Maternal total vascular resistance and concentric geometry: a key to identify uncomplicated gestational hypertension

Abstract

Objective To evaluate the prognostic impact of elevated total vascular resistance (TVR) on the outcome of pregnancy in early mild gestational hypertension (EMGH).Design Prospective observational study. Methods Women had a maternal echocardiographic examination and BP examination within 24 hours of diagnosis. From this, the TVR was calculated and the geometric pattern of the left ventricle assessed.Main outcome measures Fetal/maternal adverse outcomes (pre-eclampsia, preterm delivery, placental abruption, other maternal medical problems, fetal distress, neonatal low birthweight, admittance to neonatal intensive care unit and perinatal death).Results Ninety-two out of the 268 pregnancies showed adverse outcomes (34.3%). The best independent predictor for the composite of maternal and fetal complications was TVR (OR 64.4, 95% CI 25.9-160.1). The cutoff value was 1340 dyn seconds/cm 5 with a sensitivity and a specificity of 90 and 91%, respectively. Concentric geometry of the left ventricle was also an independent predictor (OR 4.72, 95% CI 1.85-12.04).Conclusions Echocardiography could help in identifying women with EMGH who subsequently develop maternal and fetal complications, allowing a classification in high-risk (TVR > 1340 dyn seconds/cm 5 , concentric geometry of the left ventricle) and low-risk women (TVR < 1340 dyn seconds/cm 5 , nonconcentric geometry of the left ventricle) for adverse outcomes of pregnancy.

Gestational hypertension as a subclinical preeclampsia in view of serum levels of angiogenesis-related factors

“…20,21 Davis et al 20 reported that women who developed PE after presenting with GH had generally higher awake and 24 hr systolic blood pressure levels than those who remained as GH. In addition, Valensise et al 21 reported that women with presumptive mild GH in whom total vascular resistance was significantly high tended to develop PE. However, to date, there have been no studies confirming that the presumptive GH that changes to PE shows the increases of sFlt-1, sFlt-1/PlGF ratio and sEng between, before and after the occurrence of PE.…”

Hemodynamic Prediction and Stratification of Hypertensive Disorders of Pregnancy: A Dream That Is Coming True?

“…To date, the prediction of these disorders and their complications has been based on many clinical characteristics, hemodynamics, and placental indicators (either with Doppler evaluation of uterine artery and/or levels of circulating angiogenic proteins) 2, 3, 4, 5, 6, 7, 8, 9, 10, 11. Early identification of asymptomatic women more likely to develop HDP and other complications would help clinicians in planning appropriate monitoring during pregnancy, potentially treating the condition with preventive strategies before the blood pressure actually increases, and with a possible delay or mitigation of its consequences.…”

“…The first one has been the uterine artery Doppler interrogation in the second trimester, and has been introduced since the past 2 decades of the past century 1. Lately, biochemical and central hemodynamic parameters have been used to refine and improve the classification and the prediction of HDP 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13…”

“…In particular, 14 different clinical, biochemical, and hemodynamic parameters were included in the analysis. Lately, many groups of researchers have used different methods for the detection of hemodynamic parameters in pregnancy: echocardiography8, 9, 10, 11; UltraSonic Cardiac Output Monitor and Non‐Invasive Cardiac Output Monitor (noninvasive Doppler method to determine hemodynamic values with a nonimaging continuous‐wave Doppler transducer)14; and impedance cardiography and thermodilution 13, 15. Many of the latest studies have shown that, among the hemodynamic parameters, TVR and CO represent a cornerstone for the understanding of the preclinical and clinical stages of the HDP.…”

“…In normotensive high‐risk patients and gestational hypertensive women, elevated TVR early in pregnancy strongly correlates with subsequent severe complications (ie, preeclampsia, severe hypertension, fetal growth restriction, abruption placentae, and Hemolysis, Elevated Liver enzymes, and Low platelet count [HELLP] syndrome) 8, 9. Some interesting studies have noted that, in established gestational hypertension with high TVR, the intervention based on a hemodynamic approach may be useful for the reduction of severe complications during pregnancy 16, 17.…”