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Hyperoxygenation in pregnancy exerts a more profound effect on cardiovascular hemodynamics than is observed in the nonpregnant state

Published:March 05, 2019DOI:https://doi.org/10.1016/j.ajog.2019.02.059

      Background

      Supplemental oxygen is administered to pregnant women in many different clinical scenarios in obstetric practice. Despite the accepted uses for maternal hyperoxygenation, the impact of hyperoxia on maternal hemodynamic indices has not been evaluated. As a result, there is a paucity of data in the literature in relation to the physiological changes to the maternal circulation in response to supplemental oxygen.

      Objective

      The hemodynamic effects of oxygen therapy are under-recognized and the impact of hyperoxygenation on maternal hemodynamics is currently unknown. Using noninvasive cardiac output monitoring which employs transthoracic bioreactance, we examined the effect of brief hyperoxygenation on cardiac index, systemic vascular resistance, blood pressure, stroke volume, and heart rate in pregnant mothers during the third trimester, compared with those effects observed in a nonpregnant population subjected to the same period of hyperoxygenation.

      Study Design

      Hemodynamic monitoring was performed in a continuous manner over a 30-minute period using noninvasive cardiac output monitoring. Hyperoxygenation (O2 100% v/v inhalational gas) was carried out at a rate of 12 L/min via a partial non-rebreather mask for 10-minutes. Cardiac index, systemic vascular resistance, stroke volume, heart rate, and blood pressure were recorded before hyperoxygenation, at completion of hyperoxygenation, and 10 minutes after the cessation of hyperoxygenation. Two-way analysis of variance with repeated measures was used to assess the change in hemodynamic indices over time and the differences between the 2 groups.

      Results

      Forty-six pregnant and 20 nonpregnant women with a median age of 33 years (interquartile range, 26–38 years) and 32 years (interquartile range, 28-37 years) were recruited prospectively, respectively (P=.82). The median gestational age was 35 weeks (33–37 weeks). In the pregnant group, there was a fall in cardiac index during the hyperoxygenation exposure period (P=.009) coupled with a rise in systemic vascular resistance with no recovery at 10 minutes after cessation of hyperoxygenation (P=.02). Heart rate decreased after hyperoxygenation exposure and returned to baseline by 10 minutes after cessation of therapy. There was a decrease in stroke volume over the exposure period, with no change in systolic or diastolic blood pressure. In the nonpregnant group, there was no significant change in the cardiac index, systemic vascular resistance, stroke volume, heart rate, or systolic or diastolic blood pressure during the course of exposure to hyperoxygenation.

      Conclusion

      Hyperoxygenation during the third trimester is associated with a fall in maternal cardiac index and a rise in systemic vascular resistance without recovery to baseline levels at 10 minutes after cessation of hyperoxygenation. The hemodynamic changes that were observed in this study in response to hyperoxygenation therapy during pregnancy could counteract any intended increase in oxygen delivery. The observed maternal effects of hyperoxygenation call for a reevaluation of the role of hyperoxygenation treatment in the nonhypoxemic pregnant patient.

      Key words

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      References

        • Parpaglioni R.
        • Capogna G.
        • Celleno D.
        • Fusco P.
        Intraoperative fetal oxygen saturation during caesarean section: general anaesthesia using sevoflurane with either 100% oxygen or 50% nitrous oxide in oxygen.
        Eur J Anaesthesiol. 2002; 19: 115-118
        • Haydon M.L.
        • Gorenberg D.M.
        • Nageotte M.P.
        • et al.
        The effect of maternal oxygen administration on fetal pulse oximetry during labour in fetuses with nonreassuring fetal heart rate patterns.
        Am J Obstet Gynecol. 2006; 195: 735-738
        • Fawole B.
        • Hofmeyr G.J.
        Maternal oxygen administration for fetal distress.
        Cochrane Database Syst Rev. 2012; 12: CD000136
        • Chatmongkolchart S.
        • Prathep S.
        Supplemental oxygen for caesarean section during regional anaesthesia.
        Cochrane Database Syst Rev. 2016; 3: CD006161
        • Say L.
        • Gülmezoglu A.M.
        • Hofmeyr G.J.
        Maternal oxygen administration for suspected impaired fetal growth.
        Cochrane Database Syst Rev. 2003; 1: CD000137
        • Zeng S.
        • Zhou J.
        • Peng Q.
        • et al.
        Sustained maternal hyperoxygenation improves aortic arch dimensions in fetuses with coarctation.
        Sci Rep. 2016; 6: 39304
        • Szwast A.
        • Tian Z.
        • McCann M.
        • Donaghue D.
        • Rychik J.
        Vasoreactive response to maternal hyperoxygenation in the fetus with hypoplastic left heart syndrome.
        Circ Cardiovasc Imaging. 2010; 3: 172-178
        • Kohl T.
        Chronic intermittent maternofetal hyperoxygenation in late gestation may improve on hypoplastic cardiovascular structures associated with cardiac malformations in human fetuses.
        Pediatr Cardiol. 2010; 31: 250-263
        • Hamel M.S.
        • Anderson B.L.
        • Rouse D.J.
        Oxygen for intrauterine resuscitation: of unproved benefit and potentially harmful.
        Am J Obstet Gynecol. 2014; 211: 124-127
        • Bullens L.M.
        • van der Hout-van der Jagt M.B.
        • Van Runnard Heimel P.J.
        • Oei G.
        A simulation model to study maternal hyperoxygenation during labor.
        Acta Obstet Gynecol Scand. 2014; 93: 1268-1275
        • Haydon M.L.
        • Gorenberg D.M.
        • Nageotte M.P.
        • et al.
        The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns.
        Am J Obstet Gynecol. 2006; 195: 735-738
        • Simpson K.R.
        • James D.C.
        Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor.
        Obstet Gynecol. 2005; 105: 1362-1368
        • Aldrich C.J.
        • Wyatt J.S.
        • Spencer J.A.
        • Reynolds E.O.
        • Delpy D.T.
        The effect of maternal oxygen administration on human fetal cerebral oxygenation measured during labour by near infrared spectroscopy.
        BJOG. 1994; 101: 509-513
        • Althabe O.
        • Schwarcz R.L.
        • Pose S.V.
        • Escarcena L.
        • Caldeyro-Barcia R.
        Effects on fetal heart rateand fetal pO2 of oxygen administration to the mother.
        Am J Obstet Gynecol. 1967; 98: 858-870
        • Qian X.
        • Xu L.
        • Chen S.
        • et al.
        The effect of maternal low flow oxygen administration during the second stage of labour on umbilical cord artery pH: a randomised controlled trial.
        BJOG. 2017; 124: 678-685
        • Khatib N.
        • Thaler I.
        • Beloosesky R.
        • et al.
        The effect of maternal hyper oxygenation on fetal circulatory system in normal growth and IUGR foetuses. What we can learn from this impact.
        J Matern Fetal Neonetal Med. 2018; 31: 914-918
        • Arduini D.
        • Rizzo G.
        • Romanini C.
        • Mancuso S.
        Fetal haemodynamic response to acute maternal hyperoxygenation as predictor of fetal distress in intrauterine growth retardation.
        BMJ. 1989; 298: 1561-1562
        • McNamara H.
        • Barclay P.
        • Sharma V.
        Accuracy and precision of the ultrasound cardiac output monitor (USCOM 1A) in pregnancy: comparison with three-dimensional transthoracic echocardiography.
        Br Anaesth. 2014; 113: 669-676
        • Cornette J.
        • Laker S.
        • Jeffery B.
        • et al.
        Validation of maternal cardiac output assessed by transthoracic echocardiography against pulmonary artery catheters in severely ill pregnant women: a prospective comparative study and systematic review.
        Ultrasound Obstet Gynecol. 2017; 49: 25-31
        • Vinayagam D.
        • Patey O.
        • Bowe S.
        • Thilaganathan B.
        • Khalil A.
        Comparison of a non-invasive, ultrasound based method of cardiac output monitoring (USCOM (R)) to two-dimensional transthoracic echocardiography in pregnancy.
        BJOG. 2016; 123: 20-21
        • Ohashi Y.
        • Ibrahim H.
        • Furtado L.
        • Kingdom J.
        • Carvalho J.
        Non-invasive hemodynamic assessment of non-pregnant, healthy pregnant and preeclamptic women using bio-reactance.
        Rev Bras Anestesiol. 2010; 60: 603-613
        • McLaughlin K.
        • Wright S.P.
        • Kingdom J.C.P.
        • Parker J.D.
        Clinical validation of non-invasive cardiac output monitoring in healthy pregnant women.
        J Obstet Gynaecol Can. 2017; 39: 1008-1014
        • Monteith C.
        • McSweeney L.
        • Breatnach C.R.
        • et al.
        Non-invasive cardiac output monitoring (NICOM®) can predict the evolution of uteroplacental disease- results of the prospective HANDLE study.
        Eur J Obstet Gynecol Reprod Biol. 2017; 216: 116-124
        • Vinayagam D.
        • Bowe S.
        • Sheehan E.
        • et al.
        Non-invasive haemodynamic monitoring in pregnancy: a comparative study using ultrasound and bioreactance.
        Fetal Diagn Ther. 2017; 41: 273-282
        • Vinayagam D.
        • Patey O.
        • Thilaganathan B.
        • Khalil A.
        Cardiac output assessment in pregnancy: comparison of two automated monitors with echocardiography.
        Ultrasound Obstet Gynecol. 2017; 49: 32-38
        • Doherty A.
        • EL-Khuffash A.
        • Monteith C.
        • et al.
        Comparison of bioreactance and echocardiographic non-invasive cardiac output monitoring and myocardial function assessment in primagravida women.
        Br J Anaesth. 2017; 118: 527-532
        • Keren H.
        • Burkhoff D.
        • Squara P.
        Evaluation of a noninvasive continuous cardiac output monitoring system based on thoracic bioreactance.
        Am J Physiol Heart Circ Physiol. 2007; 293: H583-H589
        • Soma-Pillay P.
        • Nelson-Piercy C.
        • Tolppanen H.
        • Mebazaa A.
        Physiological changes in pregnancy.
        Cardiovasc J Afr. 2016; 27: 89-94
        • Simchen M.J.
        • Tesler J.
        • Azami T.
        • et al.
        Effects of maternal hyperoxia with and without normocapnia in uteroplacental and fetal doppler studies.
        Ultrasound Obstet Gynaecol. 2005; 26: 495-499
        • DeKoninck P.
        • Lewi P.
        • Done E.
        • et al.
        Sonographic evaluation of vascular pulmonary reactivity following oxygen administration in fetuses with normal lung development.
        Prenat Diagn. 2012; 32: 1300-1304
        • Bilardo C.M.
        • Snijders R.M.
        • Campbell S.
        • Nicolaides K.H.
        Doppler study of the fetal circulation during long-term maternal hyperoxygenation for severe early onset intrauterine growth retardation.
        Ultrasound Obstet Gynecol. 1991; 1: 250-257
        • Done E.
        • Allegaert K.
        • Lewi P.
        • et al.
        Maternal hyperoxygenation test in fetuses undergoing FETO for severe isolated congenital diaphragmatic hernia.
        Ultrasound Obstet Gynecol. 2011; 37: 264-271
        • Sorensen A.
        • Peters D.
        • Simonsen C.
        • et al.
        Changes in human fetal oxygenation during maternal hyperoxia as estimated by BOLD MRI.
        Prenat Diagn. 2013; 33: 141-145
        • McNulty P.H.
        • King N.
        • Scott S.
        • et al.
        Effects of supplemental oxygen administration on coronary blood flow in patients undergoing cardiac catheterization.
        Am J Phys Heart Circ Physiol. 2005; 288: H1057-H1062
        • Mak S.
        • Azevedo E.R.
        • Liu P.P.
        • Newton G.E.
        Effect of hyperoxia on left ventricular function and filling pressures in patients with and without congestive heart failure.
        Chest. 2001; 120: 467-473
        • Lund V.E.
        • Kentala E.
        • Scheinin H.
        • et al.
        Heart rate variability in healthy volunteers during normobaric and hyperbaric hyperoxia.
        Acta Physiol Scand. 1999; 167: 29-35
        • Jamieson D.
        • Chance B.
        • Cadenas E.
        • et al.
        The relation of free radical pro- duction to hyperoxia.
        Annu Rev Physiol. 1986; 48: 703-719
        • Rubanyi G.M.
        • Vanhoutte P.M.
        Superoxide anions and hyperoxia inactivate endothelium-derived relaxing factor.
        Am J Physiol. 1986; 250: H822-H827
        • Crawford P.
        • Good P.A.
        • Gutierrez E.
        • et al.
        Effects of supplemental oxygen on forearm vasodilation in humans.
        J Appl Physiol. 1997; 82: 1601-1606
        • Moradkhan R.
        • Sinoway L.I.
        Revisiting the role of oxygen therapy in cardiac patients.
        J Am Coll Cardiol. 2010; 56: 1013-1016
        • Welsh D.G.
        • Jackson W.F.
        • Segal S.S.
        Oxygen induces electromechanical coupling in arteriolar smooth muscle cells: a role for L-type Ca2+ channels.
        Am J Physiol Heart Circ Physiol. 1998; 274: H2018-H2024
        • Waring W.S.
        • Thomson A.J.
        • Adwani S.H.
        • et al.
        Cardiovascular effects of acute oxygen administration in healthy adults.
        J Cardiovasc Pharmacol. 2003; 42: 245-250
        • Crawford P.
        • Good P.A.
        • Gutierrez E.
        • et al.
        Effects of supplemental oxygen on forearm vasodilation in humans.
        J Appl Physiol. 1997; 82: 1601-1606
        • Milone S.D.
        • Newton G.E.
        • Parker J.D.
        Hemodynamic and biochemical effects of 100% oxygen breathing in humans.
        Can J Physiol Pharmacol. 1999; 77: 124-130
        • Feigl E.O.
        Coronary physiology.
        Physiol Rev. 1983; 63: 1-205
        • Thomson A.J.
        • Drummond G.B.
        • Waring W.S.
        • Webb D.J.
        • Maxwell S.R.
        Effects of short-term isocapnic hyperoxia and hypoxia on cardiovascular function.
        J Appl Physiol. 2006; 101: 809-816
        • Ganz W.
        • Donoso R.
        • Marcus H.
        • Swan H.J.
        Coronary hemodynamics and myocardial oxygen metabolism during oxygen breathing in patients with and without coronary artery disease.
        Circulation. 1972; 45: 763-768
        • Dyer R.A.
        • James M.F.
        Maternal hemodynamic monitoring in obstetric anesthesia.
        Anesthesiology. 2008; 109: 765-767
        • Marik P.
        Noninvasive cardiac output monitors: a state-of the-art review.
        J Cardiothorac Vasc Anesth. 2013; 27: 121-134
        • Estensen M.
        • Beitnes J.
        • Grindheim G.
        • et al.
        Altered maternal left ventricular contractility and function during normal pregnancy.
        Ultrasound Obstet Gynecol. 2013; 41: 659-666
        • Fok W.
        • Chan L.
        • Wong J.
        • Yu C.
        • Lau T.
        Left ventricular diastolic function during normal pregnancy: assessment by spectral tissue Doppler imaging.
        Ultrasound Obstet Gynecol. 2006; 28: 789-793
        • Shahul S.
        • Rhee J.
        • Hacker M.
        • et al.
        Subclinical left ventricular dysfunction in preeclamptic women with preserved left ventricular ejection fraction a 2D speckle-tracking imaging study.
        Circ Cardiovasc Imaging. 2012; 5: 734-739
        • Squara P.
        • Denjean D.
        • Estagnasie P.
        • et al.
        Non-invasive cardiac output monitoring (NICOM): a clinical validation.
        Intensive Care Med. 2007; 33: 1191-1194
        • Branberg A.
        • Sonesson S.-E.
        Central arterial hemodynamics in small for gestational age fetuses before and during maternal hyperoxygenation: a Doppler velocimetric study with particular attention to the aortic isthmus.
        Ultrasound Obstet Gynecol. 1999; 14: 237-243
        • Channing A.
        • Szwast A.
        • Natarajan S.
        • Degenhardt K.
        • Tian Z.
        • Rychik J.
        Maternal hyperoxygenation improves left heart filling in fetuses with atrial septal aneurysm causing impediment to left ventricular inflow.
        Ultrasound Obstet Gynecol. 2015; 45: 664-669
        • Ramanathan S.
        • Gandhi S.
        • Arismendy J.
        • Chalon J.
        • Turndorf H.
        Oxygen transfer from mother to fetus during cesarean section under epidural anesthesia.
        Anesth Analg. 1982; 61: 576-581
        • Khaw K.S.
        • Wang C.C.
        • Ngan Kee W.D.
        • Pang C.P.
        • Rogers M.S.
        Effects of high inspired oxygen fraction during elective caesarean section under spinal anaesthesia on maternal and fetal oxygenation and lipid peroxidation.
        Br J Anaesth. 2002; 88: 18-23
        • Raghuraman N.
        • Wan L.
        • Temming L.A.
        • et al.
        Effect of oxygen vs room air on intrauterine fetal resuscitation randomized noninferiority clinical trial.
        JAMA Pediatr. 2018; 172: 818-823
        • Broth R.E.
        • Wood D.C.
        • Rasanen J.
        Prenatal prediction of lethal pulmonary hypoplasia: the hyperoxygenation test for pulmonary artery reactivity.
        Am J Obstet Gynecol. 2002; 187: 940-945