Comparison of total blood volume in normal, preeclamptic, and nonproteinuric gestational hypertensive pregnancy by simultaneous measurement of red blood cell and plasma volumes

doi:10.1016/S0002-9378(98)70255-8

American Journal of Obstetrics and Gynecology

Volume 179, Issue 1, July 1998, Pages 87-93

https://doi.org/10.1016/S0002-9378(98)70255-8 Get rights and content

Abstract

OBJECTIVE: Our purpose was to demonstrate reduced blood volume in preeclampsia compared with nonproteinuric gestational hypertension and normal pregnancy by use of independent measures of red blood cell and plasma volumes.

STUDY DESIGN: Red blood cells labeled with a nonradioactive stable isotope of chromium and Evans’ blue were infused in subjects with preeclampsia or gestational hypertension and normotensive pregnant controls. Blood was sampled eight times over 60 minutes for dye concentration and at 30 minutes for chromium analysis.

RESULTS: Total blood and plasma volumes are decreased in preeclampsia (2660 ± 382 mL/m² and 1790 ± 332 mL/m², respectively) compared with normotensive subjects (3217 ± 391 mL/m², P < 0.001 and 2279 ± 325 mL/m², P < .001) and gestational hypertension (3139 ± 272 mL/m², P < .001 and 2132 ± 265 mL/m², P = .003). Total body/peripheral hematocrit ratio is increased in preeclampsia.

CONCLUSIONS: Blood volume, by measurement of red blood cell and plasma volumes, is reduced and has altered distribution in preeclampsia but is normal in gestational hypertension. (Am J Obstet Gynecol 1998;179:87-93.)

Section snippets

Subjects

Pregnant women were recruited from the outpatient center or antepartum unit of Women and Infants’ Hospital of Rhode Island. The subjects were of diverse ethnic and socioeconomic backgrounds, reflecting the general patient population of the hospital. Inclusion criteria for subjects with a pregnancy-related hypertensive disorder were no history of hypertension before pregnancy, documented normal blood pressure in the first trimester, and newly diagnosed hypertension before the onset of labor

Clinical characteristics

Baseline clinical characteristics of the groups are compared in Table I.

. Baseline clinical characteristics

Empty Cell	Controls	Preeclampsia	GH
No. of subjects	20	20	15
Gestational age (wk)*	34.4 ± 4.1	34.6 ± 2.9	36.8 ± 3.2
Maternal age (y)	26 ± 5.3	24.4 ± 6.9	26.9 ± 6.0
Gravidity	1.8 ± 1.1	2.0 ± 1.4	2.1 ± 1.4
Parity	0.5 ± 0.7	0.6 ± 0.9	0.8 ± 1.1
Ethnic group
White	15 (75%)	11 (73%)	8 (40%)
Black	3 (15%)	2 (13%)	3 (15%)
Hispanic	2 (10%)	2 (13%)	9 (45%)
Height (cm)	162.0 ± 5.8	163.3 ± 5.1	160.1 ± 5.5
Prepregnant weight (kg)	62.7 ± 16.2	70.0 ± 13.7

Comment

With use of exacting methods for measurement of blood volume we have confirmed that total blood volume is reduced in patients with preeclampsia and is not reduced in patients with gestational hypertension. A new finding in preeclampsia is a significant increase in the total body/peripheral hematocrit ratio, suggesting that less of the circulating volume is found in the smaller blood vessels in patients with preeclampsia. This suggests a vasoconstricted state in preeclampsia, a concept that has

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This chapter reviews physiological changes in volume and osmolality in normal pregnancy, as well as alterations in volume associated with preeclampsia. There is a marked stimulation of the renin–angiotensin–aldosterone (RAA) system and a rise in the plasma concentration during normal pregnancy. In contrast, plasma volume and components of the RAA system decreased preeclampsia. Importantly, activating autoantibodies to the angiotensin II type I receptor (AT1-AA) are present in preeclampsia. There is an evolving literature on the role of inflammatory cells and cytokines in contributing to preeclampsia by leading to production of the AT1-AA, which is discussed in this chapter.
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Ferritin and transferrin saturation in first trimester detected women who subsequently had anaemia pre-delivery, with ferritin being most discriminatory. Both were superior to haemoglobin concentration. Iron studies in second trimester did not predict pre-delivery anaemia and haemoglobin remained poorly discriminatory. Iron studies lost predictive value when a systematic program ensured treatment of iron depletion during pregnancy. The ability of ferritin to predict pre-delivery anaemia in the first, but not the second, trimester was confirmed on the validation cohort.
First trimester serum ferritin may identify candidates for iron therapy during pregnancy. This strategy may be preferable to haemoglobin screening alone or universal replacement in centres at low risk of anaemia.
An efficient method for measuring plasma volume using indocyanine green dye
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Plasma volume (PV) can be an important marker of health status and may affect the interpretation of plasma biomarkers, but is rarely measured due to the complexity and time required. Indocyanine green (ICG) is a water-soluble tricarbocyanine dye with a circulatory half-life of 2–3 min, allowing for quick clearance and repeated use. It is used extensively in medical diagnostic tests including ophthalmologic imaging, liver function, and cardiac output, particularly in critical care. ICG has been validated for measuring PV in humans, however previous work has provided minimal published details or has focused on a single aspect of the method. We aimed to develop a detailed, optimal protocol for the use of ICG to measure PV in women of reproductive age. We combined best practices from other studies and optimized the protocol for efficiency.
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  This method reduces the time from blood collection to PV determination to ˜2 h and the amount of plasma required to estimate PV to 2.5 mL (1.5 mL before ICG injection and 1.0 mL post-injection).
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Despite the extensive research, the pathophysiology is still unclear. A defect in terms of plasma volume expansion has been reported by many authors to relate to a poor foetal-maternal outcome including pathologies such as foetal growth restriction [14,15] and hypertensive gestational disorders [16,17]. During physiological pregnancy the increase in TBW and ECW seems to play an important role in maternal cardiovascular adaptation.
To assess and correlate changes in body composition and haemodynamic function during pregnancy. To identify different haemodynamic profiles based on the onset of hypertensive diseases such as gestational hypertension and preeclampsia.
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In patients who developed gestational hypertension we found lower total body water (TBW) percentage, higher Fat Mass (FM), associated with lower Cardiac Output (CO) and higher Total Vascular Resistance (TVR) during the second trimester. In the third trimester we didn’t find haemodynamic differences, but a significative increase in extracellular water (ECW) percentage. In patients who developed preeclampsia we found since the first trimester significative higher TVR and hypodynamic circulation, associated with lower FM percentage.
Assessment of body composition and maternal cardiac function may help to identify earlier in pregnancy, patients with different (mal) adaptations to pregnancy. Women with high TVR, hypodynamic circulation and low fat mass during the first trimester, might be at higher risk to develop preeclampsia. Patients with higher BMI and FM percentage, and increased TVR in the second trimester, might be at risk of gestational hypertension and excessive fluid retention at the end of pregnancy.
Hematocrit and plasma albumin levels difference may be a potential biomarker to discriminate preeclampsia and eclampsia in patients with hypertensive disorders of pregnancy
2017, Clinica Chimica Acta
We evaluated whether alterations of hemoglobin (HB), hematocrit (HCT), serum albumin level (ALB), and the difference of HCT and ALB can be used in the diagnosis of preeclampsia and eclampsia in patients with hypertensive disorders of pregnancy (HDP).
A total of 509 individuals were recruited and divided into 4 groups: Group 1, 170 healthy non–pregnant women; Group 2, 125 normal pregnant women; Group 3, 105 pregnant women diagnosed with gestational and chronic hypertension; Group 4, 109 pregnant women diagnosed as having preeclampsia and eclampsia. Data of HB, HCT, ALB, globulin (GLB) were collected at the time of a prenatal examination during the third trimester.
Alterations in the HCT and the ALB levels in these groups were significantly different. Group 4 had a higher mean HCT-ALB value (P < 0.01), but lower ALB and GLB values compared with the other three groups. We used Groups 2 and 3 as the respective reference to draw the receiver operating characteristic (ROC) curves of HCT-ALB in Group 4, and found that the threshold values of maximum index corresponding were 12.95 and 12.65 (sensitivity > 57.0%, specificity > 98.9%), respectively.
The value of HCT-ALB > 12.65 might be used as a potential biomarker for the auxiliary diagnosis of preeclampsia and eclampsia in HDP.
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Au cours de sa vie, la femme passe par trois phases hormonales durant lesquelles les hormones sexuelles joueront un rôle fondamental dans son risque cardiovasculaire et coronarien. Afin d’évaluer au mieux ce risque, il faut donc tenir compte de cette phase en association à ses facteurs de risque cardiovasculaires et ce aux trois étapes clefs : la contraception, la grossesse, la ménopause. Le risque artériel de la contraception estroprogestative dépend de l’estrogène et de son dosage. Le principal facteur de risque cardiovasculaire augmentant le risque d’infarctus du myocarde est le tabac surtout après 35 ans, âge auquel la contraception estroprogestative est alors contre-indiquée au profit de progestatif. Les lésions coronaires de la femme sous contraception estroprogestative sont dominées par les dissections spontanées et les emboles coronaires. L’infarctus chez la femme enceinte survient surtout en période de péri- et post-partum sur des lésions principalement de dissections spontanées. Concernant la procréation médicalement assistée, elle majore le risque gestationnel surtout après stimulation ovarienne mais n’affecte pas le devenir cardiovasculaire des mères. Le traitement hormonal de la ménopause n’augmente pas le risque coronarien dans les 10 premières années suivant la ménopause et pourrait même avoir un effet protecteur en favorisant le maintien de l’intégrité artérielle. La voie transdermique doit être privilégiée pour son effet métabolique. Le traitement hormonal de la ménopause reste contre-indiqué en cas de maladies coronaires avérés et devant des facteurs de risque cardiovasculaires non contrôlés.
During their lives, women go through three different phases during which sex hormones play a fundamental role in contributing to specific cardiovascular and coronary risks. To evaluate this risk, we must take into account these various phases with their associated cardiovascular risk factors, and this during three key steps: contraception, pregnancy and menopause. Arterial risk linked to estrogen combined with progestin contraception, depends on the dosage of estrogen. The main cardiovascular risk factor responsible for increasing the risk of myocardial infarction is tobacco, especially after 35 years of age, contraindicating estrogen combined with progestin contraception at the benefit of progestin. Spontaneous dissections and coronary emboli are the most common coronary lesions linked with oestroprogestative contraception. Acute myocardial infarction during pregnancy occurs mostly in the peripartum or postpartum period; and is often caused by spontaneous coronary dissection lesions. Fertility treatment is not associated with an increased risk of developing cardiovascular disease later in life. Hormone therapy during menopause does not increase coronary risk in the first 10 years after menopause and may even have a protective effect, by sustaining arterial integrity. The transdermal route is to be preferred for its metabolic effect. Hormonal treatment during menopause is nonetheless contraindicated in the case of proven coronary disease and uncontrolled cardiovascular risk factors.

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^☆: From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brown University.

^☆☆: Reprint requests: Helayne M. Silver, MD, Women and Infants’ Hospital of Rhode Island, 101 Dudley St, Providence, RI 02905.

^★: 0002-9378/98 $5.00 + 0 6/1/88531

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Comparison of total blood volume in normal, preeclamptic, and nonproteinuric gestational hypertensive pregnancy by simultaneous measurement of red blood cell and plasma volumes☆,☆☆,★

Abstract

Section snippets

Subjects

Clinical characteristics

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Maternal plasma volume and disorders of pregnancy [editorial]

Br Med J Clin Res Ed

Intravascular mass of albumin in preeclampsia and normal pregnancy

Scand J Clin Lab Invest

Blood volume studies in normal pregnancy, toxemia and gynecologic patients

Am Surgeon

Posture and apparent plasma volume in late pregnancy

J Obstet Gynaecol Br Commonw

Evans blue disappearance rate in normal and preeclamptic pregnancy

Clin Exp Hypertens Preg

Fall in blood pressure in response to volume expansion in pregnancy-associated hypertension (preeclampsia): why does it occur?

J Hypertens