BACKGROUND:Antenatal fetal heart rate (FHR) monitoring is currently limited by hospital-based accessibility as well as the availability of relevant equipment and expertise required to position device electrodes. Ambulatory FHR monitoring in the form of noninvasive fetal electrocardiography (NIFECG) is currently an area of research interest, particularly during the era of the COVID-19 pandemic, and the potential to improve maternity care and reduce hospital attendances need to be evaluated. OBJECTIVES:To assess the feasibility, acceptability, and signal success of ambulatory NIFECG monitoring and identify research areas required to facilitate clinical utilization of this method of monitoring. METHODS:Medline, EMBASE, and PubMed databases were searched from January 2005 to April 2021 using terms relevant to antenatal ambulatory or home NIFECG. The search was compliant with PRISMA guidelines, and was registered with the PROSPERO database (CRD42020195809). All studies reporting the clinical utilization of NIFECG inclusive of its use in the ambulatory setting performed in the antenatal period, human studies, and those in the English language were included. Those reporting novel technological methods and electrophysiological algorithms, satisfaction surveys, intrapartum studies, case reports and reviews, and animal studies were excluded. Study screening and data extraction were conducted in duplicate. Risk of bias was appraised using the Modified Downs and Black tool. Due to the heterogeneity of the reported findings, a meta-analysis was not feasible. RESULTS:The search identified 193 citations, where 11 studies were deemed eligible for inclusion. All studies used a single NIFECG system with a duration of monitoring ranging from 5.6 to 21.4 h. Predefined signal acceptance threshold ranged from 34.0-80.0%. Signal success in the study populations was 48.6-95.0% and was not affected by maternal BMI. Good signals were achieved in the 2nd trimester, but less so in the early 3rd trimester. NIFECG was a well-accepted method of FHR monitoring, with up to 90.0% of women's satisfaction levels when worn during outpatient induction of labor. Placement of the acquisition device needed input from healthcare staff in every report. CONCLUSIONS:Although there is evidence for the clinical feasibility of ambulatory NIFECG, the disparity in the literature limits the ability to draw firm conclusions. Further studies to establish repeatability and device validity, whilst developing standardized FHR parameters and set evidence-based standards for signal success for NIFECG are required to ascertain the clinical benefit and potential limitations of ambulatory outpatient FHR monitoring.

ABSTRACTObjectivePre‐eclampsia (PE) is a pregnancy complication associated with premature cardiovascular disease morbidity and mortality (i.e. before 60 years of age or in the first year postpartum). PE is associated with adverse left ventricular (LV) remodeling in the peri‐ and postpartum periods, an independent risk factor for cardiovascular disease. This study aimed to compare LV geometry by LV mass (LVM) and LVM index (LVMI) between participants with a high vs low screening risk for preterm PE in the first trimester.MethodsThis was a prospective cohort study of singleton pregnancies between 11 + 0 and 13 + 6 weeks' gestation that underwent screening for preterm PE as part of their routine first‐trimester ultrasound assessment at a tertiary center in London, UK, from February 2019 until March 2020. Screening for preterm PE was performed using the Fetal Medicine Foundation algorithm. Participants with a screening risk of ≥ 1 in 50 for preterm PE were classified as high risk and those with a screening risk of ≤ 1 in 500 were classified as low risk. All participants underwent two‐dimensional and M‐mode transthoracic echocardiography.ResultsA total of 128 participants in the first trimester of pregnancy were included in the analysis, with 57 (44.5%) participants screened as low risk and 71 (55.5%) participants as high risk for PE. The risk groups did not vary in maternal age and gestational age at assessment. Maternal body surface area and body mass index were significantly higher in the high‐risk group (all P < 0.05). The high‐risk participants were significantly more likely to be Afro‐Caribbean, nulliparous and have a family history of hypertensive disease in pregnancy as well as other cardiovascular disease (all P < 0.05). In addition, mean arterial blood pressure (P < 0.001), mean heart rate (P < 0.001), median LVM (130.06 (interquartile range, 113.62–150.50) g vs 97.44 (81.68–114.16) g; P < 0.001) and mean LVMI (72.87 ± 12.2 g/m2 vs 57.54 ± 12.72 g/m2; P < 0.001) were significantly higher in the high‐risk group. Consequently, those in the high‐risk group were more likely to have abnormal LV geometry (37.1% vs 7.0%; P < 0.001).ConclusionsEarly echocardiographic assessment in participants at high risk of preterm PE may unmask clinically healthy individuals who are at increased risk for future cardiovascular disease. Adverse cardiac remodeling in the first trimester of pregnancy may be an indicator of decreased cardiovascular reserve and subsequent dysfunctional cardiovascular adaptation in pregnancy. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Background Women with a history of hypertensive disorders of pregnancy (HDP) are at increased long-term risk of cardiovascular disease. However, there has been increasing evidence on the same risks in the months following birth. Objectives This review aims to estimate the incidence of hypertension in the first 2 years after HDP. Search strategy MEDLINE, Embase and Cochrane databases were systematically searched in October 2019. Selection criteria Observational studies comparing hypertension rate following HDP and normotensive pregnancies up to 2 years. Data collection and analysis A meta-analysis to calculate the odds ratio (OR) with a 95% confidence interval (CI) and a sub-group analysis excluding women with chronic hypertension were performed. Main results Hypertension was diagnosed within the first 2 years following pregnancy in 468/1646 (28.4%) and 584/6395 (9.1%) of the HDP and control groups, respectively (OR 6.28; 95% CI 4.18-9.43;I-2 = 56%). The risk of hypertension in HDP group was significantly higher in the first 6 months following delivery (OR 18.33; 95% CI 1.35-249.48;I-2 = 84%) than at 6-12 months (OR 4.36; 95% CI 2.81-6.76;I-2 = 56%) or between 1-2 years postpartum (OR 7.24; 95% CI 4.44-11.80;I-2 = 9%). A sub-group analysis demonstrated a similar increase in the risk of developing postpartum hypertension after HDP (OR 5.75; 95% CI 3.92-8.44;I-2 = 49%) and pre-eclampsia (OR 6.83; 95% CI 4.25-10.96;I-2 = 53%). Conclusions The augmented risk of hypertension after HDP is highest in the early postpartum period, suggesting that diagnosis and targeted interventions to improve maternal cardiovascular health may need to be commenced in the immediate postpartum period. Tweetable abstract The risk of hypertension within 2 years of birth is six-fold higher in women who experienced pre-eclampsia.

Patients with history of hypertensive disorders of pregnancy (HDP) are at increased risk of developing chronic hypertension and adverse cardiovascular events postpartum. The aim of this study is to evaluate postpartum maternal cardiovascular function at 3–6 months from delivery and compare cardiac changes between the peripartum and postpartum period. Prospective longitudinal study which enrolled women being delivered because of a diagnosis of HDP. Standard trans-thoracic echocardiography (TTE) was performed in the peripartum period and 3–6 months following the birth. Three cardiac cycles of non-compressed data were stored in cine-loop format and analysed off-line by an operator who was blinded to the diagnosis and timing of assessment. A total of 62 HDP patients were included in the present analysis. The mean maternal age was 34.9 years, 45.2% were primigravida and median gestation at delivery was 38.2 weeks. Postpartum women demonstrated improvement in left ventricle (LV) morphology and function with significant reductions in LV mass index (80.2 vs. 62.7 g/m2, P = 0.0001), relative wall thickness (0.43 vs. 0.37, P = 0.0001), rate of LV remodelling (56.5% vs. 24.2%, P = 0.002) and diastolic dysfunction (46.8% vs. 19.4%, P = 0.005) and improvement in global longitudinal strain (-15.4% vs. -16.5%, P = 0.010). There was a persistent impairment of hemodynamic function with a significant increase in systemic vascular resistance index (2897.1 vs. 3179.9 dynes*sec/cm5/m2, P = 0.031), reduction in cardiac index (2.9 vs. 2.5 L/min/m2, P = 0.0001) and lower heart rate (81 vs. 71 bpm, P = 0.0001) – all associated with a diagnosis of persistent hypertension in 24 (38.7%) at follow-up assessment. Although cardiac function and morphology improved considerably after a pregnancy complicated by HDP, the rate of persistent maternal hypertension at follow-up was significant. These findings have important implications for postpartum care after a hypertensive pregnancy.

Preterm pre-eclampsia has been associated with a more severe cardiac dysfunction in pregnancy than term pre-eclampsia. The aim of this study was to compare maternal cardiac and hemodynamic indices in women affected by hypertensive disorders of pregnancy (HDP) delivering before or after 37 weeks of gestation. Women with a diagnosis of HDP underwent transthoracic echocardiography (TTE) in the peripartum period. All the measurements were analysed off-line by an operator who was blinded to the diagnosis and gestational age. A total of 78 patients with HDP (30 preterm and 48 at term) were included in this study. These groups did no differ in maternal age (33.7 vs. 34.3 years, P = 0.705), booking BMI (26.8 vs. 26.9 Kg/m2, P = 0.910) and booking mean arterial pressure (MAP, 94.5 vs. 94.1 mmHg, P = 0.807). Significant differences were noted between preterm and term HDP for cardiac remodelling (73.3% vs. 54.2%, P = 0.045), heart rate (78 vs. 83 bpm, P = 0.037) and total vascular resistance (1737 vs. 1499 dynes*sec/cm5/m2, P = 0.026). No significant changes were found with regards to left ventricle systolic function, diastolic function, stroke volume index (35 vs. 36 mL/m2, P = 0.285) and cardiac index (2.8 vs. 3.0 L/m2, P = 0.202). MAP values were similar in both groups (preterm vs. term: 105 vs. 102.2 mmHg, p = 0.306). These findings demonstrate that women who required preterm delivery because of HDP demonstrated more severe cardiovascular impairment compared to those that delivered at term despite having similar blood pressures. Further research is required to understand if maternal cardiovascular impairment predates the pregnancy and/or persists into the postpartum period.

Changes in maternal cardiac function and morphology are common in patients affected by hypertensive disorders of pregnancy (HDP) and may be significantly affected by changes in volume and resistance load such as is known to occur at birth. The aim of this study is to compare echocardiographic findings immediately before birth with the early postpartum period in women with HDP. Prospective longitudinal study, where women with a diagnosis of HDP were enrolled and underwent standard transthoracic echocardiography (TTE) in the immediate prepartum and early postpartum period within one week of giving birth. Three cardiac cycles of non-compressed data were stored in cine-loop format and analysed off-line by an operator who was blinded to the timing of the assessment. 30 patients with HDP were included in this preliminary analysis. Mean age was 33.5 years, with 20 (66.7%) affected by pre-eclampsia. The prepartum assessment-to-birth and birth-to-postpartum assessment intervals were 5 and 3.5 days, respectively. Left ventricular (LV) concentric remodelling was the most frequent finding and did not exhibit significant peripartum variation (60% vs. 50%, P = 0.332). Similarly, there were no significant differences in other cardiac morphology indices (LV mass index [78.5 vs. 77.9 g/m2, P = 0.803], relative wall thickness [0.44 vs. 0.45, P = 0.748]) and systolic function indices (LV ejection fraction [57.1% vs. 56.5%, P = 0.483], global longitudinal strain [-15.7% vs. -15.2%, P = 0.369]). LV diastolic function parameters also did not demonstrate any peripartum variation – left atrium volume index (25.4 vs. 24.6 mL/m2, P = 0.692); lateral E' (0.12 vs. 0.13 m/sec, P = 0.134) and E/E' ratio (7.7 vs. 7.7, P = 0.893). The volume and resistance load changes associated with birth did not significantly influence maternal peripartum TTE indices. Maternal echocardiographic findings in HDP may be the consequence of chronic pregnancy volume and resistance load changes and therefore need longer to resolve in the postpartum period.

Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations. These women are known to have higher cardiovascular morbidity and mortality later in life in comparison with parous controls who had normotensive pregnancies. Several studies have demonstrated that women with preeclampsia present in a state of segmental impaired myocardial function, biventricular chamber dysfunction, adverse biventricular remodeling, and hypertrophy, a compromised hemodynamic state and indirect echocardiographic signs of localized myocardial ischemia and fibrosis. These cardiac functional and geometric changes are known to have strong predictive value for cardiovascular disease in non-pregnant subjects. A "dose effect" response seems to regulate this relationship with severe HDP, early-onset HDP, coexistence of fetal growth disorders, and recurrence of HDP resulting in poorer cardiovascular measures. The mechanism underlying the relationship between HDP in younger women and cardiovascular disease later in life is unclear but could be explained by sharing of pre-pregnancy cardiovascular risk factors or due to a direct impact of HDP on the maternal cardiovascular system conferring a state of increased susceptibility to future metabolic or hemodynamic insults. If so, the prevention of HDP itself would become all the more urgent. Shortly after delivery, women who experienced HDP express an increased risk of classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile, and diabetes with higher frequency than controls. Within one or two decades after delivery, this group of women are more likely to experience premature cardiovascular events, such as symptomatic heart failure, myocardial ischemia, and cerebral vascular disease. Although there is general agreement that women who suffered from HDP should undertake early screening for cardiovascular risk factors in order to allow for appropriate prevention, the exact timing and modality of screening has not been standardized yet. Our findings suggest that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, stop smoking, healthy diet, and daily exercise which are well-established and cost-effective prevention strategies.

Maternal uterine artery blood flow is critical to maintaining the intrauterine environment, permitting normal placental function, and supporting fetal growth. It has long been believed that inadequate transformation of the maternal uterine vasculature is a consequence of primary defective trophoblast invasion and leads to the development of preeclampsia. That early pregnancy maternal uterine artery perfusion is strongly associated with placental cellular function and behaviour has always been interpreted in this context. Consistently observed changes in pre-conceptual maternal and uterine artery blood flow, abdominal pregnancy implantation, and late pregnancy have been challenging this concept, and suggest that abnormal placental perfusion may result in trophoblast impairment, rather than the other way round. This review focuses on evidence that maternal cardiovascular function plays a significant role in the pathophysiology of preeclampsia.