal transthoracic echocardiography throughout pregnancy. Multiples of the median (MoM) were calculated for each index using a reference group of uncomplicated singleton pregnancies (n = 411) in order to adjust for changes associated with gestational age. Cardiac findings were indexed for body surface area and compared among normotensive twin pregnancies, singleton pregnancies complicated by HDP and twin pregnancies complicated by HDP.

RESULTS

The total cohort included 119 HDP singleton pregnancies, 52 normotensive twin pregnancies and 24 HDP twin pregnancies. Left ventricular mass index (LVMi) MoM (median (interquartile range)) did not differ between singleton pregnancies complicated by HDP and normotensive twin pregnancies, but was significantly higher in HDP twin compared with HDP singleton pregnancies (1.31 (1.08-1.53) vs 1.17 (0.98-1.35), P = 0.032). Two diastolic indices, left atrial volume index MoM (1.12 (0.66-1.38) vs 0.65 (0.55-0.84), P = 0.003) and E/e' MoM (1.29 (1.09-1.54) vs 0.99 (0.99-1.02), P = 0.036), were significantly higher in HDP twin compared with normotensive twin pregnancies. In normotensive twin compared with HDP singleton pregnancies, stroke volume index (SVi) MoM was higher (1.20 (1.03-1.36) vs 1.00 (0.81-1.15), P = 0.004) and total vascular resistance index (TVRi) was lower (0.73 (0.70-0.86) vs 1.29 (1.04-1.56), P < 0.0001). In contrast, SVi MoM was lower (1.10 (1.02-1.35) vs 1.20 (1.03-1.36), P = 0.018) and TVRi was higher (1.00 (0.88-1.31) vs 0.73 (0.70-0.86), P = 0.029) in HDP twin compared with normotensive twin pregnancies.

CONCLUSION

The maternal cardiovascular system is altered severely in twin pregnancy with or without HDP. Despite the low total vascular resistance, cardiac changes in normotensive twin pregnancies are comparable to those seen in singleton pregnancies complicated by HDP, reflecting the high cardiovascular demand imposed by twin pregnancy. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal Growth Restriction: Does an Integrated Maternal Hemodynamic-Placental Model Fit Better?

In recent years, a growing interest has arisen regarding the possible relationship between adverse pregnancy outcomes (APOs) and inadequate maternal hemodynamic adaptations to the pregnancy. A possible association between "placental syndromes," such as preeclampsia (PE) and fetal growth restriction (FGR), and subsequent maternal cardiovascular diseases (CVD) later in life has been reported. The two subtypes of FGR show different pathogenetic and clinical features. Defective placentation, due to a poor trophoblastic invasion of the maternal spiral arteries, is believed to play a central role in the pathogenesis of early-onset PE and FGR. Since placental functioning is dependent on the maternal cardiovascular system, a pre-existent or subsequent cardiovascular impairment may play a key role in the pathogenesis of early-onset FGR. Late FGR does not seem to be determined by a primary abnormal placentation in the first trimester. The pathological pathway of late-onset FGR may be due to a primary maternal cardiovascular maladaptation: CV system shows a flat profile and remains similar to those of non-pregnant women. Since the second trimester, when the placenta is already developed and increases its functional request, a hypovolemic state could lead to placental hypoperfusion and to an altered maturation of the placental villous tree and therefore to an altered fetal growth. Thus, this review focalizes on the possible relationship between maternal cardiac function and placentation in the development of both early and late-onset FGR. A better understanding of maternal hemodynamics in pregnancies complicated by FGR could bring various benefits in clinical practice, improving screening and therapeutic tools.

Effect of maternal age on cardiac adaptation in pregnancy

OBJECTIVE

To compare longitudinal maternal hemodynamic changes throughout gestation between different age groups.

METHODS

This was a prospective longitudinal study assessing maternal hemodynamics using a bioreactance technique at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. Women were divided into four groups according to maternal age at the first visit at 11 + 0 to 13 + 6 weeks: Group 1, < 25.0 years; Group 2, 25.0-30.0 years; Group 3, 30.1-34.9 years; and Group 4, ≥ 35.0 years. A multilevel linear mixed-effects model was performed to compare the repeat measurements of hemodynamic variables, correcting for demographics, medical and obstetric history, pregnancy complications, maternal age and gestational-age window.

RESULTS

The study population included 254 women in Group 1, 442 in Group 2, 618 in Group 3 and 475 in Group 4. Younger women (Group 1) had the highest cardiac output (CO) and lowest peripheral vascular resistance (PVR), and older women (Group 4) had the lowest CO and highest PVR throughout pregnancy. The higher CO seen in younger women was achieved through an increase in heart rate alone and not with a concomitant rise in stroke volume. Although the youngest age group demonstrated an apparently more favorable hemodynamic profile, it had the highest incidence of a small-for-gestational-age neonate. There was no significant difference between the groups in the incidence of pre-eclampsia.

CONCLUSION

Age-specific differences in maternal hemodynamic adaptation do not explain the differences in the incidence of a small-for-gestational-age neonate between age groups. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Maternal myocardial dysfunction after normotensive fetal growth restriction compared with hypertensive pregnancies: a speckle-tracking study

OBJECTIVE

Pregnancy complicated by preeclampsia and fetal growth restriction (FGR) relates to increased risk of cardiovascular disease later in life, but to different extents. Subclinical cardiac alterations precede eminent cardiovascular disease. Speckle-tracking echocardiography is an elegant method to assess subclinical myocardial dysfunction. We performed a myocardial speckle tracking study to evaluate the prevalence of subclinical myocardial dysfunction in former preeclampsia patients (with and without FGR) compared with normotensive women with FGR.

METHODS

For this cross-sectional study, we retrospectively selected women with a history of normotensive FGR (n = 17), preeclampsia with FGR (n = 26) and preeclampsia without FGR (n = 134) who underwent conventional echocardiography as part of the clinical cardiovascular work-up after complicated pregnancies between 6 months and 4 years postpartum in Maastricht, The Netherlands. We excluded women with chronic hypertension, hypercholesterolemia and obesity.

RESULTS

Women with normotensive FGR showed subclinical left ventricular (LV) impairment in systodiastolic function with concentric remodeling, slight alteration in right ventricular systolic function and left atrial strain, similarly to the preeclampsia group independently from the fetal growth. LV hypertrophy was only present in about 10% of cases who experienced preeclampsia (independently from the fetal growth) but not in those with normotensive FGR.

CONCLUSION

Similar to women with a history preeclampsia, women with a history of normotensive pregnancy but with FGR have abnormal myocardial function, shown with speckle-tracking echocardiography. Therefore, both preeclampsia and normotensive FGR should be viewed upon as risk indicator for subclinical myocardial impairment that may benefit from cardiovascular risk management.

Maternal cardiac adaptation and fetal growth

BACKGROUND

Pregnancies with small-for-gestational-age fetuses are at increased risk of adverse maternal-fetal outcomes. Previous studies examining the relationship between maternal hemodynamics and fetal growth were mainly focused on high-risk pregnancies and those with fetuses with extreme birthweights, such as less than the 3rd or 10th percentile and assumed a similar growth pattern in fetuses above the 10th percentile throughout gestation.

OBJECTIVE

This study aimed to evaluate the trends in maternal cardiac function, fetal growth, and oxygenation with advancing gestational age in a routine obstetrical population and all ranges of birthweight percentiles.

STUDY DESIGN

This was a prospective, longitudinal study assessing maternal cardiac output and peripheral vascular resistance by bioreactance at 11⁺⁰ to 13⁺⁶, 19⁺⁰ to 24⁺⁰, 30⁺⁰ to 34⁺⁰, and 35⁺⁰ to 37⁺⁰ weeks' gestation, sonographic estimated fetal weight in the last 3 visits and the ratio of the middle cerebral artery by umbilical artery pulsatility indices or cerebroplacental ratio in the last 2 visits. Women were divided into the following 5 groups according to birthweight percentile: group 1, <10th percentile (n=261); group 2, 10 to 19.9 percentile (n=180); group 3, 20 to 29.9 percentile (n=189); group 4, 30 to 69.9 percentile (n=651); and group 5, ≥70th percentile (n=508). The multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables and z scores of the estimated fetal weight and cerebroplacental ratio.

RESULTS

In visit 2, compared with visit 1, in all groups, cardiac output increased, and peripheral vascular resistance decreased. At visit 3, groups 1, 2, and 3, compared with 4 and 5, demonstrated an abrupt decrease in cardiac output and increase in peripheral vascular resistance. From visit 2, group 1 had a constant decline in estimated fetal weight, coinciding with the steepest decline in maternal cardiac output and rise in peripheral vascular resistance. In contrast, in groups 4 and 5, the estimated fetal weight had a stable or accelerative pattern, coinciding with the greatest increase in cardiac output and lowest peripheral vascular resistance. Groups 2 and 3 showed a stable growth pattern with intermediate cardiac output and peripheral vascular resistance. Increasing birthweight was associated with higher cerebroplacental ratio. Groups 3, 4, and 5 had stable cerebroplacental ratio across visits 3 and 4, whereas groups 1 and 2 demonstrated a significant decline (P<.001).

CONCLUSION

In a general obstetrical population, maternal cardiac adaptation at 32 weeks' gestation parallels the pattern of fetal growth and oxygenation; babies with birthweight<20th percentile have progressive decline in fetal cerebroplacental ratio, decline in maternal cardiac output, and increase in peripheral vascular resistance.

Evolution of cardiac geometry and function in women with severe preeclampsia from immediately post-delivery to 1 year postpartum

Preeclampsia is associated with left ventricular (LV) geometrical and functional changes, which could be related to cardiovascular risk later in life. The purpose of our study was to evaluate evolution of LV dimensions and function in severe preeclamptic women from immediately post-delivery to 1 year postpartum. Twenty-five women with severe preeclampsia and 15 healthy term controls underwent standard and speckle-tracking echocardiography 1 day after delivery and 1 year postpartum. On day 1 post-delivery preeclamptic women were exposed to higher preload (p = 0.003) and afterload (p < 0.001) compared to controls. Parameter of longitudinal LV systolic function s' was significantly lower in preeclamptic compared to control group (p = 0.017) 1 day post-delivery. Additionally, diastolic function parameters were significantly more impaired in preeclamptic compared to control group (lower e' (p = 0.02) and higher E/e' ratio (p = 0.003) in preeclamptic group). Larger LV mass (p = 0.03) and a trend of higher proportion of altered cardiac geometry (p = 0.061) were observed in preeclampsia 1 day post-delivery. One year after delivery both groups had comparable geometric and functional parameters with similar afterload and preload (p > 0.05, for all). In preeclamptic group systolic and diastolic functional parameters improved significantly during follow-up (p < 0.05), while no such evolution was noted in controls (> 0.05). In women with severe preeclampsia subtle cardiac functional impairment immediately post-delivery completely resolved 1 year postpartum. Observed cardiac alterations suggest intrinsic myocardial dysfunction in preeclampsia, which became unmasked or exacerbated by higher load imposed on the LV immediately post-delivery that disappeared in mid-term follow-up.

Hemodynamic findings in normotensive women with small-for-gestational-age and growth-restricted fetuses

INTRODUCTION

Fetal growth restriction (FGR) in most instances is a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational-age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome.

MATERIAL AND METHODS

An observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria, and pregnant women underwent hemodynamic assessment using a cardiac output monitor. A group of women with singleton uncomplicated pregnancies ar ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume, and heart rate were measured and compared among the three groups (controls vs FGR vs SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis.

RESULTS

A total of 51 women with fetal smallness were assessed at 34.8 ± 2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5 ± 0.8 weeks of gestation. Women with FGR had a lower cardiac output Z-score (respectively, -1.3 ± 1.2 vs -0.4 ± 0.8 vs -0.2 ± 1.0; P < .001) and a higher systemic vascular resistance Z-score (respectively, 1.2 ± 1.2 vs 0.2 ± 1.1 vs -0.02 ± 1.2; P < .001) compared with both SGA and controls, whereas no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of neonatal intensive care unit admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; P = .13), but FGR fetuses had a longer hospitalization compared with SGA fetuses (14.2 ± 17.7 vs 4.5 ± 1.6 days; P = .02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (P = .012) and the birthweight Z-score (P = .007) were independent predictors of the length of neonatal hospitalization.

CONCLUSIONS

Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization.

Hemodynamic Complications in Pregnancy: Preeclampsia and Beyond

Normal pregnancy is a complex and dynamic process that requires significant adaptation from the maternal system. Failure of this adaptive process in pregnancy contributes to many pregnancy related disorders, including the hypertensive disorders of pregnancy. This article discusses placental development and how abnormalities in the process of vascular remodeling contribute to the multisystem maternal and fetal disease that is preeclampsia and fetal growth restriction. We review some of the consequences of this condition on the mother and fetus, aspects of the clinical management of preeclampsia and how it can influence both mother and infant in the postnatal period and beyond.

Impact of gestational diabetes mellitus on maternal cardiac adaptation to pregnancy

OBJECTIVE

To determine whether maternal cardiac adaptation at term differs between women with, and those without, gestational diabetes mellitus (GDM).

METHODS

This was a prospective case-control study of pregnant women at term with or without GDM. For both cases and controls, only women without any comorbidity or form of pre-existing diabetes who had a singleton pregnancy without complication (such as pre-eclampsia or fetal growth restriction) were included. All women underwent conventional and speckle-tracking echocardiography to assess both the left- and right-heart geometry and function.

RESULTS

A total of 40 women with GDM and 40 healthy controls were enrolled. Women with GDM, compared with controls, had a significantly higher heart rate (83 ± 10 vs 75 ± 9 beats per min; P < 0.001), left ventricular (LV) relative wall thickness (0.43 ± 0.07 vs 0.37 ± 0.08; P < 0.001), LV early diastolic transmitral valve velocity (E) (0.80 ± 0.15 vs 0.73 ± 0.12 m/s; P = 0.026) and LV late diastolic transmitral valve velocity (A) (0.65 ± 0.13 vs 0.57 ± 0.11 m/s; P = 0.006). In women with GDM compared with controls, speckle-tracking analysis revealed a significant reduction in LV global longitudinal strain (GLS) (-16.29 ± 2.26 vs -17.61 ± 1.89; P = 0.012), LV endocardial GLS (-18.50 ± 2.59 vs -19.84 ± 2.35; P = 0.031) and LV epicardial GLS (-14.40 ± 2.01 vs -15.73 ± 1.66; P = 0.005). Right ventricular (RV) analysis revealed a reduced pulmonary acceleration time (58 ± 10 vs 66 ± 11 ms; P = 0.001) and RV E/A ratio (1.13 ± 0.18 vs 1.29 ± 0.35; P = 0.017), as well as a higher RV myocardial systolic annular velocity (0.16 ± 0.04 vs 0.14 ± 0.02; P = 0.023) and peak late diastolic transtricuspid valve velocity (0.46 ± 0.1 m/s vs 0.39 ± 0.08 m/s; P = 0.001), in women with GDM compared to controls.

CONCLUSIONS

Our findings show that even a short period of exposure to hyperglycemia, as occcurs in women with GDM, is associated with significant maternal functional cardiac impairment at term. Given these findings, further study of postnatal maternal cardiovascular recovery after GDM pregnancy is warranted. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Effect of race on longitudinal central hemodynamics in pregnancy

OBJECTIVE

To compare central hemodynamics between white, black and Asian women in pregnancy.

METHODS

This was a prospective, longitudinal study of maternal central hemodynamics in white, black and Asian women with a singleton pregnancy, assessed using a bioreactance method at 11 + 0 to 13 + 6, 19 + 0 to 24 + 0, 30 + 0 to 34 + 0 and 35 + 0 to 37 + 0 weeks' gestation. At each visit, cardiac output (CO), stroke volume (SV), heart rate (HR), peripheral vascular resistance (PVR) and mean arterial pressure were recorded. Multilevel linear mixed-effects analysis was performed to compare the repeated measures of the cardiac variables between white, black and Asian women, controlling for maternal characteristics, medical history and medication use.

RESULTS

The study population included 1165 white, 247 black and 116 Asian women. CO increased with gestational age to a peak at 32 weeks and then decreased; the highest CO was observed in white women and the lowest in Asian women. SV initially increased after the first visit but subsequently declined with gestational age in white women, decreased with gestational age in black women and remained static in Asian women. In all three study groups, HR increased with gestational age until 32 weeks and then remained constant; HR was highest in black women and lowest in white women. PVR showed a reversed pattern to that of CO; the highest values were in Asian women and the lowest in white women. The least favorable hemodynamic profile, which was observed in black and Asian women, was reflected in higher rates of a small-for-gestational-age infant.

CONCLUSIONS

There are race-specific differences in maternal cardiac adaptation to pregnancy. White women have the most favorable cardiac adaptation by increasing SV and HR, achieving the highest CO and lowest PVR. In contrast, black and Asian women have lower CO and higher PVR than do white women, with CO increasing through a rise in HR due to declining or static SV. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Maternal arterial stiffness in hypertensive pregnancies with and without small-for-gestational-age neonate

OBJECTIVE

Pregnancies complicated by pre-eclampsia with a small-for-gestational-age (SGA) neonate have poorer maternal hemodynamic function compared to those with hypertensive disorders of pregnancy (HDP) and an appropriately grown neonate. Arterial stiffness is a recognized prognostic marker of cardiovascular disease in the general population. The aim of this study was to compare maternal arterial stiffness between hypertensive pregnancies with, and those without, a SGA neonate and normotensive control pregnancies.

METHODS

This was a prospective cohort study of pregnancies complicated by pre-eclampsia or gestational hypertension and healthy normotensive control pregnancies, presenting to a tertiary referral hospital between January 2012 and May 2018. Maternal arterial stiffness was assessed by aortic pulse-wave velocity (PWV) and aortic augmentation index (AIx), which were recorded using a non-invasive device (Arteriograph®). Maternal and hemodynamic factors were adjusted for using linear regression analysis. Pregnancies with HDP were divided into those that delivered a SGA (birth weight < 10^th percentile) neonate (HDP + SGA group) and those that delivered an appropriately grown neonate (HDP-only group). Comparisons between groups were carried out using the Mann-Whitney U-test for continuous variables and the chi-square (or Fisher's exact) test for categorical variables.

RESULTS

Included in the analysis were 69 patients with HDP who delivered a SGA neonate, 129 with HDP who delivered a normally grown neonate and 220 healthy controls. Maternal age, weight, height and heart rate were associated significantly with brachial and aortic AIx. Maternal weight, height, mean arterial pressure, heart rate and gestational age were significant predictors of aortic PWV. Adjusted aortic AIx was significantly higher in both the HDP + SGA and HDP-only groups, compared with in controls (12.5% and 10.0% vs 7.6%; both P < 0.01), and was significantly different between the two HDP groups (P = 0.002). Adjusted PWV was significantly higher in the HDP-only group compared with in controls and the HDP + SGA group (7.7 m/s vs 7.1 m/s and 7.1 m/s; both P < 0.001). Conversely, unadjusted PWV was not significantly different between the two HDP groups (P = 0.414).

CONCLUSIONS

Pregnancies complicated by HDP with, and those without, a SGA neonate have significantly higher aortic AIx compared with uncomplicated normotensive pregnancies. Aortic AIx was highest in those pregnancies complicated by HDP with a SGA neonate, reflecting a progression in severity of arterial stiffness abnormality with a worsening clinical picture. These findings most likely reflect systemic reduced vascular compliance and increased systemic vascular resistance in pregnancy complicated by HDP. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women: JACC State-of-the-Art Review

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for women in the United States and worldwide. There has been no American College of Cardiology (ACC)/American Heart Association guideline update specifically for the prevention of CVD in women since 2011. Since then, the body of sex-specific data has grown, in addition to updated hypertension, cholesterol, diabetes, atrial fibrillation, and primary prevention guidelines. The ACC CVD in Women Committee undertook a review of the recent guidelines and major studies to summarize recommendations pertinent to women. In this update, the authors address special topics, particularly the risk factors and treatments that have led to some controversies and confusion. Specifically, sex-related risk factors, hypertension, diabetes, hyperlipidemia, anticoagulation for atrial fibrillation, use of aspirin, perimenopausal hormone therapy, and psychosocial issues are highlighted.

Are maternal hemodynamic indices markers of fetal growth restriction in pregnancies with a small-for-gestational-age fetus?

OBJECTIVE

Pregnancies complicated by fetal growth restriction (FGR) have a worse outcome than those with a small-for-gestational-age (SGA) fetus. There is increasing evidence of a maternal cardiovascular role in the pathophysiology of FGR. We aimed to compare maternal hemodynamic indices between pregnancies complicated by FGR and those delivering a SGA neonate, using a non-invasive device.

METHODS

This was a prospective study of normotensive pregnancies complicated by FGR (defined as estimated fetal weight (EFW) < 3^rd centile or Doppler evidence of impaired placental-fetal blood flow), those with a SGA fetus (defined as EFW < 10^th centile) and control pregnancies with an appropriately grown fetus. Assessment of maternal hemodynamics (heart rate (HR), cardiac output (CO), mean arterial pressure (MAP), systemic vascular resistance (SVR) and stroke volume) was performed using a non-invasive device (USCOM-1A®). Uterine artery (UtA) pulsatility index (PI) was measured using transabdominal ultrasound. Hemodynamic variables that are affected by gestational age and maternal characteristics were corrected for using device-specific reference ranges. Comparison between groups was performed using the chi-square test or the Mann-Whitney U-test, as appropriate.

RESULTS

A total of 102 FGR, 64 SGA and 401 control pregnancies, with a median gestational age of 36 weeks, were included in the analysis. Women with a pregnancy complicated by FGR and those with a SGA fetus were shorter and weighed less than did controls. Compared with controls, the FGR group had significantly lower median maternal HR (80 beats per min (bpm) vs 85 bpm; P = 0.001) and CO multiples of the median (MoM; 0.91 vs 0.98; P = 0.003), and higher median maternal MAP (90 mmHg vs 87 mmHg; P = 0.040), SVR MoM (1.2 vs 1.0; P < 0.001) and UtA-PI MoM (1.1 vs 0.96; P < 0.001), but there was no significant difference in stroke volume MoM (1.0 vs 0.98; P = 0.647). Compared with the SGA group, the FGR group had a significantly lower median HR (80 bpm vs 87 bpm; P = 0.022), and higher median maternal MAP (90 mmHg vs 85 mmHg; P = 0.025), SVR MoM (1.2 vs 1.0; P = 0.002) and UtA-PI MoM (1.1 vs 0.98; P = 0.005), but there was no significant difference in CO MoM (0.91 vs 0.96; P = 0.092) or stroke volume MoM (1.0 vs 1.0; P = 0.806). There were no significant differences in adjusted maternal hemodynamic indices between the SGA group and controls.

CONCLUSION

Pregnancies complicated by FGR presented with impaired maternal hemodynamic function, as evidenced by lower HR and CO, as well as higher MAP, SVR and UtA resistance. Pregnancies delivering a SGA neonate, without evidence of FGR, had normal maternal hemodynamic function. Maternal hemodynamic indices may therefore be of value in distinguishing FGR from SGA pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Placental Growth Factor as an Indicator of Maternal Cardiovascular Risk After Pregnancy

BACKGROUND

Angiogenic placental growth factor (PlGF) concentrations rise during pregnancy, peaking at the end of midpregnancy. Low PlGF concentrations during pregnancy are associated with pregnancy complications with recognized later-life cardiovascular risk. We hypothesized that low PlGF concentrations, especially in midpregnancy, identify not only a subset of women at risk for pregnancy complications but also women with greater cardiovascular risk factor burden after pregnancy regardless of pregnancy outcome.

METHODS

In a population-based prospective cohort study of 5475 women, we computed gestational age-adjusted multiples of the medians of early pregnancy and midpregnancy PlGF concentrations. Information on pregnancy complications (preeclampsia, small for gestational age, and spontaneous preterm birth) was obtained from hospital registries. Six years after pregnancy, we measured maternal systolic and diastolic blood pressures, cardiac structure (aortic root diameter, left atrial diameter, left ventricular mass, and fractional shortening), carotid-femoral pulse wave velocity, and central retinal arteriolar and venular calibers. Blood pressure was also measured 9 years after pregnancy.

RESULTS

Women were on average 29.8 (SD, 5.2) years of age in pregnancy, were mostly European (55.2%), and 14.8% developed a pregnancy complication. Quartile analysis showed that especially women with midpregnancy PlGF in the lowest quartile (the low-PlGF subset) had a larger aortic root diameter (0.40 mm [95% CI, 0.08-0.73]), left atrial diameter (0.34 mm [95% CI, -0.09 to 0.78]), left ventricular mass (4.6 g [95% CI, 1.1-8.1]), and systolic blood pressure (2.3 mm Hg [95% CI, 0.93-3.6]) 6 years after pregnancy than women with the highest PlGF. Linear regression analysis showed that higher midpregnancy PlGF concentrations were associated with a smaller aortic root diameter (-0.24 mm [95% CI, -0.39 to -0.10]), smaller left atrial diameter (-0.75 mm [95% CI, -0.95 to -0.56]), lower left ventricular mass (-3.9 g [95% CI, -5.5 to -2.3]), and lower systolic blood pressure (-1.1 mm Hg [95% CI, -1.7 to -0.46]). These differences persisted after the exclusion of women with complicated pregnancies.

CONCLUSIONS

Women with low PlGF in midpregnancy have a greater aortic root diameter, left atrial diameter, and left ventricular mass and higher systolic blood pressure 6 and 9 years after pregnancy compared to women with higher PlGF, including women with uncomplicated pregnancies. The pathophysiological implications of lower PlGF concentrations in midpregnancy might provide insight into the identification of pathways contributing to greater cardiovascular risk factor burden.

Central hemodynamics are associated with fetal outcomes in pregnancies of advanced maternal age

OBJECTIVES

Age is a known risk factor for both maternal cardiovascular disease and adverse outcomes in pregnancy. We aimed to characterize the hemodynamic profiles in pregnancies of advanced maternal age (AMA) and correlate these with fetal outcomes.

STUDY DESIGN

This was a prospective observational study of pregnancies undergoing antenatal testing. Maternal hemodynamics were measured non-invasively using an imaging probe at the descending aorta and the Uscom BP + arm cuff utilizing pulse pressure wave analysis. The Wilcoxon rank-sum test, Fisher's exact test, and Spearman rank correlation test were used for statistical analysis in R.

MAIN OUTCOME MEASURES

Hemodynamic measurements, neonatal birthweight.

RESULTS

Twenty-one AMA and twenty-four control patients were enrolled. Mean age ± SD was 39 ± 3.22 in the AMA cohort and 28 ± 4.32 in the control cohort (p < 0.001). AMA patients were evaluated at a later gestational age (36 4/7 weeks) compared to control (34 1/7 weeks, p = 0.02). Between groups, there was no difference in BMI, race, hypertensive disease, diabetes, asthma, drug use, or indication for antenatal testing. 38% (AMA) and 37% (control) had hypertensive disorders of pregnancy. In AMA patients but not control patients, cardiac output (r = 0.52, p = 0.01), systemic vascular resistance (r = -0.53, p = 0.01), and systemic vascular resistance index (r = -0.62, p = 0.002) were significantly correlated with neonatal birthweight percentile.

CONCLUSIONS

Hemodynamic alterations consistent with a low output, high resistance cardiovascular circuit were associated with lower birthweight in AMA, but not in control pregnancies.

Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms

BACKGROUND

A primary role of maternal heart dysfunction in the pathophysiology of preeclampsia had been previously advocated although if contradictory results have been reported.

OBJECTIVES

The objectives of the study were to describe maternal hemodynamic parameters according to 2 main preeclampsia phenotypes and to investigate whether cardiac findings may be helpful in characterizing the severity and the progression of the disease.

STUDY DESIGN

This was a prospective cohort study. We used an ultrasonic cardiac output monitor system to compare the hemodynamic parameters of women with preeclampsia with a group of healthy normotensive women enrolled as controls with a ratio of 1:2. Cardiac output, systemic vascular resistance, and stroke volume were compared among controls and preeclamptic women who were grouped in accordance to the following characteristics: early preeclampsia (<34 weeks' gestation) vs late preeclampsia onset (≥34 weeks' gestation); preeclampsia associated with appropriate for gestational age or small-for-gestational-age newborns. Hemodynamic characteristics were also compared between preeclamptic women with a mild form vs those who progressed toward a severe form.

RESULTS

A total of 38 preeclamptic women and 61 normotensive women were included in the study. Both cases of preeclampsia associated with small-for-gestational-age neonates as those with normal-sized ones showed higher systemic vascular resistance compared with the control group (respectively, 1580.6 ± 483.2 vs 1479.1 ± 433.3 vs 1105.3 ± 293.1; P < .0001), while a lower cardiac output was reported only for preeclamptic women with small-for-gestational-age neonates compared with controls (5.7 ± 1.5 vs 6.5 ± 1.3; P = .02). Maternal cardiac parameters were comparable between these 2 groups of preeclamptic women (small-for-gestational-age vs appropriate-for-gestational-age preeclampsia) with the exception of a lower stroke volume in the former one (64.8 ± 24.4 vs 75.2 ± 17.8; P = .04). Similarly, women with both early and late preeclampsia showed higher systemic vascular resistance compared with controls (1559.5 ± 528.3 vs 1488.5 ± 292.9 vs 1105.3 ± 293.1, respectively; P < .001), while a lower cardiac output was noted only in the early-onset group compared with controls (5.5 ± 1.2 P = .02). Maternal cardiac findings were similar between women with early vs late-onset preeclampsia. Hemodynamic parameters are significantly different between those women with mild preeclampsia who remained stable compared with those who progressed toward a severe disease. Cardiac output Z-score, systemic vascular resistance Z-score, and uterine arteries' pulsatility index Z-score showed similar sensitivity (80% vs 75% vs 80%, respectively) and specificity (73% vs. 73% vs 74%, respectively), while the association of systemic vascular resistance Z-score and uterine arteries pulsatility index Z-score showed a sensitivity of 95% and a specificity of 80% (area under the curve, 0.90) in predicting evolution toward severe forms.

CONCLUSION

Evaluation of maternal cardiovascular system could help clinician in defining a subset of preeclamptic patients with more profound placental impairment and might predict the likelihood of progression toward a severe condition in cases with a mild preeclampsia at clinical onset.

Multivariable evaluation of maternal hemodynamic profile in pregnancy complicated by fetal growth restriction: prospective study

OBJECTIVE

To evaluate the association between fetal growth restriction (FGR) and maternal hemodynamic parameters using multivariable analysis, adjusting for major confounding factors, such as hypertensive disorders of pregnancy (pre-eclampsia and gestational hypertension).

METHODS

A prospective cohort study was conducted between January 2013 and April 2016. Two cohorts of patients were recruited, between 24 and 39 weeks of gestation, in a high-risk outpatient setting. These cohorts comprised 49 appropriate-for-gestational-age singleton fetuses and 93 that were FGR (abdominal circumference (AC) at recruitment in the second half of pregnancy ≤ 10th percentile with a previous normal AC at 20-22 weeks). Maternal echocardiography was performed at the time of enrolment and included hemodynamic parameters of systolic and diastolic function and cardiac remodeling indices. Data were analyzed using a multivariable generalized linear model to estimate the association of FGR with maternal hemodynamic parameters after adjusting for significant confounding factors.

RESULTS

In the multivariable analysis, after adjustment for hypertensive disorders of pregnancy and smoking, FGR was associated with a 14% increase in maternal total vascular resistance, 16% reduction in cardiac output, 13% reduction in left ventricular mass and 11% reduction in heart rate; similar results were observed for the corresponding indexed parameters. Hypertensive disorders of pregnancy in the absence of FGR were associated with a 25% increase in total vascular resistance, 16% increase in left ventricular mass and 14% reduction in diastolic function; similar results were observed for the corresponding indexed parameters.

CONCLUSION

FGR is significantly and independently associated with several maternal hemodynamic parameters, even after adjustment for major confounding factors, such as hypertensive disorders of pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Mathematical simulation of Doppler changes in late-onset smallness; progression patterns of cerebral and umbilical anomalies define two types of late-onset fetal growth restriction

OBJECTIVE

To evaluate the progression of Doppler abnormalities in fetuses with late-onset fetal smallness (SGA) that become growth restricted (FGR).

METHODS

524 Doppler examinations of the umbilical and cerebral arteries systems, belonging to 442 late-onset SGA fetuses after week 34, were studied, evaluating by means of the statistical difference with the respective abnormal centiles, the pattern of progression into abnormal Doppler values and the distribution and cumulative sum of Doppler anomalies according to the interval to delivery.

RESULTS

Only one third (33.5%, N = 148) of late-onset SGA fetuses presented Doppler anomalies, suggesting that most were of constitutional origin. The most frequent progression pattern into abnormal Doppler (N = 127, 85.81%) was that in which only one system (umbilical or cerebral) became abnormal. Half of fetuses debuted with abnormal umbilical flow (52%, N = 77) and half with cerebral anomalies (47.97%, N = 71), which were more likely to appear later and at shorter intervals to delivery (p = .007). These progression patters defined two varieties of late-onset FGR (type I and II) with similar outcome but different birth weight centiles (BW centile = 2.51, SD 2.91 versus 3.97, SD 3.17, p < .01).

CONCLUSION

Two thirds of late-onset fetal smallness occurs without hemodynamic changes. In half of the remaining cases an initial cerebral vasodilation defines a group of fetuses with similar outcome but higher BW centile.

Friendly help for clinical use of maternal hemodynamics

OBJECTIVES

Maternal hemodynamics plays a major role during pregnancy and its evaluation is fundamental to understand obstetric conditions. The modern opinion about maternal hemodynamics assessment is to shift focus from single hemodynamic parameters to the whole hemodynamic profile. Our aim is to create a simple, intuitive, and easily understandable graphing technique to evaluate the main hemodynamic parameters.

METHODS

We enrolled 531 pregnant women without maternal or fetal disease. One hundred and forty five in the first trimester of pregnancy, 258 in the second one and 128 in the third one. We performed hemodynamic assessment with ultrasonic cardiac output monitor method. We selected the six main parameters: cardiac output, systemic vascular resistance, heart rate, potential-to-kinetic energy ratio, inotropy index, and stroke volume variation. We chose the radar chart to display the multivariate data of the hemodynamic measurement of the patient in evaluation.

RESULTS

We have obtained mean and deviation standard values for the six main hemodynamic parameters in every trimester. They deeply change during the pregnancy, so it is correct to compare a new hemodynamic measurement with the mean values for the specific trimester in order to evaluate any possible alterations. In fact, once a new hemodynamic assessment is performed, we calculate the Z-score in order to fix the positions of the six measured parameters in their specific axis of radar chart.

CONCLUSIONS

At the end of a hemodynamic exam, the physician can input the data in the program obtaining a graphic representation. Using this technique, which simultaneously evaluates six hemodynamic parameters, it is possible to easily understand the patient's hemodynamic status. By converting the parameters values in Z-score, it is easier to understand when hemodynamics is altered, even if the physician does not have any experience in maternal hemodynamics.

Cardiac maladaptation in obese pregnant women at term

OBJECTIVE

Obesity is an increasing problem worldwide, with well recognized detrimental effects on cardiovascular health; however, very little is known about the effect of obesity on cardiovascular adaptation to pregnancy. The aim of the present study was to compare biventricular cardiac function at term between obese pregnant women and pregnant women with normal body weight, utilizing conventional echocardiography and speckle-tracking assessment.

METHODS

This was a prospective case-control study of 40 obese, but otherwise healthy, pregnant women with a body mass index (BMI) of ≥ 35 kg/m² and 40 healthy pregnant women with a BMI of ≤ 30 kg/m² . All women underwent a comprehensive echocardiographic examination and speckle-tracking assessment at term.

RESULTS

Obese pregnant women, compared with controls, had significantly higher systolic blood pressure (117 vs 109 mmHg; P = 0.002), cardiac output (6.73 vs 4.90 L/min; P < 0.001), left ventricular (LV) mass index (74 vs 64 g/m² ; P < 0.001) and relative wall thickness (0.43 vs 0.37; P < 0.001). Diastolic dysfunction was present in five (12.5%) controls and 16 (40%) obese women (P = 0.004). In obese women, compared with controls, LV global longitudinal strain (-15.59 vs -17.61%; P < 0.001), LV endocardial (-17.30 vs -19.84%; P < 0.001) and epicardial (-13.10 vs -15.73%; P < 0.001) global longitudinal strain as well as LV early diastolic strain rate (1.05 vs 1.24 /s; P = 0.006) were all significantly reduced. No differences were observed in the degree of LV twist and torsion between the two groups.

CONCLUSIONS

Morbidly obese, but otherwise healthy, pregnant women at term had significant LV hypertrophy with evidence of diastolic dysfunction and impaired deformation indices compared with pregnant women of normal weight. These findings are likely to represent a maladaptive response of the heart to volume overload in obese pregnancy. The impact of theses changes on pregnancy outcome and long-term maternal outcome is unclear. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The effect of parity on longitudinal maternal hemodynamics

BACKGROUND

Parous women have a lower risk for pregnancy complications, such as preeclampsia or delivery of small-for-gestational-age neonates. However, parous women are a heterogeneous group of patients because they contain a low-risk cohort with previously uncomplicated pregnancies and a high-risk cohort with previous pregnancies complicated by preeclampsia and/or small for gestational age. Previous studies examining the effect of parity on maternal hemodynamics, including cardiac output and peripheral vascular resistance, did not distinguish between parous women with and without a history of preeclampsia or small for gestational age and reported contradictory results.

OBJECTIVE

The objective of the study was to compare maternal hemodynamics in nulliparous women and in parous women with and without previous preeclampsia and/or small for gestational age.

STUDY DESIGN

This was a prospective, longitudinal study of maternal hemodynamics, assessed by a bioreactance method, measured at 11⁺⁰ to 13⁺⁶, 19⁺⁰ to 24⁺⁰, 30⁺⁰ to 34⁺⁰, and 35⁺⁰ to 37⁺⁰ weeks' gestation in 3 groups of women. Group 1 was composed of parous women without a history of preeclampsia and/or small for gestational age (n = 632), group 2 was composed of nulliparous women (n = 829), and group 3 was composed of parous women with a history of preeclampsia and/or small for gestational age (n = 113). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal characteristics, medical history, and development of preeclampsia or small for gestational age in the current pregnancy.

RESULTS

In groups 1 and 2, cardiac output increased with gestational age to a peak at 32 weeks and peripheral vascular resistance showed a reversed pattern with its nadir at 32 weeks; in group 1, compared with group 2, there was better cardiac adaptation, reflected in higher cardiac output and lower peripheral vascular resistance. In group 3 there was a hyperdynamic profile of higher cardiac output and lower peripheral vascular resistance at the first trimester followed by an earlier sharp decline of cardiac output and increase of peripheral vascular resistance from midgestation. The incidence of preeclampsia and small for gestational age was highest in group 3 and lowest in group 1.

CONCLUSION

There are parity-specific differences in maternal cardiac adaptation in pregnancy.

Maternal hemodynamics in screen-positive and screen-negative women of the ASPRE trial

OBJECTIVE

To compare maternal hemodynamics and perinatal outcome, in pregnancies that do not develop pre-eclampsia (PE) or deliver a small-for-gestational-age (SGA) neonate, between those identified at 11-13 weeks' gestation as being screen positive or negative for preterm PE, by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, serum placental growth factor and pregnancy associated plasma protein-A.

METHODS

This was a prospective longitudinal cohort study of maternal cardiovascular function, assessed using a bioreactance method, in women undergoing first-trimester screening for PE. Maternal hemodynamics and perinatal outcome were compared between screen-positive and screen-negative women who did not have a medical comorbidity, did not develop PE or pregnancy-induced hypertension and delivered at term a live neonate with birth weight between the 5^th and 95^th percentiles. A multilevel linear mixed-effects model was used to compare the repeated measures of cardiac variables, controlling for maternal characteristics.

RESULTS

The screen-negative group (n = 926) had normal cardiac function changes across gestation, whereas the screen-positive group (n = 170) demonstrated static or reduced cardiac output and stroke volume and higher mean arterial pressure and peripheral vascular resistance with advancing gestation. In the screen-positive group, compared with screen-negative women, birth-weight Z-score was shifted toward lower values, with prevalence of delivery of a neonate below the 35^th , 30^th or 25^th percentile being about 70% higher, and the rate of operative delivery for fetal distress in labor also being higher.

CONCLUSION

Women who were screen positive for impaired placentation, even though they did not develop PE or deliver a SGA neonate, had pathological cardiac adaptation in pregnancy and increased risk of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Ambulatory Blood Pressure Trajectory and Perceived Stress in Relation to Birth Outcomes in Healthy Pregnant Adolescents

OBJECTIVE

An early decline in resting blood pressure (BP), followed by an upward climb, is well documented and indicative of a healthy pregnancy course. Although BP is considered both an effector of stress and a clinically meaningful measurement in pregnancy, little is known about its trajectory in association with birth outcomes compared with other stress effectors. The current prospective longitudinal study examined BP trajectory and perceived stress in association with birth outcomes (gestational age (GA) at birth and birth weight (BW) percentile corrected for GA) in pregnant adolescents, a group at risk for stress-associated poor birth outcomes.

METHODS

Healthy pregnant nulliparous adolescents (n = 139) were followed from early pregnancy through birth. At three time points (13-16, 24-27, and 34-37 gestational weeks ±1 week), the Perceived Stress Scale was collected along with 24-hour ambulatory BP (systolic and diastolic) and electronic diary reporting of posture. GA at birth and BW were abstracted from medical records.

RESULTS

After adjustment for posture and pre-pregnancy body mass index, hierarchical mixed-model linear regression showed the expected early decline (B = -0.18, p = .023) and then increase (B = 0.01, p < .001) of diastolic BP approximating a U-shape; however, systolic BP displayed only an increase (B = 0.01, p = .010). In addition, the models indicated a stronger systolic and diastolic BP U-shape for early GA at birth and lower BW percentile and an inverted U-shape for late GA at birth and higher BW percentile. No effects of perceived stress were observed.

CONCLUSIONS

These results replicate the pregnancy BP trajectory from previous studies of adults and indicate that the degree to which the trajectory emerges in adolescence may be associated with variation in birth outcomes, with a moderate U-shape indicating the healthiest outcomes.

Serum podocalyxin at 11-13 weeks of gestation in the prediction of small for gestational age neonates

OBJECTIVE

To investigate a potential new marker for the prediction of small for gestational age (SGA) infants.

STUDY DESIGN

Nested case-control study involving 280 uncomplicated pregnancies and 70 cases of SGA without pre-eclampsia. Serum podocalyxin was measured at 11-13 weeks of gestation and results were expressed in multiples of the median (MoM). The performance of screening by a combination of maternal history and podocalyxin levels was assessed with ROC curves.

RESULTS

SGA was predicted by maternal age, height, South Asian ethnicity, and previous delivery without pre-eclampsia. Median podocalyxin levels were higher in affected than uncomplicated pregnancies (1.303 versus 0.994 MoM, p < 0.001). At a 10% false-positive rate, maternal history identified 40.0% of the cases (AUC = 0.74, 95%CI 0.671-0.809). The addition of podocalyxin increased the detection to 54.3% (AUC = 0.78, 95%CI 0.771-0.842, p = 0.027 for the difference in ROC curves).

CONCLUSION

First-trimester podocalyxin may be useful in screening for SGA infants.

Uterine and fetal placental Doppler indices are associated with maternal cardiovascular function

BACKGROUND

The mechanism underlying fetal-placental Doppler index changes in preeclampsia and/or fetal growth restriction are unknown, although both are associated with maternal cardiovascular dysfunction.

OBJECTIVE

We sought to investigate whether there was a relationship between maternal cardiac output and vascular resistance and fetoplacental Doppler findings in healthy and complicated pregnancy.

STUDY DESIGN

Women with healthy pregnancies (n=62), preeclamptic pregnancies (n=13), preeclamptic pregnancies with fetal growth restriction (n=15), or fetal growth restricted pregnancies (n=17) from 24-40 weeks gestation were included. All of them underwent measurement of cardiac output with the use of an inert gas rebreathing technique and derivation of peripheral vascular resistance. Uterine and fetal Doppler indices were recorded; the latter were z scored to account for gestation. Associations were determined by polynomial regression analyses.

RESULTS

Mean uterine artery pulsatility index was higher in fetal growth restriction (1.37; P=.026) and preeclampsia+fetal growth restriction (1.63; P=.001) but not preeclampsia (0.92; P=1) compared with control subjects (0.8). There was a negative relationship between uterine pulsatility index and cardiac output (r²=0.101; P=.025) and umbilical pulsatility index z score and cardiac output (r²=0.078; P=.0015), and there were positive associations between uterine pulsatility index and peripheral vascular resistance (r²=0.150; P=.003) and umbilical pulsatility index z score and peripheral vascular resistance (r²= 0.145; P=.001). There was no significant relationship between cardiac output and peripheral vascular resistance with cerebral Doppler indices.

CONCLUSION

Uterine artery Doppler change is abnormally elevated in fetal growth restriction with and without preeclampsia, but not in preeclampsia, which may explain the limited sensitivity of uterine artery Doppler changes for all these complications when considered in aggregate. Furthermore, impedance within fetoplacental arterial vessels is at least, in part, associated with maternal cardiovascular function. This relationship may have important implications for fetal surveillance and would inform therapeutic options in those pathologic pregnancy conditions currently, and perhaps erroneously, attributed purely to placental maldevelopment. Uterine and fetal placental Doppler indices are associated significantly with maternal cardiovascular function. The classic description of uterine and fetal Doppler changes being initiated by placental maldevelopment is a less plausible explanation for the pathogenesis of the conditions than that relating to maternal cardiovascular changes.

Maternal hemodynamics, fetal biometry and Doppler indices in pregnancies followed up for suspected fetal growth restriction

OBJECTIVES

To assess whether, in a cohort of patients with a small-for-gestational-age (SGA) fetus with estimated fetal weight ≤ 10^th percentile, maternal hemodynamics, fetal biometry and Doppler indices at presentation can predict the subsequent development of an abnormal fetal Doppler index or delivery of a baby with birth weight < 3^rd percentile.

METHODS

This was a prospective observational cohort study conducted at a specialist clinic for the management of pregnancies with a SGA fetus at King's College Hospital, London, UK. The study population comprised 86 singleton pregnancies with a SGA fetus, presenting at a median gestational age of 32 (range, 26-35) weeks. We measured maternal cardiac function using a non-invasive transthoracic bioreactance monitor, as well as mean arterial pressure, fetal biometry, and umbilical artery (UA), fetal middle cerebral artery (MCA) and uterine artery (UtA) pulsatility indices (PI), and the deepest vertical pool of amniotic fluid. Z-scores of these variables were calculated based on reported reference ranges and the values were compared between pregnancies with evidence of an abnormal fetal Doppler index at presentation (Group 1), those that had developed an abnormal Doppler index at a subsequent visit (Group 2) and those that did not develop an abnormal Doppler index throughout pregnancy (Group 3). Abnormal fetal Doppler was defined as UA-PI > 95^th percentile and/or MCA-PI < 5^th percentile. Differences in measured variables at presentation were also compared between pregnancies delivering a baby with birth weight < 3^rd percentile and those delivering a baby with birth weight ≥ 3^rd percentile. Multivariate logistic regression analysis was used to determine significant predictors of birth weight < 3^rd percentile and evolution from normal to abnormal fetal Doppler.

RESULTS

In the study population, 14 (16%) cases were in Group 1, 19 (22%) in Group 2 and 53 (62%) in Group 3. Birth weight was < 3^rd percentile in 39 (45%) cases and ≥ 3^rd percentile in 47 (55%). There was decreased cardiac output and stroke volume and increased peripheral vascular resistance compared with a normal population, and the deviations from normal were most marked in Group 1. Pregnancies with birth weight < 3^rd percentile, compared with those with birth weight ≥ 3^rd percentile, had greater deviations from normal in fetal biometry, maternal cardiac output, stroke volume, heart rate, peripheral vascular resistance and UtA-PI. Multivariate logistic regression analysis demonstrated that, in the prediction of birth weight < 3^rd percentile, maternal hemodynamic profile provided significant improvement to the prediction provided by maternal demographics, fetal biometry, UtA-PI, UA-PI and MCA-PI (difference between areas under receiver-operating characteristics curves, 0.18 (95% CI, 0.06-0.29); P = 0.002). In contrast, there was no significant independent contribution from maternal hemodynamics in the prediction of the subsequent development of abnormal fetal Doppler.

CONCLUSIONS

In pregnancies with a SGA fetus, there is decreased maternal cardiac output and stroke volume and increased peripheral vascular resistance, and the deviations from normal are most marked in cases of redistribution in the fetal circulation and reduced amniotic fluid volume. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Modeling Superimposed Preeclampsia Using Ang II (Angiotensin II) Infusion in Pregnant Stroke-Prone Spontaneously Hypertensive Rats

Hypertensive disorders of pregnancy are the second leading cause of maternal deaths worldwide. Superimposed preeclampsia is an increasingly common problem and often associated with impaired placental perfusion. Understanding the underlying mechanisms and developing treatment options are crucial. The pregnant stroke-prone spontaneously hypertensive rat has impaired uteroplacental blood flow and abnormal uterine artery remodeling. We used Ang II (angiotensin II) infusion in pregnant stroke-prone spontaneously hypertensive rats to mimic the increased cardiovascular stress associated with superimposed preeclampsia and examine the impact on the maternal cardiovascular system and fetal development. Continuous infusion of Ang II at 500 or 1000 ng/kg per minute was administered from gestational day 10.5 until term. Radiotelemetry and echocardiography were used to monitor hemodynamic and cardiovascular changes, and urine was collected prepregnancy and throughout gestation. Uterine artery myography assessed uteroplacental vascular function and structure. Fetal measurements were made at gestational day 18.5, and placentas were collected for histological and gene expression analyses. The 1000 ng/kg per minute Ang II treatment significantly increased blood pressure (P<0.01), reduced cardiac output (P<0.05), and reduced diameter and increased stiffness of the uterine arteries (P<0.01) during pregnancy. The albumin:creatinine ratio was increased in both Ang II treatment groups (P<0.05; P<0.0001). The 1000 ng/kg per minute-treated fetuses were significantly smaller than vehicle treatment (P<0.001). Placental expression of Ang II receptors was increased in the junctional zone in 1000 ng/kg per minute Ang II-treated groups (P<0.05), with this zone showing depletion of glycogen content and structural abnormalities. Ang II infusion in pregnant stroke-prone spontaneously hypertensive rats mirrors hemodynamic, cardiac, and urinary profiles observed in preeclamptic women, with evidence of impaired fetal growth.

Effect of a nitric oxide donor on maternal hemodynamics in fetal growth restriction

OBJECTIVE

To evaluate the effect on maternal cardiovascular parameters of treatment with a nitric oxide (NO) donor and plasma volume expansion in pregnancies complicated by fetal growth restriction (FGR).

METHODS

Twenty-six pregnant women with a diagnosis of FGR were treated with transdermal patches of a NO donor and plasma volume expansion by co-administration of oral fluids. We compared the treated group to a historical control group of untreated FGR patients. Hemodynamic indices were obtained using the UltraSonic Cardiac Output Monitor system.

RESULTS

At diagnosis, the two groups were similar in terms of maternal and hemodynamic characteristics. In the treated group, we found a significant increase in maternal cardiac output and stroke volume and a decrease in systemic vascular resistance after 2 weeks of therapy. No significant differences were found 2 weeks after diagnosis in the untreated group. The treated group delivered infants with higher birth-weight centile than did the untreated control group.

CONCLUSIONS

The combined therapeutic approach of NO donor administration and plasma volume expansion in FGR apparently improves significantly maternal hemodynamic indices. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Epigenetics and Preeclampsia: Programming of Future Outcomes

Pregnancy is known to induce rapid, progressive, and substantial changes to the cardiovascular system, ultimately facilitating successful pregnancy outcomes. Women who develop hypertensive disorders during pregnancy are considered to have "failed" the cardiovascular stress test of pregnancy and likely represent a subpopulation with inadequate cardiovascular accommodation. Preeclampsia is a serious complication with a myriad of manifestations in both mother and offspring. This pregnancy syndrome is a polygenic disease and has now been linked to a greater incidence of cardiovascular disease. Moreover, offsprings born to preeclamptic mothers exhibit an elevated risk of cardiovascular disease, stroke, and mental disorders during adulthood. This suggests that preeclampsia not only exposes the mother and the fetus to complications during pregnancy but also programs chronic diseases during adulthood in the offspring. The etiology of preeclampsia remains unknown, with various theories being suggested to explain its origin. It is primarily thought to be associated with poor placentation and entails excessive maternal inflammation and endothelial dysfunction. It is well established now that the maternal immune system and the placenta are involved in a highly choreographed cross talk that underlies adequate spiral artery remodeling required for uteroplacental perfusion and free flow of nutrients to the fetus. Although it is not clear whether immunological alterations occur early during pregnancy, studies have proposed that dysregulated systemic and placental immunity contribute to impaired angiogenesis and the onset of preeclampsia. Recently emerged strong evidence suggests a potential link among epigenetics, microRNAs (miRNAs), and pregnancy complications. This chapter will focus on important aspects of epigenetics, immunological aspects, and cardiovascular and vascular remodeling of preeclampsia.

N-cadherin knockdown leads to disruption of trophoblastic and endothelial cell interaction in a 3D cell culture model - New insights in trophoblast invasion failure

INTRODUCTION

Trophoblast homing to maternal spiral arteries is mandatory for successful placentation. Cell-cell adhesion molecules regulate this process and adhesion molecule expression is altered in impaired placentation. We hypothesize that, similar to immune cell recruitment, trophoblast cell adherence and rolling are primarily mediated by adhesion molecules like, cadherins, immunoglobulins, selectins and their partnering ligands. Here, the interdependence of adhesion molecule expression in trophoblastic cell lines of diverse origin was investigated in relation to their interaction with endothelial cell networks on Matrigel® co-cultures and the effect of specific adhesion molecule knockdown analyzed.

METHODS

Trophoblastic cells were labeled in red and co-cultured with green HUVEC networks on Matrigel®. Association was quantified after collection of fluorescence microscopy pictures using Wimasis® internet platform and software. Expression of adhesion molecules was analyzed by PCR and Western blot, immuno-fluorescence and flow cytometry. The impact of adhesion molecules on trophoblast-endothelial-cell interaction was investigated using siRNA technique.

RESULTS

N-cadherin and CD162 were specifically expressed in the trophoblast cell line HTR-8/SVneo, which closely adhere to and actively migrate toward HUVEC networks on Matrigel®. Suppression of N-cadherin led to a significant alteration in trophoblast-endothelial cell interaction. Expression of VE-cadherin in closely interacting trophoblast cells was not confirmed in vitro.

DISCUSSION

We identified N-cadherin to mediate specific interaction between HUVEC and the migrating trophoblast cells HTR-8/SVneo in a Matrigel® co-culture model. VE-cadherin contribution could not be confirmed in vitro. Our results support the hypothesis that impaired N-cadherin but not VE-cadherin expression is involved in trophoblast recruitment to the maternal endothelium.

High normal blood pressure in early pregnancy also contribute to early onset preeclampsia and severe preeclampsia

OBJECTIVE

This study was to evaluate effects of high normal blood pressure (HNBP) in early pregnancy on total preeclampsia, early preeclampsia, and severe preeclampsia.

METHODS

We conducted a multicenter, national representative retrospective cohort study. HNBP was defined as systolic blood pressure between 130 and 140 mmHg or diastolic blood pressure between 85 and 90 mmHg. We used multivariable logistic regression to examine the associations of HNBP and the risks of above three types of preeclampsia.

RESULTS

We included 58 054 women who were normotensive and nulliparous in early pregnancy. 4 809 (8.3%) fulfilled the definition of having HNBP, 16 682 (28.7%) were in normal blood pressure group, and 36 563 (63.0%) were in optimal blood pressure group. The incidence rates of total preeclampsia, early preeclampsia, and severe preeclampsia were 2.1% (1 217), 0.8% (491), and 1.4% (814), respectively. Compared to having optimal blood pressure, women with HNBP had significantly higher odds of total preeclampsia (odds ratio (OR) = 4.028, 95% confidence interval (CI) 3.377, 4.804), severe preeclampsia (OR = 3.542, 95% CI 2.851, 4.400), and early preeclampsia (OR = 8.163, 95% CI 6.219, 10.715). Our restricted cubic spline results supported the dose-response relationship between continuous blood pressure and the odds ratio of three types of preeclampsia. The fraction of early preeclampsia associated with prehypertension was 58.6%, which was higher than those of total preeclampsia (42.2%) or severe preeclampsia (40.5%).

CONCLUSION

Women in early pregnancy with HNBP more likely develop total preeclampsia, early preeclampsia and severe preeclampsia, compared to those with optimal blood pressure. HNBP contribute more to early preeclampsia than severe preeclampsia. Our study provided robust epidemiological evidences for monitoring HNBP in early pregnancy to reduce the risks of preeclampsia.

Maternal endothelial function and vascular stiffness after HELLP syndrome: a case-control study

OBJECTIVES

To assess endothelial function and arterial stiffness in women with a previous pregnancy complicated by pre-eclampsia (PE) with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome, and to compare these findings to those in women with previous PE but no HELLP and to those in controls with previous uncomplicated pregnancy, in order to investigate the influence of HELLP syndrome on subsequent cardiovascular impairment.

METHODS

In this prospective single-center case-control study, we performed peripheral arterial tonometry (PAT) (using the EndoPAT method) and pulse-wave velocity (PWV) assessment in 109 women who had had a singleton pregnancy complicated by PE with (n = 49) or without (n = 60) HELLP syndrome, as well as in 60 controls with previous uncomplicated pregnancy, between 6 months and 4 years after delivery. The following EndoPAT and PWV indices were compared between groups: reactive hyperemia index (RHI), as an indication of endothelial function, and peripheral and aortic heart-rate-corrected augmentation indices (AIx) standardized for a heart rate of 75 bpm (AIx@75) and carotid-femoral pulse-wave velocity (cfPWV), as indications of arterial stiffness.

RESULTS

PAT and arterial stiffness indices were significantly different between PE cases, with or without previous HELLP, and controls, except for carotid-femoral PWV. There were no significant differences among PE groups: women who had experienced HELLP and those with a history of PE without HELLP showed similar rates of RHI ≤ 1.67 (28.6% vs 18.3%, P = 0.254) and RHI ≤ 2.00 (61.2% vs 41.7%, P = 0.055), peripheral AIx@75 ≥ 17% (38.8% vs 30.0%, P = 0.417), aortic AIx@75 ≥ 35% (29.2% vs 20.0%, P = 0.461) and cfPWV × 0.8 > 9.6 m/s, which occurred in only three women, all in the group without previous HELLP (0% vs 5.0%, P = 0.251). On multivariate regression analysis, HELLP syndrome, intrauterine growth restriction (IUGR) and early-onset PE independently predicted endothelial dysfunction at 6 months to 4 years postpartum, after correcting for uterine artery pulsatility index, birth-weight percentile, and maternal blood pressure, age and body mass index. Women with both previous HELLP and early-onset IUGR had a significantly higher prevalence of endothelial dysfunction (P = 0.001).

CONCLUSION

Similar vascular abnormalities were found in women previously affected by HELLP syndrome and those with previous PE without HELLP. However, a history of HELLP syndrome, IUGR and early-onset PE seems to identify a subgroup of women with a higher risk for future development of endothelial dysfunction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Maternal cardiac output response to colloid preload and vasopressor therapy during spinal anaesthesia for caesarean section in patients with severe pre-eclampsia: a randomised, controlled trial

We examined the haemodynamic effects of colloid preload, and phenylephrine and ephedrine administered for spinal hypotension, during caesarean section in 42 women with severe early onset pre-eclampsia. Twenty patients with pre-delivery spinal hypotension were randomly allocated to receive an initial dose of either 50 μg phenylephrine or 7.5 mg ephedrine; the primary outcome was percentage change in cardiac index. After a 300-ml colloid preload, mean (SD) cardiac index increased from 4.9 (1.1) to 5.6 (1.2) l.min^-1 .m^-2 (p < 0.01), resulting from an increase in both heart rate, from 81.3 (17.2) to 86.3 (16.5) beats.min^-1 (p = 0.2), and stroke volume, from 111.8 (19.0) to 119.8 (17.9) ml (p = 0.049). Fourteen (33%) and 23 (54.8%) patients exhibited a stroke volume response > 10% and > 5%, respectively; a significant negative correlation was found between heart rate and stroke volume changes. Spinal hypotension in 20 patients was associated with an increase from baseline in cardiac index of 0.6 l.min^-1 .m^-2 (mean difference 11.5%; p < 0.0001). After a median [range] dose of 50 [50-150] μg phenylephrine or 15 [7.5-37.5] mg ephedrine, the percentage change in cardiac index during the measurement period of 150 s was greater, and negative, in patients receiving phenylephrine vs. ephedrine, at -12.0 (7.3)% vs. 2.6 (6.0)%, respectively (p = 0.0001). The percentage change in heart rate after vasopressor was higher in patients receiving phenylephrine, at -9.1 (3.4)% vs. 5.3 (12.6)% (p = 0.0027), as was the change in systemic vascular resistance, at 22.3 (7.5) vs. -1.9 (10.5)% (p < 0.0001). Phenylephrine effectively reverses spinal anaesthesia-induced haemodynamic changes in severe pre-eclampsia, if left ventricular systolic function is preserved.