|Year : 2016 | Volume
| Issue : 3 | Page : 94-96
Echo changes in hypertensive disorder of pregnancy
Chaitra Shivananjiah, Ashwini Nayak, Asha Swarup
Department of Obstetrics and Gynaecology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||8-Aug-2016|
Dr. Chaitra Shivananjiah
No. 11, Devi Krupa, 11th A Cross, 2nd Stage, WOC Road, Bangalore - 560 056, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: Acute preeclampsia is associated with significantly higher prevalence of asymptomatic global left ventricular (LV) abnormal function and myocardial injury than uneventful pregnancy. Hence, this study was undertaken to evaluate the LV changes in preeclamptic women and to compare with normotensive women. Materials and Methods: This study was conducted in the Department of Obstetrics and Gynaecology, M. S. Ramaiah Medical College and Teaching Hospital, Bengaluru. Two-hundred women were in each group: 200 patients with preeclampsia as cases and 200 normotensive patients as controls. Results: The mean LV end-systolic volume (LV ESV) in preeclamptic women was 33.45 ± 2.8, LV end-diastolic volume (LV EDV) was 106 ± 3.01, and LV systolic mass (LV Ms) was 87.1 ± 1.65 when compared to normotensive women LV ESV - 27 ± 0.74, (P < 0.0001) LV EDV - 106.2 ± 0.43, (P - 0.3528), and LV Ms - 84 ± 0.56 (P < 0.0001). Conclusion: This study emphasizes the importance of identifying this subset of preeclamptic patients with echo changes who are at higher risk of developing cardiovascular complications later in life by undergoing echocardiography.
Keywords: Echocardiography, echocardiography in pregnancy, pregnancy
|How to cite this article:|
Shivananjiah C, Nayak A, Swarup A. Echo changes in hypertensive disorder of pregnancy. J Cardiovasc Echography 2016;26:94-6
| Introduction|| |
Preeclampsia is an acute increase in blood pressure during pregnancy, which is short-lived. More than 50% of the women with elevated blood pressure during pregnancy return to normal by 6 weeks. Nearly every one in four mothers with preeclampsia/eclampsia is at risk of persistent hypertension after the puerperium.  Acute preeclampsia is associated with significantly higher prevalence of asymptomatic global left ventricular (LV) abnormal function/geometry and myocardial injury than uneventful pregnancy.  Cross-sectional studies of women with preeclampsia have revealed diverse hemodynamic findings such as elevated cardiac output (CO), high vascular resistance, and reduced CO and myocardial contractility.  Impairment of LV diastolic function as well as systolic function appear very early in the course of heart disease.  Detection of any abnormality in the LV diastolic function and its treatment at an asymptomatic phase can help in improving the prognosis. There are not many studies on myocardial function in preeclamptic women. Hence, this study was undertaken to evaluate the LV changes in preeclamptic women and to compare with normotensive women.
| Materials and Methods|| |
This study was conducted in the Department of Obstetrics and Gynecology, M. S. Ramaiah Medical College, Bengaluru. A case-control type of study was done which included 200 women in each group - 200 patients with preeclampsia as cases and 200 normotensive patients as controls. Preeclampsia is defined as new-onset hypertension of 140/90 mmHg or more and 24 h proteinuria of 0.3 g or more, occurring after 20 weeks of gestation. , Blood pressure was checked with a mercury sphygmomanometers using an appropriate size cuff with the woman lying in semi-reclining or sitting position with arm at the level of the heart and phase V Korotkoff sound (sound disappearance) to measure diastolic blood pressure. Echocardiography was performed, and data regarding LV function were recorded with patients in left lateral position.
The criteria for exclusion were gestational age <20 weeks of gestation, preexisting medical disorders such as hypertension, diabetes mellitus, heart disease, and renal disease, and connective tissue disorders. A P < 0.05 was considered statistically significant.
| Results|| |
A majority of the patients in both hypertensive and normotensive patients were in the age group 21-30 years. Body mass index was normal in 60 women (30%) of preeclamptic women and in 168 women (84%) of normotensives while 108 women (54%), 32 (16%) of preeclamptic women were overweight and obese, respectively, in comparison to the normotensives in which only 28 women (14%) were overweight and none were obese [Table 1].
|Table 1: Distribution of patients according to age, gestational age and BMI |
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Out of the 200 women with preeclampsia, the mean systolic pressure was 161.4 mmHg ± 10.4 and mean diastolic blood pressure was 110.3 mmHg ± 7.6 and among the 200 normotensive women the mean systolic pressure was 105 mmHg ± 8.2 and mean diastolic blood pressure was 73.5 mmHg ± 7.1. CO in the preeclamptic group was 64.2 ± 3.4 ml/min as compared to 56.99 ± 0.78 ml/min in normotensive group. This observation was statistically significant at P < 0.0001. The mean LV end-systolic volume (LV ESV) in preeclamptic women was 33.45 ± 2.8, LV end-diastolic volume (LV EDV) was 106 ± 3.01, and LV systolic mass (LV Ms) was 87.1 ± 1.65 when compared to normotensive women LV ESV - 27 ± 0.74, (P < 0.0001) LV EDV - 106.2 ± 0.43, (P - 0.3528), and LV Ms - 84 ± 0.56 (P < 0.0001) [Table 2].
[Table 3] shows comparison of diastolic parameters between normotensive and preeclamptic subjects. Mean isovolumetric relaxation time (IVRT) in preeclamptic women was 98 ± 9.99, E-wave deceleration time mean was 162 ± 18.99, mean peak E-wave velocity as 0.98 ± 0.14, A-wave - 0.70 ± 0.12, ratio of E/A - 1.4 ± 0.24 while that of normotensives IVRT - 84.6 ± 0.59, E-wave deceleration time mean 128.2 ± 5.1, mean peak E-wave velocity as 0.66 ± 0.09, A-wave - 0.56 ± 0.03, ratio of E/A - 1.20 ± 0.24.
| Discussion|| |
Preeclampsia is a disease unique to pregnancy that contributes substantially to maternal and fetal morbidity and mortality, and the condition has been thought to be one of hypoperfusion in which increased vascular resistance characterizes the associated hypertension.  Arterial hypertension produces evident structural changes in the left ventricle usually accompanied by functional alterations and in the great majority of cases, these alterations precede the appearance of clinical manifestations.  In this study, we have evaluated the role of echocardiography in preeclampsia and found that there were marked LV changes in these patients. In normal pregnancy, an increased preload and a decreased afterload favor an improved emptying of the left ventricle during systole and a reduction of the end-systolic pressure.  In preeclamptic women, the elevated afterload is linked with a reduced emptying of the left ventricle and elevated end-systolic pressure. In our study, we found that the mean LV ESV in normotensive women was 27 ± 0.74 while in preeclamptic women 33.45 ± 2.8 (P < 0.0001).
The prolonged IVRT in hypertensive patients in comparison to normotensives (98 ± 9.99, 84.6 ± 0.59) was significant (P < 0.0001) as LV pressure takes greater time to fall below the atrial pressure compared with normotensive patients as also shown in study by Valensise et al. in which IVRT in normotensives was 71.1 ± 5.0 ms (at 33 ± 1 weeks), P < 0.001.  The mean E-wave deceleration time in preeclamptic subjects was 162 ± 18.99 compared to 128.2 ± 5.1 in normotensive women which indicates that passive filling of left ventricle is increased during early diastole. The mean E-wave velocity in preeclamptic subjects was 0.98 ± 0.14 compared to normotensive women in whom it was 0.66 ± 0.09 (P < 0.0001), which indicates that the pressure gradient across the mitral valve during early passive filling was higher. This was comparable to the study by Solanki and Maitra in which the preeclamptic patients had E-wave velocity was 1.023 ± 0.1926 in comparison to the normotensives 0.675 ± 0.137.  The mean peak A-wave velocity in preeclamptic patients was 0.70 ± 0.12 in comparison to the normotensives (0.56 ± 0.03, P < 0.0001) which reveals the significance of atrial systole.
| Conclusion|| |
Preeclampsia still contributes to a majority of maternal mortality and morbidity. This study shows that there are significant cardiovascular dynamics changes in subjects with preeclampsia which can be studied by echo. Hence, this study emphasizes the importance of identifying this subset of preeclamptic patients who are at higher risk of developing cardiovascular complications later in life by undergoing a timely echocardiography.
Our sincere thanks to Dr. V. S. Prakash, Professor, Department of Cardiology, M. S. Ramaiah Medical College, Bengaluru for all the help provided for the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ndayambagye EB, Nakalembe M, Kaye DK. Factors associated with persistent hypertension after puerperium among women with pre-eclampsia/eclampsia in Mulago hospital, Uganda. BMC Pregnancy Childbirth 2010;10:12.
Melchiorre K, Sutherland GR, Baltabaeva A, Liberati M, Thilaganathan B. Maternal cardiac dysfunction and remodeling in women with preeclampsia at term. Hypertension 2011;57:85-93.
Solanki R, Maitra N. Echocardiographic assessment of cardiovascular hemodynamics in preeclampsia. J Obstet Gynaecol India 2011;61:519-22.
Kuznetsova T, Herbots L, Jin Y, Stolarz-Skrzypek K, Staessen JA. Systolic and diastolic left ventricular dysfunction: From risk factors to overt heart failure. Expert Rev Cardiovasc Ther 2010;8:251-8.
North R. Classification and diagnosis of pre-eclampsia. In: Lyall F, Belfort M, editors. Pre-eclampsia. Cambridge: Cambridge University Press; 2007. p. 243-57.
Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC 3 rd
, Wenstrom KD. Hypertensive disorders in pregnancy. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap L, editors. Williams Obstetrics. 22 nd
ed. New York: McGraw Hill; 2005. p. 761-98.
Easterling TR, Benedetti TJ, Schmucker BC, Millard SP. Maternal hemodynamics in normal and preeclamptic pregnancies: A longitudinal study. Obstet Gynecol 1990;76:1061-9.
Escudero EM, Favaloro LE, Moreira C, Plastino JA, Pisano O. Study of the left ventricular function in pregnancy-induced hypertension. Clin Cardiol 1988;11:329-33.
Valensise H, Novelli GP, Vasapollo B, Di Ruzza G, Romanini ME, Marchei M, et al.
Maternal diastolic dysfunction and left ventricular geometry in gestational hypertension. Hypertension 2001;37:1209-15.
Valensise H, Novelli GP, Vasapollo B, Borzi M, Arduini D, Galante A, et al.
Maternal cardiac systolic and diastolic function: Relationship with uteroplacental resistances. A Doppler and echocardiographic longitudinal study. Ultrasound Obstet Gynecol 2000;15:487-97.
[Table 1], [Table 2], [Table 3]
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