Acute Cardiac Effects of Severe Pre-Eclampsia

Study Questions:

What are the acute echocardiographic changes that occur in the setting of severe pre-eclampsia?

Methods:

This was an observational study at Johns Hopkins that prospectively enrolled 63 women with pre-eclampsia with severe features and 36 pregnant control patients.

Results:

Women with pre-eclampsia with severe features had the following significantly different (p < 0.001) echocardiographic parameters compared to pregnant control patients: higher right ventricular systolic pressure (RVSP) (31.0 ± 7.9 mm Hg vs. 22.5 ± 6.1 mm Hg); decreased global RV longitudinal systolic strain (RVLSS) (-19.6 ± 3.2% vs. -23.8 ± 2.9); higher mitral septal e’ velocity (9.6 ± 2.4 cm/s vs. 11.6 ± 1.9 cm/s); higher septal E/e’ ratio (10.8 ± 2.8 vs. 7.4 ± 1.6); larger left atrial area size (20.1 ± 3.8 cm2 vs. 17.3 ± 2.9 cm2), and increased posterior and septal wall thickness (median [interquartile range]: 1.0 cm [0.9-1.1 cm] vs. 0.8 cm [0.7-0.9 cm], and 1.0 cm [0.8-1.2 cm] vs. 0.8 cm [0.7-0.9 cm]). Of the women with pre-eclampsia with severe features, eight (12.7%) had grade II diastolic dysfunction and six (9.5%) had peripartum pulmonary edema.

Conclusions:

Pre-eclampsia with severe features is associated with higher RVSP, higher rates of abnormal diastolic function, decreased global RVLSS, increased left atrial size and LV wall thickness, and pulmonary edema.

Perspective:

A portion of women with pre-eclampsia with severe features develop clinically apparent pulmonary edema, often occurring in the early post-partum period in the setting of hemodynamic changes and fluid resorption. Previously, these women were presumed to have some degree of diastolic dysfunction. This study illustrates the differences in echocardiographic parameters among women with severe pre-eclampsia, thus confirming that cardiac dysfunction does occur in this setting. These women are sometimes reassured as long as the left ventricular systolic function is normal, thus ruling out peripartum cardiomyopathy; however, the long-term implications of diastolic dysfunction in the setting of pre-eclampsia are unknown. Pre-eclampsia is associated with an increased future risk of cardiovascular disease. Whether aggressive risk factor modification can modify or reduce this long-term risk remains to be studied. Further studies could assess the duration of these echocardiographic changes with serial measurements and examine the effects of risk factor modification.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Blood Pressure, Cardiomyopathies, Diagnostic Imaging, Diastole, Echocardiography, Heart Failure, Peripartum Period, Pre-Eclampsia, Pregnancy, Pulmonary Edema, Risk Factors, Systole, Ventricular Dysfunction, Ventricular Function, Left


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