Echocardiographic Structure and Function in Hypertensive Disorders of Pregnancy

Abstract

C ardiac disease is the leading non-obstetric cause of death in pregnancy and the puerperium. 1 In uncomplicated pregnancy, there is no significant change in systolic blood pressure.2,3 Diastolic blood pressure and mean arterial pressure decrease during the first trimester and then plateau in the second trimester before rising in the final weeks of pregnancy. 2,3 Hypertension is seen in 6% to 8% of pregnancies 4 and the incidence is increasing as the obstetric population becomes older and more obese. 5 Hypertension causes one third of severe maternal morbidity 4 and is the second most common direct cause of maternal mortality worldwide, accounting for ≈14% of maternal deaths. 6 Adverse fetal outcomes include preterm birth, growth restriction, and stillbirth. See Clinical PerspectiveThe hypertensive disorders specific to pregnancy are gestational hypertension (GH) and preeclampsia. Guidelines and terminology vary across the world. 4,[7][8][9][10] The diagnosis and classification of these conditions depend on the gestation at which elevated blood pressure is identified (GH and preeclampsia are acquired conditions in the second half of pregnancy), the presence or absence of multisystem involvement or significant proteinuria (traditionally the hallmark of preeclampsia 4 ), and whether the blood pressure normalizes in the postnatal period. The onset of hypertension in GH and preeclampsia must be after 20 weeks of gestation to distinguish them from chronic hypertension. Preeclampsia can develop in patients with GH and also be superimposed on chronic hypertension.Understanding the structure and function of the heart in pregnancy is vital if we are to recognize abnormalities at an Background-Echocardiography is commonly used to direct the management of hypertensive disorders in medical patients, but its application in pregnancy is unclear. Our objective was to define the use of echocardiography in pregnancies complicated by gestational hypertension (GH) and preeclampsia. Methods and Results-We performed a systematic review of articles using an electronic search of databases from inception to March 2015, prospectively registered with PROSPERO (CRD42015015700). Eligible studies included pregnant women with GH or preeclampsia, evaluating left ventricular structure and function using echocardiography. The search strategy identified 36 studies, including 745 women with GH and 815 women with preeclampsia. The populations were heterogeneous with respect to clinical characteristics, parity, and risk of bias. Increased vascular resistance and left ventricular mass were the most consistent findings in GH and preeclampsia. Differentiating features from normal pregnancy were left ventricular wall thickness of ≥1.0 cm, exaggerated reduction in E/A, and lateral e′ of <14 cm/s. There was disagreement between studies with regard to cardiac output because of the timing of echocardiography, although reduced stroke volume was an indicator of adverse prognosis. Diastolic dysfunction and left ventricular remodeling are most marked i...

Hypertensive Disorders of Pregnancy and Future Cardiovascular Health

“…Several studies assessed the relationship between HDP and the subsequent development of asymptomatic (stage B) or symptomatic (stage C) heart failure (97,101). The American Heart Association and American College of Cardiologists define asymptomatic stage B heart failure as any subject being affected by LV hypertrophy or dysfunction (102).…”

Preeclampsia: a gestational cardiorenal syndrome

“…A recent systematic review, summarizing 19 echocardiographic studies in pregnancy demonstrated that increased left ventricular mass and total vascular resistance were the most consistent findings in preeclampsia (Castleman et al . ). The finding of diastolic dysfunction and left ventricular remodelling were seen before clinical manifestation of preeclampsia, more marked in severe and early‐onset disease, and also associated with adverse pregnancy outcomes.…”

“…A major inconsistency with this hypothesis is that regardless of gestation, preeclampsia is consistently associated with reduced stroke volume and higher/normal total vascular resistance (Castleman et al . ). The latter is in keeping with the findings of hypertension and myocardial dysfunction in both early and late preeclampsia (Melchiorre et al .…”

“…; Castleman et al . ). This hypothesis is further undermined by the interpretation of cardiac output indices independently of maternal morphological characteristics.…”

Methods and considerations concerning cardiac output measurement in pregnant women: recommendations of the International Working Group on Maternal Hemodynamics

“…Echocardiography and Doppler ultrasound have been widely used for the assessment of CO during pregnancy [3][4][5][6][7][8][11][12][13][14][15][24][25][26][27][28][29][30]32,56,[82][83][84] , and have proved to be reliable when compared with the invasive techniques 3,85,86 . The general availability of ultrasound and its low cost, portability and true non-invasiveness, make TTE an ideal method for rapid hemodynamic assessment in pregnancy.…”