Rose, Carl H.

Abstract Background Cardiovascular disease (CVD) has been identified as a major threat to maternal health in the US and UK with cardiomyopathy being one of the most common acquired CVD in the pregnant and postpartum period. Diagnosing cardiomyopathy in pregnancy is challenging due to an overlap of cardiovascular symptoms with normal pregnancy symptoms. Purpose The purpose of this study was to evaluate the effectiveness of an ECG based deep learning model in identifying cardiomyopathy among pregnant and postpartum women. Methods We utilized an ECG based deep learning model to detect cardiomyopathy in a cohort of pregnant or postpartum women seen at multiple hospital sites. Model performance was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. Results 1,807 women were included. 7%, 10% and 13% had LVEF ≤35%, <45% and <50% respectively. The ECG based deep learning model identified cardiomyopathy with an AUC of 0.92 for left ventricular ejection fraction (LVEF) ≤35%, 0.89 for LVEF <45% and 0.87 for LVEF <50%. For LVEF ≤35%, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to white (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 and 0.72 respectively. Conclusions A deep learning model effectively identifies cardiomyopathy in pregnant or postpartum women, outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): This study was made possible using resources supported by the Mayo Clinic Women's Health Research Center and the Mayo Clinic Building Interdisciplinary Research Careers in Women's Health (BIRCWH) Program funded by the National Institutes of Health (NIH), grant number K12 HD065987. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Importance Monochorionic (MC) twins are hemodynamically connected by vascular anastomoses within the single shared placenta. The transfer of fluid or blood from one fetus to the other may result in development of pathologic complications, such as twin-twin transfusion syndrome, twin anemia polycythemia sequence, selective intrauterine growth restriction, and twin reversed arterial perfusion sequence. Monoamniotic gestations, which comprise a small fraction of MC pregnancies, can also present with unique challenges, particularly antepartum umbilical cord entanglement. All these complications carry a high risk of fetal morbidity and mortality if not recognized and managed in a timely fashion. Objective The purpose of this article is to review evidence-based management of complicated MC twin gestations and propose a standardized approach to surveillance. Evidence Acquisition Monochorionic gestations account for the majority of complications that occur in twin pregnancies; however, there is unclear evidence on the appropriate surveillance for and management of specific complications associated with these pregnancies. Results This article summarizes management for each specific type of MC complication in a structured and clear manner. Conclusions Early pregnancy ultrasound, ideally between 10 and 13 weeks' gestation, is critical for the diagnosis and characterization of twin pregnancies. To improve outcomes for MC twins, appropriate fetal surveillance should be initiated at 16 weeks' gestation and continued until delivery. Relevance Improve perinatal outcomes in MC twin pregnancies. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to describe the sonographic findings used to establish the diagnosis of MC twin pregnancies; identify complications unique to MC twins pregnancies, including twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, twin anemia polycythemia syndrome, co-twin demise, cord entanglement, and conjoined twins; and explain the management of complications associated with MC twin pregnancies.

Abstract Aims Cardiovascular disease is a major threat to maternal health, with cardiomyopathy being among the most common acquired cardiovascular diseases during pregnancy and the postpartum period. The aim of our study was to evaluate the effectiveness of an electrocardiogram (ECG)-based deep learning model in identifying cardiomyopathy during pregnancy and the postpartum period. Methods and results We used an ECG-based deep learning model to detect cardiomyopathy in a cohort of women who were pregnant or in the postpartum period seen at Mayo Clinic. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. We compared the diagnostic probabilities of the deep learning model with natriuretic peptides and a multivariable model consisting of demographic and clinical parameters. The study cohort included 1807 women; 7%, 10%, and 13% had left ventricular ejection fraction (LVEF) of 35% or less, <45%, and <50%, respectively. The ECG-based deep learning model identified cardiomyopathy with AUCs of 0.92 (LVEF ≤ 35%), 0.89 (LVEF < 45%), and 0.87 (LVEF < 50%). For LVEF of 35% or less, AUC was higher in Black (0.95) and Hispanic (0.98) women compared to White (0.91). Natriuretic peptides and the multivariable model had AUCs of 0.85 to 0.86 and 0.72, respectively. Conclusions An ECG-based deep learning model effectively identifies cardiomyopathy during pregnancy and the postpartum period and outperforms natriuretic peptides and traditional clinical parameters with the potential to become a powerful initial screening tool for cardiomyopathy in the obstetric care setting.

Antisynthetase syndrome is a rare multisystem autoimmune disorder which clinically manifests with myositis, arthritis, interstitial lung disease, Raynaud phenomenon, and skin hyperkeratosis. Lung involvement represents the most severe form of disease and has rarely been reported in pregnancy. We present the case of a 22-year-old woman with antisynthetase syndrome and severe restrictive pulmonary disease who experienced a successful pregnancy and delivery. We discuss anesthetic considerations and highlight the importance of a multidisciplinary team approach in caring for parturients with multifactorial medical conditions.

Background: Spontaneous coronary artery dissection (SCAD) is the principal cause of peripartum myocardial infarction (MI). Clinical features remain incompletely understood. Methods: Medical records of all women enrolled in a SCAD registry at the Mayo Clinic were reviewed to identify those who were either pregnant or ≤12 weeks postpartum at time of initial event. Diagnosis of SCAD was confirmed with coronary angiography in all cases. Obstetrical outcomes and incidence of recurrent SCAD events were assessed. Results: In total, 38 of 363 women enrolled in the registry met criteria for peripartum MI due to SCAD. Mean age at time of SCAD was 36±3 (range 27-42) years; 3 patients were pregnant at the time of initial event, and all pregnancies except 2 resulted in a live birth. Ten (26%) were diagnosed with multivessel SCAD (MV-SCAD). Most (60%) postpartum events occurred within 30 days of delivery. Antecedent co-morbidities included gestational hypertension/preeclampsia (9), fibromuscular dysplasia (7), gestational diabetes (4), and mixed connective tissue disease (1). Compared to US population birth data, women with peripartum SCAD were more likely to be ≤ 30 years at the time of first delivery (60% vs 42%) and more often multiparous (80% vs 59%). On long-term follow-up (median 3.7 years, IQR 1.1-7.1), 5 (13%) women experienced recurrent SCAD, with one episode occurring following a subsequent pregnancy. MV-SCAD was not associated with increased risk of recurrence (p=0.44). Conclusion: Women with peripartum SCAD are both older than the general obstetrical population at the time of first pregnancy and frequently multiparous at time of initial SCAD event. The highest frequency of SCAD was encountered during the first postpartum month, suggesting variations in hormonal and hemodynamic factors may contribute to SCAD events in susceptible women.

Introduction: Spontaneous coronary artery dissection (SCAD) is a rare but life threatening cause of acute coronary syndrome and a common etiology of pregnancy-associated myocardial infarction (PAMI). Hypothesis: We aimed to examine the clinical presentation, treatment, and outcomes of the largest pregnancy associated-SCAD (P-SCAD) patient cohort to date. Methods: A total of 128 women enrolled in the Mayo Clinic SCAD Registry between 2010-2020 who were pregnant or up to 1 year postpartum at time of P-SCAD were identified. We subdivided P-SCAD in an “early” group with <12 weeks of delivery and a “late” group presenting between >12 weeks -12 months following delivery. Results: Among the 128 women with P-SCAD, 7(5%) occurred during pregnancy (2/7 first trimester, 5/7 third trimester). Of the 121 women with postpartum P-SCAD, 88/121(72%) occurred <12 weeks of delivery and 33/121(27%) at 12 weeks to 1 year postpartum. The mean age of P-SCAD was 35.3 +/- 4 years (26-48). The most common symptom on presentation was chest pain 118/128(92%); 62/128(48%) presented with ST elevation MI and 58/128(45%) presented with non-ST elevation MI. Multivessel involvement occurred in 40/128(31%), left anterior descending artery (LAD) in 88/128(69%), and left main (LM) in 28/128(22%) of all P-SCAD. Percutaneous coronary intervention (PCI) was performed in 52/128(41%) with a success rate of 81%. Coronary artery bypass grafting was performed in 24/128(19%) of which 6/24 patients had an unsuccessful PCI, 14/24 had proximal or multivessel SCAD, and 4/24 had persistent or extension of initial SCAD. Of those treated conservatively 52/128(40%), 11/52(21%) had LM and LAD. Among all the P-SCAD patients, 84/128 (66%) were screened for an underlying arteriopathy, of whom 44 (52 %) were diagnosed with fibromuscular dysplasia. At a median follow up of 3 years (IQR 1 to 6), 12/128 (9%) of all P-SCAD survivors had a recurrent SCAD event and 7/12 (58%) were within 1 year postpartum. There were no deaths. Conclusions: P-SCAD most commonly presents with ST-elevation MI and multivessel involvement within the initial 12 weeks postpartum. Clinicians need to be familiar with this etiology of PAMI to avoid delay in diagnosis and appropriate management.

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Background The purpose of this study was to compare the incidence of pregnancy‐related adverse outcomes ( PRAO ) between patients with versus without hemodynamically significant right ventricle outflow tract ( RVOT) . Methods and Results This was a retrospective cohort study of all pregnant patients with isolated RVOT lesions undergoing evaluation at the Mayo Clinic, 1990 to 2017. Hemodynamic significance was defined as ≥moderate pulmonary/conduit stenosis (≥3 m/s) and/or ≥moderate regurgitation. Patients with concomitant significant left heart disease were excluded. PRAO was defined as cardiovascular, obstetric, and/or neonatal complications occurring during the pregnancy through 6 weeks postpartum. A total of 224 pregnancies in 114 patients with RVOT lesions were identified; 38 pregnancies occurred in 24 patients with hemodynamically significant RVOT . Forty‐eight (21%) pregnancies ended in spontaneous abortion. Of the 173 completed pregnancies, median gestational age at delivery was 38 (35–40) weeks and median birth weight 2965 (2065–4122) g. Seven pregnancies (4%) were complicated by cardiovascular events, 14 (8%) by obstetric complications, with adverse neonatal outcomes occurring in 38 (22%). There were no maternal deaths. The incidence of spontaneous abortion and PRAO were similar in both the RVOT and hemodynamically significant RVOT groups. As an isolated condition, Tetralogy of Fallot–pulmonary atresia was associated with spontaneous abortion and neonatal complications. Conclusions The risk of cardiovascular complications was low in patients with isolated RVOT lesions, and hemodynamically significant RVOT lesions were not associated with either cardiovascular complications or PRAO . Further studies are required to explore the factors responsible for PRAO in patients with Tetralogy of Fallot–pulmonary atresia.

Glomerular damage is common in preeclampsia (PE), but the extent and etiology of tubular injury are not well understood. The aim of this study was to evaluate tubular injury in patients with PE and to assess whether it predates clinical disease. We performed a prospective cohort study of 315 pregnant women who provided urine samples at the end of the second trimester and at delivery. This analysis included women who developed PE ( n = 15), gestational hypertension (GH; n = 14), and normotensive controls (NC; n = 44). Urinary markers of tubular injury, α1-microglobulin (A1M), retinol-binding protein (RBP), kidney-injury molecule-1 (KIM1), complement C5b-9, tissue inhibitor metalloproteinase-2 (TIMP-2), and insulin-like growth factor binding protein-7 (IGFBP-7) were measured by enzyme-linked immunosorbent assay (ELISA) and reported in relation to urine creatinine concentration. Second-trimester concentrations of all markers were similar among groups. At delivery, A1M concentrations were higher in the PE group than in the GH and NC groups as an A1M/creatinine ratio >13 (66.7, 8.3, and 35%, respectively, P = 0.01). Concentrations of C5b-9 were higher in the PE group than in the GH and NC groups (medians 9.85, 0.05, and 0.28 ng/mg, respectively, P = 0.003). KIM1, RBP, TIMP-2, and IGFBP-7 concentrations did not differ among groups at delivery. In conclusion, proximal tubular dysfunction, as assessed by A1M and C5b-9, developed during the interval between the end of the second trimester and delivery in patients with PE. However, this was not matched by abnormalities in markers previously associated with tubular cell injury (KIM-1, IGFBP-7, and TIMP-2).