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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 1, January/February 2018
26
AFRICA
Cardiac diastolic function after recovery from pre-eclampsia
P Soma-Pillay, MC Louw, AO Adeyemo, J Makin, RC Pattinson
Abstract
Background:
Pre-eclampsia is associated with significant
changes to the cardiovascular system during pregnancy.
Eccentric and concentric remodelling of the left ventri-
cle occurs, resulting in impaired contractility and diastolic
dysfunction. It is unclear whether these structural and func-
tional changes resolve completely after delivery.
Aims:
The objective of the study was to determine cardiac
diastolic function at delivery and one year post-partum in
women with severe pre-eclampsia, and to determine possible
future cardiovascular risk.
Methods:
This was a descriptive study performed at Steve
Biko Academic Hospital, a tertiary referral hospital in
Pretoria, South Africa. Ninety-six women with severe pre-
eclampsia and 45 normotensive women with uncomplicated
pregnancies were recruited during the delivery admission.
Seventy-four (77.1%) women in the pre-eclamptic group were
classified as a maternal near miss. Transthoracic Doppler
echocardiography was performed at delivery and one year
post-partum.
Results:
At one year post-partum, women with pre-eclampsia
had a higher diastolic blood pressure (
p
=
0.001) and body
mass index (
p
=
0.02) than women in the normotensive
control group. Women with early onset pre-eclampsia requir-
ing delivery prior to 34 weeks’ gestation had an increased
risk of diastolic dysfunction at one year post-partum (RR
3.41, 95% CI: 1.11–10.5,
p
=
0.04) and this was irrespective of
whether the patient had chronic hypertension or not.
Conclusion:
Women who develop early-onset pre-eclampsia
requiring delivery before 34 weeks are at a significant risk
of developing cardiac diastolic dysfunction one year after
delivery compared to normotensive women with a history of
a low-risk pregnancy.
Keywords:
pre-eclampsia, diastolic function, left ventricular
remodelling, pregnancy
Submitted 23/3/17, accepted 10/7/17
Published online 31/8/17
Cardiovasc J Afr
2018;
29
: 26–31
www.cvja.co.zaDOI: 10.5830/CVJA-2017-031
Pre-eclampsia is a pregnancy-specific disorder characterised
by new-onset hypertension and proteinuria after 20 weeks’
gestation. Hypertensive disorders in pregnancy have been one
of the top five causes of maternal mortality in South Africa
for more than a decade.
1
It was previously believed that the
complications of pre-eclampsia ended with the delivery of the
foetus and placenta, however it is now well established that
pre-eclampsia is a risk for future hypertension, ischaemic heart
disease, stroke and venous thromboembolism.
2
Pregnancy is associated with significant haemodynamic and
hormonal changes affecting the cardiovascular system. There
is a 20% increase in cardiac output by eight weeks’ gestation.
3
Peripheral vasodilatation leads to a 20 to 30% fall in systemic
vascular resistance and a 40% increase in cardiac output. The
heart undergoes remodelling, with an increase in left ventricular
wall thickness and mass.
4
Despite these changes, the left ventricular contractile function
is maintained and any changes in cardiac geometry are rapidly
reversible within three months post-partum in normotensive
women.
4
By contrast, vascular reactivity is augmented in
pregnancies affected by pre-eclampsia.
5
Pre-eclampsia results in a
state of increased vascular stiffness, generalised vasoconstriction
and a high total vascular resistance and low cardiac output
compared to the changes seen in a normal pregnancy.
5
Cardiac changes classically associated with pre-eclampsia are
diastolic dysfunction and an after-load-mediated left ventricular
remodelling of the maternal heart.
6-8
The heart remodelling is a
response to the increased systemic afterload in order to minimise
myocardial oxygen demand and preserve left ventricular function.
About 20% of women with pre-term pre-eclampsia and
severe disease undergo severe left ventricular hypertrophy with
advanced cardiac dysfunction.
9
Typically there is preservation
of both left atrial geometry and function, and left ventricular
systolic function.
4,10
The right ventricle is also usually unaffected.
10
Levels of brain naturetic peptide (BNP) increase in pregnancies
complicated by pre-eclampsia, and Fayers
et al.
have shown that
the increase in BNP is accompanied by changes in left ventricular
diastolic function.
11
Elevated BNP levels are possibly the result of
myocardial remodelling and sub-clinical ventricular dysfunction
that accompanies the severe vasoconstriction observed in
pre-eclampsia.
11
Diastolic dysfunction is described as impaired left ventricular
filling and may be present in the setting of normal or abnormal
systolic function. Pre-clinical diastolic dysfunction is associated
with the development of future heart failure and is a predictor
Cardiac Obstetric Unit, Department of Obstetrics and
Gynaecology, University of Pretoria, Steve Biko Academic
Hospital, Pretoria, South Africa
P Soma-Pillay, FCOG, Cert (Maternal and Foetal Med) SA, priya.
soma-pillay@up.ac.zaAO Adeyemo, MB BS, MCFP (SA), FCP (SA), Cert Cardiol (SA)
Department of Cardiology, University of Pretoria, Steve
Biko Academic Hospital, Pretoria, South Africa
MC Louw, N Dip Clin Technol, B Tech Clin Technol; Cardiology
MediClinic Heart Hospital, Pretoria, South Africa
AO Adeyemo, MB BS, MCFP (SA), FCP (SA), Cert Cardiol (SA)
South African Medical Research Council Maternal
and Infant Health Care Strategies Unit, Department of
Obstetrics and Gynaecology, University of Pretoria,
Pretoria, South Africa
P Soma-Pillay, FCOG, Cert (Maternal and Foetal Medicine) SA
J Makin, MB BCh, MSc (Epidemiology and Biostatistics)
RC Pattinson, MD, FRCOG, FCOG (SA)