Abstract-Because early and late preeclampsia (PE) are thought to be different disease entities, we compared maternal cardiac function at 24 weeks gestation in a group of normotensive asymptomatic patients with subsequent development of early (Ͻ34 weeks gestation) and late (Ն34 weeks gestation) PE (blood pressure Ͼ140/90ϩproteinuria Ͼ300 mg/dL) to detect possible early differences in the hemodynamic state. ; PϽ0.001). Early and late PE appear to develop from different hemodynamic states. Late PE appears to be more frequent in patients with high body mass index and low total vascular resistance; earlier forms of PE appear to be more frequent in patients with lower BMI and with bilateral notching of the uterine artery. These findings support the hypothesis of different hemodynamics and origins for early PE (placental mediated, linked to defective trophoblast invasion with high percentage of altered uterine artery Doppler) and late PE (linked to constitutional factors such as high body mass index). Key Words: preeclampsia/pregnancy Ⅲ hemodynamcs Ⅲ echocardiography P reeclampsia (PE) is associated with maternal perinatal morbidity and mortality 1 and affects 5% to 7% of pregnant patients worldwide. 2 Hemodynamic investigations during the latent phase of PE are scarce and conflicting because of the different classifications 3,4 used in the definition: mild, moderate, and severe, as well as early and late. The concept of early and late PE is more modern, and it is widely accepted that these two entities have different etiologies and should be regarded as different forms of the disease. 3,4 Early-onset PE (before 34 weeks) is commonly associated with abnormal uterine artery Doppler, fetal growth restriction (FGR), and adverse maternal and neonatal outcomes. 1,5 In contrast, late-onset PE (after 34 weeks) is mostly associated with normal or slight increased uterine resistance index, a low rate of fetal involvement, and more favorable perinatal outcomes. 5,6 Early-onset PE and FGR are placenta-mediated diseases that share important similarities as recently demonstrated by Crispi et al, 7,8 who reported placental growth factor (PIGF) as a useful second-trimester screening test for this form of the disease, but not for late-onset PE/FGR. Maternal echocardiography might identify at 24 weeks gestation patients who subsequently develop early severe maternal and fetal complications through the assessment of maternal hemodynamics and left ventricular geometry (elevated maternal total vascular resistance [TVR] and the presence of concentric geometry) 9 -11 suggesting an involvement of the whole cardiovascular system in the placental mediated disorder. Previous data published by Bosio 12 and Easterling 13 on the latent phase of PE are in contrast with this model (describing low TVR and high cardiac output [CO]), although the patients from those series developed late forms of PE.Interestingly, hemodynamics and volume homeostasis in women with previous PE appear to be similar to hypertensive subjects and different from healthy paro...
Maternal cardiovascular health represents the key point for developing an uneventful pregnancy, and its proper function is important for a normal evolution of pregnancy. Serious pregnancy-related hypertensive disorders such as preeclampsia might entail severe future effects on women's health even after delivery and influence the long-term quality of life as well as the following pregnancy outcomes. A proper maternal cardiovascular adaptation to the pregnancy plays a key role for preventing gestational hypertensive complications, such as preeclampsia. [1][2][3][4][5] Preeclampsia affects the 3% to 8% of pregnancies and represents a cause of increased maternal and perinatal morbidity and mortality. 6,7 According to the different onset time, the origin and hemodynamics, preeclampsia is classified as early (placental mediated, linked to defective trophoblast invasion with high incidence of altered uterine artery Doppler, and lower body mass index [BMI]) and late (related to higher BMI and no alteration of uterine artery Doppler) 8 recurring in 15% of the following pregnancies.9-11 Former preeclamptics have a 7× higher risk of disease recurrence compared with women who have had a normal pregnancy. 12,13Patients with a previous preeclampsia show maternal cardiac dysfunction, and they are more likely to develop systemic hypertension and to die at an early age from cardiovascular disease. [14][15][16][17] In particular, postpartum follow-up of women with a previous preeclampsia showed persistence of altered cardiac geometry and left ventricular dysfunction. 18,19 The latest studies in literature highlight the importance of assessing maternal cardiac function and structure evaluating hemodynamics in terms of total vascular resistance (TVR), left ventricular geometric pattern with regard to the presence of concentric geometry, and diastolic dysfunction. [20][21][22] It is of primary importance to understand how to select and identify those women at increased risk for recurrent preeclampsia. In a recent study, Scholten et al 23 concluded that the risk of recurrent preeclampsia and fetal growth restriction in a subsequent pregnancy is inversely and linearly related to pregnancy plasma volume, and this condition might predispose to abnormal hemodynamic adaptation to pregnancy. In previously early preeclamptic women, given the high incidence of postpartum asymptomatic left ventricular abnormalities, the high See Editorial Commentary, pp 690-692Abstract-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 echocardiograp...
Objective-Evaluation of incremental risk factors for early mortality in children undergoing orthotopic heart transplantation (OHT) for congenital heart disease. Methods-Between 1988 and 2002, 43 patients (mean age 9.1Ϯ7.2 years) underwent 44 OHT for complex TGA (6), DORV (4), single ventricle (21), and other end-stage structural heart disease (11). Two discernible ventricular chambers were present in 18 pts (41.8%). Previous reconstructive or palliative procedures had been previously accomplished in 35 pts (83.3%), including atrial switch (5), systemic-to-pulmonary shunts (10), cavopulmonary anastomosis (9), Fontan completion (6), and others (5). Results-30-day survival for the 2-ventricle subgroup was 94.4Ϯ5.4% compared with 67.2Ϯ9.5% for the single ventricle subgroup (Pϭ0.04) (overall 78.6%Ϯ3.3%). OHT following single ventricle staging to bi-directional cavopulmonary anastomosis exhibited 100% early survival, as opposed to 62.5Ϯ17.1% for OHT after systemic-to-pulmonary shunts, and 33.3Ϯ19.2% for OHT following failing Fontan (Pϭ0.010). HLHS diagnosis (0.0085) and failing Fontan (Pϭ0.003) were identified as independent predictors of early mortality by regression logistic modeling, while Fontan stage represented the only predictor of overall mortality by Cox proportional hazard. Overall 10-year survival was 54.3Ϯ11%. Conclusions-OHT for structural congenital heart disease with single ventricle physiology entails substantial early mortality and bi-directional cavopulmonary anastomosis enables the best transition to heart transplant. OHT should be considered in the decision making process as an alternative to Fontan completion in high-risk candidates, since rescue-OHT after failing Fontan seems unwarranted.
Objective Complications in early-onset mild gestational hypertension (GH) are better predicted by total peripheral vascular resistance (TPVR)>
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