What are the cardiovascular changes associated with preeclampsia (pregnancy-induced hypertension)?

From the Guidelines

Preeclampsia is associated with significant cardiovascular changes, including increased systemic vascular resistance, reduced cardiac output, and hypertension, which can lead to long-term cardiovascular consequences, such as hypertension, stroke, ischemic heart disease, and thrombo-embolic disease in later adult life. The cardiovascular changes associated with preeclampsia include endothelial dysfunction and vasospasm due to an imbalance of vasoactive substances, particularly decreased nitric oxide and increased sensitivity to angiotensin II 1. This leads to widespread vasoconstriction, reducing blood flow to vital organs including the placenta, kidneys, liver, and brain. The heart experiences increased afterload from the elevated peripheral resistance, which can lead to left ventricular hypertrophy and diastolic dysfunction in severe or prolonged cases. Blood volume is typically decreased despite the edema seen clinically, as plasma volume is reduced while fluid shifts into extravascular spaces. Hypercoagulability is another key feature, with increased platelet activation and consumption. These cardiovascular changes explain many of the clinical manifestations of preeclampsia, including hypertension, proteinuria, edema, and end-organ damage. Some key points to consider in the management of preeclampsia include:

• The decision to transfer a patient to the intensive care unit (ICU) should be made collectively by a team of specialists based on the stability of the patient, physical examination, vital signs, laboratory values, imaging, and expected care required 1.
• Long-term cardiovascular consequences of gestational hypertension, including increased risk of developing hypertension, stroke, ischemic heart disease, and thrombo-embolic disease in later adult life, should be considered in the management of preeclampsia 1.
• Cardiovascular risk assessment and lifestyle modifications are recommended in all women with a pregnancy-related hypertensive disorder to avoid complications in subsequent pregnancies and to reduce maternal cardiovascular risk in the future 1. Key management strategies for preeclampsia include:
• Antihypertensive medication, which is usually continued until BP has normalized, which may be days to several weeks postpartum 1.
• Home BP monitoring is suggested to ensure that blood pressure is well-controlled 1.
• The use of ACE inhibitors, such as enalapril, may be considered in lactating mothers unless the neonate is premature or has renal failure 1. It is essential to prioritize the management of preeclampsia to prevent long-term cardiovascular consequences and improve outcomes for mothers and babies.

From the Research

Cardiovascular Changes Associated with Preeclampsia

The cardiovascular changes associated with preeclampsia are complex and multifaceted. Some of the key changes include:

• Cardiac dysfunction, which can occur not only during pregnancy but also after delivery, with long-term implications for both maternal and neonatal cardiovascular health 2
• Abnormal cardiovascular phenotype, which can precede conception and is associated with the development of preeclampsia 2
• Two distinct phenotypes of preeclampsia, one associated with fetal growth restriction, low cardiac output, and high peripheral resistance, and another associated with normal fetal growth, high cardiac output, and low peripheral resistance 2
• Cardiac remodeling and diastolic dysfunction, which can occur in women with early-onset preeclampsia and increase the risk of premature cardiac morbidity and mortality later in life 3
• Increased total vascular resistance and left ventricular mass indices, which suggest that left ventricular remodeling is an adaptive response to maintain myocardial contractility in preeclampsia 4
• Vascular dysfunction, including endothelial dysfunction and increased peripheral resistance, which is a hallmark of preeclampsia and contributes to the development of cardiovascular disease 5, 6

Key Findings

Some of the key findings from the studies include:

• Women with early-onset preeclampsia have significantly higher total vascular resistance and left ventricular mass indices compared to normotensive controls 3
• Diastolic dysfunction is more common in women with preeclampsia compared to normotensive controls, and can be detected using echocardiography and tissue Doppler analysis 3, 4
• Preeclampsia is associated with an increased risk of future cardiovascular events, and women with a history of preeclampsia have approximately double the risk of future cardiovascular events compared to women with normotensive pregnancies 6
• Vascular dysfunction in preeclampsia is characterized by endothelial dysfunction, increased peripheral resistance, and enhanced endothelial oxidative stress, which can contribute to the development of cardiovascular disease 5