Hypertensive Disorders and Cardiovascular Severe Maternal Morbidity in the US, 2015-2019.

Importance: The incidence of severe maternal morbidity (SMM)-and particularly cardiovascular SMM (cvSMM), the first cause of pregnancy-related mortality-has been rising in North America. Although hypertensive disorders of pregnancy (HDP) are common, their association with cvSMM specifically remains unclear. Objective: To assess the association between individual subtypes of HDP and cvSMM, in addition to overall SMM, in a large, nationally representative sample. Design, Setting, and Participants: A population-based cohort study using the United States National Inpatient Sample was conducted. Individuals with obstetric deliveries between 2015 and 2019 were included. Data analysis was performed from October 2023 to February 2024. Exposure: HDP subtypes included gestational hypertension, chronic hypertension, preeclampsia without severe features, severe preeclampsia, and HELLP (hemolysis, elevated liver enzymes, and low platelet) syndrome. Main Outcomes and Measures: The primary outcome was a composite of cvSMM (including conditions such as pulmonary edema, stroke, and acute myocardial infarction) and the secondary outcome was a composite of overall SMM (including cvSMM and other conditions such as respiratory failure, severe postpartum hemorrhage, and sepsis). Adjusted risk ratios (aRRs) for the association between HDP subtypes and the outcomes were estimated using modified Poisson regression models adjusted for demographic and clinical characteristics. Results: Among 15 714 940 obstetric deliveries, 2 045 089 (13.02%) had HDP, 23 445 (0.15%) were affected by cvSMM, and 282 160 (1.80%) were affected by SMM. The mean (SD) age of the cohort was of 29 (6) years. The incidence of cvSMM was higher in participants with HDP than those without HDP (0.48% [9770 of 2 045 089] vs 0.10% [13 680 of 13 669 851]; P < .001). Participants with HELLP syndrome had the highest risk for cvSMM (aRR, 17.55 [95% CI, 14.67-21.01]), followed by severe preeclampsia (aRR, 9.11 [95% CI, 8.26-10.04]), and chronic hypertension (aRR, 3.57 [95% CI, 3.15-4.05]). Although HDP subtypes were also associated with overall SMM, the association with HELLP syndrome (aRR, 9.94 [95% CI, 9.44-10.45]), severe preeclampsia (aRR, 3.66 [95% CI, 3.55-3.78]), and chronic hypertension (aRR, 1.96 [95% CI, 1.88-2.03]) was attenuated compared with cvSMM. Conclusions and Relevance: In this cohort study, a graded relationship by severity characterized the association between HDP and cvSMM. Although all HDP subtypes were associated with an increased risk of overall SMM, the risk was more pronounced for cvSMM.

Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel.

Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.

Trends in maternal ICU admissions at a quaternary centre in Montreal, Canada, and impact of maternal age on critical care outcomes.

Background: Advancing maternal age is increasingly prevalent and is associated with severe maternal morbidity often requiring intensive care unit (ICU) admission. Objectives: To describe maternal ICU admissions at a quaternary care hospital in Montreal, Canada, and evaluate the association between maternal age and composite of: need for invasive interventions, ICU stay > 48 h, or maternal death. Methods: Chart review of ICU admissions during pregnancy/postpartum (2006-2016); logistic regressions to evaluate the impact of age on outcomes. Results: With 5.1 ICU admissions per 1000 deliveries, we included 187 women (mean age 32 ± 6.3 years; 20 (10.7%) ≥ 40 years). The composite outcome occurred in 105 (56.2%) patients; there were two maternal deaths. Age ≥ 40 years increased the odds of invasive interventions (OR 4.03; 95% confidence interval [CI] 1.15-14.1) but not of the composite outcome (OR 2.30; 95% CI 0.66-8.02). Conclusion: Peripartum women aged ≥ 40 years had worse outcomes in ICU, with an increased need for invasive interventions.

Severe Maternal Morbidity and Mental Health Hospitalizations or Emergency Department Visits.

Importance: Severe maternal morbidity (SMM) can have long-term health consequences for the affected mother. The association between SMM and future maternal mental health conditions has not been well studied. Objective: To assess the association between SMM in the first recorded birth and the risk of hospitalization or emergency department (ED) visits for a mental health condition over a 13-year period. Design, Setting, and Participants: This population-based retrospective cohort study used data from postpartum individuals aged 18 to 55 years with a first hospital delivery between 2008 and 2021 in 11 provinces and territories in Canada, except Québec. Data were analyzed from January to June 2023. Exposure: SMM, defined as a composite of conditions, such as septic shock, severe preeclampsia or eclampsia, severe hemorrhage with intervention, or other complications, occurring after 20 weeks' gestation and up to 42 days after a first delivery. Main Outcomes and Measures: The main outcome was a hospitalization or ED visit for a mental health condition, including mood and anxiety disorders, substance use, schizophrenia, and other psychotic disorder, or suicidality or self-harm event, arising at least 43 days after the first birth hospitalization. Cox regression models generated hazard ratios with 95% CIs, adjusted for baseline maternal comorbidities, maternal age at delivery, income quintile, type of residence, hospital type, and delivery year. Results: Of 2 026 594 individuals with a first hospital delivery, 1 579 392 individuals (mean [SD] age, 30.0 [5.4] years) had complete ED and hospital records and were included in analyses; among these, 35 825 individuals (2.3%) had SMM. Compared with individuals without SMM, those with SMM were older (mean [SD] age, 29.9 [5.4] years vs 30.7 [6.0] years), were more likely to deliver in a teaching tertiary care hospital (40.8% vs 51.1%), and to have preexisting conditions (eg, ≥2 conditions: 1.2% vs 5.3%), gestational diabetes (8.2% vs 11.7%), stillbirth (0.5% vs 1.6%), preterm birth (7.7% vs 25.0%), or cesarean delivery (31.0% vs 54.3%). After a median (IQR) duration of 2.6 (1.3-6.4) years, 1287 (96.1 per 10 000) individuals with SMM had a mental health hospitalization or ED visit, compared with 41 779 (73.2 per 10 000) individuals without SMM (adjusted hazard ratio, 1.26 [95% CI, 1.19-1.34]). Conclusions and Relevance: In this cohort study of postpartum individuals with and without SMM in pregnancy and delivery, there was an increased risk of mental health hospitalizations or ED visits up to 13 years after a delivery complicated by SMM. Enhanced surveillance and provision of postpartum mental health resources may be especially important after SMM.

Exploring pregnant individuals' counseling needs regarding urgent imaging to rule out pulmonary embolism.

Background: Computed tomography pulmonary angiogram and lung scintigraphy with ventilation/perfusion scan are needed to diagnose pulmonary embolism (PE) in pregnancy. Their associated ionizing radiation doses are considered safe in pregnancy. A standardized patient information tool may improve patient counseling and reduce testing hesitancy. Objectives: In this context, we sought to address 1) what patients want to know before undergoing these tests and 2) how they want the information to be provided to them. Methods: We used a qualitative descriptive methodology. We recruited pregnant participants at the McGill University Health Center in Montreal, Canada. Structured interviews explored information needs about PE and diagnostic imaging for PE. The interview transcripts' themes were analyzed with a hybrid deductive and inductive approach. Results: Of 21 individuals approached, 20 consented to participate. Four had been previously investigated for PE. Participants requested information about the risks associated with PE and radiation and their effects on maternal and fetal health. They preferred for radiation doses to be presented in comparison with known radiation thresholds for fetal harm. They suggested that a written tool should be developed using an accessible language. Participants also indicated that the tool would be integrated into their decision-making process, emphasizing a lower risk tolerance for their fetus than for themselves. Conclusion: This single-center group of pregnant patients wished to be informed about the risks of PE and radiation associated with imaging. A written tool could help put information into context and facilitate decision making. These new insights may be used to inform counseling.

Accuracy of aspirin prophylaxis for preeclampsia prevention documentation within a large administrative dataset.

BACKGROUND: Low-dose aspirin prophylaxis is recommended for women at risk of preeclampsia. Capturing aspirin prophylaxis within administrative databases can be challenging since it is an over-the-counter medication. The Better Outcome Registry and Network (BORN) database, a perinatal health registry in Ontario, Canada, includes a formal variable that captures aspirin prophylaxis for preeclampsia. This variable has not been formally validated. OBJECTIVES: To assess the accuracy of the aspirin prophylaxis variable in the BORN database against an electronic medical record (EMR). METHODS: This validation study comprised 200 randomly selected women who had a livebirth at St. Michael's Hospital (SMH) in Toronto, Ontario, from January 2018 to July 2022. Recorded aspirin prophylaxis in pregnancy and maternal sociodemographic characteristics were independently extracted by two abstractors. Accuracy of aspirin prophylaxis use in the BORN database was compared to that in the SMH EMR, expressed as sensitivity, specificity, positive (PPV) and negative predictive values (NPV), Cohen's kappa (κ), and overall percent agreement, with 95% confidence intervals (CI). Sensitivity analyses were performed to account for missing or unclear aspirin prophylaxis use. RESULTS: Among 200 women, 24 (12.0%) received aspirin prophylaxis - 12.5% within the SMH EMR and 8.0% in the BORN database. Women using aspirin were older (37.0 vs 33.0 years) and had higher median gravidity (3 vs. 2). Sensitivity and specificity of the BORN aspirin prophylaxis variable were 62.5% (95% CI 40.6, 81.2) and 100.0% (95% CI 97.3, 100.0), respectively. The corresponding positive and negative predictive values were 100.0% (95% CI 78.2, 100.0), and 93.8% (95% CI 88.6, 97.1), respectively. Cohen's κ was 0.74 (95% CI 0.58, 0.90), and overall percent agreement was 94.4% (95% CI 87.1, 100.0). CONCLUSIONS: Aspirin use within the BORN database, based on a standard variable field, appears accurate enough for the potential use in epidemiological studies of aspirin prophylaxis for preeclampsia or as a covariate in related studies.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity.

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

A Simple Admission Order-set Improves Adherence to Canadian Guidelines for Hospitalized Patients With Severe Ulcerative Colitis.

Background: Individuals hospitalized with severe ulcerative colitis represent a complex group of patients. Variation exists in the quality of care of admitted patients with inflammatory bowel disease. We hypothesized that implementation of a standardized admission order set could result in improved adherence to current best practice guidelines (Toronto Consensus Statements) for the management of this patient population. Methods: A retrospective cohort study of patients admitted with severe ulcerative colitis to a Montreal tertiary center was conducted. Two cohorts were defined based on pre- and post-implementation of a standardized order set. Adherence to 11 quality indicators was assessed before and after implementation of the intervention. These included: Clostridioides difficile and stool cultures testing, ordering an abdominal X-ray and CRP, organizing a flexible sigmoidoscopy, documenting latent tuberculosis, initiating thromboprophylaxis, use of intravenous steroids, prescribing infliximab if refractory to steroids, limiting narcotics, and surgical consultation if refractory to medical therapy. Results: Adherence to 6 of the 11 quality indicators was improved in the post-intervention cohort. Significant increases were noted in adherence to C difficile testing (75.5% versus 91.9%, P < 0.05), CRP testing (71.4% versus 94.6%, P < 0.01), testing for latent tuberculosis (38.1% versus 84.6%, P < 0.01), thromboprophylaxis (28.6% versus 94.6%, P < 0.01), adequate corticosteroids prescription (72.9% versus 94.6%, P < 0.01), and limitation of narcotics prescribed (68.8% versus 38.9%, P < 0.01). Conclusions: Implementation of a standardized order set, focused on pre-defined quality indicators for hospitalized patients with severe UC, was associated with meaningful improvements to most quality indicators defined by the Toronto Consensus Statements.

Risk of recurrent severe maternal morbidity: a population-based study.

BACKGROUND: Severe maternal morbidity is a composite indicator of maternal health and obstetrical care. Little is known about the risk of recurrent severe maternal morbidity in a subsequent delivery. OBJECTIVE: This study aimed to estimate the risk of recurrent severe maternal morbidity in the next delivery after a complicated first delivery. STUDY DESIGN: We analyzed a population-based cohort study of women with at least 2 singleton hospital deliveries between 1989 and 2021 in Quebec, Canada. The exposure was severe maternal morbidity in the first hospital-recorded delivery. The study outcome was severe maternal morbidity at the second delivery. Log-binomial regression models adjusted for maternal and pregnancy characteristics were used to generate relative risks and 95% confidence intervals comparing women with and without severe maternal morbidity at first delivery. RESULTS: Among 819,375 women, 43,501 (3.2%) experienced severe maternal morbidity in the first delivery. The rate of severe maternal morbidity recurrence at second delivery was 65.2 vs 20.3 per 1000 in women with and without previous severe maternal morbidity (adjusted relative risk, 3.11; 95% confidence interval, 2.96-3.27). The adjusted relative risk for recurrence of severe maternal morbidity was greatest among women who had ≥3 different types of severe maternal morbidity at their first delivery, relative to those with none (adjusted relative risk, 5.50; 95% confidence interval, 4.26-7.10). Women with cardiac complication at first delivery had the highest risk of severe maternal morbidity in the next delivery. CONCLUSION: Women who experience severe maternal morbidity have a relatively high risk of recurrent morbidity in the subsequent pregnancy. In women with severe maternal morbidity, these study findings have implications for prepregnancy counseling and maternity care in the next pregnancy.

Identifying Targets to Improve the Management of Severe Hypertension in Pregnancy and Postpartum.

OBJECTIVES: To (1) define quality indicators, (2) describe care gaps, and (3) identify process issues in severe hypertension (sustained systolic blood pressure [BP] ≥160 mm Hg or diastolic BP ≥110 mm Hg) management at our tertiary care centre. METHODS: Pregnant and postpartum persons diagnosed with a hypertensive disorder of pregnancy from 2018 to 2019 were identified. A retrospective cohort of patients with severe hypertension was constructed, and data were collected through chart review. Severe hypertension management was assessed according to defined quality indicators. Clinical characteristics were compared between participants with and without time-to-target BP within 60 minutes. Process issues were examined for each severe hypertension occurrence. RESULTS: Of 608 participants with a hypertensive disorder of pregnancy, 90 (15%) experienced severe hypertension. Median time-to-target BP was 76 minutes (interquartile range 47-123 minutes), and target BP (<155/105 mm Hg) was achieved within 60 minutes in 31/90 (34%) participants. Appropriate antihypertensives for severe hypertension were used in 55/90 (61%), and time-to-treatment initiation was within 30 minutes in 42/54 (78%). Chronic hypertension and oral labetalol use were associated with delays in achieving target BP. Process issues related to severe hypertension management included inappropriate treatment (n = 35/90; 39%), failure to recognize severe hypertension as an emergency (n = 21/90; 23%), and delayed treatment initiation (n = 12/54; 22%). CONCLUSION: We defined quality indicators for severe hypertension management. Time-to-target BP within 60 minutes was achieved in a minority of patients, and chronic hypertension was associated with delayed severe hypertension resolution. Process issues in severe hypertension management were described.

The use of loop diuretics in the context of hypertensive disorders of pregnancy: a systematic review and meta-analysis.

AIMS: Addressing volume expansion may improve the management of hypertension across the pregnancy continuum. We conducted a systematic review to summarize the evidence on the use of loop diuretics in the context of hypertensive disorders during pregnancy and the postpartum period. METHODS AND RESULTS: Medline, Embase, Cochrane library, ClinicalTrials.gov, and Google Scholar were searched for original research articles published up to 29 June 2021. Of the 2801 results screened, 15 studies were included: eight randomized controlled trials, six before-after studies, and one cohort study. Based on random effects meta-analysis of before-after studies, antepartum use of loop diuretics was associated with lower DBP [mean difference -17.73 mmHg, (95% confidence intervals -34.50 to -0.96); I2 = 94%] and lower cardiac output [mean difference -0.75 l/min, (-1.11 to -0.39); I2 = 0%], with no difference in SBP, mean arterial pressure, heart rate, or total peripheral resistance. Meta-analysis of randomized controlled trials revealed that postpartum use of loop diuretics was associated with decreased need for additional antihypertensive patients [relative risk 0.69, (0.50-0.97); I2 = 14%], and an increased duration of hospitalization [mean difference 8.80 h, (4.46-13.14); I2 = 83%], with no difference in the need for antihypertensive therapy at hospital discharge, or persistent postpartum hypertension. CONCLUSION: Antepartum use of loop diuretics lowered DBP and cardiac output, while their postpartum use reduced the need for additional antihypertensive medications. There was insufficient evidence to suggest a clear benefit. Future studies focusing on women with hypertensive pregnancy disorders who may most likely benefit from loop diuretics are required.

Thrombocytopenia and neonatal outcomes among extremely premature infants exposed to maternal hypertension.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) are associated with neonatal hematological disturbances, such as thrombocytopenia. The association of HDP to platelet counts in the context of extreme prematurity, to trends of platelet counts during neonatal hospitalization, and to frequency of platelet transfusions remain to be explored. PROCEDURE: Retrospective study of infants born at less than 29 weeks born between 2015 and 2019. Platelet counts were collected on initial complete blood count, at 2 weeks, 32 weeks post-menstrual age (PMA), 36 weeks PMA, and closest to discharge. We examined the association between HDP and platelet counts at each time point, frequency of platelet transfusions and intraventricular hemorrhage (IVH) grade 3 or more. RESULTS: Total 296 infants were included, 43 exposed to HDP. Infants exposed had lower platelet counts at each time point, as well as a higher prevalence of platelet less than 150 × 109 /L on one of the time points (32% vs. 65%, p < .001). Infants exposed to maternal hypertension were more frequently exposed to platelet transfusions (63% vs. 18%, p < .001). Mixed effect model demonstrated an association between HDP and a lower trend in platelet counts at each time point (ß = -94 × 103 /µl, p < .001). Although initial platelet count was associated with severe IVH, it was not associated to exposure to HDP. CONCLUSION: Premature infants exposed to HDP have a higher prevalence of thrombocytopenia, increased frequency of platelet transfusion, and an altered trend in platelet counts during neonatal hospitalization.

Mobile Health Fitness Interventions: Impact of Features on Routine Use and Data Sharing Acceptability.

Background: Mobile health (mHealth) interventions are increasingly being used for cardiovascular research and physical activity promotion. Objectives: As a result, the authors aimed to evaluate which features facilitate and impede routine engagement with mobile fitness applications. Methods: We distributed a pan-Canadian online questionnaire via the behavioral research platform Prolific.co to evaluate what features are associated with the use and routine engagement (ie, daily or weekly use) of mHealth fitness applications and attitudes about data sharing. Binary logistic regression was used to quantify the association between these endpoints and exploratory factors such as the perceived utility of various mHealth application features. Results: The survey received 694 responses. Most people were women (62%), the median age was 28 years (range: 18-78 years), and most people reported current use of an mHealth fitness application (48%). The perceived importance of personal health (OR: 2.40; 95% CI: 1.34-4.50) was the factor most associated with the current use of an mHealth fitness application. The feature most associated with routine engagement was the ability to track progress toward a goal (OR: 5.10; 95% CI: 2.73-9.61) while the most significant barrier was the absence of goal customization features (OR: 0.44; 95% CI: 0.25-0.81). The acceptance of sharing health data for research was high (56%), and privacy concerns did not significantly affect routine engagement (OR: 0.81; 95% CI: 0.40-1.77). Results were consistent across race and gender. Conclusions: mHealth interventions have the potential to be scaled across populations. Optimizing applications to improve self-monitoring and personalization could increase routine engagement and, thus, user retention and intervention effectiveness.

The multidisciplinary management of a mechanical mitral valve thrombosis in pregnancy: a case report and review of the literature.

Background: The management of anticoagulation for mechanical heart valves during pregnancy poses a unique challenge. Mechanical valve thrombosis is a devastating complication for which surgery is often the treatment of choice. However, cardiac surgery for prosthetic valve dysfunction in pregnant patients confers a high risk of maternofetal morbidity and mortality. Case summary: A 39-year-old woman in her first pregnancy at 30 weeks gestation presented to hospital with a mechanical mitral valve thrombosis despite therapeutic anticoagulation with low-molecular-weight heparin. She underwent an emergent caesarean section followed immediately by a bioprosthetic mitral valve replacement. This occurred after careful planning and organization on the part of a large multidisciplinary team. Discussion: A proactive, rather than reactive, approach to the surgical management of a mechanical valve thrombosis in pregnancy will maximize the chances of successful maternal and fetal outcomes.

Sleep disordered breathing and the risk of severe maternal morbidity in women with preeclampsia: A population-based study.

OBJECTIVE: Obstructive sleep apnea (OSA) may exacerbate the widespread endothelial dysfunction seen in preeclampsia, potentially worsening clinical outcomes. We aimed to assess whether OSA is associated with an increased risk of severe maternal morbidity, cardiovascular morbidity, and healthcare utilization among women with preeclampsia. STUDY DESIGN: We performed a retrospective cohort study utilizing data from the National Perinatal Information Center (2010-2014) in the United States.The cohort comprised women with preeclampsia. We estimated the association between OSA and the outcomes using logistic regression analyses and determined odds ratio adjusted for demographic factors and comorbidities (ORadj) and associated 95% confidence intervals (CI). MAIN OUTCOME MEASURES: The primary outcome was a composite of mortality and severe maternal morbidity comprising intensive care unit (ICU) admission, acute renal failure, pulmonary edema, pulmonary embolism, congestive heart failure, cardiomyopathy, and stroke. Secondary outcomes comprised the subset of cardiovascular events, as well as increased healthcare utilization (including Cesarean delivery, preterm birth, ICU admission, and prolonged length of hospital stay). RESULTS: In total, 71,159 women had preeclampsia, including 270 (0.4 %) with OSA. Women with preeclampsia and OSA were more likely to experience severe maternal morbidity than women without OSA (ORadj 2.65, 95 % CI [1.94-3.61]). Moreover, women with concomitant OSA had more severe cardiovascular morbidity than women without OSA (ORadj 5.05, 95 % CI [2.28-11.17]). Accordingly, OSA was associated with increased healthcare utilization in women with preeclampsia (ORadj. 2.26, 95 % CI [1.45-3.52]). CONCLUSION: In women with preeclampsia, OSA increases the risk for severe maternal morbidity, cardiovascular morbidity, and healthcare utilization.

Association Between Right Ventricular Dysfunction and Adverse Outcomes in Peripartum Cardiomyopathy: Insights From the BRO-HF Quebec Cohort Study.

Background: Peripartum cardiomyopathy (PPCM) is associated with severe morbidity and mortality, and the significance of right ventricular (RV) involvement is unclear. We sought to determine whether RV systolic dysfunction or dilatation is associated with adverse clinical outcomes in women with PPCM. Methods: We conducted a multicentre retrospective cohort study examining the association between echocardiographic RV systolic dysfunction or dilatation at the time of PPCM diagnosis and clinical outcomes. Clinical endpoints of interest were the need for mechanical support, recovery of left ventricular ejection fraction at follow-up, and a combined endpoint of hospitalization for heart failure, cardiac transplant, or death. Results: A total of 67 women, median age 30 years (interquartile range: 7), were diagnosed with PPCM between 1994 and 2015 in 17 participating centres. Twin pregnancies occurred in 11%; 62% of women were multiparous; and 24% had preeclampsia. RV systolic function was impaired in 18 (27%) and dilated in 8 (12%). Seven women required ventricular assistance, and 8 experienced the composite outcome during follow-up (25 [interquartile range 61] months). RV dysfunction was associated with the need for mechanical support (odds ratio 10.10 (95% confidence interval: 1.86-54.81), P = 0.007), but neither RV dysfunction nor dilatation was associated with left ventricular ejection fraction recovery, the need for cardiac transplant, heart failure hospitalization, or death. Conclusions: RV dysfunction is associated with the need for mechanical support in women with PPCM. These findings may improve risk stratification of complications and clinical management.

Introduction: La cardiomyopathie du péripartum (CMP-PP) est associée à la morbidité grave et à la mortalité, mais on ignore l'importance de l'atteinte ventriculaire droite (VD). Nous avons cherché à déterminer si la dysfonction systolique ou la dilatation VD sont associées aux résultats cliniques défavorables chez les femmes atteintes de CMP-PP. Méthodes: Nous avons mené une étude de cohorte rétrospective multicentrique sur l'association entre la dysfonction systolique ou la dilatation VD à l'échographie au moment du diagnostic de CMP-PP et les résultats cliniques. Les critères cliniques d'intérêt étaient la nécessité d'une assistance mécanique, la récupération de la fraction d'éjection ventriculaire gauche (FEVG) au suivi et un critère combiné d'hospitalisation liée à l'insuffisance cardiaque (IC), la transplantation cardiaque ou la mort. Résultats: Un total de 67 femmes, dont l'âge médian était de 30 ans (écart interquartile [EI] : 7), ont reçu un diagnostic de CMP-PP entre 1994 et 2015 dans 17 centres participants. Les grossesses gémellaires sont survenues chez 11 % ; 62 % de femmes étaient multipares ; et 24 % souffraient de prééclampsie. La fonction systolique VD était compromise chez 18 (27 %) femmes et le VD, dilaté, chez huit (12 %) femmes. Sept femmes ont eu besoin d'une assistance ventriculaire, et huit ont subi le critère composite durant le suivi (25 [EI : 61] mois). La dysfonction VD a été associée à la nécessité d'une assistance mécanique (rapport de cotes 10,10 [intervalle de confiance à 95 % : 1,86-54,81], P = 0,007), mais ni la dysfonction ni la dilatation VD n'ont été associées à la récupération de la FEVG, à la nécessité d'une transplantation cardiaque, à une hospitalisation liée à l'IC ou à la mort. Conclusions: La dysfonction VD est associée à la nécessité d'une assistance mécanique chez les femmes atteintes de CMP-PP. Ces conclusions peuvent permettre d'améliorer la stratification des risques de complications et la prise en charge clinique.

Serotonin Syndrome After Treatment of Nausea and Vomiting in Pregnancy.

BACKGROUND: Nausea and vomiting in pregnancy often require pharmacotherapy for symptom management. Serotonin syndrome is a rare clinical entity that can be precipitated by the medications used to treat nausea and vomiting in pregnancy. CASE: A 35-year-old pregnant individual with a history of hyperemesis gravidarum in an earlier pregnancy requiring prolonged hospitalization presented with nausea and vomiting at 7 weeks of gestation. She was incidentally found to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection when she was universally screened at the time of admission. She required pharmacotherapy, including prochlorperazine and ondansetron for treatment of nausea as well as sumatriptan for migraine. She developed acute spasticity, autonomic dysfunction, and temperature rise, precipitated by antiemetic therapy, consistent with serotonin syndrome. The syndrome resolved with supportive care and benzodiazepines. CONCLUSION: Serotonin syndrome is a serious clinical entity that can be provoked by the pharmacotherapy given to treat nausea and vomiting in pregnancy. This medical emergency requires early recognition and prompt management.