Reduced left ventricular function and sustained hypertension in women seven years after severe preeclampsia.

Objective. To study left ventricular (LV) function and blood pressure (BP) at a long-term follow-up in women after severe pre-eclampsia. Design. In this single-centre, cross-sectional study, 96 patients were eligible for inclusion. LV function was examined by transthoracic echocardiography including tissue Doppler echocardiography and speckle tracking. BP was measured at rest using repeated non-invasive techniques. Results. We compared 36 patients with early-onset and 33 patients with late-onset pre-eclampsia with 28 healthy controls. Mean age (40 ± 3 years) and median time since delivery (7 ± 2 years) were similar across the study groups. The patients had 18% higher systolic BP (139 ± 15 mmHg) and 24% higher diastolic BP (87 ± 19 mmHg) than controls (p < .01). Hypertension was present in 23 patients (33%), where the estimated LV mass was 16% higher (p = .05) than in controls. The LV ejection fraction was 19% lower in the early-onset group (51 ± 4%; p = .01) and 14% lower in the late-onset group (54 ± 6; p = .04) compared with controls. LV global longitudinal strain was 18% lower in the patient group (-17.7 ± 2.1%) compared with controls (p = .01). Indicative of a more restrictive filling pattern, the diastolic indices showed a lower e' mean (p < .01) and subsequently higher E/e' ratio (p < .01). There were no significant differences in BP, systolic or diastolic function indices between the patient groups. Conclusion. We found sustained hypertension, higher LV mass and reduced LV systolic and diastolic function 7 y after severe pre-eclampsia. Our findings emphasize the importance of early risk stratification and clinical counselling, and follow-up for such cases.

Haemodynamic changes during labour: continuous minimally invasive monitoring in 20 healthy parturients.

BACKGROUND: There are few studies on maternal haemodynamic changes during labour. None have used continuous cardiac output monitoring during all labour stages. In this observational study, we monitored haemodynamic variables continuously during the entire course of labour in healthy parturients. METHODS: Continuous haemodynamic monitoring with the LiDCOplus technique was performed in 20 healthy parturients during spontaneous labour, vaginal delivery and for 15minutes postpartum. Cardiac output, stroke volume, heart rate, systemic vascular resistance, and systolic arterial pressure were measured longitudinally at baseline (periods between/without contractions) and during contractions in early and late stage 1, stage 2, during delivery, and postpartum, and were analysed with marginal linear models. RESULTS: Twenty parturients were included. In early stage 1, baseline cardiac output was 6.3L/min (95% CI 5.7 to 6.9). Baseline values were similar across both labour stages and postpartum for all haemodynamic variables. During stage 2 contractions, cardiac output decreased by 32%, stroke volume decreased by 44%, heart rate increased by 52%, systemic vascular resistance increased by 88%, and systolic arterial pressure increased by 36% compared to baseline. During stage 1 contractions, haemodynamic changes were less profound and less uniform than during stage 2. CONCLUSION: Progression of labour had no major effect on haemodynamic baseline values. Haemodynamic stress during contractions was substantial in both labour stages, yet most pronounced during the second stage of labour. The absence of an increase in stroke volume and cardiac output postpartum questions the common belief in an immediate rise in cardiac output after delivery due to autotransfusion from the contracted uterus.

Haemodynamic effects of oxytocin in women with severe preeclampsia.

BACKGROUND: Several previous publications demonstrate the significant haemodynamic effects of oxytocin in healthy pregnant women, but there is only one publication of the oxytocin effects in women with severe preeclampsia. We investigated the haemodynamic effects of oxytocin in women with severe preeclampsia using invasive haemodynamic monitoring. METHODS: Eighteen women with severe preeclampsia were included in this observational study. All women had continuous invasive haemodynamic monitoring during spinal anaesthesia for caesarean section using the LiDCOplus monitor. Preeclamptic patients were given intravenous boluses of 5IU oxytocin following delivery. RESULTS: Following an intravenous bolus of 5IU oxytocin all patients had an increase in heart rate, a decrease in systemic vascular resistance and a decrease in blood pressure. Five patients had a decrease in cardiac output due to an inability to increase stroke volume. CONCLUSIONS: The haemodynamic effects of oxytocin in women with severe preeclampsia may be less predictable compared to findings in healthy pregnant women, suggesting that oxytocin should be given with caution in women with severe preeclampsia.

Regional anaesthesia for a Caesarean section in women with cardiac disease: a prospective study.

BACKGROUND: We conducted a prospective observational survey of pregnant women with cardiac disease. The aim was to analyse and present the mode of delivery, outcome, and haemodynamic changes during a caesarean section under regional anaesthesia in women with cardiac disease. METHODS: All pregnant women with a cardiovascular diagnosis, except hypertension, were included in the registry. Based on the cardiac diagnoses, and on the New York Heart Association classification, a multidisciplinary group made recommendations for each patient and decided on the mode of delivery. The data from continuous, invasive haemodynamic monitoring in intermediate- and high-risk patients under regional anaesthesia for a caesarean section were analysed and presented. RESULTS: The hospital had approximately 9000 deliveries in the period from November 2003 to April 2008. A total of 113 pregnancies in 107 women were included. Thirty-two (28.3%) pregnancies were classified into the high-risk category. Of 103 deliveries, caesarean sections were performed in 59 (52.2%) cases, with regional anaesthesia in 51 patients (18 emergencies), general anaesthesia in eight patients (five emergencies), and a planned vaginal delivery in 44 patients. There was no mortality among the mothers or the babies during the hospital stay or 6 months postpartum. Pre-operative cardiovascular stability during the caesarean section was maintained by volume and phenylephrine infusion guided by invasive monitoring of haemodynamic variables. CONCLUSION: Our study suggests that pregnant women with cardiac disease may safely deliver the baby by a caesarean section under regional anaesthesia. According to our findings, haemodynamic stability can be obtained by titrated regional anaesthesia, intravenous (i.v.) volume, phenylephrine infusion, and small repeated doses of i.v. oxytocin guided by invasive monitoring.

Haemodynamic effects of repeated doses of oxytocin during Caesarean delivery in healthy parturients.

BACKGROUND: The haemodynamic effects of oxytocin 5 u have been described previously, but still some authors attribute these effects to the delivery itself. We studied the haemodynamic effects of two repeated doses of oxytocin i.v. in 20 healthy women during spinal anaesthesia for Caesarean delivery. METHODS: Data were obtained from a randomized controlled study of 80 pregnant women undergoing an elective Caesarean section. All women had an arterial line inserted, and LidCOPlus was used for measuring cardiac output (CO), stroke volume (SV), and systemic vascular resistance (SVR). RESULTS: Twenty women required a second bolus of oxytocin 5 u. Both the first and the second doses produced clinically and statistically significant haemodynamic changes, but the haemodynamic changes induced by the second dose were smaller than after the first dose. The mean maximal change in CO after the first and second doses were 94% (CI 70-117) and 42% (CI 33-52), respectively (P<0.0001), and for systolic arterial pressure 31% (CI 27-35) and 23% (CI 20-27), respectively (P=0.003). CONCLUSIONS: An initial bolus of oxytocin 5 u produced prominent haemodynamic changes, whereas a second bolus produced smaller changes. This could be due to desensitization of endothelial oxytocin receptors.

Hemodynamic changes during vaginal delivery in a parturient with no labor pain.

This is the case of a 35-year-old woman who had an induction for vaginal delivery because of severe pre-eclampsia. This case demonstrates the hemodynamic changes during the second stage of labor in a patient with epidural analgesia and complete pain relief during delivery.