LAUSR

BACKGROUND Chronic hypertension (CH) complicates around 3% of all pregnancies and is associated with an increased risk for pregnancy complications such as superimposed preeclampsia, fetal growth restriction, preterm delivery, and stillbirth, reaching a rate of complications up to 25-28%. OBJECTIVES We performed an echocardiographic study, to evaluate pre-pregnancy cardiac geometry and function, and the hemodynamic features of treated CH patients searching for a possible correlation with the development of feto-maternal complications and with pre-pregnancy therapy. STUDY DESIGN This was a prospective observational cohort study of 192 consecutive CH treated patients (Calcium Channel Blockers [CCB], ACE-inhibitors/Angiotensin Receptor Blockers [ACEI/ARB], ß-blockers, α1-adrenoceptor antagonists and/or diuretics). Patients were submitted to echocardiography before pregnancy, assessing left ventricular morphology and function, cardiac output (CO) and Total Vascular Resistance (TVR). Pre-pregnancy therapy was noted, patients were shifted to alpha methyldopa right before pregnancy, and followed until delivery noting major early (<34week' gestation) and late (≥34 weeks' gestation) complications. Comparisons among the 3 groups (uncomplicated, early complications and late complications) were performed with 1-way ANOVA with Student-Newman-Keuls correction for multiple comparisons. The Mann-Whitney U test was used for non normally distributed data. Comparison of proportions was used as appropriate. ROC curve analysis was used to identify cut off values of diastolic dysfunction in this population using E/e' ratio, and separate cut-off of values for TVR for the prediction of early and late complications of pregnancy. Binary univariate and multivariate logistic regression, as well as Cox proportional-hazards regression were used to evaluate the possible correlation among ACEI/ARB and/or CCB pre-pregnancy therapy, cardiovascular features and the risk for subsequent early and late complications of pregnancy. RESULTS 141 out of 192 patients had no complications, and 51 had a complicated pregnancy (24 had early complications, and 27 late complications). Concentric geometry was more frequent in the early vs late and no complications (50% vs 13.5% and 11.1%, respectively; p<0.05), whereas eccentric hypertrophy was more represented in the late vs early and no complications (32% vs 12.5% and 1.4%, respectively; p<0.05). ROC curve showed E/e' ratio value>7.65 (sensitivity 59.6%, specificity 68.6%) as a predictor of subsequent complications of pregnancy, whereas TVR<1048 (sensitivity 83.7%, specificity 55.6%) was predictive for late complications and TVR>1498 (sensitivity 87.5%, specificity 78.0%) for the early complications of pregnancy. Univariate analysis showed that the following parameters were predictive for complications of pregnancy: altered geometry of the left ventricle (OR 5.94; 95% CI 2.90-12.19); diastolic dysfunction (OR, 3.22; 95% CI 1.63-6.37), altered TVR (OR, 3.52; 95% CI 1.78-6.97); and pre-pregnancy therapy without CCB/ACEis/ARBs (OR 2.73; 95% CI 1.37-5.42). These parameters, except for altered TVR, resulted as independent predictors in the multivariate analysis corrected for Body Mass Index, heart rate, parity and mean arterial pressure. CONCLUSIONS CH patients with pre-pregnancy cardiac remodeling and dysfunction more often develop early and late complications of pregnancy. Pre-pregnancy therapy of CH patients with Calcium Channel Blockers and/or ACE inhibitors/Angiotensin Receptor Blockers may positively influence cardiac profiles and the outcome of a future pregnancy with a reduced rate of complications.