Maternal Diastolic Dysfunction and Left Ventricular Geometry in Gestational Hypertension

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...

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“…19 CO was calculated as the product of SV and heart rate derived from electrocardiographic monitoring. …”

Section: Systolic Functionmentioning

confidence: 99%

Early and Late Preeclampsia

Valensise¹,

Vasapollo²,

Gagliardi³

et al. 2008

Hypertension

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“…29 Relative wall thickness (RWT) was calculated as the ratio of (interventricular septum diastolic thicknessϩposterior wall diastolic thickness)/left ventricular end-diastolic diameter. 20 …”

Section: Left Ventricular Geometric Patternmentioning

confidence: 99%

“…20 Cardiac output (CO) was calculated as the product of SV and heart rate derived from electrocardiographic monitoring.…”

Section: Systolic Functionmentioning

confidence: 99%

“…In recent years, maternal cardiac function was studied in normal and complicated pregnancy obtaining important information on systolic and diastolic function and on morphological parameters of the left ventricle. [13][14][15][16][17][18][19][20][21][22][23] In particular total vascular resistance (TVR) was found to be an important parameter in the early identification of hypertensive patients who subsequently developed complications. 22 In our previous pilot study, 24 we observed that normotensive high-risk patients with bilateral notch of the uterine arteries who subsequently showed abnormal outcome of pregnancy had higher TVR compared with the normal-outcome group.…”

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confidence: 99%

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Total Vascular Resistance and Left Ventricular Morphology as Screening Tools for Complications in Pregnancy

Vasapollo¹,

Novelli²,

Valensise³

2008

Hypertension

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Abstract-We evaluated the predictive value of elevated total vascular resistance on the outcome of pregnancy in normotensive high-risk primigravidas with bilateral notching of the uterine artery Doppler. A total of 526 high-risk primigravidas referred to the obstetrics outpatient clinic of Tor Vergata University with bilateral notching of the uterine artery at 20 to 22 weeks' gestation were submitted to a maternal echocardiographic examination and uterine artery Doppler evaluation at 24 weeks' gestation. Blood pressure was recorded at the time of the examination, total vascular resistance was calculated, and the geometric pattern of the left ventricle was assessed. Patients were followed until the end of pregnancy to detect fetal/maternal adverse outcomes (gestational hypertension, preeclampsia, abruptio placentae, fetal growth restriction, perinatal death, etc). A total of 111 of the 526 pregnancies showed a bilateral notch at 24 weeks' gestation, and 97 had an adverse outcome (18.44%). The best independent predictor for maternal and fetal complications was total vascular resistance (odds ratio: 91.25; 95% CI: 39.64 to 210.05; PϽ0.001). The cutoff value was 1400 dynes ⅐ s ⅐ cm Ϫ5, with a sensitivity and a specificity of 89% and 94%, respectively. A high relative wall thickness of the left ventricle (Ͼ0.37; odds ratio: 2.47; 95% CI: 1.12 to 5.44) and a hypertrophized ventricle (left ventricular mass Ͼ130 g; odds ratio: 2.52; 95% CI: 1.12 to 5.64) were also independent predictors (PϽ0.05). Echocardiography might identify at 24 weeks' gestation patients who subsequently develop maternal and fetal complications through the assessment of maternal hemodynamics and left ventricular geometry. (Hypertension. 2008;51:1020-1026.)

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“…6,7,8 Normal diastolic function allows adequate filling of ventricles during rest and exercise without an abnormal increase in filling pressures. Initial diastolic dysfunction is impaired relaxation and with further progression of disease, there is mild to moderate increase in left atrial pressure and the mitral inflow velocity pattern appears similar to a normal filling pattern (pseudo normalization).…”

mentioning

confidence: 99%