Afshan B. Hameed

Maternal and Fetal Outcomes of Subsequent Pregnancies in Women with Peripartum Cardiomyopathy

BACKGROUND Peripartum cardiomyopathy is a rare and sometimes fatal form of heart failure. Little is known about the outcomes of subsequent pregnancies in women who have had the disorder. METHODS Through a survey of members of the American College of Cardiology, we identified 44 women who had had peripartum cardiomyopathy and had a total of 60 subsequent pregnancies. We then reviewed the medical records of these women and interviewed the women or their physicians. RESULTS Among the first subsequent pregnancies in the 44 women, 28 occurred in women in whom left ventricular function had returned to normal (group 1) and 16 occurred in women with persistent left ventricular dysfunction (group 2). The pregnancies were associated with a reduction in the mean (+/-SD) left ventricular ejection fraction both in the total cohort (from 49+/-12 percent to 42+/-13 percent, P<0.001) and in each group separately (from 56+/-7 percent to 49+/-10 percent in group 1, P=0.002; and from 36+/-9 percent to 32+/-11 percent in group 2, P=0.08). During these pregnancies, a decrease of more than 20 percent in the left ventricular ejection fraction occurred in 21 percent of the women in group 1 and 25 percent of those in group 2, and symptoms of heart failure occurred in 21 percent of the women in group 1 and 44 percent of those in group 2. The mortality rate was 0 percent in group 1 and 19 percent in group 2 (P=0.06). In addition, the frequency of premature delivery was higher in group 2 (37 percent vs. 11 percent), as was that of therapeutic abortions (25 percent vs. 4 percent). CONCLUSIONS Subsequent pregnancy in women with a history of peripartum cardiomyopathy is associated with a significant decrease in left ventricular function and can result in clinical deterioration and even death.

Longitudinal Changes in the B-Type Natriuretic Peptide Levels in Normal Pregnancy and Postpartum

Normal levels of B‐type natriuretic peptide (BNP) are not well established in pregnancy. We obtained longitudinal BNP levels in 29 healthy pregnant women in each trimester and postpartum period, and compared these levels to the 25 nonpregnant controls. There were no significant differences among the cases and controls with respect to weight, diastolic blood pressure, and ethnicity. A total of 116 BNP values were obtained during pregnancy. The median (and range) BNP level during pregnancy was 19 (10–143) pg/ml versus 10 (10–37) pg/ml in the nonpregnant controls (p = 0.003). However, there were no statistically significant differences in the median BNP levels at various stages of pregnancy: first trimester 20 (10–115) pg/ml versus the second trimester 18 (10–112) pg/ml (p = 0.8), second trimester 18 pg/ml versus third trimester 26 (10–143) pg/ml (p = 0.06), and third trimester 26 pg/ml versus postpartum18 (10–62) pg/ml (p = 0.08). There were no significant differences between the BNP levels throughout the trimesters and postpartum period. Pregnant BNP levels were approximately twice as high as the nonpregnant BNP levels. Our study is unique in evaluating longitudinal changes in BNP levels in normal pregnancies and the postpartum period in comparison with healthy, nonpregnant controls. It demonstrates that pregnant BNP levels are approximately 2‐fold higher than their nonpregnant counterparts, and do not significantly fluctuate during pregnancy. In conclusion, pregnancy is associated with a significant, but small increase in the BNP levels compared with nonpregnant women. Copyright

Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy

OBJECTIVE Maternal mortality rates rose markedly from 2002 to 2006 in California, prompting an in-depth maternal mortality review in a state that comprises one twelfth of the US birth cohort. Cardiovascular disease has emerged as the leading cause of pregnancy-related death in the United States. The primary aim of this analysis was to describe the incidence and type of cardiovascular disease as a cause of pregnancy-related mortality in California. The secondary aims were to describe racial/ethnic and socioeconomic disparities, risk factors, birth outcomes, timing of death and diagnosis, and signs and symptoms of cardiovascular disease and identify contributing factors. STUDY DESIGN The California Pregnancy-Associated Mortality Review retrospectively examined a case series of 64 cardiovascular pregnancy-related deaths from 2002 through 2006. Two cardiologists independently reviewed complete inpatient and outpatient medical records including laboratory, radiology, electrocardiogram, chest X-ray, echocardiograms, and autopsy findings for each cardiovascular death and classified cause of death by type of cardiovascular disease. Demographic data, racial disparities, risk factors, signs and symptoms, timing of diagnosis and death, birth outcomes, and contributing factors were analyzed using bivariate comparisons with noncardiovascular pregnancy-related deaths and population-based data. RESULTS Among 2,741,220 California women who gave birth, 864 died while pregnant or within 1 year of pregnancy; 257 of the deaths were deemed pregnancy related, and of these, 64 (25%) were attributed to cardiovascular disease. There were 42 deaths caused by cardiomyopathy, and the pregnancy-related mortality rate from cardiomyopathy was 1.54 per 100,000 births. Dilated cardiomyopathy existed in 29 cases, of which 15 met the definition of peripartum cardiomyopathy. Women with cardiovascular disease were more likely than women who died from noncardiovascular causes to be African-American (39.1% vs 16.1%; P < .01) and more likely to use illicit substances (23.7% vs 9.4%; P < .01). Thirty-seven percent were obese and 20% had a concomitant diagnosis of hypertension or preeclampsia during pregnancy. Health care decisions in the diagnosis or treatment of cardiovascular disease during and after pregnancy contributed to the fatal outcomes. CONCLUSION African-American race, substance use, and obesity were risk factors for pregnancy-related cardiovascular disease mortality. Chronic disease prevention and better recognition and response to cardiovascular disease during pregnancy are needed to reduce maternal mortality.

Cardiopulmonary Resuscitation in Pregnancy

Cardiac arrest in pregnancy is not only uncommon but also catastrophic. Early aggressive resuscitation by well-trained health care providers improves the chances of successful outcomes for both the patient and her fetus. Significant physiologic changes that occur normally in pregnancy require several modifications to standard cardiopulmonary resuscitation, and urgent cesarean delivery may be indicated to benefit both the mother and the infant.

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women’s Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

Cardiovascular disease screening

Cardiovascular disease is the leading cause of death amongst women worldwide. Cardiovascular risk assessment and primary prevention are important strategies to improve morbidity and mortality. In additional to the traditional risk factors, pregnancy complications such as pre-eclampsia and gestational diabetes increment future risk of developing cardiovascular complications. Additionally, several serum biomarkers are valuable measures for both risk assessment and predictors of clinical outcomes in women. The purpose of this review is to describe current risk stratification schemes as well as outline the role of obstetric history and serum biomarkers in adjusting risk stratification in women.

The role of catheter balloon commissurotomy for severe mitral stenosis in pregnancy.

Mitral stenosis is one of the more commonly seen valve lesions encountered in pregnancy. The pathophysiologic implications, management strategies, and a comprehensive review of literature over the past 20 years for optimal timing of catheter balloon commissurotomy during pregnancy are discussed. Mechanical relief of obstruction is indicated for cases of severe symptomatic mitral stenosis in pregnancy refractory to medical therapy. Catheter balloon commissurotomy is the procedure of choice in a select group of these patients with suitable valve morphology.

Augmented H2S production via cystathionine-beta-synthase upregulation plays a role in pregnancy-associated uterine vasodilation

Abstract Endogenous hydrogen sulfide (H2S) synthesized via metabolizing L-cysteine by cystathionine-betasynthase (CBS) and cystathionine-gamma-lyase (CSE) is a potent vasodilator and angiogenic factor. The objectives of this study were to determine if human uterine artery (UA) H2S production increases with augmented expression and/or activity of CBS and/or CSE during the menstrual cycle and pregnancy and whether exogenous H2S dilates UA. Uterine arteries from nonpregnant (NP) premenopausal proliferative (pPRM) and secretory (sPRM) phases of the menstrual cycle and pregnant (P) women were studied. H2S production was measured by the methylene blue assay. CBS and CSE mRNAs were assessed by quantitative real-time PCR, and proteins were assessed by immunoblotting and semiquantitative immunofluorescence microscopy. Effects of H2S on rat UA relaxation were determined by wire myography ex vivo. H2S production was greater in NP pPRM and P than NP sPRM UAs and inhibited by the specific CBS but not CSE inhibitor. CBS but not CSE mRNA and protein were greater in NP pPRM and P than NP sPRM UAs. CBS protein was localized to endothelium and smooth muscle and its levels were in a quantitative order of P >NP UAs of pPRM>sPRM. CSE protein was localized in UA endothelium and smooth muscle with no difference among groups. A H2S donor relaxed P > NP UAs but not mesentery artery. Thus, human UA H2S production is augmented with endothelium and smooth muscle CBS upregulation, contributing to UA vasodilation in the estrogen-dominant physiological states in the proliferative phase of the menstrual cycle and pregnancy. Summary Sentence Augmented hydrogen sulfide biosynthesis via upregulating endothelium and smooth muscle cystathionine β-synthase expression plays a role in pregnancy-associated uterine vasodilation.

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into 4 domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

Patient-prosthesis mismatch in pregnancy.

BACKGROUND: Patient–prosthesis mismatch is a known and severe complication after aortic valve repair in the general population. There is a paucity of literature regarding this condition in pregnancy. CASE: We present the clinical course of a pregnant woman with severe patient–prosthesis mismatch after aortic valve replacement. After extensive workup, the patient underwent aortic valve replacement, enlargement of the aortic root, and placement of a larger prosthetic valve at 21 weeks of gestation. Her postoperative course was complicated by fetal death. CONCLUSION: Cardiopulmonary bypass and aortic valve replacement present a multitude of risks to maternal and fetal health. The obstetrician managing pregnant women with prosthetic heart valves should be aware of the complications that may arise, including patient–prosthesis mismatch.