Maternal cardiac function and uterine artery Doppler at 11–14 weeks in the prediction of pre-eclampsia in nulliparous women A Khaw, NA Kametas, OM Turan, JEAK Bamfo, KH Nicolaides Harris Birthright Research Centre for Fetal Medicine, Golden Jubilee Wing – Suite 9, King’s College Hospital, London, UK Correspondence: Dr NA Kametas, Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, Golden Jubilee Wing – Suite 9, Denmark Hill, London, SE5 9RS, UK. Email n.kametas@btinternet.com Accepted 7 October 2007. Objective To assess maternal cardiac function in nulliparous women in the first trimester of pregnancy and evaluate its potential role for predicting pre-eclampsia and small for gestational age (SGA). Design Prospective, observational, cross-sectional study. Setting Maternity unit of a teaching hospital. Population Nulliparous women with singleton pregnancies presenting consecutively for routine antenatal care (n = 534). Methods Two-dimensional and M-mode echocardiography and uterine artery Dopplers were carried out at 11-14 weeks. Main outcome measures Cardiac output (CO), stroke volume (SV), mean arterial pressure (MAP), total vascular resistance and uterine artery pulsatility index (UAPI) were compared in four outcome groups according to the development of pre-eclampsia and/or SGA. Results Compared with the normal outcome group (n = 457), in those with pre-eclampsia but not SGA (n = 8), CO and MAP were increased; in the group with pre-eclampsia and SGA (n = 19) MAP, TRP and UAPI were increased and in the group with SGA but no pre-eclampsia (n = 50) total peripheral resistance and UAPI were increased. Independent predictors of pre-eclampsia were MAP, SV and UAPI and of SGA SV and UAPI. Conclusions Alterations in maternal cardiac function and UAPI are observed in the first trimester of pregnancy in nulliparous women that subsequently develop pre-eclampsia and/or SGA. Keywords Echocardiography, maternal cardiac output, pre-eclampsia, pregnancy. Please cite this paper as: Khaw A, Kametas N, Turan O, Bamfo J, Nicolaides K. Maternal cardiac function and uterine artery Doppler at 11–14 weeks in the prediction of pre-eclampsia in nulliparous women. BJOG 2008;115:369–376. Introduction Pre-eclampsia is not a uniformly high-resistance, volume- contracted state as previously thought. 1 Earlier studies, using direct haemodynamic measurements in women with severe pre-eclampsia requiring invasive monitoring, have described variations in haemodynamic characteristics ranging from a hyperdynamic state with a higher-than-normal cardiac out- put (CO) and increased left ventricular function to a vaso- constrictive state with decreased CO and diminished left ventricular function. These studies also document variable systemic resistance profiles, ranging from normal- to high- resistance states. 2–4 However, since the introduction and evaluation of the Doppler technique for maternal cardiac function in pregnancy, 5,6 a series of echocardiographic studies have confirmed the existence of apparent haemodynamic subgroups in women with overt or preclinical pre-eclampsia. 7–9 These studies have advocated a maternal hyperdynamic cir- culation 7,9 that is preceding the clinically overt disease 9 and may also be present to a variable degree during the more severe stages. 7 Furthermore, in one study the effect of mater- nal haemodynamics on fetal growth in hypertensive pregnan- cies have been investigated. 10 Easterling et al. observed that high-resistance hypertension was associated with lower per- centile weights for gestational age, while high CO and low- resistance hypertension were associated with normal fetal growth. 10 However, the cardiac investigations in their study were performed in women who were clinically hypertensive. In previous studies on pre-eclampsia, the influence of the variable characteristics in the maternal central and peripheral haemodynamics on the sensitivity of screening tests or the efficacy of treatment has been masked by the analysis of all ª 2008 Fetal Medicine Foundation Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 369 DOI: 10.1111/j.1471-0528.2007.01577.x www.blackwellpublishing.com/bjog Maternal medicine