Hypertensive disorders of pregnancy (HDP) occur in 10% of pregnancies in the general population, pre-eclampsia specifically in 3-5%. Hypertensive disorders of pregnancy may have a high prevalence in, ...and be poorly tolerated by, women with heart disease.
The prevalence and outcomes of HDP (chronic hypertension, gestational hypertension or pre-eclampsia) were assessed in the ESC EORP ROPAC (n = 5739), a worldwide prospective registry of pregnancies in women with heart disease.The overall prevalence of HDP was 10.3%, made up of chronic hypertension (5.9%), gestational hypertension (1.3%), and pre-eclampsia (3%), with significant differences between the types of underlying heart disease (P < 0.05). Pre-eclampsia rates were highest in women with pulmonary arterial hypertension (PAH) (11.1%), cardiomyopathy (CMP) (7.1%), and ischaemic heart disease (IHD) (6.3%). Maternal mortality was 1.4 and 0.6% in women with vs. without HDP (P = 0.04), and even 3.5% in those with pre-eclampsia. All pre-eclampsia-related deaths were post-partum and 50% were due to heart failure. Heart failure occurred in 18.5 vs. 10.6% of women with vs. without HDP (P < 0.001) and in 29.1% of those with pre-eclampsia. Perinatal mortality was 3.1 vs. 1.7% in women with vs. without HDP (P = 0.019) and 4.7% in those with pre-eclampsia.
Hypertensive disorders of pregnancy and pre-eclampsia rates were higher in women with CMP, IHD, and PAH than in the general population. Adverse outcomes were increased in women with HDP, and maternal mortality was strikingly high in women with pre-eclampsia. The combination of HDP and heart disease should prompt close surveillance in a multidisciplinary context and the diagnosis of pre-eclampsia requires hospital admission and continued monitoring during the post-partum period.
During normal pregnancy, placental oxidative stress (OS) is present during all three trimesters and is necessary to obtain normal cell function. However, if OS reaches a certain level, pregnancy ...complications might arise. In preeclampsia (PE), a dangerous pregnancy specific hypertensive disorder, OS induced in the ischemic placenta causes a systemic inflammatory response and activates maternal endothelial cells. In this study, we aimed to quantify superoxide concentrations (as a measure of systemic OS) using electron paramagnetic resonance (EPR) and correlate them to markers of systemic inflammation, iron status and vascular function.
Fifty-nine women with a healthy pregnancy (HP), 10 non-pregnant controls (NP) and 28 PE patients (32±3.3weeks) were included. During HP, blood samples for superoxide, neutrophil to lymphocyte ratio (NLR), mean platelet volume (MPV) and iron status were taken at 10, 25 and 39 weeks. Vascular measurements for arterial stiffness (carotid-femoral pulse wave velocity (CF-PWV), augmentation index (AIx), augmentation Pressure (AP)) and microvascular endothelial function (reactive hyperemia index (RHI)) were performed at 35 weeks. In PE, all measurements were performed at diagnosis. CMH (1-hydroxy-3-methoxycarbonyl-2,2,5,5-tetramethylpyrrolidine) was used as spin probe for EPR, since the formed CM radical corresponds to the amount of superoxide.
Superoxide concentration remains stable during pregnancy (p = 0.92), but is significantly higher compared to the NP controls (p<0.0001). At 25 weeks, there is a significant positive correlation between superoxide and ferritin concentration. (p = 0.04) In PE, superoxide, systemic inflammation and iron status are much higher compared to HP (all p<0.001). During HP, superoxide concentrations correlate significantly with arterial stiffness (all p<0.04), while in PE superoxide is significantly correlated to microvascular endothelial function (p = 0.03).
During HP there is an increased but stable oxidative environment, which is correlated to ferritin concentration. If superoxide levels increase, there is an augmentation in arterial stiffness. In PE pregnancies, systemic inflammation and superoxide concentrations are higher and result in a deterioration of endothelial function. Together, these findings support the hypothesis that vascular function is directly linked to the amount of OS and that measurement of OS in combination with vascular function tests might be used in the prediction of PE.
Pregnancy Outcomes in Women With Aortic Valve Substitutes Heuvelman, Helena J., MD, MSc; Arabkhani, Bardia, MSc; Cornette, Jerome M.J., MD ...
The American journal of cardiology,
02/2013, Letnik:
111, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Young women who require aortic valve replacement need information on the potential cardiac and obstetric complications of pregnancy for the different valve substitutes available. We, therefore, ...assessed the pregnancy outcomes in women who had received an autograft, homograft, or mechanical valve in the aortic position. Women who were pregnant after surviving aortic valve replacement at our institution from 1987 to 2011 were included. Information on cardiac status and pregnancy outcome was obtained through the hospital medical records and by an extensive patient questionnaire. A total of 40 women experienced 67 pregnancies, of which 55 (82%) were completed pregnancies, 6 (9%) were miscarriages, and 6 (9%) were terminated. Of the 40 women, 18 (45%) had a pulmonary autograft, 13 (32%) a homograft, and 9 (23%) a mechanical valve. The mean age at the first pregnancy was 30.0 ± 5.7 years. No maternal mortality but 1 fetal death (1.8%) and 1 neonatal death (1.8%) occurred. Maternal cardiac complications developed in 13% and obstetric complications in 38% of the completed pregnancies. Heart failure (9%), arrhythmias (7%), hypertension-related disorders (7%), preterm delivery (24%), and small-for-gestational-age infants (15%) were most often encountered. Mechanical valve recipients had the greatest incidence of both cardiac and obstetric complications. In conclusion, pregnancy-associated complications after aortic valve replacement were common, and human tissue valves should be considered in the discussion for the optimal aortic valve substitute in a young woman. However, careful obstetric monitoring is mandatory.
There is no published evidence on pregnancy after right ventricular outflow tract (RVOT) reconstruction with an allograft.
The aim of this study was to describe pregnancy outcomes in women with ...allografts in the RVOT position.
A retrospective cohort study of consecutive female patients who received allografts in the RVOT position was conducted. All patients between 18 and 50 years of age were screened for cardiac, obstetric, and fetal outcomes of completed (≥20 weeks’ gestation) pregnancies.
In total, 196 women met the inclusion criteria, of whom 56 had 89 completed pregnancies. Information could be retrieved in 84 cases (94.4%). Mean maternal age was 29.6 ± 4.3 years, with 80 patients (95.2%) in New York Heart Association functional class I or II. The most common diagnosis was tetralogy of Fallot. All women survived pregnancy. There were 2 cases (2.4%) of heart failure (arrhythmic and diastolic dysfunction), 1 case (1.2%) of infection (chorioamnionitis), and 3 cases (3.6%) of pre-eclampsia. No other cardiac or obstetric events were reported. All children were born alive at a median gestational age of 38.4 weeks (interquartile range: 36.9 to 39.6 weeks), with a median birthweight of 2,930 g (interquartile range: 2,535 to 3,385 g). Seventeen (20.2%) were small for gestational age, and 20 (23.8%) were premature. Neonatal death was reported in 2 children (2.5%). Preconception pulmonary regurgitation was associated with an increased probability of pre-term labor (odds ratio: 2.610; 95% confidence interval: 1.318 to 5.172). Compared with the general Dutch population, pre-term delivery (25.0% vs. 7.4%, p < 0.001) and children small for gestational age (20.2% vs. 10.0%, p = 0.002) were more common.
Women in good cardiac health after RVOT reconstruction with allografts can safely experience pregnancy and labor. The higher incidence of pre-term delivery and children small for gestational age warrants special attention.
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Aims
Data on diuretic use in pregnancy are limited and inconsistent, and consequently it remains unclear whether they can be used safely. Our study aims to evaluate the perinatal outcomes after ...in‐utero diuretic exposure.
Methods and results
The Registry Of Pregnancy And Cardiac disease (ROPAC) is a prospective, global registry of pregnancies in women with heart disease. Outcomes were compared between women who used diuretics during pregnancy versus those who did not. Multivariable regression analysis was used to assess the impact of diuretic use on the occurrence of congenital anomalies and foetal growth. Diuretics were used in 382 (6.7%) of the 5739 ROPAC pregnancies, most often furosemide (86%). Age >35 years (odds ratio OR 1.5, 95% confidence interval CI 1.2–2.0), other cardiac medication use (OR 5.4, 95% CI 4.2–6.9), signs of heart failure (OR 1.7, 95% CI 1.2–2.2), estimated left ventricular ejection fraction <40% (OR 2.9, 95% CI 2.0–4.2), New York Heart Association class >II (OR 3.4, 95% CI 2.3–5.1), valvular heart disease (OR 6.3, 95% CI 4.7–8.3) and cardiomyopathy (OR 3.9, 95% CI 2.6–5.7) were associated with diuretic use during pregnancy. In multivariable analysis, diuretic use during the first trimester was not significantly associated with foetal or neonatal congenital anomalies (OR 1.3, 95% CI 0.7–2.6), and diuretic use during pregnancy was also not significantly associated with small for gestational age (OR 1.4, 95% CI 1.0–1.9).
Conclusions
Our study does not conclusively establish an association between diuretic use during pregnancy and adverse foetal outcomes. Given these findings, it is essential to assess the risk–benefit ratio on an individual basis to guide clinical decisions.
Outcomes of the Registry of Pregnancy and Cardiac disease (ROPAC) regarding diuretic use during pregnancy. Data in n (%) unless otherwise specified. CI, confidence interval; LMIC, low‐or‐middle‐income country; LVEF, left ventricular ejection fraction; MACE, major adverse cardiac event (combined endpoint of maternal mortality, heart failure, arrhythmia, endocarditis, thromboembolic event and dissection); mWHO, modified World Health Organization; NYHA, New York Health Association; OR, odds ratio. *p < 0.05.
Introduction
Women with severe hypertension during pregnancy require prompt stabilization with a combination of magnesium sulfate and rapidly acting intravenously administered antihypertensives. It ...remains unknown which antihypertensive is best suited for pregnancy. The present study evaluated the intravenous use of the calcium antagonist, nicardipine.
Material and Methods
This multicenter, retrospective case series included all pregnant women beyond 20 weeks of gestation with severe antepartum hypertension that were treated with intravenous nicardipine. Primary outcome measures: successful treatment, time to successful treatment, and maternal safety. Severe hypertension was defined as systolic blood pressure (SBP) of 160 mm Hg or more and/or diastolic blood pressure (DBP) of 110 mm Hg or more.
Results
This study included 830 women. After 1 h of treatment, two‐thirds of the women had SBP below 160 mm Hg and DBP below 100 mm Hg. In three out of four women, the mean arterial pressure was below 120 mm Hg. Within 2 h of treatment, 77.4% of women achieved successful treatment. In all cases, nicardipine was eventually effective. Within the first 2 h, 42.7% of women experienced temporary low DBP (ie below 70 mm Hg) without clinical consequences for the mother or fetus. In all cases, the low DBP resolved after discontinuing or reducing the dosage of nicardipine. One case of fetal distress was attributable to maternal hypotension, and a cesarean section was performed at more than 2 h after initiating therapy. During treatment, headache, nausea, and vomiting decreased significantly.
Conclusions
To date, this was the largest case‐series study on the use of nicardipine for treating severe antepartum hypertension in pregnancy. We found that nicardipine could effectively and safely treat this condition. Based on its high success rate and acceptable safety profile, nicardipine should be considered a first‐line treatment in women with severe hypertension in pregnancy.
Peripartum cardiomyopathy (PPCM) is a rare form of pregnancy-associated heart failure and is considered to be a diagnosis of exclusion. There are many hypotheses on the aetiology of PPCM; however, ...the exact pathophysiological mechanism remains unknown. It shows many resemblances to other conditions, such as familial dilated cardiomyopathy or myocarditis, and therefore it can be hard to make a definite diagnosis. We describe four cases of peripartum-onset heart failure in women who were suspected of having PPCM. We discuss the differential diagnosis, pathophysiological mechanisms and various diagnostic modalities.
Influence of pregnancy on long-term durability of allografts in right ventricular outflow tract Romeo, Jamie L.R.; Papageorgiou, Grigorios; Takkenberg, Johanna J.M. ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
April 2020, 2020-04-00, 20200401, Letnik:
159, Številka:
4
Journal Article
Recenzirano
Odprti dostop
There is very limited published evidence about the influence of pregnancy on allograft durability in right ventricular outflow tract position. We present the first study using mixed and joint ...modeling.
This retrospective study compared clinical and valve related outcomes of all consecutive female hospital survivors in their fertile life phase (18-50 years) based on pregnancy. Serial echocardiographic measurements of pulmonary gradient and regurgitation were analyzed for their association with valve replacement using joint models for longitudinal and time-to-event data. Occurrence of first pregnancy was included as a time-dependent intermediate event in both the longitudinal and survival analyses of the joint model to assess its impact on the hemodynamic and clinical outcome.
In total, 196 consecutive women in their fertile life-phase with an allograft were included. Complete information of 176 (90%) allografts in 165 women was available, including 1395 echocardiograms. Of these women, 51 (30.9%) women had 84 completed pregnancies at an average age of 29.1 ± 3.9 (SD) years; 8.1 ± 6.1 years since allograft implantation. Tetralogy of Fallot was the most common diagnosis in both groups. After a mean follow-up of 15.2 years (range 0.1-30), 7 (13.7%) parous women underwent valve replacement versus 20 (17.5%) nulliparous women. During this follow-up, the mean allograft gradient in parous (24.2 mm Hg) and nulliparous (21.0 mm Hg) women was comparable (P = .225). A 1-mm Hg increase in pulmonary gradient increased the instantaneous risk of pulmonary valve replacement (PVR) by a ratio of 1.051 (P < .001), regardless of pregnancy. Similarly, development of moderate or severe regurgitation increased the risk of PVR (P = .038), regardless of pregnancy. Pregnancy was not associated with a change in the allograft gradient (P = .258), regurgitation grade (P = .774), or hazard of PVR (P = .796) during follow-up.
Pregnancy is not associated with impaired allograft durability in women with good cardiac health.
To evaluate microvasculature in pregnant women with and without cardiovascular risk factors.
Cross-sectional, observational study.
Women were recruited at the outpatient clinic for high risk prenatal ...care. Out of a total of 345 women assessed at first and/or second and/or third trimester, 169 women without and 176 with cardiovascular risk factors were included.
Nailfold video capillaroscopy (NVC) measurements were performed at magnification of 200x at all fingers except thumbs. Images were stored for offline measurement of capillary density (CDe) and capillary diameters (CDi). Maternal anthropometrics, obstetric, and medical history were used for categorization in low and high cardiovascular risk. Comparison between groups and trimesters, with respect to pregnancy outcome, was performed using linear mixed model analysis.
Women with a high risk cardiovascular profile show higher CDe, regardless of pregnancy outcome. CDi drops during pregnancy, with lowest CDi in third trimester in patients with preeclampsia. Capillary bed (CB), as a composite of CDe and CDi, is stable during pregnancy in women with low risk cardiovascular profile. In women with high risk cardiovascular profile, CB drops from the first to the second trimester, regardless of pregnancy outcome. Only in women with pre-eclampsia, the CB is lower in the third trimester as compared to the first trimester.There is an inverse association between CDe and mean arterial pressure (MAP) in women with high cardiovascular risk and pre-eclampsia.
Microcirculation is altered during the course of pregnancy and microcirculatory behavior is different in patients with low and high cardiovascular risk profile, as well as in patients with preeclampsia.
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