Basky Thilaganathan

Preeclampsia Is Associated With Persistent Postpartum Cardiovascular Impairment

Preeclampsia is associated with asymptomatic global left ventricular abnormal function and geometry during the acute phase of the disorder. These subclinical abnormalities in cardiac findings are known to be important in cardiovascular risk stratification for nonpregnant patients. Furthermore, epidemiological studies have also demonstrated a relationship between preeclampsia and cardiac morbidity and mortality later in life. The aim of this study was to evaluate the postpartum natural history and clinical significance of asymptomatic left ventricular impairment known to occur with acute preeclampsia. This was a prospective longitudinal case-control study of 64 subjects with preeclampsia and 78 matched controls. There were 3 time point assessments, pregnancy and 1 and 2 years postpartum. The assessments included a medical and family history, blood pressure profile, echocardiography, and 12-lead ECG. At 1 year postpartum, asymptomatic left ventricular moderate-severe dysfunction/hypertrophy was significantly higher in preterm preeclampsia (56%) compared with term preeclampsia (14%) or matched controls (8%; P values <0.001). The risk of developing essential hypertension within 2 years was significantly higher in both preterm preeclamptic women and those with persistent left ventricular moderate-severe abnormal function/geometry. The cardiovascular implications of preeclampsia do not end with the birth of the infant and placenta. The majority of preterm preeclamptic women have stage B asymptomatic heart failure postpartum, and 40% develop essential hypertension within 1 to 2 years after pregnancy. Women with a history of preterm preeclampsia may benefit from formal cardiovascular risk assessment in the 1 to 2 years after delivery to identify those who would benefit from targeted therapeutic intervention.

Maternal Cardiac Dysfunction and Remodeling in Women With Preeclampsia at Term

Preeclampsia is a disease associated with significant cardiovascular morbidity during pregnancy and in later life. This study was designed to evaluate cardiac function and remodeling in preeclampsia occurring at term. This was a prospective case–control study of 50 term preeclampsia and 50 normal pregnancies assessed by echocardiography and tissue Doppler analysis. Global diastolic dysfunction was observed more frequently in preeclampsia versus control pregnancies (40% versus 14%, P=0.007). Increased cardiac work and left ventricular mass indices suggest that left ventricular remodeling was an adaptive response to maintain myocardial contractility with preeclampsia at term. Approximately 20% of patients with preeclampsia at term have more evident myocardial damage. Diastolic dysfunction usually precedes systolic dysfunction in the evolution of ischemic or hypertensive cardiac diseases and is of prognostic value in the prediction of long-term cardiovascular morbidity. The study findings also have significant implications for the acute medical management of preeclampsia.

Placental edge to internal os distance in the late third trimester and mode of delivery in placenta praevia

Objectives To correlate transvaginal ultrasound findings with mode of delivery in cases of placenta praevia.

Cardiovascular Implications in Preeclampsia An Overview

Preeclampsia is a pregnancy-specific multi-organ syndrome that affects 2% to 8% of pregnancy.1 It is a unique condition of placental pathogenesis with acute onset of predominantly cardiovascular manifestations attributable to generalized vascular endothelial activation and vasospasm resulting in hypertension and multi-organ hypoperfusion.2,3 The major scientific societies provide different criteria for the diagnosis of preeclampsia. Common to all diagnostic criteria is that preeclampsia is a syndrome characterized by new-onset hypertension (≥140 mm Hg systolic blood pressure [SBP] or ≥90 mm Hg diastolic blood pressure [DBP]) arising after 20 weeks of gestation with ≥1 organ system involvement2–7 and complete resolution within 12 weeks postpartum2–5 (Table 1). The terms “preterm” or “early-onset” preeclampsia are used to try and delineate the severity of the disease in relation to the need for iatrogenic delivery before 37 weeks (preterm preeclampsia)8 or the time of the diagnosis at or before 34 weeks of gestational age (early-onset preeclampsia),6,7 respectively. Although not distinct entities, it is increasingly becoming apparent that early-onset or preterm preeclampsia is especially associated with poor placentation,9 fetal growth restriction, and worse long-term maternal cardiovascular outcomes than late-onset preeclampsia, whose pathogenesis is more related to predisposing cardiovascular or metabolic risks for endothelial dysfunction.10 Furthermore, because the pathogenesis of preeclampsia has not been fully elucidated, the search for predictive markers and a preventative strategy remains an unfulfilled goal. Hence, clinical management is mainly symptomatic and directed to prevent maternal morbidity and mortality.2–4 Preeclampsia is 1 of the leading causes of maternal morbidity and mortality worldwide, and delay in the treatment of severe hypertension and diagnosis of preeclampsia complications contribute significantly to maternal mortality.11 Mortality rates have been shown to be reduced in countries such as the United …

Is fetal cerebroplacental ratio an independent predictor of intrapartum fetal compromise and neonatal unit admission

OBJECTIVE We sought to evaluate the association between fetal cerebroplacental ratio (CPR) and intrapartum fetal compromise and admission to the neonatal unit (NNU) in term pregnancies. STUDY DESIGN This was a retrospective cohort study in a single tertiary referral center over a 14-year period from 2000 through 2013. The umbilical artery pulsatility index, middle cerebral artery pulsatility index, and CPR were recorded within 2 weeks of delivery. The birthweight (BW) values were converted into centiles and Doppler parameters converted into multiples of median (MoM), adjusting for gestational age using reference ranges. Logistic regression analysis was performed to identify, and adjust for, potential confounders. RESULTS The study cohort included 9772 singleton pregnancies. The rates of operative delivery for presumed fetal compromise and neonatal admission were 17.2% and 3.9%, respectively. Doppler CPR MoM was significantly lower in pregnancies requiring operative delivery or admission to NNU for presumed fetal compromise (P < .01). On multivariate logistic regression, both CPR MoM and BW centile were independently associated with the risk of operative delivery for presumed fetal compromise (adjusted odds ratio [OR], 0.67; 95% confidence interval [CI], 0.52-0.87; P = .003 and adjusted OR, 0.994; 95% CI, 0.992-0.997; P < .001, respectively). The latter associations persisted even after exclusion of small-for-gestational-age cases from the cohort. Multivariate logistic regression also demonstrated that CPR MoM was an independent predictor for NNU admission at term (adjusted OR, 0.55; 95% CI, 0.33-0.92; P = .021), while BW centile was not (adjusted OR, 1.00; 95% CI, 0.99-1.00; P = .794). The rates of operative delivery for presumed fetal compromise were significantly higher for appropriate-for-gestational-age fetuses with low CPR MoM (22.3%) compared to small-for-gestational-age fetuses with normal CPR MoM (17.3%). CONCLUSION Lower fetal CPR, regardless of the fetal size, was independently associated with the need for operative delivery for presumed fetal compromise and with NNU admission at term. The extent to which fetal hemodynamic status could be used to predict perinatal morbidity and optimize the mode of delivery merits further investigation.

Maternal cardiac function in preeclampsia.

Purpose of review Acute cardiovascular complications affect 6% of severe preeclampsia and epidemiological studies demonstrate a strong association between preeclampsia and subsequent cardiovascular morbidity and mortality. This data suggests that not only can preeclampsia acutely impair cardiac function, but also it has the potential to provoke myocardial ischaemia and affect long-term cardiovascular health. This review highlights the recent insights on cardiovascular impairment in preeclampsia and postpartum. Recent findings Recent studies on preeclampsia have used newer echocardiographic indices that are more sensitive at detecting asymptomatic myocardial damage, better correlated to invasive indices of myocardial function and are predictive for subsequent cardiovascular morbidity. Current findings indicate an unexpectedly high prevalence of cardiac impairment in preeclampsia and postpartum. These findings have important implications for the long-term cardiovascular health of women whose pregnancies were complicated by preeclampsia. Summary Preeclampsia is associated with stage B heart failure (asymptomatic left ventricular dysfunction/hypertrophy), a high prevalence of essential hypertension and an increased cardiovascular risk status within few years postpartum. These findings are more prevalent with early onset/preterm preeclampsia. These cardiovascular findings are consistent with epidemiological studies showing a ‘dose-dependent’ relationship between preeclampsia and long-term cardiovascular morbidity and mortality. There is increasing evidence supporting the concept that a history of early onset/preterm preeclampsia should be taken into account to identify women at high cardiovascular risk even in the absence of other concomitant risk factors.

Recent advances in the management of placenta previa.

Purpose of review Despite the widespread and routine use of ultrasound to make the diagnosis of placenta previa, evidence-based classification and management strategies have failed to evolve over the years. The purpose of this review is to present the current evidence supporting the screening, diagnosis and management of placenta previa. Recent findings The prevalence of placenta previa is significantly overestimated due to the practice of routine mid-pregnancy scan, and many women currently undergo a repeat scan in late pregnancy for placental localization. Recent reports support limiting third-trimester scans to only those cases where the placental edge either reaches or overlaps the internal cervical os at 20-23 weeks of pregnancy. In some cases of mid-trimester placenta previa, the placental edge is more likely to ‘migrate’ than others, and it appears that ultrasound may be useful to predict this process. At term, women with placental edge within 2 cm of the internal cervical os require a Caesarean section for delivery, whereas an attempt at vaginal birth is appropriate if this distance is more that 2 cm. Ultrasound also has a role in the diagnosis and management of both vasa previa and placenta accreta. Summary This review addresses screening for placenta previa. A simple and pragmatic ultrasound classification of placenta previa and low-lying placenta is proposed. Caesarean section is recommended for delivery in cases of placenta previa. Women with a low-lying placenta have at least 60% chance of a vaginal birth, but should be monitored for post-partum haemorrhage. Vasa previa is a rare complication but antenatal diagnosis is possible. It should particularly be suspected in in-vitro fertilization conceptions, and where the placental edge covers the os in mid-pregnancy but recedes later on. Prenatal diagnosis of placenta accreta should be based on the placental lacunae signs rather than the absence of retro-placental clear space.

Early-pregnancy multiple serum markers and second-trimester uterine artery Doppler in predicting preeclampsia.

OBJECTIVE: To estimate the ability of maternal serum markers and uterine artery Doppler in predicting preeclampsia. METHODS: In this nested case–control study, maternal serum concentrations of cystatin C, &bgr;2-microglobulin, serum amyloid A, C-reactive protein (CRP), and neopterin were measured, and resistance index of uterine artery blood flow was assessed in 45 women in whom preeclampsia subsequently developed and in 125 women with normal pregnancy outcome. Univariable regression analysis was performed to estimate correlations between serum markers and resistance index for the development of preeclampsia. Significant variables were identified using multiple logistic regressions. RESULTS: Maternal serum markers were measured at a median gestational age of 14.7 weeks (interquartile range 3.1) in control group members and 16.3 weeks (interquartile range 4.8) in the case group members, and uterine resistance index was measured at the second-trimester scan. Univariable logistic regression showed that women with subsequent preeclampsia had increased levels of cystatin C, &bgr;2-microglobulin, neopterin, CRP, and resistance index. Cystatin C, CRP, and resistance index remained independently associated with preeclampsia when multiple logistic regression was applied. Receiver-operating characteristic curve analysis showed that a combination of markers had a better area under the curve (AUC; 0.825) than when used in isolation (cystatin C, AUC 0.725; CRP, AUC 0.634; resistance index, AUC 0.728). Sensitivity of uterine artery resistance index, cystatin C, and CRP combined for predicting preeclampsia was 69.2% for a screen-positive rate of 15%. CONCLUSION: Maternal serum cystatin C, CRP, and uterine artery mean resistance index are independent predictors of preeclampsia. There is improved prediction of preeclampsia when serum markers are combined with Doppler indices.

Cardiac structure and function in normal pregnancy.

Purpose of review To review the published data on maternal cardiac adaptation to pregnancy. Recent findings Normal pregnancy is characterized by significant changes in the cardiovascular system. Studies on systemic arterial system and heart remodelling in pregnancy provide somewhat uniform results. In normal pregnancy, left ventricle mass, cardiac output and arterial compliance increase, whereas total vascular resistance decreases. In contrast, findings on left ventricular systolic and diastolic chamber and myocardial function are conflicting. Summary The major limitation of earlier studies on left ventricular systolic function is the use of ejection-phase indices that are dependent on loading conditions. Even when tissue Doppler velocity and deformation indices were measured, studies interpreted diastolic indices in isolation, rather than using validated diagnostic algorithms which account for the interdependency of cardiac events. Furthermore, the strong age-dependency of diastolic function indices was not accounted for in the majority of assessments and none of the studies diagnose or grade diastolic dysfunction. Future studies should aim to use appropriate control individuals, age-adjusted cutoff of cardiac diastolic indices and extended tissue Doppler velocity and deformation indices to provide objective information about chamber and myocardial function.

Prenatal diagnosis of non‐immune hydrops fetalis: what do we tell the parents?

The aim of this study is to outline the aetiology and outcome of a series of fetuses with non‐immune hydrops (NIH), detected prenatally. The findings are compared with a comprehensive review of recent reports.