Objective: To determine the prevalence of pre-eclampsia and fetal growth restriction (FGR; <3rd centile) in women with pre-existing cardiac dysfunction. Design: Retrospective cohort study. Setting: Maternity units in UK and Australia. Population: Pregnant women with impaired left ventricular ejection fraction<55%. Methods: Routine clinical data, including medical history and pregnancy outcome were collected retrospectively. Main Outcome Measures: Pre-specified outcomes included pre-eclampsia and FGR prevalence in women with pre-existing cardiac impairment, compared with the general population; and the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. Results: In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] versus population prevalence of 4.6% [95% C.I. 2.7-8.2], p=0.99); 12/13 of these women had additional obstetric/medical risk factors. However, prevalences of preterm pre-eclampsia (<37 weeks) and FGR were increased (1.8% versus 0.7%, p=0.03; 15.2% versus 5.5%, p<0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome; however, left ventricular mass index (LVMi) weakly correlated with pre-eclampsia (5g/m2 increase: OR 1.18 [95% C.I. 1.01-1.38], p=0.04). Antenatal ß blockers (n=116) were associated with lower birthweight Z score (adjusted difference -0.33 [95% C.I. -0.63- -0.02], p=0.04). Conclusions: This study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with cardiac dysfunction. These results do not support a causal relationship between cardiac dysfunction and pre-eclampsia, especially accounting for the background risk status of the population. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.

Objective Explore the nature of postnatal cardiovascular morbidity following pregnancies complicated by preterm pre-eclampsia and identify associations between pregnancy characteristics and postnatal cardiovascular function. Design Observational sub-study of a single-centre feasibility randomised double-blind placebo-controlled trial. Setting Tertiary maternity hospital, UK. Population Women with preterm pre-eclampsia, delivering <37 weeks. Methods Eligible women underwent echocardiography, arteriography and blood pressure monitoring <3 days, 6 weeks and 6 months postpartum. Correlations between pregnancy and cardiovascular characteristics were assessed using Spearman’s correlation. Main Outcome Measure Prevalence of cardiovascular dysfunction and remodelling 6 months following preterm pre-eclampsia. Results Forty-four women completed the study. At 6 months, 27 (61%) had diastolic dysfunction, 33 (75%) had raised total vascular resistance (TVR) and 18 (41%) had left ventricular remodelling. Sixteen (46%) women had de novo hypertension by 6 months and only 2 (5%) women had a completely normal echocardiogram. Echocardiography did not change significantly from 6 weeks to 6 months. Earlier gestation at delivery and lower birthweight centile were associated with worse 6-month diastolic dysfunction (E/E’: rho=-0.39, p=0.001 & rho=-0.42, p=0.005) and TVR (rho=-0.34, p=0.02 & rho=-0.37, p=0.01). Conclusions Preterm pre-eclampsia is associated with persistent cardiovascular morbidity 6 months postpartum in the majority of women. These cardiovascular changes have significant implications to long-term cardiovascular health. The graded severity of diastolic dysfunction and TVR with worsening pre-eclampsia phenotype suggests a dose-effect. However, the mechanistic link remains uncertain. Funding Medical Research Council (MR/R001693/1). Registration https://www.clinicaltrials.gov; NCT03466333. Key words Pre-eclampsia: clinical research; radiological imaging: ultrasound; medical disorders in pregnancy.