Echo Sees Traces of Past Preeclampsia That Predict Recurrence

Patrice Wendling

March 01, 2016

ROME, ITALY — Preeclampsia is the leading cause of premature delivery worldwide, but clinicians continue to be stymied in their ability to predict which pregnancies are at risk of developing new or recurrent preeclampsia. New research suggests that in women with a history of early preeclampsia, echocardiographic findings between pregnancies may predict recurrence[1].

Specifically, women with recurrent preeclampsia had shown signs of diastolic and systolic dysfunction and high total vascular resistance.

"These cardiovascular features might represent the prepregnancy predisposition involved in the genesis of recurrent preeclampsia," Dr Herbert Valensise (Tor Vergata University, Rome, Italy) and his colleagues write in their report, published online February 22, 2016 in Hypertension.

Women with previous preeclampsia face a sevenfold higher risk of recurrent preeclampsia than women with normal pregnancies and are more likely to develop hypertension and heart disease later in life.

The group previously showed that elevated total vascular resistance and other hemodynamic changes are present in normotensive pregnant women before early-onset preeclampsia.

Maternal cardiac dysfunction is known to persist postpartum, but what's less clear is the pattern of cardiac and hemodynamic alterations in these women before a second pregnancy and whether it can predict recurrent preeclampsia.

To evaluate this, the investigators performed two-dimensional and Doppler echocardiography 12 to 18 months after the first pregnancy in 75 women with previous early preeclampsia and 147 women with an uneventful, normotensive first pregnancy and matched for age and body mass index.

All patients went on to become pregnant within 24 months of the evaluation; preeclampsia recurred in 22 of the 75 patients (29%).

In between pregnancies, the women who went on to have recurrent preeclampsia showed a lower stroke volume than controls and nonrecurrent-preeclampsia patients (63 vs 73 vs 70 mL/min; P<0.05) and lower cardiac output (4.6 vs 5.3 vs 5.2 L/min; P<0.05), the investigators report.

Notably, total vascular resistance was dramatically higher in recurrent-preeclampsia patients than controls and nonrecurrent-preeclampsia patients (1638 dyne·s-1·cm -5 vs 1341 dyne·s-1·cm-5 vs 1383 dyne·s-1·cm-5).

Left ventricular mass index, however, was higher in both recurrent- and nonrecurrent-preeclampsia patients than controls (30.0 g/m2.7 vs 30.4 g/m2.7 vs 24.8 g/m2.7).

"The fact that in between pregnancies the left ventricle in nonrecurrent preeclamptic patients is similar to recurrent ones but diastolic function and total vascular resistance differ between the two groups highlights how complex the cardiovascular response is in these women and how multifactorial this disease is," study coauthor Dr Gian Paolo Novelli (Tor Vergata University, Rome, Italy) told heartwire from Medscape in an email. "On the other hand, echocardiography appears to differentiate the recurrent and nonrecurrent patients in a relatively easy way, through the detection of simple parameters."

In an accompanying editorial[2], Dr Eliyahu Khankin (Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA) and Dr Zoltan Arany (University of Pennsylvania, Philadelphia, PA) write: "Echocardiography thus could potentially allow early identification of women at highest risk of recurrent preeclampsia, using a noninvasive, low-risk, well-established, and relative quick screening procedure. One could also imagine simplifying the screening modality by focusing simply on measuring total vascular resistance noninvasively."

Novelli said total vascular resistance is only part of the evaluation but that they already use total vascular resistance as a predictor for complications in normotensive patients with altered uterine Doppler flow at 24 weeks.

"My personal opinion is that a good echocardiographic examination with the assessment of diastolic function and the calculation of left ventricular mass should be performed," he added. "In our clinical experience, though, high total vascular resistance appears to be a strong predictor of severe complications during pregnancy."

Novelli agreed with the editorialists that larger follow-up studies and calculation of positive and negative predictive values are needed to determine whether echocardiography has clinical use. Also unclear is whether the results are generalizable to lower-risk patients.

If validated, however, echocardiography as a tool to predict recurrent preeclampsia could have vast ramifications for clinicians and patients. Early identification of these women would greatly assist counseling in the consideration of another pregnancy, planning appropriate monitoring during that pregnancy, and potentially treating the condition when therapy becomes available, the editorialists observe.

Noninvasive echocardiography could also be combined with a blood test for antiangiogenic variables, like soluble fms-like tyrosine kinase-1 (sFlt-1).

A recent study[3] found that infusion of recombinant human placental growth factor in an experimental rat model "abolishes placental-ischemia–induced hypertension" by antagonizing sFlt-1, without major adverse consequences to mother or fetus.

"I think confirmation of the importance of total vascular resistance and intervention starting before pregnancy are the next steps," Novelli said.

The authors and editorialists reported no relevant financial relationships.

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