Advertisement

Longitudinal maternal cardiac function in hypertensive disorders of pregnancy

Published:November 30, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100824

      BACKGROUND

      Compared with gestational hypertension, preeclampsia has traditionally been considered the worse end of the spectrum of hypertensive disorders of pregnancy. It is associated with worse pregnancy outcomes and future cardiovascular morbidities. Both hypertensive disorders may be associated with cardiac maladaptation in pregnancy. However, previous studies were limited by small numbers and a paucity of longitudinal data and unaccounted for the contribution of maternal characteristics that can affect hemodynamics.

      OBJECTIVE

      This study aimed to assess, in an unselected population, the maternal cardiac adaptation in normotensive and hypertensive pregnancies after controlling for important maternal characteristics that affect maternal cardiac function and the interaction among these covariates.

      STUDY DESIGN

      This was a prospective, multicenter longitudinal study of maternal hemodynamics, assessed by a noninvasive bioreactance technology, measured at 11 0/7 to 13 6/7, 19 0/7 to 24 0/7, 30 0/7 to 34 0/7, and 35 0/7 to 37 0/7 weeks of gestation in 3 groups of women. Group 1 was composed of women with preeclampsia (n=45), group 2 was composed of women with gestational hypertension (n=61), and group 3 was composed of normotensive women (n=1643). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal age, height, weight, weight gain, race, previous obstetrical history, and birthweight.

      RESULTS

      After adjusting for confounders that significantly affect maternal hemodynamics, both group 1 and group 2, compared with group 3, had pathologic cardiac adaptation. Group 1, compared with group 3, demonstrated hyperdynamic circulation with significantly higher cardiac output driven by greater stroke volume in the first trimester of pregnancy. As the pregnancies progressed to after 20 0/7 weeks of gestation, this hyperdynamic state transitioned to hypodynamic state with low cardiac output and high peripheral vascular resistance. Group 2, compared with group 3, had no significant differences in cardiac output, stroke volume, and heart rate before 20 0/7 weeks of gestation but thereafter demonstrated a continuous decline in cardiac output and stroke volume, similar to group 1. Both groups 1 and 2, compared with group 3, had persistently elevated mean arterial pressure and uterine artery pulsatility index throughout pregnancy.

      CONCLUSION

      After adjusting for confounders that affect maternal hemodynamics in an unselected pregnant population, women with preeclampsia and gestational hypertension, compared with normotensive women, demonstrated similar cardiac maladaptation. This pathologic profile was evident after 20 0/7 weeks of gestation and at least 10 weeks before the clinical manifestation of the disease.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology MFM
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Melamed N
        • Ray JG
        • Hladunewich M
        • Cox B
        • Kingdom JC.
        Gestational hypertension and preeclampsia: are they the same disease?.
        J Obstet Gynaecol Can. 2014; 36: 642-647
        • Corrêa RR
        • Gilio DB
        • Cavellani CL
        • et al.
        Placental morphometrical and histopathology changes in the different clinical presentations of hypertensive syndromes in pregnancy.
        Arch Gynecol Obstet. 2008; 277: 201-206
        • Stott D
        • Nzelu O
        • Nicolaides KH
        • Kametas NA.
        Maternal hemodynamics in normal pregnancy and in pregnancy affected by pre-eclampsia.
        Ultrasound Obstet Gynecol. 2018; 52: 359-364
        • Melchiorre K
        • Sharma R
        • Khalil A
        • Thilaganathan B.
        Maternal cardiovascular function in normal pregnancy: evidence of maladaptation to chronic volume overload.
        Hypertension. 2016; 67: 754-762
        • deMartelly VA
        • Dreixler J
        • Tung A
        • et al.
        Long-term postpartum cardiac function and its association with preeclampsia.
        J Am Heart Assoc. 2021; 10e018526
        • Lo CCW
        • Lo ACQ
        • Leow SH
        • et al.
        Future cardiovascular disease risk for women with gestational hypertension: a systematic review and meta-analysis.
        J Am Heart Assoc. 2020; 9e013991
        • Khosla K
        • Heimberger S
        • Nieman KM
        • et al.
        Long-term cardiovascular disease risk in women after hypertensive disorders of pregnancy: recent advances in hypertension.
        Hypertension. 2021; 78: 927-935
        • Erez O
        • Romero R
        • Jung E
        • et al.
        Preeclampsia and eclampsia: the conceptual evolution of a syndrome.
        Am J Obstet Gynecol. 2022; 226: S786-S803
        • Melchiorre K
        • Sutherland G
        • Sharma R
        • Nanni M
        • Thilaganathan B.
        Mid-gestational maternal cardiovascular profile in preterm and term pre-eclampsia: a prospective study.
        BJOG. 2013; 120: 496-504
        • Di Pasquo E
        • Ghi T
        • Dall'Asta A
        • et al.
        Maternal cardiac parameters can help in differentiating the clinical profile of preeclampsia and in predicting progression from mild to severe forms.
        Am J Obstet Gynecol. 2019; 221 (633.e1–9)
        • Guy GP
        • Ling HZ
        • Garcia P
        • Poon LC
        • Nicolaides KH.
        Maternal cardiac function at 35-37 weeks’ gestation: prediction of pre-eclampsia and gestational hypertension.
        Ultrasound Obstet Gynecol. 2017; 49: 61-66
        • Valensise H
        • Vasapollo B
        • Gagliardi G
        • Novelli GP.
        Early and late preeclampsia: two different maternal hemodynamic states in the latent phase of the disease.
        Hypertension. 2008; 52: 873-880
        • Tay J
        • Foo L
        • Masini G
        • et al.
        Early and late preeclampsia are characterized by high cardiac output, but in the presence of fetal growth restriction, cardiac output is low: insights from a prospective study.
        Am J Obstet Gynecol. 2018; 218 (517.e1–12)
        • Foo FL
        • Mahendru AA
        • Masini G
        • et al.
        Association between prepregnancy cardiovascular function and subsequent preeclampsia or fetal growth restriction.
        Hypertension. 2018; 72: 442-450
        • Bosio PM
        • McKenna PJ
        • Conroy R
        • O'Herlihy C
        Maternal central hemodynamics in hypertensive disorders of pregnancy.
        Obstet Gynecol. 1999; 94: 978-984
        • Ling HZ
        • Garcia Jara P
        • Nicolaides KH
        • Kametas NA
        Effect of maternal age on cardiac adaptation in pregnancy.
        Ultrasound Obstet Gynecol. 2021; 58: 285-292
        • Ling HZ
        • Jara PG
        • Nicolaides KH
        • Kametas NA.
        Impact of maternal height, weight at presentation and gestational weight gain on cardiac adaptation in pregnancy.
        Ultrasound Obstet Gynecol. 2022; 60: 523-531
        • Ling HZ
        • Guy GP
        • Bisquera A
        • Poon LC
        • Nicolaides KH
        • Kametas NA.
        The effect of parity on longitudinal maternal hemodynamics.
        Am J Obstet Gynecol. 2019; 221 (249.e1–14)
        • Ling HZ
        • Jara PG
        • Bisquera A
        • Poon LC
        • Nicolaides KH
        • Kametas NA.
        Effect of race on longitudinal central hemodynamics in pregnancy.
        Ultrasound Obstet Gynecol. 2020; 56: 37-43
        • Pottel H
        • Björk J
        • Courbebaisse M
        • et al.
        Development and validation of a modified full age spectrum creatinine-based equation to estimate glomerular filtration rate: a cross-sectional analysis of pooled data.
        Ann Intern Med. 2021; 174: 183-191
        • Kagan KO
        • Wright D
        • Spencer K
        • Molina FS
        • Nicolaides KH.
        First-trimester screening for trisomy 21 by free beta-human chorionic gonadotropin and pregnancy-associated plasma protein-a: impact of maternal and pregnancy characteristics.
        Ultrasound Obstet Gynecol. 2008; 31: 493-502
        • Wright D
        • Wright A
        • Nicolaides KH.
        The competing risk approach for prediction of preeclampsia.
        Am J Obstet Gynecol. 2020; 223 (e7): 12-23
        • Ling HZ
        • Guy GP
        • Bisquera A
        • Nicolaides KH
        • Kametas NA.
        Maternal cardiac adaptation and fetal growth.
        Am J Obstet Gynecol. 2021; 224 (601.e1–18)
        • Robinson HP
        • Fleming JE.
        A critical evaluation of sonar “crown-rump length” measurements.
        Br J Obstet Gynaecol. 1975; 82: 702-710
        • Ling HZ
        • Gallardo-Arozena M
        • Company-Calabuig AM
        • Nicolaides KH
        • Kametas NA.
        Clinical validation of bioreactance for the measurement of cardiac output in pregnancy.
        Anaesthesia. 2020; 75: 1307-1313
        • Bower S
        • Vyas S
        • Campbell S
        • Nicolaides KH.
        Color doppler imaging of the uterine artery in pregnancy: normal ranges of impedance to blood flow, mean velocity and volume of flow.
        Ultrasound Obstet Gynecol. 1992; 2: 261-265
        • Brown MA
        • Magee LA
        • Kenny LC
        • et al.
        Hypertensive disorders of pregnancy: Isshp classification, diagnosis, and management recommendations for international practice.
        Hypertension. 2018; 72: 24-43
        • Nicolaides KH
        • Wright D
        • Syngelaki A
        • Wright A
        • Akolekar R.
        Fetal medicine foundation fetal and neonatal population weight charts.
        Ultrasound Obstet Gynecol. 2018; 52: 44-51
        • Meah VL
        • Cockcroft JR
        • Backx K
        • Shave R
        • Stöhr EJ.
        Cardiac output and related haemodynamics during pregnancy: a series of meta-analyses.
        Heart. 2016; 102: 518-526
        • de Haas S
        • Ghossein-Doha C
        • van Kuijk SM
        • van Drongelen J
        • Spaanderman ME.
        Physiological adaptation of maternal plasma volume during pregnancy: a systematic review and meta-analysis.
        Ultrasound Obstet Gynecol. 2017; 49: 177-187
        • Easterling TR
        • Benedetti TJ
        • Schmucker BC
        • Millard SP.
        Maternal hemodynamics in normal and preeclamptic pregnancies: a longitudinal study.
        Obstet Gynecol. 1990; 76: 1061-1069
        • Lee RM
        • Dickhout JG
        • Sandow SL.
        Vascular structural and functional changes: their association with causality in hypertension: models, remodeling and relevance.
        Hypertens Res. 2017; 40: 311-323
        • Nzelu D
        • Dumitrascu-Biris D
        • Nicolaides KH
        • Kametas NA.
        Chronic hypertension: first-trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational age.
        Am J Obstet Gynecol. 2018; 218 (337.e1–7)
        • Julius S
        Transition from high cardiac output to elevated vascular resistance in hypertension.
        Am Heart J. 1988; 116: 600-606
        • Simmons LA
        • Gillin AG
        • Jeremy RW.
        Structural and functional changes in left ventricle during normotensive and preeclamptic pregnancy.
        Am J Physiol Heart Circ Physiol. 2002; 283: H1627-H1633
        • Melchiorre K
        • Sutherland GR
        • Watt-Coote I
        • Liberati M
        • Thilaganathan B.
        Severe myocardial impairment and chamber dysfunction in preterm preeclampsia.
        Hypertens Pregnancy. 2012; 31: 454-471
        • Ferguson S
        • Teodorescu MC
        • Gangnon RE
        • et al.
        Factors associated with systemic hypertension in asthma.
        Lung. 2014; 192: 675-683
        • Nardin C
        • Maki-Petaja KM
        • Miles KL
        • et al.
        Cardiovascular phenotype of elevated blood pressure differs markedly between young males and females: the enigma study.
        Hypertension. 2018; 72: 1277-1284
        • Inoue T
        • Iseki K
        • Iseki C
        • Kinjo K
        • Ohya Y
        • Takishita S.
        Higher heart rate predicts the risk of developing hypertension in a normotensive screened cohort.
        Circ J. 2007; 71: 1755-1760
        • Shigetoh Y
        • Adachi H
        • Yamagishi S
        • et al.
        Higher heart rate may predispose to obesity and diabetes mellitus: 20-year prospective study in a general population.
        Am J Hypertens. 2009; 22: 151-155
        • Behrens I
        • Basit S
        • Melbye M
        • et al.
        Risk of post-pregnancy hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study.
        BMJ. 2017; 358: j3078
        • Khaw A
        • Kametas NA
        • Turan OM
        • Bamfo JE
        • Nicolaides KH.
        Maternal cardiac function and uterine artery doppler at 11-14 weeks in the prediction of pre-eclampsia in nulliparous women.
        BJOG. 2008; 115: 369-376
        • De Paco C
        • Kametas N
        • Rencoret G
        • Strobl I
        • Nicolaides KH.
        Maternal cardiac output between 11 and 13 weeks of gestation in the prediction of preeclampsia and small for gestational age.
        Obstet Gynecol. 2008; 111: 292-300
        • Sağol S
        • Özkinay E
        • Öztekin K
        • Özdemir N.
        The comparison of uterine artery doppler velocimetry with the histopathology of the placental bed.
        Aust N Z J Obstet Gynaecol. 1999; 39: 324-329
        • Vázquez Blanco M
        • Roisinblit J
        • Grosso O
        • et al.
        Left ventricular function impairment in pregnancy-induced hypertension.
        Am J Hypertens. 2001; 14: 271-275
        • Valensise H
        • Novelli GP
        • Vasapollo B
        • et al.
        Maternal diastolic dysfunction and left ventricular geometry in gestational hypertension.
        Hypertension. 2001; 37: 1209-1215