Left ventricular midwall mechanics at 24 weeks' gestation in high-risk normotensive pregnant women: Relationship to placenta-related complications of pregnancy

Most studies during pregnancy have assessed maternal left ventricular (LV) function by load-dependent indices, assessing only chamber function. The aim of this study was to assess afterload-adjusted LV myocardial and chamber systolic function at 24 weeks' gestation and 6 months postpartum in high-risk normotensive pregnant women

Maternal cardiovascular dysfunction is associated with hypoxic cerebral and umbilical doppler changes

We investigate the relationship between maternal cardiovascular (CV) function and fetal Doppler changes in healthy pregnancies and those with pre-eclampsia (PE), small for gestational age (SGA) or fetal growth restriction (FGR). This was a three-centre prospective study, where CV assessment was performed using inert gas rebreathing, continuous Doppler or impedance cardiography. Maternal cardiac output (CO) and peripheral vascular resistance (PVR) were analysed in relation to the uterine artery, umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PI, expressed as z-scores by gestational week) using polynomial regression analyses, and in relation to the presence of absent/reversed end diastolic (ARED) flow in the UA. We included 81 healthy controls, 47 women with PE, 65 with SGA/FGR and 40 with PE + SGA/FGR. Maternal CO was inversely related to fetal UA PI and positively related to MCA PI; the opposite was observed for PVR, which was also positively associated with increased uterine artery impedance. CO was lower (z-score 97, p = 0.02) and PVR higher (z-score 2.88, p = 0.02) with UA ARED flow. We report that maternal CV dysfunction is associated with fetal vascular changes, namely raised impedance in the fetal-placental circulation and low impedance in the fetal cerebral vessels. These findings are most evident with critical UA Doppler changes and represent a potential mechanism for therapeutic intervention

Persistent maternal cardiac dysfunction after preeclampsia identifies patients at risk for recurrent preeclampsia

The purpose of our study was to assess cardiac function in nonpregnant women with previous early preeclampsia before a second pregnancy to highlight the cardiovascular pattern, which may take a risk for recurrent preeclampsia. Seventy-five normotensive patients with previous preeclampsia and 147 controls with a previous uneventful pregnancy were enrolled in a case-control study and submitted to echocardiographic examination in the nonpregnant state 12 to 18 months after the first delivery. All patients included in the study had pregnancy within 24 months from the echocardiographic examination and were followed until term. Twenty-two (29%) of the 75 patients developed recurrent preeclampsia. In the nonpregnant state, patients with recurrent preeclampsia compared with controls and nonrecurrent preeclampsia had lower stroke volume (63 +/- 14 mL versus 73 +/- 12 mL and 70 +/- 11 mL, P<0.05), cardiac output (4.6 +/- 1.2 L versus 5.3 +/- 0.9 L and 5.2 +/- 1.0 L, P<0.05), higher E/E ratio (11.02 +/- 3.43 versus 7.34 +/- 2.11 versus 9.03 +/- 3.43, P<0.05), and higher total vascular resistance (1638 +/- 261 dynes(-1)cm(-5) versus 1341 +/- 270 dynes(-1)cm(-5) and 1383 +/- 261 dynes(-1)cm(-5), P<0.05). Left ventricular mass index was higher in both recurrent and nonrecurrent preeclampsia compared with controls (30.0 +/- 6.3 g/m(2.7) and 30.4 +/- 6.8 g/m(2.7) versus 24.8 +/- 5.0 g/m(2.7), P<0.05). Signs of diastolic dysfunction and different left ventricular characteristics are present in the nonpregnant state before a second pregnancy with recurrent preeclampsia. Previous preeclamptic patients with nonrecurrent preeclampsia show left ventricular structural and functional features intermediate with respect to controls and recurrent preeclampsia

The maternal cardiovascular effect of carbetocin compared to oxytocin in women undergoing caesarean section

Objective: To compare haemodynamic changes, measured noninvasively using the USCOM monitor, after combined spino-epidural anaesthesia and after administration of two different uterotonic drugs, oxytocin and carbetocin, in a population of pregnant women during elective caesarean delivery.Methods: Haemodynamic measurements were obtained with the USCOM system, by positioning a probe at maternal suprasternal notch (SSN) until the aortic valve flow's profile was optimally identified. Evaluations of the haemodynamic profile were obtained in seven different moments: before anaesthesia; during skin incision; 60, 180 and 300 s after administration of uterotonic drug, at closure of the uterus, at closure of the skin. Doses of uterotonic drugs were: Oxytocin 5 UI in 500 cc NaCl eV, Carbetocin 100 mcg in bolus eV. Main measured parameters were: heart rate, mean blood pressure, stroke volume, cardiac output and total vascular resistance.Results: We enrolled 32 pregnant women. Patients were randomized in two groups: oxytocin and carbetocin. A reduction in mean blood pressure, a reduction of total vascular resistance and an increase of cardiac output and of stroke volume were seen, while heart rate values remained stable in both treatment groups. No statistically significant differences were found.Discussion: Administration of carbetocin is associated with a substantial global haemodynamic stability in patients undergoing elective caesarean section without any difference with oxytocin. This observation allows us to consider carbetocin comparable to oxytocin, with minimum haemodynamic impact on the maternal circulation. This minimal effect on global haemodynamic stability might extend the use of this uterotonic drug in patients at high haemorrhagic risk with preeclampsia. (C) 2012 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved

Hypertension in pregnancy and endothelial activation: An emerging risk factor for cardiovascular disease

Objective: There is emerging evidence suggesting that women who develop hypertensive disorders of pregnancy should be considered at risk for cardiovascular disease (CVD). Our objective was to determine whether persistent endothelial activation, which represents the earliest step in atherogenesis, is present after delivery in women with a history of hypertensive pregnancies compared to women with normal pregnancies.Study design: Two matched case-control studies were conducted. In the first study, endothelial activation was assessed by the measurement of soluble intercellular adhesion molecules, namely, intercellular adhesion molecules-1 (ICAM-1), vascular cellular adhesion molecules-1 (V-CAM-1), E-selectin and P-selectin in 25 women with hypertensive pregnancies and in a matched control group with an uncomplicated pregnancy one month and three months after delivery. In the second study, adhesion molecules were measured in 20 patients with a history of HELLP syndrome several years after pregnancy and in 20 matched controls.Results: Increased levels of soluble adhesion molecules were found in women with hypertensive complications compared to women with uncomplicated pregnancies shortly after delivery. Significant differences were still present, several years after delivery comparing levels of adhesion molecules in women with a history of HELLP syndrome with those found in control patients.Conclusions: Patients with hypertensive pregnancies showed an abnormal activation of the endothelium which persists after pregnancy. This activation was particularly marked in patients experiencing HELLP syndrome. These observations may represent an explanation to the increased risk of CVD later in life in patients experiencing hypertensive pregnancies, especially in women with a history of HELLP syndrome. (C) 2012 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved

Preterm delivery and elevated maternal total vascular resistance: signs of suboptimal cardiovascular adaptation to pregnancy?

Objective To evaluate the maternal hemodynamic profile in women with a diagnosis of threatened preterm delivery (TPD) in order to understand the possible pathophysiologic mechanism leading to an increased lifetime risk for future cardiovascular disease.Methods Patients with a diagnosis of TPD were enrolled and assessed using a non-invasive method (USCOM (R)) for the determination of hemodynamic parameters. Vaginal and rectal swabs were taken, cervical length, blood inflammatory indices, fetal blood-vessel Doppler velocimetry were measured and gestational age at the time of delivery and neonatal outcomes were noted.Results A total of 68 patients were enrolled and included in the analysis. The population was divided into two groups according to total vascular resistance (TVR): Group A with a TVR of <= 1000 dynesxs/cm(5) (n=48) and Group B with a TVR of > 1000 dynesxs/cm(5) (n = 20). C-reactive protein (CRP) was higher in Group B than in Group A, suggesting a systemic inflammation status. Group B delivered earlier (32+4weeks vs 38+2weeks; P<0.01) and neonatal outcome was worse than in Group A. Significantly lower values of cardiac output, stroke volume, peak velocity of flow, velocity time integral, minute distance, stroke volume index, cardiac index, stroke work, cardiac power, inotropy index and potential-to-kinetic energy ratio were observed in Group B than in Group A.Conclusions Women with a diagnosis of TPD showing TVR values of > 1000 dynesxs/cm(5) and elevated levels of CRP are at high risk of preterm delivery. An impaired maternal cardiovascular adaptation during pregnancy in these patients might suggest a possible higher risk for subsequent future cardiovascular disease. Copyright (C) 2016 ISUOG. Published by John Wiley & Sons Ltd

Restricted physical activity in pregnancy reduces maternal vascular resistance and improves fetal growth

Objectives To test the efficacy of maternal activity restriction for reducing peripheral vascular resistance in normotensive pregnant women with raised total vascular resistance (TVR) and to evaluate its effect on fetal growth.Methods This was a prospective case-control study of 30 women enrolled between 27 and 29weeks' gestation. All patients met the following criteria: normal blood pressure before and during pregnancy, TVR between 1300 and 1400 dynes x s/cm(5) at enrolment, normal fetal Doppler parameters at enrolment and abdominal circumference between the 10(th) and 25(th) centiles. Patients were assigned to activity restriction (activity-restriction group; n=15) or no treatment (control group; n=15) and were assessed after 4weeks for TVR and fetal growth.Results TVR at enrolment and estimated fetal weight centile were similar in the activity-restriction group vs controls (1358 +/- 26 vs 1353 +/- 30 dynesxs/cm(5); 18th +/- 4 vs 19th +/- 4 centile; P = NS). After 4 weeks, the activity-restriction group compared with controls showed significantly lower TVR (1165 +/- 159 vs 1314 +/- 190 dynes x s/cm(5); P < 0.05), which was associated with higher estimated fetal weight centile (25th +/- 5 vs 20th +/- 5 centile; P < 0.05). TVR was lower and estimated fetal weight centile higher for the activity-restriction group after 4weeks compared with at enrolment.Conclusions In normotensive pregnant women with raised TVR, maternal activity restriction appears to be effective in reducing TVR and therefore enhancing fetal growth. Copyright (C) 2017 ISUOG. Published by John Wiley & Sons Ltd

Maternal hemodynamics early in labor: a possible link with obstetric risk?

ObjectiveTo determine if hemodynamic assessment in low-risk' pregnant women at term with an appropriate-for-gestational age (AGA) fetus can improve the identification of patients who will suffer maternal or fetal/neonatal complications during labor.MethodsThis was a prospective observational study of 77 women with low-risk term pregnancy and AGA fetus, in the early stages of labor. Hemodynamic indices were obtained using the UltraSonic Cardiac Output Monitor (USCOM (R)) system. Patients were followed until the end of labor to identify fetal/neonatal and maternal outcomes, and those which developed complications of labor were compared with those delivering without complications.ResultsEleven (14.3%) patients had a complication during labor: in seven there was fetal distress and in four there were maternal complications (postpartum hemorrhage and/or uterine atony). Patients who developed complications during labor had lower cardiac output (5.61.0 vs 6.7 +/- 1.3 L/min, P=0.01) and cardiac index (3.1 +/- 0.6 vs 3.5 +/- 0.7 L/min/m(2), P=0.04), and higher total vascular resistance (1195.3 +/- 205.3 vs 1017.8 +/- 225.6 dynes x s/cm(5), P=0.017) early in labor, compared with those who did not develop complications. Receiver-operating characteristics curve analysis to determine cut-offs showed cardiac output 5.8 L/min (sensitivity, 81.8%; specificity, 69.7%), cardiac index 2.9 L/min/m(2) (sensitivity, 63.6%; specificity, 76.9%) and total vascular resistance >1069 dynes x s/cm(5) (sensitivity, 81.8%; specificity, 63.6%) to best predict maternal or fetal/neonatal complications.ConclusionsThe study of maternal cardiovascular adaptation at the end of pregnancy could help to identify low-risk patients who may develop complications during labor. In particular, low cardiac output and high total vascular resistance are apparently associated with higher risk of fetal distress or maternal complications. Copyright (c) 2017 ISUOG. Published by John Wiley & Sons Ltd