Abstract
Background
Although insufficient maternal cardiac output (CO) has been implicated in poor outcomes
in mothers with heart disease (HD), maternal-fetal interactions remain incompletely
understood. We sought to quantify maternal-fetal hemodynamics with the use of magnetic
resonance imaging (MRI) and explore their relationship with adverse events.
Methods
Pregnant women with moderate or severe HD (n = 22; mean age 32 ± 5 years) were compared
with healthy control women (n = 21; 34 ± 3 years). An MRI was performed during the
third trimester at peak output (maternal-fetal) and 6 months postpartum with return
of maternal hemodynamics to baseline (reference). Phase-contrast MRI was used for
flow quantification and was combined with T1/T2 relaxometry for derivation of fetal
oxygen delivery/consumption.
Results
Third-trimester CO and cardiac index (CI) measurements were similar in HD and control
groups (CO 7.2 ± 1.5 vs 7.3 ± 1.6 L/min, P = 0.79; CI 4.0 ± 0.7 vs 4.3 ± 0.7 L/min/m,2 P = 0.28). However, the magnitude of CO/CI increase (Δ, peak pregnancy − reference)
in the HD group exceeded that in the control group (CO 46 ± 24% vs 27 ± 16% [P = 0.007]; CI 51 ± 28% vs 28 ± 17% [P = 0.005]). Fetal growth and oxygen delivery/consumption were similar between groups.
Adverse cardiovascular outcomes (nonmutually exclusive) in 6 HD women included arrhythmia
(n = 4), heart failure (n = 2), and hypertensive disorder of pregnancy (n = 1); premature
delivery was observed in 2 of these women. The odds of a maternal cardiovascular event
were inversely associated with peak CI (odds ratio 0.10, 95% confidence interval 0.001-0.86;
P = 0.04) and Δ,CI (0.02, 0.001-0.71; P = 0.03).
Conclusions
Maternal-fetal hemodynamics can be well characterised in pregnancy with the use of
MRI. Impaired adaptation to pregnancy in women with HD appears to be associated with
development of adverse outcomes of pregnancy.
Résumé
Contexte
Bien qu’un débit cardiaque maternel insuffisant ait été mis en cause dans les issues
médiocres apparues chez des mères atteintes d’une cardiopathie, les interactions mère-fœtus
à l’origine de ces issues ne sont pas encore bien comprises. Notre objectif était
de quantifier les paramètres hémodynamiques mère-fœtus à l’aide de l’imagerie par
résonance magnétique (IRM) et d’explorer leur lien avec les événements indésirables.
Méthodologie
Des femmes enceintes atteintes d’une cardiopathie modérée ou sévère (n = 22; âge moyen
: 32 ± 5 ans) ont été comparées avec des femmes témoins en bonne santé (n = 21; 34
± 3 ans). Une IRM a été effectuée pendant le troisième trimestre, lorsque le débit
cardiaque (mère-fœtus) est maximal, et six mois après la naissance, après la normalisation
des paramètres hémodynamiques maternels (valeurs de référence). L’IRM en contraste
de phase a été utilisée pour la quantification du flux vasculaire, et a été combinée
à la relaxométrie en T1/T2 pour calculer l’approvisionnement en oxygène et la consommation
d’oxygène chez le fœtus.
Résultats
Les mesures du débit cardiaque et de l’index cardiaque au troisième trimestre étaient
similaires dans le groupe atteint d’une cardiopathie et le groupe témoin (débit cardiaque
: 7,2 ± 1,5 vs 7,3 ± 1,6 L/min, p = 0,79; index cardiaque : 4,0 ± 0,7 vs 4,3 ± 0,7
L/min/m2; p = 0,28). Toutefois, l’ampleur de l’augmentation du débit/de l’index cardiaque
(delta, valeur maximale de référence pendant la grossesse) dans le groupe atteint
d’une cardiopathie était supérieure à celle du groupe témoin (débit cardiaque : 46
± 24 % vs 27 ± 16 % [p = 0,007]; index cardiaque : 51 ± 28 % vs 28 ± 17 % [p = 0,005]).
La croissance fœtale et l’approvisionnement en oxygène/la consommation d’oxygène étaient
similaires dans les groupes. Les issues cardiovasculaires indésirables (non mutuellement
exclusives) survenues chez six femmes atteintes d’une cardiopathie comprenaient l’arythmie
(n = 4), l’insuffisance cardiaque (n = 2) et un trouble hypertensif gestationnel (n =
1); l'accouchement prématuré fœtale a été observé chez deux de ces femmes. La probabilité
d’une manifestation cardiovasculaire maternelle était inversement associée à l’index
cardiaque maximal (rapport d'incidence approché 0,10; intervalle de confiance à 95
% : 0,001-0,86; p = 0,04) et au delta de l’index cardiaque (0,02; 0,001-0,71; p =
0,03).
Conclusions
Les paramètres hémodynamiques maternels-fœtaux peuvent être bien caractérisés pendant
la grossesse à l’aide de l’IRM. Chez les femmes atteintes d’une cardiopathie, les
troubles de l’adaptation hémodynamique à la grossesse semblent être associés à des
issues gestationnelles indésirables.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Maternal cardiac function in fetal growth restriction.BJOG. 2006; 113: 784-791
- Maternal cardiac output and fetal doppler predict adverse neonatal outcomes in pregnant women with heart disease.J Am Heart Assoc. 2015; 4e002414
- Cardiac magnetic resonance imaging for the evaluation of ventricular function.Sem Roentgenol. 2008; 43: 183-192
- Cardiovascular magnetic resonance in pregnancy: insights from the Cardiac Hemodynamic Imaging and Remodeling in Pregnancy (CHIRP) study.J Cardiovasc Magn Reson. 2014; 16: 1
- Direct measurement of aortic regurgitation with phase-contrast magnetic resonance is inaccurate: proposal of an alternative method of quantification.Pediatr Radiol. 2014; 44: 1358-1369
- Aortopulmonary collaterals after bidirectional cavopulmonary connection or Fontan completion: quantification with MRI.Circ Cardiovasc Imaging. 2009; 2: 219-225
- Uterine artery and umbilical vein blood flow are unaffected by moderate habitual physical activity during pregnancy.Prenat Diagn. 2019; 39: 976-985
- Reference ranges of blood flow in the major vessels of the normal human fetal circulation at term by phase-contrast magnetic resonance imaging.Circ Cardiovasc Imaging. 2014; 7: 663-670
- The utility of MRI for measuring hematocrit in fetal anemia.Am J Obstet Gynecol. 2020; 222: 81.e1-13
- Normal human and sheep fetal vessel oxygen saturations by T2 magnetic resonance imaging.J Physiol. 2020; 598: 3259-3281
- The hemodynamics of late-onset intrauterine growth restriction by MRI.Am J Obstet Gynecol. 2016; 214: 367.e1-17
- Fetal weight estimation by echo-planar magnetic resonance imaging.Lancet. 1994; 343: 644-645
- Three-dimensional sonographic measurement of normal fetal brain volume during the second half of pregnancy.Am J Obstet Gynecol. 2004; 190: 275-280
- Maternal vascular malperfusion and adverse perinatal outcomes in low-risk nulliparous women.Obstet Gynecol. 2017; 130: 1112-1120
- Pregnancy-related mortality in the United States, 1998 to 2005.Obstet Gynecol. 2010; 116: 1302-1309
- Effect of maternal heart disease on fetal growth.Obstet Gynecol. 2011; 117: 886-891
- Effect of maternal heart disease on pregnancy outcomes.Exp Rev Obstet Gynecol. 2010; 5: 605-617
- Cardiac output and related haemodynamics during pregnancy: a series of meta-analyses.Heart. 2016; 102: 518-526
- Longitudinal maternal hemodynamics in pregnancies affected by fetal growth restriction.Ultrasound Obstet Gynecol. 2017; 49: 761-768
- Maternal cardiac function in fetal growth-restricted and nongrowth-restricted small-for-gestational age pregnancies.Ultrasound Obstet Gynecol. 2007; 29: 51-57
- Longitudinal quantification of uterine artery blood volume flow changes during gestation in pregnancies complicated by intrauterine growth restriction.BJOG. 2003; 110: 301-305
- Outcome of pregnancy in women with congenital heart disease: a literature review.J Am Coll Cardiol. 2007; 49: 2303-2311
- Pregnancy outcomes in women with cardiovascular disease: evolving trends over 10 years in the ESC Registry of Pregnancy and Cardiac Disease (ROPAC).Eur Heart J. 2019; 40: 3848-3855
- Pregnancy and delivery in women after Fontan palliation.Heart. 2006; 92: 1290-1294
- The effect of maternal position on venous return for pregnant women during MRI.NMR Biomed. 2021; 34: e4475
- Associations of pregnancy complications with calculated cardiovascular disease risk and cardiovascular risk factors in middle age: the Avon Longitudinal Study of Parents and Children.Circulation. 2012; 125: 1367-1380
Article info
Publication history
Published online: July 01, 2021
Accepted:
June 12,
2021
Received:
February 11,
2021
Footnotes
See page 1949 for disclosure information.
Identification
Copyright
© 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
