Pre-eclampsia and Cardiovascular Disease: From Pregnancy to Postpartum

Hypertensive disorders of pregnancy (HDP) complicate approximately 10% of pregnancies. In addition to multiorgan manifestations related to endothelial dysfunction, HDP confers an increased risk of cardiovascular disease during delivery hospitalisation, such as heart failure, pulmonary oedema, acute MI and cerebrovascular events. However, the cardiovascular legacy of HDP extends beyond birth since these women are significantly more likely to develop cardiovascular risk factors in the immediate postnatal period and major cardiovascular disease in the long term. The main mediator of cardiovascular disease in women with a history of HDP is chronic hypertension, followed by obesity, hypercholesterolaemia and diabetes. Therefore, optimising blood pressure levels from the immediate postpartum period until the first months postnatally could have beneficial effects on the development of hypertension and improve long-term cardiovascular health. Peripartum screening based on maternal demographic, and clinical and echocardiographic data could help clinicians identify women with HDP at highest risk of developing postpartum hypertension who would benefit from targeted primary cardiovascular prevention

The management of pregnancy and labour in women with cardiac disease

Within my thesis I have shown that women with congenital heart disease are amenable to preconception counselling, but that many women are not referred to see a specialist cardiologist or obstetrician prior to pregnancy. Women with more severe forms of heart disease such as a Fontan repair have worse obstetric outcomes with high rates of miscarriage, preterm delivery and postpartum haemorrhage (PPH), hence the importance of comprehensive counselling prior to pregnancy. When women are counselled prior to pregnancy regarding the potential risks that they face, I have shown that the quoted risk of an adverse event assessed by an experienced clinician has a better correlation with actual outcome than other validated scoring systems such as the modified WHO score. Women with congenital heart disease are at much greater than average risk of postpartum haemorrhage (PPH). My analysis has shown that after correcting for known risk factors for PPH, women with a Fontan repair are at the highest risk of increased blood loss, and that low molecular weight heparin at both a prophylactic and therapeutic dose is associated with higher rates of PPH even when stopped at an appropriate time prior to delivery. I have focussed on the management of labour in women with heart disease, in particular of the second and third stages. Having shown that a restricted second stage for women with heart disease recommended by the multidisciplinary team (MDT) is often not adhered to in our actual clinical practice, my pilot study showed that there was only a modest measured haemodynamic effect of pushing (bearing down), with a small but significant increase in maternal heart rate in the active second stage of labour. I have found from a literature review and from our own historical dataset that the practice of a restricted oxytocin regimen for the management of the third stage (designed to minimise cardiovascular side-effects) is associated with greater rates of PPH, mainly due to uterine atony. In a prospective cohort study, women with heart disease were allocated to either a low dose infusion or a combination of the low dose infusion with an initial bolus of 2IU of oxytocin over ten minutes; those receiving the additional oxytocin had a significantly lower volume of blood loss and rate of PPH. Importantly, the women receiving the higher dose of oxytocin had no measured deleterious cardiovascular side effects.Open Acces

Management of stroke and pregnancy

Stroke continues to be one of the main causes of death in the developed countries and the incidence in pregnancy appears to be increasing. Pregnancy-related stroke has a relatively high mortality rate of 10% and so clinicians need to be mindful of appropriate investigations and referral of a pregnant woman with suspected stroke, so they can receive timely treatment. In this review we address the risk factors associated with stroke, diagnosis and appropriate management of the different stroke types. We also discuss implications for care around pregnancy and delivery as well as reviewing how a pregnancy with previous stroke should be managed. </jats:p

Encouraging brisk walking with the free Active10 app in postnatal women who had a hypertensive pregnancy: "Just Walk It" feasibility study.

ObjectiveTo explore the feasibility of a future trial to investigate whether encouraging use of the free NHS smartphone app Active10 increases brisk walking and reduces blood pressure (BP) in postnatal mothers who had hypertensive disorders of pregnancy (HDP).Design3-month feasibility study.SettingLondon maternity unit.Population21 women with HDP.MethodsAt recruitment we recorded initial (booking) clinic BP and asked participants to complete a questionnaire. Two months after delivery all participants were sent (by post/email/WhatsApp) a "Just Walk It" leaflet encouraging them to download the Active10 app and walk briskly for at least 10 minutes/day. This was backed by a telephone call after 2-weeks. Assessments were repeated 3-months later, and included telephone interviews about the acceptability and use of Active10.Main outcome measuresWere recruitment rate, follow-up rate and acceptability/use of Active10.ResultsOf 28 women approached, 21 (75%, 95% CI 55.1-89.3%) agreed to participate. Age range was 21-46 years and five (24%) self-identified as black ethnicity. One woman dropped out of the study, and one became ill. The remaining participants (90%, 19/21, 95% CI 69.6-98.8%) were followed up after 3-months. Ninety-five percent (18/19) downloaded the Active10 app and 74% (14/19) continued using it at 3-months, averaging 27-minutes brisk walking/day according to Active10 weekly screenshots. Comments included: "Brilliant app", "Really motivates me". Mean BP was 130/81mmHg at booking and 124/80mmHg at 3-months follow-up.ConclusionsThe Active10 app was acceptable to postnatal women after HDP and may have increased minutes of brisk walking. A future trial could explore whether this simple, low-cost intervention could reduce long-term BP in this vulnerable group

Encouraging brisk walking with the free Active10 app in postnatal women who had a hypertensive pregnancy: “Just Walk It” feasibility study

Objective To explore the feasibility of a future trial to investigate whether encouraging use of the free NHS smartphone app Active10 increases brisk walking and reduces blood pressure (BP) in postnatal mothers who had hypertensive disorders of pregnancy (HDP). Design 3-month feasibility study. Setting London maternity unit. Population 21 women with HDP. Methods At recruitment we recorded initial (booking) clinic BP and asked participants to complete a questionnaire. Two months after delivery all participants were sent (by post/email/WhatsApp) a “Just Walk It” leaflet encouraging them to download the Active10 app and walk briskly for at least 10 minutes/day. This was backed by a telephone call after 2-weeks. Assessments were repeated 3-months later, and included telephone interviews about the acceptability and use of Active10. Main outcome measures Were recruitment rate, follow-up rate and acceptability/use of Active10. Results Of 28 women approached, 21 (75%, 95% CI 55.1–89.3%) agreed to participate. Age range was 21–46 years and five (24%) self-identified as black ethnicity. One woman dropped out of the study, and one became ill. The remaining participants (90%, 19/21, 95% CI 69.6–98.8%) were followed up after 3-months. Ninety-five percent (18/19) downloaded the Active10 app and 74% (14/19) continued using it at 3-months, averaging 27-minutes brisk walking/day according to Active10 weekly screenshots. Comments included: “Brilliant app”, “Really motivates me”. Mean BP was 130/81mmHg at booking and 124/80mmHg at 3-months follow-up. Conclusions The Active10 app was acceptable to postnatal women after HDP and may have increased minutes of brisk walking. A future trial could explore whether this simple, low-cost intervention could reduce long-term BP in this vulnerable group

Pregnancy outcomes in women with primary biliary cholangitis and primary sclerosing cholangitis: a retrospective cohort study

Objective To determine maternal, obstetric and neonatal outcomes in a cohort of women with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) Design Retrospective cohort study. Setting 10 specialist centres managing pregnant women with liver disease Population Women with a diagnosis of PBC and PSC and a pregnancy of ≥20 completed weeks’ gestation. Methods Retrospective case notes review Main outcome measures Adverse outcomes were defined as maternal: development of ascites, variceal bleeding, encephalopathy and jaundice; obstetric events: gestational hypertension, pre-eclampsia and postpartum haemorrhage; and neonatal: stillbirth, preterm delivery, and admission to neonatal unit. The relationship of alanine transferase (ALT) and bile acid levels with gestation at delivery was studied. Results The first recorded pregnancies of 34 women with PSC and 27 with PBC were analysed. There were 60 livebirths and one intrapartum stillbirth that did not occur in the context of maternal cholestasis. Overall median gestation of delivery was 38 weeks, but the rate of preterm birth was 28% (17/61 deliveries) of which 76% (13/17) were spontaneous. Gestation at birth negatively correlated with maternal serum ALT concentration at booking (p=0.017) and serum bile acid concentration during pregnancy (p=0.016). There were no other significant correlations and maternal and neonatal outcomes were good. Conclusion Pregnancy in PBC and PSC is well tolerated, but women should be counselled regarding the increased risk of preterm birth. Measurement of maternal ALT and bile acids may help identify women at risk of preterm delivery