G. M. Tiralongo

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 dyne·s−1·cm−5 versus 1341±270 dyne·s−1·cm−5 and 1383±261 dyne·s−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/m2.7 and 30.4±6.8 g/m2.7 versus 24.8±5.0 g/m2.7, 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.

Assessment of total vascular resistance and total body water in normotensive women during the first trimester of pregnancy. A key for the prevention of preeclampsia

INTRODUCTION Maternal cardiovascular system adapts to pregnancy, thanks to complex physiological mechanisms that involve cardiac output, total vascular resistance and water body distribution. Abnormalities of these adaptive mechanisms are connected with hypertensive disorders. OBJECTIVE To identify patients at a high risk of developing hypertensive complications of pregnancy during the first trimester of pregnancy, through the use of non-invasive methods such as USCOM (Ultrasonic Cardiac Output Monitor) and Bioimpedance. MATERIALS AND METHODS We enrolled 120 healthy normotensive women during the first trimester of pregnancy obtaining all measurements with the USCOM system and Bioimpedance. RESULTS 20 patients were excluded for a bad USCOM signal. The remaining patients (n = 100) were retrospectively divided into two groups: Group A (n = 75) TVR<1200 dynes s cm(-5), Group B (n = 25) TVR>1200 dynes s cm(-5). No statistically significant difference was identified in terms of water distribution, Fat Free Mass, Systolic/Diastolic Blood Pressure, Heart Rate, Hematocrit, Flow Time Corrected and Water Balance Index between the two groups. In contrast, higher values of the Cardiac Output, Stroke Volume, Fat Mass and Inotropy Index have been highlighted in the Group A. Moreover, in the Group A we found a better maternal-neonatal outcome and a lower incidence of hypertensive complications. CONCLUSIONS High TVR during the first weeks of gestation may be an early marker of cardiovascular maladaptation more than the evaluation of water distribution and, in particular, with respect to the single blood pressure assessment. Moreover lower values of Inotropy Index could be an indicative of the worst cardiac performance.

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.

Medical treatment of early-onset mild gestational hypertension reduces total peripheral vascular resistance and influences maternal and fetal complications

Complications in early‐onset mild gestational hypertension (GH) are better predicted by total peripheral vascular resistance (TPVR) > 1350 dyne than by blood pressure. We therefore aimed to assess the possible reduction of severe complications by lowering TPVR with nitric oxide (NO) donors, oral fluids and standard antihypertensive therapy in women with early‐onset mild GH.

Effect of a nitric oxide donor on maternal hemodynamics in fetal growth restriction

To evaluate the effect on maternal cardiovascular parameters of treatment with a nitric oxide (NO) donor and plasma volume expansion in pregnancies complicated by fetal growth restriction (FGR).

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).

Nitric oxide (NO) donors and haemodynamic changes in fetal growth restriction.

To evaluate the effect on maternal cardiovascular parameters of treatment with a nitric oxide (NO) donor and plasma volume expansion in pregnancies complicated by fetal growth restriction (FGR).

H1. Persistent maternal cardiac dysfunction after preeclampsia identifies patients at risk for recurrent pre-eclampsia.

Abstract Objective: The purpose of our study was to assess cardiac function in non-pregnant women with previous early preeclampsia before a second pregnancy to highlight the cardiovascular pattern, which may take a risk for recurrent preeclampsia. Methods: 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 non-pregnant state 12–18 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. Results: Twenty-two (29%) of the 75 patients developed recurrent preeclampsia. In the non-pregnant state, patients with recurrent preeclampsia compared to controls and non-recurrent 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 dyne·s·cm−5 versus 1341 ± 270 dyne·s·cm−5 and 1383 ± 261 dyne·s·cm−5, p < 0.05). Left ventricular mass index was higher in both recurrent and non-recurrent preeclampsia compared to controls (30.0 ± 6.3 g/m2.7 and 30.4 ± 6.8 g/m2.7 versus 24.8 ± 5.0 g/m2.7, p < 0.05). Conclusions: Signs of diastolic dysfunction and different left ventricular characteristics are present in the non-pregnant state before a second pregnancy with recurrent preeclampsia. Previous preeclamptic patients with non-recurrent preeclampsia show left ventricular structural and functional features intermediate with respect to controls and recurrent preeclampsia.

F4. NO donors and haemodynamic changes in fetal growth restriction.

Abstract Introduction: Pregnancies complicated by fetal growth restriction (FGR) are known to be associated with a reduced expansion of maternal intravascular space and a lower cardiac output. Therapy with nitric oxide (NO) donors, in addition to plasma volume expansion (PVE) could improve maternal haemodynamic indices and pregnancy outcome. Methods: To evaluate maternal cardiovascular effects of NO donors. We enrolled 52 women with the diagnosis of FGR. Patients were divided into those treated with transdermal patches of NO donors and PVE or a control group. We obtained haemodynamic indices using an USCOM system. Results: At enrolment, the two groups were similar in terms of maternal, fetal and haemodynamic characteristics. In the group treated with NO donors and PVE, we found a significant increase in cardiac output, stroke volume and a decrease of systemic vascular resistance after therapy (see table). At birth the treated group also gave birth to babies with higher birth weight centile. Conclusions: The combined therapeutic approach of NO donor administration and PVE in FGR significantly improves maternal hemodynamic indices. Despite the observation nature of the data, there is suggestion that the use of NO donors together with PVE may also improve pregnancy outcome by increasing the fetal growth.

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 flows profile was optimally identified. Evaluations of the haemodynamic profile were obtained in seven different moments: before anaesthesia; during skin incision; 60, 180 and 300s after administration of uterotonic drug, at closure of the uterus, at closure of the skin. Doses of uterotonic drugs were: Oxytocin 5UI in 500cc NaCl eV, Carbetocin 100mcg 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.