249 ASSESSMENT OF MATERNAL HEART DISEASE: DISCREPANCY BETWEEN DIRECT ANDINDIRECTLY MEASURED CARDIAC FUNCTION DURING PREGNANCY DIANEBARKER1, GERALD MASON2, DOMINIK SCHLOSSHAN1, HILARY MCLOUGHLIN1, LIP-BUN TAN1, 1Leeds General Infirmary, Cardiology, Leeds, Yorkshire, UnitedKingdom, 2Leeds General Infirmary, Feto-Maternal Medicine, Leeds, York-shire, United Kingdom

OBJECTIVE: Oxygen consumption during maximal exercise (VO2 mx) iswidely accepted as an indirect indicator of cardiac dysfunction and is used toselect patients for cardiac transplantation. We tested the hypothesis thatdeterioration in VO2mx during pregnancy is necessarily indicative of decliningcardiac functional reserve.

STUDY DESIGN:We conducted a longitudinal study on 20 female volunteers(mean age 32.2 G 6.3 years) who performed a third trimester (mean gestation34 weeks) symptom-limited cardiopulmonary exercise test (CPX) and a control(post-partum) CPX. Measurements of VO2 and hemodynamic indices wereobtained during CPX. Cardiac output (CO) was measured non-invasively withthe CO2 re-breathing technique. All subjects exercised to their cardiopulmo-nary limits. Cardiac power output (CPO) was calculated from the product ofCO and mean arterial pressure (MAP).

RESULTS: Exercise duration and VO2 mx were significantly lower duringthe third trimester than the non-pregnant control CPX. Despite this, directlymeasured cardiac function (CO, MAP, CPO) at peak exercise was maintainedin late pregnancy.

Graphshowingdiscrepancybetweendirectand indirectmarkersof cardiac function

CONCLUSION: In a common physiological condition, pregnancy, we foundthat a decrease in VO2 mx was not accompanied by any deterioration incardiac function, indicating a discrepancy between indirect and direct mea-sures of cardiac function. To evaluate cardiac dysfunction reliably, we wouldrecommend direct measurements of cardiac functional reserve if doubt orconfounding factors exist, such as during pregnancy.

250 MAXIMAL EXERCISE TESTING CAN BE SAFELY USED TO ASSESS PREGNANT CARDIACPATIENTS DIANE BARKER1, GERALD MASON2, DOMINIK SCHLOSSHAN1, HILARYMCLOUGHLIN1, LIP-BUN TAN1, 1Leeds General Infirmary, Cardiology, Leeds,United Kingdom, 2Leeds General Infirmary, Feto-Maternal Medicine, Leeds,Yorkshire, United Kingdom

OBJECTIVE: Pregnancy is traditionally considered a contraindication to ex-ercise testing, especially in women with heart disease, despite the fact that preg-nancy and labor constitute a natural stress to the heart. Exercise testing is oftenrequired to provide objective assessments of cardiac function. Relying on as-sessments performed at rest to estimate whether the cardiovascular system hasenough reserve to cope with the stresses of pregnancy and labor may be sub-optimal. We evaluated the safety of maximal exercise testing during pregnancy.

STUDY DESIGN: We have performed maximal cardiopulmonary exercisetestingmore than230 times in 63pregnantwomenat varying stagesof pregnancy,ranging from12 to 38weeks gestation. The exercise was performedon a treadmillaccording to standard Bruce protocol, with measurement of respiratory gasesand hemodynamic variables including cardiac output and cardiac power output.Thirty-nine of the subjects were normal healthy controls and twenty-four werereferred for investigation of known cardiac abnormalities.Womenwith absolutecontraindications to exercise testing such as aortic aneurysm, Marfan’s syn-drome, outflow tract obstruction or serious arrhythmias were excluded.

RESULTS: Pregnant women were happy to take part in maximal exercisetests during pregnancy. All tests were completed without significant compli-cations. The minor complications were a vasovagal reaction and an asymp-tomatic salvo of ventricular tachycardia, neither requiring intervention. Theresults of the exercise test can grade the cardiovascular reserve of individualsubjects, enabling assessment of functional impairment in patients with struc-turally abnormal hearts.

CONCLUSION: Maximal symptom-limited exercise testing can be safelycarried out in pregnancy, under adequate supervision in a specialised centre,even up to 38 weeks gestation.

251 PREGNANT WOMEN HAVE REDUCED CARDIAC FUNCTIONAL RESERVEDIANE BARKER1, GERALD MASON2, LISA SHARP3, DOMINIK SCHLOSSHAN1,HILARY MCLOUGHLIN1, DAVID GOLDSPINK3, LIP-BUN TAN1, 1Leeds General Infir-mary, Cardiology, Leeds, Yorkshire, United Kingdom, 2Leeds General Infir-mary, Feto-Maternal Medicine, Leeds, Yorkshire, United Kingdom,3Liverpool John Moores University, Research Institute for Sports & ExerciseSciences, Liverpool, Merseyside, United Kingdom

OBJECTIVE: The maternal cardiovascular system undergoes profoundchanges during pregnancy. How the extra demands of the uterine circulationaffect the cardiac reserve available for exertion (including labor) is unknown.We investigated peak exercise physiology during pregnancy.

STUDY DESIGN:We conducted symptom-limited maximal cardiopulmonaryexercise testing on 39 healthy pregnant women (P) (mean age 32 [range 19-41],mean gestation 24 weeks), and 47 healthy non-pregnant women (NP) (meanage 32 [range 19-40]). Non-invasive measurement of standard hemodynamicindices included heart rate (HR), mean systemic arterial pressure (MAP, usingcuff manometry) and cardiac output (CO, using CO2-rebreathing methods) atrest and during peak exercise. Cardiac power output (CPO, in watts) wascalculated as the product of CO and MAP and a conversion factor.

RESULTS: All subjects exercised to their cardiopulmonary limits (respira-tory exchange ratio O1). The pregnant subjects showed higher HR and CO atrest, but lower values during peak exercise. Both resting and peak exerciseMAP were lower in pregnant subjects. The overall cardiac reserve (DCPO =peak – rest CPO) was significantly lower in pregnant subjects, accounting forthe significantly lower peak oxygen uptake (VO2).

CONCLUSION: In healthy subjects, the significantly lower cardiac functionalreserve available for exercise during pregnancy compromised their exerciseability. Further study is required to investigate whether pregnant patients withcongenital or acquired cardiac diseases have even further reduced cardiacreserve.

Table showing physiological differences between pregnant and non-pregnantsubjects at rest and at peak exercise

NP rest P rest p value NP peak P peak p value

HR 71G11 85G13 !0.001 176G14 167G9 !0.001CO 4.1G0.8 5.1G1.1 !0.001 16.8G 2.5 15.6G 2.2 0.01MAP 90.1G 7.5 78.3G 7.4 !0.001 111.8G9.3 104.6G9.6 0.001CPO 0.8G0.2 0.9G0.2 0.08 4.0G0.6 3.6G0.5 0.001VO2 3.6G0.7 4.3G0.7 !0.001 31.6G 6.2 26.2G 4.8 !0.001

252 INTRACEREBRAL HEMORRHAGE IN PREGNANCY: INCIDENCE, RISK FACTORS, ANDOUTCOME IN A NATIONWIDE SAMPLE OF DELIVERIES BRIAN T. BATEMAN1, H.CHRISTIAN SCHUMACHER1, JOHN PILE-SPELLMAN1, LYNN L. SIMPSON2, MITCHELLF. BERMAN1, 1Columbia University, New York, New York, 2Columbia Univer-sity, Division of Maternal Fetal Medicine, New York, New York

OBJECTIVE: To characterize the incidence, risk factors, and outcome ofintracerebral hemorrhage (ICH) in pregnancy and the postpartum periodusing the largest available in-patient database of U.S. hospitalizations.

STUDY DESIGN: Data for this study were obtained from an administrativedataset, the Nationwide Inpatient Sample, which includes about 20% of alldischarges from non-Federal hospitals, for the years 1993-2002. Women age15-44 with a diagnosis of ICH were selected from the database for analysis,and within this group patients coded as pregnant or postpartum wereidentified. Incorporating U.S. Census data, estimates were made of theincidence of ICH in pregnant/postpartum and non-pregnant women. Therates of various comorbidies in patients with pregnancy-related ICH werecompared to the rates found in the general population of delivering patients toidentify risk factors for pregnancy-related ICH.

RESULTS: Pregnancy-related ICH was identified in 423 patients, corre-sponding to 6.07 pregnancy-related ICH per 100,000 deliveries and 7.18pregnancy-related ICH per 100,000 at-risk person-years (compared to 4.99 per100,000 person-years for non-pregnant women in the age range considered).The increased risk of ICH associated with pregnancy was largely attributableto ICH occurring in the postpartum period. ICH accounted for 7.0% of allpregnancy-related mortality recorded in this database and the in-hospitalmortality rate for pregnancy-related ICH was 20.7%. Significant risk factorsfor pregnancy-related ICH included advanced maternal age(OR 2.16, 95%CI1.73-2.70), preexisting hypertension (OR 3.01, 95%CI 1.55-5.82), gestationalhypertension (OR 2.19, 95%CI 1.47-3.25), preeclampsia/eclampsia (OR 11.98,95%CI 9.68-14.82), cocaine abuse (OR 3.30, 95%CI 1.47-7.39), and tobaccoabuse (OR 1.82, 95%CI 1.05-3.16).

CONCLUSION: ICH accounted for a substantial portion of pregnancy-related mortality. It is imperative that obstetricians be alert for the signs andsymptoms of ICH, particularly in at-risk groups.

S80 SMFM Abstracts