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1.
Ultrasound Obstet Gynecol ; 57(5): 739-747, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33294998

RESUMO

OBJECTIVES: First, to examine the factors from maternal characteristics and medical history that affect maternal cardiovascular indices, and, second, to examine the potential value of maternal cardiovascular indices at 19-23 weeks' gestation, on their own and in combination with maternal factors and the established biomarkers of pre-eclampsia (PE), including uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1), in the prediction of subsequent development of PE. METHODS: This was a prospective observational study in women attending for a routine hospital visit at 19 + 1 to 23 + 3 weeks' gestation. This visit included recording of maternal demographic characteristics and medical history, assessment of maternal E/A ratio, E/e' ratio, myocardial performance index, global longitudinal systolic strain, left ventricular ejection fraction, peripheral vascular resistance, left ventricular cardiac output and left ventricular mass indexed for body surface area, and measurement of MAP, UtA-PI, serum PlGF and serum sFlt-1. The measurements of the eight maternal cardiac indices were standardized to remove the effects of maternal characteristics and elements from the medical history. The competing-risks model was used to estimate the individual patient-specific risks of delivery with PE and determine the detection rate, at a 10% false-positive rate, in screening by a combination of maternal demographic characteristics and medical history with biomarkers. RESULTS: The study population of 2853 pregnancies contained 76 (2.7%) that developed PE. In pregnancies that subsequently developed PE, there was evidence of altered cardiac geometry, impaired myocardial function and increased peripheral vascular resistance. All maternal cardiovascular indices were affected significantly by maternal demographic characteristics and elements of medical history known to be associated with an increased risk for subsequent development of PE. After adjustment for maternal demographic characteristics and medical history, the only cardiovascular index that was affected significantly by subsequent development of PE was peripheral vascular resistance. Peripheral vascular resistance multiples of the median (MoM) was correlated with MAP MoM, which is not surprising because blood pressure is involved in the estimation of both. There were weak correlations between several cardiovascular indices and MAP MoM, but none was correlated with MoM values of UtA-PI, PlGF or sFlt-1. The performance of screening for delivery with PE at < 37 weeks' gestation or delivery with PE at any gestational age in screening by maternal demographic characteristics and medical history or combinations of maternal factors with MAP, UtA-PI, PlGF and sFlt-1 was not improved by the addition of peripheral vascular resistance. CONCLUSION: Assessment of maternal cardiovascular function provides information on the pathophysiology of PE but is not useful in the prediction of PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.


Assuntos
Testes de Função Cardíaca/estatística & dados numéricos , Pré-Eclâmpsia/diagnóstico , Segundo Trimestre da Gravidez , Diagnóstico Pré-Natal/estatística & dados numéricos , Adulto , Pressão Arterial , Biomarcadores/análise , Feminino , Idade Gestacional , Testes de Função Cardíaca/métodos , Humanos , Fator de Crescimento Placentário/sangue , Valor Preditivo dos Testes , Gravidez , Diagnóstico Pré-Natal/métodos , Estudos Prospectivos , Fluxo Pulsátil , Artéria Uterina/diagnóstico por imagem , Artéria Uterina/fisiopatologia , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangue
2.
Ultrasound Obstet Gynecol ; 57(3): 417-422, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33098138

RESUMO

OBJECTIVE: To compare fetal cardiac morphology and function between pregnancies that subsequently developed pre-eclampsia (PE) and those that remained normotensive. METHODS: This was a prospective observational study in 1574 pregnancies at 35-37 weeks' gestation, including 76 that subsequently developed PE. We carried out comprehensive assessment of fetal cardiac morphology and function including novel imaging modalities, such as speckle-tracking echocardiography, and measured uterine artery pulsatility index, mean arterial pressure (MAP), serum placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and cerebroplacental ratio (CPR). The findings in the group that subsequently developed PE were compared to those in pregnancies that remained normotensive. RESULTS: In fetuses of mothers who subsequently developed PE, compared to those from normotensive pregnancies, there was a more globular right ventricle, as shown by reduced right ventricular sphericity index, reduced right ventricular systolic contractility, as shown by reduced global longitudinal strain, and reduced left ventricular diastolic function, as shown by increased E/A ratio. On multivariable regression analysis, these indices demonstrated an association with PE, independent of maternal characteristics and fetal size. In pregnancies that subsequently developed PE, compared to those that remained normotensive, MAP, sFlt-1 and the incidence of low birth weight were higher, whereas serum PlGF, CPR and the interval between assessment and delivery were lower. These findings demonstrate that, in pregnancies that develop PE, there is evidence of impaired placentation, reflected in low PlGF and reduced birth weight, placental ischemia, evidenced by increased sFlt-1 which becomes apparent in the interval of 2-4 weeks preceding the clinical onset of PE, and consequent fetal hypoxia-induced redistribution in the fetal circulation, reflected in the low CPR. CONCLUSION: Although the etiology of the observed fetal cardiac changes in pregnancies that subsequently develop PE remains unclear, it is possible that the reduction in right-heart systolic function is the consequence of high afterload due to increased placental resistance, whilst the early left ventricular diastolic changes could be due to fetal hypoxia-induced redistribution in the fetal circulation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.


Assuntos
Coração Fetal/fisiopatologia , Feto/irrigação sanguínea , Pré-Eclâmpsia/fisiopatologia , Terceiro Trimestre da Gravidez/sangue , Adulto , Pressão Arterial , Estudos de Casos e Controles , Circulação Cerebrovascular , Feminino , Coração Fetal/diagnóstico por imagem , Coração Fetal/embriologia , Feto/embriologia , Feto/fisiopatologia , Idade Gestacional , Ventrículos do Coração/fisiopatologia , Humanos , Fator de Crescimento Placentário/sangue , Circulação Placentária , Pré-Eclâmpsia/diagnóstico por imagem , Gravidez , Estudos Prospectivos , Fluxo Pulsátil , Análise de Regressão , Ultrassonografia Pré-Natal/métodos , Artéria Uterina/diagnóstico por imagem , Artéria Uterina/embriologia , Artéria Uterina/fisiopatologia , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangue , Resistência Vascular
3.
Ultrasound Obstet Gynecol ; 56(2): 247-254, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32530101

RESUMO

OBJECTIVE: Women with gestational diabetes mellitus (GDM) are at increased risk for adverse cardiovascular outcome later in life. However, it is uncertain whether this increased risk is due to cardiovascular changes occurring during pregnancy and persisting thereafter or to an adverse underlying cardiovascular risk factor profile. Some studies have reported that GDM is associated with reduced systolic and diastolic left ventricular function in pregnancy; however, it remains unknown whether these changes persist after delivery. The objective of this study was to compare cardiac function and structure in women with GDM and those with uncomplicated pregnancy at 35-36 weeks' gestation and about 6 months after delivery. METHODS: This was a longitudinal study in which women with GDM and those with uncomplicated pregnancy had detailed cardiovascular assessment at 35-36 weeks' gestation and repeat examination around 6 months after delivery. In all women, left ventricular systolic and diastolic indices were measured and left ventricular mass indexed for body surface area was calculated. Cardiac output and peripheral vascular resistance were also calculated using echocardiography. Linear mixed model analysis accounting for differences in maternal characteristics was carried out to compare findings of cardiovascular function between the GDM group and controls and within each group at 35-36 weeks' gestation and at 6 months after delivery. RESULTS: We studied 73 women with GDM and 73 controls with uncomplicated pregnancy. At 35-36 weeks' gestation, women with GDM, compared to controls, had higher E/e' ratio and lower E/A ratio and global longitudinal systolic strain; there were no significant differences between the groups in ejection fraction. Left ventricular mass indexed for body surface area was also increased in women with GDM. There were no significant differences between the groups in cardiac output and peripheral vascular resistance. At 6 months after delivery, cardiac functional indices improved in both patients with GDM and controls, but in the GDM group, compared to controls, there was a lower degree of improvement in E/A ratio and global longitudinal systolic strain. CONCLUSION: In the third trimester, patients with GDM have subtle differences in diastolic and systolic left ventricular function compared to controls and, despite improvement after delivery, these changes persist for at least 6 months. Long-term follow-up is therefore needed to assess whether women with GDM are at risk for an accelerated decline in their cardiac function and, if so, whether this trend can be reversed or delayed by optimal cardiovascular risk factor modification. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.


Assuntos
Doenças Cardiovasculares/etiologia , Diabetes Gestacional/fisiopatologia , Período Pós-Parto/fisiologia , Terceiro Trimestre da Gravidez/fisiologia , Disfunção Ventricular/etiologia , Adulto , Débito Cardíaco/fisiologia , Estudos de Casos e Controles , Diástole/fisiologia , Ecocardiografia , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Modelos Lineares , Estudos Longitudinais , Gravidez , Sístole/fisiologia , Resistência Vascular/fisiologia , Função Ventricular Esquerda
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