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Ultrazvočna ocena hemodinamičnega stanja in srčne funkcije pri težki preeklampsiji
ID Ambrožič, Jana (Author), ID Lučovnik, Miha (Mentor) More about this mentor... This link opens in a new window, ID Prokšelj, Katja (Comentor)

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Abstract
Objective. The objective of this study was to assess whether echocardiographic parameters in combination with lung ultrasound can detect dynamic changes in hemodynamic status, cardiac function and lung congestion in women with severe features of preeclampsia and healthy controls immediately before and in the first days after delivery. We hypothesized that women with severe features of preeclampsia more frequently present with impaired left ventricular diastolic function, have higher degree of lung congestion that is related to impaired diastolic function parameters and are less fluid responsive compared with healthy pregnant women. Methods. 30 severe preeclamptic women and 30 healthy term controls were evaluated within 1 day before delivery, 1 day post-delivery and 4 days post-delivery. At each examination standard two-dimensional, pulsed wave and tissue Doppler echocardiography was performed. Left ventricular myocardial deformation parameters were assessed by two-dimensional speckle tracking imaging. Lung ultrasound was performed by the 28-rib interspaces technique and Echo Comet Score (ECS) was obtained as the sum of B-lines representing the amount of extravascular lung water. Fluid responsiveness was assessed by measuring changes in left ventricular stroke volume with passive leg rising and it was defined as an increase in stroke volume of at least 12%. Results. Hemodynamic characteristics Women with severe features of preeclampsia had significantly higher arterial blood pressures (mean arterial pressure: median 110 (range 103–119) mmHg vs. 88 (81–96) mmHg, p<0.001) and peripheral vascular resistance (1694 (1480–1871) dynes×s×cm-5 vs. 1411 (1173–1612) dynes×s×cm-5, p=0.004), while heart rate (77 (70–89) bpm vs. 75 (69–84) bpm, p=0.736) and stroke volumes (70 (61–78) ml vs. 68 (57–76) ml, p=0.194) were comparable between both groups. Left ventricular systolic and diastolic function Ejection fraction was similar in both groups at all examinations (before delivery: 66 (64–71)% vs. 66 (61–67)%, p=0.061; 1 day post-delivery: 65 (62–70)% vs. 64 (62–66)%, p=0.09; 4 days post-delivery: 64 (60–71)% vs. 65 (60–69)%, p=0.592); however, peak systolic myocardial velocities (s’) at the septal and lateral mitral annulus and global longitudinal strain values (GLS) were lower in preeclamptic women 4 days post-delivery (s’ at the septal mitral annulus: 7.4 (6.6-7.8) cm/s vs. 8.1 (7.9-9.3) cm/s, p=0.001; GLS: &#8210;21.7 (&#8210;22.6 to &#8210;20.8)% vs. &#8210;23.0 (&#8210;23.9 to &#8210;21.8)%, p=0.027). At all assessments peak early diastolic myocardial velocities (e’) were significantly lower (e’ at the septal mitral annulus before delivery: 8.7 (7.0-10.3) cm/s vs. 9.0 (8.2-10.7) cm/s, p=0.062; 1 day post-delivery: 8.2 (7.2-9.6) cm/s vs. 9.8 (8.7-11.0) cm/s, p=0.001; 4 days post-delivery: 8.5 (7.7-9.6) cm/s vs. 10.3 (9.0-12.1) cm/s, p<0.001) and the ratio of the peak velocity of early diastolic mitral inflow (E) to e’ (E/e’) was significantly higher in preeclamptic women than in controls (before delivery: 8.2 (6.3-10.1) vs. 6.3 (5.3-7.7), p=0.002; 1 day post-delivery: 8.6 (7.6-10.2) vs. 6.9 (6.2-7.7), p=0.001; 4 days post-delivery: 8.3 (7.1-9.0) vs. 6.8 (5.9-7.3), p=0.003). Lung ultrasound and fluid responsiveness ECS was significantly higher in preeclamptic women than in controls before delivery (16 (9–25) vs. 6 (2–7), p<0.001) and 1 day post-delivery (15 (8–26) vs. 9 (6–14), p=0.007), but not 4 days post-delivery (7 (2–13) vs. 4 (2–8), p=0.091). Significant positive correlations between ECS and E/e’ were found before and immediately post-delivery in preeclamptic group (Spearman, before delivery: r=0.572, p=0.001; 1 day post-delivery: r=0.442, p=0.018). Fluid responsiveness was observed in significantly more controls than in women with severe features of preeclampsia (12 (43%) vs. 3 (11%), p=0.014) before delivery. Conclusions. Preeclampsia with severe features is associated with impaired diastolic function parameters that persist in the first days after delivery. Preeclamptic women have greater amount of extravascular lung water before and immediately post-delivery compared with healthy controls and lung congestion correlates with impaired parameters of diastolic function. Worsening of systolic function parameters 4 days after delivery in preeclamptic women might indicate subtle systolic dysfunction, which could become unmasked with the effect of augmented volume load related to fluid mobilization in the postpartum period. This finding seems to corroborate our results of passive leg raising test showing that the majority of preeclamptic women were fluid non-responsive and as such, could not be able to increase myocardial contraction force with fluid loading.

Language:Slovenian
Keywords:preeclampsia, echocardiography, diastolic function, lung ultrasound, fluid responsiveness
Work type:Doctoral dissertation
Organization:MF - Faculty of Medicine
Year:2019
PID:20.500.12556/RUL-107745 This link opens in a new window
COBISS.SI-ID:4015636 This link opens in a new window
Publication date in RUL:22.05.2019
Views:1292
Downloads:385
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Secondary language

Language:English
Title:Ultrasonographic assessment of hemodynamic changes and cardiac function in patients with severe features of preeclampsia
Abstract:
Izhodišča. Namen raziskave je opredeliti uporabnost ultrazvočne preiskave srca in pljuč za oceno hemodinamičnega stanja, srčne funkcije in pljučne kongestije bolnic s težko preeklampsijo pred in v prvih dneh po porodu. Predvidevamo, da imajo bolnice s težko preeklampsijo pogosteje prisotne kazalce motene diastolične funkcije levega prekata in večjo stopnjo pljučne kongestije pred in po porodu ter so manj odzivne na tekočino v primerjavi z zdravimi nosečnicami. Metode. V raziskavo smo vključili 30 nosečnic s težko preeklampsijo in kontrolno skupino zdravih nosečnic ob predvidenem terminu poroda. Preiskovankam smo opravili ultrazvočno preiskavo srca in pljuč dan pred porodom, dan po porodu in četrti dan po porodu. Dimenzije srčnih votlin in srčno funkcijo smo ocenili s standardnimi dvodimenzionalnimi, doplerskimi in tkivno doplerskimi metodami. Za meritve deformacije levega prekata smo uporabili metodo sledenja ultrazvočnega vzorca (angl. speckle tracking imaging). Z ultrazvočnim pregledom pljuč po protokolu 28 medrebrnih prostorov smo ocenili prisotnost in število B linij; vsota B linij je predstavljala količino zunajžilne pljučne tekočine (Echo Comet Score - ECS). Odzivnost na tekočino smo ocenili dan pred in dan po porodu in jo definirali kot povečanje utripnega volumna, ocenjenega s pulzno doplersko preiskavo, za &#8805; 12% ob pasivnem dvigu nog. Rezultati. Hemodinamične značilnosti Preeklamptične bolnice so imele pričakovano višji arterijski krvni tlak (srednji arterijski tlak: 110 (103 – 119) mmHg vs. 88 (81 – 96) mmHg, p < 0,001) in višjo periferno žilno upornost (1694 (1480 – 1871) dynes×s×cm-5 vs. 1411 (1173 – 1612) dynes×s×cm-5, p = 0,004) v primerjavi s kontrolno skupino, medtem ko med skupinama ni bilo statistično značilnih razlik v srčni frekvenci (77 (70 – 89)/min vs. 75 (69 – 84)/min, p = 0,736) in utripnemu volumnu srca (70 (61 – 78) ml vs. 68 (57 – 76) ml, p = 0,194). Sistolična in diastolična funkcija levega prekata Iztisni delež levega prekata je bil med skupinama primerljiv (pred porodom: 66 (64 – 71)% vs. 66 (61 – 67)%, p = 0,061; prvi dan po porodu: 65 (62 – 70)% vs. 64 (62 – 66)%, p = 0,09; četrti dan po porodu: 64 (60 – 71)% vs. 65 (60 – 69)%, p = 0,592). Preeklamptične bolnice so imele značilno nižje vrednosti najvišje sistolične hitrosti miokarda (s') in globalnega kazalca longitudinalne deformacije levega prekata (GLS) v primerjavi s kontrolno skupino četrti dan po porodu (s’ na medialnem mitralnem obroču: 7,4 (6,6 – 7,8) cm/s vs. 8,1 (7,9 – 9,3) cm/s, p = 0,001; GLS: &#8210;21,7 (&#8210;22,6 do &#8210;20,8)% vs. &#8210;23,0 (&#8210;23,9 do &#8210;21,8)%, p = 0,027). V skupini s preeklampsijo so bile vrednosti zgodnje diastolične hitrosti miokarda (e') na septalnem in lateralnem mitralnem obroču značilno nižje (e’ na medialnem mitralnem obroču pred porodom: 8,7 (7,0 – 10,3) cm/s vs. 9,0 (8,2 – 10,7) cm/s, p = 0,062; prvi dan po porodu: 8,2 (7,2 – 9,6) cm/s vs. 9,8 (8,7 – 11,0) cm/s, p = 0,001; četrti dan po porodu: 8,5 (7,7 – 9,6) cm/s vs. 10,3 (9,0 – 12,1) cm/s, p < 0,001), razmerje zgodnje diastolične hitrosti mitralnega vtoka E in e' (E/e') pa značilno večje (pred porodom: 8,2 (6,3 – 10,1) vs. 6,3 (5,3 – 7,7), p = 0,002; prvi dan po porodu: 8,6 (7,6 – 10,2) vs. 6,9 (6,2 – 7,7), p = 0,001; četrti dan po porodu: 8,3 (7,1 – 9,0) vs. 6,8 (5,9 – 7,3), p = 0,003) v primerjavi s kontrolno skupino. Pljučna kongestija in odzivnost na tekočino ECS je bil pomembno večji v skupini s preeklampsijo v primerjavi s kontrolno skupino pred porodom (16 (9 – 25) vs. 6 (2 – 7), p < 0,001) in prvi dan po porodu (15 (8 – 26) vs. 9 (6 – 14), p = 0,007), ni pa se pomembno razlikoval četrti dan po porodu (7 (2 – 13) vs. 4 (2 – 8), p = 0,091). Dokazali smo tudi pomembno povezavo med ECS in E/e' v skupini s preeklampsijo pred porodom (Spearman: r = 0,572, p = 0,001) in prvi dan po porodu (r = 0,442, p = 0,018). Pred porodom je bilo več zdravih nosečnic odzivnih na tekočino (12; 43%) v primerjavi s preeklamptičnimi bolnicami (3; 11%) (p = 0,014). Zaključki. Pri bolnicah s težko preeklampsijo so pogosteje prisotni kazalci motene diastolične funkcije levega prekata pred porodom in v prvih dneh po porodu v primerjavi z zdravimi nosečnicami. Preeklamptične bolnice imajo večjo stopnjo pljučne kongestije pred in po porodu v primerjavi z zdravimi nosečnicami. Stopnja pljučne kongestije je povezana s kazalci diastolične disfunkcije. V prvih dneh po porodu se pri preeklamptičnih bolnicah stopnja pljučne kongestije zmanjša, medtem ko kazalci motene diastolične funkcije vztrajajo. Četrti dan po porodu se vrednosti nekaterih sistoličnih kazalcev (s' in GLS) pri preeklamptičnih bolnicah zmanjšajo, kar lahko kaže tudi na subtilno okvaro sistolične funkcije, ki se razkrije ob povečani volumski obremenitvi srca zaradi premika tekočine iz zunajžilnega prostora. V naši raziskavi je bila večina bolnic s težko preeklampsijo neodzivna na tekočino.

Keywords:preeklampsija, ehokardiografija, diastolična funkcija, ultrazvočna preiskava pljuč, odzivnost na tekočino

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