Maternal Cardiovascular Impairment in Pregnancies Complicated by Severe Fetal Growth Restriction

Abstract

Abstract-Fetal growth restriction and preeclampsia are both conditions of placental etiology and associated to increased risk for the long-term development of cardiovascular disease in the mother. At presentation, preeclampsia is associated with maternal global diastolic dysfunction, which is determined, at least in part, by increased afterload and myocardial stiffness. The aim of this study is to test the hypothesis that women with normotensive fetal growth-restricted pregnancies also exhibit global diastolic dysfunction. This was a prospective case-control study conducted over a 3-year period involving 29 preterm fetal growth-restricted pregnancies, 25 preeclamptic with fetal growth restriction pregnancies, and 58 matched control pregnancies. Women were assessed by conventional echocardiography and tissue Doppler imaging at diagnosis of the complication and followed-up at 12 weeks postpartum. Fetal growth-restricted pregnancies are characterized by a lower cardiac index and higher total vascular resistance index than expected for gestation. Compared with controls, fetal growth-restricted pregnancy was associated with significantly increased prevalence (PϽ0.001) of asymptomatic left ventricular diastolic dysfunction (28% versus 4%) and widespread impaired myocardial relaxation (59% versus 21%). Unlike preeclampsia, cardiac geometry and intrinsic myocardial contractility were preserved in fetal growth-restricted pregnancy. Fetal growth-restricted pregnancies are characterized by a low output, high resistance circulatory state, as well as a higher prevalence of asymptomatic global diastolic dysfunction and poor cardiac reserve. These findings may explain the increased long-term cardiovascular risk in these women who have had fetal growth-restricted pregnancies. Further studies are needed to clarify the postnatal natural history of cardiac dysfunction in these women. 1,2 FGR and PE are both also associated with increased risk for the long-term development of metabolic syndrome and cardiovascular disease in the mother.3-9 Acute PE is associated with cardiac remodeling, impaired myocardial relaxation and global left ventricular (LV) diastolic chamber dysfunction.10,11 Furthermore, it is evident that the cardiovascular implications of PE do not cease with the birth of the infant, with a significant proportion of women demonstrating asymptomatic LV diastolic chamber dysfunction and essential hypertension for within 2 years of delivery.11,12 Despite these cardiovascular findings in PE, previous studies of maternal cardiac function in FGR pregnancy failed to identify a clear pattern of myocardial impairment or chamber dysfunction. [13][14][15][16] This is possibly due to the inadequacy of the load-dependent indices used and the interpretation of diastolic measures in isolation, disregarding the interdependency of cardiac events. The aim of this study was to test the hypothesis that women with normotensive FGR pregnancies also exhibit cardiac remodeling and myocardial and ventricular dysfunction, as seen in PE pregnanci...

Prehypertension in Pregnancy and Risks of Small for Gestational Age Infant and Stillbirth

“…17 We could not confirm previous findings of associations between hypotension and increased risks of both SGA birth 10 and stillbirth. 9,18,19 The divergent findings might be explained by differences in study design.…”

“…24 Similar but even more severe insufficient maternal physiological adaptation has been shown in pregnancies complicated with preeclampsia. 17,25 Intrauterine growth restriction and preeclampsia are closely linked with abnormal placentation. 26,27 Reduced uteroplacental perfusion has been shown to induce a rise in maternal blood pressure through increased production of vasoconstrictive agents.…”

Hypertension in Pregnancy: Natural History and Treatment Options

“…Cases of pre-eclampsia associated foetal growth restriction have lower cardiac index (a ratio of cardiac output and body surface area) and higher peripheral resistance compared to unaffected pregnancies [59]. Furthermore, longitudinal assessments in the first trimester (from 5 to 8 weeks) found that pregnancies with growth restriction had a significantly lower increase in cardiac output in early pregnancy, when compared with controls [60].…”

“…Several weeks prior to the onset of clinical symptoms, late-onset pre-eclampsia can be characterised by a hyper-dynamic state with very low peripheral resistance and a very high cardiac output, with large left ventricular diameters and higher stroke volume when compared to normal pregnancies [58,59]. In contrast, earlyonset disease is denoted by a hypovolemic state with low cardiac output and elevated peripheral resistance with smaller left ventricular diameters, suggesting an under-filled state with pressure overload [58,59].…”

Association of Higher Maternal Blood Pressure With Lower Infant Birthweight

“…6 Finally, in well-conducted, prospective, and blinded studies, the only placental histological findings seen more frequently in pregnancies resulting in SGA infants compared with pregnancies resulting in normal-weight infants are associated with maternal hypoperfusion of the placenta. 7 This compelling evidence indicates that SGA and stillbirth at term may well occur as a consequence of secondary placental dysfunction caused by impaired maternal cardiovascular function related to prehypertension. This hypothesis is in contrast to that of preterm fetal growth restriction, in which placental cause is unchallenged, and implies that both impaired maternal perfusion of the placenta (an extrinsic defect) and impaired placental development (an intrinsic defect) may lead to SGA and stillbirth.…”