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The evaluation of cardiovascular disease in pregnancy is challenging due to overlaps between cardiac and normal pregnancy symptomatology, as well as concerns about the potential impact, if any, of imaging studies on fetal development. We discuss here an approach to the evaluation of the pregnant cardiac patient and review the safety and utility of available diagnostic tests, including labs, electrocardiogram, echocardiography, stress testing, computed tomography, magnetic resonance imaging, and cardiac catheterization. Importantly, the majority of standard imaging studies can be safely performed in pregnancy, and a high index of suspicion must be maintained when evaluating pregnant patients, especially those with preexisting cardiovascular disease.

Background: There is a large increase in uterine arterial blood flow during normal pregnancy. Structural and cellular adjustments occur in the uterine vasculature during pregnancy to accommodate this increased blood flow through a process is known as ‘vascular remodeling’. The etiology of preeclampsia involves aberrant placentation and vascular remodeling leading to reduced uteroplacental perfusion. However, the underlying source of the deficient vascular remodeling and the subsequent development of preeclampsia remains to be fully understood. Piezo 1 channels have been shown to be highly expressed in vascular smooth muscle cells of small-diameter arteries and play a role in the structural remodeling of the arteries. Studies have also shown that Piezo 1 is present in uterine arteries and it’s not exclusive to the endothelial cells. Hypothesis: This study tests the hypothesis that reduced Piezo 1 activity contributes to decreased uterine vascular relaxation in hypertensive pregnant rats. Methods: Hypertension was induced by treating the pregnant rats with synthetic CpG ODN (ODN 2395) via three intraperitoneal injections (100μg/rats) while the normotensive controls were treated with saline (vehicle) on the 14 th , 17th and 18 th days of pregnancy. Mean arterial pressure (MAP) was measured. In vitro vascular reactivity of uterine arterial (UA) ring segments were evaluated using isometric wire myograph system. Rings were pre-contracted with 3μM phenylephrine (PE), concentration responses of to Yoda1; a pharmacological agonist of Piezo 1 channel were compared. Statistical analysis was performed using nonlinear regression and Students’ t-test. Results: Our results show that MAP was greater in rats treated with ODN2395 vs untreated rats (112 ± 1 vs 90 ± 1 p =0.0004). Concentration-dependent relaxation responses to Yoda1 were greater in UAs of untreated rats compared to those treated with ODN2395 (EC50 0.06571 ± 0.09781 vs. 0.5774 ± 0.1187 p =0.0018). Conclusion: These results suggest that the reduced vasodilation in pregnancy-associated hypertension may be due to a reduced Piezo 1 channel activity.

OBJECTIVE To assess cardiac function, myocardial mechanoenergetic efficiency (MEE), and ventricular-arterial coupling (VAC) longitudinally during normal pregnancy, and to study if there was an association between cardiac structure and function, and fetal growth. METHODS Cardiac structure and function, MEE, and ventricular-arterial coupling was assessed longitudinally in 52 healthy nulliparous women at 14, 24, and 34 weeks' gestation and 9-month postpartum. RESULTS Left atrial diameter increased during pregnancy (30.41 ± 3.59 mm in the nonpregnant state and 31.02 ± 3.91, 34.06 ± 3.58, and 33.9 ± 2.97 mm in the first, second, and third trimesters, P

The stories are frighteningly similar—a normal pregnancy taken to term, a perinatal crisis, followed by an emergent cesarean section and infant transport to a tertiary hospital, where therapeutic hypothermia is initiated. I usually meet the family shortly after arrival, at which point I am charged with helping them understand the next steps. Like so many others, I frequently find myself in complex discussions with families about prognostic uncertainty, advanced care planning, and lifelong disability. Navigating these conversations poorly can have devastating consequences. In many conditions I treat, whether or not a child dies does not rest on my ability to learn, understand, or recommend treatment, but instead on the outcome of conversations in which a family considers whether to withdraw or withhold life-sustaining treatment. As a neonatal neurointensivist, these high-stakes conversations are the most critical interventions I perform. The authors thank Drs. Renee Boss and Claire Creutzfeldt for critical review of the manuscript.

Determining the viability of a pregnancy is a major challenge, especially with a pregnancy of unknown location. This review provides specific guidance, including stringent criteria for nonviability, that can reduce the risk of inadvertent harm to a potentially normal pregnancy.

Objective:Normal pregnancy is associated with reversible changes in both systolic and diastolic mechanics, consistent with an increase in preload and decrease in afterload and systemic vascular resistance. The aim of the study is to evaluate left ventricular cardiac mechanics via speckle tracking ec

Objective:Although ambulatory blood pressure monitoring (ABPM) is recommended in pregnant patients with hypertension, few data are available on ABPM values and targets in pregnant hypertensives and in normal normotensive pregnancies. The aim of the study was to evaluate blood pressure (BP) values in

To investigate the clinical characteristics and risk factors for miscarriage of intrauterine normal pregnancy of patients with a heterotopic pregnancy (HP) after treatment. This was a retrospective study of medical records from CHA Bundang Medical Center. Sixty-four patients who were diagnosed with a HP between February 2006 and July 2017 were included in this study. All analyses were performed using SAS software, version 9.4 (SAS Institute, Inc., Cary, NC). P values

In normal pregnancy there is an increase in procoagulant activity. Furthermore, the fibrinolytic activity is impaired and remains low during labor and delivery, but returns rapidly to normal, following delivery. Here, we show ultrastructural changes in fibrin networks found in pregnant individuals and nonpregnant individuals. Typically thick, major fibers, and irregularly placed thin, minor fibers are present in healthy, nonpregnant individuals. In this qualitative assessment, changes in fibrin networks and platelet morphology were studied with scanning electron microscopy in healthy individuals, a healthy individual at 30-week pregnancy and post partum. We also included results from an individual with dysfibrinogenaemia (30-week pregnant and postpartum). Results suggest that in the healthy pregnant and pregnant dysfibrinogenaemia individuals, the minor, thin fibers form a fine, dense net distributed evenly over the major fibers. This net was not present in the nonpregnant dysfibrinogenaemia or healthy nonpregnant individuals. No ultrastructural changes were found in platelet morphology. These morphological changes seen during pregnancy might contribute to increased thrombotic risk, because, due to the denser appearance of fibrin networks because of the fine minor network morphology during pregnancy, clots might take longer to be broken down by normal fibrinolytic activity.

Gestation is a challenge to haemostasis and it is associated with significant haemostatic changes. Several studies have evaluated von Willebrand factor in normal pregnancy, but none considered the personal history of bleeding. We studied a group of healthy non-bleeding women (184 pregnant, 64 puerperium, 37 non-pregnant) to evaluate normal ranges and their relationship to blood group and parity. The von Willebrand factor increased markedly from non-pregnant values up to the end of early puerperium (P < 0.0001), while factor VIII only showed a slight increase. Factor VIII and von Willebrand factor activity remained within the normal range for non-pregnant women. The return to non-pregnant factor levels occurred in late puerperium, later than previously reported. Only factor VIII was significantly lower in the O blood group (P = 0.035). As regards parity, there were no differences in factor VIII, von Willebrand factor antigen and von Willebrand factor ristocetin cofactor between primigravidae and multigravidae for any period studied (P = 0.888, 0.999, and 0.237, respectively). Our results provide reference ranges that may help to design a study in von Willebrand factor disease in pregnancy.

Introduction: Higher parity (number of births) is associated with increased subclinical cardiovascular disease (CVD) in mid-life and older women, and with increased risk of CVD overall. In the only study of reproductive age women, common carotid artery intima-media thickness (CCA IMT) was greater after each birth. Prospective studies of arterial change throughout normal pregnancy are lacking; without them it is unclear whether unhealthy changes of the vasculature during pregnancy persist postpartum and raise women’s risk of CVD. The goal of this study was to prospectively assess normal vascular adaptation in healthy pregnant women. Hypotheses: During the course of healthy pregnancy: 1. CCA adventitial diameter (AD) will increase, then return to baseline postpartum, 2. CCA IMT will initially thin, then thicken as pregnancy progresses, then return to baseline postpartum, and 3. brachial artery distensibility will not change. Methods: We assessed 43 healthy women during each trimester of their first pregnancy and 6-8 weeks postpartum with B-mode ultrasound imaging of the CCA IMT and AD, independent predictors of CVD risk. Brachial artery distensibility, representing elasticity of the artery, was measured using the DynaPulse wave form analyzer. Linear mixed models were used to compare measures of CCA IMT, adventitial diameter, and brachial artery distensibility at each time point, after adjustment for age and pre-pregnancy BMI. Results: There were 37 women (age 28.2 ± 4.5 years, pre-pregnant BMI 24.4 ± 3.2 kg/m 2 ) with uncomplicated pregnancies. Six women with pregnancy complications were excluded from these analyses. After adjustment for age and pre-pregnancy BMI, mean (SE) CCA AD (mm) increased each trimester, from 6.38(0.08) in the 1 st trimester to 6.92(0.09) in the 3 rd trimester, and returned to baseline, 6.35 (0.07), postpartum. Pairwise comparisons were all statistically significant at pst (0.539 (0.01)) and 2 nd trimester values (0.546 (0.01), p < .05 for each). Mean (SE) brachial artery distensibility (%/mmHg) decreased from 7.64 (0.28) 1st trimester to 6.84 (0.21) 3rd trimester (p < .01) and then remained unchanged at 6.82 (0.21) postpartum. Conclusions: As we hypothesized, in uncomplicated first pregnancies CCA AD increased throughout and returned to baseline postpartum. However, contrary to our hypotheses, CCA IMT increased postpartum, and the brachial artery stiffened during pregnancy and remained stiffer 6-8 weeks postpartum. In uncomplicated first pregnancies, some vascular changes resolved (CCA AD) and others persisted (CCA IMT and brachial artery stiffness). Whether this indicates that persistence of specific vascular effects of pregnancy may inform long term CVD risk remains to be explored.

Background Second trimester routine ultrasound evaluation of the fetal heart by means of the four-chamber view has been proposed for prenatal detection of cardiac anomalies. The aim of this study was to evaluate the efficacy of this procedure. Methods and Results A prospective follow-up study on 6922 scanned fetuses was performed. Pregnant women without known risk factors who were scheduled for a routine fetal ultrasound examination between 16 and 24 weeks gestation were invited to participate. Follow-up until 6 months postpartum was available for 5660 subjects (81.8%), of whom 5319 fulfilled all eligibility criteria. By comparing the prenatal diagnosis to the postnatal diagnosis, we obtained sensitivity, specificity, and predictive value (positive and negative). A total of 80 cases of congenital malformations were diagnosed during the study: 44 cases of congenital heart disease, 40 cases of noncardiac malformations, and a combination of the two in 4 cases. The fetal four chamber–view examination was considered abnormal in 7 women who were subsequently referred for extensive fetal ultrasound examination. Two proved to be carrying an affected fetus. Similarly, prenatal referral of 14 women because of suspected noncardiac malformations yielded 12 such cases. The fetal four chamber–view examination had a sensitivity of 4.5% (95% CI, 0.6% to 15%). Sensitivity for noncardiac anomalies was 30% (95% CI, 16.6% to 46.5%). Overall sensitivity of ultrasound examination was 16.3% (95% CI, 2.09% to 48.8%). Specificity and negative predictive value were high (>98%). The positive predictive value was low with wide CIs. Conclusions These results suggest that the current mode of routine prenatal ultrasound screening for congenital malformations is inefficient, particularly for cardiac anomalies.

Objective To review the literature about the effect of normal pregnancy on cardiac output, with special attention to study design, measurement technique, position of the subject, and parity. Data Sources For studies from the period 1955–1987, we examined Cumulated Index Medicus (National Library of Medicine Cataloging in Publication. Chicago: American Medical Association). For studies from 1988 to May 1, 1994, we used Medline on SUver Platter (U.S. National Library of Medicine SUver Platter International, 1994). Methods of Study Selection Thirty-three cross-sectional and 19 longitudinal studies on cardiac output measurement in normal pregnancy were retrieved and reviewed. Thirteen longitudinal studies were excluded from analysis because an unvalidated technique was used or because not all subjects were measured at each study interval. The six remaining studies of genuine longitudinal design with at least two measurements throughout pregnancy were used for the definitive analysis. The results of the cross-sectional studies were included only to demonstrate a trend. Data Extraction and Synthesis By pooling data from cross-sectional studies, a tendency was shown toward a higher cardiac output in the second trimester compared with the first trimester, and a tendency toward lower cardiac output was found in the third trimester compared with the second trimester. After delivery, cardiac output was lower than at any time during pregnancy. Selected longitudinal studies showed that the rise in cardiac output occurred early in the first trimester, and a further rise occurred during the second trimester. During the third trimester, cardiac output rose, fell, or plateaued, irrespective of the method of measurement applied or conditions during measurement. Conclusions Cardiac output during the third trimester was widely divergent among the studies and probably dependent on individual factors. The tendency to report cardiac output as averages negated these inter-individual differences.

This review of recurrent pregnancy loss examines our current understanding of the major etiologies of this unfortunate condition including genetic and endocrine abnormalities, anatomic variations, autoimmune conditions, alloimmune problems, systemic disease, and infection. Diagnostic protocols and treatment strategies are briefly presented. With a high rate of spontaneous normal pregnancy outcome, great care must be taken to do more good than harm.

It has long been observed that pregnancy may influence the development and course of urinary tract disorders. The physiological and anatomical changes inherent in normal pregnancy and the changing hormonal environment are generally assumed to play a role in the pathogenesis of urinary tract symptomatology. The purpose of this review is to examine the reported effect(s) of pregnancy on the lower urinary tract and to evaluate the possible role of pregnancy and delivery in lower urinary tract dysfunction.

Preeclampsia is associated with increased peripheral resistance. This study was performed to determine whether an increase of venous distensibility occurs as well in preeclampsia. We obtained venous distensibility by measuring the venous pressure-volume relation in the forearm with a water-filled plethysmograph. Twenty-one women with normal pregnancy, 12 women with severe preeclampsia, and 8 women with mild preeclampsia were studied during the third trimester and/or 6 weeks after the delivery. Ten nonpregnant normotensive women were also studied. Venous distensibility was greater (P < .01) in normal pregnant women and smaller (P < .01) in women with preeclampsia during pregnancy than postpartum. The magnitude of the decrease of venous distensibility correlated with the severity of preeclampsia. Venous distensibility was similar between normotensive nonpregnant women, women with normal pregnancy during the postpartum period, and women with preeclampsia during the postpartum period. Thus, venous distensibility increased during normal pregnancy. In preeclampsia, the decrease of venous distensibility occurred during pregnancy but was reversed postpartum. These results may suggest that a decrease of venous distensibility occurs during preeclampsia. These venous abnormalities may contribute to impaired control of hemodynamics in preeclampsia during pregnancy.

Objective To assess the role Na plays in the pathogenesis of pregnancy-induced hypertension (PIH). Methods We assessed Na and K content, the maximum number of ouabain binding sites, Na(+)-Li+ countertransport and Na(+)-K+ cotransport in erythrocytes from women with untreated PIH, normal pregnant women and healthy non-pregnant women. Results In normal pregnancy, the Na content of erythrocytes decreased, accompanied by the activation of Na excretion systems. In women with PIH, the Na content of erythrocytes and the Na(+)-K+ cotransport activity significantly increased, whilst erythrocyte K content and the maximum number of ouabain binding sites significantly decreased, compared with observations in normal pregnancy. In both normal pregnancy and PIH, there were no differences in Na(+)-Li+ countertransport. Conclusions These results suggest that the increase of erythrocyte Na content in women with PIH may be contributed to by a reduction in the number of ouabain binding sites, whilst Na(+)-K+ cotransport and Na(+)-Li+ countertransport may compensate for this effect in women with PIH.

To the Editor: We read with interest the article by Tsukimori et al1 analyzing the relationship between the superoxide-anion (O2−) production of neutrophils during pregnancy in women with preeclampsia and essential hypertension. The results of the study demonstrated that n -formyl-methionyl-leucyl-phenylalanine stimulated O2− production of neutrophils during pregnancy was increased in women with preeclampsia compared with healthy pregnant women. There was no significant difference in the neutrophil O2− production in normal pregnancy between pregnant and postpartum women. In …

We thank Lampe et al1 for their interest in our article.2 These investigators have highlighted the fact that granulocyte superoxide-anion (O2−) production is decreased in normal pregnancy, whereas preeclampsia is associated with failure of this reduction of O2− production. We have previously studied O2− production in neutrophils from 78 normal pregnant women at 7 to 39 weeks of gestation to determine whether there is a critical gestational age at which maternal neutrophil O2− production occurs.3 In this report, we demonstrated that …

A neonate was admitted at the age of 8 days with a history of increasing cyanosis and tachydyspnea after a normal pregnancy and delivery at 42 weeks’ gestation. A transthoracic echocardiography appeared to indicate pulmonary atresia with an intact ventricular septum. The child was intubated, intravenous prostaglandin E1 was started, and the patient was transferred to our hospital. The newborn presented with central cyanosis while being ventilated with 100% oxygen. No heart murmur was perceptible. Transthoracic echocardiography revealed marked apical displacement of the tricuspid valve leaflets (Figure 1 and Movie I). Linear attachments of the anterior and the mural leaflets resulted in complete separation of the inlet portion from the apical trabecular and outlet portions of the right ventricle (Figure 2 and Movie II). On color Doppler, we were unable to demonstrate either antegrade or regurgitant flow across the valve …

Objective: To report our experience with essential thrombocythemia complicating pregnancy. Methods: Over a 5-year period, we studied 21 women of reproductive age affected by essential thrombocythemia. Diagnoses were based on previously published Polycythemia Vera Study Group criteria. Results: Five of our 21 patients became pregnant (total six pregnancies). All pregnancies were carried to term, with uncomplicated deliveries of normally formed infants. No thrombotic or hemorrhagic complications were encountered. Conclusion: Normal pregnancy and delivery is readily possible in patients with essential thrombocythemia.(Obstet Gynecol 1994;83:915-7)

See related article, pp 859-866 Recent years have seen considerable advances in the identification of biomarkers related to the development of preeclampsia.1–4 Elegant translational studies reported by Maynard et al3 and Venkatesha et al4 from the Karumanchi laboratory clearly demonstrated that the antiangiogenic factors soluble Fms-like tyrosine kinase 1 (sFlt-1; a vascular endothelial growth factor antagonist) and soluble endoglin (a transforming growth factor-β antagonist) play important roles in the pathophysiology of preeclampsia. In the following years, additional progress has been made with respect to our understanding of the mechanisms underlying the role of antiangiogenic factors in the pathophysiology of preeclampsia.2–6 Viewed in concert, these studies have clearly established the importance of angiogenic balance in the maintenance of cardiovascular function in normal pregnancy. Despite marked progress toward these ends, the translation of these findings into clinically useful paradigms has moved at a much slower pace. In lieu of the development of novel treatments for preeclampsia, much current attention has been paid to determining the usefulness of these biomarkers for identification of patients who will go on to develop preeclampsia. Indeed, this is an important endeavor for several reasons, not the least of which is that early identification of preeclamptic patients is a high yield objective for enhancing the management and treatment of this devastating disorder. Moreover, the use of angiogenic markers may be helpful in discriminating patients with preeclampsia from those …

Summary: The purpose of this study was to examine the changes in activated protein C (APC) anticoagulant activity during pregnancy and determine whether changes in APC could contribute to thrombosis in the placental bed in preeclampsia. We measured APC anticoagulant activity in 150 women with a normal pregnancy and 50 women with preeclampsia. There was a significant reduction in the mean APC sensitivity ratio (APC-SR) during pregnancy (p

OBJECTIVE: To describe the form of midwifery practice preferred by physicians practising obstetrics, nurses providing maternity care and midwives. DESIGN: Mail survey conducted in 1991. SETTING: Province of Quebec. PARTICIPANTS: A systematic random sample of 844 physicians, 808 nurses and 92 midwives; 597, 723 and 92 respectively completed the questionnaire, for an overall response rate of 80%. MAIN OUTCOME MEASURES: Midwife training options, range of responsibilities, location of midwifery care, relationship to other maternity care providers and degree of autonomy. RESULTS: Most of the physicians, nurses and midwives surveyed agreed that if midwifery was legalized, midwives should have a university degree, provide basic care to women with normal pregnancy and delivery, provide prenatal and postnatal care in hospitals and community health centres, perform delivery in hospitals and work in close collaboration with the other maternity care professionals. Disagreement existed concerning the level of university training required, the need for training in nursing first, the scope of medical intervention performed by midwives, out-of-hospital delivery, the autonomy of midwives and control over their practice. CONCLUSION: Some consensus on midwifery practice exists between physicians, nurses and midwives. In jurisdictions where opposition to midwives is strong, such consensus could serve as the starting point for the introduction of midwifery.

Noncytotoxic antibodies were detected in sera from 6 of 7 primigravid women during the first trimester of pregnancy. Such antibodies directed to antigens expressed on paternal B lymphocytes were detectable within the first 4-5 weeks of gestation. Antibody activity toward paternal B lymphocytes was also detected in 6 of 10 placental eluates, and in 3 of 10 predelivery and 2 of 10 postdelivery maternal serum samples. When B lymphocytes from umbilical cord blood were used as target cells, antibodies were detected in 5 of 7 placental eluates, and in 3 of 7 predelivery and 2 of 7 postdelivery serum samples. These antibodies also reacted with selected members of a normal B lymphocyte panel. The concept of an immunological enhancing mechanism in normal pregnancy is supported by these data.

The excretion rates of the C19-mineralcorticoids, 16beta-hydroxy-DHEA and 16-oxo-androstenediol, were measured in subjects with low-renin essential hypertension and toxemia of pregnancy. C19-mineralocorticoid excretion in low-renin essential hypertension ranged from 70-790 microgram per day. No significant difference in 16beta-hydroxy-DHEA and 16-oxo-androstenediol excretion was found between these subjects and normal controls. Subjects with toxemia of pregnancy excreted between 350 and 2500 microgram per day of these steroids. There was no significant difference between toxemic and normal pregnancy. Thus, 16beta-hydroxy - DHEA and 16-oxo-androstenediol probably do not play an important role in either low-renin essential hypertension or toxemia of pregnancy.

Evaluations of diagnostic tests have focused primarily on their value in clinical decisions. Patients may attach value to 1) information that has little or no medical significance, and 2) information (medical or nonmedical) that has no bearing on decisions to be made by the doctor or the patient. Ul

Pregnant women with epilepsy have a greater risk for complications of pregnancy and adverse pregnancy outcomes. Problems that may arise during the course of pregnancy include an increase in seizure frequency, reduction of serum antiepileptic drug levels, and an increase in bleeding during pregnancy and after delivery. The infant of an epileptic mother is at twice the risk of infants in the general population to have a major malformation, and the risk for perinatal death is 1.2 to 3 times greater. Despite these facts, at least 90% of women with epilepsy have a normal pregnancy and deliver a normal infant. The pregnant woman with epilepsy may minimize the risk of adverse outcome by taking measures to ensure an optimal prenatal course. The neuroscience nurse can provide these clients with accurate information regarding pregnancy and epilepsy and can review measures that may be taken to reduce chances of an unfavorable outcome.