Association Between Prepregnancy Cardiovascular Function and Subsequent Preeclampsia or Fetal Growth Restriction

Maternal vascular dysfunction in gestational diabetes is associated with birth of small neonates

AIMS

The study aimed to evaluate maternal hemodynamic and vascular changes in women with small-for-gestational age(SGA) and large-for-gestational age(LGA) fetuses in the presence and absence of gestational diabetes mellitus(GDM).

MATERIALS

Women at 35+0 to 36+6 weeks' gestation with and without GDM were included. Maternal demographics, ultrasound for fetal growth, Doppler studies of uterine and ophthalmic arteries, carotid-femoral pulse-wave velocity(PWV), augmentation index, cardiac output, and total peripheral resistance(TPR) were recorded. Multinomial logistic regression was used.

RESULTS

Of 11,132 women, 1,228(11.0%) developed GDM. In GDM pregnancies, 158(12.8%) delivered SGA and 136(11.1%) delivered LGA neonates, while non-GDM pregnancies had 1,051(10.6%) SGA and 806(8.1%) LGA neonates. In GDM and non-GDM women, SGA groups had the highest uterine artery pulsatility index(PI) percentiles, PWV and ophthalmic artery peak systolic velocity ratio. PWV was higher in the GDM SGA group compared to non-GDM SGA group. Cardiac output was lower in SGA groups when compared to the AGA group. In women with GDM, TPR, ophthalmic artery PSV ratio and uterine artery PI percentile had a positive association with the development of SGA.

CONCLUSIONS

Women with GDM and vascular dysfunction have higher risk to deliver SGA neonates. Maternal hemodynamic and vascular maladaptation could potentially explain the development of SGA in women with GDM.

Maternal cardiovascular profile is altered in the preclinical phase of normotensive early and late intrauterine growth restriction

BACKGROUND

The maternal cardiovascular profile of patients who develop late fetal growth restriction has yet to be well characterized, however, a subclinical impairment in maternal hemodynamics and cardiac function may be present before pregnancy and may become evident because of the hemodynamic alterations associated with pregnancy.

OBJECTIVE

This study aimed to investigate if maternal hemodynamics and the cardiovascular profile might be different in the preclinical stages (22-24 weeks' gestation) in cases of early and late fetal growth restriction in normotensive patients.

STUDY DESIGN

This was a prospective echocardiographic study of 1152 normotensive nulliparous pregnant women at 22 to 24 weeks' gestation. The echocardiographic evaluation included morphologic parameters (left ventricular mass index and relative wall thickness, left atrial volume index) and systolic and diastolic maternal left ventricular function (ejection fraction, left ventricular global longitudinal strain, E/A ratio, and E/e' ratio). Patients were followed until the end of pregnancy to note the development of normotensive early or late fetal growth restriction.

RESULTS

Of the study cohort, 1049 patients had no complications, 73 were classified as having late fetal growth restriction, and 30 were classified as having early fetal growth restriction. In terms of left ventricular morphology, the left ventricular end-diastolic diameter was greater in uneventful pregnancies (4.84±0.28 cm) than in late (4.67±0.26 cm) and in early (4.55±0.26 cm) (P<.001) fetal growth restriction cases, whereas left ventricular end-systolic diameter was smaller in uneventful pregnancies (2.66±0.39 cm) than in late (2.83±0.40 cm) and in early (2.82±0.38 cm) (P<.001) fetal growth restriction cases. The relative wall thickness was slightly higher in early (0.34±0.05) and late (0.35±0.04) fetal growth restriction cases than in uneventful pregnancies (0.32±0.05) (P<.05). In terms of systolic left ventricular function, at 22 to 24 weeks' gestation, cardiac output was higher in uneventful pregnancies (6.58±1.07 L/min) than in late (5.40±0.97 L/min) and in early (4.76±1.05 L/min) (P<.001) fetal growth restriction cases with the lowest values in the early-onset group. Left ventricular global longitudinal strain was lower in appropriate for gestational age neonates (-21.6%±2.0%) and progressively higher in late (-20.1%±2.2%) and early (-18.5%±2.3%) (P<.001) fetal growth restriction cases. In terms of diastolic left ventricular function, the E/e' ratio showed intermediate values in the late fetal growth restriction group (7.90±2.73) when compared with the appropriate for gestational age group (7.24±2.43) and with the early fetal growth restriction group (10.76±3.25) (P<.001). The total peripheral vascular resistance was also intermediate in the late fetal growth restriction group (1300±199 dyne·s·cm-5) when compared with the appropriate for gestational age group (993±175 dyne·s·cm-5) and the early fetal growth restriction group (1488±255 dyne.s.cm-5) (P<.001).

CONCLUSION

Early and late fetal growth restriction share similar maternal hemodynamic and cardiovascular profiles with a different degree of expression. These features are already present at 22 to 24 weeks' gestation and are characterized by a hypodynamic state. The degree of these cardiovascular changes may influence the timing of the manifestation of the disease; a hypovolemic, high resistance, low cardiac output state might be associated with early-onset fetal growth restriction, whereas a milder hypovolemic state seems to favor the development of the disease in the final stages of pregnancy.

Adverse pregnancy outcomes, familial predisposition, and cardiovascular risk: a Swedish nationwide study

BACKGROUND AND AIMS

Adverse pregnancy outcomes (APOs) are recognized as significant female-specific risk factors for cardiovascular disease (CVD). A potential shared familial susceptibility between APOs and CVD has been proposed, but not thoroughly explored. This study employs a quasi-experimental family comparison design to investigate shared familial predisposition between APOs and CVD, by assessing risk of CVD in APO-exposed women and their APO-free sisters.

METHODS

Nationwide population-based cohort study encompassing primiparous women, without prior CVD, with registered singleton births in the Swedish Medical Birth Register between 1992 and 2019, grouped into: women with ≥1 APO (165 628), APO-free sisters (60 769), and unrelated APO-free comparator women (992 108). All study participants were followed longitudinally, through linkage with national health registers, from delivery until 2021, for primary endpoint major adverse cardiac events, and its individual components: ischaemic heart disease, heart failure, and cerebrovascular events.

RESULTS

Over a median follow-up of 14 years, APO-exposed women exhibited increased rates of CVDs compared with APO-free comparators. Adverse pregnancy outcome-free sisters exhibited elevated adjusted hazard ratios (aHRs) of major adverse cardiac event {aHR 1.39 [95% confidence interval (CI) 1.13-1.71]}, heart failure [aHR 1.65 (95% CI 1.14-2.39)], and cerebrovascular events [aHR 1.37 (1.04-1.72)] compared with the APO-free comparators, while no significant increase in ischaemic heart disease was observed. Within-family analysis revealed lower CVD rates in APO-free sisters compared with their APO-exposed counterparts, except for no significant difference in cerebrovascular events.

CONCLUSIONS

Sisters of women with APOs face a moderately increased risk of CVD, suggesting a genetic and/or environmental influence on the association between APOs and CVDs. These findings underscore the need for evaluating the effectiveness of targeted preventive measures in women with APOs and their sisters.

Life course trajectories of maternal cardiovascular disease risk factors by obstetric history: a UK cohort study using electronic health records

BACKGROUND

Women who experience adverse pregnancy outcomes (APOs; gestational hypertension, preeclampsia (PE), gestational diabetes (GD), preterm birth (PTB), small or large for gestational age, miscarriage, multiple miscarriages, stillbirth, and offspring with major congenital anomalies) have increased risk of developing cardiovascular disease (CVD). We aimed to compare cardiometabolic health trajectories across the life course between women with and without APOs.

METHODS

We studied 187,186 women with a registered pregnancy in the UK Clinical Practice Research Datalink (CPRD) GOLD linked to Hospital Episode Statistics. Fractional polynomial multilevel models were used to compare trajectories of cardiometabolic risk factors (body mass index [BMI], blood pressure [BP], cholesterol, and glucose) between women with and without a history of APOs (individual APOs in any pregnancy and number of APOs). We explored two underlying time axes: (1) time relative to first pregnancy (from 10 years before first pregnancy to 15 years after) and (2) age. Models controlled for age at first pregnancy, residential area deprivation, non-singleton pregnancy, parity, smoking status, ethnicity, and medications use.

RESULTS

Women with a history of PE, gestational hypertension, or GD had higher BMI, BP, and glucose 10 years before first pregnancy compared to women without these APOs. These differences persisted 15 years post-first pregnancy. Women with a history of GD had a steeper post-partum rise in glucose. Women who experienced multiple (3 +) miscarriage, stillbirth, and/or medically indicated PTB had higher BP and BMI before and after pregnancy, with BP trajectories converging 15 years after first pregnancy. Women who experienced multiple APOs had the most adverse measurements across all cardiometabolic risk factors, with more unfavourable mean levels with each additional APO. There was little difference in cardiometabolic trajectories between women with and without a history of 1 or 2 miscarriages or congenital anomalies.

CONCLUSIONS

Women with APOs had adverse cardiometabolic profiles before first pregnancy, persisting up to 15 years post-pregnancy. Findings highlight the potential for targeted public health interventions to promote good cardiometabolic health in young adults transitioning from contraceptive use to planning pregnancies. APOs may identify young women who could benefit from monitoring CVD risk factors and interventions to improve cardiometabolic health.

Prediction of pre-eclampsia using maternal hemodynamic parameters at 12 + 0 to 15 + 6 weeks

OBJECTIVES

To compare the maternal hemodynamic profile at 12 + 0 to 15 + 6 weeks' gestation in women who subsequently developed pre-eclampsia (PE) and those who did not, and to assess the screening performance of maternal hemodynamic parameters for PE in combination with the Fetal Medicine Foundation (FMF) triple test, including maternal factors (MF), mean arterial pressure (MAP), uterine artery pulsatility index and placental growth factor.

METHODS

This was a prospective case-control study involving Chinese women with a singleton pregnancy who underwent preterm PE screening at 11 + 0 to 13 + 6 weeks' gestation using the FMF triple test, between February 2020 and February 2023. Women identified as being at high risk (≥ 1:100) for preterm PE by the FMF triple test were matched 1:1 with women identified as low risk (< 1:100) for maternal age ± 3 years, maternal weight ± 5 kg and date of screening ± 14 days. Two-dimensional transthoracic echocardiography was performed at 12 + 0 to 15 + 6 weeks to evaluate maternal hemodynamic parameters (heart rate (HR), stroke volume (SV), cardiac output (CO) and systemic vascular resistance (SVR)). Maternal hemodynamic parameters were expressed as multiples of the median (MoM) values, determined by linear regression models to adjust for gestational age (GA) and MF. The distribution of log10 MoM values of maternal hemodynamic parameters in cases of PE and unaffected pregnancies, and the association between these hemodynamic parameters and GA at delivery, were assessed. The risks of preterm PE (delivery before 37 weeks) and any-onset PE (delivery at any time) were reassessed using Bayes' theorem after maternal hemodynamic parameters were added to the FMF triple test. The screening performance for preterm PE and any-onset PE was determined by the area under the receiver-operating-characteristics curve (AUC) and detection rate at a 10% fixed false-positive rate (FPR). Differences in AUC (ΔAUC) were assessed using DeLong's test.

RESULTS

A total of 743 cases were analyzed, of whom 39 (5.2%) subsequently developed PE, including 29 (3.9%) cases of preterm PE and 10 (1.3%) cases of term PE. Mean log10 SVR MoM was significantly higher in cases of preterm PE and any-onset PE compared with unaffected pregnancies. Mean log10 SV MoM and log10 CO MoM were significantly lower in cases of preterm PE and any-onset PE compared with unaffected pregnancies. Mean log10 HR MoM was not significantly different between the study groups. Mean log10 CO MoM and log10 SVR MoM were not significantly correlated with GA at delivery in preterm PE and any-onset PE. For the prediction of preterm PE and any-onset PE, adding CO or SVR or replacing MAP with CO and SVR in the FMF triple test achieved an identical or greater AUC compared with the FMF triple test, but ΔAUC was not significantly different. In addition, adding CO or SVR or replacing MAP by CO and SVR in the FMF triple test did not improve the detection rate for preterm PE and any-onset PE at a fixed FPR of 10%.

CONCLUSIONS

Women with preterm PE or any-onset PE exhibited increased SVR and decreased CO before the clinical manifestations of PE became apparent. These changes may serve as early indicators of cardiovascular maladaptation. However, assessment of maternal hemodynamics at 12 + 0 to 15 + 6 weeks does not enhance the screening performance for preterm PE and any-onset PE of these parameters. The FMF triple test remains superior to other biomarker combinations for predicting PE. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

At mid-gestation, markers of placental function rather than maternal cardiac function are stronger determinants of birthweight

BACKGROUND

The role of maternal cardiac and hemodynamic assessment during normal and complicated pregnancies has gained attention during the last few years. Some researchers suggested that the manifestation of complications in pregnancy suffering from impaired placentation is mainly driven by preexisting cardiac changes, identifiable at an early stage by echocardiographic and hemodynamic assessment. It is therefore of great importance to determine the link between placental perfusion and maternal cardiac function and hemodynamics. Also, the impact of maternal cardiac function on birth weight has not been thoroughly studied.

OBJECTIVE

To elucidate the possible association of maternal cardiovascular indices with placental perfusion at mid-gestation and birthweight.

STUDY DESIGN

Prospective study on women with singleton pregnancies attending Kings' College Hospital, London, UK for a routine hospital visit at 19 to 24 weeks of gestation. We recorded maternal characteristics and medical history, measured mean arterial pressure, heart rate, uterine artery pulsatility index, umbilical artery pulsatility index, middle cerebral artery pulsatility index, and serum placental growth factor. We also performed maternal echocardiogram to assess cardiac output and peripheral vascular resistance as well as indices of diastolic and systolic cardiac function. Multivariable regression modeling was used.

RESULTS

Our cohort included 4006 women. Higher uterine artery pulsatility index values were associated with lower mean arterial pressure, heart rate, and left ventricular systolic function, after adjustment for maternal characteristics and subsequent development of hypertensive disorders of pregnancy and gestational diabetes mellitus. In a multivariable approach that explained 17.9% of the variance of the birthweight, we found that some cardiovascular indices provided small but significant contribution to the model after accounting for maternal factors and development of hypertensive disorders of pregnancy and gestational diabetes mellitus, uterine artery pulsatility index, and placental growth factor.

CONCLUSION

The findings of our study indicate a weak but significant association between maternal cardiovascular indices with placental perfusion at mid-gestation and birthweight. Our data would not support routine maternal cardiovascular assessment for predicting birthweight.

The microcirculation: master in normal pregnancy, puppet in preeclampsia

BACKGROUND

The microcirculation is studied sparsely in the field of maternal hemodynamics. With nailfold video capillaroscopy, further insight is possible in this interesting field within maternal hemodynamics.

OBJECTIVE

This study aimed to investigate the association between functional parameters of the microcirculation and the systemic cardiovascular system in pregnant women at risk for gestational hypertension disorders.

STUDY DESIGN

For this observational study, women with high cardiovascular risk according to maternal anthropometrics and obstetrical and medical history were recruited at random gestational ages, depending on the time of referral to the outpatient clinic for high-risk prenatal care at Ziekenhuis Oost-Limburg, Genk, Belgium. After birth, data on maternal and neonatal outcomes were obtained from hospital records, and only women with normal pregnancy (n=142) and preeclampsia (n=34) were included in this analysis. Nailfold video capillaroscopy measurements were performed in the first, second, and/or third trimesters. Video magnification of 200× was used for all fingers except the thumbs, and the stored images were analyzed offline. Capillary density was quantified (n/mm2), mean capillary diameter measured (μm), and capillary bed surface calculated as density × diameter. Cardiac output and total peripheral resistance were measured using impedance cardiography, together with sphygmomanometric blood pressure measurement. A linear mixed model for repeated measures was used to investigate the association between the microvascular and macrovascular parameters. No corrections for multiple testing were applied.

RESULTS

In normal pregnancies, a positive association was observed between the capillary bed surface and total vascular resistance (1.807; P=.01) and a negative association between capillary density and cardiac output (-0.269; P=.037). In preeclampsia, a negative association was observed between capillary density and mean arterial pressure (-0.5649; P=.010), and between capillary diameter and cardiac output (-0.165; P=.032).

CONCLUSION

The finding of a reduction in capillary density with an increase in blood pressure in preeclampsia is similar to observations in chronic hypertension. This is considered to be the result of capillary closure after the constriction of the precapillary arterioles. However, in normal pregnancy, the increase in capillary bed surface with rising vascular resistance can only be explained by the primary role of microcirculation in preventing capillary overflow via stimulation of arteriolar constriction. These observations elucidate the earliest hemodynamic origins of hypertension at the microcirculatory level in preeclampsia.

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

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

Abnormal Venous Flow in Pregnant Women with Mild Right Ventricular Dysfunction in Repaired Tetralogy of Fallot: A Clinical Model for Organ Dysfunction in Preeclampsia

Background: Pregnant women with congenital heart disease carry a high risk of complications, especially when cardiac function is suboptimal. Increasing evidence suggests that impaired right ventricular (RV) function has a negative effect on placental function, possibly through venous congestion. We report a case series of hepatic and renal venous flow patterns in pregnant women with right ventricular dysfunction after repaired Tetralogy of Fallot (ToF), relative to those observed in normal pregnancy and preeclampsia. Methods: At 20-24 weeks pregnancy, RV function was measured by echocardiography and by cardiovascular magnetic resonance in women with repaired ToF. Combined Doppler-ECG of the hepatic and renal interlobular veins were performed in three women with asymptomatic right ventricular dysfunction. Venous impedance index and pulse transit time were measured and classified as abnormal at >75th and <25th reference percentile, respectively. Results: All three women showed dilated RV and mildly impaired RV function. Both hepatic and intrarenal Doppler flow waves were abnormal and very much resembled the patterns seen in preeclampsia. One of the three women had complications including ventricular tachycardia, intrauterine growth restriction, antenatal bleeding, emergency cesarean section and acute heart failure 2 days postpartum. Conclusions: Pregnant women with mild right ventricular dysfunction after repaired ToF show abnormal venous Doppler flow waves in the liver and kidneys, similar to those observed in preeclampsia. These findings are in line with reported observations on the association between impaired RV function, abnormal return of venous blood, venous congestion and organ dysfunction. The parallel with venous Doppler flow observations in preeclampsia suggest that the venous compartment might play an important role in the etiology of preeclampsia-induced organ dysfunction. Whether this phenomenon directly affects the uteroplacental circulation is to be assessed in future research.

Fragmented QRS in patients with preeclampsia

PURPOSE

This study aims to investigate the prevalence, clinical correlates, and prognostic implications of fragmented QRS complexes (fQRS) in pregnant women with preeclampsia (PE), shedding light on the potential role of electrocardiographic markers in identifying cardiac involvement in hypertensive disorders of pregnancy.

METHODS

Patients with PE and age-matched low-risk control patients were recruited at a tertiary hospital between January 2015 and January 2023. A comprehensive assessment, including heart rate, PR duration, QRS duration, corrected QT duration, and fragmented QRS, was conducted by 12-lead electrocardiography. Baseline clinical characteristics, laboratory parameters, and electrocardiographic findings were compared between the study groups.

RESULT

128 preeclampsia patients and 122 age- and comorbidity-matched controls were included in the study. The prevalence of fQRS was significantly higher in preeclamptic women compared to normotensive controls (14.1% vs. 3.3%, p = 0.04). ALT levels of pregnant women with preeclampsia and without preeclampsia groups were 43,77 (35.25-48.22) and 23,18 (13.75-33.00) (p: 0.038), respectively. In univariate regression analyses, Na and fragmented QRS were found to be associated with preeclampsia. (p: 0.016 and 0.009, respectively). After multivariable adjustment for variables, Na and fragmented QRS remained strongly associated with preeclampsia (OR: 4.787 (1.556-14.720), p: 0.06; 0.941 (0.893-0.992), p: 0.023, respectively).

CONCLUSION

This study provides compelling evidence of an association between preeclampsia and fragmented QRS complexes, implicating electrolyte imbalances and hemodynamic stress as potential contributors to myocardial electrical instability in hypertensive disorders of pregnancy. Further research is warranted to validate these findings and improve risk stratification and clinical outcomes in affected women. Number: 2023/4705 Retrospectively Registered.

Hypertensive pregnancy disorder, an under-recognized women specific risk factor for heart failure?

During pregnancy, the maternal cardiovascular (CV) system undergoes major haemodynamic alterations ensuring adequate placental perfusion and a healthy pregnancy course. Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations and preeclampsia, a more severe form, in 3-4%. Women with HDP demonstrated impaired myocardial function, biventricular chamber dysfunction and adverse biventricular remodelling. Shortly after delivery, women who experienced HDP express increased risk of classic CV risk factors such as hypertension, renal disease, abnormal lipid profile, and diabetes. Within the first two decades following a HDP, women experience increased rates of heart failure, chronic hypertension, ischaemic heart and cerebral disease. The mechanism underlying the relationship between HDP in younger women and CV disease later in life could be explained by sharing pre-pregnancy CV risk factors or due to a direct impact of HDP on the maternal CV system conferring a state of increased susceptibility to future metabolic or haemodynamic insults. Racial disparities in CV risk and social determinants of health also play an important role in their remote CV risk. Although there is general agreement that women who suffered from HDP should undertake early CV screening to allow appropriate prevention and timely treatment, a screening and intervention protocol has not been standardized due to limited available evidence. In this review, we discuss why women with hypertensive pregnancy may be disproportionately affected by heart failure with preserved ejection fraction and how cardiac remodelling during or after pregnancy may influence its development.

Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Preeclampsia and Italian Society of Perinatal Medicine

OBJECTIVE

 The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art.

STUDY DESIGN

 AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

RESULTS

 More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life.

CONCLUSION

 Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications.

KEY POINTS

· Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..

Preeclampsia and neonatal outcomes in pregnancies with maternal congenital heart disease: A nationwide cohort study from Norway

INTRODUCTION

The prevalence of congenital heart disease (CHD) among women of reproductive age is rising. We aimed to investigate the risk of preeclampsia and adverse neonatal outcomes in pregnancies of mothers with CHD compared to pregnancies of mothers without heart disease.

MATERIAL AND METHODS

In a nationwide cohort of pregnancies in Norway 1994-2014, we retrieved information on maternal heart disease, the course of pregnancy, and neonatal outcomes from national registries. Comparing pregnancies with maternal CHD to pregnancies without maternal heart disease, we used Cox regression to estimate the adjusted hazard ratio (aHR) for preeclampsia and log-binomial regression to estimate the adjusted risk ratio (aRR) for adverse neonatal outcomes. The estimates were adjusted for maternal age and year of childbirth and presented with 95% confidence intervals (CIs).

RESULTS

Among 1 218 452 pregnancies, 2425 had mild maternal CHD, and 603 had moderate/severe CHD. Compared to pregnancies without maternal heart disease, the risk of preeclampsia was increased in pregnancies with mild and moderate/severe maternal CHD (aHR1.37, 95% CI 1.14-1.65 and aHR 1.62, 95% CI 1.13-2.32). The risk of preterm birth was increased in pregnancies with mild maternal CHD (aRR 1.33, 95% CI 1.15-1.54) and further increased with moderate/severe CHD (aRR 2.49, 95% CI 2.03-3.07). Maternal CHD was associated with elevated risks of both spontaneous and iatrogenic preterm birth. The risk of infants small-for-gestational-age was slightly increased with mild maternal CHD (aRR 1.12, 95% CI 1.00-1.26) and increased with moderate/severe CHD (aRR 1.63, 95% CI 1.36-1.95). The prevalence of stillbirth was 3.9 per 1000 pregnancies without maternal heart disease, 5.6 per 1000 with mild maternal CHD, and 6.8 per 1000 with moderate/severe maternal CHD. Still, there were too few cases to report a significant difference. There were no maternal deaths in women with CHD.

CONCLUSIONS

Moderate/severe maternal CHD in pregnancy was associated with increased risks of preeclampsia, preterm birth, and infants small-for-gestational-age. Mild maternal CHD was associated with less increased risks. For women with moderate/severe CHD, their risk of preeclampsia and adverse neonatal outcomes should be evaluated together with their cardiac risk in pregnancy, and follow-up in pregnancy should be ascertained.

Can short- and long-term maternal and infant risks linked to hypertension and diabetes during pregnancy be reduced by therapy?

Hypertensive disorders of pregnancy (HDP), especially preeclampsia, and diabetes during pregnancy pose significant risks for both maternal and infant health, extending to long-term outcomes such as early-onset cardiovascular disease and metabolic disorders. Current strategies for managing HDP focus on screening, prevention, surveillance, and timely intervention. No disease-modifying therapies exist so far for established preeclampsia; delivery remains the definitive resolution. Preventive measures-including early pregnancy screening, exercise, and low-dose aspirin-show promise. Antihypertensive treatments reduce severe hypertension risks, whereas magnesium sulfate remains the standard for preventing eclampsia. Planned delivery from gestational week 37 can balance maternal benefits and neonatal risks in women with established preeclampsia. Delivery between 34 and 37 weeks gestation in women with preeclampsia has to balance risks for mother and infant. Lifestyle interventions-particularly diet and physical activity-are pivotal in managing gestational diabetes mellitus and type 2 diabetes. The oral antidiabetic metformin has shown benefits in glycaemic control and reducing maternal weight gain, although its long-term effects on offspring remain uncertain. The safety of other peroral antidiabetics in pregnancy is less studied. Advancements in glucose monitoring and insulin administration present encouraging prospects for enhancing outcomes in women with diabetes types 1 and 2. Both HDP and diabetes during pregnancy necessitate vigilant management through a combination of lifestyle modifications, pharmacological interventions, and timely obstetric care. Although certain treatments such as low-dose aspirin and metformin show efficacy in risk reduction, further research is ongoing to ensure safety for both mothers and their offspring to reduce short- and long-term adverse effects.

Does the use of angiogenic biomarkers for the management of preeclampsia and fetal growth restriction improve outcomes?: Challenging the current status quo

Monitoring and timing of delivery in preterm preeclampsia and fetal growth restriction is one of the biggest challenges in Obstetrics. Finding the optimal time of delivery of these fetuses usually involves a trade-off between the severity of the disease and prematurity. So far, most clinical guidelines recommend the use of a combination between clinical, laboratory and ultrasound markers to guide the time of delivery. Angiogenic biomarkers, especially placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1), have gained significant attention in recent years for their potential role in the prediction and diagnosis of placenta-related disorders including preeclampsia and fetal growth restriction. Another potential clinical application of the angiogenic biomarkers is for the differential diagnosis of patients with chronic kidney disease, as this condition shares similar clinical features with preeclampsia. Consequently, angiogenic biomarkers have been advocated as tools for monitoring and deciding the optimal time of the delivery of fetuses affected by placental dysfunction. In this clinical opinion, we critically review the available literature on PlGF and sFlt-1 for the surveillance and time of the delivery in fetuses affected by preterm preeclampsia and fetal growth restriction. Moreover, we explore the use of angiogenic biomarkers for the differentiation between chronic kidney disease and superimposed preeclampsia.

Alterations in maternal cardiovascular parameters and their impact on uterine and fetal circulation in hypertensive pregnancies and fetal growth restriction

Objective

To examine potential alterations in maternal cardiovascular parameters in hypertensive pregnancies with or without fetal growth restriction (FGR) in comparison to uncomplicated normotensive pregnancies, and to determine the correlation between maternal cardiovascular parameters and changes in umbilical and uterine artery circulation.

Materials and methods

This study enrolled 73 pregnant women starting from the 20th week of gestation, categorized into three groups: hypertensive conditions (pregnancy-induced hypertension, preeclampsia or eclampsia, n = 30), hypertensive conditions with FGR (n = 8) and a control group of healthy normotensive pregnant women (n = 35). All participants underwent echocardiography to assess cardiac output and calculate peripheral vascular resistance. Additionally, fetal biometric measurements and Doppler ultrasound examinations of the uterine and umbilical artery were performed. The results were standardized into gestational age-adjusted z-scores.

Results

The mean pulsatility index (PI) of the uterine artery (1.36, p < 0.001) and umbilical artery PI z-scores (1.32, p < 0.001) showed significant increases in the hypertensive conditions + FGR group. Maternal cardiac output z-scores were notably lower in both the hypertensive + FGR group (-2.62, p = 0.001) and the hypertensive group (-2.49, p < 0.001). Peripheral vascular resistance was significantly elevated in the hypertensive + FGR group (7.43, p < 0.001) and the hypertensive group (6.06, p < 0.001). There was a positive correlation between maternal peripheral vascular resistance and uterine artery PI (R2 = 0.172; p = 0.0004), and a negative correlation between cardiac output and uterine artery PI (R2 = 0.067; p = 0.031). However, significant correlation between maternal cardiovascular parameters and umbilical artery PI was not identified.

Conclusions

Maternal cardiac output exhibits a significant decrease whereas peripheral vascular resistance increases in hypertensive pregnancies, irrespective of the presence of FGR. Both uterine and umbilical artery PI notably increase when hypertensive pregnancies are accompanied by FGR. A positive correlation exists between maternal peripheral vascular resistance and uterine artery PI, as well as a negative correlation between maternal cardiac output and uterine artery PI. However, changes in maternal cardiovascular parameters do not exhibit significant correlations with umbilical artery PI.

Preconception Physical Exercise Is Associated with Phenotype-Specific Cardiovascular Alterations in Women at Risk for Gestational Hypertensive Disorders

Background/Objectives: Gestational hypertensive disorders (GHD) pose significant maternal and fetal health risks during pregnancy. Preconception physical exercise has been associated with a lower incidence of GHD, but insights into the cardiovascular mechanisms remain limited. This study aimed to evaluate the effect of preconception physical exercise on the complete cardiovascular functions of women at risk for GHD in a subsequent pregnancy. Methods: A non-invasive hemodynamics assessment of arteries, veins, and the heart was performed on 40 non-pregnant women at risk for developing GHD in a subsequent pregnancy. Measurements of an electrocardiogram Doppler ultrasound, impedance cardiography and bio-impedance spectrum analysis were taken before and after they engaged in physical exercise (30-50 min, 3×/week, 4-6 months). Results: After a mean physical exercise period of 29.80 weeks, the total peripheral resistance (TPR), diastolic blood pressure and mean arterial pressure decreased in the total study population, without changing cardiac output (CO). However, in 42% (9/21) of women categorized with high or low baseline CO (>P75 or Collapse

Key Words

• cardiac output
• gestational hypertensive disorders
• maternal hemodynamics
• physical exercise
• preconception care
• total peripheral resistance

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Grants

• LCRC PhD-2019/FP03 & BOF20DOC18 Hasselt University (LCRC and BOF), Belgium

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Affiliation(s)

Pauline Dreesen Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590 Diepenbeek, Belgium (D.L.); (W.G.) Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
Pauline Volders Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590 Diepenbeek, Belgium (D.L.); (W.G.)
Dorien Lanssens Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590 Diepenbeek, Belgium (D.L.); (W.G.) Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
Sandy Nouwen Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590 Diepenbeek, Belgium (D.L.); (W.G.)
Birgit Vrancken Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590 Diepenbeek, Belgium (D.L.); (W.G.)
Febe Janssen Future Health, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium
Bert O. Eijnde SMRC Sports Medical Research Center, BIOMED Biomedical Research Institute, Faculty of Medicine & Life Sciences, Hasselt University, 3590 Diepenbeek, Belgium Division of Sport Science, Faculty of Medicine & Health Sciences, Stellenbosch University, Stellenbosch 7602, South Africa
Dominique Hansen REVAL Rehabilitation Research Centre, Faculty of Rehabilitation Sciences, Hasselt University, 3590 Diepenbeek, Belgium; Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, 3500 Hasselt, Belgium
Michael Ceulemans Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000 Leuven, Belgium; IQ Health, Radboud University Medical Center, 6525 XZ Nijmegen, The Netherlands Child & Youth Institute, KU Leuven, 3000 Leuven, Belgium
Adelheid Soubry Epigenetic Epidemiology Lab, Department of Human Genetics, Faculty of Medicine, KU Leuven, 3000 Leuven, Belgium;
Wilfried Gyselaers Faculty of Medicine and Life Sciences, Limburg Clinical Research Center, Hasselt University, 3590 Diepenbeek, Belgium (D.L.); (W.G.) Department of Obstetrics & Gynecology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium

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Maternal Cardiac Function in Pregnancies with Metabolic Disorders

The obesity epidemic is growing and poses significant risks to pregnancy. Metabolic impairment can be associated with short- and long-term maternal and perinatal morbidity and mortality. The cardiovascular implications are known in those with metabolic disorder outside of pregnancy; however, little is known of the cardiac function in pregnancies complicated by obesity. Maternal cardiac adaptation plays a vital role in normal pregnancy and is known to be involved in the pathophysiology of adverse pregnancy outcomes. Bariatric surgery is the most successful treatment for sustainable weight loss and pre-pregnancy bariatric surgery can drastically change the maternal metabolic profile and pregnancy outcomes. In this review, we discuss the available evidence on maternal cardiac function in pregnancies affected by obesity and its associated consequences of gestational diabetes and hypertension (chronic and hypertensive disorders in pregnancy), as well as pregnancies following bariatric surgery.

Heart disease in pregnancy and risk of pre-eclampsia: a Swedish register-based study

BACKGROUND AND AIMS

Pre-eclampsia complicates 3-5% of pregnancies worldwide and is associated with adverse outcomes for the mother and the offspring. Pre-eclampsia and heart failure have common risk factors, including hypertension, obesity and diabetes. It is not known whether heart failure increases the risk of pre-eclampsia. This study examines whether pregestational heart failure increases the risk of pre-eclampsia.

METHODS

In a registry-based case-cohort study that included all pregnancies in Sweden (n=3 125 527) between 1990 and 2019, all pregnancies with pre-eclampsia (n=90 354) were identified and up to five control pregnancies (n=451 466) for each case were chosen, matched on the mother's birth year. Multiple logistic regression analysis was used to evaluate the impact of heart failure on the risk of pre-eclampsia, with adjustment for established risk factors and other cardiovascular diseases.

RESULTS

Women with heart failure had no increased risk for pre-eclampsia, OR 1.02 (95% CI 0.69 to 1.50). Women with valvular heart disease had an increased OR of preterm pre-eclampsia, with an adjusted OR of 1.78 (95% CI 1.04 to 3.06). Hypertension and diabetes were independent risk factors for pre-eclampsia. Obesity, multifetal pregnancies, in vitro fertilisation, older age, Nordic origin and nulliparity were more common among women who developed pre-eclampsia compared with controls.

CONCLUSION

Women with heart failure do not have an increased risk of pre-eclampsia. However, women with valvular heart disease prior to pregnancy have an increased risk of developing preterm pre-eclampsia independent of other known risk factors.

The Association between Fetal Growth Restriction and Maternal Morbidity

OBJECTIVE

This study aimed to compare adverse maternal outcomes between pregnancies complicated by fetal growth restriction (FGR) and those without FGR.

STUDY DESIGN

This was a secondary analysis of the data from the Consortium on Safe Labor, which was conducted from 2002 to 2008 in 12 clinical centers with 19 hospitals across 9 American College of Obstetricians and Gynecologists districts. We included singleton pregnancies without any maternal comorbidities or placenta abnormalities. We compared the outcomes of individuals with FGR with individuals without FGR. Our primary outcome was severe maternal morbidity. Our secondary outcome included various adverse maternal and neonatal outcomes. Multivariable logistic regression was performed to obtain adjusted odds ratios (aOR) and 95% confidence intervals (95% CI), adjusting for confounders. Missing values for maternal age and body mass index were imputed.

RESULTS

Of 199,611 individuals, 4,554 (2.3%) had FGR and 195,057 (97.7%) did not have FGR. Compared with the individuals without FGR, individuals with FGR had increased odds of severe maternal morbidity (0.6 vs. 1.3%; aOR: 1.97 [95% CI: 1.51-2.57]), cesarean delivery (27.7 vs. 41.2%; aOR: 2.31 [95% CI: 2.16-2.48]), pregnancy-associated hypertension (8.3 vs. 19.2%; aOR: 2.76 [95% CI: 2.55-2.99]), preeclampsia without severe features (3.2 vs. 4.7%; aOR: 1.45 [95% CI: 1.26-1.68]), preeclampsia with severe features (1.4 vs. 8.6%; aOR: 6.04 [95% CI: 5.39-6.76]), superimposed preeclampsia (18.3 vs. 30.2%; aOR: 1.99 [95% CI: 1.53-2.59]), neonatal intensive care unit admission (9.7 vs. 28.4%; aOR: 3.53 [95% CI: 3.28-3.8]), respiratory distress syndrome (2.2 vs. 7.7%; aOR: 3.57 [95% CI: 3.15-4.04]), transient tachypnea of the newborn (3.3 vs. 5.4%; aOR: 1.62 [95% CI: 1.40-1.87]), and neonatal sepsis (2.1 vs. 5.5%; aOR: 2.43 [95% CI: 2.10-2.80]).

CONCLUSION

FGR was associated with increased odds of severe maternal outcomes in addition to adverse neonatal outcomes.

KEY POINTS

· FGR is associated with cesarean section.. · FGR is not associated with severe maternal morbidity.. · FGR is related to pregnancy-associated hypertension.. · FGR is associated with neonatal morbidity..

Novel Associations Between Mid-Pregnancy Cardiovascular Biomarkers and Preeclampsia: An Explorative Nested Case-Control Study

Prediction of women at high risk of preeclampsia is important for prevention and increased surveillance of the disease. Current prediction models need improvement, particularly with regard to late-onset preeclampsia. Preeclampsia shares pathophysiological entities with cardiovascular disease; thus, cardiovascular biomarkers may contribute to improving prediction models. In this nested case-control study, we explored the predictive importance of mid-pregnancy cardiovascular biomarkers for subsequent preeclampsia. We included healthy women with singleton pregnancies who had donated blood in mid-pregnancy (~ 18 weeks' gestation). Cases were women with subsequent preeclampsia (n = 296, 10% of whom had early-onset preeclampsia [< 34 weeks]). Controls were women who had healthy pregnancies (n = 333). We collected data on maternal, pregnancy, and infant characteristics from medical records. We used the Olink cardiovascular II panel immunoassay to measure 92 biomarkers in the mid-pregnancy plasma samples. The Boruta algorithm was used to determine the predictive importance of the investigated biomarkers and first-trimester pregnancy characteristics for the development of preeclampsia. The following biomarkers had confirmed associations with early-onset preeclampsia (in descending order of importance): placental growth factor (PlGF), matrix metalloproteinase (MMP-12), lectin-like oxidized LDL receptor 1, carcinoembryonic antigen-related cell adhesion molecule 8, serine protease 27, pro-interleukin-16, and poly (ADP-ribose) polymerase 1. The biomarkers that were associated with late-onset preeclampsia were BNP, MMP-12, alpha-L-iduronidase (IDUA), PlGF, low-affinity immunoglobulin gamma Fc region receptor II-b, and T cell surface glycoprotein. Our results suggest that MMP-12 is a promising novel preeclampsia biomarker. Moreover, BNP and IDUA may be of value in enhancing prediction of late-onset preeclampsia.

Maternal vascular indices at 36 weeks' gestation in the prediction of preeclampsia

BACKGROUND

Epidemiological studies have shown that women with preeclampsia (PE) are at increased long term cardiovascular risk. This risk might be associated with accelerated vascular ageing process but data on vascular abnormalities in women with PE are scarce.

OBJECTIVE

This study aimed to identify the most discriminatory maternal vascular index in the prediction of PE at 35 to 37 weeks' gestation and to examine the performance of screening for PE by combinations of maternal risk factors and biophysical and biochemical markers at 35 to 37 weeks' gestation.

STUDY DESIGN

This was a prospective observational nonintervention study in women attending a routine hospital visit at 35 0/7 to 36 6/7 weeks' gestation. The visit included recording of maternal demographic characteristics and medical history, vascular indices, and hemodynamic parameters obtained by a noninvasive operator-independent device (pulse wave velocity, augmentation index, cardiac output, stroke volume, central systolic and diastolic blood pressures, total peripheral resistance, and fetal heart rate), mean arterial pressure, uterine artery pulsatility index, and serum concentration of placental growth factor and soluble fms-like tyrosine kinase-1. The performance of screening for delivery with PE at any time and at <3 weeks from assessment using a combination of maternal risk factors and various combinations of biomarkers was determined.

RESULTS

The study population consisted of 6746 women with singleton pregnancies, including 176 women (2.6%) who subsequently developed PE. There were 3 main findings. First, in women who developed PE, compared with those who did not, there were higher central systolic and diastolic blood pressures, pulse wave velocity, peripheral vascular resistance, and augmentation index. Second, the most discriminatory indices were systolic and diastolic blood pressures and pulse wave velocity, with poor prediction from the other indices. However, the performance of screening by a combination of maternal risk factors plus mean arterial pressure was at least as high as that of a combination of maternal risk factors plus central systolic and diastolic blood pressures; consequently, in screening for PE, pulse wave velocity, mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 were used. Third, in screening for both PE within 3 weeks and PE at any time from assessment, the detection rate at a false-positive rate of 10% of a biophysical test consisting of maternal risk factors plus mean arterial pressure, uterine artery pulsatility index, and pulse wave velocity (PE within 3 weeks: 85.2%; 95% confidence interval, 75.6%-92.1%; PE at any time: 69.9%; 95% confidence interval, 62.5%-76.6%) was not significantly different from a biochemical test using the competing risks model to combine maternal risk factors with placental growth factor and soluble fms-like tyrosine kinase-1 (PE within 3 weeks: 80.2%; 95% confidence interval, 69.9%-88.3%; PE at any time: 64.2%; 95% confidence interval, 56.6%-71.3%), and they were both superior to screening by low placental growth factor concentration (PE within 3 weeks: 53.1%; 95% confidence interval, 41.7%-64.3%; PE at any time: 44.3; 95% confidence interval, 36.8%-52.0%) or high soluble fms-like tyrosine kinase-1-to-placental growth factor concentration ratio (PE within 3 weeks: 65.4%; 95% confidence interval, 54.0%-75.7%; PE at any time: 53.4%; 95% confidence interval, 45.8%-60.9%).

CONCLUSION

First, increased maternal arterial stiffness preceded the clinical onset of PE. Second, maternal pulse wave velocity at 35 to 37 weeks' gestation in combination with mean arterial pressure and uterine artery pulsatility index provided effective prediction of subsequent development of preeclampsia.

Placentation and complications of ART pregnancy. An update on the different possible etiopathogenic mechanisms involved in the development of obstetric complications

INTRODUCTION

Infertile couples' percentage is increasing all over the world, especially in Italy, with high number of children born in our country through assisted reproductive techniques (ART). However, pregnancies obtained by ART have increased potential obstetrical risks which could be caused by fetus-placenta unit development, most of all due to placentation's evolution. These can be reassumed into miscarriage, chromosomal abnormalities, preterm delivery, multiple pregnancy, IUGR, placenta previa, abruptio placentae, preeclampsia and hypertensive disorders, postpartum hemorrhage.

METHODS

The aim of this article is to evaluate hypothetic mechanism involved in placentation process and in the etiopathology of ART pregnancies disorders, giving an updating overview of different etiopathogenetic pathways and features. On this scenario, we create an updated review about the etiopathogenesis of abnormal placentation in ART pregnancies.

RESULTS

Several features and different etiopathogenetic characteristic might impact differently such as advanced maternal age, poor ovarian reserve, oocyte quality and causes of subfertility themselves, and the ART techniques itself, as hormonal medical treatments and laboratory techniques such as gamete and embryo laboratory culture, cryopreservation versus fresh ET, number of embryos transferred.

CONCLUSION

To further explore the molecular mechanisms behind placentation in ART pregnancies, further studies are necessary to gain a better understanding of the various aspects involved, particularly those which are not fully comprehended. This could prove beneficial to clinicians in both ART care and obstetric care, as it could help to stratify obstetrical risk and decrease complications in women undergoing ART, as well as perinatal disorders in their children. Correct placentation is essential for a successful pregnancy for both mother and baby.

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

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

Early Fetal Growth Restriction with or Without Hypertensive Disorders: a Clinical Overview

Early onset fetal growth restriction (FGR) is one of the main adverse pregnancy conditions, often associated with poor neonatal outcomes. Frequently, early onset FGR is associated with early onset hypertensive disorders of pregnancy (HDP), and in particular preeclampsia (PE). However, to date, it is still an open question whether pregnancies complicated by early FGR plus HDP (FGR-HDP) and those complicated by early onset FGR without HDP (normotensive-FGR (n-FGR)) show different prenatal and postnatal outcomes and, consequently, should benefit from different management and long-term follow-up. Recent data support the hypothesis that the presence of PE may have an additional impact on maternal hemodynamic impairment and placental lesions, increasing the risk of poor neonatal outcomes in pregnancy affected by early onset FGR-HDP compared to pregnancy affected by early onset n-FGR. This review aims to elucidate this poor studied topic, comparing the clinical characteristics, perinatal outcomes, and potential long-term sequelae of early onset FGR-HDP and early onset n-FGR.

Parental genetically predicted liability for coronary heart disease and risk of adverse pregnancy outcomes: a cohort study

BACKGROUND

Adverse pregnancy outcomes (APO) may unmask or exacerbate a woman's underlying risk for coronary heart disease (CHD). We estimated associations of maternal and paternal genetically predicted liability for CHD with lifelong risk of APOs. We hypothesized that associations would be found for women, but not their male partners (negative controls).

METHODS

We studied up to 83,969‬ women (and up to 55,568‬ male partners) from the Norwegian Mother, Father and Child Cohort Study or the Trøndelag Health Study with genotyping data and lifetime history of any APO in their pregnancies (1967-2019) in the Medical Birth Registry of Norway (miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes, small for gestational age, large for gestational age, and spontaneous preterm birth). Maternal and paternal genetic risk scores (GRS) for CHD were generated using 148 gene variants (p-value < 5 × 10-8, not in linkage disequilibrium). Associations between GRS for CHD and each APO were determined using logistic regression, adjusting for genomic principal components, in each cohort separately, and combined using fixed effects meta-analysis.

RESULTS

One standard deviation higher GRS for CHD in women was related to increased risk of any hypertensive disorders of pregnancy (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.05-1.10), pre-eclampsia (OR 1.08, 95% CI 1.05-1.11), and small for gestational age (OR 1.04, 95% CI 1.01-1.06). Imprecise associations with lower odds of large for gestational age (OR 0.98, 95% CI 0.96-1.00) and higher odds of stillbirth (OR 1.04, 95% CI 0.98-1.11) were suggested. These findings remained consistent after adjusting for number of total pregnancies and the male partners' GRS and restricting analyses to stable couples. Associations for other APOs were close to the null. There was weak evidence of an association of paternal genetically predicted liability for CHD with spontaneous preterm birth in female partners (OR 1.02, 95% CI 0.99-1.05), but not with other APOs.

CONCLUSIONS

Hypertensive disorders of pregnancy, small for gestational age, and stillbirth may unmask women with a genetically predicted propensity for CHD. The association of paternal genetically predicted CHD risk with spontaneous preterm birth in female partners needs further exploration.

Preeclampsia's Cardiovascular Aftermath: A Comprehensive Review of Consequences for Mother and Offspring

Preeclampsia (PE), a multisystem hypertensive disorder affecting 2-8% of pregnancies, has emerged as a novel risk factor for cardiovascular disease (CVD) in affected mothers and in their offspring. Between 10 and 15 years following gestation, women with a history of PE have double the risk of CVD, nearly 4 times the risk of hypertension, and increased all-cause mortality. Offspring exposed to PE in utero carry an increased risk of CVD and congenital heart defects. Due to the multifactorial nature of both PE and CVD, a clear dependency has been difficult to establish. The interplay between CVD and PE is an area of active investigation, likely involving placental, genetic, and epigenetic factors resulting in enduring endothelial, vascular, and immune dysfunction. Fetal developmental programming induced by adverse intrauterine environments, epigenetic changes triggered by oxidative stress, and underlying genetic predisposition play pivotal roles in the development of CVD in offspring exposed to PE. Though the literature has discussed the cardiovascular outcomes associated with PE for nearly a decade, patient risk perception and health care provider awareness remain low, representing a substantial missed opportunity for early intervention in this vulnerable population. This review article will discuss the pathophysiology of preeclampsia, its intersection with CVD, and the long-term cardiovascular consequences for affected mothers and their offspring. Our objective is to increase health care provider awareness and garner greater research interest in this important topic.

Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review

AIMS

Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum.

METHODS AND RESULTS

Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum.

CONCLUSION

The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.

Beetroot juice, exercise, and cardiovascular function in women planning to conceive

OBJECTIVE

Prepregnancy optimization of cardiovascular function may reduce the risk of pre-eclampsia. We aimed to assess the feasibility and effect of preconception cardiovascular monitoring, exercise, and beetroot juice on cardiovascular parameters in women planning to conceive.

DESIGN AND METHOD

Prospective single-site, open-label, randomized controlled trial. Thirty-two women, aged 18-45 years, were allocated into one of four arms (1 : 1 : 1 : 1): exercise, beetroot juice, exercise plus beetroot juice and no intervention for 12 weeks. Blood pressure (BP) was measured at home daily. Cardiac output ( CO ) and total peripheral resistance (TPR) were assessed via bio-impedance.

RESULTS

Twenty-nine out of 32 (91%) participants completed the study. Adherence to daily BP and weight measurements were 81% and 78%, respectively ( n  = 29). Eight out of 15 (53%) of participants did not drink all the provided beetroot juice because of forgetfulness and taste. After 12 weeks, exercise was associated with a reduction in standing TPR (-278 ± 0.272 dynes s cm -5 , P  < 0.05), and an increase in standing CO (+0.88 ± 0.71 l/min, P  < 0.05). Exercise and beetroot juice together was associated with a reduction in standing DBP ( 7 ± 6 mmHg, P  < 0.05), and an increase in standing CO (+0.49 ± 0.66 l/min, P  < 0.05). The control group showed a reduction in standing TPR ( 313 ± 387 dynes s cm -5 ) and standing DBP ( 8 ± 5mmHg). All groups gained weight.

CONCLUSION

Exercise and beetroot juice in combination showed a signal towards improving cardiovascular parameters. The control group showed improvements, indicating that home measurement devices and regular recording of parameters are interventions in themselves. Nevertheless, interventions before pregnancy to improve cardiovascular parameters may alter the occurrence of hypertensive conditions during pregnancy and require further investigation in adequately powered studies.

Expert review: preeclampsia Type I and Type II

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

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

NO donors on top of anti-hypertensive therapy reduces complications in chronic hypertensive pregnancies with hypodynamic circulation

OBJECTIVES

Chronic hypertension is associated with significant adverse maternal and fetal outcomes that appear to be often associated to a hypodynamic circulation. Treatment of hypertensive disorders of pregnancy tailored on maternal hemodynamics might reduce or mitigate these complications. Our purpose was to assess the hemodynamic modifications induced by the addition of NO donors and increased oral fluid intake on top of standard antihypertensive therapy in hypodynamic chronic hypertensive patients. We further evaluated if the possible hemodynamic modification induced by NO donors and increased oral fluid intake might be associated to a reduction of the severity and rate of complications vs. patients on antihypertensive standard treatment.

STUDY DESIGN

This was a case-control study of 321 chronic hypertensive patients with a hypodynamic circulation at the echocardiographic evaluation at 24 weeks' gestation. We included 160 controls (standard antihypertensive therapy) and 161 cases (standard therapy + NO donor patches + increased oral fluid intake). Student T test for paired and unpaired data, univariate logistic regression analysis, ROC curve analysis, and Cox Hazards Regression analysis were used as appropriate.

RESULTS

At enrollment the hemodynamic parameters were similar between the two groups. After 3-4 weeks stroke volume (77 ± 19 mL vs. 69 ± 19 mL; p < 0.001), and cardiac output (6.2 ± 1.7 L vs. 5.0 ± 1.6 L; p < 0.001) were higher and total peripheral vascular resistance (1465 ± 469 dyne·s·cm-5 vs. 1814 ± 524 dyne·s·cm-5; p < 0.001) was lower in the cases vs controls. Superimposed preeclampsia, preterm delivery before 34 weeks, abruptio placentae, HELLP Syndrome, fetal growth restriction, and perinatal death were more represented in the standard treatment group vs NO treated patients (81% vs 53%; p < 0.001). In particular, the standard treatment group showed 48% fetal growth restriction vs 34% in the NO treated group (p < 0.011). The Cox proportional-hazards regression showed a lower proportion of event-free pregnancies in controls on standard treatment (HR 2.6; 95% CI 2.0-3.5; p < 0.0001), and a prolongation of pregnancies in CH cases complicated by fetal growth restriction taking NO donors (HR 0.29; 95% CI 0.19-0.43; p = 0.0001).

CONCLUSIONS

The tailored treatment with NO donors and oral fluids of hypodynamic CH might have positive effects on the reduction or mitigations of adverse outcomes.

Endothelial Dysfunction and Pregnant COVID-19 Patients with Thrombophilia: A Narrative Review

Pregnancy with SARS-CoV-2 infection can raise the risk of many complications, including severe COVID-19 and maternal-fetal adverse outcomes. Additionally, endothelial damage occurs as a result of direct SARS-CoV-2 infection, as well as immune system, cardiovascular, and thrombo-inflammatory reactions. In this narrative review, we focus on endothelial dysfunction (ED) in pregnancy, associated with obstetric complications, such as preeclampsia, fetal growth retardation, gestational diabetes, etc., and SARS-CoV-2 infection in pregnant women that can cause ED itself and overlap with other pregnancy complications. We also discuss some shared mechanisms of SARS-CoV-2 pathophysiology and ED.

Placental syndromes and maternal cardiovascular health

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

Placental syndromes and long-term risk of hypertension

Higher blood pressure prior to pregnancy is associated with increased risk of placental abruption, hypertension and preeclampsia, preterm delivery and fetal growth restriction. These conditions are jointly termed placental syndromes as they are characterised by impaired placentation and early placental vascularization. Placental syndromes are associated with an increased maternal risk of progression to hypertension and cardiovascular disease (CVD) in later life. Women affected by both a clinical placental syndrome and with evidence of placental maternal vascular malperfusion (MVM) have a particularly high risk of hypertension and CVD. Yet whether placental impairment and clinical syndromes are causes or consequences of higher blood pressure in women remains unclear. In this review, we address the relationship between blood pressure and maternal health in pregnancy. We conclude that there is a pressing need for studies with a range of detailed measures of cardiac and vascular structure and function taken before, during and after pregnancy to solve the 'chicken and egg' puzzle of women's blood pressure and pregnancy health, and to inform effective precision medicine prevention and treatment of both placental syndromes and chronic hypertension in women.

A Balancing Act: Navigating Hypertensive Disorders of Pregnancy at Very Advanced Maternal Age, from Preconception to Postpartum

The decision to postpone parenting has gained momentum in recent years, a shift driven by evolving social dynamics and improved access to fertility treatments. Despite their increasing prevalence, pregnancies at advanced maternal ages are associated with increased risks of adverse maternal and neonatal outcomes. This article addresses the association between advanced maternal age and hypertensive disorders of pregnancies (HDPs), which are more prevalent and a significant cause of maternal morbidity and mortality in this population. This review explores the biological mechanisms and age-related risk factors that underpin this increased susceptibility and offers practical management strategies that can be implemented prior to, as well as during, each stage of pregnancy to mitigate the incidence and severity of HDPs in this group. Lastly, this review acknowledges both the short-term and long-term postpartum implications of HDPs in women of advanced maternal age.

High prevalence of pre-eclampsia in women with coarctation of the aorta

Aims

The aim was to study pregnancy outcomes in women with coarctation of the aorta (CoA) and associations to hypertensive disorders of pregnancy. Maternal morbidity and mortality are higher in women with heart disease and pre-eclampsia. Chronic hypertension, frequently encountered in CoA, is a risk factor for pre-eclampsia.

Methods and results

Clinical data from the National Unit for Pregnancy and Heart Disease database was reviewed for pregnant women with CoA from 2008 to 2021. The primary outcome was hypertensive pregnancy disorders. The secondary outcomes were other cardiovascular, obstetric, and foetal complications. Seventy-six patients were included, with a total of 87 pregnancies. Seventeen (20%) patients were treated for chronic hypertension before pregnancy. Fifteen (20%) patients developed pre-eclampsia, and 5 (7%) had pregnancy-induced hypertension. Major adverse cardiac events developed in four (5%) patients, with no maternal or foetal mortality. Maternal age at first pregnancy [odds ratio (OR) 1.37], body mass index before first pregnancy (OR 1.77), and using acetylsalicylic acid from the first trimester (OR 0.22) were statistically significantly associated with pre-eclampsia. At follow-up (median) 8 years after pregnancy, 29 (38%) patients had anti-hypertensive treatment, an increase of 16% compared to pre-pregnancy. Five (7%) patients had progression of aorta ascendens dilatation to >40 mm, seven (9%) had an upper to lower systolic blood pressure gradient >20 mmHg, and six (8%) had received CoA re-intervention.

Conclusion

Pre-eclampsia occurred in 20% of women with CoA in their first pregnancy. All pre-eclamptic patients received adequate anti-hypertensive treatment. All CoA patients were provided multi-disciplinary management, including cardiologic follow-up, to optimize maternal-foetal outcomes.

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

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

Linking Electronic Health Records With Wearable Technology From the All of Us Research Program

OBJECTIVE

To evaluate the feasibility of using electronic health records (EHRs) and wearable data to describe patterns of longitudinal change in day-level heart rate before, during, and after pregnancy and how these patterns differ by age and body mass index.

DESIGN

Descriptive secondary analysis feasibility study using data from the National Institutes of Health All of Us Research Program.

SETTING

United States.

PARTICIPANTS

Women (N = 89) who had a birth or length of gestation code in the EHR and at least 60 days of Fitbit heart rate data during pregnancy.

METHODS

We estimated pregnancy-related episodes using EHR codes. Time consisted of five 3-month periods: before pregnancy, first trimester, second trimester, third trimester, and after birth. We analyzed data using descriptive statistics and locally estimated scatterplot smoothing.

RESULTS

An average of 330 days (SD = 112) of Fitbit heart rate data (29,392 days) were available from participants. During pregnancy, distinct peaks in heart rate occurred during the first trimester (6% increase) and third trimester (15% increase).

CONCLUSION

Future researchers can examine whether longitudinal timing and patterns of heart rate from wearable devices could be leveraged to detect health problems early in pregnancy.

The cardiac-fetal-placental unit: fetal umbilical vein flow rate is linked to the maternal cardiac profile in fetal growth restriction

BACKGROUND

The functional maternal-fetal hemodynamic unit includes fetal umbilical vein flow and maternal peripheral vascular resistance.

OBJECTIVE

This study investigated the relationships between maternal and fetal hemodynamics in a population with suspected fetal growth restriction.

STUDY DESIGN

This was a prospective study of normotensive pregnancies referred to our outpatient clinic for a suspected fetal growth restriction. Maternal hemodynamics measurement was performed, using a noninvasive device (USCOM-1A) and a fetal ultrasound evaluation to assess fetal biometry and velocimetry Doppler parameters. Comparisons among groups were performed with 1-way analysis of variance with Student-Newman-Keuls correction for multiple comparisons and with Kruskal-Wallis test where appropriate. The Spearman rank coefficient was used to assess the correlation between maternal and fetal hemodynamics. Pregnancies were observed until delivery.

RESULTS

A total of 182 normotensive pregnancies were included. After the evaluation, 54 fetuses were classified as growth restricted, 42 as small for gestational age, and 86 as adequate for gestational age. The fetus with fetal growth restriction had significantly lower umbilical vein diameter (P<.0001), umbilical vein velocity (P=.02), umbilical vein flow (P<.0001), and umbilical vein flow corrected for fetal weight (P<.01) than adequate-for-gestational-age and small-for-gestational-age fetuses. The maternal hemodynamic profile in fetal growth restriction was characterized by elevated systemic vascular resistance and reduced cardiac output. The umbilical vein diameter was positively correlated to maternal cardiac output (r_s=0.261), whereas there was a negative correlation between maternal systemic vascular resistance (r_s=-0.338) and maternal potential energy-to-kinetic energy ratio (r_s=-0267). The fetal umbilical vein time averaged max velocity was positively correlated to maternal cardiac output (r_s=0.189) and maternal inotropy index (r_s=0.162), whereas there was a negative correlation with maternal systemic vascular resistance (r_s=-0.264) and maternal potential energy-to-kinetic energy ratio (r_s=-0.171). The fetal umbilical vein flow and the flow corrected for estimated fetal weight were positively correlated with maternal cardiac output (r_s=0.339 and r_s=0.297) and maternal inotropy index (r_s=0.217 and r=0.336), whereas there was a negative correlation between maternal systemic vascular resistance (r_s=-0.461 and r_s=-0.409) and maternal potential energy-to-kinetic energy ratio (r_s=-0.336 and r_s=-0.408).

CONCLUSION

Maternal and fetal hemodynamic parameters were different in the 3 groups of fetuses: fetal growth restriction, small for gestational age, and adequate for gestational age. Maternal hemodynamic parameters were closely and continuously correlated with fetal hemodynamic features. In particular, a maternal hemodynamic profile with high systemic vascular resistance, low cardiac output, reduced inotropism, and hypodynamic circulation was correlated with a reduced umbilical vein flow and increased umbilical artery pulsatility index. The mother, placenta, and fetus should be considered as a single cardiac-fetal-placental unit. The correlations of systemic vascular resistance, cardiac output, and inotropy index with umbilical artery impedance indicate the key role of these 3 parameters in placental vascular tree development. The umbilical vein flow rate and, therefore, the placental perfusion seems to be influenced not only by these three parameters but also by the maternal cardiovascular kinetic energy.

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

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

Longitudinal maternal cardiac function in hypertensive disorders of pregnancy

BACKGROUND

Compared with gestational hypertension, preeclampsia has traditionally been considered the worse end of the spectrum of hypertensive disorders of pregnancy. It is associated with worse pregnancy outcomes and future cardiovascular morbidities. Both hypertensive disorders may be associated with cardiac maladaptation in pregnancy. However, previous studies were limited by small numbers and a paucity of longitudinal data and unaccounted for the contribution of maternal characteristics that can affect hemodynamics.

OBJECTIVE

This study aimed to assess, in an unselected population, the maternal cardiac adaptation in normotensive and hypertensive pregnancies after controlling for important maternal characteristics that affect maternal cardiac function and the interaction among these covariates.

STUDY DESIGN

This was a prospective, multicenter longitudinal study of maternal hemodynamics, assessed by a noninvasive bioreactance technology, measured at 11 0/7 to 13 6/7, 19 0/7 to 24 0/7, 30 0/7 to 34 0/7, and 35 0/7 to 37 0/7 weeks of gestation in 3 groups of women. Group 1 was composed of women with preeclampsia (n=45), group 2 was composed of women with gestational hypertension (n=61), and group 3 was composed of normotensive women (n=1643). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal age, height, weight, weight gain, race, previous obstetrical history, and birthweight.

RESULTS

After adjusting for confounders that significantly affect maternal hemodynamics, both group 1 and group 2, compared with group 3, had pathologic cardiac adaptation. Group 1, compared with group 3, demonstrated hyperdynamic circulation with significantly higher cardiac output driven by greater stroke volume in the first trimester of pregnancy. As the pregnancies progressed to after 20 0/7 weeks of gestation, this hyperdynamic state transitioned to hypodynamic state with low cardiac output and high peripheral vascular resistance. Group 2, compared with group 3, had no significant differences in cardiac output, stroke volume, and heart rate before 20 0/7 weeks of gestation but thereafter demonstrated a continuous decline in cardiac output and stroke volume, similar to group 1. Both groups 1 and 2, compared with group 3, had persistently elevated mean arterial pressure and uterine artery pulsatility index throughout pregnancy.

CONCLUSION

After adjusting for confounders that affect maternal hemodynamics in an unselected pregnant population, women with preeclampsia and gestational hypertension, compared with normotensive women, demonstrated similar cardiac maladaptation. This pathologic profile was evident after 20 0/7 weeks of gestation and at least 10 weeks before the clinical manifestation of the disease.

First-Trimester Normotension Is a Weak Indicator of Normal Maternal Cardiovascular Function

BACKGROUND

As by definition, mean arterial pressure equals the product of cardiac output (CO) and total vascular resistance (TPR), we hypothesized that, irrespective of thresholds to define hypertension, a CO-TPR imbalance might exist in first-trimester normotensive pregnancies with altered risks for adverse gestational outcomes.

METHODS

A standard protocol was used for automated blood pressure measurement combined with impedance cardiography assessment of CO and TPR (NICCOMO). First-trimester normotensive pregnant women were categorized into 3 groups relative to the reference 75th percentile (P75) of CO and TPR: (1) normal CO and TPR, (2) high CO, and (3) high TPR. These subgroups were compared at blood pressure thresholds 140/90, 130/85, and 130/80 mmHg. The gestational outcome was categorized after birth according to International Society for Studies of Hypertension in Pregnancy criteria.

RESULTS

Compared with pregnancies with normal CO and TPR (≤P75), women with high TPR at blood pressure <140/90 mmHg are at risk for developing gestational hypertension (odds ratio, 3.795 [1.321-10.904]; P<0.010), late-onset preeclampsia (odds ratio, 3.137 [1.060-9.287]; P<0.050), and neonates small for gestational age (odds ratio, 1.780 [1.056-2.998]; P<0.050).

CONCLUSIONS

Cardiovascular imbalance can present in normotensive women in the first trimester and is associated with increased risks for adverse gestational outcomes. This study illustrates the relevance of CO and TPR assessments as an adjunct to blood pressure measurement and invites for further exploring their value in screening algorithms for gestational hypertensive disorders and/or small for gestational age.

Effect of bariatric surgery on maternal cardiovascular system

OBJECTIVE

Bariatric surgery is a successful treatment for sustainable weight loss and has been associated with improvement in cardiovascular function. Pregnancy after bariatric surgery is becoming increasingly common; however, little is known about the maternal cardiovascular system postsurgery. The aim of this study was to investigate maternal cardiovascular adaptation to pregnancy in women with previous bariatric surgery, compared with that in women with no history of weight-loss surgery and an early-pregnancy body mass index (BMI) similar to the presurgery BMI of the postbariatric women.

METHODS

This was a prospective, observational, longitudinal study conducted from April 2018 to June 2020 including 30 pregnant women who had undergone bariatric surgery and 30 who had not, matched for presurgery BMI. Participants were seen at three timepoints during pregnancy: 12-14, 20-24 and 30-32 weeks' gestation. At all visits, maternal blood pressure (BP) was measured and cardiac geometry and function were assessed using two-dimensional (2D) transthoracic echocardiography. On a subset of patients (15 in each group), 2D speckle tracking was performed to assess global longitudinal and circumferential strain. Offline analysis was performed, and multilevel linear mixed-effects models were used for all comparisons.

RESULTS

Compared with the no-surgery group, and across all trimesters, pregnant women with previous bariatric surgery had lower BP, heart rate and cardiac output and higher peripheral vascular resistance (P < 0.01 for all). Similarly, the postbariatric group demonstrated more favorable cardiac geometry and diastolic indices, including lower left ventricular mass, left atrial volume and relative wall thickness, together with higher E-wave/A-wave flow velocity across the mitral valve and higher mitral velocity (E') at the lateral and medial annulus on tissue Doppler imaging (P < 0.01 for all). There was no difference in ejection fraction, although global longitudinal strain was lower in postbariatric women (P < 0.01), indicating better systolic function.

CONCLUSION

Our findings indicate better maternal cardiovascular adaptation in women with previous bariatric surgery compared with presurgery BMI-matched pregnant women with no history of weight-loss surgery. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study

Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.

Preeclampsia: Maternal cardiovascular function and optimising outcomes

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

Remote multimodality monitoring of maternal physiology from the first trimester to postpartum period: study results

OBJECTIVES

Current antenatal care largely relies on widely spaced appointments, hence only a fraction of the pregnancy period is subject to monitoring. Continuous monitoring of physiological parameters could represent a paradigm shift in obstetric care. Here, we analyse the data from daily home monitoring in pregnancy and consider the implications of this approach for tracking pregnancy health.

METHODS

Prospective feasibility study of continuous home monitoring of blood pressure, weight, heart rate, sleep and activity patterns from the first trimester to 6 weeks postpartum.

RESULTS

Fourteen out of 24 women completed the study (58%). Compared to early pregnancy [week 13, median heart rate (HR) 72/min, interquartile range (IQR) 12.8], heart rate increased by week 35 (HR 78/min, IQR 16.6; P  = 0.041) and fell postpartum (HR 66/min, IQR 11.5, P  = 0.021). Both systolic and diastolic blood pressure were lower at mid-gestation (week 20: SBP 103 mmHg, IQR 6.6; DPB 63 mmHg, IQR 5.3 P  = 0.005 and P  = 0.045, respectively) compared to early pregnancy (week 13, SBP 107 mmHg, IQR 12.4; DPB 67 mmHg, IQR 7.1). Weight increased during pregnancy between each time period analyzed, starting from week 15. Smartwatch recordings indicated that activity increased in the prepartum period, while deep sleep declined as pregnancy progressed.

CONCLUSION

Home monitoring tracks individual physiological responses to pregnancy in high resolution that routine clinic visits cannot. Changes in the study protocol suggested by the study participants may improve compliance for future studies, which was particularly low in the postpartum period. Future work will investigate whether distinct adaptative patterns predate obstetric complications, or can predict long-term maternal cardiovascular health.

Preeclampsia and Fetal Growth Restriction as Risk Factors of Future Maternal Cardiovascular Disease-A Review

Cardiovascular diseases (CVDs) remain the leading cause of death in women worldwide. Although traditional risk factors increase later-life CVD, pregnancy-associated complications additionally influence future CVD risk in women. Adverse pregnancy outcomes, including preeclampsia and fetal growth restriction (FGR), are interrelated disorders caused by placental dysfunction, maternal cardiovascular maladaptation to pregnancy, and maternal abnormalities such as endothelial dysfunction, inflammation, hypercoagulability, and vasospasm. The pathophysiologic pathways of some pregnancy complications and CVDs might be linked. This review aimed to highlight the associations between specific adverse pregnancy outcomes and future CVD and emphasize the importance of considering pregnancy history in assessing a woman's CVD risk. Moreover, we wanted to underline the role of maternal cardiovascular maladaptation in the development of specific pregnancy complications such as FGR.