MINISTRY OF EDUCATION
MINISTRY OF DEFENSE
AND TRAINING
MILITARY MEDICAL UNIVERSITY
LE HOANG OANH
A STUDY ON CHANGES IN SOME MORPHOLOGICAL,
FUNCTIONAL AND HEMODYNAMIC PARAMETERS OF
LEFT VENTRICULAR BY UNLTRASOUND DOPPLER
CARDIAC ON PREGNANT WOMEN AND PREELAMPSIA
WOMEN
SYNOPSIS OF MEDICAL DOCTORAL THESIS
SPECIALITY: CARDIOVASCULAR INTERNAL MEDICINE DEPT
CODE: 62 72 01 41
HA NOI 2018
The study was completed at:
MILITARY MEDICAL UNIVERSITY
Instructors:
1. Assoc, Prof PhD: DINH THI THU HUONG
2. Assoc, Prof PhD: PHAM NGUYEN SON
ỗ
ợ Critic 1: GS.TS Đ Doãn L i
Critic 2: PGS.TS Ngô Văn Tài
ễ
ế
Critic 3: PGS.TS Nguy n Vi
t Trung
The thesis will be defended at the Council of School level
at: Military Medical University
at ....o'clock ..... day ...... month ..... year 2018
Thesis can be found in the library:
1 Vietnam National Library
2 Military Medical University Library
THE PUBLISHED ARTICLES RELATED
TO THE STUDY
1. Le Hoang Oanh ; Dinh Thi Thu Huong ; Pham Nguyen Son,
Nguyen Duc Cong, Nguyen Thi Minh Tam (2013). Study of altered
left ventricular geomatry and structural cardiac in normal pregnancy and
women with preeclampsia. Journal of Military Pharmacomedicine, 38
(3): 1723.
2. Le Hoang Oanh ; Dinh Thi Thu Huong ; Pham Nguyen Son,
Nguyen Duc Cong, Nguyen Thi Minh Tam (2013). Study of changers
of heat morphology and structure in normal during prenancy. Journal of
Military Pharmacomedicine, 38 (5): 47152.
1
INTRODUCTION
Nowadays, cardiovascular disease in pregnancy has been growing in the developed and developing countries. Maternal hypertension accompanied by proteinuria (preeclampsia) is one of the most important causes associated with increased rates of cardiovascular disease (stroke, myocardial infarction and heart failure...) during in the pregnancy, childbirth, and possibly postpartum; was delayed fetal growth restriction, earlyonset preeclampsia and death. Currently, women should be checked and assessed for cardiovascular disfunction and ultrasound Doppler was necessary for pregnancy to determine because of noninvasive method, nonharmful examination, inexpensive and safe. On the other hand, it was the good method for assessing the overall maternal morphology, structure and function heart. Particularity, Color tissue Doppler study for assessing morphologic, structural and left ventricular diastolic dysfunction (LVDD) in maternal women has been highly appreciated by scientists around in the world. However, it is not interested in going studying in Vietnam. The aim study has been investigated:
1. Investigated some parameters of morphology, left ventricular function and hemodynamic changes by using Doppler cardiac ultrasonography in normal pregnancy and preeclampsia.
2. Find the relationship between the parameters of morphology, left ventricular function and hemodynamic changes and some clinical, subclinical characteristics with normal pregnancy and preeclampsia.
The new main scientific contributions of the thesis:
This is a relatively comprehensive firstever scientific study of changes in morphological, functional left ventricular and hemodynamic parameters of normal pregnancy and preeclampsia (PE) in Viet Nam with new contributions as follows:
1. Left ventricular hypertrophy in normal pregnancy group (NPG) was increased according to gestational trimester, especially in PE group, the rate of left ventricular hypertrophy was higher than that of NPG (p <0.001). Left ventricular diastolic dysfunction in PE was also significantly higher than that of NPG (p <0.001). The changes of hemodynamic in the normal pregnancy: the rate of cardiac output (CO) increased and the rate of total peripheral vascular resistance (TVR) decreased from the first gestation period to the 3rd trimester of NPG. In particular, the increase of total vascular resistance in PE was higher than that of the NPG with 19.7 times (p <0.001). This significance of changes about morphological, functional and hemodynamic parameters were closely related to cardiovascular disease and other important complications during pregnancy, childbirth, and possibly postpartum.
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2. When pregnant women had been PE who has associated symptoms such as severe hypertension, proteinuria, elevated liver enzymes, thrombocytopenia, elevated creatinine and hyperuricemia, their risk of concentric hypertrophy and left ventricular diastolic dysfunction is significantly higher than that of pregnant women with PE without these symptoms (p < 0.001). In particular, for pregnant women with PE who give birth ≤ 34 weeks, newborn weight ≤ 2500 g, the incidence of concentric hypertrophy and left ventricular diastolic dysfunction is significantly higher than that of those who give birth > 34 weeks and newborn weight > 2500 g (p < 0.001). These characteristics help Cardiology clinical practitioners and Obstetrics Gynecology clinical practitioners in assessing the prognosis of PE associated with the above mentioned symptoms; they should be addressed in specialized medical facilities to be given treatment and closely monitored to avoid the risk of cardiovascular complications for the mothers, other dangerous complications as well as complications for the fetus.
3. There is a high correlation between the changes of cardiac morphology and structure in the PE (especially relative wall thicknessRWT) and left ventricular diastolic dysfunction with OR (95%, CI) = 29.4 (1.6 541.6), p < 0.001. Therefore, in medical facilities without Doppler ultrasound (or without Tissue Doppler Imaging), only 2D/ TM cardiac ultrasound provided, the cardiac morphology and structure may also be preliminarily assessed, thereby predicting the left ventricular diastolic function of the patient to anticipate cardiovascular disease in this object.
4. This study opens the way for further research to monitor the postpartum complications of cardiovascular disease in the PE, aimed at timely monitoring and management of preventive treatment to minimize the risk of postpartum cardiovascular disease and death for PE.
* Thesis structure: The thesis consists of 131 pages (excluding annexes and references): 2 pages for Introduction; 33 pages for Overview; 18 pages for Subjects and Methods; 37 pages for Results; 36 pages for Discussion; 3 pages for Conclusion. The research results consist of: 39 tables, 22 charts and 2 diagrams. There are 160 references, including 37 Vietnamese and 123 English documents.
Chapter 1: OVERVIEW
1. Cardiovascular disease changes in the PE
1.1. Definition of the PE
PE is usually diagnosed based on proteinuria (≥ 0.3 g/ 24 hours) in line with systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥
3 90 mmHg occuring from the 20th week of pregnant women with normal blood pressure previously or chronic hypertension during pregnancy.
Diagnosis of degree of PE according to ACOG (2013) standards.
1.2. Mechanism of disease causing cardiovascular dysfunction in pregnant women
with PE
During pregnancy, the cells in the cytotrophoblast move to the tortuous uterine arteries, replace the capillary endothelial cells, destroy the elasticity of the middle layer, smooth muscle, and nervous tissue. At the end of the second trimester, the tortuous uterine arteries are damaged by the cells in the cytotrophoblast, the endothelial cells that are not permanently present in the inner membrane of uterine, causing damage to the small blood vessel system, reducing artery diameter, increasing capillary viscosity, reducing blood supply to the fetus, resulting in tissue hypoxia thereby producing chemical intermediates that cause hypertension and damage for kidney, brain and liver.
α
In normal pregnant women, the increase in intravascular volume, high cardiac output and vasodilation shall reduce peripheral resistance, whereas in PE, there is a decrease in intravascular volume, cardiac output, cardiac index and contraction, thereby increasing TVR and pulmonary capillary wedge pressure. The reduction in uterine artery blood flow results in the ischemic placental disease, causing the endothelial cells to release some elements such as increase in endothelin1 causing smooth muscle contraction, increase in cytokine and chemical intermediates causing inflammatory response, reduction in nitric oxide in kidney, reduction in prostaglandin levels, increase in antibody for resistance to activated receptor of Angiotensin II, increase in TNF resulting in reduction in blood flow to kidney and increase in peripheral resistance to hypertension. Hemodynamic changes such as increase in heart rate, increase in cardiac output in the first period, increase in systemic vascular resistance, especially hypertension in the PE, result in the increase in cardiac work and left ventricular diastolic filling pressure. At the same time, diastolic dysfunction along with the effects of increased activity of the reninangiotensinaldosterol system increases myocardial fibrosis.
Volumetric overload, increased myocardial fibrosis and myocardial fiber shortening ultimately lead to the increase in the left ventricular mass, thickening of the heart wall, and ectasia of chambers of the heart, in association with the changes and restructuring of the left ventricular wall, thereby change the cardiac morphology and structure, including: concentric hypertrophy, eccentric hypertrophy, cardiac valve regurgitation and pericardial effusion.
Pregnant women with preeclampsia due to insulin resistance, hypercoagulability and ischemic placental disease shall release chemical intermediates causing inflammation
α
4 such as interleukin6 (IL6), cytokine, TNF ... along with the risk factors associated with PE, resulting in metabolic transformation and circulatory system changes, hypertension and myocardial ischemia, thereby causing changes in the cardiac morphology and structure, left ventricular diastolic dysfunction, especially PE have delayed fetal development inside the womb, morphology and structure changes, left ventricular systolic and diastolic dysfunction, which result in arrhythmias and heart failure.
2. Assessment of the left ventricular morphology, structure, hemodynamic changes
and function by cardiac ultrasound in women with normal pregnancy and
PE
2.1. Assessment of cardiac morphology and structure
Left ventricular mass: LVM and Left ventricular mass index: LVMI Relative wall thickness: RWT
2.2. Assessment of systolic function and left ventricular hemodynamic features
Cardiac output (CO) and Cardiac index (CI) Total peripheral vascular resistance (TVR) and TVR index
2.3. Functional assessment and classification of diastolic dysfunction: according to ASE (American Society of Echocardiography) 2016
2.4. Research situation on cardiac morphology and function by Doppler cardiac
ultrasound in women with normal pregnancy and preeclampsia
Alicia T. Dennis (2010) had studied in 40 PE patients, then compared to NPG and nonpregnant women. The author found the statistically significant differences (p < 0.01; ANOVA) between the changes of cardiac morphology and function of these subjects.
Fok W.Y. et al. (2006) found an increase in LVM (g) from the 1st trimester to the 3rd trimester in normal pregnant women, while the rate of LVDD decreased (p < 0.05). Melchiorre K. et al. (2012) studied PE associated with delayed fetal development inside the uterus: LVMI (g/m2) and RWT index were higher than that of NPG (p < 0.001) and there was LVDD (p < 0.001). The incidence of LVDD in this PE group (52%) was higher than that of NPG (4%) with p < 0.001. Myocardial dysfunction (ectasia and contraction were 76% and 48%, respectively) compared to NPG (21% and 5% respectively) were statistically significant with p < 0.001 [92].
In Viet Nam, there is currently no comprehensive study on cardiac morphology, structure and function in normal pregnant women, especially in the PE, because PE is closely related to cardiovascular disease and death for pregnant women as well as fetus during pregnancy and postpartum.
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Chapter 2: RESEARCH SUBJECTS AND METHODS
2.1. Research subjects
Consists of 190 people who are divided into two groups: Research group consists of 86 PE, gestational age from 26 to 36 weeks. NPG consists of 104 people with the same age as the research group,
registering for periodic pregnancy examination. 2.1.1. Criteria for selection of research subjects 2.1.1.1. PE:
There are two levels of PE according to the standards of the American College of
Obstetricians and Gynecologists ACOG (2013)
2.1.1.2. Normal pregnant women:
Healthy pregnant women without hypertension and PE during pregnancy register for giving birth in Ha Dong General Hospital and must be monitored for all trimesters which are divided by distance during pregnancy as prescribed in obstetrics (the 1st trimester, 2nd trimester and 3rd trimester):
+ First trimester: the 10th week to the 14th week. + Second trimester: the 18th week to the 24th week. + Third trimester: the 26th week to the 36th thweek.
2.1.2. Exclusion criteria
Pregnant women have a history of internal medicine diseases and
cardiovascular diseases before being pregnant, such as:
+ Hypertension, congenital heart disease, mitral valve regurgitation (HoHL), aortic valve regurgitation, myocardial infarction, systemic diseases: lupus erythematosus, scleroderma...
+ Rhythm disorders such as: atrial fibrillation, premature ventricular contraction and paroxysmal atrial tachycardia > 10%, thirddegree and second degree atrioventricular bloc
+ Liver failure, kidney failure, chronic cor pulmonale, pulmonary
tuberculosis
+ Pregnant women who are detected with abnormalities of the fetus during pregnancy may have been referred to early terminate pregnancy in the second trimester.
+ Pregnant women with diabetes type 1. + Patients do not sufficiently meet criteria for subclinical testing and cardiac
ultrasound according to the research medical record sample. + Patients do not agree to participate in the research.
6
2.1.3. Time and location of the research
* Time of the research: from January 2010 to December 2013. * Location of the research: Vietnam National Heart Istitute Bach Mai Hospital: echocardiography for
subjects with PE was transferred from Hanoi Obstetrics and Gynecology Hospital.
Hanoi Obstetrics and Gynecology Hospital: paraclinical tests and obstetric
ultrasonography for women with PE.
Ha Dong Hospital: paraclinical tests, echocardiography, ultrasound for pregnancy.
2.2. Research contents 2.2.1. Research design: Prospective studies, crosssectional description, longitudinal
vertical control.
Comparative descriptive research: a comparison of the two groups of normal trimester pregnancies from the 26th week to the 36th week of pregnancy with the same PE pregnancy group.
Longitudinal vertical control for the first trimester, the second trimester and the
2
Z × 2pq+Z × p q +p q
third trimester for normal pregnancy group. 2.2.2. Calculation of sample size: the sample size for the descriptive research of the two groups is:
(
)
β
α
1 1
2
/2
2
n =
2
(p p ) 1 2
Instead of the formula: n = 72,78 Based on the results of a total of at least 73x2 = 146 women with normal pregnancy and preeclampsia. Because we selected the normal pregnancy group in the research as a comparison group with the preeclampsia group for more accurate statistical results, we chose to adjust the sample size according to the following formula: n* = 146×32/8 = 164,25.
The minimum sample size for the research: n = 165. In this study: n = 190
2.2.3. Steps to conduct the research 2.2.3.1. Clinical examination and some paraclinical tests
Blood pressure: diagnosing hypertension and hypertension levels in pregnant
women according to ACOG (2013) standards.
Clinical examination: + Find the functional symptoms associated with PE + BMI increased: based on the World Health Organization (2011) criteria. + Evaluation of young offspring (≤ 34 weeks) and low birth weight (≤ 2500) g of
pregnant mothers based on standards of ACOG
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ECG changes: implement full 12lead Urinalysis: Diagnosis of proteinuria and proteinuria levels according to
standards of Ministry of Health of Vietnam (2015) and ACOG (2013).
Hematological test: + Anemia occurs when: HST < 110 g/L. + Thrombocytopenia occurs when: platelet < 100 G + Leukocytosis occurs when: white blood cell > 11.0 G/L. Blood chemistry test: + Hyperuricemia when: ≥ 360 µmol/L. + Creatinine increase when: ≥ 100 µmol/L. + Elevated liver enzymes (ALT and AST): when ≥ 40UI/L; increase in severity ≥ 80UI/L. 2.2.3.2. Fetal ultrasound: Fetal ultrasound for fetal age, fetal weight gain, fetal development and
abnormalities.
2.2.4. Doppler Cardiac Ultrasound:
Probe morphology and cardiac structure: Evaluation of morphologic changes and
cardiac structure changes in pregnant women in accordance with standards of ASE (2013):
+ Left ventricular mass index increase (g): ≥ 130 g. + LVMI increase (g/m2): ≥ 95 (g/m2). + RWT increase: > 0,42. Evaluation of left ventricular structure change: + Concentric remodeling: RWT: > 0,42. + Eccentric hypertrophy: LVMI (≥ 95 (g/m2) + RWT (≤ 0,42). + Concentric hypertrophy: LVMI (≥ 95 (g/m2) + RWT (> 0,42). Investigate pericardial effusion on 2D and Mmode when: if there is a left ventricular clearance, the diastole will be on 2D and measuring the size of space on Mmode ≥ 5 mm.
Determination of the mitral valve opening: color Doppler ultrasound can jet backward
into the inside left atrium, systole is called as the mitral valve opening.
Probe for LVSD and LVDD: Diagnostic criteria for left ventricular systolic dysfunction: according to the
American Heart Association (ASE 2016).
2.2.5. Main criteria used in the research: 2.2.5.1. Clinical and paraclinical criteria a) General criteria: + Average age and age distribution between the two groups.
+ BMI (kg/m2), fetal weight. + Edema and edema levels. +Severe hypertension in preeclampsia. +Fetal complications: stillbirth, delivery preterm birth with ≤ 34 weeks. b) Hematological and biochemical criteria: + White blood cells and rate of leukocytosis (> 11.0 G / L) between the two
8
+ Platelets, rate of thrombocytopenia. + Concentrations of uric acid, creatinine and rate of increasing uric acid and
groups.
+ Liver enzymes (AST, ALT) and elevated liver enzyme levels, distribution of
creatinine between the two groups.
+ Severe proteinuria in preeclampsia. 2.2.5.2. Criteria of left ventricular morphology between normal pregnancy
elevated liver enzymes..
+ LVM (g) and LVMI (g/m2) and and the rate of increasing LVM (g), LVMI (g/m2). + RWT and RWT increase. + Rate of concentric remodeling, eccentric hypertrophy and left ventricular hypertrophy. + Rate of pericardial effusion. + Rate of the mitral valve opening. 2.2.5.3. Systolic and hemodynamic left ventricular criteria between normal
and PE groups
pregnancy and PE groups
′ ′
′
′
′ ′ ′ ′ ′ ′
+ Average hypertension + EF% + CO (L/min) and rate of increasing CO (L/min). + TVR (dynes/s/cm5) and rate of increasing TVR (dynes/s/cm5). 2.2.5.4. LVDD between the two groups including a normal pregnancy and PE + E Wave velocity (cm/s). + A Wave velocity (cm/s). + E/A ratio. + DT time (ms) and rate of increasing DT (ms). + IVRT (ms) and rate of increasing IVRT (ms). + e ′ vave velocity (cm/s) and rate of decreasing wave velocity e (< 10). + a Wave velocity (cm/s). + E/e ratio and increase of E/e ratio (> 10). + e /a ratio and increase of e /a ratio (< 1). + Grading of diastolic dysfunction between two normal pregnancy groups and PE.
9
2.2.5.5. Index of Tei and Tei' in the normal pregnancy and PE 2.2.5.6. The relationship between morphology, left ventricular function and haemodynamic with some indicators of clinical, paraclinical in the normal pregnancy and PE
+ Edema.
a) Normal pregnancy group + Increase BMI (kg/m2).
+ Severe hypertension.
+ Severe proteinuria.
+ Elevated liver enzymes.
+ Thrombocytopenia.
+ Increased creatinine.
+ Hyperuricemia.
+ Delivery preterm birth with ≤ 34 weeks.
+ Birth weight ≤ 2500 g.
b) Pregnant women group with PE.
2.2.6. Statistical data processing
The data was processed using SPSS 16.0 software. The subject was complied with the protocol approved by the Medical Council of Vietnam Military Medical University and the Board of Management of Ha Dong General Hospital, Hanoi Obstetrics and Gynecology Hospital and Bach Mai Hospital agreed to allow the collection of research data. The research does not adversely affect diagnosis, monitoring and treatment for patients.
Chapter 3: RESULTS
3.1. General characteristics of the subjects 3.1.1. Age and risk factors for NPG and PE
No difference in mean age was compared between NPG (29.1 ± 4.5 years) and PE (29.9 ± 4.4 years) and the same age distribution (<25, 25 29, 3034 and ≥ 35) wered observed (p> 0.05).
Fetal weight in the PE (2.5 ± 0.6 kg) was significantly lower than that the 3rd
trimester of NPG (2.9 ± 0.5 kg) with p <0.01.
Prevalence percentages of obesity in NPG (BMI ≥ 25kg/m2) was increased according to gestational trimester (p <0.001); the prevalence percentages of obesity in
10 the PE (75.6%) was significantly higher than that the 3rd trimester of NPG (49.0%) with p <0.01. 3.1.2. Clinical, subclinical characteristics and complications in the NPG and PE
Prevalence percentages swelling and edema in the PE (96.5% and 16.3%, respectively) were higher than the 3rd trimester of NPG (39.4% and 2.9%, respectively), statistical significance was p <0.001.
The prevalence percentages of severe hypertension and severe proteinuria in
the PE were accounted for 52.2%.
pConcentric hypertrophy < 0,001
Platelet concentration in the PE (201.2 ± 93.1 G/L) was lower than that the 3rd trimester of NPG (226.6 ± 46.7 G/L) with p <0.05. The rate of thrombocytopenia was also higher (18.6%) compared to the 3rd gestational trimester of normal pregnancy group (0%), statistical significance was p <0.001. 3.2. Characterictical morphology left ventricular and left ventricular function in NPG and PE 3.2.1. Characterictical morphology left ventricular and left ventricular function in the NPG 3.2.1.1. The chances of characterictical morphology left ventricular
Chart 3.6. The chances of characterictical morphology left ventricular in NPG Comment: The rate of Concentric remodeling, eccentric hypetrophy, left eccentric hypertrophy in normal pregnancy group increases for pregnancy period and a statistically significant p <0.001
3.2.1.2. Chanced of characterictical LVSD and hemodynamic in the NPG
ả B ng 3.12. Chanced systolic function left ventricular and hemodynamic in the
NPG
Groups
c
NPG (n = 104) 1st trimester a 2nd trimester b 3rd trimester
11
Variables CO (L/min) 5.6 ± 1.7a 6,4 ± 1,0b 7.2 ± 1.5c
Increased CO (> 8 L/min), n (%) TVR (dyne/s/cm5) 4(3.8) 1243.5± 7(6.7) 1029.3 ± 26(25.0)c 955.2 ±
IncreasedTVR (≥1400 dyne/s/cm5), n (%) 281.4a 179.2b 247.2c
23(22.1)a 4(3.8) 6(5.8)c
Comment: CO index increased with gestational age are statistically significant p <0.05
TVR index decreased with gestational age are statistically significant p <0.05
12
3.2.1.3. Chanced of characterictical LVDD in the NPG
ả B ng 3.14. The rates of characterictical LVDD diameters in the NPG
Groups
χ2
NPG (n = 104) 2nd 3rd pdc
1st trimester trimester trimester
′
′ < 0.001 < 0.001 < 0.001
Variables , n (%) Ve < 10 cm/s ′ Increased E/e (>10) Decreased e /a (< 1) Diastolic
dysfunction < 0.001 , n (%) ′ , n (%) Stage 1, n (%) Stage 2, n (%) Stage 3, n (%) 0 0 1(1.0) 0 0 0 0 0 7(6.7) 0 0 0 12(11.5) 12(11.6) 20(19.2) 8(8,6 3(2,9) 0
Commen: The rate of left ventricular diastolic dysfunction in normal pregnant women occurs in the third trimester (11,6%). In which, the rates of left ventricular diastolic dysfunction in stages 1, 2 in turn are: 8,6% and 2,9% . This rate in stage 3 is 0%.
3.2.2. Characterictical morphology left ventricular and left ventricular
function in the PE
3.2.2.1. The chances of characterictical morphology left ventricular
Chart 3.9. The chances of characterictical morphology left ventricular in PE
Comment: The rate of concentric left ventricular hypertrophy in preeclampsia group
is higher than women with normal pregnancy, and has a statistically significant with
p <0.001.
13 3.2.2.2. LVSD and hemodynamic in the PE:
TVR and prevalence rate of TVR in the PE (1446.3 ± 301.5 and 54.7%, respectively) were higher than that 3rd trimester NPG (955.2 ± 247.2 and 5.8%, respectively) with OR (95%, CI): 19.7 (CI: 7.849.7), p < 0,001.
3.2.2.3. LVDD in the PE: The rate of ventricular diastolic dysfunction in the pregnant group with pre eclampsia (48.8%) is significantly higher than the normal pregnant group in the third trimester (11,6%) and has a statistically significant with (p <0.001) The rate of diastolic dysfunction in stages 1, 2 and 3 in the pregnant group with preeclampsia (in turn: 23.3%, 23.3% and 2.3%, respectively) is significantly higher than normal pregnant group in the third trimester (in turn: 8.6%, 2.9% and 0%, respectively) and has a statistically significant with (p <0.001)
3.3. The relationship between characteristics of morphology, functions of the left
ventricular and hemodynamic and some clinical, subclinical characteristics in
NPG and PE 3.3.1. In the 3rd trimester of NPG Table 3.24. The relationship between characteristics of morphology, functions of the left
Group OR (CI); p
ventricular and hemodynamic in the 3rd trimester of NPG and BMI ≥ 25 kg/m2. BMI < 25 kg/m2 (n = 53), n (%) 8 (15.1) 1 (1.9) BMI ≥ 25 kg/m2 (n = 51), n (%) 16 (31.4) 11 (21.6) Variables RWT > 0,42 Ve′< 10 cm/s 2.57 (1.006.69); < 0.05 14.3 (1.8115.4); < 0.05
′ Comment: Increasing ratio RWT (> 0,42), Ve (< 10 m/s) of left ventricular in normal
pregnant women with BMI ≥ 25 kg/m2 compared to those with BMI < 25 kg/m2
has a statistically significant with (p <0.05)
Table 3.25. The relationship between characteristics of morphology, functions of the left ventricular and hemodynamic in the 3rd trimester of NPG and symptomatic
edema.
Group OR (CI); p
Edema (n = 41), n (%) Nonedema (n = 63), n (%)
9 (22.0) 5 (7.9) 3.26 (1.0110.57); < 0.05
Variables Concentric hypertrophy Ve′< 10 cm/s 11 (26.8) 1 (1.6) 22.7 (2.8184.4); < 0.05
14
ꞌ
Comment: Increasing ratio concentric hypertrophy and Ve (<10 m/s) of left ventricular in normal pregnant women with edema compared to those without edema has a statistically significant with (p <0.05)
3.3.2. Preeclampsia pregnancy
* Characteristics clinical of symptom going together with PE:
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the severe hypertension group (72.7% and 75.0%, pespectively) were higher than that the mild hypertension group (31.0% and 21.4%, pespectively) with statistically significant of OR (95%, CI): 5.9 (2.315.1) and 11.0 (4.030.0), pespectively with p < 0.05.
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the severe proteinuria group (92.6% and 88.9%, pespectively) were higher than that the mild proteinuria group (33.9% and 30.5%, pespectively), with statistically significant of OR (95%, CI): 24.4 (22.8529.7) and 18.2 (4.968.3), pespectively with p < 0.05.
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the elevated liver enzymes group (73.3% and 71.1%, pespectively) were higher than that the normal liver enzymes group (29.3% and 22.4%, pespectively), with statistically significant of OR (95%, CI): 6.6 (2.617.1) and 7.6 (2.919.9), pespectively with p < 0.05.
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the thrombocytopenia group (100% and 100%, pespectively) were higher than that the normal platelet concentration group (41.1% and 37.1%, pespectively), with statistically significant of OR (95%, CI): 17.1 (2.1137.3) and 27.1 (3.4216.2), pespectively with p < 0.05.
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the elevated creatinine group (100% and 100%, pespectively) were higher than that the normal creatinine group (38.8% and 34.3%, pespectively), with statistically significant of OR (95%, CI): 30.0(3.8237.5) and 36.3(4.6289.0), pespectively with p < 0.05.
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the hyperuricemia group (67.9% and 62.5%, pespectively) were higher than that the normal uric acid group (23.3% and 22.3%, pespectively), with statistically significant of OR (95%, CI): 6.9 (2.519.1) and 5.5 (2.015.0), pespectively with p < 0.05. * Complications of childbirth:
15
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the delivery preterm birth with ≤ 34 weeks group (78.6% and 89.3%, pespectively) were higher than that the delivery > 34 weeks group (39.7% and 29.3%, pespectively), with statistically significant of OR (95%, CI): 5.6 (1.915.9) and 20.1 (5,375.6), pespectively with p < 0.05.
The prevalence rate of concentric hypertrophy and left ventricular diastolic dysfunction in the childbirth ≤ 2500 g group (70.3% and 73.0%, pespectively) were higher than that the childbirth > 2500 g group (38.8% and 30.6%, pespectively), with statistically significant of OR (95%, CI): 3.7(1.59.3) and 6.1 (2.415.8), pespectively with p < 0.05. 3.3.3. Multiple regression correlation between morphology and left ventricular function and some risks factor in the PE 3.3.3.1. Heart morphology and structure:
Table 3.35. The multiple relationship between the change in heart morphology and structure with some indicators of clinical in the pregnant women with preeclamsia.
R Square P 2 Log Likelihood
Predicted percentage of correct concentric hypertrophy left ventricular 70,0% 96,574 < 0,001
Variables Exp (B) P
0,005 Hypertension in severity 4,492 0,307 Confidence interval (95%, CI) 1,568 12,868
R Square
P
2 Log Likelihood
Predicted percentage of correct concentric hypertrophy left ventricular 76,7%
77,517
< 0,001
Variables
Exp (B)
P
Elevated liver enzymes Proteinuria in severity
5,198 8,140
0,511 Confidence interval (95%, CI) 1,623 16,644 1,20555,009
0,006 0,031
Comment: Symptom as severe hypertension relates closely to left concentric ventricular hypertrophy, with statistically significant (p < 0.01). When having severe hypertension, it’s high risk to get left concentric ventricular hypertrophy for pregnant women with preeclampsia with OR (95%, CI) = 4,492 (1,568 12,868). Table 3.36. The multiple relationship between the change in heart morphology and structure with some indicators of paraclinical in the pregnant women with preeclamsia.
16 Comment: When having elevated liver enzymes and especially severe proteinuria, it’s higher risk getting left concentric ventricular hypertrophy for pregnant women with preeclampsia 3.3.3.2. Diastolic left ventricular Table 3.37. The multiple relationship between left ventricular diastolic dysfunction with
R Square
P
2 Log Likelihood
Predicted percentage of correct diastolic dysfunction left ventricular 79,1%
77,778
< 0,001
Variables
Exp (B)
P
Hypertension in severity
6,368
0,510 Confidence interval (95%, CI) 2,011 20,166
0,005
some indicators of clinical in the pregnant women with PE
Comment: When pregnant women with preeclampsia get severe hypertension, it’s
high risk to get left diastolic dysfunction
Table 3.38. The multiple relationship between left ventricular diastolic dysfunction with
some indicators of paraclinical in the pregnant women withPE
R Square P
Predicted percentage of correct diastolic dysfunction left ventricular 76,7% Variables 2 Log Likeliho od 69,900 Exp (B) < 0,001 P
Increased creatinine Elevated liver enzymes 1,051 3,863 0,582 Confidence interval (95%, CI) 1,006 1,098 1,198 12,454 0,025 0,024
Comment: Creatinine ratio and especially elevated liver enzymes relate to left
diastolic dysfunction with statistically significant of (p <0,05). When having elevated
liver enzymes, pregnant women with preeclampsia get higher risk to get left diastolic
dysfunction with OR (95%, CI) = 3,863 (1,198 12,454).
Table 3.39. The multiple relationship between left ventricular diastolic dysfunction and
some morphological diameters left ventricular in the PE
Predicted percentage 2 Log R Square P
of correct diastolic Likelihood
dysfunction left ventricular 89,5% 50,260 0,735 < 0,001
17
Variables Increased RWT Exp (B) 29,437 (95%, CI) 1,600 541,569 P 0,023
Commen: Only in RWT which had been connected LVDD significantly with OR
(95%, CI) = 29,437 (1,600 541,569), p < 0,05.
Chapter 4: DISCUSSION
4.1. General characteristics of the research objects
4.1.1. Clinical characteristics
In our study, the mean age of the NPG and PE was 29.1 ± 4.5 and 29.9 ± 4.4 (years) respectively. Age distribution (<25, 2529, 3034 and ≥ 35) between two groups was not statistically significant (p> 0.05). Because age is related to left ventricular diastolic function change according to Nagueh S.F. (2009) and many scientists, the mean e' (characteristic of left ventricular diastolic function) decreased with age, IVRT time (m/s), DT time also increased in the age of normal people. Therefore, as well as an age distribution of similarity between two groups to avoid confounding factors for morphological and left ventricular diastolic function in women with NPG and PE and also compare the normal values in nonpregnant women.
Obesity is often associated with metabolic syndrome, insulin resistance, hypertension, blood glucose, increase of uric acid and etc increasing risk of PE. In this study, the BMI and the rate of BMI (≥ 25 kg/m2) in the PE group (75.6%)w ere significantly higher than those of the 3rd trimester NPG (49.0%) with p <0.01. GauglerSenden I. (2011) in light PE women is 2.5 times more likely to develop eclampsia; in heavy PE women is 3.5 times more likely to develop eclampsia than nonfat PE women.
Renal dysfunction is the normal overwatering of the interstitial fluid, the natural cavities of the body. In the PE group, the edema rate was very high (96.5%); serious edema rate was higher (16.3%) than one in 3 last months (2.9%) with p <0.001. Both domestic and foreign authors report that edema especially severe edema syndrome in PE, is closely related to maternal complications and delayed development of the uterus.
The rates of mild and severe hypertiension in this study were: 47.8% and 52.2%, respectively. The values of SBP and DBP were one of the most important criteria in PE classification.
18
4.1.2. Subclinical characteristics
Creatinine concentration and creatinine increase rate (≥100 μmol / L) in the PE group [80.9 ± 24.3 μmol/L (22.1%)] were higher than those in NPG group [78.5 ± 13.3 μmol / L (1.0%)] with p <0.001; The incidence of mild and severe proteinuria in the PE group was 68.6% and 31.4%, respectively. Our results were similar to those of Koopmans C.M. (2011) At the same time, there was a strong correlation between urinary protein/creatinine ratio versus 24hour proteinuria.
Hyperuricemia was usually associated with PE in pregnant women because of the strong association between hyperuricemia and hypercalcemia, elevated uric acid levels associated with changes in the body of pregnant mothers (the exchange and metabolism of the placenta, the placenta and the maternal organs) and delayed pregnancy in the uterus.
The results of this study on uric acid were similar to that of Seow K.M. (2005) found that there was a good correlation between SBP, DBP and uric acid concentration in severe PE women (correlation coefficient of 0.58 and 0.59 for p <0.001, respectively). Recent studies have suggested that elevated uric acid levels in pregnant women with PE are strongly associated with delayed growth in the uterus, especially in pregnant women with severe PE and uric acid values.
The liver lesion was more common in pregnant women with PE, especially severe PE and HELLP syndrome, in pregnant women with PE. Hepatic damage is common in patients with liver pain, elevated liver enzymes, especially in hepatic and liver hemorrhage (HELLP syndrome). The results of this study on uric acid were similar to that of Koopmans C.M. (2011), particularly study of Martin M.N. (2012): severe elevated liver enzyme was be 49% and 23% in pregnant women suffering from PE,
Therefore, in pregnant women, plateletheavy PE should be monitored regularly to prevent HELLP syndrome, prevent cerebral hemorrhage and blood clotting syndrome. Especially severe PE and HELLP syndrome, platelets decrease, and were associated with cerebral hemorrhage, hemorrhage and blood clotting syndrome. In this study, platelet counts and platelet depletion rates in the PE group were [202.2 ± 93.1 G/L (18.6%)], while in the third trimester [226.6 ± 41.3 G/L (0%)], the difference was statistically significant (p <0.001); In accordance with the study by Koopmans C.M. (2011), Reyes L.M. (2012), Seow K.M. (2005), Tejera E. (2012), Martin J.N. (2012);
4.1.3 Fetal distress in normal pregnant women and preeclampsia
19
Fetal injury such as stillbirth, premature birth, uterine retardation, underweight, and perinatal death ... is one of the most important issues in monitoring and caring for pregnant mothers, PE is the important causes of postpartum fetal distress and death. In this study, fetal weight in the PE group (2.5 ± 0.6 kg) was lower than in the last 3 months (2.9 ± 0.5 kg), statistical significance was p <0.01. The rate of complications related to pregnancy (including stillbirth, delivery preterm birth <34 weeks, child birth <2500 g) accounted for quite high (46.5%). Today, studies of the pathophysiology of PE show that ischemia is localized to cytokines and hemodynamic changes that alter the shape of the placenta. As a function of the heart, inflammatory mediators also damage the fetus.
4.2. Morphological characteristics and functions of left ventricular and
haemodynamic features in NPG and PE
4.2.1. Morphology and fuctions of heart in NPG women
* Morphology and structure of the heart: in this study, LVMI (g/m2) and LVMI> 95 g/m2 increased with gestational age [84.2 ± 8.3 (9.6%); 91.9 ± 16.5 (26.0%) and 95.3 ± 11.5 (42.3%) with p <0.001); RWT rates were similar (2.9%, 11.5% and 23.1%, respectively, with p <0.001); similar to some previous studies such as Mesa A. (1999), Kametas N.A. (2001). However, this change in morphology and structure is only functional due to hemodynamic changes, and these changes will return to normal after birth according to the results of the study. Savu O. (2012) found that LVEDd, LVEDs, RWT, LVMI decreased significantly after 4 months of birth and was comparable to that of healthy nonpregnant women (p > 0.05).
* Functions of systole and hemodynamics: The results of this study similer Bamfo J.E. (2007): In pregnancy, CO (L/min) increased significantly (p <0.001) and CO increased significantly (30%). TVR (dyne/s /cm5) and S waves on Doppler tissue were decreased gradually in pregnancy (p <0.05). Savu O. (2012): TVR (dyne/s/cm5) decreased gradually from the gestational of 1st trimester to the 3rd trimester with p <0.05.
* Diastolic function: In this study, the results of LVDD parameters such as DT time (m/s), DT increase (> 200 m/s) and IVRT' (m/s), IVRT' (> 90 m/s) increasingly according to the pregnancy. Similarly, the E/A, Ve' and e'/a' ratios were statistically significant (p <0.05); E/e ratio increased (p <0.001). The incidence of infarction in the gestational of 3rd trimester of NPG was 11.6% (LVDD in the first and second stage: 8.6% and 2.9% respectively). In accordance with the results of research in the world as: Mesa
′
′
20 A. (1999), Fok W.Y. (2006), Simmons L.A (2002). On the other hand, the Tei index was increased (1.9%, 3.8% and 7.7% respectively, p = 0.045); Tei index also showed similar results (5.8%, 77.7% and 13.5%, p = 0.053) in pregnancy. The change in Tei and Tei indexes is consistent with the changes in systolic and diastolic function parameters in the women of this study and in previous studies.
4.2.2. Morphology, functional structure of heart in pregnant women with PE
* Morphology and structure: Changes in morphology and structure of the heart in pregnant women with PE have been demonstrated by many studies in the world such as Dennis A.T. (2010), Cho K.I. (2005), Simmons LA (2002), Novelli G.P. (2003). Results of the study showed that the indexes of morphology and cardiac structure in the PE group matched the results of the previous study. LVM (g) and LVMI (g/m2) in the PE group were [182.7 ± 33.0 (g) and 111.1 ± 21.2 (g/m2), respectively] compared the gestational of 3rd trimester of NPG [respectively: 152.9 ± 19.4 (g) and 95.3 ± 11.5 (g / m2)]; At the same time, the prevalence percentage of increased LVMI (g/m2) in the PE group (79.1%) was higher than that in the 3rd trimester of NPG (42.3%) with p <0.001. RWT and prevalence percentage of increased RWT in the PE group (0.45 ± 0.07 and 60.5%, respectively) were higher than those in the 3rd trimester of NPG (0.39 ± 0, 05 and 23.1%) were statistically significant p <0.001.
Overloading of the blood volume in the PE, increased heart rate and pressure at the left atrium, increases the pressure on the heart muscle, shortens the contraction of the heart muscle eventually leading to increased left ventricular mass, enlargement of the heart chambers, alteration of the left ventricular structure resulting in concentric reconstruction, hypertrophy of the heart and especially concentric hypertrophy. Novelli G.P. (2003) found that the risk of left ventricular hypertrophy in hypertensive patients was 3.65 times higher than that of nonTHA patients (p <0.05). Melchiorre K. (2011) found that the rate of left ventricular dysfunction in the PE group (40.7%) was higher than that of the NPG group (6.4%) with p <0.001. On the other hand, the rate of left ventricular structure change in the PE group (especially in the concentric hypertrophy period: 52.3%) was significantly higher than that in 3rd trimester of NPG (13.4%). The rate of pericardial effusion and mitral valve opening in the PE group (32.6% and 52.3%, respectively) were higher than those in the 3rd trimester of NPG (respectively: 0.0% and 20.2%), p <0.001 with OR (95% CI): 2.8 (2.33.4) and 4.3 (2.28.2), respectively. Dennis A.T. (2010) there was no case of pericardial effusion in the NPG group, but in the PE, the rates of pericardial effusion were relatively high (37.5%) consistent with the cause of urinary protein loss in the PE, especially severe PE, which reduced blood albuminemia causing multiple membrane drainage.
* Functions of systole and hemodynamics:
21
The results of this study are consistent with those of Marshall L (2009), Dennis A.T. (2010), Simmons L.A. (2002). However, the change in systolic function in PE differs from that of the NPG group because of the length of the change that occurs after birth. Therefore, further research is needed to shed light on the role of systolic function and hemodynamic changes related to cardiovascular disease in women with PE during pregnancy and postpartum.
* Diastolic function: Due to the change in morphology and structure of the heart in pregnant women with PE, pregnant women with PE often have a change in left LVDD as a result of Cho K.I. (2005), Novelli G.P. (2003), Yuan L (2006), Vasapollo B. (2008), Dennis A.T. (2010), Melchiorre K. (20112012, 2013). The results of this study are consistent with the findings of the authors, especially the diastolic function (Ve '<10) in the PE group (48.8%) compared to the in 3rd trimester of NPG (11.5%) was statistically significant p <0.001 with OR (95%, CI) = 7.3 (3.515.3). The prevalence rates of diastolic dysfunction stage 1, 2 and 3 in the PE group (23.3%, 23.3% and 2.3%, respectively) were higher than those in 3rd trimester of NPG (8.6%, 2.9% and 0%) with p <0.001.
Dennis A.T. (2010) found that the incidence of LVDD based on interventricles e‘ (inter ventricles Ve‘ <8 cm/s) in the PE group was much higher (50.0%) than in the control group (8.0%) with p = 0.006. Other indicators including E/A (<1.4); E/e '(> 8) and e' / a '(<1) in the PE group (73.0%, 85.0% and 50.0%, respectively) were higher than that in 3rd trimester of NPG (45.0%, 15.0% and 0%, respectively) with p <0.05 and p <0.001.
Melchiorre K. (2011) showed that the LVDD in the first and second stages in the PE group were 29.6% and 22.2%; On the other hand, the Tei Index has the advantage over EF% in that the index does not depend on the shape of the left ventricle. Kansal M. (2012) suggested that there was an association of LVDD with congestive heart failure and brain natriuretic peptide (BNP) in pregnant women. In this study, the Tei index (Tei index increased) and Tei '(Tei' increased ratio) in the PE group were consistent with those of Dennis A.T. (2010), Bamfo J.E. (2008), Strobl I. (2010). However, further research is needed to assess the role of the Tei index, especially the Tei' index in the LVDD tracking in pregnant women with PE.
* Morphology, structure, and function of the heart in severe PE pregnant women In this study, the morphologic and cardiac manifestations in the severe PE group, such as LVMI (g/m2) increased frequency, RWT elevation, left ventricular eccentricity left ventricular hypertrophy, and pericardial effusion was higher than that of the PE group (p <0.001). Concentration of concentric hypertrophy in the severe PE group was higher (80.6%) than that of the mild PE group (32.0%), which was statistically significant (p < 0.001).
22
The rate of decline in LVDD in the severe PE group was 83.3% higher than that of the minor PE group (24.0%) with OR (95%, CI) = 15.8 (5.347.1), p <0.001 according to study by Dennis A.T. (2010). In addition, the authors found that in the severe PE group, pericardial effusion was > 1 cm (63.0%) higher than that of the midl PE group (14%) with p = 0.007. The greater the pericardium, the higher the risk of heart failure and death for the mother and the fetus, consistent with the pathogenesis of severe PE in women, is due to loss of proteinuria and increased capillary permeability. Severe edema (multiple membrane effusion) is therefore present on ultrasound images of pericardial effusion is common in severe PE women.
Changes in left ventricular diastolic function in the PE group may be significantly higher than those with mild PE (p <0.001) as well as the study by Melchiorre K. (2011) and Dennis A.T. (2010) have showed. 4.3. Relationship between some morphological, left ventricular and haemodynamic parameters with some clinical, subclinical, and cardiovascular characteristics in women with NPG and PE. 4.3.1. Normal pregnancy
In this study, we investigated the association between cardiovascular morphology, structure and function in pregnancy in gestational 3rd trimester and PE with risk factors in the caring process sush as obesity, proteinuria, blood pressure, uric acid, creatinine and the relationship between LVDD and morphologic and structural changes ...
The results of the study showed that in the NPG group there was an increase The rate of LVMI, RWT, COPD and CO loss (>8 L/min) was statistically significantly lower (p <10 cm / s) in the NPG group with a BMI ≥ 25 kg/m2 and there was edema in comparison with those with BMI <25 kg/m2 and statistically significant (p <0.05) with OR (95% CI) respectively: 14.3 (1, 8115.4) and 22.7 (2.8184.4). In accordance with the study by Zentner F. (2009), Melchiorre K. (2011).
Therefore, during the gestational 3rd trimester of NPG, morphologic changes, cardiac structure and left ventricular dysfunction should be routinely monitored to identify and prevent cardiovascular disease of postpartum women, especially when a woman is old, obese and overeating.
4.3.2. PE pregnancy In this study, pregnant women with PE showed a statistically significant association (p <0.01 and p <0.001) in the group of pregnant women with symptomatic PE, severe hypertention, proteinuria, elevated liver enzymes, thrombocytopenia, elevated creatinine and hyperuricemia, left ventricular hypertrophy is significantly higher in comparison with mild hypertention, mild proteinuria, no increase in creatinine and no increase in uric acid with OR (95% CI),
23 respectively: 5.9 (2.315.1); 24.4 (5.2113.4); 6.6 (2.617.1); 17.1 (2.1137.3); 30.0 (3.8237.5) and 6.9 (2.519.1).
Similarly, when PE has got symptoms associated with: severe hypertention, severe proteinuria, elevated liver enzymes, thrombocytopenia, elevated creatinine and hyperuricemia, the risk of severe LVDD was higher than one of the PE group with mild hypertension, mild protein, no hyperlactatemia, no thrombocytopenia, no elevated creatinine and normal uric acid increased with OR (95% CI) respectively: 11.0 (4.0 30.0); 18.2 (4.968.3); 7.6 (2.919.9); 27.1 (3.4216.2); 36.3 (4.6289.0) and 5.5 (2.0 15.0) were statistically significant (p <0.001); In combination with the pathogenesis, there is an increase in total peripheral vascular resistance, particularly with an increase in cardiovascular activity in pregnant women. PE results in increased cardiac output resulting in disturbance of LVDD function and severe left ventricular thrombosis.
Fetal complications such as stillbirth, preterm delivery (<34 weeks or 37 weeks), low birth weight <2500 ... are complications in pregnant women with PE. Dennis A.T. (2010) showed that the prevalence of maternal complications was greater in the PE group (53%) than in the subgroup (28%); weeks earlier (37.6 ± 3.4 weeks vs mean PE: 40.1 ± 1.0 weeks).
MongrawChaffin M.L. (2010) studied cardiovascular disease after 37 years in pregnant PE with preterm birth <34 weeks, the authors found risk of cardiovascular disease in this group 9.54 times (CI = 4.50 20.76) compared to the NPG group. Mulla Z.D. (2010) found severe PE or eclampsia, the risk of long hospital stay (> 5 days) was higher than ORG (95% CI), respectively: 2.34 (2.16 2.53) and 3.24 (2.90 3.62) with p <0.0001.
In this study, the prevalence of concentric hypertrophy and LVDD in the delivery preterm birth ≤ 34 weeks group (78.6% and 89.3%, respectively) was higher than in the delivery preterm birth <34 weeks (39.7% and 29.3%, respectively) (p <0.05) with OR (95% CI): 5.6 (1.9 15.9) and 20,1 (5.3 75.6), respectively. The rate of concentric hypertrophy and LVDD in the childbirth ≤ 2500 g group (70.3% and 73.0%, respectively) were higher than that the childbirth > 2500 g group (38.8% and 30.6%, pespectively), (p <0.05) with OR (95% CI): 3.7 (1.5 9.3) and = 6.1 2.4 15.8), respectively. In accordance with Melchiorre K. (2012) also found that in preterm infants with PE, the rate of hypertension was high (52%) compared to the control group (0%) at gestational age (39 weeks) with p <0.001; The rate of structural change was very high (81%), higher than the control group (13%) with p <0.001. Diastolic dysfunction, respectively (85.2% and 59.3%) was higher than controls (18% and 18.5%, respectively) with p <0.001; The DT (m/s) and IVRT (m/s) ratios were higher while the E/A, and e'/a' values were lower in the preterm infants group than in the control group statistically significant with p <0.001.
24
We performed a multivariate logistic regression to identify clinical and clinical factors that were closely related to cognitive impairment and left ventricular CNTTr dysfunction, with the aim of helping clinicians to achieve goals. Prognosis of the risk of CNTTr dysfunction, cardiac damage in pregnant women with TSG. The results of the study showed that when THA was severe, there was a significant correlation with PDTT, statistically significant decrease (p <0.05) with OR (95% CI), respectively: 4,492 (1,56812,868) and 6,368 (2,01120,166)
The relationship between morphologic changes, left ventricular structure and cardiac function and heart failure in pregnant women with PE is being investigated in a number of recent studies. In this study, the finding of left ventricular ejection and left ventricular ejection factors (LVEDd, LVEDV, IVSd, PWd, LVMI, RWT and pericardial effusion) were associated with LVDD by logistic regression. We found that the RWT index was most closely related to the risk of maternal LVDD in the PE with OR (95%, CI) = 29.4 (1.6 541.6); p <0.05 with accurate predictions of LVDD in the PE: 89.5%. Predictors of cardiovascular disease and cardiovascular complications in pregnant women are important in monitoring clinical and postnatal clinical disease because PE is a high risk of progressive disability and death from cardiovascular disease in the mother. In the PE with complications, echocardiography for cardiomyopathy should be performed.
Melchiorre K. (2012) also found that the rate of structural left ventricular dysfunction in the PE group was significantly higher in uterus (80.0%) than in non hypertensive pregnant women in the uterus (28 %) with p <0.0001; In the PE group with delivery preterm birth <37 weeks, the rate of left ventricular dysfunction (81%), severe left ventricular ectropion (19%), decrease in ventricular tachycardia of LVDD (19%) compared to normal delivery birth group (13%, 4% and 2%, respectively) were statistically significant (p <0.05). The relationship of severe structural change and LVDD (both right and left ventricular) in PE with delivery preterm birth < 37 weeks of gestation revealed severe cardiac overload, for a long time, it will lead to heart failure and postpartum ischemic heart disease.
Thus, in pregnant women with PE should be recommended echocardiography during pregnancy to assess the morphologic changes, cardiac function (especially LVDD) from which therapeutic measures in time and postpartum to reduce the risk of cardiovascular disease and mortality during and after birth. Doppler ultrasonography is performed not only in the last 3 months but should be performed in the midmonth period (weeks 2023) for screening morphology and cardiac function in pregnant women with PE. Evidence for muscle relaxation (72%), concentric remodeling (33%), LVDD and LVSD were showed 33%. The practice of highvalue tisue Doppler cardiac
25 ultrasound technique in diagnosis and very good detection of morphologic changes, structure and cardiac function in pregnant women.
CONCLUSION By studying the variability of hemodynamic parameters in 104 normal pregnant women and 86 PE using Doppler cardiac ultrasound, we draw the following conclusions:
1. Morphology and function of left ventricular diastolic and hemodynamic
changes in the normal pregnancy and PE
The prevalence of percentage concentric hypertrophy increased for the 1st trimester, 2rd trimester and 3rd trimester (0%, 2.9% and 13.4%, respectively) were statistically significant (p <0,05), LVDD only occurs in the gestational 3rd trimester (11.6%) in normal pregnancy.
The prevalence of percentage concentric hypertrophy in the PE (52.3%) was significantly higher than that the NPG (13.4%) and has a statistically significant with (p <0.001)
The prevalence of percentage LVDD in the PE (48.8%) was significantly higher
than that the NPG (11,6%) and has a statistically significant with (p <0.001)
Diastolic dysfunction in stages 1, 2 and 3 in the PE (23.3%, 23.3% and 2.3%, respectively) was significantly higher than that the NPG (8.6%, 2.9% and 0%, respectively) and has a statistically significant with (p <0.001).
There is a hemodynamic change in the NPG: cardiac output ratio (> 8 L/min) is gradually increased and TVR (≥1400 dyne/s/cm5) is gradually decreased from the 1st trimester (3.8% and 22.1%, respectively) to the 3rd trimester (25.0% and 5.8% respectively) and has a statistically significant with (p <0.05). TVR rate of increase in the PE (54,7%) was higher than that in the 3rd trimester NPG (5,8%) and has a statistically significant with (p < 0,001).
2. Relationship between morphology, diastolic function, hemodynamic changes and some clinical and paraclinical indexes in the normal pregnancy and preeclampsia
+ Normal pregnancy group: there was a risk of concentric hypertrophy and LVDD in the NPG with BMI ≥ 25 kg/m2 (21.6%), with edema (26.8%) compared to the NPG with BMI <25 kg/m2 (1.9%), without edema (1,6%) and statistically significant with (p < 0,05).
+ Pregnant women group with PE: If the PE have associated symptoms such as severe hypertension, elevated blood pressure, elevated liver enzymes, thrombocytopenia, elevated creatinine and hyperuricemia, the risk of transforming the concentric hypertrophy and left ventricular diastolic dysfunction are significantly higher than the PE who have above
26 clinical and paraclinical symptoms at a moderate level with OR (95%): respectively 5.9 and 11.0; 24.4 and 18.2; 6.6 and 7.6; 17.1 and 27.1; 30.0 and 36.3; 6.9 and 5.5 with statistically significant of (p <0.001).
The PE who was delivery preterm birth ≤ 34 weeks, childbirth ≤ 2500 g, increasing rate of concentric hypertrophy (78.6% and 70.3%, respectively) and LVDD (89.3% and 73%, respectively) were higher than that PE who was delivery preterm birth ≤ 34 weeks, childbirth ≤ 2500 g with concentric hypertrophy (39.7% and 38.8, respectively); LVDD (29.3% and 30.6%, respectively) with statistically significant of (p <0.05); OR (95%, CI): 5.6 (1.915.9); 3.7 (1.59.3) and 20.1 (5.3 75.6); 6.1 (2.415.8), respectively.
The RWT index is highly correlated with LVDD in the PE with a statistically significant (p <0.05) and with OR (95%, CI) = 29.4 (1,6 541,6) with predictive accuracy of LVDD was 89.5%.
The association between hemodynamic changes (CO and TVR indexs) with some clinical and paraclinical parameters in the normal pregnancy and preeclampsia without a statistically significant (p> 0.05).
RECOMMENDATIONS
Through the research we make two recommendations: 1. In pregnant women with hypertension or with proteinuria or with preeclampsia, a Doppler cardiac ultrasound should be performed to assess the morphology and the function of hemodynamic changes for early detection of abnormalities to handle
2. Followup studies on preeclampsia on changes of morphology, function and hemodynamic changes after birth as well as studies on fetal effects for a comprehensive assessment are needed.
