D. Farsetti

Screening for pre‐eclampsia in the first trimester: role of maternal hemodynamics and bioimpedance in non‐obese patients

To test if maternal hemodynamics and bioimpedance, assessed at the time of combined screening for PE, are able to identify in the first trimester of gestation normotensive non‐obese patients at risk for pre‐eclampsia (PE) and/or intrauterine growth restriction (IUGR).

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

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.

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

To 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.

OC09.02: Maternal hemodynamics in SGA fetuses that turn to IUGR and the potential efficacy of treatment

Objectives: To evaluate the effect of the treatment with nitric oxide (NO) donors in pregnant women with small-for-gestational age fetuses. Methods: 48 pregnant women referred for small for gestational age (SGA) fetus underwent a non-invasive hemodynamic measurement and an ultrasonic assessment of fetal growth. We obtained three subgroups according to total vascular resistance (TVR): Group A (high TVR treated, n=13), Group B (high TVR untreated, n=15) and Group C (low TVR untreated, n=20). After 4 weeks, we repeated fetal biometry and maternal cardiovascular assessment. Furthermore our aim was to identify those fetuses which turned their conditions to pathological intrauterine growth restriction (IUGR). Results: In table 1, we reported maternal main hemodynamic parameters in the three groups after 4 weeks of treatment/no treatment. Our data demonstrated that SGA fetuses with high TVR under treatment showed an improvement of maternal hemodynamic parameters after 4 weeks (see graph). Group B patients showed an impaired hemodynamic pattern, having an increased risk to develop IUGR and other complications. Conclusions: Maternal hemodynamic assessment at diagnosis of a SGA fetus might identify patients at risk to turn to pathological growth restriction. The preventive use of NO donors has shown to improve the impaired cardiovascular pattern and fetal outcomes.

OP21.06: Gestational diabetes mellitus: could hemodynamic assessment identify patients with poor glycemic control at higher risk of labour complications?

Methods: A prospective cohort study was conducted at Korle Bu Teaching Hospital, Ghana over a six-month period. SCD patients at 34 weeks gestation or more were recruited to undergo weekly Doppler assessment until delivery. The CPR was calculated and participants were categorised into two study arms based on a CPR<1.1 or >1.1. Adverse perinatal outcomes including IUGR, stillbirth, low birth weight and NICU admissions were compared between the two groups. Results: There were five fetuses with CPR<1.1 and 25 adverse perinatal events: 2 stillbirths, 10 low birth weight neonates, 12 NICU admissions and 1 APGAR score below 7 at 5 minutes. A CPR<1.1 had positive and negative predictive values of 100% and 72% respectively for predicting composite adverse perinatal outcomes. The sensitivity and specificity for predicting stillbirths were 100% and 93% respectively and 40% and 97% respectively for low birth weight. There was no significant difference in perinatal outcomes between the two major sickle cell genotypes (SS and SC). Mothers in the CPR< 1.1 group were also more likely to have severe anemia, blood transfusions and acute malaria during their pregnancy. Conclusions: A CPR <1.1 was shown to be significantly associated with adverse perinatal outcome especially low birthweight (<2.5kg) and antenatal stillbirths in fetuses of women with sickle cell disease.

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

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.

G1. Maternal haemodynamics assessment in preterm delivery: two different haemodynamic profiles

Abstract Introduction: The purpose of our study was to evaluate the maternal haemodynamic profile in women diagnosed with threatened preterm delivery (TPD) in order to understand the possible pathophysiologic mechanism leading to an increased lifetime risk for future cardiovascular disease. Methods: Sixty-eight patients diagnosed with TPD were enrolled and assessed using a non-invasive method (USCOM®) to determine the haemodynamic parameters. Cervix length assessment, vaginal and rectal swabs, blood inflammatory indexes, foetal vessel Doppler velocimetry, gestational age at the delivery and neonatal outcomes were considered. Results: The population was divided into two groups according to the total vascular resistance (TVR) in Group A ≤ 1000 dynes.s.cm−5, and Group B 41 000 dynes.s.cm−5. C-reactive protein was higher in Group B versus Group A, suggesting a systemic inflammation status. Group B delivered earlier (32 weeks + 4 days versus 38 weeks + 2 days, p <0.01), and the neonatal outcome was worse in comparison to Group A. There were significantly lower cardiac output, cardiac index, cardiac power, inotropy index and higher PE/KE in Group B versus Group A. Conclusions: Women diagnosed with TPD showed TVR values 41 000. We enrolled patients between 24 and 38 weeks, and the elevated CRP levels present high risk of preterm delivery. Impaired maternal cardiovascular adaptation during pregnancy in these patients might suggest a possible higher risk for future cardiovascular disease.

G2. Low pregestational fat mass and subsequent maternal cardiovascular maladaptation in early pregnancy. The missing link for preeclampsia.

Abstract Introduction: Several studies have demonstrated the correlation between maternal obesity and pregnancy complications. Obese women seem to be at higher risk to develop late preeclampsia, which shows a more favorable perinatal outcome compared to the early form. The assessment of total vascular resistance (TVR) could play an additional role in the detection of these patients. Targets: To identify patients at higher risk of hypertensive complications through the assessment of pre-pregnancy maternal fat mass (FM) and TVR. Results: Patients were divided into two groups in the first trimester: group A with low TVR and group B with high TVR. Cardiac output, stroke volume and TVR were statistically different at preconceptional visit and during the first trimester. FM was the only bioimpedance parameter to be found significantly different, higher in group A (Table 1). In group A, it is possible to identify a subgroup with higher FM that could be at high risk of late preeclampsia difficultly recognizable throughout TVR and BMI (Figure 1).Figure 1. Correlation between FM/TVR. On the other side, a too low FM might negatively influence maternal adaptation to pregnancy. Conclusions: FM could represent a better marker of body composition and a target to monitor the effectiveness of dietary changes improving maternal and neonatal outcome.

F1. Is there a correlation between total body water distribution and haemodynamic changes during pregnancy

Abstract Introduction: During pregnancy, maternal body composition and haemodynamics undergo important changes that are of increasing interest for understanding the evolving maternal physiology. Targets: To assess and correlate changes in body composition and haemodynamic function of healthy normotensive pregnant women. To identify different populations based on TVR values, we enrolled 235 patients subjected to bioimpedance analysis and haemodynamic assessment using the USCOM system. Results: We found an increase of BMI as result of an increase of all its components and a change in water distribution: ECW percentage increases while ICW decreases (see table). With regard to haemodynamics, we observed an increase in CO, SV and HR during all trimesters and a decrease in TVR. We divided the patients into two groups according to TVR values: we found lower TBW in patients with high TVR during the second trimester of pregnancy (see figure). Conclusions: Assessment of BMI is unable to disentangle the components of weight gain. TBW is strictly related to plasma volume expansion and has an important role in cardiac function enhancement. Assessment of TBW and TVR may identify patients with different adaptation to pregnancy: women with high TVR and insufficient plasma volume expansion and women with high TVR and excessive fluid retention.

D2. Screening of preeclampsia (PE) in the first trimester: high total vascular resistance (TVR) with a reduced fat mass increase the risk in normo BMI patients.

Abstract Introduction: Abnormalities of cardiac output, TVR and water body distribution are connected with PE and foetal growth restriction (FGR). Targets: To identify patients at risk of PE in the first trimester through USCOM system, bioimpedance and combined screening (maternal history, biophysical and biochemical markers). We enrolled 150 healthy nulliparous women with normal BMI. Results: The patients were divided into two groups: Group A (TVR <1200 dynes sec cm−5), Group B (TVR41200 dynes sec cm−5). Lower values of the Cardiac Output (CO), Cardiac index (CI), Inotropy index (INO), Heart rate (HR) and higher values of Flow Time correct (TFC) have been highlighted in the group B (p < 0.01) compared to group A. 8% of study population developed PE or PE + FGR. In this group 75% of the patients presented high TVR values and 50% is at high risk on the basis of combined screening. We found lower Fat Mass in complicated pregnancies with high TVR values compared to uncomplicated pregnancies with high TVR (Table 1). Conclusions: High TVR and lower Fat Mass in the first trimester may be an early marker of PE more than the combined screening. Moreover, lower fat mass increases the positive predictive value of isolated high TVR from 18% to 50% (Figure 1).Figure 1. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) of high Total Vascular Resistence (TVR), Combined first trimester screening (maternal history + mean artery pressure + pulsatility index of uterine artery Doppler + PAPP-A + PlGF) and high TVR + Fat Mass <20%.