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Conti-Ramsden F, de Marvao A, Chappell LC. Pharmacotherapeutic options for the treatment of hypertension in pregnancy. Expert Opin Pharmacother 2024; 25:1739-1758. [PMID: 39225514 DOI: 10.1080/14656566.2024.2398602] [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: 04/23/2024] [Revised: 08/21/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy affect approximately one in 10 pregnancies and are associated with increased risk of adverse fetal, neonatal and maternal outcomes. There is strong evidence that effective treatment of hypertension (blood pressure ≥ 140/90 mmHg), and enhanced monitoring throughout pregnancy reduces these risks. AREAS COVERED This article provides a contemporaneous review of treatment of hypertension in pregnancy with antihypertensive agents. We completed a systematic search and review of all meta-analyses and systematic reviews of studies comparing antihypertensives for treatment of pregnancy hypertension in the last five years. We provide a clinically focused summary of when to treat hypertension in pregnancy and which antihypertensive agents can be offered. Special scenarios reviewed include treatment-resistant hypertension and pre-pregnancy antihypertensive optimization. EXPERT OPINION Several antihypertensives are considered safe and are known to be effective for treatment of hypertension in pregnancy. Given the current uncertainty as to which antihypertensive(s) are superior for treatment of hypertension in pregnancy, women should be counselled and offered a range of antihypertensive options in keeping with evidence on clinical effectiveness, local context and availability of antihypertensive(s), potential side effect profile, and women's preference. Further research is required to help guide clinical decision making, and move toward personalized treatment.
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Affiliation(s)
- Frances Conti-Ramsden
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Antonio de Marvao
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
- Medical Research Council Laboratory of Medical Sciences, Imperial College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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Sampson R, Davis S, Wong R, Baranco N, Silverman RK. Pulse Pressure as a Hemodynamic Parameter in Preeclampsia with Severe Features Accompanied by Fetal Growth Restriction. J Clin Med 2024; 13:4318. [PMID: 39124585 PMCID: PMC11312723 DOI: 10.3390/jcm13154318] [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: 06/28/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Modern management of preeclampsia can be optimized by tailoring the targeted treatment of hypertension to an individual's hemodynamic profile. Growing evidence suggests different phenotypes of preeclampsia, including those with a hyperdynamic profile and those complicated by uteroplacental insufficiency. Fetal growth restriction (FGR) is believed to be a result of uteroplacental insufficiency. There is a paucity of research examining the characteristics of patients with severe preeclampsia who do and who do not develop FGR. We aimed to elucidate which hemodynamic parameters differed between these two groups. Methods: All patients admitted to a single referral center with severe preeclampsia were identified. Patients were included if they had a live birth at 23 weeks of gestation or higher. Multiple gestations and pregnancies complicated by fetal congenital anomalies and/or HELLP syndrome were excluded. FGR was defined as a sonographic estimation of fetal weight (EFW) < 10th percentile or abdominal circumference (AC) < 10th percentile. Results: There were 76% significantly lower odds of overall pulse pressure upon admission for those with severe preeclampsia comorbid with FGR (aOR = 0.24, 95% CI = 0.07-0.83). Advanced gestational age on admission was associated with lower odds of severely abnormal labs and severely elevated diastolic blood pressure in preeclampsia also complicated by FGR. Conclusions: Subtypes of preeclampsia with and without FGR may be hemodynamically evaluated by assessing pulse pressure on admission.
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Affiliation(s)
- Rachael Sampson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Sidney Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Roger Wong
- Department of Public Health and Preventive Medicine, Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
- Department of Geriatrics, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Nicholas Baranco
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Robert K. Silverman
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
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Thomopoulos C, Hitij JB, De Backer T, Gkaliagkousi E, Kreutz R, Lopez-Sublet M, Marketou M, Mihailidou AS, Olszanecka A, Pechère-Bertschi A, Pérez MP, Persu A, Piani F, Socrates T, Stolarz-Skrzypek K, Cífková R. Management of hypertensive disorders in pregnancy: a Position Statement of the European Society of Hypertension Working Group 'Hypertension in Women'. J Hypertens 2024; 42:1109-1132. [PMID: 38690949 DOI: 10.1097/hjh.0000000000003739] [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: 05/03/2024]
Abstract
Hypertensive disorders in pregnancy (HDP), remain the leading cause of adverse maternal, fetal, and neonatal outcomes. Epidemiological factors, comorbidities, assisted reproduction techniques, placental disorders, and genetic predisposition determine the burden of the disease. The pathophysiological substrate and the clinical presentation of HDP are multifarious. The latter and the lack of well designed clinical trials in the field explain the absence of consensus on disease management among relevant international societies. Thus, the usual clinical management of HDP is largely empirical. The current position statement of the Working Group 'Hypertension in Women' of the European Society of Hypertension (ESH) aims to employ the current evidence for the management of HDP, discuss the recommendations made in the 2023 ESH guidelines for the management of hypertension, and shed light on controversial issues in the field to stimulate future research.
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Affiliation(s)
- Costas Thomopoulos
- Department of Cardiology, General Hospital of Athens 'Laiko', Athens, Greece
| | - Jana Brguljan Hitij
- Department of Hypertension, University Medical Centre Ljubljana, Medical University Ljubljana, Slovenia
| | - Tine De Backer
- Cardiovascular Center & Clinical Pharmacology, University Hospital Gent, Belgium
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Reinhold Kreutz
- Charite-Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Marilucy Lopez-Sublet
- AP-HP, Hopital Avicenne, Centre d'Excellence Europeen en Hypertension Arterielle, Service de Medecine Interne, INSERM UMR 942 MASCOT, Paris 13-Universite Paris Nord, Bobigny, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists)
| | - Maria Marketou
- School of Medicine, University of Crete, Heraklion, Greece
| | - Anastasia S Mihailidou
- Department of Cardiology and Kolling Institute, Royal North Shore Hospital, St Leonards
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Agnieszka Olszanecka
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | | | - Mariana Paula Pérez
- Department of Hypertension. Hospital de Agudos J. M. Ramos Mejía, Buenos Aires, Argentina
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Federica Piani
- Hypertension and Cardiovascular Risk Research Center, Medical and Surgical Sciences Department, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thenral Socrates
- Medical Outpatient and Hypertension Clinic, ESH Hypertension Centre of Excellence University Hospital Basel, Basel, Switzerland
| | - Katarzyna Stolarz-Skrzypek
- 1st Department of Cardiology, Interventional Electrocardiology, and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital
- Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic
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Bertschy G, Iannaccone M, Grosso Marra W, Bogliatto F. Obstetric echodynamics: Approaching a new field of multidisciplinary action. Int J Cardiol 2024; 403:131850. [PMID: 38354983 DOI: 10.1016/j.ijcard.2024.131850] [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: 01/16/2024] [Revised: 01/31/2024] [Accepted: 02/10/2024] [Indexed: 02/16/2024]
Abstract
Maternal cardiovascular adaptation during pregnancy is essential for fetal development. Structural and functional changes, including increased blood volume, heart rate, and myocardial hypertrophy, are crucial for optimal tissue perfusion. Recent evidence supports viewing maternal and fetal cardiovascular systems as a unified functional unit, emphasizing the significance of hemodynamic evaluation in pregnancy. Some obstetrical syndromes result from maladaptive maternal cardiovascular responses. Non-invasive hemodynamic tests, like transthoracic echocardiography, aid in distinguishing phenotypes, guiding tailored management strategies for hypertensive disorders. Establishing obstetric hemodynamics as a multidisciplinary field, termed "Obstetric Echodynamics," promises improved clinical care through standardized practices, interdisciplinary cooperation, and enhanced education.
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Affiliation(s)
- Gianluca Bertschy
- Division of Obstetrics and Gynaecology, Ivrea Hospital, ASLTO4, Ivrea, Italy
| | - Mario Iannaccone
- Division of Cardiology, Ospedale San Giovanni Bosco, ASL Città di Torino, Turin, Italy.
| | | | - Fabrizio Bogliatto
- Division of Obstetrics and Gynaecology, Ivrea Hospital, ASLTO4, Ivrea, Italy
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di Pasquo E, Giannubilo SR, Valentini B, Salvi S, Rullo R, Fruci S, Filippi E, Ornaghi S, Zullino S, Rossi F, Farsetti D, Di Martino DD, Vasapollo B, Locatelli A, De Santis M, Ciavattini A, Lanzone A, Mecacci F, Ferrazzi E, Valensise H, Ghi T. The "Preeclampsia and Hypertension Target Treatment" study: a multicenter prospective study to evaluate the effectiveness of the antihypertensive therapy based on maternal hemodynamic findings. Am J Obstet Gynecol MFM 2024; 6:101368. [PMID: 38574856 DOI: 10.1016/j.ajogmf.2024.101368] [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: 12/31/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Despite major advances in the pharmacologic treatment of hypertension in the nonpregnant population, treatments for hypertension in pregnancy have remained largely unchanged over the years. There is recent evidence that a more adequate control of maternal blood pressure is achieved when the first given antihypertensive drug is able to correct the underlying hemodynamic disorder of the mother besides normalizing the blood pressure values. OBJECTIVE This study aimed to compare the blood pressure control in women receiving an appropriate or inappropriate antihypertensive therapy following the baseline hemodynamic findings. STUDY DESIGN This was a prospective multicenter study that included a population of women with de novo diagnosis of hypertensive disorders of pregnancy. A noninvasive assessment of the following maternal parameters was performed on hospital admission via Ultrasound Cardiac Output Monitor before any antihypertensive therapy was given: cardiac output, heart rate, systemic vascular resistance, and stroke volume. The clinician who prescribed the antihypertensive therapy was blinded to the hemodynamic evaluation and used as first-line treatment a vasodilator (nifedipine or alpha methyldopa) or a beta-blocker (labetalol) based on his preferences or on the local protocols. The first-line pharmacologic treatment was retrospectively considered hemodynamically appropriate in either of the following circumstances: (1) women with a hypodynamic profile (defined as low cardiac output [≤5 L/min] and/or high systemic vascular resistance [≥1300 dynes/second/cm2]) who were administered oral nifedipine or alpha methyldopa and (2) women with a hyperdynamic profile (defined as normal or high cardiac output [>5 L/min] and/or low systemic vascular resistances [<1300 dynes/second/cm2]) who were administered oral labetalol. The primary outcome of the study was to compare the occurrence of severe hypertension between women treated with a hemodynamically appropriate therapy and women treated with an inappropriate therapy. RESULTS A total of 152 women with hypertensive disorders of pregnancy were included in the final analysis. Most women displayed a hypodynamic profile (114 [75.0%]) and received a hemodynamically appropriate treatment (116 [76.3%]). The occurrence of severe hypertension before delivery was significantly lower in the group receiving an appropriate therapy than in the group receiving an inappropriately treated (6.0% vs 19.4%, respectively; P=.02). Moreover, the number of women who achieved target values of blood pressure within 48 to 72 hours from the treatment start was higher in the group who received an appropriate treatment than in the group who received an inappropriate treatment (70.7% vs 50.0%, respectively; P=.02). CONCLUSION In pregnant individuals with de novo hypertensive disorders of pregnancy, a lower occurrence of severe hypertension was observed when the first-line antihypertensive agent was tailored to the correct maternal hemodynamic profile.
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Affiliation(s)
- Elvira di Pasquo
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi)
| | - Stefano Raffaele Giannubilo
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy (Drs Giannubilo and Ciavattini)
| | - Beatrice Valentini
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi)
| | - Silvia Salvi
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Roberta Rullo
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Stefano Fruci
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Elisa Filippi
- Department of Obstetrics and Gynecology, Ospedale Ca Foncello, Treviso, Italy (Drs Filippi and Santis)
| | - Sara Ornaghi
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Sara Zullino
- High-Risk Pregnancy Unit, Department of Women's and Children's Health, Azienda Ospedaliera Careggi, Florence, Italy (Drs Zullino and Dr Mecacci)
| | - Francesca Rossi
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Daniele Farsetti
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Daniela Denis Di Martino
- Unit of Obstetrics, Division of Obstetrics and Gynecology, Department of Woman, Child, and Newborn, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino and Ferrazzi)
| | - Barbara Vasapollo
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Anna Locatelli
- Department of Obstetrics, University of Milan-Bicocca, Foundation Istituto di Ricovero e Cura a Carattere Scientifico San Gerardo dei Tintori, Milan, Italy (Drs Ornaghi, Rossi, and Locatelli)
| | - Michela De Santis
- Department of Obstetrics and Gynecology, Ospedale Ca Foncello, Treviso, Italy (Drs Filippi and Santis)
| | - Andrea Ciavattini
- Department of Clinical Sciences, Università Politecnica delle Marche, Ancona, Italy (Drs Giannubilo and Ciavattini)
| | - Antonio Lanzone
- High-Risk Pregnancy Unit, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Largo Agostino Gemelli, Rome, Italy (Drs Salvi, Rullo, Fruci, and Lanzone)
| | - Federico Mecacci
- High-Risk Pregnancy Unit, Department of Women's and Children's Health, Azienda Ospedaliera Careggi, Florence, Italy (Drs Zullino and Dr Mecacci)
| | - Enrico Ferrazzi
- Unit of Obstetrics, Division of Obstetrics and Gynecology, Department of Woman, Child, and Newborn, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino and Ferrazzi)
| | - Hebert Valensise
- Division of Obstetrics and Gynecology, Department of Surgical Sciences, Policlinico Casilino, Tor Vergata University of Rome, Rome, Italy (Drs Farsetti, Vasapollo, and Valensise)
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy (Drs di Pasquo, Valentini, and Ghi); Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy (Dr Ghi).
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Maykin MM, Mercer E, Saiki KM, Kaneshiro B, Miller CB, Tsai PJS. Furosemide to lower antenatal severe hypertension: a randomized placebo-controlled trial. Am J Obstet Gynecol MFM 2024; 6:101348. [PMID: 38485054 DOI: 10.1016/j.ajogmf.2024.101348] [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: 01/29/2024] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a leading cause of perinatal morbidity, and timely treatment of severely elevated blood pressure is recommended to prevent serious sequelae. In acute hypertension marked by increased blood volume, it is unknown whether diuretics used as an adjunct to antihypertensive medications lead to more effective blood pressure control. OBJECTIVE This study aimed to evaluate whether the addition of intravenous furosemide to first-line antihypertensive agents reduces systolic blood pressure in acute-onset, severe antenatal hypertension with wide (≥60 mm Hg) pulse pressure. STUDY DESIGN In this double-blinded randomized trial, participants received 40 mg of intravenous furosemide or placebo in addition to a first-line antihypertensive agent. The primary outcome was mean systolic blood pressure during the first hour after intervention. Secondary outcomes included corresponding diastolic blood pressure; systolic blood pressure, diastolic blood pressure, and pulse pressure at 2 hours after intervention; total reduction from qualifying blood pressure; duration of blood pressure control; need for additional antihypertensive doses within 1 hour; and electrolytes and urine output. A sample size of 35 participants per group was planned to detect a 15-mm Hg difference in blood pressure. RESULTS Between January 2021 and March 2022, 65 individuals were randomized: 33 to furosemide and 32 to placebo. Baseline characteristics were similar between the groups. There was no difference in the primary outcome of mean 1-hour systolic blood pressure (147 [14.8] vs 152 [13.8] mm Hg; P=.200). We found a reduction in 2-hour systolic blood pressure (139 [18.5] vs 154 [18.4] mm Hg; P=.007) and a decrease in 2-hour pulse pressure (55 [12.5] vs 67 [15.1]; P=.003) in the furosemide group. Subgroup analysis according to hypertension type showed a significant reduction in 2-hour systolic blood pressure and 2-hour pulse pressure among patients with new-onset hypertension, but not among those with preexisting hypertension. Urine output was greater in the furosemide group, with no difference in electrolytes and creatinine before and after intervention. CONCLUSION Intravenous furosemide in conjunction with a first-line antihypertensive agent did not significantly reduce systolic blood pressure in the first hour after administration. However, both systolic blood pressure and pulse pressure at 2 hours were decreased in the furosemide group. These findings suggest that a 1-time dose of intravenous furosemide is a reasonable adjunct to achieve blood pressure control, particularly in patients in whom increased volume is suspected.
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Affiliation(s)
- Melanie M Maykin
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI.
| | - Elizabeth Mercer
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Kevin M Saiki
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Corrie B Miller
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
| | - Pai-Jong Stacy Tsai
- Department of Obstetrics, Gynecology, and Women's Health, John A. Burns School of Medicine of the University of Hawaii, Honolulu, HI
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Zambrano MA, Rojas-Suarez JA, Peña-Zarate EE, Carvajal JA, Gutierrez-Puerto LS, Aguilar-Cano F, Santacruz-Arias J, Rodríguez-Lopez M, Fernanda Escobar M. Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis. Hypertens Pregnancy 2023; 42:2272176. [PMID: 38059821 DOI: 10.1080/10641955.2023.2272176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/07/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy. METHODS Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension. RESULTS Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome. CONCLUSION Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.
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Affiliation(s)
| | - Jose A Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Cartagena, Colombia
- GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia
| | - Evelyn E Peña-Zarate
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - Javier Andres Carvajal
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de Alta Complejidad Obstétrica, Departamento de Obstetricia y Ginecología, Fundación Valle del Lili, Cali, Colombia
| | | | | | - Jose Santacruz-Arias
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Cartagena, Colombia
| | | | - María Fernanda Escobar
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de Alta Complejidad Obstétrica, Departamento de Obstetricia y Ginecología, Fundación Valle del Lili, Cali, Colombia
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8
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Palmrich P, Schirwani-Hartl N, Haberl C, Haslinger P, Heinzl F, Zeisler H, Binder J. Catestatin-A Potential New Therapeutic Target for Women with Preeclampsia? An Analysis of Maternal Serum Catestatin Levels in Preeclamptic Pregnancies. J Clin Med 2023; 12:5931. [PMID: 37762872 PMCID: PMC10531844 DOI: 10.3390/jcm12185931] [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: 08/11/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Catestatin has been identified as an important factor in blood pressure control in non-pregnant adults. A possible impact on the development of hypertensive disorders of pregnancy has been indicated. Data on catestatin levels in pregnancy are scarce. The aim of this study was to investigate a potential association of maternal serum catestatin levels to the pathogenesis of preeclampsia. METHODS We evaluated serum catestatin levels of 50 preeclamptic singleton pregnancies and 50 healthy gestational-age-matched pregnancies included in the obstetric biobank registry of the Medical University of Vienna. Receiver operating characteristic curves and logistic regression models were performed to investigate an association between catestatin levels and development of preeclampsia. RESULTS Catestatin levels were significantly decreased in women with preeclampsia compared to healthy controls (median CST: 3.03 ng/mL, IQR [1.24-7.21 ng/mL] vs. 4.82 ng/mL, IQR [1.82-10.02 ng/mL]; p = 0.010), indicating an association between decreased catestatin values and the development of preeclampsia. There was no significant difference in catestatin values between early-onset preeclampsia and late-onset preeclampsia. Modelling the occurrence of preeclampsia via logistic regression was improved when adding catestatin as a predictive factor. CONCLUSIONS Decreased serum catestatin levels are associated with the presence of preeclampsia. Further investigations into the diagnostic value and possible therapeutic role of catestatin in preeclampsia are warranted.
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Affiliation(s)
| | | | | | | | | | | | - Julia Binder
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.P.); (N.S.-H.); (C.H.); (P.H.); (F.H.); (H.Z.)
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9
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Palmrich P, Haase N, Sugulle M, Kalafat E, Khalil A, Binder J. Maternal haemodynamics in Hypertensive Disorders of Pregnancy under antihypertensive therapy (HyperDiP): study protocol for a prospective observational case-control study. BMJ Open 2023; 13:e065444. [PMID: 37263704 DOI: 10.1136/bmjopen-2022-065444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) are associated with a high incidence of maternal and perinatal morbidity and mortality. HDP, in particular pre-eclampsia, have been determined as risk factors for future cardiovascular disease. Recently, the common hypothesis of pre-eclampsia being a placental disorder was challenged as numerous studies show evidence for short-term and long-term cardiovascular changes in pregnancies affected by HDP, suggesting a cardiovascular origin of the disease. Despite new insights into the pathophysiology of HDP, concepts of therapy remain unchanged and evidence for improved maternal and neonatal outcome by using antihypertensive agents is lacking. METHODS AND ANALYSIS A prospective observational case-control study, including 100 women with HDP and 100 healthy controls, which will assess maternal haemodynamics using the USCOM 1A Monitor and Arteriograph along with cardiovascular markers (soluble fms-like kinase 1/placental-like growth factor, N-terminal pro-B type natriuretic peptide) in women with HDP under antihypertensive therapy, including a follow-up at 3 months and 1 year post partum, will be conducted over a 50-month period in Vienna. A prospective, longitudinal study of cardiovascular surrogate markers conducted in Oslo will serve as a comparative cohort for the Vienna cohort of haemodynamic parameters in pregnancy including a longer follow-up period of up to 3 years post partum. Each site will provide a dataset of a patient group and a control group and will be assessed for the outcome categories USCOM 1A measurements, Arteriograph measurements and Angiogenic marker measurements. To estimate the effect of antihypertensive therapy on outcome parameters, ORs with 95% CIs will be computed. Longitudinal changes of outcome parameters will be compared between normotensive and hypertensive pregnancies using mixed-effects models. ETHICS AND DISSEMINATION Ethical approval has been granted to all participating centres. Results will be published in international peer-reviewed journals and will be presented at national and international conferences.
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Affiliation(s)
- Pilar Palmrich
- Division of Obstetrics and Feto-Maternal Medicine, Hospital of the Medical University of Vienna, Vienna, Austria
| | - Nadine Haase
- Experimental and Clinical Research Center, a cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and Charité Universitätsmedizin, Berlin, Germany
- Max-Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt Universität zu Berlin, Experimental and Clinical Research Center, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Meryam Sugulle
- Division of Gynecology and Obstetrics, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Erkan Kalafat
- Department of Obstetrics and Gynecology, Koc University Hospital, Istanbul, Turkey
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
| | - Julia Binder
- Division of Obstetrics and Feto-Maternal Medicine, Hospital of the Medical University of Vienna, Vienna, Austria
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Tamás P, Kovács K, Várnagy Á, Farkas B, Alemu Wami G, Bódis J. Preeclampsia subtypes: Clinical aspects regarding pathogenesis, signs, and management with special attention to diuretic administration. Eur J Obstet Gynecol Reprod Biol 2022; 274:175-181. [PMID: 35661540 DOI: 10.1016/j.ejogrb.2022.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/18/2022] [Accepted: 05/27/2022] [Indexed: 11/04/2022]
Abstract
During normal pregnancy, blood volume increases by nearly two liters. Distinctively, the absence coupled with the extreme extent regarding the volume expansion, are likely accompanied with pathological conditions. Undoubtedly, preeclampsia, defined as the appearance of hypertension and organ deficiency, such as proteinuria during the second half of pregnancy, is not a homogenous disease. Clinically speaking, two main types of preeclampsia can be distinguished, in which a marked difference between them is vascular condition, and consequently, the blood volume. The "classic" preeclampsia, as a two-phase disease, described in the first, latent phase, in which, placenta development is diminished. Agents from this malperfused placenta generate a maternal disease, the second phase, in which endothelial damage leads to hypertension and organ damage due to vasoconstriction and thrombotic microangiopathy. In this hypovolemia-associated condition, decreasing platelet count, signs of hemolysis, renal and liver involvement are characteristic findings; proteinuria is marked and increasing. In the terminal phase, visible edema develops due to increasing capillary transparency, augmenting end-organ damages. "Classic" preeclampsia is a severe and quickly progressing condition with placental insufficiency and consequent fetal growth restriction and oligohydramnios. The outcome of this condition often leads to fetal hypoxia, eclampsia or placental abruption. The management is limited to a diligent prolongation of pregnancy to accomplish improved neonatal pulmonary function, careful diminishing high blood pressure, and delivery induction in due time. The other subtype, associated with relaxed vasculature and high cardiac output, is a maternal disease, in which obesity is an important risk factor since predisposes to enhanced water retention, hypertension, and a weakened endothelial dysfunction. Initially, enhanced water retention leads to lowered extremity edema, which oftentimes progresses to a generalized form and hypertension. In several cases, proteinuria appears most likely due to tissue edema. This condition already fully meets preeclampsia criteria. Laboratory alterations, including proteinuria, are modest and platelet count remains within the normal range. Fetal weight is also normal or frequently over average due to enhanced placental blood supply. It is very likely, further water retention leads to venous congestion, a parenchyma stasis, responsible for ascites, eclampsia, or placental abruption. During the management of this hypervolemia-associated preeclampsia, the administration of diuretic furosemide treatment seemingly offers promise.
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Affiliation(s)
- Péter Tamás
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; Institute of Emergency Care and Pedagogy of Health, Faculty of Health Sciences, University of Pécs, Pécs, Hungary.
| | - Kálmán Kovács
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
| | - Ákos Várnagy
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
| | - Bálint Farkas
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
| | - Girma Alemu Wami
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary
| | - József Bódis
- National Laboratory for Human Reproduction, University of Pécs, Pécs, Hungary; Department of Obstetrics and Gynaecology, Medical School, University of Pécs, Pécs, Hungary; Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary; Hungarian Academy of Sciences - University of Pécs Human Reproduction Scientific Research Group, University of Pécs, Pécs, Hungary
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11
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Ornaghi S, Caricati A, Di Martino DD, Mossa M, Di Nicola S, Invernizzi F, Zullino S, Clemenza S, Barbati V, Tinè G, Mecacci F, Ferrazzi E, Vergani P. Non-invasive Maternal Hemodynamic Assessment to Classify High-Risk Pregnancies Complicated by Fetal Growth Restriction. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:851971. [PMID: 36992751 PMCID: PMC10012115 DOI: 10.3389/fcdhc.2022.851971] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022]
Abstract
ObjectivesTo verify whether the use of the temporal criterion of 32 weeks’ gestation is effective in identifying maternal hemodynamic differences between early- and late-onset fetal growth restriction (FGR), and to test the statistical performance of a classificatory algorithm for FGR.Materials and methodsA prospective multicenter study conducted at three centers over 17 months. Singleton pregnant women with a diagnosis of FGR based on the international Delphi survey consensus at ≥ 20 weeks of gestation were included. FGR was classified as early-onset if diagnosed <32 weeks’ gestation and as late-onset if ≥32 weeks. Hemodynamic assessment was performed by USCOM-1A at the time of FGR diagnosis. Comparisons between early- and late-onset FGR among the entire study cohort, FGR associated with hypertensive disorders of pregnancy (HDP-FGR), and isolated FGR (i-FGR) were performed. In addition, HDP-FGR cases were compared to i-FGR, regardless of the temporal cut-off of 32 weeks’ gestation. Finally, a classificatory analysis based on the Random Forest model was performed to identify significant variables with the ability to differentiate FGR phenotypes.ResultsDuring the study period, 146 pregnant women fulfilled the inclusion criteria. In 44 cases, FGR was not confirmed at birth, thus limiting the final study population to 102 patients. In 49 (48.1%) women, FGR was associated to HDP. Fifty-nine (57.8%) cases were classified as early-onset. Comparison of the maternal hemodynamics between early- and late-onset FGR did not show any difference. Similarly, non-significant findings were observed in sensitivity analyses performed for HDP-FGR and for i-FGR. In turn, comparison between pregnant women with FGR and hypertension and women with i-FGR, independently of the gestational age at FGR diagnosis, revealed substantial differences, with the former showing higher vascular peripheral resistances and lower cardiac output, among other significant parameters. The classificatory analysis identified both phenotypic and hemodynamic variables as relevant in distinguishing HDP-FGR from i-FGR (p=0.009).ConclusionsOur data show that HDP, rather than gestational age at FGR diagnosis, allows to appreciate specific maternal hemodynamic patterns and to accurately distinguish two different FGR phenotypes. In addition, maternal hemodynamics, alongside phenotypic characteristics, play a central role in classifying these high-risk pregnancies.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
- *Correspondence: Sara Ornaghi,
| | - Andrea Caricati
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, 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
| | - Martina Mossa
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Di Nicola
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Francesca Invernizzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Zullino
- 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
| | - Valentina Barbati
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriele Tinè
- Department of Economics and Quantitative Methods, University of Milan-Bicocca, Monza, Italy
| | - Federico Mecacci
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital 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
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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12
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Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Directive clinique n o 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:572-597.e1. [PMID: 35577427 DOI: 10.1016/j.jogc.2022.03.003] [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: 10/18/2022]
Abstract
OBJECTIF La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse. POPULATION CIBLE Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ». Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. PROFESSIONNELS CIBLES Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse. RECOMMANDATIONS
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13
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Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, von Dadelszen P, Helewa M, Rey E. Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2022; 44:547-571.e1. [PMID: 35577426 DOI: 10.1016/j.jogc.2022.03.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP. TARGET POPULATION Pregnant women. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes. EVIDENCE A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies. VALIDATION METHODS The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication. INTENDED USERS All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy. RECOMMENDATIONS
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14
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Narkhede AM, Karnad DR. Preeclampsia and Related Problems. Indian J Crit Care Med 2021; 25:S261-S266. [PMID: 35615616 PMCID: PMC9108790 DOI: 10.5005/jp-journals-10071-24032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Hypertensive disorders of pregnancy can be classified as chronic hypertension (present before pregnancy), gestational hypertension (onset after 20 weeks of pregnancy), and preeclampsia (onset after 20 weeks of pregnancy, along with proteinuria and other organ dysfunction). Preeclampsia and related disorders are a major cause of maternal and fetal morbidity and mortality. Preeclampsia is believed to result from an angiogenic imbalance in the placenta circulation. Antenatal screening and early diagnosis may help improve outcomes. Severe preeclampsia is characterized by SBP ≥160 mm Hg, or DBP ≥110 mm Hg, thrombocytopenia (platelet count <100 × 109/L), abnormal liver function, serum creatinine >1.1 mg/dL, or a doubling of the serum creatinine concentration in the absence of other renal diseases, disseminated intravascular coagulation, pulmonary edema, new-onset headache, or visual disturbances. Severe preeclampsia or eclampsia (preeclampsia with seizures) needs ICU management and is the main cause of morbidity and mortality. Severe hypertension can also result in life-threatening intracranial hemorrhage. Blood pressure control, seizure prevention, and appropriate timing of delivery are the cornerstones of the management of preeclampsia. Besides intravenous antihypertensive drugs, intravenous magnesium sulfate is the drug of choice to prevent or treat seizures, when preparing for urgent delivery. At present, delivery remains the most effective treatment for preeclampsia, and organ dysfunction rapidly recovers after delivery. Novel therapeutic interventions are under development to reduce complications. How to cite this article Narkhede AM, Karnad DR. Preeclampsia and Related Problems. Indian J Crit Care Med 2021;25(Suppl 3):S261-S266.
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Affiliation(s)
- Amit M Narkhede
- Department of Critical Care Medicine, Jupiter Hospital, Mumbai, Maharashtra, India
| | - Dilip R Karnad
- Department of Critical Care Medicine, Jupiter Hospital, Mumbai, Maharashtra, India
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Mullan SJ, Vricella LK, Edwards AM, Powel JE, Ong SK, Li X, Tomlinson TM. Pulse pressure as a predictor of response to treatment for severe hypertension in pregnancy. Am J Obstet Gynecol MFM 2021; 3:100455. [PMID: 34375751 DOI: 10.1016/j.ajogmf.2021.100455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pulse pressure is a proposed means of tailoring antihypertensive therapy for treatment of acute-onset, severe hypertension in pregnancy. OBJECTIVE This study aimed to determine whether pulse pressure predicts response to the various first-line antihypertensive medications. STUDY DESIGN This is a retrospective cohort study from a single academic tertiary care center between 2015 and 2018. Patients were screened for inclusion if they had severe hypertension (defined as systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg) lasting at least 15 minutes and were initially treated with intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine. If a patient had multiple episodes of acute treatment during the pregnancy, only one episode was included in the analysis. The primary outcome was time to resolution (in minutes) of severe hypertension. To adjust for factors that may have affected time to resolution, we first compared baseline characteristics on the basis of the antihypertensive agent received. We then assessed the association between baseline characteristics and resolution of severe hypertension within 60 minutes of treatment. Regression analysis incorporated pulse pressure and antihypertensive agents into a model to predict resolution within 60 minutes of onset of severe hypertension. RESULTS A total of 479 women hospitalized with severe maternal hypertension met the inclusion criteria. Hydralazine was the initial antihypertensive agent administered to 113 women, whereas 233 received labetalol, and 133 received nifedipine. Those who initially received nifedipine had a shorter mean time to resolution of severe hypertension (32.6 minutes vs 46.3 for hydralazine and 50.3 for labetalol; P<.01) and were more likely to have resolution of severe hypertension within 60 minutes (91.0% vs 77.9% for hydralazine and 76.8% for labetalol; P<.01). Nifedipine also resulted in a lower mean posttreatment blood pressure. Regression analysis revealed that a lack of resolution of severe hypertension within 60 minutes was independently associated with 2 measures of hypertension severity (mean arterial pressure of ≥125 mm Hg and the need for ≥2 doses of medication) and pulse pressure of >75 mm Hg at the time of treatment, initial treatment with labetalol, and gestational age of <37 weeks at the time of the hypertensive event (or at delivery if treatment was after delivery). The model's bias-corrected bootstrapped area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.79-0.88). Interaction terms between pulse pressure and each antihypertensive agent were not significant and therefore not incorporated into the final model. CONCLUSION Pulse pressure did not predict response to the various first-line antihypertensive agents. Initial treatment with oral nifedipine was associated with a higher likelihood of resolution of severe hypertension within 60 minutes of treatment than with intravenous labetalol.
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Affiliation(s)
- Samantha J Mullan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO.
| | - Laura K Vricella
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Alexandra M Edwards
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Jennifer E Powel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Samantha K Ong
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Xujia Li
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Tracy M Tomlinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
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Chappell LC, Cluver CA, Kingdom J, Tong S. Pre-eclampsia. Lancet 2021; 398:341-354. [PMID: 34051884 DOI: 10.1016/s0140-6736(20)32335-7] [Citation(s) in RCA: 405] [Impact Index Per Article: 135.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 12/13/2022]
Abstract
Pre-eclampsia is a multisystem pregnancy disorder characterised by variable degrees of placental malperfusion, with release of soluble factors into the circulation. These factors cause maternal vascular endothelial injury, which leads to hypertension and multi-organ injury. The placental disease can cause fetal growth restriction and stillbirth. Pre-eclampsia is a major cause of maternal and perinatal mortality and morbidity, especially in low-income and middle-income countries. Prophylactic low-dose aspirin can reduce the risk of preterm pre-eclampsia, but once pre-eclampsia has been diagnosed there are no curative treatments except for delivery, and no drugs have been shown to influence disease progression. Timing of delivery is planned to optimise fetal and maternal outcomes. Clinical trials have reported diagnostic and prognostic strategies that could improve fetal and maternal outcomes and have evaluated the optimal timing of birth in women with late preterm pre-eclampsia. Ongoing studies are evaluating the efficacy, dose, and timing of aspirin and calcium to prevent pre-eclampsia and are evaluating other drugs to control hypertension or ameliorate disease progression.
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Affiliation(s)
- Lucy C Chappell
- Department of Women and Children's Health, School of Life Course Sciences, Kings' College London, London, UK.
| | - Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Stellenbosch, South Africa; Tygerberg Hospital, Cape Town, South Africa
| | - John Kingdom
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Mercy Hospital for Women, Heidelberg, VIC, Australia
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McLaughlin K, Snelgrove JW, Audette MC, Syed A, Hobson SR, Windrim RC, Melamed N, Carmona S, Kingdom JC. PlGF (Placental Growth Factor) Testing in Clinical Practice: Evidence From a Canadian Tertiary Maternity Referral Center. Hypertension 2021; 77:2057-2065. [PMID: 33840202 DOI: 10.1161/hypertensionaha.121.17047] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Kelsey McLaughlin
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine (K.M., J.W.S., M.C.A., S.R.H., R.C.W., S.C., J.C.K.), Sinai Health System, Toronto, Canada.,The Research Centre for Women's and Infants' Health, Lunenfeld-Tanenbaum Research Institute (K.M., M.C.A., J.C.K.), Sinai Health System, Toronto, Canada.,Division of Cardiology, Department of Internal Medicine (K.M.), Sinai Health System, Toronto, Canada
| | - John W Snelgrove
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine (K.M., J.W.S., M.C.A., S.R.H., R.C.W., S.C., J.C.K.), Sinai Health System, Toronto, Canada
| | - Melanie C Audette
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine (K.M., J.W.S., M.C.A., S.R.H., R.C.W., S.C., J.C.K.), Sinai Health System, Toronto, Canada.,The Research Centre for Women's and Infants' Health, Lunenfeld-Tanenbaum Research Institute (K.M., M.C.A., J.C.K.), Sinai Health System, Toronto, Canada
| | - Atif Syed
- Information Services (A.D., S.C.), Sinai Health System, Toronto, Canada
| | - Sebastian R Hobson
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine (K.M., J.W.S., M.C.A., S.R.H., R.C.W., S.C., J.C.K.), Sinai Health System, Toronto, Canada
| | - Rory C Windrim
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine (K.M., J.W.S., M.C.A., S.R.H., R.C.W., S.C., J.C.K.), Sinai Health System, Toronto, Canada
| | - Nir Melamed
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada (N.M.)
| | - Sergio Carmona
- Information Services (A.D., S.C.), Sinai Health System, Toronto, Canada
| | - John C Kingdom
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine (K.M., J.W.S., M.C.A., S.R.H., R.C.W., S.C., J.C.K.), Sinai Health System, Toronto, Canada.,The Research Centre for Women's and Infants' Health, Lunenfeld-Tanenbaum Research Institute (K.M., M.C.A., J.C.K.), Sinai Health System, Toronto, Canada
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18
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Mulder EG, de Haas S, Mohseni Z, Schartmann N, Abo Hasson F, Alsadah F, van Kuijk S, van Drongelen J, Spaanderman M, Ghossein-Doha C. Cardiac output and peripheral vascular resistance during normotensive and hypertensive pregnancy - a systematic review and meta-analysis. BJOG 2021; 129:696-707. [PMID: 33630403 PMCID: PMC9291763 DOI: 10.1111/1471-0528.16678] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In-depth insight into haemodynamic changes during normotensive pregnancy may help identify women at risk for gestational hypertensive complications. OBJECTIVES To determine the magnitude of changes in cardiac output and its determinants stroke volume and heart rate, and total peripheral vascular resistance during singleton normotensive and hypertensive pregnancies. SEARCH STRATEGY PubMed (NCBI) and Embase (Ovid) databases were searched from their inception up to November 2019. SELECTION CRITERIA Studies reporting original measurements of haemodynamic parameters during pregnancy together with a non-pregnant reference measurement. Studies including women using antihypertensive medication were excluded. DATA COLLECTION AND ANALYSIS Pooled mean differences between pregnant and non-pregnant women, and absolute values of haemodynamic parameters were calculated for predefined gestational intervals using a random-effects model in normotensive and hypertensive pregnancy. Meta-regression analysis was used to analyse group differences in adjustments and absolute values during pregnancy. MAIN RESULTS In normotensive pregnancies, cardiac output increased from the first weeks on, reaching its highest level early in the third trimester (mean difference, 1.41 l·min1 ; 95% CI 1.18-1.63 l·min-1 ). In parallel, vascular resistance decreased progressively until its nadir in the early third trimester (mean difference, -331 dyn·sec-1 ·cm-5 ; 95% CI -384 to -277 dyn·sec-1 ·cm-5 ) and then increased slightly at term. In hypertensive pregnancies, the initial cardiac output increase was higher and vascular resistance did not change throughout gestation compared with reference values. CONCLUSIONS Hemodynamic changes in women who eventually develop hypertensive complications are substantially different. Serial monitoring and plotting against developed normograms can identify women at risk and may allow timely intervention. TWEETABLE ABSTRACT Monitoring haemodynamic changes in pregnancy helps identify women at risk for hypertensive complications.
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Affiliation(s)
- E G Mulder
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - S de Haas
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Z Mohseni
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - N Schartmann
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - F Abo Hasson
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - F Alsadah
- 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
| | - J van Drongelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mea Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - C Ghossein-Doha
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
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19
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Nuckols VR, Holwerda SW, Luehrs RE, DuBose LE, Stroud AK, Brandt D, Betz AM, Fiedorowicz JG, Scroggins SM, Santillan DA, Grobe JL, Sigmund CD, Santillan MK, Pierce GL. Beat-to-Beat Blood Pressure Variability in the First Trimester Is Associated With the Development of Preeclampsia in a Prospective Cohort: Relation With Aortic Stiffness. Hypertension 2020; 76:1800-1807. [PMID: 32951467 DOI: 10.1161/hypertensionaha.120.15019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Women with preeclampsia, a hypertensive disorder of pregnancy, exhibit greater beat-to-beat blood pressure variability (BPV) in the third trimester after clinical onset of the disorder. However, it remains unknown whether elevated BPV precedes the development of preeclampsia. A prospective study cohort of 139 women (age 30.2±4.0 years) were enrolled in early pregnancy (<14 weeks gestation). BPV was quantified by time domain analyses of 10-minute continuous beat-to-beat blood pressure recordings via finger photoplethysmography in the first, second, and third trimesters. Aortic stiffness (carotid-femoral pulse wave velocity) and spontaneous cardiovagal baroreflex sensitivity were also measured each trimester. Eighteen women (13%) developed preeclampsia. Systolic BPV was higher in all trimesters among women who developed versus did not develop preeclampsia (first: 4.8±1.3 versus 3.7±1.2, P=0.001; second: 5.1±1.8 versus 3.8±1.1, P=0.02; third: 5.2±0.8 versus 4.0±1.1 mm Hg, P=0.002). Elevated first trimester systolic BPV was associated with preeclampsia (odds ratio, 1.94 [95% CI, 1.27-2.99]), even after adjusting for risk factors (age, body mass index, systolic blood pressure, history of preeclampsia, and diabetes mellitus) and was a significant predictor of preeclampsia (area under the receiver operator characteristic curve=0.75±0.07; P=0.002). Carotid-femoral pulse wave velocity was elevated in the first trimester among women who developed preeclampsia (5.9±0.8 versus 5.2±0.8 m/s; P=0.002) and was associated with BPV after adjustment for mean blood pressure (r=0.26; P=0.005). First trimester baroreflex sensitivity did not differ between groups (P=0.23) and was not related to BPV (P=0.36). Elevated systolic BPV is independently associated with the development of preeclampsia as early as the first trimester, possibly mediated in part by higher aortic stiffness.
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Affiliation(s)
- Virginia R Nuckols
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Seth W Holwerda
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA.,the Abboud Cardiovascular Research Center (S.W.H., M.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Rachel E Luehrs
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Lyndsey E DuBose
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Amy K Stroud
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Debra Brandt
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Alexandria M Betz
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Jess G Fiedorowicz
- Psychiatry (J.G.F.), University of Iowa, Iowa City, IA.,Epidemiology (J.G.F.), University of Iowa, Iowa City, IA.,Internal Medicine (J.G.F.), University of Iowa, Iowa City, IA
| | - Sabrina M Scroggins
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Donna A Santillan
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Justin L Grobe
- Departments of Physiology (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI.,Biomedical Engineering (J.L.G.), Medical College of Wisconsin, Milwaukee, WI.,Cardiovascular Research Center (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | - Curt D Sigmund
- Departments of Physiology (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI.,Cardiovascular Research Center (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | - Mark K Santillan
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA.,the Abboud Cardiovascular Research Center (S.W.H., M.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Gary L Pierce
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA.,the Abboud Cardiovascular Research Center (S.W.H., M.K.S., G.L.P.), University of Iowa, Iowa City, IA.,Fraternal Order of Eagles Diabetes Research Center (G.L.P.), University of Iowa, Iowa City, IA
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20
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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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Abstract
Normal pregnancy is a complex and dynamic process that requires significant adaptation from the maternal system. Failure of this adaptive process in pregnancy contributes to many pregnancy related disorders, including the hypertensive disorders of pregnancy. This article discusses placental development and how abnormalities in the process of vascular remodeling contribute to the multisystem maternal and fetal disease that is preeclampsia and fetal growth restriction. We review some of the consequences of this condition on the mother and fetus, aspects of the clinical management of preeclampsia and how it can influence both mother and infant in the postnatal period and beyond.
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22
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Kalafat E, Perry H, Bowe S, Thilaganathan B, Khalil A. Prognostic Value of Maternal Cardiovascular Hemodynamics in Women With Gestational Hypertension and Chronic Hypertension in Pregnancy. Hypertension 2020; 76:506-513. [PMID: 32536274 DOI: 10.1161/hypertensionaha.120.14982] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study aimed to assess the prognostic value of cardiovascular assessment in women with gestational hypertension or chronic hypertension for the risk of preeclampsia and need for closer antenatal surveillance. This was a prospective study of pregnancies complicated by gestational hypertension or chronic hypertension presenting to St George's Hospital, between January 2015 and May 2018. A noninvasive ultrasonic cardiac output monitor was used to obtain cardiovascular variables of cardiac output (CO) and systemic vascular resistance (SVR) and weight-adjusted indices. The primary outcome was the time to development of preeclampsia in women with gestational hypertension or chronic hypertension. In women with gestational hypertension or chronic hypertension (n=149), cox-proportional hazards analysis showed that mean arterial pressure (P=0.006), Afro-Caribbean ethnicity (P=0.045), and gestational age at the time of diagnosis above 34 weeks (P<0.001) were significantly associated with increased risk of earlier preeclampsia. Women with high SVR and normal CO (adjusted hazard ratio, 2.32 [95% CI, 1.06-5.08]; P=0.035) and high SVR and low CO (adjusted hazard ratio, 7.79 [95% CI, 1.94-31.24]; P=0.003) cardiovascular profiles had significantly higher risk of earlier preeclampsia compared with women with normal SVR and normal CO. The findings of this study demonstrate that hypertensive women with increased SVR and low CO had a higher risk of developing preeclampsia sooner.
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Affiliation(s)
- Erkan Kalafat
- From the Fetal Medicine Unit, St George's Hospital (E.K., H.P., B.T., A.K.), St George's University of London, United Kingdom.,Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey (E.K.).,Ankara University, Faculty of Medicine, Department of Obstetrics and Gynecology, Turkey (E.K.)
| | - Helen Perry
- From the Fetal Medicine Unit, St George's Hospital (E.K., H.P., B.T., A.K.), St George's University of London, United Kingdom.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute (H.P., B.T., A.K.), St George's University of London, United Kingdom
| | | | - Basky Thilaganathan
- From the Fetal Medicine Unit, St George's Hospital (E.K., H.P., B.T., A.K.), St George's University of London, United Kingdom.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute (H.P., B.T., A.K.), St George's University of London, United Kingdom
| | - Asma Khalil
- From the Fetal Medicine Unit, St George's Hospital (E.K., H.P., B.T., A.K.), St George's University of London, United Kingdom.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute (H.P., B.T., A.K.), St George's University of London, United Kingdom
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23
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Ma'ayeh M, Krishnan V, Gee SE, Russo J, Shellhaas C, Rood KM. Fetal renal artery impedance in pregnancies affected by preeclampsia. J Perinat Med 2020; 48:/j/jpme.ahead-of-print/jpm-2020-0024/jpm-2020-0024.xml. [PMID: 32171001 DOI: 10.1515/jpm-2020-0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/11/2020] [Indexed: 12/29/2022]
Abstract
Background Preeclampsia (PE) is a pregnancy-specific vascular endothelial disorder characterized by multi-organ system involvement. This includes the maternal kidneys, with changes such as continuous vasospasm of renal arteries and reduced renal blood flow. However, it is unclear whether similar renal vascular changes are seen in the fetus. This study sought to compare renal artery impedance in fetuses of women with and without PE. Methods This was a prospective Doppler assessment study of the fetal renal artery impedance in 48 singleton fetuses. The group with PE consisted of 24 appropriately grown fetuses in pregnancy complicated by both mild and severe PE and a control group of 24 uncomplicated pregnancies. Doppler studies included renal artery systolic/diastolic (S/D) ratio, pulsatility index (PI), resistance index (RI), and identification of end-diastolic blood flow. Results Fetuses of mothers with PE were more likely to have a lower renal artery Doppler S/D ratio (7.85 [6.4-10.2] vs. 10.8 [7.75-22.5], P = 0.03) and lower RI (0.875 [0.842-0.898] vs. 0.905 [0.872-0.957], P = 0.03). However, there was no statistically significant difference in PI. There was also no difference in the incidence of absent end-diastolic flow. Conclusion This study suggests that PE results in changes in blood flow to the renal arteries of the fetus. This may be associated with long-term adverse health effects later in adulthood.
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Affiliation(s)
- Marwan Ma'ayeh
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Vidhya Krishnan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Stephen E Gee
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jessica Russo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Cynthia Shellhaas
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kara M Rood
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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24
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Tamargo J. Selecting emergency therapy for patients with pre-eclampsia. Expert Opin Pharmacother 2020; 21:1119-1122. [PMID: 32133877 DOI: 10.1080/14656566.2020.1727444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Instituto De Investigación Sanitaria Gregorio Marañón, Universidad Complutense , Madrid, Spain
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25
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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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26
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Abstract
Acute complications of preeclampsia contribute substantially to maternal and fetal morbidity and mortality. The considerable variation in onset, clinical presentation, and severity of this hypertensive disease that is unique to pregnancy creates challenges in identifying risk factors for clinical deterioration. Delivery of the fetus remains the only definitive treatment for preeclampsia. Surveillance of signs and symptoms and laboratory parameters consistent with progression in severity requires an appreciation of the dynamic and progressive nature of the disease. This article provides a comprehensive overview of the pathophysiology of preeclampsia, setting the foundation for discussion of management priorities for acute complications that pose the greatest risks to maternal health.
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Affiliation(s)
- Patricia M Witcher
- Patricia M. Witcher is Clinical Outcomes Manager, Women's Services, Northside Hospital, 1000 Johnson Ferry Road, Atlanta, GA 30342
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27
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Dominiczak AF, Kuo D, Bhalla V, Granger JP, Griffin KA. Celebrating 40 Years of Accomplishments. Hypertension 2018; 73:3-6. [PMID: 30571572 DOI: 10.1161/hypertensionaha.118.12252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anna F Dominiczak
- From the Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.)
| | - Denise Kuo
- American Heart Association, Dallas, TX (D.K.)
| | - Vivek Bhalla
- Department of Medicine, Division of Nephrology, Stanford University, Palo Alto, CA (V.B.)
| | - Joey P Granger
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS (J.P.G.)
| | - Karen A Griffin
- Loyola University Medical Center, Maywood, IL (K.A.G.).,Edward Hines, Jr. VA, Hines, IL (K.A.G.)
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28
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Gyselaers W, Vonck S, Staelens AS, Lanssens D, Tomsin K, Oben J, Dreesen P, Bruckers L. Body fluid volume homeostasis is abnormal in pregnancies complicated with hypertension and/or poor fetal growth. PLoS One 2018; 13:e0206257. [PMID: 30383796 PMCID: PMC6211673 DOI: 10.1371/journal.pone.0206257] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/09/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To evaluate body water volumes and cardiac output in each trimester of pregnancies complicated with hypertension and/or poor fetal growth, relative to uncomplicated pregnancy. METHODS In this semi-longitudinal cohort study, a standardised non-invasive maternal hemodynamics assessment in first, second or third trimester was performed in 1068 women with uncomplicated pregnancy (UP), 75 with early onset (EPE) and 117 with late onset preeclampsia (LPE), 139 with gestational hypertension (GH), 129 with small for gestational age (SGA) neonates and 43 with essential hypertension (EH). Women with hypertension or SGA were included prior to onset of symptoms or at diagnosis of disease; 46% of women (758/1631) were assessed in ≥ 2 trimesters. Impedance cardiography and spectrum analysis were used to measure cardiac output, total body water (TBW), extracellular (ECW) and intracellular water (ICW). A linear mixed model was used for inter-trimestrial comparison of parity-, age- and BMI-corrected values within and between groups. RESULTS For all pregnancies, TBW is higher in each consecutive trimester, mainly due to increasing fraction of ECW (ECW%). Compared to first trimester UP, ECW and ECW% are higher in EPE whereas TBW, ECW and ICW are lower in SGA. Compared to inter-trimestrial differences in UP, abnormal changes for body water volumes are observed in GH, EPE and LPE and for CO in EPE and LPE. Changes in EH are not different from UP. CONCLUSIONS This study is the first to show that concomitant gestational changes of ECW and CO are different from UP already in preclinical stages of pregnancies complicated with hypertension and/or poor fetal growth, except EH. This finding highlights the relevance of early gestational assessment of maternal body fluid status in pregnancies at risk for hypertension or poor fetal growth.
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Affiliation(s)
- Wilfried Gyselaers
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Physiology, Hasselt University, Diepenbeek, Belgium
| | - Sharona Vonck
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Dorien Lanssens
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Kathleen Tomsin
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jolien Oben
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pauline Dreesen
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Department of Obstetrics & Gynaecology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Liesbeth Bruckers
- Interuniversity Institute for Biostatistics and statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
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29
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Perry H, Khalil A, Thilaganathan B. Preeclampsia and the cardiovascular system: An update. Trends Cardiovasc Med 2018; 28:505-513. [PMID: 29884568 DOI: 10.1016/j.tcm.2018.04.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Helen Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK; Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Asma Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK; Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK
| | - Basky Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK; Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, UK.
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30
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Maric-Bilkan C. Portfolio analysis on preeclampsia and pregnancy-associated hypertension research funded by the National Heart, Lung, and Blood Institute. Physiol Genomics 2018; 50:982-987. [PMID: 30265594 DOI: 10.1152/physiolgenomics.00093.2018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Chronic hypertension and preeclampsia are the most common complications of pregnancy. To clarify the contributions of the National Heart, Lung, and Blood Institute (NHLBI) to the field and identify potential research gaps, we performed portfolio analysis of awards related to preeclampsia and pregnancy-associated hypertension. A list of National Institutes of Health (NIH)-funded awards between fiscal years 2008-present was obtained through an NIH RePORTER search using the following terms: "preeclampsia" and "pregnancy-associated hypertension." More in-depth analyses were performed on currently active awards supported by the NHLBI. The NHLBI is the lead institute at the NIH in funding research related to pregnancy-associated hypertension and second leading in funding research related to preeclampsia. The NHLBI currently supports 38 awards related to preeclampsia and six awards related to pregnancy-associated hypertension, with a combined total dollar investment of $21 million. Of the currently active, NHLBI-supported awards on preeclampsia and pregnancy-associated hypertension combined, 47% are related to basic science research, 30% to clinical, 14% to clinical trials, and 9% to early translational research. The focus of NHLBI-funded awards is primarily on vascular mechanisms and short and long-term cardiovascular complications of preeclampsia and pregnancy-associated hypertension. Despite steady funding for research on preeclampsia and pregnancy-associated hypertension, several gaps in knowledge exist. NHLBI held a workshop entitled Predicting, Preventing and Treating Preeclampsia to address some of these gaps and inform future research directions for the institute.
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Affiliation(s)
- Christine Maric-Bilkan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Division of Cardiovascular Sciences, Vascular biology and Hypertension branch, Bethesda, Maryland
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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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McLaughlin K, Zhang J, Lye SJ, Parker JD, Kingdom JC. Phenotypes of Pregnant Women Who Subsequently Develop Hypertension in Pregnancy. J Am Heart Assoc 2018; 7:JAHA.118.009595. [PMID: 30007936 PMCID: PMC6064839 DOI: 10.1161/jaha.118.009595] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Hypertensive disorders complicating pregnancy are a major cause of maternal death. Our objective was to evaluate maternal clinical, hemodynamic, and placental prognostic indicators in a consolidated manner to identify women who develop hypertension in pregnancy. METHODS AND RESULTS Twenty-six normotensive pregnant women from a specialized Placenta Clinic at increased risk of developing de novo hypertension and 20 normotensive healthy pregnant controls were recruited at 22 to 26 weeks' gestation. Fourteen maternal clinical, hemodynamic, and placental characteristics were assessed in the second trimester and aggregated. Principal component analysis of this combined data set determined that 3 dimensions accounted for 56% of the cohort variability. The first dimension accounted for 31% of the cohort variability, with significant contributions from total peripheral resistance, endoglin, and cardiac output. The second dimension was predominantly influenced by body mass index and mean arterial pressure, while uric acid and myeloperoxidase mainly contributed to the third dimension. Unsupervised clustering identified 3 groups within this combined data set. Total peripheral resistance was the most significant distinguishing parameter between these groups (P<0.0001), followed by placental growth factor, endoglin, and cardiac output (P<0.0001). Using these 4 parameters, a receiver operating curve was constructed with an area under the curve of 0.975 (95% confidence interval 0.93-1) for the prediction of developing hypertension in pregnancy. CONCLUSIONS Consolidated assessment of prognostic indicators in the second trimester of pregnancy may be useful to characterize and distinguish pathways by which women may develop hypertension in pregnancy. This approach could contribute to the development of pathway-specific preventative and antihypertensive treatment strategies.
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Affiliation(s)
- Kelsey McLaughlin
- Division of Cardiology, Department of Medicine, Sinai Health System University of Toronto, Canada.,The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada
| | - Jianhong Zhang
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada
| | - Stephen J Lye
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System University of Toronto, Canada
| | - John D Parker
- Division of Cardiology, Department of Medicine, Sinai Health System University of Toronto, Canada
| | - John C Kingdom
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute Sinai Health System, Toronto, Canada .,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sinai Health System University of Toronto, Canada
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