BACKGROUND:Magnesium sulfate is highly effective for the prophylactic treatment of preeclampsia with severe features, as well as the prevention of recurrent eclamptic seizures. The consequences of developing eclampsia despite treatment with magnesium sulfate prophylaxis have received little attention. OBJECTIVE:Our aim was to describe maternal and perinatal consequences in patients who develop eclampsia despite treatment with magnesium sulfate therapy. STUDY DESIGN:This was a retrospective study of all patients with eclampsia over 13 years at a single institution. Eclampsia was diagnosed in accordance with the criteria outlined in the 2013 Executive Summary of the American College of Obstetricians and Gynecologists. Hospital records of patients experiencing eclampsia and their perinatal outcomes were independently reviewed by two faculty obstetricians in the Maternal-Fetal Medicine Division. RESULTS:During the 13-year study period, a total of 166,492 patients were delivered at our institution, with 15,689 (9.4%) receiving magnesium sulfate for seizure prophylaxis in the setting of preeclampsia with severe features or for treatment of eclampsia. One hundred twenty-three patients developed eclampsia (7.4 per 10,000 births), with 94 eclamptic seizures occurring in-hospital. Of these, 26 (21%) seizures occurred despite receiving magnesium sulfate prophylaxis in the setting of preeclampsia with severe features or prior eclampsia. Two-thirds of the 26 (65%) patients developed eclampsia despite a therapeutic (4.8-8.4 mg/dL) serum magnesium concentration following magnesium sulfate administration prior to the convulsion(s). Six occurred prior to routine evaluation of serum magnesium level 2 hours following the loading dose and 3 patients experienced an eclamptic seizure associated with a sub-therapeutic magnesium serum concentration. Maternal outcomes of these 26 patients were as follows: 10 (38%) experienced multiple eclamptic seizures despite magnesium sulfate therapy, 8 (31%) underwent immediate endotracheal intubation following the eclamptic seizure, 6 (23%) developed HELLP syndrome, 5 (19%) required admission to the intensive care unit, 3 (12%) developed aspiration pneumonia, and 3 (12%) experienced placental abruption. Compared to patients with in-hospital eclampsia prior to receiving magnesium sulfate, patients with eclampsia following magnesium sulfate were more likely to have more than one seizure (P<.01), require endotracheal intubation (P=.03), and develop HELLP syndrome (P<.01). The infants of patients with eclampsia following administration of magnesium sulfate were more likely to be admitted to the neonatal intensive care unit (P=.02). CONCLUSION:While magnesium sulfate is highly effective in preventing eclampsia, there are patients who experience eclamptic seizures despite magnesium sulfate with resultant morbidity. Eclampsia occurred in 26 (28%) of 94 patients experiencing in-hospital eclamptic seizures at our institution despite receiving magnesium sulfate. Of these 26 patients, the serum magnesium level was within the desired therapeutic range in 65% of patients before the eclamptic episode. Patients who developed eclampsia despite receiving magnesium sulfate prophylaxis experienced significant severe maternal morbidity, including more than one eclamptic seizure, maternal tracheal intubation, HELLP syndrome, and their infants were more likely to be admitted to the neonatal ICU.

To examine whether administration of intravenous ferric carboxymaltose (Injectafer) to patients with severe anemia in the third trimester improves maternal outcomes. This is a retrospective cohort study of patients delivering liveborn infants between 1/1/2019 and 7/7/2022 with severe iron-deficiency anemia diagnosed in the third trimester, defined as hemoglobin < 8 g/dL or hematocrit < 25% and either iron level < 40mcg/dL or ferritin < 15ng/mL. On 10/28/2020, Injectafer was made available for pregnant patients at our institution and 2 infusions spaced 1 week apart were recommended for the treatment of severe anemia diagnosed in the third trimester to patients unresponsive to or unable to tolerate oral iron formulations. Patients were divided into 2 cohorts, those who delivered before (cohort 1) and after (cohort 2) the initiation of Injectafer therapy. Maternal characteristics, lab values, and transfusion rates were compared between cohorts. Statistical analyses included chi-square, t-test, and Kruskal-Wallis tests. There were 124 patients meeting inclusion criteria, 53 patients in cohort 1 and 71 patients in cohort 2. Fourteen patients in cohort 2 did not receive Injectafer due to delivery prior to administration, 17 received one dose, and 40 completed two doses. Laboratory indices were similar between groups except for a higher starting hemoglobin at the time of diagnosis in cohort 1 (Table). A dose-response was noted immediately prior to delivery with median hemoglobin rising to 10.8 g/dL in the group receiving two doses, compared to a median of 8.4 g/dL for patients in cohort 1, p< 0.0001 (Figure). Additionally, patients who received Injectafer were less likely to require transfusion at delivery with transfusion rates of 26% in epoch 1 compared with 2.5% in patients who received 2 doses, p< 0.001. Administration of Injectafer for the treatment of severe anemia in the third trimester improves pre-delivery hemoglobin and decreases the need for peripartum transfusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND: COVID-19 infection is associated with increased morbidity in pregnancy and adverse maternal and neonatal outcomes. Little is currently known about how the timing of infection during pregnancy affects these outcomes. OBJECTIVE: This study aimed to evaluate the effect of trimester of COVID-19 infection on disease progression and severity in pregnant patients. STUDY DESIGN: This was a prospective cohort study of pregnant patients diagnosed with COVID-19 infection who delivered at a single urban hospital. Universal testing for SARS-CoV-2 was performed at hospital admission and for symptomatic patients in inpatient, emergency department, and outpatient settings. Disease severity was defined as asymptomatic, mild, moderate, severe, or critical on the basis of National Institutes of Health criteria. We evaluated disease progression from asymptomatic to symptomatic infection and from asymptomatic or mild infection to moderate, severe, or critical illness, and stratified by trimester of COVID-19 diagnosis. Primary outcomes included progression of COVID-19 disease severity and a composite obstetrical outcome, which included delivery at <37 weeks, preeclampsia with severe features, abruption, excess blood loss at delivery (>500 mL for vaginal or >1000 mL for cesarean delivery), and stillbirth. RESULTS: From March 18, 2020 to September 30, 2021, 1326 pregnant patients were diagnosed with COVID-19 and delivered at institution, including 103 (8%) first-, 355 (27%) second-, and 868 (65%) third-trimester patients. First-trimester patients were older and had more medical comorbidities; 86% of patients in all trimesters were Hispanic. Among patients admitted within 14 days of a positive test, 3 of 18 (17%) first-trimester, 20 of 47 (43%) second-trimester, and 34 of 574 (6%) third-trimester patients were admitted for the indication of COVID-19 illness. Across all trimesters, 1195 (90%) of 1326 COVID-19 infections were asymptomatic or mild, and 45 (10%) of 436 initially asymptomatic patients developed symptoms. Of patients with asymptomatic or mild symptoms at diagnosis, 4 (4%) of 93 first-, 18 (5%) of 337 second-, and 49 (6%) of 836 third-trimester patients developed moderate, severe, or critical illness (P=.80). There was no significant difference in composite obstetrical outcome with respect to trimester of COVID-19 diagnosis (24% first-trimester, 28% second-trimester, 28% third-trimester patients; P=.69). CONCLUSION: Moderate, severe, or critical illness develops in almost 10% of pregnant patients. The frequency of COVID-19 disease progression in pregnancy does not differ by trimester of diagnosis.

BackgroundThe definition for anemia in pregnancy is outdated, derived from Scandinavian studies in the 1970's to 1980's. To identity women at risk of blood transfusion, a common cause of Severe Maternal Morbidity, a standard definition of anemia in pregnancy in a modern, healthy United States cohort is needed.ObjectiveTo define anemia in pregnancy in a United States population including a large county vs. private hospital population using uncomplicated patients.Materials and methodsInclusion criteria were healthy women with the first prenatal visit before 20 weeks. Exclusion criteria included preterm birth, preeclampsia, hypertension, diabetes, short interval pregnancy (<18 months), multiple gestation, abruption, and fetal demise. All women had iron fortification (Ferrous sulfate 325 mg daily) recommended. The presentation to care and pre-delivery hematocrits were obtained, and the percentiles determined. A total of 2000 patients were included, 1000 from the public county hospital and 1000 from the private hospital. Each cohort had 250 patients in each 2011, 2013, 2015, and 2018. The cohorts were compared for differences in the fifth percentile for each antepartum epoch. Student's t-test and chi-squared statistical tests were used for analysis, p-value of ≤0.05 was considered significant.ResultsIn the public and private populations, 777 and 785 women presented in the first trimester while 223 and 215 presented in the second. The women at the private hospital were more likely to be older, Caucasian race, nulliparous, and present earlier to care. The fifth percentile was compared between the women in the private and public hospitals and were clinically indistinguishable. When combining the cohorts, the fifth percentile for hemoglobin/hematocrit was 11 g/dL/32.8% in the first trimester, 10.3 g/dL/30.6% in the second trimester, and 10.0 g/dL/30.2% pre-delivery.ConclusionsFifth percentile determinations were made from a combined cohort of normal, uncomplicated pregnancies to define anemia in pregnancy. Comparison of two different cohorts confirms that the same definition for anemia is appropriate regardless of demographics or patient mix.

Chronic hypertension (CHTN) is associated with adverse maternal and neonatal outcomes. Additionally, CHTN has been identified as a risk factor for severe COVID-19 infection in the general population. We evaluated the impact of COVID-19 on adverse outcomes in pregnant patients with chronic hypertension. This is a prospective cohort study of pregnant patients with chronic hypertension (with or without antihypertensive medication use) who delivered at a single urban healthcare system from January 1, 2020 to May 31, 2021. We identified PCR-confirmed COVID-19 infections with universal COVID-19 PCR testing at hospital admission and symptomatic testing in inpatient, emergency department and outpatient settings. Obstetric and neonatal outcomes were compared among those with and without COVID-19 during pregnancy. The primary composite outcome included delivery < 37 weeks, preeclampsia with severe features, abruption, excess blood loss ( > 500mL for vaginal or > 1000mL for cesarean) and stillbirth. During the study period, 738 patients met inclusion criteria, and 54(7%) were diagnosed with COVID-19 infection. Mean age, race and BMI at first prenatal visit did not differ between groups (Table 1). Pregestational diabetes was prevalent in 7/54(13%) with and 91/564(13%) without COVID-19 (p=0.94). The frequency of the primary composite outcome did not differ in patients with or without COVID-19 during pregnancy (32(59%) vs 397(60%), OR 0.97(95%CI 0.55,1.71)) (Table 2). The frequencies of individual outcomes were also similar between groups. Among patients with chronic hypertension, COVID-19 infection during pregnancy does not have an additive effect on adverse maternal and perinatal outcomes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To determine whether COVID-19 disease progression differs in women with gestational and pregestational diabetes as compared to women without diabetes. This is a prospective cohort study of disease progression among all inpatient and outpatient pregnancies with PCR-confirmed COVID-19 who delivered at a single institution. Medical record review identified disease severity defined as asymptomatic, mild, moderate, severe, or critical based on National Institutes of Health (NIH) criteria. We evaluated maternal characteristics, severity of COVID-19 illness at diagnosis and progression of symptoms following initial positive test according to diabetes class. Between March 1, 2020 and May 31, 2021, 1092 patients were diagnosed with COVID-19 during pregnancy, including 992(91%) patients without diabetes, 75(7%) with gestational diabetes and 25(2%) with pregestational diabetes. Pregestational diabetics were older, diagnosed at an earlier gestational age and had a higher BMI at time of diagnosis compared to gestational diabetics and non-diabetics; Hispanic ethnicity predominated across cohorts (Table 1). Gestational age < 37 weeks at delivery occurred more frequently among pregestational diabetics compared with gestational and non-diabetics (12(48%) vs 9(12%) vs 113(11%), respectively, p < 0.001). There was no difference in frequency or severity of COVID-19 symptoms at initial diagnosis among the cohorts (p=0.38) (Table 2). Progression from asymptomatic or mild to moderate illness to severe or critical illness with oxygen requirement occurred with increasing frequency among non-diabetics (30/992(3.0%)), gestational (5/75(6.7%)), and pregestational diabetics (2/25(8.0%)), (p=0.04 for trend). There is increased maternal and neonatal morbidity among patients with diabetes and COVID-19 in pregnancy. Progression to severe or critical pulmonary illness with oxygen requirement occurred with increasing frequency among non-diabetics, gestational and pregestational diabetics.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

INTRODUCTION: To evaluate how the diagnosis of major fetal anomalies and resulting pregnancy outcomes affected the risk of postpartum depression, as assessed by the Edinburgh Postnatal Depression Scale (EPDS). METHODS: Singleton pregnancies with prenatal diagnosis of major fetal anomalies were ascertained from prospectively-maintained databases that included perinatal outcomes and subsequent EPDS responses from 1/2010 to 5/2018. EPDS scores ≥13 were considered positive and prompted referral for mental health follow-up, which was verified by electronic chart review. Statistical analyses were performed using odds ratios and χ2 with P<.05 considered significant. IRB approval was obtained. RESULTS: 912 women had a prenatal diagnosis of an anomalous fetus and postpartum EPDS screening, and 82 (9%) screened positive. Positive screening was more common with multiple fetal anomalies (15.3% vs 8.0%, P=.004) or aneuploidy (17.1% vs 8.6%, P=.02). Pregnancies complicated by fetal death (N=79, 8.6%), neonatal death (N=52, 5.7%), and termination for anomaly (N=69, 7.6%) were significantly more likely to screen positive than those with neonatal survival to discharge (all OR >2, P<.001). 34 (40%) screen-positive women attended their follow-up appointment with a mental health provider, and 18 (53%) were diagnosed with a depressive disorder. CONCLUSION: Women with prenatal diagnosis of major fetal anomalies and perinatal loss had a two-fold increased likelihood for positive depression screening using EPDS. More than half of screen positive women who seek mental health follow-up were diagnosed with a depressive disorder. Effective screening with intervention is warranted in this vulnerable population.

COVID-19 infection is associated with increased morbidity in pregnancy. We evaluate the effect of trimester of COVID-19 infection on disease progression in pregnant patients. This is a prospective cohort study of pregnant patients diagnosed with PCR-confirmed COVID-19 infection who delivered at a single urban hospital. Universal COVID-19 PCR testing was performed at hospital admission as well as for symptomatic patients in inpatient, emergency department and outpatient settings. Disease severity was determined by review of medical records and defined as asymptomatic, mild, moderate, severe, or critical based on National Institutes of Health (NIH) criteria. We evaluated disease progression from asymptomatic to symptomatic infection, stratified by trimester of COVID-19 diagnosis. From March 18, 2020 to May 31, 2021, 1092 pregnant patients were diagnosed with COVID-19, including 67(6%) first trimester, 309(28%) second trimester, and 716(66%) third trimester. There were no significant demographic differences between groups; 87% of patients in all trimesters were Hispanic. Among patients admitted within 14 days of a positive test, 2(15%) first trimester, 16(47%) second trimester, and 24(5%) third trimester patients were admitted for the indication of COVID-19 illness (Table 1). Across all trimesters, 993/1092(90.9%) of COVID-19 infections were asymptomatic or mild, and 35/345(10.1%) of asymptomatic patients developed symptoms. Of patients with asymptomatic or mild symptoms at diagnosis, 2/62(3.2%) first, 15/295(5.1%) second, and 36/689(5.2%) third trimester patients developed moderate, severe, or critical illness (p=0.79) (Table 2). Moderate, severe, or critical illness develops in almost 10 percent of pregnant patients. The frequency of COVID-19 disease progression in pregnancy does not differ by trimester of diagnosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To determine if COVID-19 infection increases adverse outcomes in pregnant patients with insulin-controlled diabetes. This is an observational cohort study of pregnancy outcomes among insulin-controlled gestational and pregestational diabetic patients with and without PCR-confirmed COVID-19 who delivered at a single institution between January 1, 2020 and May 31, 2021. COVID-19 PCR testing protocols included universal screening on hospital admission and symptomatic testing in inpatient, emergency department and outpatient areas. The primary composite outcome included delivery at < 37 weeks, preeclampsia with severe features, placental abruption, excess blood loss ( > 500mL for vaginal or > 1000mL for cesarean) and stillbirth. During the study period, 285 pregnant patients met inclusion criteria, including 27(9%) with and 258(91%) without COVID-19 infection. There was no difference in age, BMI, or race; Hispanic ethnicity predominated in COVID19-positive (25(93%)) and negative 196(76%) groups (p=0.26) (Table 1). Compared to uninfected patients, the composite primary outcome occurred more frequently among diabetic patients with COVID-19 (18(67%) vs 114(44%), OR 2.53 (95%CI 1.09,5.83) (Table 2). Delivery < 37 weeks occurred more frequently among insulin-controlled diabetic patients with COVID-19 (13(48%) vs 61 (24%), OR 3.00 (95%CI 1.34,6.73). Specifically, spontaneous preterm birth was increased in insulin-controlled diabetic patients with COVID-19 compared to patients without COVID-19 during pregnancy (4(15%) vs 11(4%), OR 3.47 (95%CI 1.19,10.17). Other neonatal outcomes did not differ. There is increased pregnancy morbidity among patients with insulin-controlled diabetes and COVID-19. Excess morbidity is driven by preterm delivery risk, which includes both spontaneous and iatrogenic deliveries.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

To compare the frequency, staging, and treatment of maternal syphilis cases and infant evaluations before and after implementing a reverse screening algorithm (using a treponemal-specific antibody assay) at a high-volume public hospital. On May 16, 2018, our hospital laboratory switched from a Traditional to a Reverse Sequence Screening algorithm. We prospectively identified deliveries to women with reactive syphilis screening tests between May 16-Dec 31, 2018, and compared these to a retrospective cohort of deliveries identified one year prior, May 16-Dec 31, 2017. We compared the number of women with reactive screening tests according to study week in each cohort. We evaluated maternal demographics, syphilis staging and treatment, and infant outcomes in 2017 and 2018. The number of women with reactive screening tests was higher throughout the study period following implementation of the reverse algorithm (Figure 1). The total number of women with reactive screening tests more than doubled, from 45 (2017) to 122 (2018); total deliveries were similar. There was no difference in age, parity, mode of delivery, or gestational age at delivery. There were more Black women with reactive treponemal antibodies in the 2018 cohort (57% in 2018 vs 36% in 2017, p=0.02). Compared with 2017, the proportion of women with previously treated syphilis increased in 2018 (43% from 20%), the frequency of untreated syphilis remained relatively unchanged (51% in 2017 vs 47% in 2018), and the frequency of false positive tests declined (29% in 2017 vs 13% in 2018) (overall p=0.003) (Table 1). Relative to 2017, the proportion with nonreactive RPR increased (61% vs 16%, p< 0.001). Although the proportion of treated women remained similar, absolute numbers requiring treatment doubled. Similarly, absolute numbers of infants undergoing lumbar puncture and receiving treatment increased two to three-fold. Implementation of the reverse syphilis screening algorithm results in a three to four-fold increase in the frequency of RPR-nonreactive maternal cases requiring evaluation and possible treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

There is sparse data for normal values constituting the definition of anemia in pregnancy in the United States population. The Centers for Disease Control and the American College of Obstetricians and Gynecologists define anemia in pregnancy as values of hematocrit less than the fifth percentile for the population. We sought to determine a standardized definition of anemia in a normal, uncomplicated gravid population. Inclusion criteria were patients with the first prenatal visit before 20 weeks. Exclusion criteria included preterm birth, preeclampsia, hypertension, diabetes, short interval pregnancy (< 18 months), multiple gestation, abruption, and fetal demise. All women had iron fortification (Ferrous sulfate 325 mg daily) recommended. The presentation and pre-delivery hematocrits were obtained, and the percentiles determined. In order to evaluate a time-independent, representative normal cohort, 240 women in each 2011 and 2018 were studied. Population based pre-delivery hematocrits in 2011 and 2018 were obtained for comparison. The mean hematocrit at presentation to care was 36.9 ± 2.8% with 31.9% as the fifth percentile. Of those presenting in the first trimester (n=91), the mean hematocrit was 37.5 ± 3.3% with 32.8% as the fifth percentile. The mean hematocrit of patients presenting in the second trimester (n=389) was 36.7± 2.6% with 31.8% as the fifth percentile. The mean pre-delivery hematocrit was 35.7 ±3.3% with the fifth percentile of 30.0%. The pre-delivery hematocrit was 35.7± 3.2% in 2011 and 35.7 ± 3.5% in 2018 with the fifth percentile 30.0% and 30.0% respectively. In the overall population (n=22,902), the pre-delivery hematocrit was 33.0 ± 4.5% with the fifth percentile of 25.9%. We were able to produce a normal distribution curve for pre-delivery hematocrits. A hematocrit value of 32.8% in the first trimester, 31.8% in the second trimester, and 30.0% pre-delivery can be used as cutoff values for diagnosing anemia in normal pregnancy. Comparison to the entire population demonstrates the importance of basing the cutoff value on normal pregnancies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Objectives To assess pulmonary artery pressure and cardiac remodeling in pregnancy in women with pulmonary hypertension and compare these findings with studies done beyond three months postpartum. Study design Pregnant women with pulmonary hypertension from 2006 to 2017 were studied. Pulmonary hypertension was diagnosed when the pulmonary artery pressure exceeded 30 mmHg as estimated by right ventricular systolic pressure (RVSP) on echocardiography or 20 mmHg measured directly by mean pulmonary artery pressure (PAPm) with right-heart catheterization (RHC). Disease severity was assigned using threshold cutoffs. Indices of cardiac remodeling were compared during pregnancy after 20 weeks' gestation and again beyond three months postpartum when available. Pulmonary artery pressures obtained by echocardiography versus right-heart catheterization were also compared. Results Forty-six pregnancies complicated by pulmonary hypertension in 41 women were identified. The study included 43 pregnancies that resulted in a livebirth. There were 20 women in whom studies were performed after 20 weeks' gestation and again at least 3 months postpartum or later. Pulmonary artery pressures determined during pregnancy versus beyond three months postpartum were not significantly different when measured by echocardiography (RVSP 53.5 +/- 20.5 mmHg and 46.7 +/- 20.4 mmHg, p = .26) in this limited cohort. In the 10 women in whom pulmonary artery pressures were measured with both echocardiography and right-heart catheterization, the former was found to significantly overestimate directly measured pulmonary artery pressure (63.3 +/- 20.7 versus 37.7 +/- 12.3 mmHg, p < .001). Conclusion Pulmonary artery pressures did not appreciably change during pregnancy after 20 weeks' gestation compared with pressures measured again beyond three months postpartum. Women with pulmonary hypertension did not show evidence of remodeling of left ventricular mass or relative wall thickness when measured in pregnancy after 20 weeks' gestation compared with beyond three months postpartum in this limited cohort. These findings suggest that cardiac remodeling in women with pulmonary hypertension is different from that of normally pregnant women and confirms the need for careful long-term follow-up.

To characterize cardiac physiology in pregnant women with pulmonary hypertension (pHTN) and to compare these measurements when taken during the remote postpartum period (> 12 weeks). Pregnant women with pHTN who delivered within our healthcare system from 2011 to 2017 were studied. pHTN was diagnosed when the pulmonary artery systolic pressure exceeded 25 mmHg as estimated by right ventricular systolic pressure (RVSP) on echocardiography or measured directly by mean pulmonary artery pressure (PAPm) on right heart catheterization (RHC). Primary outcomes included comparison of pregnant versus remote postpartum measurements of pulmonary artery pressure (PAP), left-ventricular ejection fraction (LVEF), left- ventricular mass index (LVMi), and relative wall thickness (RWT). Statistical analyses performed included Pearson correlation coefficient and student's t-test. A total of 41 pregnancies with pHTN in 36 women were identified, and there were 18 pregnancies in which these studies were performed again > 12 weeks postpartum. As shown in Figure 1, pulmonary artery pressures determined during pregnancy versus remote postpartum were not significantly different (50.9 ± 18.6 mmHg and 46.1 ± 19.7 mmHg, p=0.18). LVEF, LVMi, and RWT were also not significantly different between these two time points (Table 1). In the 14 women in whom both an initial RVSP and PAPm in pregnancy were performed, RVSP was found to overestimate directly measured pulmonary artery pressure (54.1±20.4 versus 33.9 ±10.2 mm Hg, p = 0.0004). These data allow us to make at least three observations: (1) Pulmonary artery pressure does not appreciably change during pregnancy compared with pressure in the remote postpartum period. Thus, the long- term need for follow-up should be emphasized even when mild, asymptomatic pHTN is diagnosed. (2) Woman with pHTN do not show evidence of change in left ventricular mass index or relative wall thickness when measurements in pregnancy are compared with those in the remote postpartum period. Thus, cardiac remodeling in these women is different from that of normally pregnant women. (3) Echocardiography in pregnancy overestimates PAPm compared with direct measurement by RHC. This confirms observations of others that RHC measurements should be used for major management decisions.View Large Image Figure ViewerDownload Hi-res image Download (PPT)