Future risk of cardiovascular disease risk factors and events in women after a hypertensive disorder of pregnancy

Directive clinique no 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge

OBJECTIF

La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse.

POPULATION CIBLE

Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ». Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication.

PROFESSIONNELS CIBLES

Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse.

RECOMMANDATIONS

Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management

OBJECTIVE

This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP.

TARGET POPULATION

Pregnant women.

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes.

EVIDENCE

A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies.

VALIDATION METHODS

The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication.

INTENDED USERS

All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy.

RECOMMENDATIONS

Understanding maternal postnatal blood pressure changes following hypertensive disorders in pregnancy: protocol for a prospective cohort study

INTRODUCTION

Hypertensive disorders occur in approximately 10% of women during pregnancy. There is robust population-based data to show that women who have hypertension in pregnancy are much more likely to develop cardiovascular disease (CVD) in the postpartum period. Women with a hypertensive disorder of pregnancy (HDP) are twice more at risk of heart disease and stroke, and four times more likely to develop hypertension after birth. Two out of three women who had HDP will die from CVD. Recent evidence suggests that young women with HDP develop signs of CVD in the immediate postpartum period, rather than several decades later as previously presumed. If confirmed, this concerning finding presents healthcare practitioners with an opportunity to influence women's cardiovascular health by advising on lifestyle choices and considering therapeutic interventions to prevent the development of CVD.

METHODS AND ANALYSIS

This prospective cohort study design will ask approximately 300 participants to complete 3 days of home blood pressure monitoring every fortnight for 12 weeks postpartum and will culminate with a 24-hour episode of ambulatory blood pressure monitoring at 12 weeks postpartum. Women and healthcare professionals will complete questionnaires surrounding postpartum care for women who had HDP and knowledge of CVD risk. In addition, the relationship between hypertension and factors likely to influence outcomes such as severity of HDP, maternal age, body mass index and ethnicity will be analysed using logistic regression. Blood pressure and data from questionnaires will be analysed using descriptive statistics, with temporal stratification.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from London-West London & GTAC Research Ethics Committee. Research outputs will be published and disseminated through midwifery, obstetric or general practitioner targeted academic journals. The patient and public involvement group will disseminate findings to women who have experienced HDP among their peer groups.

TRIAL REGISTRATION NUMBER

NCT05137808.

Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure

Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

Primary Care-Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.

Preconception and early-pregnancy risk prediction for birth complications: development of prediction models within a population-based prospective cohort

Background

Suboptimal maternal health already from preconception onwards is strongly linked to an increased risk of birth complications. To enable identification of women at risk of birth complications, we aimed to develop a prediction model for birth complications using maternal preconception socio-demographic, lifestyle, medical history and early-pregnancy clinical characteristics in a general population.

Methods

In a population-based prospective cohort study among 8340 women, we obtained information on 33 maternal characteristics at study enrolment in early-pregnancy. These characteristics covered the preconception period and first half of pregnancy (< 21 weeks gestation). Preterm birth was < 37 weeks gestation. Small-for-gestational-age (SGA) and large-for-gestational-age (LGA) at birth were gestational-age-adjusted birthweight in the lowest or highest decile, respectively. Because of their co-occurrence, preterm birth and SGA were combined into a composite outcome.

Results

The basic preconception model included easy obtainable maternal characteristics in the preconception period including age, ethnicity, parity, body mass index and smoking. This basic preconception model had an area under the receiver operating characteristics curve (AUC) of 0.63 (95% confidence interval (CI) 0.61 to 0.65) and 0.64 (95% CI 0.62 to 0.66) for preterm birth/SGA and LGA, respectively. Further extension to more complex models by adding maternal socio-demographic, lifestyle, medical history and early-pregnancy clinical characteristics led to small, statistically significant improved models. The full model for prediction of preterm birth/SGA had an AUC 0.66 (95% CI 0.64 to 0.67) with a sensitivity of 22% at a 90% specificity. The full model for prediction of LGA had an AUC of 0.67 (95% CI 0.65 to 0.69) with sensitivity of 28% at a 90% specificity. The developed models had a reasonable level of calibration within highly different socio-economic subsets of our population and predictive performance for various secondary maternal, delivery and neonatal complications was better than for primary outcomes.

Conclusions

Prediction of birth complications is limited when using maternal preconception and early-pregnancy characteristics, which can easily be obtained in clinical practice. Further improvement of the developed models and subsequent external validation is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04497-2.

Genetic, Molecular, and Cellular Determinants of Sex-Specific Cardiovascular Traits

Despite the well-known sex dimorphism in cardiovascular disease traits, the exact genetic, molecular, and cellular underpinnings of these differences are not well understood. A growing body of evidence currently points at the links between cardiovascular disease traits and the genome, epigenome, transcriptome, and metabolome. However, the sex-specific differences in these links remain largely unstudied due to challenges in bioinformatic methods, inadequate statistical power, analytic costs, and paucity of valid experimental models. This review article provides an overview of the literature on sex differences in genetic architecture, heritability, epigenetic changes, transcriptomic signatures, and metabolomic profiles in relation to cardiovascular disease traits. We also review the literature on the associations between sex hormones and cardiovascular disease traits and discuss the potential mechanisms underlying these associations, focusing on human studies.

Optimising Cardiometabolic Risk Factors in Pregnancy: A Review of Risk Prediction Models Targeting Gestational Diabetes and Hypertensive Disorders

Cardiovascular disease, especially coronary heart disease and cerebrovascular disease, is a leading cause of mortality and morbidity in women globally. The development of cardiometabolic conditions in pregnancy, such as gestational diabetes mellitus and hypertensive disorders of pregnancy, portend an increased risk of future cardiovascular disease in women. Pregnancy therefore represents a unique opportunity to detect and manage risk factors, prior to the development of cardiovascular sequelae. Risk prediction models for gestational diabetes mellitus and hypertensive disorders of pregnancy can help identify at-risk women in early pregnancy, allowing timely intervention to mitigate both short- and long-term adverse outcomes. In this narrative review, we outline the shared pathophysiological pathways for gestational diabetes mellitus and hypertensive disorders of pregnancy, summarise contemporary risk prediction models and candidate predictors for these conditions, and discuss the utility of these models in clinical application.

Protocol: A randomized controlled trial to assess effectiveness of a 12-month lifestyle intervention to reduce cardiovascular disease risk in families ten years after pre-eclampsia (FINNCARE)

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This is appropriately powered 12-month lifestyle intervention for PE families.

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Detailed phenotyping now and during index pregnancy may identify subgroups at CVD risk.

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Genome-wide genotyping is performed for all study participants.

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Process evaluation examines feasibility and follows Medical Research Council guidance.

Pre-eclampsia (PE) is a multisystem progressive disorder affecting 3–5% of pregnancies. PE independently increases the risk for premature cardiovascular disease (CVD) in mothers and their children long-term. The effectiveness of a family-centered lifestyle intervention to lower CVD risk in PE families has not previously been evaluated. In the current FINNCARE study, we prospectively compare CVD risk and CVD progression in PE families (mother, father and child) in a cross-sectional study setting 8–12 years from delivery with non-PE control families of comparable age. Furthermore, we evaluate the effectiveness and feasibility of an interactive web-based behavioral 12-month lifestyle intervention to reduce blood pressure and the CVD risk profile overall in a randomized controlled trial. In total, 300 PE families will be randomized 1:1 to a PE-intervention or a PE-control group, and the 100 non-PE control families similarly followed-up at 12 months. Primary outcome is 24-hour mean systolic BP change from baseline in mother and child. Study aims to provide information on CVD progression and CVD risk management in the family following PE.

Does Adding Adverse Pregnancy Outcomes Improve the Framingham Cardiovascular Risk Score in Women? Data from the Tehran Lipid and Glucose Study

Background Limited and conflicting evidence is available regarding the predictive value of adding adverse pregnancy outcomes (APOs) to established cardiovascular disease (CVD) risk factors. Hence, the objective of this study was to determine whether adding APOs to the Framingham risk score improves the prediction of CVD events in women. Methods and Results Out of 5413 women who participated in the Tehran Lipid and Glucose Study, 4013 women met the eligibility criteria included for the present study. The exposure and the outcome variables were collected based on the standard protocol. Cox proportional hazard model was used to evaluate the association of APOs and CVDs. The variant of C-statistic for survivals and reclassification of subjects into Framingham risk score categories after adding APOs was reported. Out of the 4013 eligible subjects, a total of 1484 (36.98%) women reported 1 APO, while 395 (9.84%) of the cases reported multiple APOs. Univariate proportional hazard Cox models showed the significant relations between CVD events and APOs. The enhanced model had a higher C-statistic indicating more acceptable discrimination as well as a slight improvement in discrimination (C-statistic differences: 0.0053). Moreover, we observed a greater risk of experiencing a CVD event in women with a history of multiple APOs compared with cases with only 1 APO (1 APO: hazard ratio [HR] = 1.22; 2 APOs: HR; 1.94; ≥3 APOs: HR = 2.48). Conclusions Beyond the established risk factors, re-estimated CVDs risk by adding APOs to the Framingham risk score may improve the accurate risk estimation of CVD. Further observational studies are needed to confirm our findings.

Pharmacoepidemiology in pregnancy: analysis protocol for an observational cohort study in the UK Clinical Practice Research Datalink

Large numbers of women take prescription and over-the-counter medications during pregnancy. However, there is very little definitive evidence about the potential effects of these drugs on the mothers and offspring. We will investigate the risks and benefits of continuing prescriptive drug use for chronic pre-existing maternal conditions such as diabetes, hypertension and thyroid related conditions throughout pregnancy. If left untreated, these conditions are established risk factors for adverse neonatal and maternal outcomes. However, some treatments for these conditions are associated with adverse neonatal outcomes. Our primary aims are twofold. Firstly, we aim to estimate the beneficial effect on the mother of continuing treatment during pregnancy. Second, we aim to determine whether there is an associated detrimental impact on the neonate of continuation of maternal treatment during pregnancy. To establish this evidence, we will investigate the relationship between maternal drug prescriptions and adverse and beneficial offspring outcomes to provide evidence to guide clinical decisions. We will conduct a hypothesis testing observational intergenerational cohort study using data from the UK Clinical Practice Research Datalink (CPRD). We will apply four statistical methods: multivariable adjusted regression, propensity score regression, instrumental variables analysis and negative control analysis. These methods should account for potential confounding when estimating the association between the drug exposure and maternal or neonatal outcome. In this protocol we describe the aims, motivation, study design, cohort and statistical analyses of our study to aid reproducibility and transparency within research.

Comparisons of urine protein-to-creatinine ratios and their dynamic change patterns during labor at term between normal pregnant women and women with pregnancy induced hypertension

Introduction: To evaluate patterns of change in the urine protein-to-creatinine ratios (uPCRs) during labor at term between normal and women with pregnancy-induced hypertension (PIH). Methods: This is an observational study in tertiary referral hospital, recruiting 269 women at term delivery in Taiwan from April 19, 2019 to April 18, 2021. uPCRs in four phases (latent, active, recovery and early postpartum) and related clinical data at delivery were collected. Multivariate analyses with a linear regression model were performed to analyze continuous variables after adjusting for clinical data between two groups. Results: Based on exclusion criteria, 68 normal and 24 pregnant women with PIH were included. There were no differences in the uPCR or the proportion cases of uPCRs ≥ 300 mg/g between normal and PIH group in the four phases. There was a statistically significant tendency for the proportion of uPCRs ≥ 300 mg/g to increase from the latent to the early postpartum phase in both groups. The proportion of uPCRs ≥ 300 mg/g significantly increased from the active to the recovery phase and then declined from the recovery to the early postpartum phase in the normal group. Thus no differences in uPCRs cases change between any two phases in women with PIH, except the duration above stated. Conclusion: This is the first study to demonstrate that uPCRs data are not different between normal pregnant and PIH groups during the course of labor, but it did show different dynamic change patterns throughout the labor phases.

Adverse Cardiovascular Events Following Severe Maternal Morbidity

Severe maternal morbidity (SMM) affects 50,000 women annually in the United States, but its consequences are not well understood. We aimed to estimate the association between SMM and risk of adverse cardiovascular events during the 2 years postpartum. We analyzed 137,140 deliveries covered by the Pennsylvania Medicaid program (2016-2018), weighted with inverse probability of censoring weights to account for nonrandom loss to follow-up. SMM was defined as any diagnosis on the Centers for Disease Control and Prevention list of SMM diagnoses and procedures and/or intensive care unit admission occurring at any point from conception through 42 days postdelivery. Outcomes included heart failure, ischemic heart disease, and stroke/transient ischemic attack up to 2 years postpartum. We used marginal standardization to estimate average treatment effects. We found that SMM was associated with increased risk of each adverse cardiovascular event across the follow-up period. Per 1,000 deliveries, relative to no SMM, SMM was associated with 12.1 (95% confidence interval (CI): 6.2, 18.0) excess cases of heart failure, 6.4 (95% CI: 1.7, 11.2) excess cases of ischemic heart disease, and 8.2 (95% CI: 3.2, 13.1) excess cases of stroke/transient ischemic attack at 26 months of follow-up. These results suggest that SMM identifies a group of women who are at high risk of adverse cardiovascular events after delivery. Women who survive SMM may benefit from more comprehensive postpartum care linked to well-woman care.

Maternal hypertensive disorders in pregnancy and early childhood cardiometabolic risk factors: The Generation R Study

The objective of this study was to determine the associations between hypertensive disorders of pregnancy and early childhood cardiometabolic risk factors in the offspring. Therefore, 7794 women from the Generation Rotterdam Study were included, an ongoing population-based prospective birth cohort. Women with a hypertensive disorder of pregnancy were classified as such when they were affected by pregnancy induced hypertension, pre-eclampsia or the haemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome during pregnancy. Early childhood cardiometabolic risk factors were defined as the body mass index at the age of 2, 6, 12, 36 months and 6 years. Additionally, it included systolic blood pressure, diastolic blood pressure, total fat mass, cholesterol, triglycerides, insulin and clustering of cardiometabolic risk factors at 6 years of age. Sex-specific differences in the associations between hypertensive disorders and early childhood cardiometabolic risk factors were investigated. Maternal hypertensive disorders of pregnancy were inversely associated with childhood body mass index at 12 months (confounder model: -0.15 SD, 95% CI -0.27; -0.03) and childhood triglyceride at 6 years of age (confounder model: -0.28 SD, 95% CI -0.45; -0.10). For the association with triglycerides, this was only present in girls. Maternal hypertensive disorders of pregnancy were not associated with childhood body mass index at 2, 6 and 36 months. No associations were observed between maternal hypertensive disorders of pregnancy and systolic blood pressure, diastolic blood pressure, body mass index, fat mass index and cholesterol levels at 6 years of age. Our findings do not support an independent and consistent association between maternal hypertensive disorders of pregnancy and early childhood cardiometabolic risk factors in their offspring. However, this does not rule out possible longer term effects of maternal hypertensive disorders of pregnancy on offspring cardiometabolic health.

Longitudinal blood pressure patterns of women with hypertensive disorders of pregnancy: preconception through postpartum

OBJECTIVE

To investigate the longitudinal blood pressure (BP) pattern of women with hypertensive disorders of pregnancy (HDP) preconception through the postpartum day (PPD) 42.

STUDY DESIGN

A retrospective study of women (≥15 years old) diagnosed with an HDP antenatally or postpartum, who were enrolled prospectively in a postpartum remote BP monitoring program between 3/2017 and 5/2020. BPs were collected from 47-time points: preconception, each trimester, delivery day, and 42 days postpartum. Analysis was conducted utilizing a mixed-effects longitudinal model.

MAIN OUTCOME MEASURES

Primary outcome was the longitudinal BP patterns. Secondary outcomes were the timing of BP stabilization (BPs < 140/90 mmHg for ≥48 h) and resolution (stabilized without antihypertensive medication use).

RESULTS

Our final analysis included 897 of the 964 eligible women. The peak systolic and diastolic BPs were on PPDs 3, 4, 5, and 5, 6, 7, respectively. Systolic BP fell below the preconception level after PPD15; diastolic BP reached its plateau after PPD17 and remained above the preconception level till PPD42 (p < .001). Postpartum BP peaked with the highest percentage of BP spikes on PPDs 4-7. The median survival times to BP stabilization and resolution were PPDs 11 (95% CI: 10-12) and 23 (95% CI: 21-25), respectively. By PPD42, 91.0% and 74.1% of women achieved BP stabilization and resolution, respectively.

CONCLUSION

This study data could be used to develop evidence-based recommendations for women with an HDP. Diastolic BPs remaining significantly higher than the preconception level indicates the long-term risk of cardiovascular disease. In our cohort, 26% of women had unresolved hypertension by PPD42, which reinforces the necessity to ensure long-term follow-up.

Associations of cardiovascular risk with circulating peptides related to hypertensive disorders of pregnancy

We previously identified seven peptides in serum that are associated with hypertensive disorders of pregnancy (HDP). However, the significance of these peptides in the general population is unknown. The aim of this study was to clarify the relationships of HDP-associated peptides with hypertension and other cardiovascular risks in adult men. We investigated the relationships of peptide levels with cardiovascular risk factors, including adiposity, blood pressure, blood lipids and glycemic status, in men (mean age: 46.4 years) who were receiving annual health checkups at their workplace. The concentrations of the abovementioned seven peptides in serum were measured simultaneously using a mass spectrometer. Among the seven peptides, only a peptide with m/z 2091 (P-2091) derived from fibrinogen-α showed a significant correlation with diastolic blood pressure (Spearman's rank correlation coefficient [r], -0.446). Another peptide with m/z 2378 (P-2378) originating from complement component 4 showed a significant positive correlation with body mass index (r, 0.273) and a significant inverse correlation with HDL cholesterol (r, -0.336). In addition, a peptide with m/z 3156 (P-3156) derived from an inter-α-trypsin inhibitor showed significant inverse correlations with body mass index (r, -0.258) and triglycerides (r, -0.334). There was no significant correlation of the levels of any of the seven peptides with hemoglobin A1c. Among the seven peptides related to HDP, P-2091, P-2378 and P-3156 were inversely associated with diastolic blood pressure, HDL cholesterol and triglycerides, respectively. Therefore, these peptides are possible biomarkers for discriminating cardiovascular risk in a general population.

Reducing disparities in adverse pregnancy outcomes in the United States

There is growing evidence that rural and racial disparities and social determinants of health (SDOH) impact adverse pregnancy outcomes (APOs) and overall maternal mortality in the United States. These APOs, such as preeclampsia, preterm birth, and intrauterine growth restriction, are in-turn associated with increased risk of future cardiovascular disease (CVD) later in life. Importantly, SDOH such as socioeconomic disadvantages, poor health literacy, transportation barriers, lack of access to adequate health care, food insecurity, and psychosocial stressors have cascading effects on APOs and downstream cardiovascular health. These SDOH are also deeply intertwined with and compounded by existing racial and rural disparities. Pregnancy thus provides a unique opportunity to identify at-risk women from a social determinants perspective, and provide early interventions to optimize long-term CVD and mitigate cardiovascular health disparities. Addressing the challenges posed by these disparities requires a multi-pronged approach and involves national, regional, and individual level solutions. Eliminating disparities will necessitate a nationwide obligation to ensure health care equity via enhanced health insurance coverage, resource investment, and public and clinician accountability.

Prevention Starts in the Womb: Opportunities for Addressing Cardiovascular Risk Factors During Pregnancy and Beyond

Early identification and mitigation of sex-specific cardiovascular disease risk factors is a potential trajectory-changing strategy to improve lifelong cardiovascular health in women. These sex-specific risk factors include adverse pregnancy outcomes, polycystic ovarian syndrome, and premature menopause. We start by discussing the impact and management of risk factors for adverse pregnancy outcomes as an upstream intervention for cardiovascular disease risk reduction and then address the long-term effect and mitigation of sex-specific risk factors for cardiovascular disease.

A Machine Learning-Based Prediction Model for Cardiovascular Risk in Women With Preeclampsia

Objective: Preeclampsia affects 2–8% of women and doubles the risk of cardiovascular disease in women after preeclampsia. This study aimed to develop a model based on machine learning to predict postpartum cardiovascular risk in preeclamptic women.

Methods: Collecting demographic characteristics and clinical serum markers associated with preeclampsia during pregnancy of 907 preeclamptic women retrospectively, we predicted the cardiovascular risk (ischemic heart disease, ischemic cerebrovascular disease, peripheral vascular disease, chronic kidney disease, metabolic system disease or arterial hypertension). The study samples were divided into training sets and test sets randomly in the ratio of 8:2. The prediction model was developed by 5 different machine learning algorithms, including Random Forest. 10-fold cross-validation was performed on the training set, and the performance of the model was evaluated on the test set.

Results: Cardiovascular disease risk occurred in 186 (20.5%) of these women. By weighing area under the curve (AUC), the Random Forest algorithm presented the best performance (AUC = 0.711[95%CI: 0.697–0.726]) and was adopted in the feature selection and the establishment of the prediction model. The most important variables in Random Forest algorithm included the systolic blood pressure, Urea nitrogen, neutrophil count, glucose, and D-Dimer. Random Forest algorithm was well calibrated (Brier score = 0.133) in the test group, and obtained the highest net benefit in the decision curve analysis.

Conclusion: Based on the general situation of patients and clinical variables, a new machine learning algorithm was developed and verified for the individualized prediction of cardiovascular risk in post-preeclamptic women.

Hypertensive disorders of pregnancy among women of migrant origin in Finland: A population-based study

INTRODUCTION

Hypertensive disorders of pregnancy are a leading cause of maternal and perinatal mortality and morbidity worldwide. We studied the prevalence of hypertensive disorders of pregnancy among women of migrant origin in Finland.

MATERIAL AND METHODS

This study used data from the nationwide Medical Birth Register. Information on the most recent singleton birth of women who delivered between 2004 and 2014 (n = 382 233) was included. Women were classified into nine regional categories based on the country of origin. Women of Finnish origin were the reference group. Generalized linear models adjusted for maternal age, socioeconomic position, smoking in pregnancy, parity, pre-pregnancy body mass index, preexisting diabetes and delivery year were used to study the association between region/country of origin and hypertensive disorders of pregnancy.

RESULTS

Among the study population, almost 8% were of migrant origin. The prevalence of hypertensive disorders of pregnancy varied from 1.3% (women of East Asian origin) to 4.2% (women of Sub-Saharan African origin), compared with 4.6% in the Finnish origin reference group. Compared with women of Finnish origin, the risk for any hypertensive disorders of pregnancy after adjustment for confounders was lower for women of migrant origin, with an exception for women of Sub-Saharan African origin. When analyzing gestational hypertension and preeclampsia outcomes separately, Sub-Saharan African origin women had a lower risk for gestational hypertension (risk ratio [RR] 0.41, 95% confidence interval [CI] 0.30-0.56) but a higher risk for preeclampsia (RR 1.77, 95% CI 1.44-2.17) than women of Finnish origin.

CONCLUSIONS

In general, women of migrant origin in Finland had a lower risk for any hypertensive disorders of pregnancy and gestational hypertension. The risk for preeclampsia was higher among women of Sub-Saharan African origin and may warrant special attention.

Defective Uteroplacental Vascular Remodeling in Preeclampsia: Key Molecular Factors Leading to Long Term Cardiovascular Disease

Preeclampsia is a complex hypertensive disorder in pregnancy which can be lethal and is responsible for more than 70,000 maternal deaths worldwide every year. Besides the higher risk of unfavorable obstetric outcomes in women with preeclampsia, another crucial aspect that needs to be considered is the association between preeclampsia and the postpartum cardiovascular health of the mother. Currently, preeclampsia is classified as one of the major risk factors of cardiovascular disease (CVD) in women, which doubles the risk of venous thromboembolic events, stroke, and ischemic heart disease. In order to comprehend the pathophysiology behind the linkage between preeclampsia and the development of postpartum CVD, a thorough understanding of the abnormal uteroplacental vascular remodeling in preeclampsia is essential. Therefore, this review aims to summarize the current knowledge of the defective process of spiral artery remodeling in preeclampsia and how the resulting placental damage leads to excessive angiogenic imbalance and systemic inflammation in long term CVD. Key molecular factors in the pathway-including novel findings of microRNAs-will be discussed with suggestions of future management strategies of preventing CVD in women with a history of preeclampsia.

Lifting the veil of secrecy: maternal and neonatal outcome of oocyte donation pregnancies in Germany

BACKGROUND

In Germany, performing fertility procedures involving oocyte donation is illegal, as stated by the Embryo Protection Law. Nonetheless, in our clinical routine we attend to a steadily rising number of pregnant women, who have sought oocyte donation abroad. Due to the legal circumstances many women opt to keep the origin of their pregnancy a secret. However, studies have shown, that oocyte donation is an independent risk factor for the development of pregnancy complications, such as preeclampsia.

OBJECTIVE

The aim of this study is to evaluate maternal and neonatal outcomes of oocyte donation pregnancies in three large obstetric care units in Berlin, Germany.

METHODS

We retrospectively analyzed all available medical data on oocyte donation pregnancies at Charité University hospital, Vivantes Hospital Friedrichshain, and Neukoelln in the German capital.

RESULTS

We included 115 oocyte donation (OD) pregnancies in the present study. Our data are based on 62 singleton, 44 twin, 7 triplet, and 2 quadruplet oocyte donation pregnancies. According to our data, oocyte donation pregnancies are associated with a high risk of adverse maternal and fetal outcome, i.e., hypertension in pregnancy, preterm delivery, Cesarean section as mode of delivery, and increased peripartum hemorrhage.

CONCLUSION

Although oocyte donation is prohibited by German law, many couples go abroad to seek reproductive measures using oocyte donation after former treatment options have failed. OD pregnancies are associated with a high risk of preeclampsia, C-section as mode of delivery, and peripartum hemorrhage. Detailed knowledge of the associated risks is of utmost importance to both the patient and the treating physician and midwife.

Role of ACE2 in pregnancy and potential implications for COVID-19 susceptibility

In times of coronavirus disease 2019 (COVID-19), the impact of severe acute respiratory syndrome (SARS)-coronavirus (CoV)-2 infection on pregnancy is still unclear. The presence of angiotensin-converting enzyme (ACE) 2 (ACE2), the main receptor for SARS-CoV-2, in human placentas indicates that this organ can be vulnerable for viral infection during pregnancy. However, for this to happen, additional molecular processes are critical to allow viral entry in cells, its replication and disease manifestation, particularly in the placenta and/or feto-maternal circulation. Beyond the risk of vertical transmission, COVID-19 is also proposed to deplete ACE2 protein and its biological actions in the placenta. It is postulated that such effects may impair essential processes during placentation and maternal hemodynamic adaptations in COVID-19 pregnancy, features also observed in several disorders of pregnancy. This review gathers information indicating risks and protective features related to ACE2 changes in COVID-19 pregnancies. First, we describe the mechanisms of SARS-CoV-2 infection having ACE2 as a main entry door and current evidence of viral infection in the placenta. Further, we discuss the central role of ACE2 in physiological systems such as the renin-angiotensin system (RAS) and the kallikrein-kinin system (KKS), both active during placentation and hemodynamic adaptations of pregnancy. Significant knowledge gaps are also identified and should be urgently filled to better understand the fate of ACE2 in COVID-19 pregnancies and the potential associated risks. Emerging knowledge will be able to improve the early stratification of high-risk pregnancies with COVID-19 exposure as well as to guide better management and follow-up of these mothers and their children.

The Association of Familial Hypertension and Risk of Gestational Hypertension and Preeclampsia

It has not been established how history of hypertension in the father or mother of pregnant women, combined with obesity or smoking, affects the risk of main forms of pregnancy-induced hypertension. A cohort of 912 pregnant women, recruited in the first trimester, was assessed; 113 (12.4%) women developed gestational hypertension (GH), 24 (2.6%) developed preeclampsia (PE) and 775 women remained normotensive (a control group). Multiple logistic regression was used to calculate adjusted odds ratios (AOR) (and 95% confidence intervals) of GH and PE for chronic hypertension in the father or mother of pregnant women. Some differences were discovered. (1) Paternal hypertension (vs. absence of hypertension in the family) was an independent risk factor for GH (AOR-a = 1.98 (1.2–3.28), p = 0.008). This odds ratio increased in pregnant women who smoked in the first trimester (AOR-a = 4.71 (1.01–21.96); p = 0.048) or smoked before pregnancy (AOR-a = 3.15 (1.16–8.54); p = 0.024), or had pre-pregnancy overweight (AOR-a = 2.67 (1.02–7.02); p = 0.046). (2) Maternal hypertension (vs. absence of hypertension in the family) was an independent risk factor for preeclampsia (PE) (AOR-a = 3.26 (1.3–8.16); p = 0.012). This odds ratio increased in the obese women (AOR-a = 6.51 (1.05–40.25); p = 0.044) and (paradoxically) in women who had never smoked (AOR-a = 5.31 (1.91–14.8); p = 0.001). Conclusions: Chronic hypertension in the father or mother affected the risk of preeclampsia and gestational hypertension in different ways. Modifiable factors (overweight/obesity and smoking) may exacerbate the relationships in question, however, paradoxically, beneficial effects of smoking for preeclampsia risk are also possible. Importantly, paternal and maternal hypertension were not independent risk factors for GH/PE in a subgroup of women with normal body mass index (BMI).

Incidence and Risk Factors of Hypertensive Disorders of Pregnancy - 8 Provinces, China, 2014-2018

What is already known about this topic?

As a major cause of maternal and neonatal mortality and morbidity, hypertensive disorders of pregnancy (HDP) are a global public health problem affecting maternal and children's health. What is added by this report?

The incidence of HDP was 6.40% among 277,632 pregnant women. With the progress of pregnancy, the proportion of pregnant women with high normal blood pressure (BP) and the incidence of HDP increased gradually. The incidence of HDP increased with pregnancy age, body mass index, and BP of pregnant women during first trimester.

What are the implications for public health practice?

To reduce the incidence of HDP effectively, we should pay more attention to older women who plan to become pregnant, measures should be taken to control BP and weight in pre-pregnancy.

Variations in Awareness of Association Between Adverse Pregnancy Outcomes and Cardiovascular Risk by Specialty

Introduction

Cardiovascular disease (CVD) remains the leading cause of death among women. Adverse pregnancy outcomes (APOs), including pre-eclampsia (PE), gestational diabetes mellitus (GDM) and pre-term birth (PTB) are associated with future maternal CVD risk. However, data on awareness of the association between APOs and long-term CVD risk among physicians in different specialties are lacking. This study assessed awareness of this association and whether this knowledge varies by specialty.

Methods

An anonymous web-based voluntary survey was sent to physicians in internal medicine (IM), family medicine (FM), obstetrics-gynecology (Ob-Gyn) and cardiology. The questions aimed to assess a physician’s knowledge regarding identification of APOs and their association with future CVD risk and knowledge of CVD risk factor screening in women with APOs and future CVD risk.

Results

The survey was completed by 53 physicians, of whom 21% were in IM, 26% in FM, 23% in Ob-Gyn and 30% in cardiology. Based on the responses, cardiologists screened most frequently for APOs, with 56% always screening a female patient and 31% often screening. Only half of the IM and FM physicians acknowledged awareness of the association between APOs and CVD risk. Respondents in all specialties recognized PE and GDM as APOs linked to long-term maternal CVD risk, but failed to associate PTB as an APO. The majority of physicians in IM, FM and cardiology also lacked the knowledge of how often to appropriately screen for CVD risk factors associated with APOs.

Conclusion

Awareness of the association between APO and future maternal CVD risk varies by specialty. A significant percentage of the physicians who responded to the survey did not routinely ask about APOs when assessing CVD risk and failed to identify PTB as a risk factor for APOs. Education on this topic and targeted efforts to improve screening for APOs are needed within all specialties to help reduce CVD morbidity and mortality.

Attenuation of baroreflex sensitivity and heart rate variability is linked to reduced levels of nitric oxide in pregnant women having risks of developing gestational hypertension

Purpose: Decreased baroreflex sensitivity (BRS) and sympathovagal imbalance (SVI) have been reported as a cardiovascular (CV) risk in gestational hypertension (GH). Nitric oxide (NO) has been implicated in pathophysiology of GH. In the present study, we assessed the link of CV risks (decreased BRS and SVI) to the plasma levels of NO in women having risk of developing GH. Materials and Methods: A total of 96 pregnant women having risk factors for GH were recruited for the study. The blood pressure variability (BPV), heart rate variability (HRV), plasma NO, marker of insulin resistance (HOMA-IR), lipid risk factors, inflammatory markers (hsCRP, interleukin-6), and malondialdehyde (MDA), the marker of oxidative stress (OS) were measured at 16th and 36th week. Link of various parameters to NO was assessed by correlation and multiple regression analysis. Results: Of HRV indices, parasympathetic components were decreased and sympathetic components were increased, BRS was decreased, NO was decreased, HOMA-IR, lipid risk factors, hsCRP, interleukin-6, and MDA were increased significantly at 36th week compared to 16th week of pregnancy. Most of the markers of cardiometabolic risk were correlated with NO. However, only the markers of CV risk (SVI and reduced BRS) were independently associated with decreased level of NO, but not the metabolic markers except interleukin-6. The independent contribution of BRS (β = 0.334, P < .001) to NO was found to be most significant. Conclusion: It was concluded that decreased BRS, SVI, and increased interleukin-6 are associated with reduction in NO in GH, which may possibly be linked to the development of CV risks in GH.

Identification of mRNA-, circRNA- and lncRNA- Associated ceRNA Networks and Potential Biomarkers for Preeclampsia From Umbilical Vein Endothelial Cells

Objective

The etiology and pathogenesis of preeclampsia (PE) remain unclear, and ideal biomarkers for the early detection of PE are scarce. The involvement of the competing endogenous RNA (ceRNA) hypothesis in PE is only partially understood. The present study aimed to delineate a regulatory network in PE comprised of messenger RNAs (mRNAs), circular RNAs (circRNAs), long non-coding RNAs (lncRNAs), and microRNAs (miRNAs) via ceRNA profiles from human umbilical vein endothelial cells (HUVECs) to further reveal the pathogenesis of PE and potential biomarkers.

Methods

Differentially expressed mRNAs, circRNAs, and lncRNAs were detected in HUVECs from early onset preeclampsia (EOPE) cases (n = 4) and normal pregnancies (n = 4) by microarray analysis. Bioinformatics analysis was performed to systematically analyze the data, and a relevant ceRNA network was constructed. RNAs (ANGPT2, LIPG, hsa_circ_0025992, hsa_circ_0090396, hsa_circ_0066955, hsa_circ_0041203, hsa_circ_0018116, lnc-C17orf64-1:1, lnc-SLC27A2-2:1, and lnc-UEVLD-5:1) were validated by quantitative real-time PCR (qRT-PCR) in 10 pairs of HUVECs and placental tissues from PE patients and normal pregnancies. Furthermore, expression of hsa_circ_0025992 was detected in maternal peripheral blood samples from PE patients (n = 24) and normal pregnancies (n = 30) to confirm its potential as a novel biomarker. The receiver operating characteristic (ROC) curve was applied to analyze its diagnostic value.

Results

Compared with HUVECs from normal pregnancies, HUVECs from EOPE cases had 33 differentially expressed mRNAs (DEmRNAs), 272 DEcircRNAs, and 207 DElncRNAs. GO and KEGG analyses of the DERNAs revealed the biological processes and pathways involved in PE. Based on the microarray data and the predicted miRNAs, a ceRNA network was constructed with four mRNAs, 34 circRNAs, nine lncRNAs, and 99 miRNAs. GO and KEGG analyses of the network reinforced the crucial roles of metabolic disorders, the p53 and JAK/STAT signaling pathways in PE. In addition, ROC analysis indicated that hsa_circ_0025992 could be used as a novel biomarker for PE.

Conclusion

A novel ceRNA network was revealed in PE, and the potential of hsa_circ_0025992 to serve as a new biomarker was confirmed.

Variation in the Content of Postpartum Visits by Maternal Race/Ethnicity, Preconception, and Pregnancy-Related Cardiovascular Disease Risk, PRAMS, 2016-2017

OBJECTIVES

Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content.

METHODS

We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status.

RESULTS

Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0).

CONCLUSIONS

Health systems should consider novel strategies to improve and standardize the content of postpartum visits.

Maternal exposure to air pollutants, PCSK9 levels, fetal growth and gestational age - An Italian cohort

OBJECTIVE

Exposure to airborne pollutants during pregnancy appears to be associated with uterine growth restriction and adverse neonatal outcome. Proprotein convertase subtilisin/kexin type (PCSK9), the key modulator of low-density lipoprotein (LDL) metabolism, increases following particulate matter (PM₁₀) exposure. Because maternal cholesterol is required for fetal growth, PCSK9 levels could be used to evaluate the potential impact of airborne pollutants on fetal growth.

DESIGN

A cohort of 134 healthy women during early pregnancy (11-12 weeks of gestational age) was studied.

RESULTS

A significant association between circulating PCSK9 levels and three tested air pollutants (PM₁₀, PM_2.5, nitric oxide (NO₂)) was found. Of importance, gestational age at birth was reduced by approximately 1 week for each 100 ng/mL rise in circulating PCSK9 levels, an effect that became more significant at the highest quartile of PM_2.5 (with a 1.8 week advance in delivery date for every 100 ng/mL rise in circulating PCSK9; p for interaction = 0.026). This finding was supported by an elevation of the odds ratio for urgent cesarean delivery for each 100 ng/mL rise in PCSK9 (2.99, 95% CI, 1.22-6.57), similar trends being obtained for PM₁₀ and NO₂.

CONCLUSIONS

The association between exposure to air pollutants during pregnancy and elevation in PCSK9 advances our understanding of the unforeseen influences of environmental exposure in terms of pregnancy associated disorders.

Fetal High-Density Lipoproteins: Current Knowledge on Particle Metabolism, Composition and Function in Health and Disease

Cholesterol and other lipids carried by lipoproteins play an indispensable role in fetal development. Recent evidence suggests that maternally derived high-density lipoprotein (HDL) differs from fetal HDL with respect to its proteome, size, and function. Compared to the HDL of adults, fetal HDL is the major carrier of cholesterol and has a unique composition that implies other physiological functions. Fetal HDL is enriched in apolipoprotein E, which binds with high affinity to the low-density lipoprotein receptor. Thus, it appears that a primary function of fetal HDL is the transport of cholesterol to tissues as is accomplished by low-density lipoproteins in adults. The fetal HDL-associated bioactive sphingolipid sphingosine-1-phosphate shows strong vasoprotective effects at the fetoplacental vasculature. Moreover, lipoprotein-associated phospholipase A2 carried by fetal-HDL exerts anti-oxidative and athero-protective functions on the fetoplacental endothelium. Notably, the mass and activity of HDL-associated paraoxonase 1 are about 5-fold lower in the fetus, accompanied by an attenuation of anti-oxidative activity of fetal HDL. Cholesteryl ester transfer protein activity is reduced in fetal circulation despite similar amounts of the enzyme in maternal and fetal serum. This review summarizes the current knowledge on fetal HDL as a potential vasoprotective lipoprotein during fetal development. We also provide an overview of whether and how the protective functionalities of HDL are impaired in pregnancy-related syndromes such as pre-eclampsia or gestational diabetes mellitus.

Genetic association of ERAP1 and ERAP2 with eclampsia and preeclampsia in northeastern Brazilian women

The clinical spectrum of hypertensive disorders of pregnancy (HDP) is determined by the interplay between environmental and genetic factors, most of which remains unknown. ERAP1, ERAP2 and LNPEP genes code for multifunctional aminopeptidases involved with antigen processing and degradation of small peptides such as angiotensin II (Ang II), vasopressin and oxytocin. We aimed to test for associations between genetic variants in aminopeptidases and HDP. A total of 1282 pregnant women (normotensive controls, n = 693; preeclampsia, n = 342; chronic hypertension with superimposed preeclampsia, n = 61; eclampsia, n = 74; and HELLP syndrome, n = 112) were genotyped for variants in LNPEP (rs27300, rs38034, rs2303138), ERAP1 (rs27044, rs30187) and ERAP2 (rs2549796 rs2927609 rs11135484). We also evaluated the effect of ERAP1 rs30187 on plasma Ang II levels in an additional cohort of 65 pregnant women. The genotype C/C, in ERAP1 rs30187 variant (c.1583 T > C, p.Lys528Arg), was associated with increased risk of eclampsia (OR = 1.85, p = 0.019) whereas ERAP2 haplotype rs2549796(C)–rs2927609(C)–rs11135484(G) was associated with preeclampsia (OR = 1.96, corrected p-value = 0.01). Ang II plasma levels did not differ across rs30187 genotypic groups (p = 0.895). In conclusion, ERAP1 gene is associated with eclampsia whereas ERAP2 is associated with preeclampsia, although the mechanism by which genetic variants in ERAPs influence the risk of preeclampsia and eclampsia remain to be elucidated.

Current Updates on Pre-eclampsia: Maternal and Foetal Cardiovascular Diseases Predilection, Science or Myth? : Future cardiovascular disease risks in mother and child following pre-eclampsia

PURPOSE OF REVIEW

Cardiovascular diseases (CVD), including pre-eclampsia (PE), remain the major cause of death and morbidity in women. This review elucidates the current knowledge, state of research and scientific information available on the post-event implications and complications of PE regarding maternal and foetal cardiovascular health. Does PE expose, predispose or aggravate a predilection to maternal and foetal CVD later in life?

RECENT FINDINGS

Women with a history of PE are reported to have stiffer arteries and are more likely to develop cardiovascular problems with time, especially aortic stenosis and mitral regurgitation, which were not hitherto linked with hypertensive pregnancy. Foetal cells persistence in the mother long after pregnancy, now clearly established in the lungs of mice postpartum, is suggested to portend an overexpression of STOX1, which may potentiate later life CVD. Moreover, the conventional theories of in utero stress and developmental reprogramming may not adequately explain the risk of later life CVD predilection in offspring born to mothers with pre-eclampsia as recent data has shown that siblings of offspring born from pre-eclamptic pregnancies are also at higher risk of hypertension later in life, irrespective of whether subsequent pregnancies were pre-eclamptic or normotensive. The mechanism involved in adverse cardiovascular outcome in offspring of pre-eclamptic pregnancies is most likely an intricate interaction of foetal programming, environmental and genetic factors. In light of available evidence, the question of whether PE is just a pointer or predisposing factor to maternal development of CVDs in later life begs for answers to facilitate definitive clinical solutions and preventive approaches.

Risk of type 2 diabetes mellitus in women with prior hypertensive disorders of pregnancy: a systematic review and meta-analysis

AIMS/HYPOTHESIS

The association between a history of hypertensive disorders of pregnancy (HDP) and subsequent type 2 diabetes (referred to throughout as diabetes) remains inconclusive. We reviewed the most recent evidence to quantify the association of previous HDP with incident diabetes.

METHODS

A systematic search of MEDLINE, Embase and CINAHL was performed up to 17 February 2020 to identify observational studies of the association between HDP (pre-eclampsia or gestational hypertension) and incident diabetes. Studies of women with pre-pregnancy diabetes were excluded. Two independent reviewers screened citations and abstracted results. Study quality was assessed in duplicate using the Newcastle-Ottawa Scale. Random-effects models were used to pool effect estimates. Heterogeneity was assessed using the I² statistic.

RESULTS

After screening 4617 citations, 16 cohort studies with a total of 3,095,457 participants were included (unspecified HDP n = 5, pre-eclampsia only n = 4, gestational hypertension and pre-eclampsia n = 7). Risks of subsequent diabetes were significantly higher in women with a history of any HDP (HDP: adjusted hazard ratio [aHR] 2.24, 95% CI 1.95, 2.58; gestational hypertension: aHR 2.19 [95% CI 1.69, 2.84]; pre-eclampsia: aHR 2.56 [95% CI 2.02, 3.24]; preterm pre-eclampsia: aHR 3.05 [95% CI 2.05, 4.56]). The association between HDP and diabetes persisted in studies that adjusted for gestational diabetes mellitus (aHR 2.01 [95% CI 1.77, 2.28]).

CONCLUSIONS/INTERPRETATION

HDP are independently associated with a higher risk of diabetes. Further study is needed to determine how HDP contribute to diabetes risk prediction to develop evidence-based screening and prevention strategies. Graphical abstract.

Materno-fetal cholesterol transport during pregnancy

Cholesterol is a major nutrient required for fetal growth. It is also a precursor for the synthesis of steroid hormones and essential for the development and maturation of fetal organs. During pregnancy, the placenta controls the transport of cholesterol from the mother to the fetus and vice versa. Cholesterol originating from the maternal circulation has to cross two main membrane barriers to reach the fetal circulation: Firstly, cholesterol is acquired by the apical side of the syncytiotrophoblast (STB) from the maternal circulation as high-density lipoprotein (HDL)-, low-density lipoprotein (LDL)- or very-low-density lipoprotein (VLDL)-cholesterol and secreted at the basal side facing the villous stroma. Secondly, from the villous stroma cholesterol is taken up by the endothelium of the fetal vasculature and transported to the fetal vessels. The proteins involved in the uptake of HDL-, LDL-, VLDL- or unesterified-cholesterol are scavenger receptor type B class 1 (SR-B1), cubulin, megalin, LDL receptor (LDLR) or Niemann-Pick-C1 (NPC1) which are localized at the apical and/or basal side of the STB or at the fetal endothelium. Through interaction with apolipoproteins (e.g. apoA1) cholesterol is effluxed either to the maternal or fetal circulation via the ATP-binding-cassette (ABC)-transporter A1 and ABCG1 localized at the apical/basal side of the STB or the endothelium. In this mini-review, we summarize the transport mechanisms of cholesterol across the human placenta, the expression and localization of proteins involved in the uptake and efflux of cholesterol, and the expression pattern of cholesterol transport proteins in pregnancy pathologies such as pre-eclampsia, gestational diabetes mellitus and intrauterine growth retardation.

Association Between Recommended Preconception Health Behaviors and Screenings and Improvements in Cardiometabolic Outcomes of Pregnancy

INTRODUCTION

Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are associated with increased risk of maternal and infant illness and long-term elevated cardiometabolic risk. Little information exists on the prevention of either disorder before pregnancy. Our goal was to describe the association between preconception indicators and risk of gestational diabetes and hypertensive disorders of pregnancy.

METHODS

We used logistic regression to analyze cross-sectional data from the 2016-2017 Pregnancy Risk Assessment Monitoring System (N = 68,493) to quantify the association between 14 preconception health indicators (across domains of health care, nutrition and physical activity, tobacco and alcohol, chronic conditions, mental health, and emotional and social support) and, separately, GDM and HDP. We accounted for sampling weights and controlled for maternal age, race/ethnicity, prepregnancy insurance, prepregnancy body mass index, and report of a check-up in the year before pregnancy.

RESULTS

Prepregnancy obesity was the strongest predictor of both HDP (adjusted odds ratio [aOR], 3.1; 95% CI, 2.8-3.5) and GDM (aOR, 3.1; 95% CI, 2.7-3.5). Individual behaviors (eg, exercise, attending a check-up) were not associated with either HDP or GDM. A diagnosis of diabetes before pregnancy predicted HDP (aOR, 2.3; 95% CI, 1.7-3.0).

CONCLUSION

Prepregnancy chronic disease and obesity predicted pregnancy complications (ie, GDM and HDP). Given the challenges in reversing these conditions in the year before pregnancy, efforts to improve preconception health may be best directed broadly to expand access to primary care for all women.

Role of oxidative stress in the dysfunction of the placental endothelial nitric oxide synthase in preeclampsia

Preeclampsia (PE) is a multifactorial pregnancy disease, characterized by new-onset gestational hypertension with (or without) proteinuria or end-organ failure, exclusively observed in humans. It is a leading cause of maternal morbidity affecting 3–7% of pregnant women worldwide. PE pathophysiology could result from abnormal placentation due to a defective trophoblastic invasion and an impaired remodeling of uterine spiral arteries, leading to a poor adaptation of utero-placental circulation. This would be associated with hypoxia/reoxygenation phenomena, oxygen gradient fluctuations, altered antioxidant capacity, oxidative stress, and reduced nitric oxide (NO) bioavailability. This results in part from the reaction of NO with the radical anion superoxide (O₂^•−), which produces peroxynitrite ONOO^-, a powerful pro-oxidant and inflammatory agent. Another mechanism is the progressive inhibition of the placental endothelial nitric oxide synthase (eNOS) by oxidative stress, which results in eNOS uncoupling via several events such as a depletion of the eNOS substrate L-arginine due to increased arginase activity, an oxidation of the eNOS cofactor tetrahydrobiopterin (BH4), or eNOS post-translational modifications (for instance by S-glutathionylation). The uncoupling of eNOS triggers a switch of its activity from a NO-producing enzyme to a NADPH oxidase-like system generating O₂^•−, thereby potentiating ROS production and oxidative stress. Moreover, in PE placentas, eNOS could be post-translationally modified by lipid peroxidation-derived aldehydes such as 4-oxononenal (ONE) a highly bioreactive agent, able to inhibit eNOS activity and NO production. This review summarizes the dysfunction of placental eNOS evoked by oxidative stress and lipid peroxidation products, and the potential consequences on PE pathogenesis.

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Physiological ROS production is enhanced during pregnancy.

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eNOS is one of the main target of oxidative stress in PE placenta.

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eNOS is S-glutathionylated in PE placentas.

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eNOS is modified by lipid oxidation products in PE placentas.

Maternal serum Apelin 13 and APLN gene promoter variant -1860T > C in preeclampsia

OBJECTIVE

To evaluate the apelin (APLN) -1860 T > C (rs56204867) polymorphism and maternal serum apelin 13 levels in preeclampsia and its association with blood pressure.

METHODS

This case-control study was conducted in department of Biochemistry, Sri Devaraj Urs Medical College, Karnataka, India. A total of 181 subjects were enrolled in the study from department of Department of Obstetrics and Gynecology. The recruited women were grouped as: Group-I (n = 91) cases with preeclampsia and Group-II (n = 90) normotensive healthy pregnant women as controls. Under aseptic conditions, the collected 5 mL blood was distributed for serum separation (3 mL) and genetic analysis (2 mL). Serum was stored at -80 °C after centrifugation at 3000 rpm for 10 min. The collected five mL urine sample was used for urinary protein analysis by dipstick method. The APLN gene -1860 T > C polymorphism and Apelin 13 levels were analyzed by molecular methods and ELISA technique respectively. Birth weight and demographic details were recorded.

RESULTS

In the present study, no significant difference was observed for mean gestational age and maternal age. Systolic (158.7 ± 14.0 mmHg) and diastolic (104.9 ± 10.7 mmHg) blood pressure, and mean arterial pressure (MAP) (123.0 ± 11.1 mmHg) (p-value .001) were significantly increased in preeclamptic women compared with healthy pregnant women. Birth weight (2.4 ± 0.5 kg) (p-value .001) was significantly decreased in babies born to preeclamptic mothers. Birth weights were also expressed in centiles, according to Fenton Chart. Number of small for gestational age (SGA) babies were more in preeclampsia (n = 55) than healthy pregnant women (n = 28). Mean maternal serum apelin 13 (239.4 ± 126.3 pg/mL) (p-value .001) concentrations were significantly lower in preeclampsia compared with healthy controls. Maternal serum apelin 13 concentration in preeclampsia was negatively correlated with systolic blood pressure (r = -0.235), diastolic blood pressure (r= -0.172) and mean arterial pressure (r = -0. 206). However, maternal serum apelin 13 levels showed insignificant positive correlation with age, gestational age and birth weight. The genotype and allele frequencies of APLN gene were found significant between study groups as in preeclampsia (χ² = 11.69; df = 2; p = .0028 and χ2 = 14.27; df = 1; p = .00013 respectively). CC genotype and C allele of APLN - 1860 T > C site was high in preeclampsia.

CONCLUSION

Study concludes that preeclamptic women have low level of serum apelin 13 and -1860 T > C polymorphism at APLN gene promoter site with increased allelic frequency of CC genotype and C allele compared to normotensive pregnant women. And this evidence may link to cardiac complications in preeclamptic women after delivery in later stage.

A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum

The rates of maternal overweight and obesity, but also excess gestational weight gain, are increasing. Pregnancy complications, including gestational diabetes mellitus, gestational hypertension, pre-eclampsia and delivery of a preterm or growth restricted baby, are higher for both women with overweight and obesity and women who gain excess weight during their pregnancy. Other conditions such as polycystic ovary syndrome are also strongly linked to overweight and obesity and worsened pregnancy complications. All of these conditions place women at increased risk for future cardiometabolic diseases. If overweight and obesity, but also excess gestational weight gain, can be reduced in women of reproductive age, then multiple comorbidities associated with pregnancy complications may also be reduced in the years after childbirth. This narrative review highlights the association between maternal overweight and obesity and gestational weight gain, with gestational diabetes, pre-eclampsia, polycystic ovary syndrome and delivery of a preterm or growth restricted baby. This review also addresses how these adverse conditions are linked to cardiometabolic diseases after birth. We report that while the independent associations between obesity and gestational weight gain are evident across many of the adverse conditions assessed, whether body mass index or gestational weight gain is a stronger driving factor for many of these is currently unclear. Mechanisms linking gestational diabetes mellitus, gestational hypertension, pre-eclampsia, preterm delivery and polycystic ovary syndrome to heightened risk for cardiometabolic diseases are multifactorial but relate to cardiovascular and inflammatory pathways that are also found in overweight and obesity. The need for post-partum cardiovascular risk assessment and follow-up care remains overlooked. Such early detection and intervention for women with pregnancy-related complications will significantly attenuate risk for cardiovascular disease.

Residential radon exposure and hypertensive disorders of pregnancy in Massachusetts, USA: A cohort study

BACKGROUND

Exposure to ionizing radiation has been associated with hypertension, but the relationship between residential radon exposure and hypertensive disorders of pregnancy (HDP) has not been examined.

METHODS

We used the Massachusetts Birth Registry of Vital Records from 2001 to 2015 including women with a singleton pregnancy without prior hypertension. The binary outcome (HDP) included gestational hypertension and pre-eclampsia cases and was assessed using birth certificate data. We obtained 141,665 basement radon measurements from Spruce Environmental Technologies, Inc. and modeled the monthly zip code basement radon level. We used a logistic regression model adjusted for sociodemographic covariates, maternal comorbidities, PM_2.5, season, temperature, and relative humidity. We examined effect modification by maternal age, race, and maternal education as an indicator of socio-economic status.

RESULTS

Of 975,528 women, 3.7% (36,530) of them developed HDP. Zip code level radon ranged from 22 to 333 mBq/m³. An interquartile range (IQR) increase in zip code radon level throughout pregnancy was associated with a 15% increase in the odds of HDP (95% CI 13% to 18%). In women less than 20 years old, an IQR increase in zip code level radon was associated with 38% increase in the odds of HDP (95% CI 24% to 50%), while the effect was smaller in older women. There was no effect modification by maternal race or education.

CONCLUSIONS

In this cohort, higher levels of residential radon are associated with increased odds of HDP. After stratifying by age, this effect was stronger in participants younger than 20 years old. Since the burden of hypertensive disorders of pregnancy is increasing and affects women's future cardiovascular health, identification of modifiable risk factors is of great importance.

Strategies and Challenges in Recruiting Pregnant Women with Elevated Body Mass Index for a Behavioral Lifestyle Intervention

Purpose: Pregnant women with elevated body mass index (BMI) are difficult to recruit into lifestyle studies. This article (1) summarized strategies to recruit pregnant women into a randomized trial, and (2) reported recruitment statistics and their correlates.

Materials and Methods: African American and white women with BMI ≥25 and gestational age <16 weeks were recruited primarily through obstetric clinics into the Health in Pregnancy and Postpartum study. Women completed a brief screening form, and if initially eligible, a phone screening. We compared characteristics of those randomized versus not randomized.

Results: Initially eligible pregnant women (N = 1578) were identified through direct recruitment by research staff, indirect recruitment by clinic staff at obstetric clinics, and self-referrals through advertisements. Of these women, 54.0% (850) were reached for further screening, and 43.5% (685) were fully eligible. Among eligible women, 58.8% (403) were scheduled for a baseline visit, and 33.3% (228) were randomized. The overall recruitment yield was 14.4%. Recruited participants were diverse (44% African Americans) and averaged 12.6 weeks gestation at baseline. Randomized (vs. nonrandomized) women were more likely to own a cell phone, have access to a computer with internet at home or work, and have downloaded a podcast.

Conclusions: Although this study did not reach the recruitment goal, a relatively large and diverse sample of pregnant women were recruited early in pregnancy. Recruiting women with elevated BMI for a behavioral lifestyle intervention is challenging, particularly among women with characteristics, including less phone and internet access and limited experience in using podcasts.

This study is registered at Clinicaltrials.gov: NCT02260518.

Trends in Selected Chronic Conditions and Related Risk Factors Among Women of Reproductive Age: Behavioral Risk Factor Surveillance System, 2011-2017

Introduction: Chronic diseases in the United States are the leading drivers of disability, death, and health care costs. In women of reproductive age (WRA), chronic disease and related risk factors can also affect fertility and reproductive health outcomes. This analysis of trends from 2011 to 2017 adds additional indicators and updates an analysis covering 2001-2009. Methods: Data from the 2011-2017 Behavioral Risk Factor Surveillance System were analyzed for 265,544 WRA (18-44 years). To assess trends in 12 chronic conditions and related risk factors, we calculated annual prevalence estimates and adjusted prevalence ratios (APRs) with predicted marginals accounting for age, race, Hispanic ethnicity, education, and health care coverage. Results: From 2011 to 2017, prevalence decreased for current smoking (20.7%-15.9%; p < 0.001), gestational diabetes (3.1%-2.7%; p = 0.003), and high cholesterol (19.0%-16.7%; p < 0.001); prevalence increased for depression (20.4%-24.9%; p < 0.001) and obesity (24.6%-27.6%; p < 0.001). After adjustment, in 2017 WRA were more likely to report asthma (APR = 1.06; 95% confidence interval [CI] = 1.01-1.11), physical inactivity (APR = 1.08; 95% CI = 1.04-1.12), obesity (APR = 1.15; 95% CI = 1.11-1.19), and depression (APR = 1.29; 95% CI = 1.25-1.34) compared with 2011. They were less likely to report high cholesterol (APR = 0.89; 95% CI = 0.85-0.94) in 2015 compared with 2011, and current smoking (APR = 0.86; 95% CI = 0.82-0.89) and gestational diabetes (APR = 0.84; 95% CI = 0.75-0.94) in 2017 compared with 2011. Conclusions: Some chronic conditions and related risk factors improved, whereas others worsened over time. Research clarifying reasons for these trends may support the development of targeted interventions to promote improvements, potentially preventing adverse reproductive outcomes and promoting long-term health.

Cancer and Cardiovascular Risk in Women With Hypertensive Disorders of Pregnancy Carrying a Common IGF1R Variant

OBJECTIVE

To evaluate the impact of insulin-like growth factor 1 receptor variant rs2016347 on the risk for breast and nonbreast cancers and cardiovascular disease in women with a history of hypertensive disorders of pregnancy (HDP).

PATIENTS AND METHODS

This retrospective cohort study included all parous women in the UK Biobank with prior rs2016347 genotyping (N=204,155), with enrollment taking place from March 2006 to July 2010. History of HDP was self-reported, and outcomes included breast and all nonbreast cancers, hospital diagnoses of hypertension and cardiovascular disease, and direct blood pressure measurements.

RESULTS

Women with previous HDP had a higher risk for future hypertension and cardiovascular diagnoses, increased blood pressures, and lower risk for breast cancer compared with women without HDP, consistent with prior studies. Hazard ratios for all nonbreast cancers were unchanged. However, when taking genotype into account, HDP-positive women carrying at least 1 thymine (T) allele of rs2016347 had a lower risk for nonbreast cancer (hazard ratio, 0.59; 95% CI, 0.37 to 0.92; P=.02) and lower systolic blood pressure (-2.08±0.98 mm Hg; P=.03) compared with women with the guanine/guanine (GG) genotype with positive evidence of interaction (HDP:T allele) for both outcomes; P=.04 and P=.03, respectively.

CONCLUSION

Women who experience HDP and carry a T allele of rs2016347 have 41% lower risk for developing nonbreast cancer and a lower systolic blood pressure of 2.08 mm Hg when compared with those with the GG genotype, suggesting a possible role of the insulin-like growth factor 1 axis for both cardiovascular and cancer risk in women with HDP.

Evaluating the maternal and perinatal sequelae of severe gestational hypertension

BACKGROUND

Hypertensive disorders of pregnancy are widespread and have long-standing implications for women's health. Historically, the management of "severe gestational hypertension," or the presence of severely elevated blood pressures without any other signs or symptoms of end-organ damage meeting the criteria for preeclampsia, has been unclear. The new American College of Obstetricians and Gynecologists guidelines based on expert opinion recommend that severe gestational hypertension be treated similarly to preeclampsia with severe features, but data regarding outcomes for women with this diagnosis have been limited.

OBJECTIVE

This study aimed to compare the maternal and perinatal sequelae of severe gestational hypertension with that of other types of hypertensive disorders of pregnancy.

STUDY DESIGN

This is a retrospective cohort study of women with hypertensive disease of pregnancy who delivered at a single tertiary care center between February and December 2018. Women with chronic hypertension; hemolysis, elevated liver enzymes, and low platelet count syndrome; preexisting kidney, liver, rheumatologic, or hematologic disorders; or multifetal pregnancies were excluded. Women were categorized as having severe gestational hypertension if they had a sustained systolic blood pressure of >160 mm Hg or a diastolic blood pressure of >110 mm Hg without other criteria for preeclampsia. The primary comparison was between women with severe gestational hypertension and women with preeclampsia without severe features. Secondary comparisons included women with severe gestational hypertension vs women with other types of hypertensive disease of pregnancy. The primary outcome for this analysis was small-for-gestational-age birth. We also evaluated other maternal and neonatal morbidities including but not limited to pulmonary embolism, stroke, eclampsia, blood transfusion, mechanical ventilation, intensive care unit admission, death, 5-minute Apgar score of ≤4, umbilical cord pH, neonatal intensive care unit admission of >2 days, respiratory distress syndrome, and neonatal death. Bivariate analyses using chi-square tests and logistic regressions adjusting for race, ethnicity, age, body mass index, parity, and insurance status were performed to compare frequencies of outcomes for each type of hypertensive disease of pregnancy with those of severe gestational hypertension.

RESULTS

Of 2076 women eligible for inclusion, 12.2% (n=254) had severe gestational hypertension and 379 (18.2%) had preeclampsia without severe features. Although there was no difference in the odds of small-for-gestational-age birth between women with severe gestational hypertension and women with preeclampsia without severe features (14.7% vs 9.8%; adjusted odds ratio, 0.72; 95% confidence interval, 0.44-1.21), the latter were significantly less likely to receive a prescription for antihypertensive medication at discharge (OR 0.11, 95% CI 0.06-0.22) or to be readmitted postpartum (OR 0.14, 95% CI 0.04-0.50).

CONCLUSION

There was no difference in the primary outcome, that is, rate of small-for-gestational-age birth, between women with severe gestational hypertension and women with preeclampsia without severe features. However, women with severe gestational hypertension had greater odds of other maternal and neonatal morbidities than women with preeclampsia without severe features or mild gestational hypertension. These findings support recent recommendations regarding the management of women with severe gestational hypertension.

Postpartum health risks among women with hypertensive disorders of pregnancy, California 2008-2012

OBJECTIVES

The aim of this study was to understand the associations between hypertensive disorders of pregnancy (HDP) and postpartum complications throughout the newly defined 12-week postpartum transition.

STUDY DESIGN

We conducted a retrospective cohort study of the associations of HDP (any/subtype) with postpartum complications among 2.5 million California births, 2008-2012. We identified complications from discharge diagnoses from maternal hospital encounters (emergency department visits and readmissions) in the 12 weeks after giving birth. We compared rates of complications, overall and by diagnostic category, between groups defined by HDP. In survival analyses, we calculated the adjusted hazard ratios of postpartum complications associated with HDP. We adjusted for maternal age, race/ethnicity, prepregnancy obesity, chronic diabetes, gestational diabetes, insurance, delivery mode, gestational age and birth outcome (term and size).

RESULTS

Among women with and without HDP, 12.8 and 7.7%, respectively, had a hospital encounter within 12 weeks of giving birth [adjusted hazard ratio 1.5, 95% confidence interval (95% CI): 1.5-1.5]. HDP was associated with increased risk across all major categories of complications: hypertension-related, adjusted hazard ratio 11.8 (95% CI: 11.2-12.3); childbirth-related, 1.4 (1.3-1.4); and other, 1.4 (1.4-1.4). Risk of any complication differed by hypertensive subtype: chronic hypertension with super-imposed preeclampsia, adjusted hazard ratio 1.8 (95% CI: 1.7-1.8); chronic hypertension, 1.6 (1.6-1.7); preeclampsia/eclampsia, 1.3 (1.3-1.4); and gestational hypertension, 1.2 (1.2-1.3). Over a quarter (28.9%) of maternal hospital encounters occurred more than 6 weeks after giving birth; this did not differ substantially by HDP status.

CONCLUSION

Women with HDP are at an increased risk for virtually all postpartum complications, including those not related to hypertension, and may benefit from enhanced and comprehensive postpartum care.