Background
The classification of hypertensive disorders of pregnancy is based on the time at
the onset of hypertension, proteinuria, and other associated complications. Maternal
hemodynamic interrogation in hypertensive disorders of pregnancy considers not only
the peripheral blood pressure but also the entire cardiovascular system, and it might
help to classify the different clinical phenotypes of this syndrome.
Objective
This study aimed to examine cardiovascular parameters in a cohort of patients affected
by hypertensive disorders of pregnancy according to the clinical phenotypes that prioritize
fetoplacental characteristics and not the time at onset of hypertensive disorders
of pregnancy.
Study Design
At the fetal-maternal medicine unit of Ziekenhuis Oost-Limburg (Genk, Belgium), maternal
cardiovascular parameters were obtained through impedance cardiography using a noninvasive
continuous cardiac output monitor with the patients placed in a standing position.
The patients were classified as pregnant women with hypertensive disorders of pregnancy
who delivered appropriate- and small-for-gestational-age fetuses. Normotensive pregnant
women with an appropriate-for-gestational-age fetus at delivery were enrolled as the
control group. The possible impact of obesity (body mass index ≥30 kg/m2) on maternal hemodynamics was reassessed in the same groups.
Results
Maternal age, parity, body mass index, and blood pressure were not significantly different
between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and
hypertensive disorders of pregnancy/small-for-gestational-age groups. The mean uterine
artery pulsatility index was significantly higher in the hypertensive disorders of
pregnancy/small-for-gestational-age group. The cardiac output and cardiac index were
significantly lower in the hypertensive disorders of pregnancy/small-for-gestational-age
group (cardiac output 6.5 L/min, cardiac index 3.6) than in the hypertensive disorders
of pregnancy/appropriate-for-gestational-age group (cardiac output 7.6 L/min, cardiac
index 3.9) but not between the hypertensive disorders of pregnancy/appropriate-for-gestational-age
and control groups (cardiac output 7.6 L/min, cardiac index 4.0). Total vascular resistance
was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age
group than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age
group and the control group. All women with hypertensive disorders of pregnancy showed
signs of central arterial dysfunction. The cardiovascular parameters were not influenced
by gestational age at the onset of hypertensive disorders of pregnancy, and no difference
was observed between the women with appropriate-for-gestational-age fetuses affected
by preeclampsia or by gestational hypertension with appropriate-for-gestational-age
fetuses. Women in the obese/hypertensive disorders of pregnancy/appropriate-for-gestational-age
and obese/hypertensive disorders of pregnancy/small-for-gestational-age groups showed
a significant increase in cardiac output, as well as significant changes in other
parameters, compared with the nonobese/hypertensive disorders of pregnancy/appropriate-for-gestational-age
and nonobese/hypertensive disorders of pregnancy/small-for-gestational-age groups.
Conclusion
Significantly low cardiac output and high total vascular resistance characterized
the women with hypertensive disorders of pregnancy associated with small for gestational
age due to placental insufficiency, independent of the gestational age at the onset
of hypertension. The cardiovascular parameters were not significantly different in
the women with appropriate-for-gestational-age or small-for-gestational-age fetuses
affected by preeclampsia or gestational hypertension. These findings support the view
that maternal hemodynamics may be a candidate diagnostic tool to identify hypertensive
disorders in pregnancies associated with small-for-gestational-age fetuses. This additional
tool matches other reported evidence provided by uterine Doppler velocimetry, low
vascular growth factors in the first trimester, and placental pathology. Obesity is
associated with a significantly higher cardiac output and outweighs other determinants
of hemodynamics in pregnancy; therefore, in future studies on hypertensive disorders,
obesity should be studied as an additional disease and not simply as a demographic
characteristic.
Key words
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Article Info
Publication History
Published online: November 01, 2017
Accepted:
October 25,
2017
Received in revised form:
October 23,
2017
Received:
October 16,
2017
Footnotes
The authors’ networking for this study was supported by the nonprofit scientific charity “CURE.”
The authors report no conflict of interest.
Cite this article as: Ferrazzi E, Stampalija T, Monasta L, et al. Maternal hemodynamics: a method to classify hypertensive disorders of pregnancy. Am J Obstet Gynecol 2018;218:124.e1-11.
Identification
Copyright
© 2017 Elsevier Inc. All rights reserved.
