Karen Melchiorre

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.

Counseling in isolated mild fetal ventriculomegaly

In this Review we aim to provide up‐to‐date and evidence‐based answers to the common questions regarding the diagnosis of isolated mild fetal ventriculomegaly (VM). A literature search was performed to identify all reports of antenatal VM in the English language literature. In addition, reference lists of articles identified using the search were scrutinized to further identify relevant articles. Fetal mild VM is commonly defined as a ventricular atrial width of 10.0–15.0 mm, and it is considered isolated if there are no associated ultrasound abnormalities. There is no good evidence to suggest that the width of the ventricular atria contributes to the risk of neurodevelopmental outcome in fetuses with mild VM. The most important prognostic factors are the association with other abnormalities that escape early detection and the progression of ventricular dilatation, which are reported to occur in about 13% and 16% of cases, respectively. Most infants with a prenatal diagnosis of isolated mild VM have normal neurological development at least in infancy. The rate of abnormal or delayed neurodevelopment in infancy is about 11%, and it is unclear whether this is higher than in the general population. Furthermore, the number of infants that develop a real handicap is unknown. There are limitations of existing studies of mild VM. Although they address many of the relevant questions regarding the prognosis and management of fetal isolated mild VM, there is a lack of good‐quality postnatal follow‐up studies. The resulting uncertainties make antenatal counseling for this abnormality difficult. Copyright

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 …

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.

Mid‐gestational maternal cardiovascular profile in preterm and term pre‐eclampsia: a prospective study

Pre‐eclampsia (PE) is associated with maternal cardiac remodelling and biventricular diastolic dysfunction. Preterm PE alone can also be associated with severe left ventricular hypertrophy and biventricular systolic dysfunction. The aim of this study was to assess whether the maternal cardiovascular profile at mid‐gestation in nulliparous normotensive women differs in women destined to develop preterm PE versus those who will develop PE at term.

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.

Severe Myocardial Impairment and Chamber Dysfunction in Preterm Preeclampsia

Objective. The long-term cardiovascular risk of preeclampsia is known to be significantly higher in women requiring preterm delivery before 37 weeks compared with those delivered at term. The aim of this study is to assess and compare maternal cardiac function and geometry in acute preterm and term preeclampsia. Methods. This is a prospective case–control study of 27 preterm and 50 term preeclampsia and 104 matched controls assessed by conventional echocardiography and tissue Doppler imaging. Results. Preeclampsia is associated with biventricular diastolic dysfunction, altered geometry, and widespread myocardial impairment. However, only preterm but not term preeclampsia is characterized by biventricular systolic dysfunction (26% vs. 4%; p < 0.05) and severe left ventricular hypertrophy (19% vs. 2%; p < 0.05). Conclusions. Women with preterm preeclampsia have a more severe cardiac impairment than those with term preeclampsia. This finding may explain the increased long-term cardiovascular risk associated with preterm preeclampsia. The cardiac assessment of women with preterm preeclampsia may be of relevance in identifying women at higher risk of developing cardiovascular morbidity and mortality in later life.

Uterine artery Doppler, birth weight and timing of onset of pre‐eclampsia: providing insights into the dual etiology of late‐onset pre‐eclampsia

To investigate the relationship between uterine artery Doppler ultrasound indices and birth weight in women with early‐, intermediate‐ and late‐onset pre‐eclampsia as compared with women with uneventful pregnancy outcome.

Maternal Cardiovascular Impairment in Pregnancies Complicated by Severe Fetal Growth Restriction

Fetal growth restriction and preeclampsia are both conditions of placental etiology and associated to increased risk for the long-term development of cardiovascular disease in the mother. At presentation, preeclampsia is associated with maternal global diastolic dysfunction, which is determined, at least in part, by increased afterload and myocardial stiffness. The aim of this study is to test the hypothesis that women with normotensive fetal growth-restricted pregnancies also exhibit global diastolic dysfunction. This was a prospective case-control study conducted over a 3-year period involving 29 preterm fetal growth-restricted pregnancies, 25 preeclamptic with fetal growth restriction pregnancies, and 58 matched control pregnancies. Women were assessed by conventional echocardiography and tissue Doppler imaging at diagnosis of the complication and followed-up at 12 weeks postpartum. Fetal growth-restricted pregnancies are characterized by a lower cardiac index and higher total vascular resistance index than expected for gestation. Compared with controls, fetal growth-restricted pregnancy was associated with significantly increased prevalence (P<0.001) of asymptomatic left ventricular diastolic dysfunction (28% versus 4%) and widespread impaired myocardial relaxation (59% versus 21%). Unlike preeclampsia, cardiac geometry and intrinsic myocardial contractility were preserved in fetal growth-restricted pregnancy. Fetal growth-restricted pregnancies are characterized by a low output, high resistance circulatory state, as well as a higher prevalence of asymptomatic global diastolic dysfunction and poor cardiac reserve. These findings may explain the increased long-term cardiovascular risk in these women who have had fetal growth-restricted pregnancies. Further studies are needed to clarify the postnatal natural history of cardiac dysfunction in these women.