Cardiovascular Management in Pregnancy

703 Preeclampsia is a pregnancy-specific multi-organ syndrome that affects 2% to 8% of pregnancy. It is a unique condition of placental pathogenesis with acute onset of predominantly cardiovascular manifestations attributable to generalized vascular endothelial activation and vasospasm resulting in hypertension and multi-organ hypoperfusion. The major scientific societies provide different criteria for the diagnosis of preeclampsia. Common to all diagnostic criteria is that preeclampsia is a syndrome characterized by new-onset hypertension (≥140 mm Hg systolic blood pressure [SBP] or ≥90 mm Hg diastolic blood pressure [DBP]) arising after 20 weeks of gestation with ≥1 organ system involvement and complete resolution within 12 weeks postpartum (Table 1). The terms “preterm” or “early-onset” preeclampsia are used to try and delineate the severity of the disease in relation to the need for iatrogenic delivery before 37 weeks (preterm preeclampsia) or the time of the diagnosis at or before 34 weeks of gestational age (early-onset preeclampsia), respectively. Although not distinct entities, it is increasingly becoming apparent that early-onset or preterm preeclampsia is especially associated with poor placentation, fetal growth restriction, and worse long-term maternal cardiovascular outcomes than late-onset preeclampsia, whose pathogenesis is more related to predisposing cardiovascular or metabolic risks for endothelial dysfunction. Furthermore, because the pathogenesis of preeclampsia has not been fully elucidated, the search for predictive markers and a preventative strategy remains an unfulfilled goal. Hence, clinical management is mainly symptomatic and directed to prevent maternal morbidity and mortality. Preeclampsia is 1 of the leading causes of maternal morbidity and mortality worldwide, and delay in the treatment of severe hypertension and diagnosis of preeclampsia complications contribute significantly to maternal mortality. Mortality rates have been shown to be reduced in countries such as the United States and the United Kingdom after the introduction of detailed national guidelines for the management and with increased awareness of the importance of reduction of severely raised blood pressure (BP). There is scant and conflicting information about the impact on the heart. Previous studies on the cardiovascular changes in preeclampsia provided contradictory results mainly attributable to limitations in technology, patient selection, and data interpretation. More recent studies have outlined better the cardiovascular profile in preeclampsia from the preclinical phase of the disease to the postpartum period and the cardiovascular and cardiopulmonary complications associated with this condition. Multiple exceptional and exclusive changes in cardiac structure and function have been described in preeclampsia, suggesting that these women display abnormal cardiac adaptation to pregnancy. These cardiac changes may be fundamental in explaining these women’s increased predisposition toward preeclampsia and long-term postpartum cardiovascular disease (CVD). Indeed, the development of preeclampsia is now considered a risk factor for long-term CVD. This review focuses on this recent evidence and its implication for the cardiovascular management of preeclampsia.