Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Pregnancy Hypertension: An International Journal of

Women’s Cardiovascular Health
journal homepage: www.elsevier.com/locate/preghy

Microcirculatory blood flow derangements during severe preeclampsia

and HELLP syndrome
Gustavo Adolfo Ospina-Tascón a,⇑, Albaro José Nieto Calvache a, Edgardo Quiñones a,
Humberto José Madriñan a, Juan David Valencia a, William Fernando Bermúdez a, Javier Carvajal a,
María Fernanda Escobar a, Daniel de Backer b
a
Department of Intensive Care Medicine, Fundación Valle del Lili – Universidad ICESI, Cali, Colombia
b
Intensive Care Department, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To evaluate the microcirculatory blood flow in severe preeclampsia and compare it with
Received 13 February 2017 healthy pregnant and non-pregnant women controls, using a portable intravital-microscopy technique.
Received in revised form 5 June 2017 Methods: Using a side-stream dark field (SDF) device, we prospectively evaluated the sublingual micro-
Accepted 22 July 2017
circulatory blood flow before placental delivery in 40 women with severe preeclampsia (PE-group) com-
Available online xxxx
plicated (n = 8) or not (n = 32) with HELLP syndrome, 40 healthy pregnant women (HP-group) matched
by gestational and chronological age, and 20 healthy non-pregnant women (NP-group). Microvessels
Keywords:
were classified as large or small using a cutoff value of 20 lm and those with continuous flow were con-
Preeclampsia
HELLP syndrome
sidered as normal while sluggish, intermittent and stopped flows were considered as abnormal. We com-
Microcirculation puted the proportion of well-perfused small vessels (PPV), and total and functional capillary densities
Microcirculatory dysfunction (TCD and FCD) were calculated according to the total number and quantity of well-perfused small vessels
per area unit, respectively.
Results: Total capillary densities were significantly higher in all pregnant women when compared to non-
pregnant controls. The PE-group exhibited, however, significantly lower TCD compared with the HP-
group. Meanwhile, significant decreases in PPV and FCD were observed in the PE-group, with deeper
alterations in those with coexisting HELLP syndrome. These altered PPVs were significant although
incompletely reversed after placental delivery in pregnancies complicated by HELLP syndrome, while
capillary densities remained unaltered at least during very early post-delivery period.
Conclusions: Substantial distributive microcirculatory blood flow alterations and restricted capillary den-
sities are observed in preeclampsia, suggesting a key role for microvascular dysfunction in the patho-
physiology of this condition.
Ó 2017 Published by Elsevier B.V. on behalf of International Society for the Study of Hypertension in
Pregnancy.

1. Introduction ical, genetic, behavioral and environmental factors have been

Preeclampsia remains a leading cause of maternal mortality and
a major contributor to maternal and perinatal morbidity in both
developed and emerging countries [1–3]. A myriad of immunolog-
Abbreviations: SDF, side-stream dark field; PE-group, preeclampsia group; HP-
group, healthy pregnant group; NP-group, non- pregnant group; PPV, percentage of
small-vessels perfused; TCD, total capillary density; FCD, functional capillary
density; HI, heterogeneity index; MFI, microvascular flow index; HELLP syndrome,
hemolysis, elevated liver enzymes, and low platelet count syndrome.
⇑ Corresponding author at: Department of Intensive Care Medicine, Fundación
Valle del Lili, Av. Simón Bolívar Cra. 98, Cali, Colombia.
E-mail address: gusospin@gmail.com (G.A. Ospina-Tascón).
implicated in its pathogenesis [4], although generalized endothe-
lial cell and microvascular dysfunction seem to underlie the patho-
logical manifestations leading to major cardiovascular
derangements [5,6]. In fact, the reduction of peripheral tissue
blood flow preceding the onset of clinical preeclampsia [7–10]
advocates for the key role of microvascular dysfunction as a com-
mon pathway for multiple pathophysiological mechanisms.
In normal conditions, tissue oxygenation is determined by dif-
fusive and convective components of microcirculation and these
in turn, are determined by the capillary density and the microvas-
cular blood flow itself, respectively. These physiological compo-
nents of the microcirculation are responsible for fine-tuning

http://dx.doi.org/10.1016/j.preghy.2017.07.140
2210-7789/Ó 2017 Published by Elsevier B.V. on behalf of International Society for the Study of Hypertension in Pregnancy.

Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
2 G.A. Ospina-Tascón et al. / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx
perfusion to meet local metabolic requirements and might con-
tribute to the development of multiorgan dysfunction when
altered. Exploring microcirculation had been restricted to the
experimental laboratory until the advent of new imaging tech-
niques capable of evaluating microcirculatory blood flow at the
bedside [11]. Data from critically ill patients during the last decade
suggest that microcirculatory alterations play a decisive role in the
development of multiorgan failure, independently of macro-
hemodynamic parameters [12–14], but information about
microvascular changes during preeclampsia remain partially
unknown [9,10]. Microcirculatory dysfunction in preeclampsia
has been suggested by a decrease in arteriolar and venular calibers
of retinal vessels via fundus photography [15–17] and reduced
capillary density as shown by cutaneous intravital microscopy
[9,10]. These alterations precede the onset of clinical manifesta-
tions, thus reinforcing the possible role of microvascular dysfunc-
tion and abnormal microvascular development. Unfortunately,
most of these observations were restricted to microvascular beds
highly influenced by environmental factors and macro-
hemodynamic changes [9,10].
Recently, a small-size study by Cornette et al. [18] evaluated
microcirculation in preeclamptic patients using a portable imaging
technique. They did not find significant microvascular density
abnormalities, challenging previous observations by intravital
microscopy [9,10], although they observed significant microcircu-
latory flow distribution abnormalities in preeclamptic pregnancies
complicated with HELLP syndrome. Thus, it is not clear if these
observations confirm the absence of microcirculatory blood flow
alterations during severe preeclampsia without HELLP syndrome,
whether these are product of an underpowered observation, or
whether these simply denote the inherent limitations of the imag-
ing technique.
Pathophysiological mechanisms associated with preeclampsia
are not completely understood and despite some microcirculatory
abnormalities that have been described in the past, there is little
information about diffusive and convective alterations during clin-
ically established preeclampsia. Thus, we aim to explore microcir-
culation by direct visualization in women with preeclampsia with
and without HELLP syndrome, comparing them with healthy preg-
nant and non-pregnant groups of women, hypothesizing that
preeclampsia is associated with significant microvascular density
and blood flow distribution alterations.
2. Materials and methods
We conducted a prospective observational study in a 20-bed
high-dependency obstetric unit and the antenatal consultation
clinic in a University Hospital (Fundación Valle del Lili. Cali, Colom-
bia). Our institutional Ethics and Biomedical Research Committee
approved this study (Protocol number: 627; Chart number: 037;
2.013. Renewal No. 072–2.015). An informed consent was obtained
from all the pregnant participants. Sublingual microcirculation was
explored in three groups: (a) pregnant women complicated by sev-
ere preeclampsia with (or without) HELLP syndrome: PE-group; (b)
healthy pregnant women matched by gestational and chronologi-
cal age: HP-group; (c) healthy non-pregnant women: NP-group.
Preeclampsia was defined as a new onset of blood pressure
>140/90 mm Hg on two separate opportunities at least 4 h apart
accompanied by proteinuria 300 mg/24 h, or 2+ on urine dip-
stick, or urinary protein to creatinine ratio >30 mg/mmol [19]. Sev-
ere preeclampsia was defined as severe hypertension (systolic
pressure >160 and/or diastolic pressure >110 mm Hg), and/or
symptoms (epigastric/right upper quadrant pain, cerebral or visual
disturbances, pulmonary edema), and/or with biochemical, and/or
hematological impairment [19]. HELLP syndrome was defined as
Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
the presence of hemolysis based on examination of a peripheral
blood smear and/or elevated lactate dehydrogenase
(LDH  600 U/L), associated with elevated liver enzymes (aspartate
aminotransferase, AST  70 U/l), or thrombocytopenia (platelets
count <100,000/mm3) after ruling out other causes of hemolysis
and thrombocytopenia [20].
A healthy pregnancy was determined by comprehensive exam-
ination and laboratory testing according to the attending obstetri-
cian criteria during the antenatal clinical consultation. Pregnant
women with chronic or suspected chronic hypertensive disorders
were not included in the study. A two-weeks postpartum follow-
up was carried out in healthy pregnant controls in order to discard
the development of preeclampsia after inclusion. Healthy non-
pregnant volunteers were women in childbearing age with no
hypertension and/or no antecedents of hypertensive disorders.
2.1. Study protocol
During a ten-month period (July 2013–April 2014), all patients
with pregnant hypertensive disorders were screened and evalu-
ated by two independent evaluators (M.F.E., and J.C.). After obtain-
ing written informed consent from each pregnant participant,
patients fulfilling the criteria for severe preeclampsia (PE-group)
were enrolled, while healthy pregnant women were weekly
searched at the antenatal consultation clinic and selected accord-
ing to each preeclamptic case included, matching them by gesta-
tional and chronological age (HP-group). Finally, twenty healthy
women volunteers, usually health workers from the intensive care
unit and the obstetric high-dependency unit served as non-
pregnant age-matched controls (NP-group).
Patients with preeclampsia were managed according to interna-
tional guidelines [19]. All hemodynamic measurements were per-
formed at lateral decubitus in resting conditions and maintaining
a fasting period at least of 120 min. In all cases, arterial pressure
recorded before placental delivery was obtained by sphygmo-
manometry, while in some post-placental delivery measurements,
invasive pressure by intra-arterial cannula (radial artery) was reg-
istered. Sublingual microcirculation was explored using the Side-
stream dark-field (SDF) imaging device before placental delivery
in both PE and HP groups. In PE-group, images were recorded at
the most severe point of the disease (usually, at the peak of hyper-
tension or when clinical deterioration or symptoms impairment
were detected). A new set of images was obtained within 12 h of
delivery in those patients whose pregnancy was ended or 48 h
after the first set of measurements when a delayed delivery was
planned (according to the decision of the attending physician).
General demographics, laboratory parameters, and cumulative
magnesium sulphate doses at inclusion were also recorded.
2.2. Microcirculation measurements
We used a Sidestream dark-field (SDF) imaging device (Micro
Scan; MicroVision Medical, Amsterdam, the Netherlands) to
explore microcirculation in the PE, HP and NP groups. This portable
video-microscope device uses a stroboscopic green light (around
530 nm wavelength), which is delivered to the tissues by multiple
light-emitting diodes (LEDs). This wavelength of light is absorbed
by the hemoglobin of red blood cells, allowing their observation
as dark cells flowing in the microcirculatory net while the light
reflected by superficial layers does not reach the optics. As a result
of the peripheral location of LEDs and the synchronization between
the light emission and camera frame rate, SDF provides a detailed
visualization of open capillaries using a 5x objective and providing
an on-screen magnification of x380 [21] (Fig. 1).
After gentle removal of secretions with gauze, the SDF device
was softly applied to the lateral side of the tongue covering an area
 G.A. Ospina-Tascón et al. / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx
Fig. 1. Static image of the sublingual microcirculation during preeclampsia with
HELLP syndrome. An increased number of vessels with intermittent (black arrows)
and stopped flow (white head arrows) lead to a decrease in the percentage of small
vessels perfused (PPV) and functional capillary density (FCD).
approximately of 2–4 cm from the tip of tongue. At each time point
for the measurements, we collected five sequences of video of 20 s
each from different adjacent mucosa areas using a videocard
(MicroVideo; Pinnacle system, Mountain Views, CA, U.S.A.). These
sequences of video were stored under a random number and later
analyzed by two investigators blinded to the origin and order of
sequences (H.M., G.O.T.). Vessels were classified as large or small
using a cutoff value of 20 lm. Microvessels with continuous flow
were considered as normal while sluggish, intermittent and
stopped flows were considered as abnormal. According to the con-
sensus for the evaluation of microcirculation [22], we report the
proportion of perfused small vessels (PPV) and the microvascular
flow index (MFI). We also reported the total vascular density
(TCD) and the functional capillary density (FCD) according to the
total number of vessels and to the number of well-perfused small
vessels per area unit, respectively. Finally, we calculated the blood
flow heterogeneity index (HI) defined as the difference between
the maximal and minimal proportions of perfused small vessels
evaluated at each point in the five areas divided by its own mean
value. Intra and inter-observer variability were determined by
reading five sequences analyzed five times at eight-week intervals
by two observers (H.M. and G.O.T.).
2.3. Sample calculation
A pilot study conducted in our high-dependency obstetric unit
and the antenatal consultation, in ten preeclamptic and ten healthy
pregnant women, revealed mean PPV values of 72 and 95% respec-
tively. Thus, we estimated a sample size of 40 patients per group to
demonstrate a relative difference of 25% in the proportion of well-
perfused capillaries between preeclamptic and healthy pregnant,
assuming an alpha error of 0.05 and a power of 0.8.
2.4. Statistical analysis
A Kolmogorov-Smirnov test was used to assess the distribution
of data. After discarding the Gaussian distribution, we used a
Kruskal-Wallis test to estimate differences among groups with a
post hoc Mann-Whitney analysis and adjustment for multiple com-
parisons. The Mann-Whitney test was used to compare parameters
between PE patients with and without HELLP syndrome, while a
Wilcoxon paired signed rank test was used to test the differences
Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
3
in microcirculatory parameters before and after placental delivery
in those patients subjected to an early delivery strategy. A Spear-
man rho correlation was used to assess the relationship between
the proportion of well-perfused small vessels and the degree of
proteinuria. Data are presented as medians (25th–75th per-
centiles) in text, tables and boxplots. A p-value <0.05 was consid-
ered statistically significant.
3. Results
General macro and microhemodynamics are presented in
Table 1. At enrollment, twenty-one preeclamptic patients were
receiving magnesium, with a cumulative mean dose of 1.1 [0.55–
1.2] gr. All pregnant women had a significantly higher total capil-
lary density (TCD) when compared with the NP-group; however,
the PE-group exhibited a lower TCD than HP-group (Fig. 2). Simi-
larly, PPV and MFI were significantly lower in the PE-group than
in the HP and NP-groups (Fig. 2). As a result, FCD was significantly
decreased and the heterogeneity of microvascular blood flow was
higher in preeclamptic pregnancies when compared with the other
groups (Table 1). A demonstrative video of sublingual microcircu-
latory blood flow in a case of severe preeclampsia before placental
delivery is included (Video 1).
Video 1.
Preeclamptic patients with HELLP syndrome showed a lower
PPV than those without HELLP syndrome (Fig. 3), while TCD was
not significantly different (Table 2). A new set of video sequences
of sublingual microcirculation was obtained 10 ± 2 h after placenta
delivery in thirty preeclamptic patients subjected to an early deliv-
ery strategy (eight of them coexisting with HELLP syndrome). We
observed significant improvement in PPV and MFI after placental
removal only in patients with HELLP syndrome while TCD and
FCD remained with no significant changes (Table 3). When all PE
patients (with and without HELLP syndrome) subjected to the
delivery strategy were evaluated, we did not find significant differ-
ences in microvascular blood flow distribution or capillary densi-
ties after placental removal despite a slight improvement in PPV
(p = 0.23).
Proteinuria was 352 [320–471] mg/24 h for all preeclamptic
patients. No significant differences were observed for proteinuria
in those patients with or without HELLP syndrome (394
[320–506] vs. 334 [233–378] mg/24 h for PE and PE + HELLP
respectively; p = 0.59]. Finally, we did not find significant correla-
tions between the PPV and the degree of proteinuria obtained on
the day of the microvascular exploration in the PE-group
(Spearman-Rho = 0.12, p = 0.60).
The coefficient of variability of the determination of one
video sequence of microcirculation ranged from 2.3 to 5.2%
4 G.A. Ospina-Tascón et al. / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx

Table 1
General demographics, macro hemodynamic and microvascular blood flow parameters in preeclampsia, normal-pregnant and non-pregnant groups.

Preeclampsia (n = 40) Normal pregnancy (n = 40) Non-pregnant (n = 20) P

Age 25 (22–31) 30 (25–33) 26 (24–28) 0.24
Gestational Ageà 34.1 (28.8–36.5) 35.2 (29.0–36.5) – 0.92
Birth weight (gr)àà 2315 (1408–2860) 3025 (2748–3386) – <0.001
SAP (mmHg) 164 (160–168)* 106 (100–118) 102 (97–110) <0.001
DAP (mmHg) 95 (88–100)* 63 (60–72) 60 (57–68) <0.001
Heart Rate (beats/min) 92 (84–98)§ 88 (85–92)§,– 75 (72–84) <0.001
PPV,% 85 (79–88)* 92 (86–95) 95 (92–96) <0.001
MFI 2.5 (2.3–2.8)* 3.0 (2.9–3.0) 2.9 (2.7–2.9) <0.001
Heterogeneity Index 0.25 (0.17–0.36)* 0.11 (0.07–0.16) 0.12 (0.08–0.13) <0.001
FCD, n/mm2 8.3 (7.8–8.7)à 9.3 (8.8–10.0) 8.6 (7.5–9.8) <0.001
TCD, n/mm2 12.4 (11.9–12.7)* 13.5 (12.8–14.5)– 10.9 (9.9–12.4) <0.001

SAP: Systolic arterial pressure; DAP: Diastolic arterial pressure; PPV: proportion of small vessels perfused; MFI: microvascular flow index; FCD: functional Capillary Density;
TCD: Total Capillary Density; MFI: Microvascular flow density.
à
Gestational age at the evaluation of microcirculatory blood flow
àà
Birth weight at delivery
*
Pre-eclampsia vs. normal pregnancy and Pre-eclampsia vs. non pregnant. p < 0.05.
à
Pre-eclampsia vs. normal pregnancy, p < 0.05.
–
Normal pregnancy vs. Non-pregnant group. p < 0.05.
§
Pre-eclampsia or normal pregnancy vs. non pregnant. p < 0.05.

Fig. 2. Microcirculatory blood flow parameters in preeclamptic, normal pregnancy and non-pregnant groups. Box plots depicting differences for (A) PPV: percentage of small
vessels perfused (B) MFI: microvascular flow index (C) FCD: functional capillary density (D) TCD: total capillary density. Kruskal-Wallis test, p < 0.001 between groups, for
PPV, MFI, FCD, and TCD. *p < 0.05 for preeclampsia vs. normal pregnant and preeclampsia vs. non-pregnant. **p < 0.05 for healthy pregnant vs. non-pregnant. ***p < 0.05 for
preeclampsia vs. healthy pregnant. FCD and TCD values correspond to number of vessels/mm2.

(intra-observer) and from 3.5 to 5.8% (inter-observer) for the total 4. Discussion
number of vessels, and from 1.4 to 4.5% (intra-observer) and from
4.1 to 8.0% (inter-observer) for the proportion of perfused vessels Using a portable imaging system to directly visualize the
(all sizes). microcirculation at the bedside, we observed three remarkable

Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
 G.A. Ospina-Tascón et al. / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx 5

Fig. 3. Microcirculatory alterations in preeclamptic women with or without HELLP syndrome. Boxplots depicting the differences in (A) percentage of perfused small vessels
and (B) total capillary density in preeclamptic women complicated or not with HELLP syndrome. Mann-Whitney U test, p = 0.02, for PPV; and p = 0.25, for TCD. HELLP denotes
hemolysis, elevated liver enzymes, and low platelet count syndrome. TCD denotes total capillary density. TCD values correspond to number of vessels/mm2.

tion (with or without preeclampsia) exhibited a significant higher

Table 2
General characteristics and microvascular parameters for pre-eclampsia with and TCD compared with non pregnant women; (3) a significant
without HELLP syndrome. improvement in microvascular blood flow distribution with no
variation in capillary densities after placental delivery in
Pre-eclampsia Pre-eclampsia p
+ HELLP (n = 8) without preeclamptic pregnancies coexisting with HELLP syndrome.
HELLP (n = 32) Diffusive and convective components of microcirculation are
Age 25 (23–31) 26 (21–31) 0.58
determined by the vascular density and the blood flow distribution
Gestational age 31.4 (25.5–31.4) 34.7 (31.6–37.1) 0.34 and these, in turn, are adjusted according to local metabolic
SAP (mmHg) 167 (164–175) 163 (159–167) 0.04 requirements [11]. Nevertheless, microcirculatory blood flow can
DAP (mmHg) 90 (82–101) 96 (89–100) 0.50 be severely disturbed during severe inflammatory states, leading
Heart rate (beats/min) 96 (87–99) 92 (80–98) 0.34
to tissue hypoperfusion and adverse clinical outcomes [11,12,14].
Hemoglobin (gr/dl) 10.4 (9.4–10.9) 11.6 (10.9–12.6) 0.003
ALT (UI/dl) 145 (81–294) 12 (8–19) <0.001 We found that pregnancies complicated by preeclampsia had a sig-
AST (UI/dl) 141 (85–163) 18 (14–23) <0.001 nificant decrease in the proportion of well-perfused small vessels
LDH (UI/dl) 814 (703–948) 203 (181–234) <0.001 (<20 lm) with a secondary reduction in the functional capillary
Platelets (n  103/mm3) 87.5 (66.3–130.5) 249.5 (205.5–274.8) <0.001
density and increased heterogeneity of microcirculatory blood
Creatinine (mg/dl) 0.7 (0.6–0.7) 0.6 (0.5–0.7) 0.26
Proteinuria (mg/24 h) 394 [320–506] 334 [233–378] 0.59
flow. Notably, these alterations were more pronounced in patients
PPV, % 76 (71–84) 86 (80–91) 0.02 coexisting with HELLP, thus highlighting the possible role of
Heterogeneity Index 0.35 (0.31–0.38) 0.22 (0.15–0.35) 0.04 microvascular blood flow misdistribution in the development of
MFI 2.2 (2.0–2.7) 2.5 (2.4–2.8) 0.12 organ dysfunction in more severe cases of preeclampsia. We
FCD, n/mm2 8.1 (7.9–8.4) 8.3 (7.6–9.0) 0.39
hypothesize that these microcirculatory alterations could be the
TCD, n/mm2 12.7 (12.0–13.2) 12.4 (11.9–12.7) 0.25
reflection of some endothelial derangements previously described
SAP: Systolic arterial pressure; DAP: Diastolic arterial pressure; ALT: Alanine in preeclampsia [23,24]. Predominant microcirculatory alterations
aminotransferase; AST: Aspartate aminotransferase, LDH: Lactate dehydrogenase.
observed in preeclamptic patients in our study were, however, rep-
resented by sluggish and intermittent flows but not by the stopped
Table 3 flows that are commonly observed during severe inflammatory
Microvascular parameters pre and post delivery in preeclamptic patients with HELLP states such as sepsis [13]. Previous observations have demon-
syndrome. strated the development of increased post-capillary pressure, clin-
Pre-eclampsia + HELLP Pre-eclampsia + HELLP p ically manifested by increased isovolumetric venous pressure and
Pre delivery Post delivery molecularly associated to a high expression of vascular and inter-
PPV, % 76 (71–84) 86 (81–89) 0.03 cellular cell-adhesion molecules [25], which could explain the pre-
Heterogeneity 0.35 (0.32–0.37) 0.24 (0.17–0.34) 0.06 dominant sluggish and intermittent flows observed in our patients.
Index One could also argue that discontinuous flows could be normal
MFI 2.2 (2.0–2.7) 2.6 (2.3–2.9) 0.05
since direct visualization of microcirculation using intravital
FCD, n/mm2 8.1 (7.9–8.4) 8.9 (8.0–9.4) 0.07
TCD, n/mm2 12.7 (12.0–13.2) 12.4 (12.2–13.2) 0.87 microscopy during extended periods can reveal intermittent flow
in some capillaries in normal conditions [11]. Nevertheless, the fact
PPV: Proportion of small vessels perfused; FCD: Functional Capillary Density; TCD:
that all our observations were performed in similar conditions for
Total Capillary Density.
all the study groups supports the consistency of our findings. Inde-
pendently of dissimilarities in the microvascular blood flow itself
phenomena during clinically established preeclampsia: (1) a signif- during sepsis and preeclampsia, the severity of microvascular
icant alteration in microcirculatory flow distribution with blood flow misdistribution seems to be associated with more sev-
increased blood flow heterogeneity, predominantly in those ere organ dysfunction and more severe clinical manifestations, as
patients complicated with HELLP syndrome; these alterations were observed in preeclamptic patients complicated by HELLP
mainly characterized by an increased number of capillaries with syndrome.
sluggish and intermittent flow and, to a lesser extend, by stopped Recently, Cornette et al. [18] also found a significant decrease in
blood flows; (2) a significant reduction in the total capillary density the microvascular flow index (MFI) in patients affected by HELLP
in preeclamptic pregnancies even though all the pregnant popula- syndrome. Unlike our findings, they did not, however, find signifi-

Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
6 G.A. Ospina-Tascón et al. / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx
cant differences for MFI in those preeclamptic pregnancies without
HELLP. We cannot deny that preeclampsia is highly influenced by
race and environmental factors, leading to profound differences
between populations in different geographic zones [26]. The
results reported by Cornette et al. may also, however, be due to
the lower sensitivity of MFI to detect alterations in heterogeneity
in perfusion. Microcirculatory evaluations based on the MFI some-
times differ from semi-quantitative count methods such as the De
Backer’s score [27]. The MFI is the result of the average score of the
predominant type of flow observed in each of four quadrants. As a
result, a quadrant will be considered as normally perfused even if
49% of the vessels are not perfused. Conversely, the De Backer’s
score is based on the count of each vessel crossing three equidis-
tant horizontal and vertical lines, and therefore the exact propor-
tion of vessels with normal or abnormal flow can be calculated.
Thus, a wide range of PPV or FCD values could be represented by
the same MFI leading to discordant results. Nevertheless, we report
concordant results between MFI and PPV in preeclampsia, reinforc-
ing the idea that microcirculatory convective and diffusive mecha-
nisms are more severely altered during HELLP syndrome.
While normal pregnancies are associated with reduced vascular
resistance, those complicated by preeclampsia experiment a decline
in blood flow associated to increased resistance even before the
onset of clinical manifestations [7,8]. In the past, authors have doc-
umented decreases of arteriolar and venular calibers in retinal and
conjunctival circulation during preeclamptic pregnancies [15,16,
28], hypothesizing that vascular caliber tracks vascular resistances,
as suggested by studies in populations of hypertensive (non
preeclamptic) patients across a wide range of ages, sex, and ethnicity
[17,29,30]. Interestingly, more than changes in vessel calibers, we
found significant differences in the total vascular densities among
the groups. We found increased total capillary densities in all preg-
nancies when compared with non-pregnant controls. Preeclamptic
patients showed, however, a significant lower vascular density than
healthy pregnant women, which might suggest an abnormal vascu-
lar development. One could hypothesize that defective angiogenesis
might explain this apparent truncation in the increase of capillary
density, which would agree with studies demonstrating the imbal-
ance between angiogenic and anti-angiogenic factors in preeclamp-
tic pregnancies [31–35]. In agreement with our data, Hasan et al.
[10] demonstrated a significant decrease in the functional and struc-
tural skin capillary density in preeclamptic women while Nama et al.
[9] showed that such decreases could be related to the imbalance
between angiogenic and anti-angiogenic factors. Thereby, defective
angiogenesis manifested by a reduction in the total microvascular
density seems to be a key feature of preeclampsia and could account
for the abnormalities in vascular resistance and the alterations in tis-
sue perfusion leading to clinical manifestations. The relationships
between angiogenic/anti-angiogenic factors and microcirculatory
dysfunction in preeclampsia should, therefore be addressed in
future studies.
We observed a significant improvement in microvascular blood
flow distribution in preeclamptic patients with HELLP syndrome
after placental delivery, suggesting the potential reversibility of
convective blood flow alterations. Vascular densities did not, how-
ever, change significantly, despite macro hemodynamic normaliza-
tion (at least within the first hours after delivery), suggesting that
TCD alterations could be related to abnormal vascular angiogenesis
and not to vasomotor alterations. Unfortunately, we did not use
topical mucosal vasodilators to discard whether such disturbances
were due to vasoconstriction. Conversely, when all preeclamptic
patients subjected to early placental delivery strategies were eval-
uated, we did not find significant differences for any microcircula-
tory blood flow variable, which could be explained by the low
severity of convective blood flow alterations observed in PE with-
out HELLP syndrome in our population. One could hypothesize that
Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
magnesium may have influenced our results since half of our
preeclamptic patients were receiving it at the time of their inclu-
sion in the study. Although magnesium sulphate has previously
been related to improvement in the deformability of red blood cells
[36], no substantial effects on microvascular blood flows have been
reported, even during severe inflammatory conditions such as sev-
ere sepsis [37]. Furthermore, most of our patients were initially
evaluated into the first hour of starting magnesium infusion when
the cumulative doses did not exceeding 1 gr. Likewise, the initial
microcirculatory parameters in our study did not differ between
those who were receiving or not receiving magnesium sulphate,
which also suggests that simple vasomotor changes do not explain
our results.
We recognize various limitations in our study. First, we evalu-
ated a limited number of preeclamptic patients and normal preg-
nant women and we did not explore microcirculatory alterations
during less severe cases of preeclampsia. In fact, we enrolled the
most complicated cases focusing on arterial pressure, the progres-
sion of symptoms, target organ damages and laboratory alter-
ations. Second, most preeclamptic patients were receiving
magnesium treatment at enrollment, since preeclampsia is a life-
threatening condition. However, the severity of the microvascular
alterations observed when using this therapy for preeclampsia
reinforces the suitability of this imaging technique when applied
at the bedside. Third, we evaluated the sublingual mucosa and
although we demonstrated some changes in microcirculatory
blood flow, this zone could not be representative of utero-
placental and/or systemic microcirculation. Fourth, microcircula-
tory alterations in our study were only described during the late
stage of preeclampsia, when clinical manifestations were apparent.
Hence, we have no knowledge of the time-course of microcircula-
tory alterations throughout pregnancy or whether these alter-
ations could be detected early, therefore cannot be certain
whether these alterations might precede the onset of clinical
manifestations.
Substantial distributive microcirculatory blood flow alterations
and decreased capillary densities are observed in preeclampsia,
suggesting a key role for microvascular dysfunction in the patho-
physiology of this condition. Our observations are, however,
restricted to a limited number of severe preeclamptic pregnancies
and although our findings are biologically plausible, they should be
confirmed in future studies evaluating microcirculation during
early pregnancy and its relationship with other markers of
endothelial dysfunction.
Financial support
Tecnoquímicas S.A. (Colombia) – Centro Investigaciones Clíni-
cas, Fundación Valle del Lili (CO) (CIC 001) – Universidad ICESI
(CO) (IP-FO-01).
The funding did not influence the study design, collection, anal-
ysis or interpretation of the data, nor the writing of this report, nor
the decision to submit this article to Pregnancy Hypertension
Statement of authorship
Contributions
 Gustavo Adolfo OSPINA-TASCÓN, M.D., Ph.D: Conception and
design of the study, collection of data, analysis of microcircula-
tion video sequences, analysis and interpretation of data, prepa-
ration and critical review of the manuscript.
 Albaro José NIETO CALVACHE, M.D.: Conception and design of
the study, collection of data, analysis and interpretation of data,
preparation and critical review of the manuscript.
 G.A. Ospina-Tascón et al. / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health xxx (2017) xxx–xxx
 Edgardo QUIÑONES, M.D.: Collection of data, analysis of micro-
circulation video sequences, analysis and interpretation of data,
critical review of the manuscript.
 Humberto José MADRIÑAN, M.D.: Collection of data, analysis of
microcirculation video sequences, analysis and interpretation of
data, critical review of the manuscript.
 Juan David VALENCIA, M.D.: Collection of data, analysis and
interpretation of data, critical review of the manuscript.
 William Fernando BERMÚDEZ, M.D.: Collection of data, analysis
and interpretation of data, critical review of the manuscript.
 Javier CARVAJAL, M.D.: Collection of data, analysis and interpre-
tation of data, critical review of the manuscript.
 María Fernanda ESCOBAR, M.D.: Collection of data, analysis and
interpretation of data, critical review of the manuscript.
 Daniel DE BACKER, M.D., Ph.D.: Conception and design of the
study, collection of data, analysis and interpretation of data,
preparation and critical review of the manuscript.
All authors declare that they have contributed significantly to
the study (as previously declared) and that they have seen and
approved the final version of the report that is to be considered
for publication.
Acknowledgements
The authors thank Dr. Fernando Rosso and Dr. Marcela Grana-
dos (Fundación Valle del Lili- Cali, Colombia); and Dr. Yuri Takeu-
chi and Dr. Francisco Piedrahita (Universidad ICESI, Cali, Colombia)
for their unconditional support for this project.
References
[1] L. Duley, The global impact of pre-eclampsia and eclampsia, Semin. Perinatol.
33 (3) (2009) 130–137.
[2] K.S. Khan, D. Wojdyla, L. Say, A.M. Gülmezoglu, P.F. Van Look, WHO analysis of
causes of maternal death: a systematic review, Lancet 367 (9516) (2006)
1066–1074.
[3] M.T. Lydon-Rochelle, V.L. Holt, V. Cárdenas, J.C. Nelson, T.R. Easterling, C.
Gardella, et al., The reporting of pre-existing maternal medical conditions and
complications of pregnancy on birth certificates and in hospital discharge data,
Am. J. Obstet. Gynecol. 193 (1) (2005) 125–134.
[4] J.M. Roberts, C.A. Hubel, The two stage model of preeclampsia: variations on
the theme, Placenta 30 (Suppl. A) (2009) S32–S37.
[5] J.M. Roberts, R.N. Taylor, T.J. Musci, G.M. Rodgers, C.A. Hubel, M.K. McLaughlin,
Preeclampsia: an endothelial cell disorder, Am. J. Obstet. Gynecol. 161 (5)
(1989) 1200–1204.
[6] G.M. Rodgers, R.N. Taylor, J.M. Roberts, Preeclampsia is associated with a
serum factor cytotoxic to human endothelial cells, Am. J. Obstet. Gynecol. 159
(4) (1988) 908–914.
[7] N. Anim-Nyame, S.R. Sooranna, M.R. Johnson, J. Gamble, P.J. Steer, Resting
peripheral blood flow in normal pregnancy and in pre-eclampsia, Clin. Sci. 99
(6) (2000) 505–510.
[8] N. Anim-Nyame, S. Sooranna, M. Johnson, J. Gamble, P. Steer, Longitudinal
changes in resting blood flow during normal pregnancy and pregnancies
complicated by chronic hypertension and pre-eclampsia, Cardiovasc. Res. 50
(2001) 603–609.
[9] V. Nama, I.T. Manyonda, J. Onwude, T.F. Antonios, Structural capillary
rarefaction and the onset of preeclampsia, Obstet. Gynecol. 119 (5) (2012)
967–974.
[10] K.M. Hasan, I.T. Manyonda, F.S. Ng, D.R. Singer, T.F. Antonios, Skin capillary
density changes in normal pregnancy and pre-eclampsia, J. Hypertens. 20 (12)
(2002) 2439–2443.
[11] D. De Backer, K. Donadello, F.S. Taccone, G. Ospina-Tascon, D. Salgado, J.L.
Vincent, Microcirculatory alterations: potential mechanisms and implications
for therapy, Ann. Intensive Care 1 (1) (2011) 27.
[12] J.L. Vincent, D. De Backer, Microvascular dysfunction as a cause of organ
dysfunction in severe sepsis, Crit. Care 9 (Suppl 4) (2005) S9–12.
[13] D. De Backer, K. Donadello, Y. Sakr, G. Ospina-Tascon, D. Salgado, S. Scolletta,
et al., Microcirculatory alterations in patients with severe sepsis: impact of
Please cite this article in press as: G.A. Ospina-Tascón et al., Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome,
Preg. Hyper: An Int. J. Women’s Card. Health (2017), http://dx.doi.org/10.1016/j.preghy.2017.07.140
7
time of assessment and relationship with outcome, Crit. Care Med. 41 (3)
(2013) 791–799.
[14] D. De Backer, G. Ospina-Tascon, D. Salgado, R. Favory, J. Creteur, J.L. Vincent,
Monitoring the microcirculation in the critically ill patient: current methods
and future approaches, Intensive Care Med. 36 (11) (2010) 1813–1825.
[15] A.J. Houben, P.W. de Leeuw, L.L. Peeters, Configuration of the microcirculation
in pre-eclampsia: possible role of the venular system, J. Hypertens. 25 (8)
(2007) 1665–1670.
[16] L.J. Li, C.Y. Cheung, M.K. Ikram, P. Gluckman, M.J. Meaney, Y.S. Chong, et al.,
Blood pressure and retinal microvascular characteristics during pregnancy:
growing up in Singapore towards healthy outcomes (GUSTO) study,
Hypertension 60 (1) (2012) 223–230.
[17] T.Y. Wong, R. Klein, B.E. Klein, S.M. Meuer, L.D. Hubbard, Retinal vessel
diameters and their associations with age and blood pressure, Invest.
Ophthalmol. Vis. Sci. 44 (11) (2003) 4644–4650.
[18] J. Cornette, E. Herzog, E.A. Buijs, J.J. Duvekot, D. Rizopoulos, W.C. Hop, et al.,
Microcirculation in women with severe pre-eclampsia and HELLP syndrome: a
case-control study, BJOG 121 (3) (2014) 363–370.
[19] Excellence NIfHaC, Hypertension in Pregnancy: The management of
Hypertensive disorders during pregnancy, NICE clinical guideline, 2010, vol.
107, pp. 1–53.
[20] B.M. Sibai, Diagnosis, controversies, and management of the syndrome of
hemolysis, elevated liver enzymes, and low platelet count, Obstet. Gynecol.
103 (5 Pt 1) (2004) 981–991.
[21] C. Ince, The microcirculation is the motor of sepsis, Crit. Care 9 (Suppl 4)
(2005) S13–9.
[22] D. De Backer, S. Hollenberg, C. Boerma, P. Goedhart, G. Büchele, G. Ospina-
Tascon, et al., How to evaluate the microcirculation: report of a round table
conference, Crit. Care 11 (5) (2007) R101.
[23] M.B. Pinheiro, K.B. Gomes, L.M. Dusse, Fibrinolytic system in preeclampsia,
Clin. Chim. Acta 416 (2013) 67–71.
[24] K.P. Conrad, T.M. Miles, D.F. Benyo, Circulating levels of immunoreactive
cytokines in women with preeclampsia, Am. J. Reprod. Immunol. 40 (2) (1998)
102–111.
[25] N. Anim-Nyame, J. Gamble, S.R. Sooranna, M.R. Johnson, M.H. Sullivan, P.J.
Steer, Evidence of impaired microvascular function in pre-eclampsia: a non-
invasive study, Clin. Sci. 104 (4) (2003) 405–412.
[26] O. Dulovic, E. Gvozdenovic, J. Nikolic, A.R. Spurnic, N. Katanic, D. Kovacevic-
Pavicevic, Varicella complications: is it time to consider a routine varicella
vaccination?, Vojnosanit Pregl. 67 (7) (2010) 523–529.
[27] R. Favory, G. Ospina-Tascon, K. Donadello, D. Simion, A. Neves, G. Occhipinti,
et al., Is there a correlation between near infrared spectroscopy and side dark
field imaging?, in: Intensive Care Med 35 (s205) (2009).
[28] S.J. Lupton, C.L. Chiu, L.A. Hodgson, J. Tooher, R. Ogle, T.Y. Wong, et al., Changes
in retinal microvascular caliber precede the clinical onset of preeclampsia,
Hypertension 62 (5) (2013) 899–904.
[29] C. Sun, G. Liew, J.J. Wang, P. Mitchell, S.M. Saw, T. Aung, et al., Retinal vascular
caliber, blood pressure, and cardiovascular risk factors in an Asian population:
the Singapore Malay eye study, Invest. Ophthalmol. Vis. Sci. 49 (5) (2008)
1784–1790.
[30] C. Sun, J.J. Wang, D.A. Mackey, T.Y. Wong, Retinal vascular caliber: systemic,
environmental, and genetic associations, Surv. Ophthalmol. 54 (1) (2009) 74–
95.
[31] S. Ahmad, A. Ahmed, Elevated placental soluble vascular endothelial growth
factor receptor-1 inhibits angiogenesis in preeclampsia, Circ. Res. 95 (9) (2004)
884–891.
[32] A. Ahmed, C. Dunk, S. Ahmad, A. Khaliq, Regulation of placental vascular
endothelial growth factor (VEGF) and placenta growth factor (PIGF) and
soluble Flt-1 by oxygen–a review, Placenta 21 (Suppl. A) (2000) S16–S24.
[33] T. Chaiworapongsa, R. Romero, J. Espinoza, E. Bujold, Y. Mee Kim, L.F.
Gonçalves, et al., Evidence supporting a role for blockade of the vascular
endothelial growth factor system in the pathophysiology of preeclampsia.
Young Investigator Award, Am. J. Obstet. Gynecol. 190 (6) (2004) 1541–1547.
discussion 7–50.
[34] T. Chaiworapongsa, R. Romero, Y.M. Kim, G.J. Kim, M.R. Kim, J. Espinoza, et al.,
Plasma soluble vascular endothelial growth factor receptor-1 concentration is
elevated prior to the clinical diagnosis of pre-eclampsia, J. Matern. Fetal.
Neonatal. Med. 17 (1) (2005) 3–18.
[35] S. Venkatesha, M. Toporsian, C. Lam, J. Hanai, T. Mammoto, Y.M. Kim, et al.,
Soluble endoglin contributes to the pathogenesis of preeclampsia, Nat. Med.
12 (6) (2006) 642–649.
[36] B. Schauf, S. Becker, H. Abele, T. Klever, D. Wallwiener, B. Aydeniz, Effect of
magnesium on red blood cell deformability in pregnancy, Hypertens.
Pregnancy 24 (1) (2005) 17–27.
[37] A. Pranskunas, N.A. Vellinga, V. Pilvinis, M. Koopmans, E.C. Boerma,
Microcirculatory changes during open label magnesium sulphate infusion in
patients with severe sepsis and septic shock, BMC Anesthesiol. 11 (2011) 12.