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Maisat W, Yuki K. The Fontan Circulation in Pregnancy: Hemodynamic Challenges and Anesthetic Considerations. J Cardiothorac Vasc Anesth 2024; 38:2770-2782. [PMID: 39097487 PMCID: PMC11486577 DOI: 10.1053/j.jvca.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/14/2024] [Accepted: 07/08/2024] [Indexed: 08/05/2024]
Abstract
Pregnancy in patients with Fontan physiology presents unique challenges due to altered cardiovascular dynamics inherent to both conditions. The Fontan procedure reroutes venous blood directly to the pulmonary arteries, bypassing the heart, and necessitating precise regulation of pulmonary venous resistance and systemic venous pressure to maintain effective cardiac output. The significant cardiovascular adaptations required during pregnancy to meet the metabolic demands of the mother and fetus can overburden the limited preload capacity and venous compliance in Fontan patients, predisposing them to a spectrum of potential complications, including arrhythmias, heart failure, thromboembolism, and obstetric and fetal risks. This review delineates the essential physiological adaptations during pregnancy and the challenges faced by Fontan patients, advocating for a comprehensive care approach involving multidisciplinary collaboration, vigilant monitoring, tailored anesthetic management, and postpartum care. Understanding the complex dynamics between Fontan physiology and pregnancy is crucial for anesthesiologists to develop and execute individualized management strategies to minimize risks and optimize outcomes for this high-risk population.
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Affiliation(s)
- Wiriya Maisat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
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Heijtmeijer ESET, Damhuis SE, Thilaganathan B, Groen H, Freeman LM, Middeldorp JM, Ganzevoort W, Gordijn SJ. Intrapartum epidural analgesia and emergency delivery for presumed fetal compromise: association or causation? Hypothesized mechanism explored. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:757-760. [PMID: 37910798 DOI: 10.1002/uog.27495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Affiliation(s)
- E S E Tabernée Heijtmeijer
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - S E Damhuis
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - B Thilaganathan
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - H Groen
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - L M Freeman
- Department of Obstetrics and Gynecology, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics and Gynecology, Ikazia Hospital, Rotterdam, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Bitsadze V, Khizroeva J, Alexander M, Elalamy I. Venous thrombosis risk factors in pregnant women. J Perinat Med 2022; 50:505-518. [PMID: 35044114 DOI: 10.1515/jpm-2022-0008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
Venous thromboembolism (VTE) is the third most common cause of death on Earth after myocardial infarctions and strokes, according to the World Health Organization (WHO). Pregnancy is a unique condition of woman, when enormous changes occur in functioning of the most important systems of homeostasis in a relatively short time. These are physiological hypercoagulation, slowing of blood flow, increase in circulating blood volume, etc. However, while being physiological, these changes increase the risks of venous thromboembolism by almost 6 times. In some cases, there appears an imbalance or dissociation between the functioning of natural antithrombotic systems and the activation of coagulation as a consequence of genetically or acquired determined causes (genetic thrombophilia, antiphospholipid syndrome, comorbidities, obstetric complications and other exogenous and endogenous factors). Accordingly, identification of risk factors, their systematization, and determination of VTE risks in pregnancy and puerperium is one of the most important tasks of clinical medicine. Various recommendations have appeared for practitioners during the last 10-15 years on the basis of the risk factors analysis in order to prevent VTE in pregnant women more effectively. Nevertheless, none of these recommendations can yet take into account all risk factors, although convenient scoring systems have emerged for risk assessment and clear recommendations on anti-thrombotic prophylaxis regimens in risk groups in recent years. This article will review historical understanding of thrombosis in pregnant women, progress in understanding VTE risk factors in pregnant women, and available reserves in identifying new risk factors during pregnancy and puerperium in order to stratify risks more efficiently.
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Affiliation(s)
- Victoria Bitsadze
- Department of Obstetrics and Gynecology, Russian Academy of Sciences, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, Russian Academy of Sciences, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Makatsariya Alexander
- Department of Obstetrics and Gynecology, Russian Academy of Sciences, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ismail Elalamy
- Department Hematology and Thrombosis Center, Medicine, Sorbonne University, Paris, France
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Comunale G, Susin FM, Mynard JP. Ventricular wall stress and wall shear stress homeostasis predicts cardiac remodeling during pregnancy: A modeling study. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3536. [PMID: 34599558 PMCID: PMC9285413 DOI: 10.1002/cnm.3536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/29/2021] [Indexed: 06/13/2023]
Abstract
Pregnancy is a unique and dynamic process characterized by significant changes in the maternal cardiovascular system that are required to satisfy the increased maternal and fetal metabolic demands. Profound structural and hemodynamic adaptations occur during healthy pregnancy that allows the mother to maintain healthy hemodynamics and provide an adequate uteroplacental blood circulation to ensure physiological fetal development. Investigating these adaptations is crucial for understanding the physiology of pregnancy and may provide important insights for the management of high-risk pregnancies. However, no previous modeling studies have investigated the maternal cardiac structural changes that occur during gestation. This study, therefore, had two aims. The first was to develop a lumped parameter model of the whole maternal circulation that is suitable for studying global hemodynamics and cardiac function at different stages of gestation. The second was to test the hypothesis that myofiber stress and wall shear stress homeostasis principles can be used to predict cardiac remodeling that occurs during normal pregnancy. Hemodynamics and cardiac variables predicted from simulations with and without controlled cardiac remodeling algorithms were compared and evaluated with reference clinical data. While both models reproduced the hemodynamic variations that arise in pregnancy, importantly, we show that the structural changes that occur with pregnancy could be predicted by assuming invariant homeostatic "target" values of myocardial wall stress and chamber wall shear stress.
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Affiliation(s)
- Giulia Comunale
- Cardiovascular Fluid Dynamics Laboratory HER, Department of Civil, Environmental and Architectural EngineeringUniversity of PadovaPadovaItaly
- Heart ResearchMurdoch Children's Research InstituteParkvilleVictoriaAustralia
| | - Francesca M. Susin
- Cardiovascular Fluid Dynamics Laboratory HER, Department of Civil, Environmental and Architectural EngineeringUniversity of PadovaPadovaItaly
| | - Jonathan P. Mynard
- Heart ResearchMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of PediatricsUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Biomedical EngineeringUniversity of MelbourneParkvilleVictoriaAustralia
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Bitsadze V, Khizroeva J, Elalamy I, Alexander M. Venous thrombosis risk factors in pregnant women. J Perinat Med 2020; 0:jpm-2020-0011. [PMID: 33098632 DOI: 10.1515/jpm-2020-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/09/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Assess all risk factors of venous thromboembolism (VTE) in pregnancy and puerperium. METHODS Different guidelines for VTE prevention have been analyzed. RESULTS Various recommendations have appeared for practitioners during the last 10-15 years on the basis of the risk factors analysis in order to prevent VTE in pregnant women more effectively. Nevertheless, none of these recommendations can yet take into account all risk factors, although convenient scoring systems have emerged for risk assessment and clear recommendations on anti-thrombotic prophylaxis regimens in risk groups in recent years. CONCLUSIONS VTE is the third most common cause of death on Earth after myocardial infarctions and strokes, according to the World Health Organization. Pregnancy is a unique condition of woman, when enormous changes occur in functioning of the most important systems of homeostasis in a relatively short time. These are physiological hypercoagulation, slowing of blood flow, increase in circulating blood volume, etc. However, while being physiological, these changes increase the risks of venous thromboembolism by almost six times. In some cases, there appears an imbalance or dissociation between the functioning of natural antithrombotic systems and the activation of coagulation as a consequence of genetically or acquired determined causes (genetic thrombophilia, antiphospholipid syndrome, comorbidities, obstetric complications and other exogenous and endogenous factors). Accordingly, identification of risk factors, their systematization, and determination of VTE risks in pregnancy and puerperium is one of the most important tasks of clinical medicine. This article will review historical understanding of thrombosis in pregnant women, progress in understanding VTE risk factors in pregnant women, and available reserves in identifying new risk factors during pregnancy and puerperium in order to stratify risks more efficiently.
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Affiliation(s)
- Victoria Bitsadze
- Department of Obstetrics and Gynecology, Russian Academy of Sciences, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, Russian Academy of Sciences, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ismail Elalamy
- Department Hematology and Thrombosis Center, Medicine, Sorbonne University, Paris, France
| | - Makatsariya Alexander
- Department of Obstetrics and Gynecology, Russian Academy of Sciences, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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PRE-ECLAMPSIA: ONE NAME, TWO CONDITIONS – THE CASE FOR EARLY AND LATE DISEASE BEING DIFFERENT. ACTA ACUST UNITED AC 2013. [DOI: 10.1017/s0965539513000016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Gyselaers W, Peeters L. Physiological implications of arteriovenous anastomoses and venous hemodynamic dysfunction in early gestational uterine circulation: a review. J Matern Fetal Neonatal Med 2013; 26:841-6. [DOI: 10.3109/14767058.2013.766705] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gyselaers W, Mullens W, Tomsin K, Mesens T, Peeters L. Role of dysfunctional maternal venous hemodynamics in the pathophysiology of pre-eclampsia: a review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:123-129. [PMID: 21611996 DOI: 10.1002/uog.9061] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The venous compartment has an important function in regulation and control of cardiac output. Abnormalities of cardiac output have been found in early gestational stages of both early- and late-onset pre-eclampsia. The venous compartment also maintains the balance between circulating and non-circulating blood volumes and regulates the amount of reserve blood stored in the splanchnic venous bed. It is well known that adaptive regulation of maternal blood volume is disturbed in pre-eclampsia. Abnormal venous hemodynamics and venous congestion are responsible for secondary dysfunction of several organs, such as the kidneys in cardiorenal syndrome and the liver in cardiac cirrhosis. Renal and liver dysfunctions are among the most relevant clinical features of pre-eclampsia. Doppler sonography studies have shown that the maternal venous compartment is subject to gestational adaptation, and that blood flow characteristics at the level of renal interlobar and hepatic veins are different in pre-eclampsia compared with uncomplicated pregnancy. In comparison to late-onset pre-eclampsia, in early-onset pre-eclampsia venous Doppler flow abnormalities are more prominent and present up to weeks before clinical symptoms. This paper reviews the growing evidence that dysfunction of maternal venous hemodynamics is part of the pathophysiology of pre-eclampsia and may perhaps be more important than is currently considered. Doppler sonography is a safe and easily performed method with which to study maternal venous hemodynamics. Therefore, exploring the role of maternal venous hemodynamics using Doppler sonography is an exciting new research topic for those who are interested in cardiovascular background mechanisms, as well as prediction and clinical work-up of pre-eclampsia.
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Affiliation(s)
- W Gyselaers
- Department of Obstetrics and Gynaecology, Ziekenhuis Oost Limburg, Genk, Belgium.
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Krabbendam I, Maas ML, Thijssen DHJ, Oyen WJG, Lotgering FK, Hopman MTE, Spaanderman MEA. Exercise-induced Changes in Venous Vascular Function in Nonpregnant Formerly Preeclamptic Women. Reprod Sci 2009; 16:414-20. [DOI: 10.1177/1933719109332091] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Ineke Krabbendam
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands,
| | - Martje L. Maas
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Dick H. J. Thijssen
- Research Institute for Sport and Exercise Science, John Moores University, Liverpool, United Kingdom, Department of Physiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Wim J. G. Oyen
- Department of Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Fred K. Lotgering
- Department of Obstetrics and Gynecology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Maria T. E. Hopman
- Department of Physiology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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