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.

Identification of factors associated with delayed treatment of obstetric hypertensive emergencies.

BACKGROUND: Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, confirmed 15 minutes apart. The American College of Obstetricians and Gynecologists recommends that acute-onset, severe hypertension be treated with first line-therapy (intravenous labetalol, intravenous hydralazine or oral nifedipine) within 60 minutes to reduce risk of maternal morbidity and death. OBJECTIVE: Our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN: A retrospective cohort study was performed that compared women who were treated appropriately within 60 minutes vs those with delay in first-line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension, or preeclampsia using International Classification of Diseases-10 codes and obstetric antihypertensive usage in a pharmacy database at 1 academic institution from January 2017 through June 2018. Of these, 267 women (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within 2 days of delivery; the results from 213 women were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon rank-sum, and sample t-tests were used to compare the 2 groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed; C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at P<.05. RESULTS: Of the 213 women, 110 (51.6%) had delayed treatment vs 103 (48.4%) who were treated within 60 minutes. Patients who had delayed treatment were 3.2 times more likely to have an initial blood pressure in the nonsevere range vs those who had timely treatment (odds ratio, 3.24; 95% confidence interval, 1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms; patients without preeclampsia symptoms were 2.7 times more likely to have delayed treatment (odds ratio, 2.68; 95% confidence interval, 1.50-4.80). Patients with hypertensive emergencies that occurred overnight between 10 pm and 6 am were 2.7 times more likely to have delayed treatment vs those emergencies that occurred between 6 am and 10 pm (odds ratio, 2.72; 95% confidence interval, 1.27-5.83). Delayed treatment also had an association with race, with white patients being 1.8 times more likely to have delayed treatment (odds ratio, 1.79; 95% confidence interval, 1.04-3.08). Patients who were treated at <60 minutes had a lower gestational age at presentation vs those with delayed treatment (34.6±5 vs 36.6±4 weeks, respectively; P<.001). For every 1-week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (odds ratio, 1.11; 95% confidence interval, 1.04-1.19). Another factor that was associated with delay of treatment was having a complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (odds ratio, 2.17; 95% confidence interval, 1.07-4.41). CONCLUSION: Initial blood pressure in the nonsevere range, absence of preeclampsia symptoms, presentation overnight, white race, having complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to a delay in the treatment of obstetric hypertensive emergency. Quality improvement initiatives that target these barriers should be instituted to improve timely treatment.

Committee Opinion No. 692 Summary: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period.

Acute-onset, severe systolic hypertension; severe diastolic hypertension; or both can occur during the prenatal, intrapartum, or postpartum periods. Pregnant women or women in the postpartum period with acute-onset, severe systolic hypertension; severe diastolic hypertension; or both require urgent antihypertensive therapy. Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes. Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency. Treatment with first-line agents should be expeditious and occur as soon as possible within 30-60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. Intravenous labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period. Although relatively less information currently exists for the use of calcium channel blockers for this clinical indication, the available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available. In the rare circumstance that intravenous bolus labetalol, hydralazine, or immediate release oral nifedipine fails to relieve acute-onset, severe hypertension and is given in successive appropriate doses, emergent consultation with an anesthesiologist, maternal-fetal medicine subspecialist, or critical care subspecialist to discuss second-line intervention is recommended.

Committee Opinion No. 692: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period.

Acute-onset, severe systolic hypertension; severe diastolic hypertension; or both can occur during the prenatal, intrapartum, or postpartum periods. Pregnant women or women in the postpartum period with acute-onset, severe systolic hypertension; severe diastolic hypertension; or both require urgent antihypertensive therapy. Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes. Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency. Treatment with first-line agents should be expeditious and occur as soon as possible within 30-60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. Intravenous labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period. Although relatively less information currently exists for the use of calcium channel blockers for this clinical indication, the available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available. In the rare circumstance that intravenous bolus labetalol, hydralazine, or immediate release oral nifedipine fails to relieve acute-onset, severe hypertension and is given in successive appropriate doses, emergent consultation with an anesthesiologist, maternal-fetal medicine subspecialist, or critical care subspecialist to discuss second-line intervention is recommended.

Burden of arrhythmias in peripartum cardiomyopathy: Analysis of 9841 hospitalizations.

BACKGROUND: Peripartum cardiomyopathy (PPCM) is associated with significant morbidity and mortality. Arrhythmogenic causes of death have been implicated in a significant number of patients. However, there is a dearth of systematic studies evaluating the burden of arrhythmias in PPCM. METHODS: We used the Healthcare Utilization Project, Nationwide Inpatient Sample database (2007-2012) and identified 9841 hospitalizations for women aged ≥18years with a primary diagnosis of PPCM. Frequency of arrhythmias, utilization of electrophysiologic procedures, length of stay, hospitalization costs and outcomes associated with arrhythmias were determined. RESULTS: Mean age was 30.05±6.69years. Arrhythmias were present in 18.7% of hospitalized PPCM cohort. Ventricular tachycardia was the most common arrhythmia and was noted in 4.2%. Approximately 2.2% of cases experienced cardiac arrest. Electrical cardioversion was performed in 0.3%, Catheter ablation in 1.9%, PPM implantation in 3.4% and ICD in 6.8% of hospitalizations for PPCM with arrhythmias. In-hospital mortality was 3-times more frequent in arrhythmia cohort (2.1% vs. 0.7%). Hospitalization costs were significantly higher in PPCM with arrhythmias. Elixhauser comorbidity score (adjusted OR:1.10; 95%CI:1.02-1.18; p=0.016), in-hospital mortality (adjusted OR:2.35; 95%CI:1.38-4.02; p=0.002), cardiogenic shock (adjusted OR:2.61; 95%CI:1.44-4.72; p=0.002), utilization of balloon pump (adjusted OR:13.4; 95%CI: 2.55-70.53; p<0.001), Swan-Ganz catheterization (adjusted OR:3.12; 95%CI:1.21-8.06; p=0.019), and coronary angiography (adjusted OR:1.79; 95%CI:1.19-2.70; p=0.005) were significantly associated with arrhythmias in PPCM. CONCLUSIONS: Arrhythmias were present in 18.7% of PPCM related hospitalizations. Morbidity, in-hospital mortality, length of inpatient stay, hospitalization costs and cardiac procedure utilization were significantly higher in the arrhythmia cohort.

Congenital Heart Disease and Reproductive Risk: An Overview for Obstetricians, Cardiologists, and Primary Care Providers.

Patients with congenital heart disease have improved survival rates, and most patients are now expected to survive into adulthood. This improved survival has resulted in increasing numbers of women with congenital heart disease who are of childbearing age. This patient population requires specialized advice on contraception and pregnancy risk. Understanding the unique challenges this population presents is key to providing appropriate care.

Peri-partum cardiomyopathy in a pregnant woman at term revealed by acute pulmonary edema: what to do in front this catastrophic situation?

Peripartum cardiomyopathy is insufficient congestive heart occurring in the last month of pregnancy and 5 months after delivery, in the absence of preexisting heart disease and identified etiology. This heart disease is associated with echocardiography systolic dysfunction and left ventricular dilatation. Its incidence ranges from 1/3000 to 1/15000, depending on the region, including much higher in some African countries, it particularly concern women over 30 years, multiparous and multiple pregnancies. The pathogenesis remains unclear, the prognosis is closely related to the complete recovery of cardiac function. We report through the clinical case of a woman aged 33 years admitted to the ICU for acute pulmonary edema of sudden onset of a term pregnancy and what to do before this critical situation.

[Magnesium orotate in treatment of chronic hypertension in pregnant women].

We examined 150 pregnant women with essential hypertension (EHT), EHT and connective tissue dysplasia (CTD), and healthy. Presence of CTD aggravated clinical picture of EHT and was associated with pronounced cardialgic, neurological, asthenic, vertebrogenic, visceral, and other syndromes. The use of antihypertensive, metabolic (magnesium orotate) drugs, sedative and uroseptic phytotherapy, application of other nondrug measures in conditions of multidisciplinary dynamic support of the gestational period facilitated regress of clinical symptoms of EHT and EHT+CTD, favorable course of pregnancy and successful delivery.

Hypotensive resuscitation combined with polydatin improve microcirculation and survival in a rabbit model of uncontrolled hemorrhagic shock in pregnancy.

BACKGROUND: Obstetric hemorrhage remains a leading cause of maternal death internationally. Polydatin is an effective drug in ameliorating microcirculatory insufficiency and increasing survival rate in non-pregnant animal model of controlled hemorrhagic shock. In the present study, we investigated the effects of hypotensive resuscitation combined with Polydatin administration on microcirculation and survival rate in a clinically relevant model of uncontrolled hemorrhagic shock in pregnancy. MATERIALS AND METHODS: Twenty anesthetized New Zealand white rabbits at mid and late gestation were anesthetized, and an ear chamber was prepared to examine microvessels by intravital microscopy. Shock was induced by transecting a small artery in mesometrium, followed by blood withdrawal via the femoral artery to a mean arterial pressure (MAP) of 40-45 mm Hg. Animals were randomly divided into two groups (n=10 per group): 30 min after hemorrhage induction, hypotensive resuscitation with Ringer's solution to MAP of 60 mm Hg, followed by a single volume infusion of 4 mL/Kg of normal saline or Polydatin at 60 min after hemorrhage induction (group NS, PD). Finally all the animals received hemorrhage control and resuscitated with half of the heparinized shed blood and Ringer's solution to MAP of 80 mm Hg. RESULTS: At the end of resuscitation, compared with group NS, group PD showed significantly improved capillary perfusion as indicated by increased arteriole diameter [0.95±0.02 of baseline (PD), 0.71±0.05 of baseline (NS); P=0.000] and higher functional capillary density[95.3% ± 2.6% (PD), 57.2% ± 4.1% (NS); P=0.000]. Median survival time was significantly longer in group PD than that in group NS [4 d (PD), 2 d (NS); P=0.000]. CONCLUSIONS: On the basis of hypotensive resuscitation, Polydatin administration improved microcirculation and prolonged survival time in pregnant rabbit model of uncontrolled hemorrhagic shock.

Hypertension in pregnancy: a comprehensive update.

Hypertensive disorders of pregnancies remain a central public health concern throughout the world, and are a major cause of maternal mortality in the developing world. Although treatment options have not significantly changed in recent years, insight on the pathogenesis of preeclampsia/eclampsia has been remarkable. With improved animal models of preeclampsia and large-scale human trials, we have embarked upon a new era where angiogenic biomarkers based on mechanism of disease can be designed to assist in early diagnosis and treatment. There is also a growing recognition of how elusive the diagnosis of eclampsia can be, especially in the postpartum period. Proper treatment of these patients depends heavily on the correct diagnosis, especially by the emergency physician. Finally, large epidemiologic studies have revealed that preeclampsia, once thought to be a self-limited entity, now appears to portend real damage to the cardiovascular and other organ systems in the long term. This review will present the latest update on our understanding of the various hypertensive disorders of pregnancies and their treatment options.

Symptomatic repetitive right ventricular outflow tract ventricular tachycardia in pregnancy and postpartum.

Idiopathic ventricular tachycardias, which occur in patients without structural heart disease, are a common entity, representing up to 10% of all ventricular tachycardias evaluated by cardiac electrophysiology services. Pregnancy can increase the incidence of various cardiac arrhythmias. Factors that can potentially promote arrhythmias in pregnancy include the effects of hormones, changes in autonomic tone, hemodynamic perturbations, hypokalemia, and underlying heart disease. Ventricular arrhythmias in pregnancy are repetitive monomorphic ventricular premature complexes and couplets that frequently originate at the right ventricular outflow tract. New onset symptomatic repetitive right ventricular outflow tract ventricular tachycardia during pregnancy has been inadequately reported in the literature. We present a case of symptomatic repetitive right ventricular outflow tract tachycardia that started during pregnancy and continued in the postpartum period, requiring curative treatment with electrophysiology study and radiofrequency ablation.

Volume manipulation by phlebotomy for cesarean section in a patient with pulmonary hypertension.

Pulmonary hypertension in a parturient is known for its high perioperative mortality. We describe a successful case of cesarean section performed under general anesthesia in a parturient with pulmonary hypertension. A distinctive feature of our management was active blood volume manipulation by phlebotomy and reinfusion of the blood. Just after the baby was delivered, about 250 ml of blood was phlebotomized to counteract autotransfusion by the contracting uterus. We stopped phlebotomy at this volume because moderate systemic hypotension occurred. The blood was slowly infused, with transesophageal echocardiography used to evaluate right ventricle filling. The patient was hemodynamically stable during the operation and had an uneventful postpartum period. Her baby's perioperative course was also uneventful.

More reasons why men and women are not the same (gender differences in electrophysiology and arrhythmias).

It has become increasingly apparent in recent years that there are important differences in the presentation and clinical course of many cardiovascular disorders in men and women. These gender differences extend to clinical cardiac electrophysiology, with respect to basic electrophysiology as well as the presentation and clinical courses of many arrhythmias. Women have been noted to have higher heart rates at rest and longer corrected QT intervals compared with men. Differences in gender hormones may explain some of these findings, but precisely how is still not well understood. Differences have also been documented in the incidence and prevalence of specific arrhythmias, including atrial fibrillation, other supraventricular tachycardias, and sudden cardiac death. Variations in arrhythmia frequency with respect to the menstrual cycle have been observed. In addition, an increase in arrhythmia frequency or the new onset of arrhythmias has been noted during pregnancy. With the increasing use of implantable cardioverter defibrillators and cardiac resynchronization therapy, it has been shown that men and women derive equal survival and symptom reduction benefit. However, it has been found that the use of these devices in women is much lower than would be expected from the prevalence of disease in the population. The reasons for this lower utilization rate are not well understood and remain to be explored. In conclusion, the goal of this review is to summarize the currently available published reports regarding gender differences in cardiac electrophysiology and arrhythmias and to provide an update from recent studies.

Effects of L-arginine oral supplements in pregnant spontaneously hypertensive rats

OBJETIVO: Avaliar os efeitos da oferta oral de L-arginina em ratas prenhas espontaneamente hipertensivas (SHR).MÉTODOS: 30 SHR e 10 Wistar-EPM-1 ratas virgens foram utilizadas no estudo. Antes da distribuição, as fêmeas foram acasaladas com machos da mesma linhagem (3:1); a prenhez foi confirmada pela presença de espermatozóides no esfregaço vaginal. As ratas Wistar-EPM-1 foram utilizadas como controles. As ratas SHR foram aleatoriamente distribuídas em 4 grupos (n=10): Grupo Controle-2, não-tratado; Grupo L-Arginina, tratado com L-arginina; Grupo Alfa-metildopa, tratado com alfa-metildopa; Grupo L-Arginina+Alfa-metildopa, tratado com arginina+Alfa-metildopa. L-arginina (2%) foi oferecida ad libitum na água de beber e a Alfa-metildopa (33 mg/Kg) foi administrada por gavagem, duas vezes ao dia, durante toda a prenhez (20 dias). Aferição da pressão arterial (PA) foi realizada por pletismografia da cauda, nos dias 0 e 20 e dos pesos nos dias 0-10-20. Resultados foram expressos como média±DP (Desvio Padrão). Testes estatísticos apropriados (ANOVA unidirecional/Tukey ou Kruskal-Walli/Dunn) foram utilizados para comparações intergrupais. P<0,05 foi considerado significante.RESULTADOS: Não houve ganho de peso significante nas ratas tratadas com L-arginina. A PA média diminuiu no Grupo L-Arginina comparado ao Grupo Controle-2. CONCLUSÃO: A oferta oral de L-arginina reduz a PA em ratas SBP durante a prenhez.

Effects of L-arginine oral supplements in pregnant spontaneously hypertensive rats.

PURPOSE: To evaluate the effects of L-arginine oral supplementation in spontaneously hypertensive pregnant rats (SHR). METHODS: Thirty SHR and ten Wistar-EPM-1 virgin female rats were used in the study. Before randomization, females were caged with males of the same strain (3:1). Pregnancy was confirmed by sperm-positive vaginal smear (Day 0). Wistar-EPM-1 rats served as counterpart control (C-1). SHR rats were randomized in 4 groups (n=10): Group Control 2, non-treated rats; Group L-Arginine treated with L-arginine 2%; Group Alpha-methyldopa treated with Alpha-methyldopa 33 mg/Kg; Group L-Arginine+Alpha-methyldopa treated with L-arginine 2%+Alpha-methyldopa 33 mg/Kg. L-arginine 2% solution was offered ad libitum in drinking water and Alpha-methyldopa was administered by gavage twice a day during the length of pregnancy (20 days). Blood pressure was measured by tail-cuff plethysmography on days 0 and 20. Body weight was measured on days 0, 10 and 20. Results were expressed as mean +/-SD (Standard Deviation). One-Way ANOVA/Tukey (or Kruskal-Wallis/Dunn, as appropriate) was used for group comparisons. Statistical significance was accepted as p<0.05. RESULTS: There was no significant weight gain in isolated L-arginine treated SHR. Mean blood pressure decreased in L-arginine-treated SLR compared with untreated-SHR rats. CONCLUSION: L-arginine oral supplementation reduces blood pressure in spontaneously hypertensive rats during pregnancy.

Folate supplementation during pregnancy improves offspring cardiovascular dysfunction induced by protein restriction.

Dietary protein restriction in the rat compromises the maternal cardiovascular adaptations to pregnancy and leads to raised blood pressure and endothelial dysfunction in the offspring. In this study we have hypothesized that dietary folate supplementation of the low-protein diet will improve maternal vascular function and also restore offspring cardiovascular function. Pregnant Wistar rats were fed either a control (18% casein) or protein-restricted (9% casein) diet +/-5 mg/kg folate supplement. Function of isolated maternal uterine artery and small mesenteric arteries from adult male offspring was assessed, systolic blood pressure recorded, and offspring thoracic aorta levels of endothelial nitric oxide (NO) synthase mRNA measured. In the uterine artery of late pregnancy dams, vasodilatation to vascular endothelial growth factor was attenuated in the protein-restricted group but restored with folate supplementation, as was isoprenaline-induced vasodilatation (P<0.05). In male offspring, protein restriction during pregnancy led to raised systolic blood pressure (P<0.01), impaired acetylcholine-induced vasodilatation (P<0.01), and reduced levels of endothelial NO synthase mRNA (P<0.05). Maternal folate supplementation during pregnancy prevented this elevated systolic blood pressure associated with a protein restriction diet. With folate supplementation, endothelium-dependent vasodilatation and endothelial NO synthase mRNA levels were not significantly different from either the control or protein-restricted groups. Maternal folate supplementation of the control diet had no effect on blood pressure or vasodilatation. This study supports the hypothesis that folate status in pregnancy can influence fetal development and, thus, the risks of cardiovascular disease in the next generation. The concept of developmental origins of adult disease focuses predominately on fetal life but must also include a role for maternal cardiovascular function.