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Farsetti D, Pometti F, Vasapollo B, Novelli GP, Nardini S, Lupoli B, Lees C, Valensise H. Nitric oxide donor increases umbilical vein blood flow and fetal oxygenation in fetal growth restriction. A pilot study. Placenta 2024; 151:59-66. [PMID: 38718734 DOI: 10.1016/j.placenta.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 04/25/2024] [Accepted: 04/30/2024] [Indexed: 06/03/2024]
Abstract
INTRODUCTION To evaluate the maternal and fetal hemodynamic effects of treatment with a nitric oxide donor and oral fluid in pregnancies complicated by fetal growth restriction. METHODS 30 normotensive participants with early fetal growth restriction were enrolled. 15 participants were treated until delivery with transdermal glyceryl trinitrate and oral fluid intake (Treated group), and 15 comprised the untreated group. All women underwent non-invasive assessment of fetal and maternal hemodynamics and repeat evaluation 2 weeks later. RESULTS In the treated group, maternal hemodynamics improved significantly after two weeks of therapy compared to untreated participants. Fetal hemodynamics in the treated group showed an increase in umbilical vein diameter by 18.87 % (p < 0.01), in umbilical vein blood flow by 48.16 % (p < 0.01) and in umbilical vein blood flow corrected for estimated fetal weight by 30.03 % (p < 0.01). In the untreated group, the characteristics of the umbilical vein were unchanged compared to baseline. At the same time, the cerebro-placental ratio increased in the treated group, while it was reduced in the untreated group, compared to baseline values. The treated group showed a higher birthweight centile (p = 0.03) and a lower preeclampsia rate (p = 0.04) compared to the untreated group. DISCUSSION The combined therapeutic approach with nitric oxide donor and oral fluid intake in fetal growth restriction improves maternal hemodynamics, which becomes more hyperdynamic (volume-dominant). At the same time, in the fetal circuit, umbilical vein flow increased and fetal brain sparing improved. Although a modest sample size, there was less preeclampsia and a higher birthweight suggesting beneficial maternal and fetal characteristics of treatment.
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Affiliation(s)
- Daniele Farsetti
- Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy; Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy.
| | - Francesca Pometti
- Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Barbara Vasapollo
- Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy; Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Gian Paolo Novelli
- Department of Integrated Care Processes, Fondazione PTV Policlinico Tor Vergata, Rome, Italy
| | - Sara Nardini
- Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Benedetta Lupoli
- Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Christoph Lees
- Centre for Fetal Care, Department of Obstetrics and Gynecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, United Kingdom
| | - Herbert Valensise
- Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy; Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
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Zhang L, Bi S, Gong J, Wang X, Liang J, Gu S, Su M, Wang W, Sun M, Chen J, Zheng W, Wu J, Wang Z, Liu J, Li HT, Chen D, Du L. Comparing the severity of second preeclampsia with first preeclampsia: a multicenter retrospective longitudinal cohort study. J Hypertens 2024; 42:841-847. [PMID: 38164966 DOI: 10.1097/hjh.0000000000003642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Compare the clinical severity of second preeclampsia with the first preeclampsia. METHODS This retrospective longitudinal cohort study was conducted in three teaching hospitals in Guangzhou, where there were a total of 296 405 deliveries between 2010 and 2021. Two consecutive singleton deliveries complicated with preeclampsia were included. Clinical features, laboratory results within 1 week before delivery, and maternal and neonatal outcomes of both deliveries were collected. Univariate analyses were made using paired Wilcoxon tests and McNemar tests. Multivariable logistic regression and generalized linear models were performed to assess the association of adverse maternal and neonatal outcomes with second preeclampsia. RESULTS A total of 151 women were included in the study. The mean maternal age was 28 and 33 years for the first and second deliveries, respectively. The proportion of preventive acetylsalicylic acid use was 4.6% for the first delivery and 15.2% for the second delivery. No significant differences were observed in terms of blood pressure on admission, gestational weeks of admission and delivery, application of perinatal antihypertensive agents, rates of preterm delivery, and severe features between the two occurrences. However, the rates of heart disease, edema, and admission to the ICU were lower, and hospital stays were shorter in the second preeclampsia compared with the first preeclampsia. Sensitivity analysis conducted among women who did not use preventive acetylsalicylic acid yielded similar results. After adjusting for potential confounding variables, the occurrence of second preeclampsia was associated with significantly decreased risks of heart disease, edema, complications, and admission to the NICU, with odds ratios ranging between 0.157 and 0.336. CONCLUSION Contrary to expectations, the second preeclampsia did not exhibit worse manifestations or outcomes to the first occurrence. In fact, some clinical features and outcomes appeared to be better in the second preeclampsia.
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Affiliation(s)
- Lizi Zhang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Shilei Bi
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Jingjin Gong
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Xinghe Wang
- Dongguan Maternal and Children Health Hospital
| | - Jingying Liang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Shifeng Gu
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Minglian Su
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Weiwei Wang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Manna Sun
- Dongguan Maternal and Children Health Hospital
| | - Jingsi Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Weitan Zheng
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Junwei Wu
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Zhijian Wang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianmeng Liu
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing
| | - Hong-Tian Li
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
| | - Lili Du
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases; Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology; Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine; The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou
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Vasapollo B, Zullino S, Novelli GP, Farsetti D, Ottanelli S, Clemenza S, Micaglio M, Ferrazzi E, Di Martino DD, Ghi T, Di Pasquo E, Orabona R, Corbella P, Frigo MG, Prefumo F, Stampalija T, Giannubilo SR, Valensise H, Mecacci F. Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine. Am J Perinatol 2024. [PMID: 38350640 DOI: 10.1055/a-2267-3994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
OBJECTIVE The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art. STUDY DESIGN AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version. RESULTS More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life. CONCLUSION Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications. KEY POINTS · Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..
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Affiliation(s)
- Barbara Vasapollo
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Gian Paolo Novelli
- Department of Integrated Care Services, Prehospitalization Unit, Policlinico di Tor Vergata, Rome, Italy
| | - Daniele Farsetti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Serena Ottanelli
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Sara Clemenza
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Unit of Obstetric and Gynecologic Anesthesia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Tullio Ghi
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elvira Di Pasquo
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rossana Orabona
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paola Corbella
- Maternal Infant Department SC, Obstetrics and Gynecology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Grazia Frigo
- Department of Anesthesia and Resuscitation in Obstetrics, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | - Federico Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Stefano Raffaele Giannubilo
- Department of Obstetrics and Gynecology, Marche Polytechnic University, Ancona, Italy
- Department of Clinical Sciences, Polytechnic University of Marche Salesi Hospital, Ancona, Italy
| | - Herbert Valensise
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Federico Mecacci
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
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Hauspurg A, Bryan S, Jeyabalan A, Davis EM, Hart R, Shirriel J, Muldoon M, Catov J. Blood Pressure Trajectories Through the First Year Postpartum in Overweight or Obese Individuals Following a Hypertensive Disorder of Pregnancy. Hypertension 2024; 81:302-310. [PMID: 38073563 PMCID: PMC10872368 DOI: 10.1161/hypertensionaha.123.22231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are associated with cardiovascular disease; however, patterns of blood pressure (BP) recovery are understudied. We compared pregnancy and postpartum BP trajectories among individuals with hypertensive disorders of pregnancy who developed persistent hypertension at 1-year postpartum compared with individuals with normalization of BP. METHODS We used data from a randomized clinical trial of individuals with overweight, obesity, and hypertensive disorders of pregnancy conducted in the first year after delivery. Pregnancy BPs were obtained during prenatal visits; postpartum BPs were prospectively obtained through home monitoring. Demographic characteristics and trajectories were compared by hypertensive status (systolic BP ≥130 mm Hg, diastolic BP ≥80 mm Hg, or use of antihypertensive medications) at 1 year. We used repeated BP measures to fit separate mixed-effects linear regression models for pregnancy and postpartum using restricted cubic splines. RESULTS We included 129 individuals; 75 (58%) individuals progressed to hypertension by 1-year postpartum. Individuals with hypertension were older, delivered at earlier gestational ages, and had higher body mass index at 1-year postpartum compared with those with normalization. Individuals with hypertension had similar BP trajectories during pregnancy to those with BP normalization but a significantly different BP trajectory (P<0.01 for systolic and diastolic BPs) in the first year postpartum. These differences persisted in multivariable models after adjustment for early pregnancy body mass index, age, and severity of hypertensive disorder of pregnancy (P<0.01 for systolic and diastolic BPs). CONCLUSIONS BP trajectories in the first year postpartum, but not during pregnancy, may provide important information for risk stratification after a hypertensive disorder of pregnancy. REGISTRATION URL: https://clinicaltrials.gov; Unique identifier: NCT03749746.
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Affiliation(s)
- Alisse Hauspurg
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Samantha Bryan
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Arun Jeyabalan
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Esa M. Davis
- University of Maryland School of Medicine, Baltimore, PA
| | - Renee Hart
- University of Maryland School of Medicine, Baltimore, PA
| | - Jada Shirriel
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Matthew Muldoon
- Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Janet Catov
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Zhang L, Wang W, Gong J, Wang X, Liang J, Gu S, Su M, Bi S, Sun M, Chen J, Zheng W, Wu J, Wang Z, Liu J, Li H, Chen D, Du L. Development, validation, and clinical utility of a risk prediction model for recurrent preeclampsia. J Hypertens 2024; 42:236-243. [PMID: 37796172 DOI: 10.1097/hjh.0000000000003580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVES We aim to establish a predictive model for recurrent preeclampsia. METHODS A retrospective review of medical records from three hospitals between 2010 and 2021 was conducted. The study included women who had two consecutive singleton deliveries at the same hospital, with the first delivery complicated by preeclampsia. A multivariable logistic regression model was constructed using a training cohort, and subsequently cross-validated and tested using an independent cohort. The model's performance was assessed in terms of discrimination and calibration, and its clinical utility was evaluated using decision curve analysis (DCA). RESULTS Among 296 405 deliveries, 694 women met the inclusion criteria, with 151 (21.8%) experiencing recurrent preeclampsia. The predictive model incorporated 10 risk factors from previous preeclampsia, including gestational weeks with elevated blood pressure, gestational diabetes mellitus (GDM), pericardial effusion, heart failure, limb edema, serum creatinine, white blood cell count, low platelet counts within one week before delivery, SBP on the first postpartum day, and postpartum antihypertensive use. Additionally, one risk factor from the index pregnancy was included, which was antihypertensive use before 20 weeks. The model demonstrated better discrimination, calibration, and a net benefit across a wide range of recurrent preeclampsia risk thresholds. Furthermore, the model has been translated into a clinical risk calculator, enabling clinicians to calculate individualized risks of recurrent preeclampsia. CONCLUSION Our study demonstrates that a predictive tool utilizing routine clinical and laboratory factors can accurately estimate the risk of recurrent preeclampsia. This predictive model has the potential to facilitate shared decision-making by providing personalized and risk-stratified care.
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Affiliation(s)
- Lizi Zhang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Weiwei Wang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Jingjin Gong
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Xinghe Wang
- Dongguan Maternal and Children Health Hospital
| | - Jingying Liang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Shifeng Gu
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Minglian Su
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Shilei Bi
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Manna Sun
- Dongguan Maternal and Children Health Hospital
| | - Jingsi Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Weitan Zheng
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Junwei Wu
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Zhijian Wang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Jianmeng Liu
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Hongtian Li
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Lili Du
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
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Cutler HR, Barr L, Sattwika PD, Frost A, Alkhodari M, Kitt J, Lapidaire W, Lewandowski AJ, Leeson P. Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review. Eur J Prev Cardiol 2024; 31:77-99. [PMID: 37607255 PMCID: PMC10767256 DOI: 10.1093/eurjpc/zwad275] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 08/24/2023]
Abstract
AIMS Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum. METHODS AND RESULTS Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum. CONCLUSION The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.
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Affiliation(s)
- Hannah Rebecca Cutler
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Logan Barr
- Department of Biomedical and Molecular Sciences, Queens University, Barrie St, Kingston, Canada
| | - Prenali Dwisthi Sattwika
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Bulaksumur, Caturtunggal, Kec, Kabupaten Sleman, Indonesia
| | - Annabelle Frost
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Mohanad Alkhodari
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
- Healthcare Engineering Innovation Center, Department of Biomedical Engineering, Khalifa University, Abu Dhabi, Shakhbout Bin Sultan St, Hadbat Al Za'faranah, United Arab Emirates
| | - Jamie Kitt
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Winok Lapidaire
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Adam James Lewandowski
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
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7
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Vasapollo B, Novelli GP, Farsetti D, Pometti F, Frantellizzi R, Maellaro F, Silvestrini M, Pais M, Valensise H. NO donors on top of anti-hypertensive therapy reduces complications in chronic hypertensive pregnancies with hypodynamic circulation. Eur J Obstet Gynecol Reprod Biol 2023; 291:219-224. [PMID: 37924629 DOI: 10.1016/j.ejogrb.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVES Chronic hypertension is associated with significant adverse maternal and fetal outcomes that appear to be often associated to a hypodynamic circulation. Treatment of hypertensive disorders of pregnancy tailored on maternal hemodynamics might reduce or mitigate these complications. Our purpose was to assess the hemodynamic modifications induced by the addition of NO donors and increased oral fluid intake on top of standard antihypertensive therapy in hypodynamic chronic hypertensive patients. We further evaluated if the possible hemodynamic modification induced by NO donors and increased oral fluid intake might be associated to a reduction of the severity and rate of complications vs. patients on antihypertensive standard treatment. STUDY DESIGN This was a case-control study of 321 chronic hypertensive patients with a hypodynamic circulation at the echocardiographic evaluation at 24 weeks' gestation. We included 160 controls (standard antihypertensive therapy) and 161 cases (standard therapy + NO donor patches + increased oral fluid intake). Student T test for paired and unpaired data, univariate logistic regression analysis, ROC curve analysis, and Cox Hazards Regression analysis were used as appropriate. RESULTS At enrollment the hemodynamic parameters were similar between the two groups. After 3-4 weeks stroke volume (77 ± 19 mL vs. 69 ± 19 mL; p < 0.001), and cardiac output (6.2 ± 1.7 L vs. 5.0 ± 1.6 L; p < 0.001) were higher and total peripheral vascular resistance (1465 ± 469 dyne·s·cm-5 vs. 1814 ± 524 dyne·s·cm-5; p < 0.001) was lower in the cases vs controls. Superimposed preeclampsia, preterm delivery before 34 weeks, abruptio placentae, HELLP Syndrome, fetal growth restriction, and perinatal death were more represented in the standard treatment group vs NO treated patients (81% vs 53%; p < 0.001). In particular, the standard treatment group showed 48% fetal growth restriction vs 34% in the NO treated group (p < 0.011). The Cox proportional-hazards regression showed a lower proportion of event-free pregnancies in controls on standard treatment (HR 2.6; 95% CI 2.0-3.5; p < 0.0001), and a prolongation of pregnancies in CH cases complicated by fetal growth restriction taking NO donors (HR 0.29; 95% CI 0.19-0.43; p = 0.0001). CONCLUSIONS The tailored treatment with NO donors and oral fluids of hypodynamic CH might have positive effects on the reduction or mitigations of adverse outcomes.
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Affiliation(s)
- Barbara Vasapollo
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy; Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | | | - Daniele Farsetti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy; Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Francesca Pometti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | | | - Filomena Maellaro
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Marco Silvestrini
- Pre Hospitalization Unit, Policlinico di Tor Vergata, Rome, Italy; Residency in Sports Medicine, Tor Vergata University, Rome, Italy
| | - Marcello Pais
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
| | - Herbert Valensise
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy; Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
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8
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Sayed M, Rashed M, Abbas AM, Youssef A, Abdel Ghany M. Postpartum Detection of Diastolic Dysfunction and Nondipping Blood Pressure Profile in Women With Preeclampsia. Tex Heart Inst J 2023; 50:493184. [PMID: 37209088 DOI: 10.14503/thij-20-7459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND Left ventricular diastolic dysfunction and nocturnal "nondipping" of blood pressure detected via ambulatory blood pressure monitoring are predictors of increased cardiovascular morbidity. METHODS A prospective cohort study including normotensive women with a history of preeclampsia in their current pregnancy was conducted. All cases were subjected to 24-hour ambulatory blood pressure monitoring and 2-dimensional transthoracic echocardiography 3 months after delivery. RESULTS This study included 128 women with a mean (SD) age of 28.6 (5.1) years and a mean (SD) basal blood pressure of 123.1 (6.4)/74.6 (5.9) mm Hg. Among the participants, 90 (70.3%) exhibited an ambulatory blood pressure monitoring profile illustrating nocturnal blood pressure "dipping" (the mean night to day time blood pressure ratio ≤ 0.9), whereas 38 (29.7%) were nondippers. Diastolic dysfunction (impaired left ventricular relaxation) was present in 28 nondippers (73.7%), whereas none of the dippers exhibited diastolic dysfunction. Women with severe preeclampsia were more frequently nondippers (35.5% vs 24.2%; P = .02) and experienced diastolic dysfunction (29% vs 15%; P = .01) than were those with mild preeclampsia. Severe preeclampsia (odds ratio [OR], 1.08; 95% CI, 1.05-10.56; P < .001) and history of recurrent preeclampsia (OR, 1.36; 95% CI, 1.3-4.26; P ≤ .001) were significant predictors for nondipping status and diastolic dysfunction (OR, 1.55; 95% CI, 1.1-2.2; and OR, 1.23; 95% CI, 1.2-2.2, respectively; P < .05). CONCLUSION Women with a history of preeclampsia were at higher risk for developing late cardiovascular events. The severity and recurrence of preeclampsia were significant predictors of both nondipping profile and diastolic dysfunction.
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Affiliation(s)
- Marwa Sayed
- Department of Cardiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mariam Rashed
- Department of Cardiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Amr Youssef
- Department of Cardiology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Mohamed Abdel Ghany
- Department of Cardiology, Faculty of Medicine, Assiut University, Assiut, Egypt
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9
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Di Martino DD, Stampalija T, Zullino S, Fusè F, Garbin M, Parasiliti M, Sterpi V, Farina A, Ferrazzi E. Maternal hemodynamic profile during pregnancy and in the post-partum in hypertensive disorders of pregnancy and fetal growth restriction. Am J Obstet Gynecol MFM 2023; 5:100841. [PMID: 36563878 DOI: 10.1016/j.ajogmf.2022.100841] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy (Dr Stampalija); Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy (Dr Stampalija)
| | - Sara Zullino
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Dr Zullino).
| | - Federica Fusè
- Department of Obstetrics and Gynecology, University of Milan, Hospital Luigi Sacco, Milan, Italy (Dr Fusè)
| | - Massimo Garbin
- Unit of Cardiology, Vittore Buzzi Children's Hospital, Milan, Italy (Dr Garbin)
| | - Marco Parasiliti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Vittoria Sterpi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery, IRCCS Sant'Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy (Dr Farina)
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (Dr Ferrazzi)
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10
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Ushida T, Cotechini T, Protopapas N, Atallah A, Collyer C, Toews AJ, Macdonald-Goodfellow SK, Tse MY, Winn LM, Pang SC, Adams MA, Othman M, Kotani T, Kajiyama H, Graham CH. Aberrant inflammation in rat pregnancy leads to cardiometabolic alterations in the offspring and intrauterine growth restriction in the F2 generation. J Dev Orig Health Dis 2022; 13:706-718. [PMID: 35593438 DOI: 10.1017/s2040174422000265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Children of women with pre-eclampsia have increased risk of cardiovascular (CV) and metabolic disease in adult life. Furthermore, the risk of pregnancy complications is higher in daughters born to women affected by pre-eclampsia than in daughters born after uncomplicated pregnancies. While aberrant inflammation contributes to the pathophysiology of pregnancy complications, including pre-eclampsia, the contribution of maternal inflammation to subsequent risk of CV and metabolic disease as well as pregnancy complications in the offspring remains unclear. Here, we demonstrate that 24-week-old female rats (F1) born to dams (F0) exposed to lipopolysaccharide (LPS) during pregnancy (to induce inflammation) exhibited mild systolic dysfunction, increased cardiac growth-related gene expression, altered glucose tolerance, and coagulopathy; whereas male F1 offspring exhibited altered glucose tolerance and increased visceral fat accumulation compared with F1 sex-matched offspring born to saline-treated dams. Both male and female F1 offspring born to LPS-treated dams had evidence of anemia. Fetuses (F2) from F1 females born to LPS-treated dams were growth restricted, and this reduction in fetal growth was associated with increased CD68 positivity (indicative of macrophage presence) and decreased expression of glucose transporter-1 in their utero-placental units. These results indicate that abnormal maternal inflammation can contribute to increased risk of CV and metabolic disease in the offspring, and that the effects of inflammation may cross generations. Our findings provide evidence in support of early screening for CV and metabolic disease, as well as pregnancy complications in offspring affected by pre-eclampsia or other pregnancy complications associated with aberrant inflammation.
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Affiliation(s)
- Takafumi Ushida
- Department of Gynecology and Obstetrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tiziana Cotechini
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Nicole Protopapas
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Aline Atallah
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Charlotte Collyer
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Alexa J Toews
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - M Yat Tse
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Louise M Winn
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Stephen C Pang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Michael A Adams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, Ontario, Canada
| | - Tomomi Kotani
- Department of Gynecology and Obstetrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Kajiyama
- Department of Gynecology and Obstetrics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Charles H Graham
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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11
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Barr LC, Liblik K, Johri AM, Smith GN. Maternal Cardiovascular Function Following a Pregnancy Complicated by Preeclampsia. Am J Perinatol 2022; 39:1055-1064. [PMID: 33321533 DOI: 10.1055/s-0040-1721694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preeclampsia is a hypertensive pregnancy complication with an unknown etiology and high maternal burden worldwide. Burgeoning research has linked preeclampsia to adverse maternal health outcomes remote from pregnancy; however, the intermediary mechanisms responsible for this association have not been sufficiently established. In the present narrative review, we summarize leading evidence of structural and functional cardiovascular changes associated with prior preeclampsia, and how these changes may be linked to future maternal disease. KEY POINTS: · Prior preeclampsia is associated with subclinical structural and functional vascular changes remote from pregnancy.. · Maternal cardiac adaptations to preeclampsia may have long-term implications on cardiovascular health.. · Clinicians have an opportunity to minimize maternal disease risk following preeclampsia..
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Affiliation(s)
- Logan C Barr
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Kiera Liblik
- Cardiovascular Imaging Network at Queen's, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Amer M Johri
- Cardiovascular Imaging Network at Queen's, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Graeme N Smith
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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12
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Noninvasive Cardiac Imaging in Formerly Preeclamptic Women for Early Detection of Subclinical Myocardial Abnormalities: A 2022 Update. Biomolecules 2022; 12:biom12030415. [PMID: 35327607 PMCID: PMC8946283 DOI: 10.3390/biom12030415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Preeclampsia is a maternal hypertensive disease, complicating 2–8% of all pregnancies. It has been linked to a 2–7-fold increased risk for the development of cardiovascular disease, including heart failure, later in life. A total of 40% of formerly preeclamptic women develop preclinical heart failure, which may further deteriorate into clinical heart failure. Noninvasive cardiac imaging could assist in the early detection of myocardial abnormalities, especially in the preclinical stage, when these changes are likely to be reversible. Moreover, imaging studies can improve our insights into the relationship between preeclampsia and heart failure and can be used for monitoring. Cardiac ultrasound is used to assess quantitative changes, including the left ventricular cavity volume and wall thickness, myocardial mass, systolic and diastolic function, and strain. Cardiac magnetic resonance imaging may be of additional diagnostic value to assess diffuse and focal fibrosis and perfusion. After preeclampsia, sustained elevated myocardial mass along with reduced myocardial circumferential and longitudinal strain and decreased diastolic function is reported. These findings are consistent with the early phases of heart failure, referred to as preclinical (asymptomatic) or B-stage heart failure. In this review, we will provide an up-to-date overview of the potential of cardiac magnetic resonance imaging and echocardiography in identifying formerly preeclamptic women who are at high risk for developing heart failure. The potential contribution to early cardiac screening of women with a history of preeclampsia and the pros and cons of these imaging modalities are outlined. Finally, recommendations for future research are presented.
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13
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McCarthy FP, O’Driscoll JM, Seed PT, Placzek A, Gill C, Sparkes J, Poston L, Marber M, Shennan AH, Thilaganathan B, Leeson P, Chappell LC. Multicenter Cohort Study, With a Nested Randomized Comparison, to Examine the Cardiovascular Impact of Preterm Preeclampsia. Hypertension 2021; 78:1382-1394. [PMID: 34455811 PMCID: PMC8516808 DOI: 10.1161/hypertensionaha.121.17171] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/13/2021] [Indexed: 01/22/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Fergus P. McCarthy
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
- Department of Obstetrics and Gynaecology, The INFANT Research Centre, University College Cork, Cork University Maternity Hospital, Ireland (F.P.M.)
| | - Jamie M. O’Driscoll
- School of Psychology and Life Science, Canterbury Christ Church University, Kent, United Kingdom (J.M.O.)
| | - Paul T. Seed
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
| | - Anna Placzek
- Department of Cardiology, St George’s University Hospitals National Health Service Foundation Trust, London, United Kingdom (J.M.O.)
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health (A.P.), University of Oxford
| | - Carolyn Gill
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
| | - Jenie Sparkes
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
| | - Lucilla Poston
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
| | - Mike Marber
- Cardiovascular Division (M.M.), King’s College London, London, United Kingdom
| | - Andrew H. Shennan
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George’s University Hospitals National Health Service Foundation Trust and Molecular & Clinical Sciences Research Institute, St George’s University of London, United Kingdom (B.T.)
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine (P.L.), University of Oxford
| | - Lucy C. Chappell
- From the Department of Women and Children’s Health (F.P.M., P.T.S., C.G., J.S., L.P., A.H.S., L.C.C.), King’s College London, London, United Kingdom
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14
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Mecacci F, Avagliano L, Lisi F, Clemenza S, Serena C, Vannuccini S, Rambaldi MP, Simeone S, Ottanelli S, Petraglia F. Fetal Growth Restriction: Does an Integrated Maternal Hemodynamic-Placental Model Fit Better? Reprod Sci 2021; 28:2422-2435. [PMID: 33211274 PMCID: PMC8346440 DOI: 10.1007/s43032-020-00393-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/09/2020] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- F Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - L Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milano, Milan, Italy
| | - F Lisi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Clemenza
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Caterina Serena
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy.
| | - S Vannuccini
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - M P Rambaldi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Simeone
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - S Ottanelli
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - F Petraglia
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and Gynecology, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
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15
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Point-of-care ultrasound for obstetric anesthesia. Int Anesthesiol Clin 2021; 59:60-77. [PMID: 34054061 DOI: 10.1097/aia.0000000000000330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Woldu B, Shah LM, Shaddeau AK, Goerlich E, Zakaria S, Hays AG, Vaught AJ, Creanga AA, Blumenthal RS, Sharma G. The Role of Biomarkers and Imaging to Predict Preeclampsia and Subsequent Cardiovascular Dysfunction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00913-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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17
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Mohseni Z, Derksen E, Oben J, Al-Nasiry S, Spaanderman MEA, Ghossein-Doha C. Cardiac dysfunction after preeclampsia; an overview of pro- and anti-fibrotic circulating effector molecules. Pregnancy Hypertens 2020; 23:140-154. [PMID: 33388730 DOI: 10.1016/j.preghy.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 10/29/2020] [Accepted: 12/08/2020] [Indexed: 01/09/2023]
Abstract
Preeclampsia (PE) is strongly associated with heart failure (HF) later in life. The aberrant cardiac remodelling is likely initiated or amplified during preeclamptic pregnancy. Aberrant remodelling often persists after delivery and is known to relate strongly to cardiac fibrosis. This review provides an overview of pro- and anti- fibrotic circulating effector molecules that are involved in cardiac fibrosis and their association with PE. Women with PE complicated pregnancies show increased ANG-II sensitivity and elevated levels of the pro-fibrotic factors IL-6, TNF-α, TGs and FFAs compared to uncomplicated pregnancies. In the postpartum period, PE pregnancies compared to uncomplicated pregnancies have increased ANG-II sensitivity, elevated levels of the pro-fibrotic factors IL-6, TNF-α, LDL cholesterol and leptin, as well as decreased levels of the anti-fibrotic factor adiponectin. The review revealed several profibrotic molecules that associate to cardiac fibrosis during and after PE. The role that these fibrotic factors have on the heart during and after PE may improve the understanding of the link between PE and HF. Furthermore they may provide insight into the pathways in which the relation between both diseases can be understood as potential mechanisms which interfere in the process of cardiovascular disease (CVD). Unravelling the molecular mechanism and pathways involved might bring the diagnostic and therapeutic abilities of those factors a step closer.
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Affiliation(s)
- Zenab Mohseni
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre (MUMC+), The Netherlands.
| | - Elianne Derksen
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre (MUMC+), The Netherlands
| | - Jolien Oben
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre (MUMC+), The Netherlands
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre (MUMC+), The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre (MUMC+), The Netherlands; Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Center, The Netherlands
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre (MUMC+), The Netherlands; Department of Cardiology, Maastricht University Medical Centre (MUMC+), The Netherlands
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18
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Ormesher L, Higson S, Luckie M, Roberts SA, Glossop H, Trafford A, Cottrell E, Johnstone ED, Myers JE. Postnatal Enalapril to Improve Cardiovascular Function Following Preterm Preeclampsia (PICk-UP):: A Randomized Double-Blind Placebo-Controlled Feasibility Trial. Hypertension 2020; 76:1828-1837. [PMID: 33012200 PMCID: PMC7610547 DOI: 10.1161/hypertensionaha.120.15875] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022]
Abstract
Hypertensive disease in pregnancy is associated with future cardiovascular disease and, therefore, provides an opportunity to identify women who could benefit from targeted interventions aimed at reducing cardiovascular morbidity. This study focused on the highest-risk group, women with preterm preeclampsia, who have an 8-fold risk of death from future cardiovascular disease. We performed a single-center feasibility randomized controlled trial of 6 months' treatment with enalapril to improve postnatal cardiovascular function. Echocardiography and hemodynamic measurements were performed at baseline (<3 days), 6 weeks, and 6 months postdelivery on 60 women. At randomization, 88% of women had diastolic dysfunction, and 68% had concentric remodeling/hypertrophy. No difference was seen in total vascular resistance (P=0.59) or systolic function (global longitudinal strain: P=0.14) between groups at 6 months. However, women treated with enalapril had echocardiographic measurements consistent with improved diastolic function (E/E'[the ratio of early mitral inflow velocity and early mitral annular diastolic velocity]: P=0.04) and left ventricular remodeling (relative wall thickness: P=0.01; left ventricular mass index: P=0.03) at 6 months, compared with placebo. Urinary enalapril was detectable in 85% and 63% of women in the enalapril arm at 6 weeks and 6 months, respectively. All women responded positively to taking enalapril in the future. Our study confirmed acceptability and feasibility of the study protocol with a recruitment to completion rate of 2.2 women per month. Importantly, postnatal enalapril treatment was associated with improved echocardiographic measurements; these early improvements have the potential to reduce long-term cardiovascular disease risk. A definitive, multicenter randomized controlled trial is now required to confirm these findings. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT03466333.
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Affiliation(s)
- Laura Ormesher
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
| | - Suzanne Higson
- Manchester Heart Centre (S.H., M.L.), Manchester University NHS Foundation Trust, United Kingdom
| | - Matthew Luckie
- Manchester Heart Centre (S.H., M.L.), Manchester University NHS Foundation Trust, United Kingdom
| | - Stephen A Roberts
- Centre for Biostatistics (S.A.R.), University of Manchester, United Kingdom
| | - Heather Glossop
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
| | - Andrew Trafford
- Division of Cardiovascular Sciences (A.T.), University of Manchester, United Kingdom
| | - Elizabeth Cottrell
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
| | - Edward D Johnstone
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
| | - Jenny E Myers
- From the Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine (L.O., E.C., E.D.J., J.E.M.), University of Manchester, United Kingdom
- St Mary's Hospital (L.O., H.G., E.D.J., J.E.M.), Manchester University NHS Foundation Trust, United Kingdom
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19
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Valensise H, Farsetti D, Pisani I, Tiralongo GM, Gagliardi G, Lo Presti D, Novelli GP, Vasapollo B. Hemodynamic maladaptation and left ventricular dysfunction in chronic hypertensive patients at the beginning of gestation and pregnancy complications: a case control study. J Matern Fetal Neonatal Med 2020; 35:3290-3296. [PMID: 32933343 DOI: 10.1080/14767058.2020.1818206] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate early pregnancy differences in maternal hemodynamics, cardiac geometry and function, between chronic hypertensive (CH) patients with and without the development of feto-maternal complications later in pregnancy. METHODS We performed a case-control study on nulliparous CH treated patients. From a group of CH patients referred to our outpatient clinic at 4-6 weeks for a clinical evaluation the first consecutive 30 patients with subsequent complications (superimposed PE, abruptio placentae, uncontrolled severe hypertension with delivery <34 weeks, HELLP syndrome, FGR, perinatal death) were enrolled; the first 2 CH women with uneventful pregnancy referred after the case were enrolled as controls for a total of 60 patients. All patients were shifted to alpha-methyl dopa at the beginning of pregnancy and were submitted to an echocardiographic evaluation to assess the maternal hemodynamics, cardiac geometry, diastolic and systolic function. RESULTS Patients developing complications had a lower early pregnancy heart rate (73 ± 11 vs. 82 ± 11 bpm), cardiac output (5.23 ± 1.2 vs. 6.5 ± 1.3 L/min, p<.01) and cardiac index (3.0 ± 0.7 vs. 3.6 ± 0.7 L/min/m2, p<.01); higher total vascular resistance (1554 ± 305 vs. 1248 ± 243 d.s.cm-5, p<.01) and total vascular resistance index (2666 ± 519 vs. 2335 ± 431, d.s.cm-5/m2, p<.01); higher left ventricular mass index (42.1 ± 8.6 vs. 36.9 ± 8.3 g/m2, p<.01) and relative wall thickness (0.40 ± 0.05 vs. 0.36 ± 0.05, p<.01) of the left ventricle, resulting in a higher prevalence of altered cardiac geometry vs. uneventful CH controls. Diastolic and systolic dysfunction were also present with a higher E/e' ratio (10.50 ± 3.56 vs. 7.22 ± 1.91, p<.01) and a lower stress corrected midwall mechanics (89 ± 21 vs. 100 ± 22, p=.02) of the left ventricle. CONCLUSION CH treated patients developing maternal and/or fetal complications show early pregnancy altered cardiac geometry, diastolic and systolic dysfunction, and impaired hemodynamics with a high resistance circulation.
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Affiliation(s)
- Herbert Valensise
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy.,Department of Surgery, Tor Vergata University, Rome, Italy
| | - Daniele Farsetti
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy.,Department of Surgery, Tor Vergata University, Rome, Italy
| | - Ilaria Pisani
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | | | - Giulia Gagliardi
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - Damiano Lo Presti
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | | | - Barbara Vasapollo
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
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Vasapollo B, Novelli GP, Gagliardi G, Farsetti D, Valensise H. Pregnancy complications in chronic hypertensive patients are linked to pre-pregnancy maternal cardiac function and structure. Am J Obstet Gynecol 2020; 223:425.e1-425.e13. [PMID: 32142824 DOI: 10.1016/j.ajog.2020.02.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic hypertension complicates around 3% of all pregnancies and is associated with an increased risk for pregnancy complications such as superimposed preeclampsia, fetal growth restriction, preterm delivery, and stillbirth, reaching a rate of complications of up to 25-28%. OBJECTIVE We performed an echocardiographic study to evaluate pre-pregnancy cardiac geometry and function, along with the hemodynamic features of treated chronic hypertension patients, searching for a possible correlation with the development of feto-maternal complications and with pre-pregnancy therapy. MATERIALS AND METHODS This was a prospective observational cohort study of 192 consecutive patients receiving treatment for chronic hypertension (calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, α1-adrenoceptor antagonists, and/or diuretics). Patients underwent echocardiography before pregnancy, assessing left ventricular morphology and function, cardiac output, and total vascular resistance. Pre-pregnancy therapy was noted, patients were shifted to α-methyldopa right before pregnancy, and were followed until delivery, noting major early (<34weeks' gestation) and late (≥34 weeks' gestation) complications. Comparisons among the 3 groups (ie, those with no complications, early complications, and late complications) were performed with 1-way analysis of variance with Student-Newman-Keuls correction for multiple comparisons. The Mann-Whitney U test was used for non-normally distributed data. Comparison of proportions was used as appropriate. Receiver operating characteristic curve analysis was used to identify cutoff values of diastolic dysfunction in this population using the E/e' ratio, and separate cutoff of values for total vascular resistance for the prediction of early and late complications of pregnancy. Binary univariate and multivariate logistic regression as well as Cox proportional hazards regression were used to evaluate the possible correlation among angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and/or calcium channel blocker pre-pregnancy therapy, cardiovascular features, and the risk for subsequent early and late complications of pregnancy. RESULTS Of 192 patients, 141 had no complications, and 51 had a complicated pregnancy (24 had early complications and 27 had late complications). Concentric geometry was more frequent in those women with early versus late and no complications (50% vs 13.5% and 11.1%, respectively; P < .05), whereas eccentric hypertrophy was more represented in women with late versus early and no complications (32% versus 12.5% and 1.4%, respectively; P < .05). The receiver operating characteristic curve showed an E/e' ratio value >7.65 (sensitivity, 59.6%; specificity, 68.6%) as a predictor of subsequent complications of pregnancy, whereas total vascular resistance <1048 (sensitivity, 83.7%; specificity, 55.6%) was predictive for late complications and total vascular resistance >1498 (sensitivity, 87.5%; specificity, 78.0%) for the early complications of pregnancy. Univariate analysis showed that the following parameters were predictive for complications of pregnancy: altered geometry of the left ventricle (odds ratio, 5.94; 95% confidence interval, 2.90-12.19), diastolic dysfunction (odds ratio, 3.22; 95% confidence interval, 1.63-6.37), altered total vascular resistance (odds ratio, 3.52; 95% confidence interval, 1.78-6.97), and pre-pregnancy therapy without calcium channel blockers/angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (odds ratio, 2.73; 95% confidence interval, 1.37-5.42). These parameters, except for altered total vascular resistance, were independent predictors in the multivariate analysis corrected for body mass index, heart rate, parity, and mean arterial pressure. CONCLUSION Chronic hypertension patients with pre-pregnancy cardiac remodeling and dysfunction more often develop early and late complications of pregnancy. Pre-pregnancy therapy for chronic hypertension patients with calcium channel blockers and/or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers may positively influence cardiac profiles and the outcome of a future pregnancy with a reduced rate of complications.
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21
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Mulder EG, Ghossein-Doha C, Crutsen J, Van Kuijk S, Thilaganathan B, Spaanderman M. Effect of pregnancy prolongation in early-onset pre-eclampsia on postpartum maternal cardiovascular, renal and metabolic function in primiparous women: an observational study. BJOG 2020; 128:121-129. [PMID: 32725713 PMCID: PMC7754285 DOI: 10.1111/1471-0528.16435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2020] [Indexed: 12/12/2022]
Abstract
Objective To evaluate the association between deferred delivery in early‐onset pre‐eclampsia and offspring outcome and maternal cardiovascular, renal and metabolic function in the postpartum period. Design Observational study. Setting Tertiary referral hospital. Population Nulliparous women diagnosed with pre‐eclampsia before 34 weeks’ gestation who participated in a routine postpartum cardiovascular risk assessment programme. Women with hypertension, diabetes mellitus or renal disease prior to pregnancy were excluded. Methods Regression analyses were performed to assess the association between pregnancy prolongation and outcome measures. Main outcome measures Offspring outcome and prevalence of deviant maternal cardiovascular, renal and metabolic function. Results The study population included 564 women with a median pregnancy prolongation of 10 days (interquartile range [IQR] 4–18) who were assessed at on average 8 months (IQR 6–12) postpartum. Pregnancy prolongation after diagnosis resulted in a decrease in infant mortality (adjusted odd ratio [aOR] 0.907, 95% CI 0.852–0.965 per day prolongation). This improvement in offspring outcome was associated with an elevated risk of moderately increased albuminuria (aOR 1.025, 95% CI 1.006–1.045 per day prolongation), but not with aberrant cardiac geometry, cardiac systolic or diastolic dysfunction, persistent hypertension or metabolic syndrome. Conclusion Pregnancy prolongation in early‐onset pre‐eclampsia is associated with improved offspring outcome and survival. These effects do not appear to be deleterious to short‐term maternal cardiovascular and metabolic function but are associated with a modest increase in risk of residual albuminuria. Tweetable abstract Pregnancy prolongation in pre‐eclampsia has only a limited effect on postpartum maternal cardiovascular function. Pregnancy prolongation in pre‐eclampsia has only a limited effect on postpartum maternal cardiovascular function.
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Affiliation(s)
- E G Mulder
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - C Ghossein-Doha
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jrw Crutsen
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Smj Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - B Thilaganathan
- St George's University of London, Molecular and Clinical Sciences Research Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mea Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
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22
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Gyselaers W, Lees C, Valensise H, Thilaganathan B. Preeclampsia: the role of persistent endothelial cells in uteroplacental arteries. Brosens I, Brosens JJ, Muter J, Puttemans P, Benagiano G. Am J Obstet Gynecol 2019;221:219-26. Am J Obstet Gynecol 2020; 222:633. [PMID: 31981511 DOI: 10.1016/j.ajog.2019.12.274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/21/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Wilfried Gyselaers
- Department of Physiology, Hasselt University, Hasselt, Belgium; Department of Obstetrics & Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Christoph Lees
- Professor of Obstetrics, Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Herbert Valensise
- Professor Obstetrics and Gynaecology, Obstetrics and Gynecology Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome, Italy
| | - Basky Thilaganathan
- Professor Fetal Maternal Medicine, Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
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Abstract
Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.
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Affiliation(s)
- Eliza C Miller
- From the Department of Neurology, Division of Stroke and Cerebrovascular Disease, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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24
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Affiliation(s)
- Basky Thilaganathan
- From the Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, United Kingdom (B.T.).,Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Erkan Kalafat
- Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara University, Turkey (E.K.)
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25
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Reddy M, Wright L, Rolnik DL, Li W, Mol BW, La Gerche A, da SilvaCosta F, Wallace EM, Palmer K. Evaluation of Cardiac Function in Women With a History of Preeclampsia: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2019; 8:e013545. [PMID: 31698969 PMCID: PMC6915290 DOI: 10.1161/jaha.119.013545] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Women with a history of preeclampsia are at increased risk of cardiovascular morbidity and mortality. However, the underlying mechanisms of disease association, and the ideal method of monitoring this high‐risk group, remains unclear. This review aims to determine whether women with a history of preeclampsia show clinical or subclinical cardiac changes when evaluated with an echocardiogram. Methods and Results A systematic search of MEDLINE, EMBASE, and CINAHL databases was performed to identify studies that examined cardiac function in women with a history of preeclampsia, in comparison with those with normotensive pregnancies. In the 27 included studies, we found no significant differences between preeclampsia and nonpreeclampsia women with regard to left ventricular ejection fraction, isovolumetric relaxation time, or deceleration time. Women with a history of preeclampsia demonstrated a higher left ventricular mass index and relative wall thickness with a mean difference of 4.25 g/m2 (95% CI, 2.08, 6.42) and 0.03 (95% CI, 0.01, 0.05), respectively. In comparison with the nonpreeclampsia population, they also demonstrated a lower E/A and a higher E/e′ ratio with a mean difference of −0.08 (95% CI, −0.15, −0.01) and 0.84 (95% CI, 0.41, 1.27), respectively. Conclusions In comparison with women who had a normotensive pregnancy, women with a history of preeclampsia demonstrated a trend toward altered cardiac structure and function. Further studies with larger sample sizes and consistent echocardiogram reporting with the use of sensitive preclinical markers are required to assess the role of echocardiography in monitoring this high‐risk population group.
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Affiliation(s)
- Maya Reddy
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
| | - Leah Wright
- Baker Heart and Diabetes Institute Melbourne Victoria Australia
| | - Daniel Lorber Rolnik
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
| | - Wentao Li
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Ben Willem Mol
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute Melbourne Victoria Australia.,Department of Cardiology St Vincent's Hospital Melbourne Victoria Australia
| | - Fabricio da SilvaCosta
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Department of Gynecology and Obstetrics Ribeirão Preto Medical School University of São Paulo Ribeirão Preto Brazil
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia
| | - Kirsten Palmer
- Department of Obstetrics and Gynaecology Monash University Melbourne Victoria Australia.,Monash Women's Monash Health Melbourne Victoria Australia
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26
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Thayaparan AS, Said JM, Lowe SA, McLean A, Yang Y. Pre-eclampsia and long-term cardiac dysfunction: A review of asymptomatic cardiac changes existing well beyond the post-partum period. Australas J Ultrasound Med 2019; 22:234-244. [PMID: 34760564 PMCID: PMC8411796 DOI: 10.1002/ajum.12173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/08/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pre-eclampsia is a disease of pregnancy characterised by the manifestations of multi-organ dysfunction. The recent use of transthoracic echocardiography in the assessment of women with pre-eclampsia has allowed the detection of cardiac systolic and diastolic dysfunction in the acute phase. Women with a history of pre-eclampsia also have increased lifelong risks of cardiovascular disease and mortality that persists well beyond the post-partum period. These developments raise the possibility that pre-eclampsia may be an early marker of cardiovascular disease and the potential role for echocardiography in guiding the detection and management of this. This review aims to summarise the existing evidence of echocardiographic cardiac assessment of women with a history of pre-eclampsia performed more than 12 weeks post-partum. METHODS A systematic search of PubMed and OVID EMBASE databases was performed to identify studies featuring assessment of cardiac function performed after 12 weeks post-partum in women with a history of pre-eclampsia. Studies without post-partum cardiac assessment or with other documented causes for cardiomyopathy were excluded. RESULTS Thirteen studies were identified that measured cardiac function by transthoracic echocardiography between 6 months and 18 years following a pregnancy complicated by pre-eclampsia. Common findings across the studies were of increased diastolic dysfunction, increased left ventricular mass index (LVMI) and concentric hypertrophy in women with a history of pre-eclampsia, as compared to women with uncomplicated pregnancy histories. This was predominantly seen in those with a history of early or preterm pre-eclampsia. CONCLUSIONS Women with a history of early or preterm pre-eclampsia have an increased prevalence of diastolic dysfunction. This review demonstrates that the cardiac dysfunction associated with previous pre-eclampsia is quantifiable and persistent. Progression of heart failure from asymptomatic to symptomatic stages carries a fivefold increase in mortality. The use of echocardiography could detect cardiac dysfunction in the asymptomatic stage and guide more intensive risk factor modification in these women.
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Affiliation(s)
| | - Joanne M Said
- Joan Kirner Women's and Childrens HospitalSt AlbansVictoriaAustralia
| | - Sandra A Lowe
- Royal Hospital for WomenRandwickNew South WalesAustralia
| | | | - Yang Yang
- Western Health, Eastern HealthEpworth HospitalVictoriaAustralia
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27
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Morikawa M, Umazume T, Nakagawa K, Chiba K, Kawaguchi S, Watari H. Low antithrombin activity before delivery predicts subsequent hypertensive disorders in pregnancy. Int J Gynaecol Obstet 2019; 147:375-381. [PMID: 31552678 DOI: 10.1002/ijgo.12980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/12/2019] [Accepted: 09/23/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine whether laboratory parameters can predict the onset of recurrent hypertensive disorders of pregnancy (HDP). METHODS A retrospective study of 257 women with consecutive deliveries at a hospital in Sapporo, Japan, between 2009 and 2017. Women were divided into four groups according to whether or not they had HDP in the first and second peripartum periods (HDP-HPD, HDP-Non, Non-HDP, Non-Non). HDP was defined as gestational hypertension and/or proteinuria. Laboratory parameters measured on the day of or 1 day before delivery were compared between peripartum-1 and peripartum-2. RESULTS Frequency of HDP in peripartum-2 was higher among the 24 (9.3%) women with HPD in peripartum-1 (6/24, 25.0%) than among the 233 (90.7%) women without (3/233, 1.3%) (P<0.001). In peripartum-1, women with HDP had lower median antithrombin activity than those without (74% vs 89%, P=0.021). Antithrombin activity in peripartum-1 was also lower in the HDP-HDP (67%) than in the HDP-Non (79%) group (P=0.021). Antithrombin activities of 77% or less at the first delivery predicted HDP in peripartum-1 (P<0.001) and 70% or less predicted HDP in peripartum-2 (P=0.018). CONCLUSION Women with HDP in peripartum-1 had a higher incidence of HDP recurrence. Low antithrombin before a first delivery might predict recurrent HDP in a second pregnancy.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takeshi Umazume
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kinuko Nakagawa
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Chiba
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Kawaguchi
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hidemichi Watari
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Vaught AJ, Kovell LC, Szymanski LM, Mayer SA, Seifert SM, Vaidya D, Murphy JD, Argani C, O'Kelly A, York S, Ouyang P, Mukherjee M, Zakaria S. Acute Cardiac Effects of Severe Pre-Eclampsia. J Am Coll Cardiol 2019; 72:1-11. [PMID: 29957219 DOI: 10.1016/j.jacc.2018.04.048] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 03/23/2018] [Accepted: 04/07/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Pre-eclampsia with severe features (PEC) is a pregnancy-specific syndrome characterized by severe hypertension and end-organ dysfunction, and is associated with short-term adverse cardiovascular events, including heart failure, pulmonary edema, and stroke. OBJECTIVES The authors aimed to characterize the short-term echocardiographic, clinical, and laboratory changes in women with PEC, focusing on right ventricular (RV) systolic pressure (RVSP) and echocardiographic-derived diastolic, systolic, and speckle tracking parameters. METHODS In this prospective observational study, the authors recruited 63 women with PEC and 36 pregnant control patients. RESULTS The PEC cohort had higher RVSP (31.0 ± 7.9 mm Hg vs. 22.5 ± 6.1 mm Hg; p < 0.001) and decreased global RV longitudinal systolic strain (RVLSS) (-19.6 ± 3.2% vs. -23.8 ± 2.9% [p < 0.0001]) when compared with the control cohort. For left-sided cardiac parameters, there were differences (p < 0.001) in mitral septal e' velocity (9.6 ± 2.4 cm/s vs. 11.6 ± 1.9 cm/s), septal E/e' ratio (10.8 ± 2.8 vs. 7.4 ± 1.6), left atrial area size (20.1 ± 3.8 cm2 vs. 17.3 ± 2.9 cm2), and posterior and septal wall thickness (median [interquartile range]: 1.0 cm [0.9 to 1.1 cm] vs. 0.8 cm [0.7 to 0.9 cm], and 1.0 cm [0.8 to 1.2 cm] vs. 0.8 cm [0.7 to 0.9 cm]). Eight women (12.7%) with PEC had grade II diastolic dysfunction, and 6 women (9.5%) had peripartum pulmonary edema. CONCLUSIONS Women with PEC have higher RVSP, higher rates of abnormal diastolic function, decreased global RVLSS, increased left-sided chamber remodeling, and higher rates of peripartum pulmonary edema, when compared with healthy pregnant women.
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Affiliation(s)
- Arthur Jason Vaught
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Lara C Kovell
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Linda M Szymanski
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan A Mayer
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sara M Seifert
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jamie D Murphy
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia Argani
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anna O'Kelly
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah York
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pamela Ouyang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Monica Mukherjee
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sammy Zakaria
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Zhang L, Wang K, Wu Q, Jin L, Lu H, Shi Y, Liu L, Yang L, Lv L. Let-7 inhibits the migration and invasion of extravillous trophoblast cell via targeting MDM4. Mol Cell Probes 2019; 45:48-56. [DOI: 10.1016/j.mcp.2019.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/23/2019] [Accepted: 05/09/2019] [Indexed: 01/12/2023]
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Maternal Cardiac Function after Normal Delivery, Preeclampsia, and Eclampsia: A Prospective Study. J Pregnancy 2019; 2019:9795765. [PMID: 30941219 PMCID: PMC6420982 DOI: 10.1155/2019/9795765] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/03/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction The aim of this study is to assess maternal cardiac function in the postpartum period, after 2 and 6 months in the parturient with preeclampsia and eclampsia. Materials and Methods Prospective study: 90 postpartum women after preeclampsia and eclampsia and 55 patients after an uncomplicated pregnancy. The parameters of maternal hemodynamics were recorded on days 1, 3, 5, 9, and 14 of postpartum period, after 2 and 6 months. The cardiac parameters were assessed. Results PE is accompanied by increased peripheral vascular resistance. The indicator of vascular resistance, SVR, is elevated for both mild and severe PE. With mild PE, a significant increase in SVR is observed up to 5 days of postpartum period, with severe PE/E up to 9 days. We found that in case of severe PE, SVR remains elevated to 6 months after delivery. The parameters of the contractile function of the heart (ESV, EDV, SV, SI, CO, СI, MVCF) were significantly decreased: with mild PE up to 5-9 days, with severe up to 9-14 days of puerperia. ESV, SV, SI, CO, and CI remain low with severe PE up to 6 months. The revealed decreasing of contractile function of the heart is a sign of asymptomatic heart failure. Conclusions The hemodynamics of the puerperas after PE and E is characterized by impaired contractility of the myocardium and an increase in the indices of peripheral resistance. The degree of deviation in the parameters of cardiac hemodynamics and vascular resistance depended on the severity of hypertensive complications of pregnancy.
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Pregnancy-Associated Cardiac Hypertrophy in Corin-Deficient Mice: Observations in a Transgenic Model of Preeclampsia. Can J Cardiol 2018; 35:68-76. [PMID: 30595185 DOI: 10.1016/j.cjca.2018.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 10/19/2018] [Accepted: 11/01/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Preeclampsia increases the risk of heart disease. Defects in the protease corin, including the variant T555I/Q568P found in approximately 12% of blacks, have been associated with preeclampsia and cardiac hypertrophy. The objective of this study was to investigate the role of corin and the T555I/Q568P variant in preeclampsia-associated cardiac alterations using genetically modified mouse models. METHODS Virgin wild-type (WT) and corin knockout mice with or without a cardiac WT corin or T555I/Q568P variant transgene were mated at 3 or 6 months of age. Age- and genotype-matched virgin mice were used as controls. Cardiac morphology and function were assessed at gestational day 18.5 or 28 days postpartum by histologic and echocardiographic analyses. RESULTS Pregnant corin knockout mice at gestational day 18.5 developed cardiac hypertrophy. Such a pregnancy-associated phenotype was not found in WT or corin knockout mice with a cardiac WT corin transgene. Pregnant corin knockout mice with a cardiac T555I/Q568P variant transgene developed cardiac hypertrophy similar to that in pregnant corin knockout mice. The cardiac hypertrophy persisted postpartum in corin knockout mice and was worse if the mice were mated at 6 instead of 3 months of age. There was no hypertrophy-associated decrease in cardiac function in pregnant corin knockout mice. CONCLUSIONS In mice, corin deficiency causes cardiac hypertrophy during pregnancy. Replacement of cardiac WT corin, but not the T555I/Q568P variant found in blacks, rescues this phenotype, indicating a local antihypertrophic function of corin in the heart. Corin deficiency may represent an underlying mechanism in preeclampsia-associated cardiomyopathies.
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Hieda M, Yoo JK, Sun DD, Okada Y, Parker RS, Roberts-Reeves MA, Adams-Huet B, Nelson DB, Levine BD, Fu Q. Time course of changes in maternal left ventricular function during subsequent pregnancy in women with a history of gestational hypertensive disorders. Am J Physiol Regul Integr Comp Physiol 2018; 315:R587-R594. [PMID: 29897820 PMCID: PMC6230888 DOI: 10.1152/ajpregu.00040.2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/29/2018] [Accepted: 06/11/2018] [Indexed: 01/04/2023]
Abstract
Women with a history of gestational hypertensive disorders (GHD) are at increased risk for developing perinatal cardiovascular complications (e.g., gestational hypertension, preeclampsia, etc.) in subsequent pregnancies. The underlying mechanisms remain uncertain, but impaired maternal left ventricular function may be one contributing factor for these complications. We evaluated the time course of changes in left ventricular function before, during, and after pregnancy in women with prior GHD. Sixteen women with a history of GHD (the high-risk group) and 25 women without such a history (controls) were enrolled. Resting hemodynamic and echocardiographic measurements were longitudinally performed before pregnancy, during early pregnancy (4-8 wk of gestation), during late pregnancy (32-36 wk of gestation), and postpartum (6-10 wk after delivery). Pregnancy outcomes were obtained after delivery. At prepregnancy, there was no difference in blood pressure and heart rate between the groups. Corrected isovolumic relaxation time was longer, E/ e' was larger, and Tei index was greater in the high-risk group than controls. Moreover, the rate of GHD during the study was significantly greater in the high-risk group than controls [odds ratio = 8.94 (95% confidence interval: 1.55-51.5), P = 0.007]. Multiple logistic regression analysis adjusted for age demonstrated that prepregnancy E/ e' was an independent predictor for GHD ( P = 0.017). Thus, women with a history of GHD have modestly impaired cardiac function prepregnancy compared with controls, which identifies an increased susceptibility to developing cardiovascular complications during a subsequent pregnancy.
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Affiliation(s)
- Michinari Hieda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeung-Ki Yoo
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dan-Dan Sun
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yoshiyuki Okada
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rosemary S Parker
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Monique A Roberts-Reeves
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Beverley Adams-Huet
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - David B Nelson
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Qi Fu
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas and University of Texas Southwestern Medical Center, Dallas, Texas
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Orabona R, Sciatti E, Prefumo F, Vizzardi E, Bonadei I, Valcamonico A, Metra M, Frusca T. Pre-eclampsia and heart failure: a close relationship. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:297-301. [PMID: 29266525 DOI: 10.1002/uog.18987] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/19/2017] [Accepted: 12/08/2017] [Indexed: 06/07/2023]
Affiliation(s)
- R Orabona
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - E Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - F Prefumo
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - E Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - I Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - A Valcamonico
- Department of Obstetrics and Gynecology, University of Brescia, Brescia, Italy
| | - M Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - T Frusca
- Department of Obstetrics and Gynecology, University of Parma, Parma, Italy
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34
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Novelli GP, Vasapollo B, Valensise H. Hemodynamic Prediction and Stratification of Hypertensive Disorders of Pregnancy: A Dream That Is Coming True? J Am Heart Assoc 2018; 7:JAHA.118.010084. [PMID: 30007938 PMCID: PMC6064850 DOI: 10.1161/jaha.118.010084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Gian Paolo Novelli
- Department of Cardiology, Ospedale San Sebastiano Martire, Frascati, Rome, Italy
| | - Barbara Vasapollo
- Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Herbert Valensise
- Department of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy.,Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
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Abstract
PURPOSE OF REVIEW To review the current data on maternal cardiovascular adaptation in normal pregnancy and preeclampsia. RECENT FINDINGS Defective placentation causes early-onset preeclampsia, a disease entity that is considered more or less distinct from late-onset preeclampsia. The latter has been attributed as 'maternal' preeclampsia. There are inconsistencies with the placental origins hypothesis, especially when considering the lack of a causative association with abnormal placental histology or impaired fetal growth. An alternative explanation is that placental dysfunction is secondary to maternal cardiovascular maladaptation in pregnancy. The concept that placental dysfunction is secondary to a maternal disorder is not new when one considers the clinical similarities between preeclampsia and gestational diabetes - both pregnancy-specific conditions that are cured by birth. It is accepted that gestational diabetes develops when the maternal pancreas is unable to manage the increasing glucose load of pregnancy. It is now apparent that pregnancy presents a substantial cardiovascular load on the maternal heart, and that cardiovascular dysfunction precedes the disorder, predominates in the clinical syndrome and persists for several decades postpartum. It is time to consider the evidence that failure of the maternal cardiovascular system to adapt to pregnancy may well be the primary mechanism leading to secondary placental dysfunction in preeclampsia. SUMMARY Many of the existing paradoxes of preeclampsia challenge the placental origin hypothesis and are explained if one considered preeclampsia to be a cardiovascular syndrome.
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36
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Ushida T, Macdonald-Goodfellow SK, Quadri A, Tse MY, Winn LM, Pang SC, Adams MA, Kotani T, Kikkawa F, Graham CH. Persistence of risk factors associated with maternal cardiovascular disease following aberrant inflammation in rat pregnancy. Biol Reprod 2018; 97:143-152. [PMID: 28859286 DOI: 10.1093/biolre/iox072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/04/2017] [Indexed: 01/21/2023] Open
Abstract
Introduction Pre-eclampsia is associated with increased risk of subsequent cardiovascular and metabolic disease in the affected mothers. While aberrant inflammation contributes to the pathophysiology of pre-eclampsia, it is unclear whether maternal inflammation contributes to the increased risk of disease. Here, we determined the effect of aberrant inflammation in pregnancy on cardiovascular and metabolic disease risk factors. Methods Wistar rats were administered low doses of lipopolysaccharide (LPS) on gestational days (GD) 13.5-16.5 to induce inflammation. Controls included pregnant rats treated with saline and nonpregnant rats treated with LPS or saline. We previously showed that LPS-treated pregnant rats exhibit key features of pre-eclampsia. Echocardiographic parameters, heart weight, blood pressure, blood lipids, pulse-wave velocity, and glucose tolerance, were assessed at 16 weeks postpartum. Messenger RNA levels of transcription factors associated with cardiac growth were measured in left ventricular tissue; histone modifications and global DNA methylation were determined in hearts and livers at GD 17.5 and at 16 weeks postpartum. Results Compared with saline-treated pregnant rats and nonpregnant rats treated with LPS or saline, LPS-treated pregnant rats exhibited left ventricular hypertrophy and increased blood cholesterol and low-density lipoprotein levels at 16 weeks postdelivery. LPS-treated rats had increased left ventricular mRNA levels of hypertrophy-associated transcription factors at GD 17.5 and increased levels of modified histones in hearts and livers at GD 17.5 and 16 weeks postpartum. Other parameters remained unchanged. Conclusion Aberrant inflammation during pregnancy results in persistent alterations in maternal physiological parameters and epigenetic modifications that could contribute to the pathophysiology of cardiovascular disease.
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Affiliation(s)
- Takafumi Ushida
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada.,Department of Gynecology and Obstetrics, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | | | - Allegra Quadri
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - M Yat Tse
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Louise M Winn
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Stephen C Pang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Michael A Adams
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Tomomi Kotani
- Department of Gynecology and Obstetrics, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Fumitaka Kikkawa
- Department of Gynecology and Obstetrics, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya, Japan
| | - Charles H Graham
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
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Vasapollo B, Lo Presti D, Gagliardi G, Farsetti D, Tiralongo GM, Pisani I, Novelli GP, Valensise H. Restricted physical activity in pregnancy reduces maternal vascular resistance and improves fetal growth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:672-676. [PMID: 28397385 DOI: 10.1002/uog.17489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 01/29/2017] [Accepted: 03/31/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To test the efficacy of maternal activity restriction for reducing peripheral vascular resistance in normotensive pregnant women with raised total vascular resistance (TVR) and to evaluate its effect on fetal growth. METHODS This was a prospective case-control study of 30 women enrolled between 27 and 29 weeks' gestation. All patients met the following criteria: normal blood pressure before and during pregnancy, TVR between 1300 and 1400 dynes × s/cm5 at enrolment, normal fetal Doppler parameters at enrolment and abdominal circumference between the 10th and 25th centiles. Patients were assigned to activity restriction (activity-restriction group; n = 15) or no treatment (control group; n = 15) and were assessed after 4 weeks for TVR and fetal growth. RESULTS TVR at enrolment and estimated fetal weight centile were similar in the activity-restriction group vs controls (1358 ± 26 vs 1353 ± 30 dynes × s/cm5 ; 18th ± 4 vs 19th ± 4 centile; P = NS). After 4 weeks, the activity-restriction group compared with controls showed significantly lower TVR (1165 ± 159 vs 1314 ± 190 dynes × s/cm5 ; P < 0.05), which was associated with higher estimated fetal weight centile (25th ± 5 vs 20th ± 5 centile; P < 0.05). TVR was lower and estimated fetal weight centile higher for the activity-restriction group after 4 weeks compared with at enrolment. CONCLUSIONS In normotensive pregnant women with raised TVR, maternal activity restriction appears to be effective in reducing TVR and therefore enhancing fetal growth. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- B Vasapollo
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
| | - D Lo Presti
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
| | - G Gagliardi
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
| | - D Farsetti
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
| | - G M Tiralongo
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
| | - I Pisani
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
| | - G P Novelli
- Department of Cardiology, San Sebastiano Martire Hospital, Frascati, Rome, Italy
| | - H Valensise
- Department of Biomedicine, Obstetrics and Gynaecology, Policlinico Casilino, Tor Vergata University, Rome, Italy
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McLaughlin K, Scholten RR, Parker JD, Ferrazzi E, Kingdom JCP. Low molecular weight heparin for the prevention of severe preeclampsia: where next? Br J Clin Pharmacol 2018; 84:673-678. [PMID: 29226532 DOI: 10.1111/bcp.13483] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/29/2017] [Indexed: 12/14/2022] Open
Abstract
Low molecular weight heparin has been extensively evaluated for the prevention of preeclampsia in high-risk pregnant women; however, the results from these trials have been conflicting. This review discusses the potential mechanisms of action of low molecular weight heparin for the prevention of severe preeclampsia, how to optimize the selection of high-risk women for participation in future trials, and the importance of trial standardization.
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Affiliation(s)
- Kelsey McLaughlin
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.,Department of Medicine, Division of Cardiology, Sinai Health System, University of Toronto, Canada
| | - Ralph R Scholten
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Sinai Health System, University of Toronto, Canada
| | - John D Parker
- Department of Medicine, Division of Cardiology, Sinai Health System, University of Toronto, Canada
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynaecology, Buzzi Children's Hospital, University of Milan, Italy
| | - John C P Kingdom
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.,Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Sinai Health System, University of Toronto, Canada
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Abstract
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.
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40
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Echocardiographic Techniques of Deformation Imaging in the Evaluation of Maternal Cardiovascular System in Patients with Complicated Pregnancies. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4139635. [PMID: 28904957 PMCID: PMC5585628 DOI: 10.1155/2017/4139635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 07/17/2017] [Indexed: 11/21/2022]
Abstract
Cardiovascular diseases (CVD) represent the leading cause of maternal mortality and morbidity. Knowledge of CVD in women is constantly evolving and data are emerging that female-specific risk factors as complications of pregnancy are conditions associated with an increased risk for the long-term development of CVD. Echocardiography is a safe and effective imaging technique indicated in symptomatic or asymptomatic pregnant women with congenital heart diseases who require close monitoring of cardiac function. Deformation imaging is an echocardiographic technique used to assess myocardial function by measuring the actual deformation of the myocardium through the cardiac cycle. Speckle-tracking echocardiography (STE) is a two-dimensional (2D) technique which has been found to be more accurate than tissue Doppler to assess both left ventricular (LV) and right ventricular (RV) myocardial function. The use of 2D STE however might present some technical issues due to the tomographic nature of the technique and the motion in the three-dimensional space of the myocardial speckles. This has promoted the use of 3D STE to track the motion of the speckles in the 3D space. This review will focus on the clinical value of the new echocardiographic techniques of deformation imaging used to assess the maternal cardiovascular system in complicated pregnancies.
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Piccoli GB, Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Spotti D, Giacchino F, Attini R, Limardo M, Maxia S, Fois A, Gammaro L, Todros T. A best practice position statement on the role of the nephrologist in the prevention and follow-up of preeclampsia: the Italian study group on kidney and pregnancy. J Nephrol 2017; 30:307-317. [PMID: 28434090 DOI: 10.1007/s40620-017-0390-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/09/2017] [Indexed: 02/07/2023]
Abstract
Preeclampsia (PE) is a protean syndrome causing a transitory kidney disease, characterised by hypertension and proteinuria, ultimately reversible after delivery. Its prevalence is variously estimated, from 3 to 5% to 10% if all the related disorders, including also pregnancy-induced hypertension (PIH) and HELLP syndrome (haemolysis, increase in liver enzyme, low platelets) are included. Both nephrologists and obstetricians are involved in the management of the disease, according to different protocols, and the clinical management, as well as the role for each specialty, differs worldwide. The increased awareness of the role of chronic kidney disease in pregnancy, complicating up to 3% of pregnancies, and the knowledge that PE is associated with an increased risk for development of CKD later in life have recently increased the interest and redesigned the role of the nephrologists in this context. However, while the heterogeneous definitions of PE, its recent reclassification, an emerging role for biochemical biomarkers, the growing body of epidemiological data and the new potential therapeutic interventions lead to counsel long-term follow-up, the lack of resources for chronic patients and the increasing costs of care limit the potential for preventive actions, and suggest tailoring specific interventional strategies. The aim of the present position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature and to try to identify theoretical and pragmatic bases for an agreed management of PE in the nephrological setting, with particular attention to the prevention of the syndrome (recurrent PE, presence of baseline CKD) and to the organization of the postpartum follow-up.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy. .,Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
| | | | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milan, Italy
| | - Donatella Spotti
- Nephrology and Dialysis, IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Turin, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Antioco Fois
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Linda Gammaro
- Nephrology Ospedale Fracastoro San Bonifacio, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Turin, Italy
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Shahul S, Medvedofsky D, Wenger JB, Nizamuddin J, Brown SM, Bajracharya S, Salahuddin S, Thadhani R, Mueller A, Tung A, Lang RM, Arany Z, Talmor D, Karumanchi SA, Rana S. Circulating Antiangiogenic Factors and Myocardial Dysfunction in Hypertensive Disorders of Pregnancy. Hypertension 2016; 67:1273-80. [PMID: 27113052 DOI: 10.1161/hypertensionaha.116.07252] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 03/13/2016] [Indexed: 12/13/2022]
Abstract
Hypertensive disorders of pregnancy (HDP) are associated with subclinical changes in cardiac function. Although the mechanism underlying this finding is unknown, elevated levels of soluble antiangiogenic proteins such as soluble fms-like tyrosine kinase-1 (sFlt1) and soluble endoglin (sEng) are associated with myocardial dysfunction and may play a role. We hypothesized that these antiangiogenic proteins may contribute to the development of cardiac dysfunction in HDP. We prospectively studied 207 pregnant women with HDP and nonhypertensive controls and evaluated whether changes in global longitudinal strain (GLS) observed on echocardiography is specific for HDP and whether these changes correlate with HDP biomarkers, sFlt1 and sEng. A total of 62 (30%) patients were diagnosed with preeclampsia (group A), 105 (51%) did not have an HDP (group B), and 40 (19%) were diagnosed with chronic or gestational hypertension (group C). Blood was drawn and sFlt1 and sEng levels measured using enzyme-linked immunosorbent assay. Comprehensive echocardiograms, including measurement of GLS, were performed on all patients. Overall, GLS was worse in women in group A (preeclampsia) than those in group B or C. Increasing sFlt1 and sEng levels correlated with worsening GLS (r=0.44 for sFlt1 and r=0.46 for sEng, both P<0.001), which remained significant after multivariable analysis (r=0.18 and r=0.22, both P≤0.01). Increasing levels also correlated with increasing left ventricular mass index, which also remained significant after multivariable analysis (r=0.20 for sFlt1 and 0.19 for sEng, both P=0.01). Elevated circulating levels of antiangiogenic proteins in HDP correlate with and may contribute to myocardial dysfunction as measured by GLS.
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Affiliation(s)
- Sajid Shahul
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.).
| | - Diego Medvedofsky
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Julia B Wenger
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Junaid Nizamuddin
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Samuel M Brown
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Surichhya Bajracharya
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Saira Salahuddin
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Ravi Thadhani
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Ariel Mueller
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Avery Tung
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Roberto M Lang
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Zoltan Arany
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Daniel Talmor
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - S Ananth Karumanchi
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
| | - Sarosh Rana
- From the Department of Anesthesia and Critical Care (S.S., J.N., A.T.), Section of Cardiology, Department of Medicine (D.M., R.M.L.), and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology (S.R.), University of Chicago, IL; Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston (J.B.W., R.T.); Center for Humanizing Critical Care, Intermountain Healthcare, Department of Medicine, University of Utah, Salt Lake City (S.M.B.); Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (S.B., S.A.K., S.R.); Center for Vascular Biology, Department of Medicine (S.S., S.A.K.) and Department of Anesthesia, Critical Care and Pain Medicine (A.M., D.T.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and Department of Medicine, Cardiovascular Institute, University of Pennsylvania, Philadelphia (Z.A.)
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Affiliation(s)
- Eliyahu V Khankin
- From the Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.V.K.); and Cardiovascular Institute, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Z.A.).
| | - Zoltan Arany
- From the Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.V.K.); and Cardiovascular Institute, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Z.A.)
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