Blood Pressure Trajectories Through the First Year Postpartum in Overweight or Obese Individuals Following a Hypertensive Disorder of Pregnancy.

BACKGROUND: Hypertensive disorders of pregnancy are associated with cardiovascular disease; however, patterns of blood pressure (BP) recovery are understudied. We compared pregnancy and postpartum BP trajectories among individuals with hypertensive disorders of pregnancy who developed persistent hypertension at 1-year postpartum compared with individuals with normalization of BP. METHODS: We used data from a randomized clinical trial of individuals with overweight, obesity, and hypertensive disorders of pregnancy conducted in the first year after delivery. Pregnancy BPs were obtained during prenatal visits; postpartum BPs were prospectively obtained through home monitoring. Demographic characteristics and trajectories were compared by hypertensive status (systolic BP ≥130 mm Hg, diastolic BP ≥80 mm Hg, or use of antihypertensive medications) at 1 year. We used repeated BP measures to fit separate mixed-effects linear regression models for pregnancy and postpartum using restricted cubic splines. RESULTS: We included 129 individuals; 75 (58%) individuals progressed to hypertension by 1-year postpartum. Individuals with hypertension were older, delivered at earlier gestational ages, and had higher body mass index at 1-year postpartum compared with those with normalization. Individuals with hypertension had similar BP trajectories during pregnancy to those with BP normalization but a significantly different BP trajectory (P<0.01 for systolic and diastolic BPs) in the first year postpartum. These differences persisted in multivariable models after adjustment for early pregnancy body mass index, age, and severity of hypertensive disorder of pregnancy (P<0.01 for systolic and diastolic BPs). CONCLUSIONS: BP trajectories in the first year postpartum, but not during pregnancy, may provide important information for risk stratification after a hypertensive disorder of pregnancy. REGISTRATION: URL: https://clinicaltrials.gov; Unique identifier: NCT03749746.

Peripartum Lipid Apheresis: Novel Management of Familial Hyperlipidemia in Pregnancy.

Familial hypercholesterolemia (FH) is a genetic lipid disorder associated with early-onset severe cardiovascular disease. Many FH therapeutics have not been studied in pregnancy, and management of patients with FH through pregnancy is limited. We present a patient with FH who was safely treated through pregnancy with combination therapy.

A longitudinal epigenome-wide association study of preeclamptic and normotensive pregnancy.

Background: While preeclampsia (PE) is a leading cause of pregnancy-related morbidity/mortality, its underlying mechanisms are not fully understood. DNA methylation (DNAm) is a dynamic regulator of gene expression that may offer insight into PE pathophysiology and/or serve as a biomarker (e.g., risk, subtype, a therapeutic response). This study's purpose was to evaluate for differences in blood-based DNAm across all trimesters between individuals eventually diagnosed with PE (cases) and individuals who remained normotensive throughout pregnancy, did not develop proteinuria, and birthed a normally grown infant (controls). Results: In the discovery phase, longitudinal, genome-wide DNAm data were generated across three trimesters of pregnancy in 56 participants (n=28 cases, n=28 controls) individually matched on self-identified race, pre-pregnancy body mass index, smoking, and gestational age at sample collection. An epigenome-wide association study (EWAS) was conducted, using surrogate variable analysis to account for unwanted sources of variation. No CpGs met the genome-wide significance p value threshold of 9×10-8, but 16 CpGs (trimester 1: 5; trimester 2: 1; trimester 3: 10) met the suggestive significance threshold of 1×10-5. DNAm data were also evaluated for differentially methylated regions (DMRs) by PE status. Three DMRs in each trimester were significant after Bonferonni-adjustment. Since only third-trimester samples were available from an independent replication sample (n=64 cases, n=50 controls), the top suggestive hits from trimester 3 (cg16155413 and cg21882990 associated with TRAF3IP2-AS1/TRAF3IP2 genes, which also made up the top DMR) were carried forward for replication. During replication, DNAm data were also generated for validation purposes from discovery phase third trimester samples. While significant associations between DNAm and PE status were observed at both sites in the validation sample, no associations between DNAm and PE status were observed in the independent replication sample. Conclusions: The discovery phase findings for cg16155413/cg21882990 (TRAF3IP2-AS1/TRAF3IP2) were validated with a new platform but were not replicated in an independent sample. Given the differences in participant characteristics between the discovery and replication samples, we cannot rule out important signals for these CpGs. Additional research is warranted for cg16155413/cg21882990, as well as top hits in trimesters 1-2 and significant DMRs that were not examined in the replication phase.

Maternal and Neonatal Outcomes of Pregnancy within 7 years after Roux-Y Gastric Bypass or Sleeve Gastrectomy Surgery.

PURPOSE: Few studies examine whether maternal and neonatal outcomes differ by time from metabolic and bariatric surgery (MBS) to conception. We describe maternal and neonatal outcomes among women with pregnancy after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) overall and by whether conception occurred during the period when pregnancy is not recommended (< 18 months postoperative) versus later. MATERIALS AND METHODS: A prospective cohort study enrolled 135 US adult women (median age, 30 years, body mass index [BMI], 47.2 kg/m2) who underwent RYGB or SG (2006-2009) and subsequently reported ≥ 1 pregnancy within 7 years. Participants self-reported pregnancy-related information annually. Differences in prevalence of maternal and neonatal outcomes by postoperative conception timeframe (< 18 versus ≥ 18 months) were assessed. RESULTS: Thirty-one women reported ≥ 2 postoperative pregnancies. At time of postoperative conception (median 26 [IQR:22-52] months postoperative) median BMI was 31 (IQR:27-36) kg/m2. Excessive gestational weight gain (55%), cesarean section (42%) and preterm labor or rupture of membranes (40%) were the most common maternal outcomes. Forty percent of neonates had a composite outcome of still birth (1%), preterm birth (26%), small for gestational age (11%), or neonatal intensive care unit admission (8%). Prevalence of outcomes did not statistically significantly differ by timeframe. CONCLUSION: In US women who conceived ≤ 7 years following RYGB or SG, 40% of neonates had the composite neonatal outcome. The prevalence of maternal and neonatal outcomes post-MBS were not statistically significant by conception timeframe.

Longitudinal cognitive evaluation before and after delivery among people with preeclampsia.

BACKGROUND: Cognitive impairments related to preeclampsia after pregnancy have been reported; however, it is not known if weaknesses in cognition occur before and shortly after delivery. OBJECTIVE: This study aimed to assess the feasibility of longitudinal cognitive testing before and after delivery, and to investigate whether those with preeclampsia have cognitive weaknesses during the third trimester of pregnancy and at 1 and 3 months postpartum. We hypothesized that people with preeclampsia would have lower cognition scores across all time points compared with normotensive people. STUDY DESIGN: This longitudinal, prospective, observational study in a single institution enrolled people (N=30) at ≥28 weeks of gestation with preeclampsia (N=16) or normotension (N=14). People with chronic hypertension, neurologic or developmental disabilities, moderate or severe depression or anxiety, or current substance use were excluded. Subjective (Everyday Cognition Scale) and objective assessment of executive function (Stroop Color-Word Interference Test, Trail-Making Test), attention and working memory (Digit Span subtest), and information processing speed (Digit Symbol Substitution Test) was conducted, and Z-scores were calculated. Baseline characteristics (eg, prepregnancy body mass index) were collected from the medical record. Generalized linear models were used to estimate associations. RESULTS: We enrolled 37% (30/81) of eligible people and retained 80% (24/30) and 53% (16/30) at 1 and 3 months postpartum, respectively. People with preeclampsia reported more memory problems (ß=0.87; 95% confidence interval, 0.44-1.31), and scored worse on attention and working memory (ß=-0.94; 95% confidence interval, -1.42 to -0.45) and executive function (Stroop test ß=-0.86; 95% confidence interval, -1.53 to -0.19) domains compared with normotensive people after adjusting for time, age, education, and prepregnancy body mass index. CONCLUSION: Longitudinal assessment of cognition in pregnant preeclamptic and normotensive people is feasible. People with preeclampsia reported worse subjective memory and had lower scores in attention, working memory, and executive function.

A Case Series of Parturients With Mechanical Mitral Valves: Anticoagulation Management During Labor and Delivery.

More women with mechanical mitral valves (MMVs) are pursuing pregnancy. Guidelines exist for pregnancy anticoagulation, but they do not address individualized anticoagulation during delivery-a period of risk for bleeding, thrombosis, and anesthetic complications. This case series of parturients with MMVs highlights the challenges in, and the evidence and strategies for, treating these patients. (Level of Difficulty: Advanced.).

Postpartum home blood pressure monitoring and lifestyle intervention in overweight and obese individuals the first year after gestational hypertension or pre-eclampsia: A pilot feasibility trial.

OBJECTIVE: To test the feasibility of a randomised trial of home blood pressure monitoring paired with a remote lifestyle intervention (Heart Health 4 New Moms) versus home blood pressure monitoring alone versus control in individuals with a hypertensive disorder of pregnancy in the first year postpartum. DESIGN: Single-blinded three-arm randomised clinical trial. SETTING: Two tertiary care hospitals and a community organisation. POPULATION: Postpartum overweight and obese individuals with a hypertensive disorder of pregnancy and without pre-pregnancy hypertension or diabetes. METHODS: We assessed the feasibility of recruitment and retention of 150 participants to study completion at 1-year postpartum with randomisation 1:1:1 into each arm. Secondary aims were to test effects of the interventions on weight, blood pressure and self-efficacy. RESULTS: Over 23 months, we enrolled 148 of 400 eligible, screened individuals (37%); 28% black or other race and mean pre-pregnancy body mass index (BMI) of 33.4 ± 6.7 kg/m2 . In total, 129 (87%) participants completed the 1-year postpartum study visit. Overall, 22% of participants developed stage 2 hypertension (≥140/90 mmHg or on anti-hypertensive medications) by 1 year postpartum. There were no differences in weight or self-efficacy across the study arms. CONCLUSION: In this pilot, randomised trial, we demonstrate feasibility of HBPM paired with a lifestyle intervention in the first year postpartum. We detected high rates of ongoing hypertension, emphasising the need for the development of effective interventions in this population.

Feasibility of Utilizing Telehealth in a Multidisciplinary Postpartum Hypertension Clinic.

Introduction: Remote delivery of care improves outcomes following hypertensive disorders of pregnancy, but little is known about the implementation of a multidisciplinary clinic in the virtual space. In this study, we developed a multidisciplinary postpartum hypertension clinic with a telehealth component run jointly with Maternal-Fetal Medicine and Cardiology. Materials and Methods: Women were referred from Cardiology and Obstetrics providers or through our postpartum remote blood pressure (BP) program and were offered the option of an in-person or telemedicine visit. For virtual visits, BP was recorded by home measurement. We compared clinical and demographic characteristics by visit type (virtual vs. in-person). Results: Of 175 patients scheduled (2019-2021), 140 attended visits (80% show rate) a mean of 11 weeks postpartum, with 92 (65.7%) seen virtually and 48 (34.2%) seen in-person. Clinical and demographic factors, including self-reported race and insurance type, did not differ between women seen virtually versus in-person. Overall, 97 (69.3%) of women were still on antihypertensive agents at the time of their visit with 33 (34.0%) on more than one antihypertensive agent, which did not differ by visit type. Women who were seen virtually lived a farther distance from the clinic (median 11.6 [interquartile range; IQR 7.7, 30.8] vs. median 7.9 [IQR 5.8, 21.1] miles; p = 0.02). Conclusions: Implementation of a multidisciplinary postpartum hypertension clinic in the virtual space is feasible, targets women at high risk for persistently elevated postpartum BP, and maintains equal attendance compared with in-person visits. Virtual visits deliver care equitably across different racial and socioeconomic groups and may improve access to care in rural areas.

Implementation of a universal postpartum blood pressure monitoring program: feasibility and outcomes.

BACKGROUND: New-onset postpartum preeclampsia has a higher risk of maternal morbidity and mortality than preeclampsia with antepartum onset, underscoring the need for earlier identification of elevated blood pressure among patients with this condition. Given the decrease in healthcare engagement, which is typical of the postpartum period, new-onset postpartum hypertension often goes unrecognized. Currently, there are no recommendations for universal postpartum blood pressure surveillance in women without hypertensive disorders of pregnancy. With the shift to telemedicine because of the COVID-19 pandemic, our institution's approach was to distribute blood pressure cuffs to women receiving any portion of their prenatal care virtually, thus also providing access to an opportunity for blood pressure measurement during the postpartum period for all women. OBJECTIVE: To explore the feasibility of a patient-driven universal postpartum home blood pressure monitoring program in women without a previous diagnosis of a hypertensive disorder. STUDY DESIGN: This was a prospective observational study of all postpartum women who were discharged from our institution from July 2020 through June 2021 and who were not previously identified to have hypertension. A clinical algorithm was developed and followed. All the women received discharge educational materials and were called at a 1-week interval by a nurse to review blood pressure and preeclampsia symptoms. The maternal demographics and delivery outcomes were recorded. RESULTS: Of the 10,092 deliveries during the study period, 5959 (59%) were successfully contacted. 352 were excluded, as they did not deliver at the primary hospital; 1052 (18%) had a previous hypertensive disorder of pregnancy diagnosis; 1522 (26%) did not have a blood pressure cuff; and 1841 (31%) planned to take their blood pressure at a later time. Precautions and blood pressure parameters were given to this last group. Of the remaining 1192, 222 (19%) had an initial elevated blood pressure. Of these, 98 had a second elevated blood pressure on recheck; 17 were referred to the emergency room for evaluation, with 8 being diagnosed with severe preeclampsia; and the remainder were recommended to follow with their obstetrical provider and enrolled in our institution's remote blood pressure management program. Of the 1192 women, 8% potentially had a new diagnosis of a hypertensive disorder of pregnancy, with 0.7% having severe hypertension. Women with elevated blood pressures were more likely to be of non-Hispanic Black race and have a higher early pregnancy body mass index than those without elevated blood pressures. CONCLUSION: Our study indicates that a patient-driven postpartum blood pressure monitoring program is feasible and may be incorporated using existing resources. In addition, our findings suggest that the incidence of new-onset postpartum hypertensive disorders of pregnancy may be higher than previously assessed in retrospective cohorts. Thus, there may be a role for closer surveillance of all women with patient-driven home blood pressure monitoring, particularly those with risk factors or in the setting of limited resources.

Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy.

High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.

An exploratory study of white blood cell proportions across preeclamptic and normotensive pregnancy by self-identified race in individuals with overweight or obesity.

Objective: Examine white blood cell (WBC) proportions across preeclamptic (n = 28 cases) and normotensive (n = 28 controls) pregnancy in individuals with overweight/obesity.Methods: WBC proportions were inferred from genome-wide DNA methylation data and compared by case/control status and self-identified race.Results: In Trimester 1, ean B cell proportions were suggestively lower in cases in the overall sample and significantly lower in White participants but not in Black participants. More significant WBC proportion changes were observed across normotensive than preeclamptic pregnancy.Conclusions: These findings in a small sample demonstrate need for additional studies investigating the relationship between self-identified race and WBCs in pregnancy.

An Exploratory Study of Epigenetic Age in Preeclamptic and Normotensive Pregnancy Reveals Differences by Self-Reported Race but Not Pregnancy Outcome.

Preeclampsia is a leading cause of maternal and neonatal morbidity and mortality. Chronological age and race are associated with preeclampsia, but the role of these factors is not entirely understood. We hypothesized that DNA methylation age, a measure of biological age, would be higher in individuals with preeclampsia than in individuals with normotensive pregnancy and that DNA methylation age would differ by race across pregnancy. This was a longitudinal, exploratory study of 56 pregnant individuals (n = 28 preeclampsia cases and n = 28 normotensive controls). Genome-wide DNA methylation data were generated from trimester-specific peripheral blood samples. DNA methylation age was estimated using the "Improved Precision" clock, and ∆age, the difference between DNA methylation age and chronological age, was computed. DNA methylation age was compared with chronological age using Pearson correlations. The relationships between ∆age and preeclampsia status, self-reported race, and covariates were tested using multiple linear regression and performed both with and without consideration of cell-type heterogeneity. We observed strong correlation between chronological age and DNA methylation age across pregnancy, with significantly stronger correlation observed in White participants than in Black participants. We observed no association between ∆age and preeclampsia status. However, ∆age was higher in participants with higher pre-pregnancy body mass index in trimester 1 and lower in Black participants than in White participants in trimesters 2 and 3. Observations were largely consistent when controlling for cell-type heterogeneity. Our findings in a small sample support the need for additional studies to investigate the relationship between race and biological age, which could provide further insight into racial disparities across pregnancy. However, this study does not support an association between ∆age and preeclampsia status.

Objectively Measured Sedentary Behavior and Physical Activity Across 3 Trimesters of Pregnancy: The Monitoring Movement and Health Study.

BACKGROUND: Though moderate- to vigorous-intensity physical activity is recommended, limited research exists on sedentary behavior (SED) during pregnancy. METHODS: The authors conducted a prospective cohort study to describe objectively measured patterns of SED and activity during each trimester of pregnancy. Women wore thigh- (activPAL3) and waist-mounted (ActiGraph GT3X) activity monitors. SED and activity were compared across trimesters using likelihood ratio tests and described using group-based trajectories. Exploratory analyses associated SED and activity trajectories with adverse pregnancy outcomes and excessive gestational weight gain. RESULTS: Pregnant women (n = 105; mean [SD] age = 31 [5] y; prepregnancy body mass index = 26.2 [6.6] kg/m2) had mean SED of 9.7, 9.5, and 9.5 hours per day (P = .062) across trimesters, respectively. Some activities differed across trimesters: standing (increased, P = .01), stepping (highest in second trimester, P = .04), steps per day (highest in second trimester, P = .008), and moderate- to vigorous-intensity physical activity (decreased, P < .001). Prolonged SED (bouts ≥ 30 min) and bouted moderate- to vigorous-intensity physical activity (≥10 min) were stable (P > .05). In exploratory analyses, higher SED and lower standing, stepping, and steps per day trajectories were associated with increased odds of adverse pregnancy outcomes (P < .05). No trajectories were associated with excessive gestational weight gain. CONCLUSIONS: Pregnant women exhibited stable SED of nearly 10 hours per day across pregnancy. Future research evaluating SED across pregnancy and adverse pregnancy outcome risk is warranted.

Sedentary behaviour and physical activity across pregnancy and birth outcomes.

BACKGROUND: Shorter gestation or smaller birth size are indicators of a suboptimal fetal environment and negatively impact short- and long-term offspring health. Understanding how modifiable maternal behaviours, such as moderate-to-vigorous intensity physical activity (MVPA) or sedentary behaviour (SED), improve fetal outcomes could inform strategies to improve health across the lifespan. OBJECTIVES: The objective of this study was to examine the association of MVPA and SED across pregnancy trimesters on gestational age at delivery and newborn anthropometrics. METHODS: The MoM Health Study measured SED (thigh-mounted activPAL3 micro) and MVPA (waist-worn Actigraph GTX3) in each trimester of pregnancy. Birth outcomes (gestational age at delivery, birthweight, birth length, and head circumference) were abstracted from medical records and used to calculate ponderal index (grams*100/cm3 ) and size-for-gestational age percentiles. Associations of group-based trajectories and trimester-specific SED and MVPA with birth outcomes were analysed using regression models. RESULTS: Low, medium, and high trajectory groups were generated SED and MVPA in 103 and 99 pregnant women, respectively. High vs low SED trajectory was associated with earlier gestational age at delivery (ß -1.03 weeks, 95% CI -2.01, -0.06), larger head circumference (ß 0.83 cm, 95% CI 0.24, 1.63), longer birth length (ß 1.37 cm, 95% CI 0.09, 2.64), and lower ponderal index (ß -0.24 g*100/cm3 , 95% CI -0.42, -0.06), after adjustment for demographics, pre-pregnancy BMI, and (for newborn anthropometric outcomes) gestational age. The association of high SED with lower ponderal index was the most robust across progressively adjusted models (ß -0.25 g*100/cm3 , 95% CI -0.44, -0.07). SED trajectory was not associated with birthweight or size-for-gestational age. High vs low MVPA trajectory was only associated with smaller head circumference (ß -0.86 cm, 95% CI -1.70, -0.02). CONCLUSIONS: Higher SED during pregnancy may result in shorter gestation and inhibited fetal growth. Further research evaluating the effect of reducing SED during pregnancy on birth outcomes is warranted.

DNA Methylation of Endoglin Pathway Genes in Pregnant Women With and Without Preeclampsia.

OBJECTIVE: We compared blood-based DNA methylation levels of endoglin (ENG) and transforming growth factor beta receptor 2 (TGFßR2) gene promoter regions between women with clinically-overt preeclampsia and women with uncomplicated, normotensive pregnancies. METHODS: We used EpiTect Methyl II PCR Assays to evaluate DNA methylation of CpG islands located in promoter regions of ENG (CpG Island 114642) and TGFßR2 (CpG Island 110111). Preeclampsia was diagnosed based on blood pressure, protein, and uric acid criteria. N = 21 nulliparous preeclampsia case participants were 1:1 frequency matched to N = 21 nulliparous normotensive control participants on gestational age at sample collection (±2 weeks), smoking status, and labor status at sample collection. Methylation values were compared between case and control participant groups [(ENG subset: n = 20 (9 cases, 11 controls); TGFßR2 subset: n = 28 (15 cases, 13 controls)]. RESULTS: The majority of the preeclampsia cases delivered at ⩾34 weeks' gestation (83%). Average methylation levels for ENG ([M ± (SD)]; Case Participant Group = 6.54% ± 4.57 versus Control Participant group = 4.81% ± 5.08; P = .102) and TGFßR2 (Case Participant Group = 1.50% ± 1.37 vs Control Participant Group = 1.70% ± 1.40; P = .695) promoter CpG islands did not differ significantly between the participant groups. Removal of 2 extreme outliers in the ENG analytic subset revealed a trend between levels of ENG methylation and pregnancy outcome (Case Participant Group = 5.17% ± 2.16 vs Control Participant Group = 3.36% ± 1.73; P = .062). CONCLUSION: Additional epigenetic studies that include larger sample sizes, investigate preeclampsia subtypes, and capture methylation status of CpG island shores and shelves are needed to further inform us of the potential role that ENG and TGFßR2 DNA methylation plays in preeclampsia pathophysiology.

Circulating pregnancy hormone relaxin as a first trimester biomarker for preeclampsia.

OBJECTIVE: Preeclampsia, a multi-system hypertensive disorder, is associated with perturbations in the maternal cardiovascular system during early pregnancy. The corpus luteal hormone relaxin, a potent vasodilator, may contribute to physiological circulatory changes especially in early gestation when circulating levels are highest. This study investigated whether first trimester circulating relaxin may be a suitable biomarker for the early prediction of preeclampsia. METHODS: Relaxin was initially measured in first-trimester samples of women who developed late-onset preeclamptic (LO-PE; delivery ≥ 34 weeks; n = 33) and uncomplicated pregnancies (n = 25) in Pittsburgh, USA. Subsequently, to expand the group numbers, relaxin was measured in women who developed LO-PE (n = 95), early-onset preeclamptic (EO-PE; delivery < 34 weeks; n = 57), and uncomplicated pregnancies (n = 469) in Utrecht, the Netherlands. RESULTS: In the Pittsburgh subjects, low relaxin levels (lowest centile:

Primary Presentation of Pulmonary Hypertension in the Peripartum: Preparing for Patients With Eisenmenger Physiology.

A Bosnian woman at 20 weeks' gestation presented with dyspnea and hypoxia. She was diagnosed with Eisenmenger physiology with severe pulmonary hypertension, ventricular septal defect, and patent ductus arteriosus. Given high maternal mortality, coordination of care with a multidisciplinary team approach may allow for best possible outcomes. (Level of Difficulty: Intermediate.).

Clinical Course, Associated Factors, and Blood Pressure Profile of Delayed-Onset Postpartum Preeclampsia.

OBJECTIVE: To identify clinical risk factors associated with development of delayed-onset postpartum preeclampsia, and to characterize management and subsequent risk of cardiovascular disease. METHODS: This is a case-control study of women admitted to the hospital with delayed-onset postpartum preeclampsia (defined as a new diagnosis of preeclampsia presenting between 48 hours and 6 weeks postpartum) compared with women with full-term, uncomplicated pregnancies without a hypertensive diagnosis or diabetes. Included women delivered between January 2014 and June 2018 at a single tertiary care center. Women with an antenatal diagnosis of preeclampsia or chronic hypertension were excluded. Univariate analysis was used to identify risk factors associated with delayed-onset postpartum preeclampsia and to compare rates of hypertension and antihypertensive medication use, with follow-up beyond 3 months postpartum among a subset of women in the control group who were matched 2:1 with women in the case group. Multivariable logistic regression was performed and included covariates identified in a backward stepwise approach. RESULTS: Compared with women in the control group (n=26,936), women with delayed-onset postpartum preeclampsia (n=121) were significantly more likely to be of non-Hispanic black race (31.4% vs 18.0%), obese (39.7% vs 20.1%), and deliver by cesarean (40.5% vs 25.8%), all P<.01. For women diagnosed with delayed-onset postpartum preeclampsia, the median postpartum day of presentation was 7.0 (interquartile range 5.0-9.0), with 93.4% presenting secondary to symptoms, which was most commonly a headache. A majority (73.6%) underwent imaging studies, and 49.6% received intravenous antihypertensive agents. A total of 86 (71.0%) women with delayed-onset postpartum preeclampsia and 169 (72.8%) women in the control group had longer term information available, with a median follow-up time of 1.5 years (interquartile range 0.8-2.8). Delayed-onset postpartum preeclampsia was associated with higher blood pressures at 3 months postpartum or later (median systolic 130 mm Hg vs 112 mm Hg and median diastolic 80 mm Hg vs 70 mm Hg, P<.001). CONCLUSION: Delayed-onset postpartum preeclampsia is associated with variable management strategies. There is substantial overlap between the clinical risk factors for delayed-onset postpartum preeclampsia and antepartum preeclampsia. Our findings suggest that delayed-onset postpartum preeclampsia is also associated with an increased risk of progression to chronic hypertension.

Breastfeeding, Cellular Immune Activation, and Myocardial Recovery in Peripartum Cardiomyopathy.

The etiology of peripartum cardiomyopathy remains unknown. One hypothesis is that an increase in the 16-kDa form of prolactin is pathogenic and suggests that breastfeeding may worsen peripartum cardiomyopathy by increasing prolactin, while bromocriptine, which blocks prolactin release, may be therapeutic. An autoimmune etiology has also been proposed. The authors investigated the impact of breastfeeding on cellular immunity and myocardial recovery for women with peripartum cardiomyopathy in the IPAC (Investigations in Pregnancy Associated Cardiomyopathy) study. Women who breastfed had elevated prolactin, and prolactin levels correlated with elevations in CD8+ T cells. However, despite elevated prolactin and cytotoxic T cell subsets, myocardial recovery was not impaired in breastfeeding women.