Maternal Venous Hemodynamic Dysfunction in Proteinuric Gestational Hypertension: Evidence and Implications

Abstract

This review summarizes current knowledge from experimental and clinical studies on renal function and venous hemodynamics in normal pregnancy, in gestational hypertension (GH) and in two types of preeclampsia: placental or early-onset preeclampsia (EPE) and maternal or late-onset (LPE) preeclampsia, presenting at <34 weeks and ≥34 weeks respectively. In addition, data from maternal venous Doppler studies are summarized, showing evidence for (1) the maternal circulation functioning closer to the upper limits of capacitance than in non-pregnant conditions, with intrinsic risks for volume overload, (2) abnormal venous Doppler measurements obtainable in preeclampsia, more pronounced in EPE than LPE, however not observed in GH, and (3) abnormal venous hemodynamic function installing gradually from first to third trimester within unique pathways of general circulatory deterioration in GH, EPE and LPE. These associations have important clinical implications in terms of screening, diagnosis, prevention and management of gestational hypertensive diseases. They invite for further hypothesis-driven research on the role of retrograde venous congestion in the etiology of preeclampsia-related organ dysfunctions and their absence in GH, and also challenge the generally accepted view of abnormal placentation as the primary cause of preeclampsia. The striking similarity between abnormal maternal venous Doppler flow patterns and those observed at the ductus venosus and other abdominal veins of the intra-uterine growth restricted fetus, also invites to explore the role of venous congestion in the intra-uterine programming of some adult diseases.

Increased Intra-Abdominal Pressure During Laparoscopic Pneumoperitoneum Enhances Albuminuria via Renal Venous Congestion, Illustrating Pathophysiological Aspects of High Output Preeclampsia

“…Maternal hemodynamics change in pregnancy and maladaptation of the maternal cardiovascular system may result in the development of gestational hypertensive disorders. Contrary to non-proteinuric gestational hypertension, PE presents with abnormal venous Doppler measurements, more pronounced in earlythan in late-onset disease, suggestive for hampered venous outflow and as such, predisposing to renal venous congestion [32].…”

Blood Coagulation Indices in Twin Pregnancy Complicated with Preeclampsia

“…The coagulation indicators with predictive value in these studies on PE included TT, APTT, and D-Di. [20][21][22][23] Han L et al performed a retrospective study in 174 women with singleton pregnancy (53 cases of mild PE, 42 cases of severe PE, and 79 cases of normal pregnant women). 24 The ROC curve analysis showed that TT had the highest predictive value for PE (AUC: 0.743) with a cut-off value of 12.65s, which is recommended as a potential indicator for early monitoring of the onset and severity of PE.…”

Development of a biophysical screening model for gestational hypertensive diseases

“…As such, our study population could be considered representative for a general obstetric population, however it is to be recognized that we excluded pregnancies complicated with EH, superimposed late preeclampsia with or without SGA, HELLP with or without SGA, isolated SGA and multiplets from the prediction model analysis. Next to this, the Achilles’ heel of our screening method is maternal venous Doppler sonography, which not only is subject to human error but also vulnerable for a variety of interfering anatomo-physiologic factors such as respiration, muscle tension, anatomical variability, etc.… [36]. High inter- and intra-observer variability is reported for maternal venous Doppler measurements, markedly improving to intraclass correlations > 0.9 with the use of (a) an ECG signal as a reference for Doppler wave interpretation, (b) repeated measures and (c) sonographer’s training [17].…”