Vasapollo Barbara, Novelli Gian Paolo, Maellaro Filomena, Gagliardi Giulia, Pais Marcello, Silvestrini Marco, Pometti Francesca, Farsetti Daniele, Valensise Herbert
Department of Surgical Sciences, Tor Vergata University, Rome, Italy; Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy.
Prehospitalization Unit, Department of Integrated Care Processes, Policlinico di Tor Vergata, Rome, Italy.
Am J Obstet Gynecol. 2025 Mar;232(3):312.e1-312.e21. doi: 10.1016/j.ajog.2024.05.015. Epub 2024 May 17.
The maternal cardiovascular profile of patients who develop late fetal growth restriction has yet to be well characterized, however, a subclinical impairment in maternal hemodynamics and cardiac function may be present before pregnancy and may become evident because of the hemodynamic alterations associated with pregnancy.
This study aimed to investigate if maternal hemodynamics and the cardiovascular profile might be different in the preclinical stages (22-24 weeks' gestation) in cases of early and late fetal growth restriction in normotensive patients.
This was a prospective echocardiographic study of 1152 normotensive nulliparous pregnant women at 22 to 24 weeks' gestation. The echocardiographic evaluation included morphologic parameters (left ventricular mass index and relative wall thickness, left atrial volume index) and systolic and diastolic maternal left ventricular function (ejection fraction, left ventricular global longitudinal strain, E/A ratio, and E/e' ratio). Patients were followed until the end of pregnancy to note the development of normotensive early or late fetal growth restriction.
Of the study cohort, 1049 patients had no complications, 73 were classified as having late fetal growth restriction, and 30 were classified as having early fetal growth restriction. In terms of left ventricular morphology, the left ventricular end-diastolic diameter was greater in uneventful pregnancies (4.84±0.28 cm) than in late (4.67±0.26 cm) and in early (4.55±0.26 cm) (P<.001) fetal growth restriction cases, whereas left ventricular end-systolic diameter was smaller in uneventful pregnancies (2.66±0.39 cm) than in late (2.83±0.40 cm) and in early (2.82±0.38 cm) (P<.001) fetal growth restriction cases. The relative wall thickness was slightly higher in early (0.34±0.05) and late (0.35±0.04) fetal growth restriction cases than in uneventful pregnancies (0.32±0.05) (P<.05). In terms of systolic left ventricular function, at 22 to 24 weeks' gestation, cardiac output was higher in uneventful pregnancies (6.58±1.07 L/min) than in late (5.40±0.97 L/min) and in early (4.76±1.05 L/min) (P<.001) fetal growth restriction cases with the lowest values in the early-onset group. Left ventricular global longitudinal strain was lower in appropriate for gestational age neonates (-21.6%±2.0%) and progressively higher in late (-20.1%±2.2%) and early (-18.5%±2.3%) (P<.001) fetal growth restriction cases. In terms of diastolic left ventricular function, the E/e' ratio showed intermediate values in the late fetal growth restriction group (7.90±2.73) when compared with the appropriate for gestational age group (7.24±2.43) and with the early fetal growth restriction group (10.76±3.25) (P<.001). The total peripheral vascular resistance was also intermediate in the late fetal growth restriction group (1300±199 dyne·s·cm) when compared with the appropriate for gestational age group (993±175 dyne·s·cm) and the early fetal growth restriction group (1488±255 dyne.s.cm) (P<.001).
Early and late fetal growth restriction share similar maternal hemodynamic and cardiovascular profiles with a different degree of expression. These features are already present at 22 to 24 weeks' gestation and are characterized by a hypodynamic state. The degree of these cardiovascular changes may influence the timing of the manifestation of the disease; a hypovolemic, high resistance, low cardiac output state might be associated with early-onset fetal growth restriction, whereas a milder hypovolemic state seems to favor the development of the disease in the final stages of pregnancy.
发生晚期胎儿生长受限的患者的母体心血管状况尚未得到充分描述，然而，母体血流动力学和心脏功能的亚临床损害可能在妊娠前就已存在，并且可能由于与妊娠相关的血流动力学改变而变得明显。
本研究旨在调查血压正常的患者在临床前期（妊娠22 - 24周），早期和晚期胎儿生长受限病例中母体血流动力学和心血管状况是否存在差异。
这是一项对1152名妊娠22至24周的血压正常初产妇进行的前瞻性超声心动图研究。超声心动图评估包括形态学参数（左心室质量指数和相对室壁厚度、左心房容积指数）以及母体左心室收缩和舒张功能（射血分数、左心室整体纵向应变、E/A比值和E/e'比值）。对患者进行随访直至妊娠结束，记录血压正常的早期或晚期胎儿生长受限的发生情况。
在研究队列中，1049例患者无并发症，73例被归类为晚期胎儿生长受限，30例被归类为早期胎儿生长受限。在左心室形态方面，正常妊娠时左心室舒张末期内径（4.84±0.28 cm）大于晚期（4.67±0.26 cm）和早期（4.55±0.26 cm）胎儿生长受限病例（P<0.001），而正常妊娠时左心室收缩末期内径（2.66±0.39 cm）小于晚期（2.83±0.40 cm）和早期（2.82±0.38 cm）胎儿生长受限病例（P<0.001）。早期（0.34±0.05）和晚期（0.35±0.04）胎儿生长受限病例的相对室壁厚度略高于正常妊娠（0.32±0.05）（P<0.05）。在左心室收缩功能方面，妊娠22至24周时，正常妊娠的心输出量（6.58±1.07 L/min）高于晚期（5.40±0.97 L/min）和早期（4.76±1.05 L/min）胎儿生长受限病例（P<0.001），早期发病组的值最低。适于胎龄新生儿的左心室整体纵向应变较低（-21.6%±2.0%），晚期（-20.1%±2.2%）和早期（-18.5%±2.3%）胎儿生长受限病例逐渐升高（P<0.001）。在左心室舒张功能方面，与适于胎龄组（7.24±2.43）和早期胎儿生长受限组（10.76±3.25）相比，晚期胎儿生长受限组的E/e'比值呈中间值（7.90±2.73）（P<0.001）。与适于胎龄组（993±175达因·秒·厘米）和早期胎儿生长受限组（1488±255达因·秒·厘米）相比，晚期胎儿生长受限组的总外周血管阻力也呈中间值（1300±199达因·秒·厘米）（P<0.001）。
早期和晚期胎儿生长受限具有相似的母体血流动力学和心血管状况，但表达程度不同。这些特征在妊娠22至24周时就已存在，其特点是动力不足状态。这些心血管变化的程度可能会影响疾病表现的时间；低血容量、高阻力、低心输出量状态可能与早期发病的胎儿生长受限有关，而较轻的低血容量状态似乎有利于疾病在妊娠后期发展。
