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Abstract

A higher chance of maternal cardiovascular disease in later life is linked to pregnancies complicated by preeclampsia and foetal growth restriction. Before significant cardiovascular illness manifests itself, subclinical cardiac abnormalities are discernible. An elegant way to evaluate subclinical cardiac dysfunction is to use strain measurement in conjunction with speckle-tracking echocardiography (STE). The current study sought to assess the subclinical cardiac dysfunction in mothers with preeclampsia and intrauterine growth restriction (IUGR) by measuring Global Longitudinal Strain (GLS) using the 2D STE technique). This cross-sectional research was done on pregnant individuals with preeclampsia (n=29), IUGR (n=26), or both (n=20) who were referred to the prenatal department of Imam Khomeini Hospital in Ahvaz between January 2021 and June 2022. Demographic and clinical characteristics of the patients were recorded and the patients underwent 2D STE to evaluate the cardiac function and measure GLS using 2D speckle tracking echocardiography. In the current research, seventy-five pregnant women having a mean age of 31.37 ± 6.69 years (range of 19 to 45 years) participated. The mean GLS was a significant difference between preeclampsia, IUGR, and Preeclampsia + IUGR groups (-19.97 ± 2.02 vs. -20.59 ± 1.90 vs. -18.56±0.57; P=0.001). There was no significant difference between the three groups regarding other echocardiography parameters (LVEF, LVEDD, LVESD, RVD, LAD, PWD, IWD, and PAP) (P > 0.05).  The current literature results revealed that Preeclampsia with or without IUGR may be related to subclinical myocardial LV dysfunction. Thus, accurate evaluation of cardiac function by STE echocardiography is recommended for proper management of possible cardiac dysfunction in preeclampsia. Long-term follow-up with a larger sample is required to evaluate the changes in GLS during and after pregnancy‎.

Keywords: Preeclampsia, IUGR, Speckle tracking echocardiography, Global longitudinal strain (GLS), LV function

 

 

 

The findings of comparing the mean GLS between two groups with and without Table 3 displays IUGR and consequences related to preeclampsia. The mean GLS of patients with preeclampsia was considerably lower than that of patients without preeclampsia, according to the findings of the independent t-test used to compare the means between the two groups (P=0.008). Furthermore, there was a significant difference (P<0.0001) in the mean GLS between patients with preeclampsia + IUGR and those without preeclampsia + IUGR. However, the mean GLS in patients with and without IUGR was not significantly different (P=0.565).

Table 3. Comparison of mean GLS evaluated by 2D STE echocardiography
Group	Yes	No	* P-value
Preeclampsia	-19.39 ± 1.73	-20.59 ± 1.90	0.008
IUGR	-19.71 ± 1.78	-19.97 ± 2.02	0.565
Preeclampsia + IUGR	-18.56 ± 0.57	-20.26 ± 1.97	<0.0001

* Independent t-test

2DSTE: Two-dimensional speckle tracking echocardiography; GLS: Global longitudinal strain; IUGR: Intrauterine growth restriction

The findings of the current research showed that the mean GLS was different between the three groups of preeclampsia, IUGR, and preeclampsia + IUGR, so the mean GLS in the preeclampsia + IUGR was significantly lower in this group as compared to compared to two preeclampsia and IUGR groups combined. However, the mean GLS did not show any significant difference between the two groups of preeclampsia and IUGR. Additionally, the data showed that preeclamptic individuals had a significantly lower mean GLS than non-preeclamptic patients. Nonetheless, there was no discernible difference in the mean GLS between patients with and without IUGR. Furthermore, there was no discernible difference in the three groups' ventricular diameters, LVEF, or PAP, among other echocardiographic characteristics. These findings suggest that in women with preeclampsia and IUGR, GLS assessment can be utilised as a sensitive marker to identify the early stages of LV dysfunction even in the presence of normal LVEF. Other studies have also reported that preeclampsia is associated with subclinical myocardial dysfunction in the form of abnormal strain (GLS reduction) in STE [15, 16].

GLS assessment by STE is a new and accurate technique to identify left ventricular systolic function disorders. GLS indicates longitudinal myocardial contractions and is used to assess ventricular systolic function [17]. GLS measurement is an accurate, repeatable, and operator-independent method. In the general population, GLS is superior to LVEF for predicting cardiac events and all types of mortality [18]. The normal rate of GLS has been reported between -15.9 and -22.1 in different studies [19, 20]. Recently, GLS less than -20 in pregnant women has been used as an accurate marker to predict myocardial dysfunction and cardiac events during the postpartum period [21]. Other studies have also indicated that preeclampsia significantly affects the cardiac function of pregnant mothers. In the study by Paudel et al. the evaluation of echocardiography by speckle tracking revealed that patients with preeclampsia have less left ventricular GLS than normal pregnant women (-0.18 vs. -19.8). Also, patients with preeclampsia had larger left atrium, thicker interventricular walls, higher pulmonary artery systolic blood pressure, and higher mitral E/e index than the control group, but the LVEF of the two groups was similar [22].

In the study by Cong et al. women with preeclampsia had thicker left ventricular walls and higher left ventricular mass index (LVMi) compared to normal pregnant women. Also, in Speckle tracking, LVEF, tissue Doppler, and strain indices including GLS were significantly lower in the preeclampsia group [23]. In the study by Mostafavi et al. 2D-STE evaluation showed that pregnant women with preeclampsia have lower systolic function than normal pregnant women, which is detected as a reduction in GLS and GCS of the left ventricle [24]. The study by Ajmi et al. also reported that the GLS of the left ventricle is significantly reduced in the preeclampsia group [25]. These results indicate that preeclampsia can cause significant heart damage in pregnant women, which can be identified as a reduction in GLS in STE echocardiography during pregnancy.

The results of a study by Domínguez also revealed that pregnancies with IUGR fetuses were associated with a significant reduction in GLS in 2D-STE echocardiography, indicating subclinical cardiac dysfunction in these patients [26]. In the study by Orabona et al. the examination of cardiac function and echocardiography of three groups of pregnant women with preeclampsia, FGR, and preeclampsia + FGR revealed that the rate of left ventricular hypertrophy in the two preeclampsia groups with and without FGR was higher than the FGR alone group. However, the FGR normotensive group had smaller left ventricular mass (LVM), less EDV and ESV, and less LVM than the other two groups. The rate of GLS in the three groups did not show any significant difference. Finally, both groups of women with a history of preeclampsia or FGR showed abnormal myocardial function in speckle-tracking echocardiography. Thus, both groups of women with preeclampsia and normotensive FGR have the risk factor of clinical myocardial dysfunction and should be examined for the control of cardiovascular disorders [4]. However, in the present study, GLS in the preeclampsia group was significantly lower than in the IUGR group. However, other echocardiographic parameters were not different between the three groups. Thus, the results of our study indicate that the risk of left ventricular dysfunction is higher in preeclampsia women.

Both preeclampsia and IUGR are characterized by chronic inflammation, oxidative stress, and hypertension (in the case of preeclampsia) [27, 28]. Afterload can be the reason for the difference in the rate of left ventricular dysfunction (abnormal LV strain) in IUGR patients with or without preeclampsia (hypertension) [4]. In various clinical areas, chronic inflammation has been associated with subclinical cardiovascular changes [29, 30]. Coronary microvascular changes are the primary cause of three-quarters of cases of heart failure with preserved LVEF [31]. Inflammation and oxidative stress lead to heart failure through disruption of the nitric oxide (NO) pathway, which is an effective factor in the proper functioning of endothelial elasticity of arteries [32].

Finally, the present study revealed that the mean GLS in patients with preeclampsia with and without IUGR is significantly lower than in patients without preeclampsia. Since there is a direct association between myocardial strain parameters and left ventricular GLS reduction, despite normal LVEF, it is associated with negative pregnancy outcomes such as gestational hypertension, preeclampsia, gestational diabetes, preterm delivery, postpartum hemorrhage, premature rupture of membranes (PROM), and maternal death [33]. Therefore, 2D STE echocardiography examination of GLS can be employed as a low-cost, non-invasive, and practical means for the early detection of subclinical cardiac impairment, particularly in patients with preeclampsia. It can also be used to control and avoid other pregnancy-related issues. The minimal number of examined samples and lack of a control group (normal pregnancy) to compare echocardiogram results were two of the study's shortcomings. Also, the lack of echocardiography evaluation before and after pregnancy makes it impossible to investigate the cause-and-effect relationship between preeclampsia, IUGR, and cardiac function. Also, it is not clear whether the subclinical myocardial dysfunction is directly associated with preeclampsia and IUGR or caused by other factors such as genetic predisposition and other cardiovascular risk factors (obesity and dyslipidemia]. Thus, more accurate results can be obtained by conducting more studies with a larger sample size.

Conclusion

The findings proved that the mean GLS of the three groups was substantially differ, so the mean GLS in patients with preeclampsia with or without IUGR was considerably lower than that of patients with IUGR alone. However, other echocardiography parameters were not substantially different amongst the 3 groups. These results indicate that preeclampsia with or without IUGR can be related to subclinical myocardial LV dysfunction. Thus, accurate assessment of maternal cardiac function by STE echocardiography is recommended for proper management of possible cardiac disorders in preeclampsia. It is also recommended to conduct a study with a larger sample size and long-term follow-up to investigate and determine the clinical association of GLS changes during and after pregnancies with preeclampsia and IUGR.

Acknowledgments: This article was derived from the thesis of the specialized assistant course in obstetrics and gynecology with the research code FIRC-0107 in the Faculty of Medicine of Jundishapur University of Medical Sciences, Ahvaz. It was financially supported by the Research Deputy of Jundishapur University of Ahvaz.

Conflict of interest: None

Financial support: This article was financially supported by the Research Deputy of Jundishapur University of Ahvaz with the research code FIRC-0107.

Ethics statement: This investigation is approved by Jundishapur University of Medical Sciences, Ahvaz Research Ethics Committee with Ethics code of IR. AJUMS.HGOLESTAN. REC.1401.030. Informed consent was attained from all patients before starting the study. Furthermore, the Helsinki Research Ethics Statement's rules and the patient information confidentiality guidelines were followed during the entire investigation.

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