Progressive calcification of bioprosthetic mitral valve observed during pregnancy resulting from in vitro fertilization: a case report.

BACKGROUND: Women with pre-existing cardiac conditions who undergo assisted reproductive technologies (ART) are believed to be at a heightened risk of cardiovascular events during both the treatment and pregnancy phases. An unresolved question within this context pertains to whether the ART procedure itself constitutes a risk factor for individuals with bioprosthetic heart valves (BHV). Additionally, there is ongoing controversy regarding whether pregnancies expedite the process of structural valve degeneration (SVD) in BHV. The purpose of this study is to present the developmental process of BHV calcification, which is considered the primary cause of SVD, during a pregnancy resulting from in vitro fertilization and embryo transfer (IVF-ET), an ART modality, and to elucidate the underlying mechanisms. CASE PRESENTATION: At 7 + 3 weeks of gestation in a twin pregnancy resulting from IVF-ET, a 27-year-old woman with a bioprosthetic mitral valve manifesting severe mitral stenosis and moderate pulmonary arterial hypertension, was suspected of SVD. Despite undergoing fetal reduction, she experienced progressive calcification of the bioprosthetic valve, increasing pulmonary arterial pressure and ultimately deteriorated into heart failure. An elective cesarean section and redo valve replacement was subsequently administered to improve her cardiovascular condition. As a result, a healthy young boy was delivered and the dysfunctional BHV was replaced with a mechanical valve. She did not report any discomfort during the 3-month follow-up. CONCLUSION: The progressive calcification of the BHV was observed during IVF pregnancy, indicating a potential connection between fertility therapy, pregnancy and calcification of BHV. Pregnant women with pre-implanted BHV should be treated with caution, as any medical interventions during ART and pregnancy can have a significant impact on both maternal and fetal outcomes. Thus, involving a multidisciplinary team in decision-making early on, starting from the treatment of the original heart disease, throughout the entire process of ART and pregnancy, is crucial.

Connecting the Dots: Exploring the Interplay Between Preeclampsia and Peripartum Cardiomyopathy.

Preeclampsia and peripartum cardiomyopathy (PPCM) are significant obstetric problems that can arise during or after pregnancy. Both are known to be causes of maternal mortality and morbidity. Several recent studies have suggested a link between preeclampsia and the pathophysiology of PPCM. However, the common thread that connects the two has yet to be thoroughly and fully articulated. Here, we investigate the complex dynamics of preeclampsia and PPCM in this review. Our analysis focuses mainly on inflammatory and immunological responses, endothelial dysfunction as a shared pathway, and potential genetic predisposition to both diseases. To begin, we will look at how excessive inflammatory and immunological responses can lead to clinical symptoms of both illnesses, emphasizing the role of proinflammatory cytokines and immune cells in modifying vascular and tissue responses. Second, we consider endothelial dysfunction to be a crucial point at which endothelial damage and activation contribute to pathogenesis through increased vascular permeability, vascular dysfunction, and thrombus formation. Finally, we examine recent information suggesting genetic predispositions to preeclampsia and PPCM, such as genetic variants in genes involved in the management of blood pressure, the inflammatory response, and heart structural integrity. With this synergistic study, we seek to encourage more research and creative therapy solutions by emphasizing the need for an interdisciplinary approach to understanding and managing the connection between preeclampsia and PPCM.

Obstetrical and neonatal outcomes in patients with surgically repaired heart disease.

BACKGROUND: Congenital and acquired heart disease complicate 1% to 4% of pregnancies in the United States. Beyond the risks of the underlying maternal congenital heart disease, cardiac surgery and its sequelae, such as surgical scarring resulting in higher rates of arrhythmias and implanted valves altering anticoagulation status, have potential implications that could affect gestation and delivery. OBJECTIVE: This study aimed to investigate whether history of maternal cardiac surgery is associated with adverse obstetrical or neonatal outcomes compared with patients without a history of cardiac disease or surgery, considered "healthy controls." STUDY DESIGN: This is a secondary analysis of retrospective cohort studies performed at a tertiary care facility in the United States comparing obstetrical outcomes in patients with a history of open cardiac surgery who delivered from January 2007 to December 2018 with healthy controls, who delivered from April 2020 to July 2020. There were 74 pregnancies in 61 patients with a history of open cardiac surgery that were compared with pregnancies in healthy controls. Of the 74 pregnancies, 65 were successfully matched based on gestational age to controls at a 1:3 (case-to-control) ratio. The remainder of cases were matched at a 1:2 or 1:1 ratio; therefore, a total of 219 control pregnancies were included in the analysis. Our primary outcome was the incidence of hypertensive disorders of pregnancy, as well as cesarean delivery, in patients with a history of open cardiac surgery compared with healthy controls. Our secondary outcome was the incidence of low-birthweight neonates in patients with a history of open cardiac surgery compared with healthy controls. RESULTS: Patients with a history of cardiac surgery were not more likely to have any hypertensive disorder diagnosed than healthy controls. Patients with a history of cardiac surgery were more likely to have an operative delivery (P<.0001) but equally likely to have a cesarean delivery (P=.528) compared with healthy controls. Birthweight was not statistically different of 2655±808 g in neonates born to patients with a history of cardiac surgery vs 2844±830 g born to healthy controls (P=.092). CONCLUSION: Patients with a history of cardiac surgery may not be at higher risk of hypertensive disorder diagnosis during pregnancy. Similarly, most patients with a history of cardiac surgery are also likely not at higher risk of cesarean delivery or low-birthweight neonates.

Disease features and management of cardiomyopathies in women.

Over the last years, there has been a growing interest in the clinical manifestations and outcomes of cardiomyopathies in women. Peripartum cardiomyopathy is the only women-specific cardiomyopathy. In cardiomyopathies with X-linked transmission, women are not simply healthy carriers of the disorder, but can show a wide spectrum of clinical manifestations ranging from mild to severe manifestations because of heterogeneous patterns of X-chromosome inactivation. In mitochondrial disorders with a matrilinear transmission, cardiomyopathy is part of a systemic disorder affecting both men and women. Even some inherited cardiomyopathies with autosomal transmission display phenotypic and prognostic differences between men and women. Notably, female hormones seem to exert a protective role in hypertrophic cardiomyopathy (HCM) and variant transthyretin amyloidosis until the menopausal period. Women with cardiomyopathies holding high-risk features should be referred to a third-level center and evaluated on an individual basis. Cardiomyopathies can have a detrimental impact on pregnancy and childbirth because of the associated hemodynamic derangements. Genetic counselling and a tailored cardiological evaluation are essential to evaluate the likelihood of transmitting the disease to the children and the possibility of a prenatal or early post-natal diagnosis, as well as to estimate the risk associated with pregnancy and delivery, and the optimal management strategies.

Cardiovascular Disease Screening in Women: Leveraging Artificial Intelligence and Digital Tools.

Cardiovascular disease remains the leading cause of death in women. Given accumulating evidence on sex- and gender-based differences in cardiovascular disease development and outcomes, the need for more effective approaches to screening for risk factors and phenotypes in women is ever urgent. Public health surveillance and health care delivery systems now continuously generate massive amounts of data that could be leveraged to enable both screening of cardiovascular risk and implementation of tailored preventive interventions across a woman's life span. However, health care providers, clinical guidelines committees, and health policy experts are not yet sufficiently equipped to optimize the collection of data on women, use or interpret these data, or develop approaches to targeting interventions. Therefore, we provide a broad overview of the key opportunities for cardiovascular screening in women while highlighting the potential applications of artificial intelligence along with digital technologies and tools.

The Impact of Sex and Gender on Stroke.

Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.

An integrated model of preeclampsia: a multifaceted syndrome of the maternal cardiovascular-placental-fetal array.

Maternal tolerance of the semiallogenic fetus necessitates conciliation of competing interests. Viviparity evolved with a placenta to mediate the needs of the fetus and maternal adaptation to the demands of pregnancy and to ensure optimal survival for both entities. The maternal-fetal interface is imagined as a 2-dimensional porous barrier between the mother and fetus, when in fact it is an intricate multidimensional array of tissues and resident and circulating factors at play, encompassing the developing fetus, the growing placenta, the changing decidua, and the dynamic maternal cardiovascular system. Pregnancy triggers dramatic changes to maternal hemodynamics to meet the growing demands of the developing fetus. Nearly a century of extensive research into the development and function of the placenta has revealed the role of placental dysfunction in the great obstetrical syndromes, among them preeclampsia. Recently, a debate has arisen questioning the primacy of the placenta in the etiology of preeclampsia, asserting that the maternal cardiovascular system is the instigator of the disorder. It was the clinical observation of the high rate of preeclampsia in hydatidiform mole that initiated the focus on the placenta in the etiology of the disease. Over many years of research, shallow trophoblast invasion with deficient remodeling of the maternal spiral arteries into vessels of higher capacitance and lower resistance has been recognized as hallmarks of the preeclamptic milieu. The lack of the normal decrease in uterine artery resistance is likewise predictive of preeclampsia. In abdominal pregnancies, however, an extrauterine pregnancy develops without remodeling of the spiral arteries, yet there is reduced resistance in the uterine arteries and distant vessels, such as the maternal ophthalmic arteries. Proponents of the maternal cardiovascular model of preeclampsia point to the observed maternal hemodynamic adaptations to pregnancy and maladaptation in gestational hypertension and preeclampsia and how the latter resembles the changes associated with cardiac disease states. Recognition of the importance of the angiogenic-antiangiogenic balance between placental-derived growth factor and its receptor soluble fms-like tyrosine kinase-1 and disturbance in this balance by an excess of a circulating isoform, soluble fms-like tyrosine kinase-1, which competes for and disrupts the proangiogenic receptor binding of the vascular endothelial growth factor and placental-derived growth factor, opened new avenues of research into the pathways to normal adaptation of the maternal cardiovascular and other systems to pregnancy and maladaptation in preeclampsia. The significance of the "placenta vs heart" debate goes beyond the academic: understanding the mutuality of placental and maternal cardiac etiologies of preeclampsia has far-reaching clinical implications for designing prevention strategies, such as aspirin therapy, prediction and surveillance through maternal hemodynamic studies or serum placental-derived growth factor and soluble fms-like tyrosine kinase-1 testing, and possible treatments to attenuate the effects of insipient preeclampsia on women and their fetuses, such as RNAi therapy to counteract excess soluble fms-like tyrosine kinase-1 produced by the placenta. In this review, we will present an integrated model of the maternal-placental-fetal array that delineates the commensality among the constituent parts, showing how a disruption in any component or nexus may lead to the multifaceted syndrome of preeclampsia.

Hypertension induced by pregnancy and neonatal outcome: Results from a retrospective cohort study in preterm under 34 weeks.

OBJECTIVE: The present study seeks to assess the impact of gestational hypertensive disorders on premature newborns below 34 weeks and to establish the main morbidities and mortality in the neonatal period and at 18 months. MATERIALS AND METHODS: A retrospective observational study was carried out with 695 premature newborns of gestational age (GA) between 24 and 33 weeks and 6 days, born alive in the Neonatal ICU of Brasília's Mother and Child Hospital (HMIB), in the period from January 1, 2014, to July 31, 2019. In total, 308 infants were born to hypertensive mothers (G1) and 387 to normotensive mothers (G2). Twin pregnancies and diabetic patients with severe malformations were excluded. Outcomes during hospitalization and outcomes of interest were evaluated: respiratory distress syndrome (RDS), brain ultrasonography, diagnosis of bronchopulmonary dysplasia (BPD), diagnosis of necrotizing enterocolitis, retinopathy of prematurity, breastfeeding rate at discharge, survival at discharge and at 18 months of chronological age and relationship between weight and gestational age. RESULTS: Newborns with hypertensive mothers had significantly lower measurements of birth weight and head circumference. The G1 group had a higher risk small for gestational age (OR 2.4; CI 95% 1.6-3.6; p <0.00), as well as a greater risk of being born with a weight less than 850 g (OR 2.4; 95% CI 1.2-3.5; p <0.00). Newborns of mothers with hypertension presented more necrotizing enterocolitis (OR 2.0; CI 95% 1.1-3.7); however, resuscitation in the delivery room and the need to use surfactant did not differ between groups, nor did the length of stay on mechanical ventilation, or dependence on oxygen at 36 weeks of gestational age. Survival was better in newborns of normotensive mothers, and this was a protective factor against death (OR 0.7; 95% CI 0.5-0.9; p <0.01). In the follow-up clinic, survival at 18 months of chronological age was similar between groups, with rates of 95.3% and 92.1% among hypertensive and normotensive mothers, respectively. Exclusive breastfeeding at discharge was 73.4% in the group of hypertensive women and 77.3% in the group of normotensive mothers. There were no significant differences between groups. CONCLUSION: Among the analyzed outcomes, arterial hypertension during pregnancy can increase the risk of low weight, small babies for gestational age (SGA), deaths in the neonatal period and enterocolitis, with no differences in weight and survival at 18 months of chronological age. Arterial hypertension presents a high risk of prematurity in the neonatal period, with no difference at 18 months of age.

Outcomes of women with congenital heart disease admitted to acute-care hospitals for delivery in Japan: a retrospective cohort study using nationwide Japanese diagnosis procedure combination database.

BACKGROUND: The number of women with congenital heart disease (CHD) who are of childbearing age is increasing due to advancements in medical management. Nonetheless, data on the outcomes of delivery in women with CHD remain limited. Therefore, we conducted a retrospective cohort study using a nationwide database of deliveries by women with CHD. METHODS: Deliveries by women with CHD discharged from acute-care hospitals between April 2017 and March 2018 were identified based on the Diagnosis Procedure Combination database which covers almost all acute-care hospitals in Japan. By using this database, we tried to include relatively high-risk deliveries by women with CHD. Subjects were divided into three groups according to the underlying disease complexity: simple, moderate, and great complexity. The clinical characteristics and incidence of peripartum cardiovascular events were compared among the three groups. RESULTS: A total of 249 deliveries from 107 hospitals were included. The largest facility had 29 deliveries per year. Given the uncertainty of underlying cardiac anomalies, 48 women were excluded, and the remaining 201 women (median age, 32 years) were analyzed. In-hospital maternal death, use of extracorporeal membrane oxygenation, intra-aortic balloon pump, pacemaker, and direct current cardioversion were not observed. Nine patients (4.5%) required intravenous diuretic administration. However, the difference in the frequency of diuretic use was not significant among the three groups (simple, 1.9%; moderate, 7.2%; great, 6.9%; P = 0.204). One participant required valve replacement surgery at 22 days after a successful cesarean section. As the disease complexity increased, deliveries occurred more frequently at university hospitals (simple, 41.7%; moderate, 52.2%; great, 72.4%; P = 0.013) and the length of hospitalization was significantly longer, with median durations of 9.0 (interquartile range [IQR] 7.0-11.0) days, 10.0 (IQR 8.0-24.0) days, and 11.0 (IQR 8.0-36.0) days in the simple, moderate, and great complexity groups, respectively (P = 0.002). CONCLUSIONS: Appropriate patient selection and management by specialized tertiary institutions may contribute to positive outcomes in pregnancies in women with CHD.

Pregnancy and delivery in a patient with a Fontan circulation and primary ciliary dyskinesia: A case report.

A patient had primary ciliary dyskinesia with a complex cardiac malformation. As a child, she had benefited from a Fontan surgery to maintain a proper cardiac function. In such patients, whether it is safe to become pregnant is controversial. This case illustrates the possibility of carrying a pregnancy to term and providing a vaginal birth if a rigorous preconception consultation is performed to ensure care by a multidisciplinary specialized team, and the patient is properly informed of the risks.

Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review.

Over the past decade, spontaneous coronary artery dissection (SCAD) has emerged as an important cause of myocardial infarction, particularly among younger women. The pace of knowledge acquisition has been rapid, but ongoing challenges include accurately diagnosing SCAD and improving outcomes. Many SCAD patients experience substantial post-SCAD symptoms, recurrent SCAD, and psychosocial distress. Considerable uncertainty remains about optimal management of associated conditions, risk stratification and prevention of complications, recommendations for physical activity, reproductive planning, and the role of genetic evaluations. This review provides a clinical update on the diagnosis and management of patients with SCAD, including pregnancy-associated SCAD and pregnancy after SCAD, and highlight high-priority knowledge gaps that must be addressed.

Radiofrequency catheter ablation without radiation exposure in a 13th week pregnant woman with Wolff-Parkinson-White syndrome.

A 36-year-old woman with 12-week gestation visited the emergency department, complaining of palpitations. Her electrocardiography (ECG) demonstrated ventricular pre-excitation combined with atrial fibrillation. The polarity of the delta waves in leads V5, V6, I, and aVL were positive and negative in leads V1, III, and aVF, suggesting that the accessory pathway (AP) was located on the right posterior free wall. She did not want to take any medicine to prevent the tachycardia. Moreover, the shortest pre-excited RR interval during the atrial fibrillation was 200 ms, so we decided to ablate the AP without fluoroscopy. An electrophysiology study was performed with guidance of a 3-dimension (3D) navigation system and intracardiac echocardiography (ICE). We ablated the right free wall AP without fluoroscopy. A follow-up ECG no longer exhibited any delta waves. Even in the early period of pregnancy, catheter ablation might be performed safely using ICE and a 3D navigation system without fluoroscopy. Therefore, it could more often be considered as a therapeutic option in pregnant women without concern for radiation exposure.

Pregnancy and cardiac interventions: What are the optimal management options?

Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.

Risk factors for cardiac, obstetric, and neonatal complications in patients with heart disease during pregnancy / Factores de riesgo para complicaciones cardíacas, obstétricas y neonatales en pacientes con enfermedad cardíaca durante el embarazo

Abstract Objective: Heart disease in pregnancy can cause clinical deterioration and maternal-fetal death. It is essential to evaluate risk factors related to complications. Methodology: This was a observational, analytical retrospective cohort study with a non-probabilistic convenience sample of pregnant women with congenital or acquired heart disease, corrected or not, or arrhythmias requiring urgent intervention. Patients with mild or moderate valvular regurgitation, mild valvular stenosis, patients without echocardiography or without delivery information were excluded from the study. The outcome was a composite of cardiac, obstetric, and neonatal events. Univariate and multivariate analyzes were performed with logistic regression model and discriminatory capacity with area under the curve and independent analysis of the modified World Health Organization (mWHO) risk classification (mWHO). Results: A total of 104 patients with an average age of 25 ± 6.5 years presented cardiac events in 13.5%, obstetric in 14.42%, and neonatal in 28.85%. The univariate analysis found an association with New York Heart Association functional status, hypertensive disorders of pregnancy, cesarean delivery, gestational age < 27 weeks, hypoxemia, and mWHO risk. In multivariate only cesarean delivery (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.05-6.86) and gestational age at delivery (OR, 0.39; 95% CI, 0.22-0.67) maintain association with outcomes. The area under the curve for the mWHO risk is 0.75. Conclusions: There is a high rate of adverse events in patients with heart disease during pregnancy. Gestational age and cesarean delivery behaved as predictors of adverse maternal-fetal outcomes. The mWHO risk classification had an acceptable prediction of adverse outcomes.

Resumen Objetivo: La enfermedad cardíaca en el embarazo puede ocasionar deterioro clínico y muerte maternofetal. Es indispensable evaluar factores de riesgo relacionados con complicaciones. Método: Estudio observacional y analítico de cohorte retrospectivo con muestra no probabilística por conveniencia de embarazadas con cardiopatía congénita o adquirida, corregida o no, o arritmias que requerían intervención urgente. Se excluyó a pacientes con insuficiencias valvulares leves o moderadas, estenosis valvulares leves, pacientes sin ecocardiografía o sin información del parto. El desenlace fue un compuesto de episodios cardíacos, obstétricos y neonatales. Se realizó análisis univariado y multivariado con modelo de regresión logística y capacidad diferenciadora con área bajo la curva y análisis independiente de la clasificación de riesgo de la OMS modificada (OMSm). Resultados: 104 pacientes con edad promedio de 25 ± 6.5 años presentaron episodios cardíacos en 13.5%, obstétricos en 14.42% y neonatales en 28.85%. El análisis univariado encontró una relación con el estado funcional de la NYHA, trastornos hipertensivos del embarazo, parto por cesárea, edad gestacional < 27 semanas, hipoxemia y riesgo de la OMSm. En el multivariado sólo el parto por cesárea (OR, 2.68; IC 95%, 1.05-6.86) y la edad gestacional al momento del parto (OR, 0.39; IC 95%, 0.22-0.67) mantienen nexo con los desenlaces. El área bajo la curva para el riesgo de la OMSm es de 0.75. Conclusiones: Hay una elevada tasa de efectos adversos en pacientes con enfermedad cardíaca durante el embarazo. La edad gestacional y el parto por cesárea se comportaron como predictores de resultados adversos maternofetales. La clasificación de riesgo de la OMSm tuvo una predicción aceptable de desenlaces adversos.

Successful completion of pregnancy after Mustard procedure for transposition of great arteries: a rare case from the developing world.

Surgical repair of transposition of great arteries has undergone various evolutionary changes over the years. The initial of these treatment options was atrial septectomy followed by atrial switch and the current preferred treatment option is arterial switch operation worldwide. Due to various reasons, like lack of medical and surgical expertise atrial switch operation was commonly in practice in developing countries until few years back. Pregnancy in a patient with history of atrial switch operation poses a unique haemodynamic challenge. We report the case of a successful pregnancy in a 26 years old lady who had undergone Mustard repair surgery in the past in Pakistan.

The Spectrum of Pregnancy-Associated Heart Failure Phenotypes: An Echocardiographic Study.

Compare echocardiographic phenotypes of women presenting with peripartum heart failure. A retrospective case-control study of pregnant women (n = 86) presenting with PP-HF symptoms (i.e., dyspnea, PND, orthopnea) and objective examination and laboratory findings (lung congestion, elevated JVP and/or HJR, elevated brain natriuretic peptide [BNP] and pulmonary edema on chest X-ray). Three distinct phenotypes based on echocardiographically-defined LVEF were identified: (a) PP-HF with preserved ejection fraction (PP HFpEF, LVEF: > 50%); (b) PP-HF with midrange ejection fraction (PP HFmrEF, LVEF: 40-50%); c) PP-HF with reduced ejection fraction (PP HFrEF, LVEF: < 40%); these were compared with 17 pregnant subjects without PP-HF symptoms/findings. Most patients were African American (n = 63; 73%), with low prevalence of hypertension (n = 15, 17%) or diabetes mellitus (n = 5, 5%); pre-eclampsia was highly prevalent (n = 52, 60%). Echocardiographically-defined phenotypes (HFpEF, n = 37; HFmrEF, n = 18; HFrEF, n = 31) showed progressively worse abnormalities in LV remodeling (LV enlargement, LV hypertrophy), LV diastolic function, and right ventricular function; the three PP-HF groups had comparable abnormalities in increased left atrial size and estimated peak tricuspid valve regurgitation velocity. Compared to controls, all three groups had significantly increased filling pressures, LV mass index and left atrial volume index. Peripartum women presenting with the clinical syndrome of heart failure exhibit a spectrum of echocardiographic phenotypes. Significant abnormalities in LV structure, diastolic function, LA size, peak TR velocity and RV function were identified in women with preserved and mid-range EFs, suggesting pregnancy-related cardiac pathophysiologic derangements.

Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period.

Importance: Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancy-related ICH risk, including risk during the extended postpartum period. Objective: To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum. Design, Setting, and Participants: This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7- to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020. Exposures: Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed. Main Outcomes and Measures: Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes. Results: A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23). Advanced maternal age (adjusted odds ratio [OR], 1.08; 95% CI, 1.05-1.10), nonwhite race (adjusted ORs, 2.44 [95% CI, 1.73-3.44] for black patients, 2.12 [95% CI, 1.34-3.35] for Asian patients, and 1.59 [95% CI, 1.12-2.26] for Hispanic patients), hypertension (adjusted OR, 2.02; 95% CI, 1.19-3.42), coagulopathy (adjusted OR, 14.17; 95% CI, 9.17-21.89), preeclampsia or eclampsia (adjusted OR, 9.23; 95% CI, 6.99-12.19), and tobacco use (adjusted OR, 2.83; 95% CI, 1.53-5.23) were independently associated with ICH during pregnancy and the postpartum period. Pregnancy-related ICH was associated with a higher risk of maternal (relative risk difference, 792.6; absolute risk difference, 0.18) and fetal (relative risk difference, 5.3; absolute risk difference, 0.03) death, compared with pregnancies without ICH. Conclusions and Relevance: These findings suggest that the risk of ICH is significantly higher during the third trimester of pregnancy and the first 12 weeks post partum. There are age and race disparities in ICH risk that are associated with devastating maternal and fetal outcomes. These data illustrate the critical need for continuous monitoring and aggressive management of ICH-associated risk factors. These findings suggest that extended postpartum monitoring of high-risk women may be warranted.

Preeclampsia y enfermedad cardiovascular: un enfoque integral para detectar las fases subclínicas de complicaciones obstétricas y cardiovasculares / Preeclampsia and cardiovascular disease: an integrated approach to detect the subclinical stages of obstetrical and cardiovascular complications

Desde 1995 hasta la fecha la asociación entre patologías derivadas los embarazos hipertensivos y las enfermedades cardiovasculares ha generado un gran volumen de potentes evidencias epidemiológicas y clínicas. Los propósitos de esta revisión son varios. Mostrar la consistencia y magnitud de la evidencia científica. Integrar los riesgos/enfermedades cardiovasculares y los problemas obstétricos a través de la disfunción endotelial. Preconizar el seguimiento postparto de la hipertensa embarazada, como una ventana de oportunidad para beneficiar la salud de las mujeres y sus hijos. Incluir la historia obstétrica como factor de riesgo de enfermedad coronaria. Proponer cuestionarios adaptables a las prácticas locales para facilitar la pronta incorporación de los índices de riesgo obstétrico y cardiovascular en dos etapas de la vida de una mujer. Ha llegado el momento para que los equipos obstétricos, cardiológicos y las pacientes jueguen un rol en la prevención de los riesgos y enfermedades cardiovasculares.

From 1995 onwards the association between hypertensive pregnancies and cardiovascular disease has generated a great volume of epidemiologic and clinical evidence. The purposes of this review are several. To demonstrate the consistence and weight of the scientific evidence. To integrate cardiovascular risks/diseases and obstetric complications through the link of endothelial dysfunction. To advocate postpartum follow-up after a hypertensive pregnancy as a window of opportunity to benefit the health of mothers and offsprings. To include the obstetrical history as a risk factor for coronary disease. To propose questionnaires adaptable to local practices to incorporate cardiovascular and obstetrical indexes in two stages of a woman's lifetime. The time has come for obstetrical teams, cardiologists and patients to play a preventive role regarding cardiovascular risks and diseases.