Roberta Licia Scala

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.

Optimization of the viability of stem cells derived from umbilical cord blood after maternal supplementation with DHA during the second or third trimester of pregnancy: Study protocol for a randomized controlled trial

BackgroundUmbilical cord blood (UCB) is an important source of hematopoietic stem cells (HSCs). However, the concentration of cells in cord blood units is limited and this may represent the main restriction to their therapeutic clinical use. The percentage of metabolically active stem cells provides a measure of the viability of cells in an UCB sample. It follows that an active cellular metabolism causes a proliferation in stem cells, offering an opportunity to increase the cellular concentration. A high cell dose is essential when transplanting cord stem cells, guaranteeing, in the receiving patient, a successful outcome.This study is designed to evaluate the impact of docosahexaenoic acid (DHA) supplementation in pregnant women, in order to increase the quantity and viability of the cells in UCB samples.Methods/designThe metabolic demand of DHA increases in the course of pregnancy and reaches maximum absorption during the third trimester of pregnancy. According to these observations, this trial will be divided into two different experimental groups: in the first group, participants will be enrolled from the 20th week of estimated stage of gestation, before the maximum absorption of DHA; while in the second group, enrolment will start from the 28th week of estimated stage of gestation, when the DHA request is higher. Participants in the trial will be divided and randomly assigned to the placebo group or to the experimental group. Each participant will receive a complete set of capsules of either placebo (250 mg of olive oil) or DHA (250 mg), to take one a day from the 20th or from the 28th week, up to the 40th week of estimated gestational age. Samples of venous blood will be taken from all participants before taking placebo or DHA, at the 20th or at the 28th week, and at the 37th to 38th week of pregnancy to monitor the level of DHA. Cell number and cellular viability will be evaluated by flow cytometry within 48 hours of the UCB sample collection.Trial registrationInternational Standard Randomised Controlled Trial Number Register: ISRCTN58396079. Registration date: 8 October 2013.

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.

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.

P51. Screening for preeclampsia in the first trimester: A reduced fat mass increases the risk in normo BMI patients

Introduction Maternal cardiovascular system adapts to pregnancy thanks to complex physiological mechanisms that involve cardiac output, total vascular resistance (TVR) and water body distribution. Abnormalities of this adaptive mechanism are connected with hypertensive disorders and foetal growth restriction. Moreover, maternal serum PAPP-A is considered a biochemical marker extensively used for the first trimester screening of PE. Objective To identify patients at high risk of developing hypertensive complications of pregnancy during the first trimester through the use of non-invasive methods such as USCOM (Ultrasonic Cardiac Output Monitor), bioimpedance and biochemical marker. Materials and Methods We enrolled 96 healthy normotensive women with normal Body Mass Index during the first trimester of pregnancy (from 11+0 to 13+6weeks of gestation) obtaining all measurements with the USCOM system, Bioimpedance and collecting MoM values of PAPP-A Results Patients were divided into two groups: Group A ( n =54) with TVR n =42) with TVR >1200dynesseccm −5 . 10% ( n =10) of our study population developed pregnancy complications as IUGR and hypertensive disorders. In this group 81% of patients presented high TVR values and 37% PAPP-A p Conclusions High TVR and lower Fat Mass during the first weeks of gestation may be an early marker of cardiovascular maladaptation more than the evaluation of PAPP-A values and blood pressure assessment.

PP064. Total vascular resistances in early pregnancy: A key to understand abnormal cardiovascular adaptation associated with spontaneous abortion.

INTRODUCTION From early pregnancy, maternal hemodynamic profile begins to change. The absence of these changes leads to increased risk of complication during the gestation. OBJECTIVES Aim of this study is to understand in early pregnancy the behaviour of total vascular resistances (TVR) as a sign of maternal cardiovascular adaptation to pregnancy. METHOD A cross section study was conducted. We followed 160 healthy women with singleton pregnancy during the first trimester of gestation. We evaluated cardiac output (CO) and TVR at 7, 9 and 11 weeks of gestation. We obtained the following haemodynamic measurements with the USCOM system, a non invasive method: heart rate (HR), systolic and diastolic blood pressure (SBP, DBP), CO and TVR. RESULTS 160 healthy pregnant women were selected, 8 patients, were excluded for a bad signal. Absolute values of the haemodynamic measures are shown in Fig. 1. 41 patients underwent spontaneous embryonic demise. This last group of patients showed in 54% (group A) TVR values within the normal limits (TVR<1200), while 46% patients (group B) showed TVR values well above the normal limits (TVR>1200) and CO values below the normal adaptation to pregnancy. Table 1 shows hemodynamic measures for the group A and group B; we found differences in term of CO, TVR and PAS between the two groups. CONCLUSION Elevated TVR might indicate an abnormal vascular adaptation already in first weeks of pregnancy. Moreover, in women who undergo to abortion, elevated TVR could be use to distinguish genetic or environmental causes of miscarriage.

O21. Total vascular resistance and multigate spectral doppler analysis (MSDA) as a screening tool for preeclampsia: A pilot study

Aim of the study: Comparison between uterine artery Doppler, realized with traditional method and Multigate Spectral Doppler Analysis (MSDA), and Total Vascular Resistance (TVR), obtained with ultrasonic cardiac output monitor USCOM, in a population of healthy priimgravidae at 22–24 weeks of gestation. The study tries to identificate a normal/abnormal Z flow profile with MSDA associated with high or borderline TVR values in patients with abnormal uterine artery Doppler. This can allow us to select a group of patients with high risk of preeclampsia. Methods: A prospective observational study was conducted. 27 healthy pregnant women at 22–24 weeks of gestation were enrolled. For all patients uterine artery doppler measurements were performed using traditional method (PI and RI) and with Multigate Spectral Doppler Analysis that analyze the flow profile in the third dimension (Z-axis). During the same exame, TVR were collected for all patients with a non invasive ultrasonographic method (USCOM Spacelabs monitor). Results: After processing uterine artery Doppler measeurements, patients were divided into two groups: Group A, 36 patients with normal uterine artery resistance values and Group B, 31 patients with high uterine artery resistance values. At the same time, it was evaluate the features of the flow profile obtained with MSDA and classified in: t0 (laminar flow), t1 (least turbulent flow) and t2 (strongly turbulent flow) according to vessel wall’s tension. Results are shown in the table. Results of our pilot study shows that normal QDP profile with normal TVR values are observed in 75% of group A compared with 63% of group B. MSDA profile alterations (flow t1/t1 or at least flow t2) with normal TVR are present in 19% of group A compared with the 18% of the group B. TVR values more than 1200 dyne, without MSDA profile alterations, are found in 6% of group A compared with 9% of the group B. Moreover, in group A no patients shows both TVR and flow profile alterations but, in the group B, 9% of pregnants shows both TVR and flow profile alterations. Conclusions: Even if observed in a small study population, our data confirms that uterine artery Doppler velocimetry can be usefully integrated with new important parameters