Preclinical atherosclerosis at the time of pre-eclamptic pregnancy and up to 10 years postpartum: systematic review and meta-analysis

Maternal and cardiovascular factors related to carotid intima-media thickness during pregnancy: A prospective cohort study

OBJECTIVE

Cardiovascular disease continues to be the most important cause of death among women worldwide. Carotid intima-media thickness (CIMT) is a well-known indicator of cardiovascular disease. The study aims to establish associations between CIMT measurements and cardiovascular disease risk factors in pregnancy.

METHODS

A prospective observational study including normotensive pregnant women. CIMT was measured by mode B-ultrasound in 51 women. Baseline characteristics, weight gain, SBP, DBP, uterine artery Doppler, HbA1c, lipid profile, perceived stress (PSS), anxiety symptoms (STAI) and the level of physical activity during pregnancy were recorded.

RESULTS

Normal reference values (mean ± sd) for CIMT (mm) were described for 20-22 weeks (0.513 ± 0.0067), 28-30 weeks (0.504 ± 0.077) and 33-36 weeks (0.499 ± 0.059). Maternal age was correlated to CIMT (Rho Spearman = 0.392, p = 0.016). However, other variables studied such as weight gain, SBP, DBP, uterine artery Doppler, HbA1c, lipid profile, perceived stress (PSS), and anxiety symptoms (STAI) showed no correlation with CIMT measurements. CIMT was similar in active vs non-active participants (0.540 ± 0.069 vs. 0.489 ± 0.054 mm, p = 0.053). CIMT measurements did not change with gestational age (p = 0.751).

CONCLUSIONS

Among normotensive pregnant individuals, CIMT is associated with maternal age but remains stable across gestational age and unaffected by various cardiovascular risk factors during pregnancy.

Preeclampsia as an independent predictor of atherosclerosis progression in women with type 1 diabetes: a 5-year prospective study

BACKGROUND

Preeclampsia (PE) and type 1 diabetes (T1D) are significant risk factors for cardiovascular disease (CVD), but their combined effect on atherosclerosis progression has not been fully explored. This study aimed to evaluate the impact of T1D and PE on the progression of atherosclerosis.

METHODS

Prospective cohort study of 112 women divided into four groups: T1D + /PE + (n = 28), T1D + /PE- (n = 28), T1D-/PE + (n = 28), and T1D-/PE- (n = 28). Participants underwent an initial assessment and a follow-up visit five years later, which included anthropometric evaluation, blood tests, and carotid ultrasound. Atherosclerosis progression was defined as an increase in carotid plaque number or the occurrence of a cardiovascular event (CVE) during follow-up (fatal or non-fatal ischemic heart disease, fatal or non-fatal stroke, and/or heart failure).

RESULTS

A total of 104 women (92.9%) completed the follow-up (54 with T1D, mean age at inclusion 45.2 ± 7.6 years, mean follow-up 5.3 ± 1.2 years). An increase in carotid plaques was identified in 34 women (32.7%), and 3 CVEs (2.9%) occurred. In women with T1D, a history of PE was associated with a twofold increase in atherosclerosis progression (57.7% vs 25.0%, p = 0.015). In multivariate models adjusted for age, T1D and cardiovascular risk factors, PE [OR 4.97 (1.61-15.29), p = 0.005] and PE + T1D [OR 7.69 (1.25-47.29), p = 0.028] were independently associated with atherosclerosis progression.

CONCLUSIONS

PE was a strong independent predictor of atherosclerosis progression over a 5-year follow-up period, with an additive effect in T1D. These findings highlight preeclampsia as a significant CVD risk enhancer in young women with T1D.

Excessive Hypercholesterolemia in Pregnancy Impairs Later-Life Maternal Vascular Function in Rats

BACKGROUND

Preeclampsia is a risk factor for the development of later-life cardiovascular disease. However, the underlying mechanisms are poorly understood. Excessive hypercholesteremia in pregnancy induces a preeclampsia-like phenotype, but whether this also impacts maternal vascular function later in life has not been fully characterized.

METHODS AND RESULTS

Sprague Dawley rats received a control diet (CD) or a high-cholesterol (HCD) diet from gestational day 6 to 20, after which maternal vascular function was assessed 3 months postpartum. Exposure to an HCD in pregnancy reduced later-life endothelium-dependent vasodilation in carotid arteries (-15.24±3.27%), which was mediated via prostaglandin H synthase 2. There were no differences in vasodilation between CD and HCD postpartum rats in the mesenteric arteries, coronary arteries, or aortas. Vasoconstriction to phenylephrine increased in carotid arteries (61.02±21.48%) and reduced in aortas (-23.24±6.19%) of the HCD postpartum group versus CD dams, without differences in mesenteric and coronary arteries. The increased vasoconstriction in carotid arteries was due to lower nitric oxide modulation of constriction. Moreover, carotid artery myogenic response was reduced (-37.68±10.07%) and stiffness was increased (19.67±6.21%) in the HCD postpartum rats compared with CD along with decreased elastin density (-20.85±4.52%). The impact of the HCD on vascular function did not occur in age-matched never-pregnant female rats.

CONCLUSIONS

Excessive hypercholesterolemia in pregnancy impairs later-life maternal vascular function in rats with varying impacts across different vascular beds. Understanding mechanisms for pregnancy-specific excessive hypercholesterolemia provides avenues for targeted intervention strategies to reduce the burden of cardiovascular disease in women who had a complicated pregnancy.

Excessive hypercholesterolaemia during pregnancy as a risk factor for endothelial dysfunction in pre-eclampsia

Pregnancy induces significant changes in the maternal cardiovascular system, and insufficient vascular endothelial adaptations to pregnancy contribute to the development of pregnancy complications such as pre-eclampsia. Pre-eclampsia is not only a major cause of maternal morbidity and mortality, but also a significant risk factor for the development of later-life cardiovascular disease. However, the specific mechanisms underlying the pathophysiology of pre-eclampsia, as well as the mechanisms for an increased susceptibility to cardiovascular disease later in life, are not fully characterized. In this review, we discuss the concept that excessive pregnancy-specific dyslipidaemia, particularly hypercholesterolaemia, is a significant risk factor for the development of pre-eclampsia. We further outline novel potential mechanisms (i.e. oxidized low-density lipoprotein receptor 1 and toll-like receptor 4) underlying endothelial dysfunction induced by excessively high cholesterol levels during pregnancy (in the context of pre-eclampsia), in addition to discussing the overall implications of having had a pregnancy complicated by pre-eclampsia on later-life maternal vascular health. Determining the mechanisms by which excessive, pregnancy-specific dyslipidaemia/hypercholesterolaemia impact maternal endothelial health in pregnancy, and later in life, will create a window of opportunity to diagnose and develop targeted therapy for a susceptible population of women, aiming to ultimately reduce the societal burden of cardiovascular disease.

Hypertensive Disorders of Pregnancy Increase the Risk for Myocardial Infarction: A Population-Based Study

BACKGROUND

Angiographic evidence of the anatomy of coronary arteries and the type of coronary artery lesions in women with a history of hypertensive disorders of pregnancy (HDP) are poorly documented.

OBJECTIVES

This study sought to determine the role of a history of HDP as a unique risk factor for early coronary artery disease (CAD) and type of acute coronary syndrome (ACS) (ie, atherosclerotic vs myocardial infarction with nonobstructive coronary arteries [MINOCA]) in women who underwent coronary angiography.

METHODS

This study used a population-based cohort of parous female patients with incident CAD who underwent coronary angiography and age-matched control subjects. The SYNTAX (Synergy between PCI [percutaneous coronary intervention] with TAXUS [Boston Scientific] and Cardiac Surgery) score was assessed to determine the complexity and degree of CAD; MINOCA was diagnosed in the presence of clinical acute myocardial infarction in the absence of obstructive coronary disease.

RESULTS

A total of 506 parous female Olmsted County, Minnesota (USA) residents had incident CAD and angiographic data from November 7, 2002 to December 31, 2016. Women with HDP were younger than normotensive women at the time of the event (median: 64.8 years vs 71.8 years; P = 0.030). There was a strong association between HDP and ACS (unadjusted P = 0.018). Women with HDP compared with women with normotensive pregnancies were more likely to have a higher SYNTAX score (OR: 2.28; 95% CI: 1.02-5.12; P = 0.046), and MINOCA (OR: 2.08; 95% CI: 1.02-4.25; P = 0.044).

CONCLUSIONS

A history of HDP is associated with CAD earlier in life and with a future risk for myocardial infarction with both obstructive and nonobstructive coronary arteries. This study underscores the need for timely detection and treatment of nonobstructive disease, in addition to traditional risk factors.

Pregnancy complications and long-term risk of cardiovascular events in women with structural heart disease

BACKGROUND

To determine the frequency of pregnancy complications and their association with the risk of cardiovascular outcomes in women with structural heart disease (SHD).

METHODS

This nationwide registry-based cohort study included women in Sweden with SHD (pulmonary arterial hypertension, congenital heart disease or acquired valvular heart disease) with singleton births registered in the national Medical Birth Register (MBR) between 1973 and 2014. Exposures were pregnancy complications; pre-eclampsia/gestational hypertension (PE/gHT), preterm birth and small for gestational age (SGA) collected from MBR. The outcomes were cardiovascular mortality and hospitalisations defined from the Cause of Death Register and the National Patient Register. Cox regression models were performed with time-dependent covariates, to determine the possible association of pregnancy complications for cardiovascular outcomes.

RESULTS

Among the total of 2 134 239 women included in the MBR, 2554 women with 5568 singleton births were affected by SHD. Women without SHD (N=2 131 685) were used as a reference group. PE/gHT affected 5.8% of pregnancies, preterm birth 9.7% and SGA 2.8%. Preterm birth (adjusted HR, aHR 1.91 (95% CI 1.38 to 2.64)) was associated with an increased risk of maternal all-cause mortality. PE/gHT (aHR 1.64 (95% CI 1.18 to 2.29)) and preterm birth (aHR 1.56 (95% CI 1.19 to 2.04)) were associated with an increased risk of hospitalisations for atherosclerotic CVD.

CONCLUSIONS

Pregnancy complications were frequent in women with SHD. With a median follow-up time of 22 years, preterm birth was associated with a higher risk of cardiovascular mortality, and PE/gHT and preterm birth were associated with cardiovascular morbidity. In women with SHD, pregnancy complications may provide additional information for the risk assessment of future cardiovascular outcomes.

Women With a History of Preeclampsia Exhibit Accelerated Aging and Unfavorable Profiles of Senescence Markers

BACKGROUND

Senescence, a mechanism of cellular aging, which is characterized by irreversible proliferation arrest and a proinflammatory secretory phenotype, has been documented in women with preeclampsia. As cellular senescence can persist and progress, we postulated that it is associated with accelerated aging phenotype and accumulation of comorbidities in women with a history of preeclampsia.

METHODS

We included a cohort of women with a history of preeclampsia (n=40) age- and parity-matched to a group of referent women with normotensive pregnancies (n=40). Women with prior major cardiovascular events, neurological, or autoimmune conditions were excluded. We collected urine and blood samples to study markers of aging, data on multimorbidity at the time of enrollment, and prospectively followed them for events over the course of 6 years, on average.

RESULTS

Women with a history of preeclampsia exhibited unfavorable aging profiles compared with referent women, including decreased urinary α-Klotho (P=0.018); increased leptin (P=0.016) and leptin/adiponectin ratio (P=0.027), and increased extracellular vesicles positive for tissue factor (P=0.025). Women with a history of preeclampsia likewise had a higher rate of comorbidities at the time of enrollment (P=0.003) and had a 4× higher risk of developing major cardiovascular events compared with referent women (P=0.003).

CONCLUSIONS

Our data suggest that a history of preeclampsia is associated with accelerated aging as indicated by senescence marker differences and the accumulation of multimorbidity later in life. Targeting cellular senescence may offer novel, mechanism-based approaches for the diagnosis and treatment of adverse health outcomes in women with a history of preeclampsia.

Addressing Social Determinants of Health in Maternal Cardiovascular Health

Cardiovascular diseases (CVDs) remain the number-one cause of maternal mortality, with over two-thirds of cases being preventable. Social determinants of health (SDoH) encompass the nonmedical social and environmental factors that an individual experiences that have a significant impact on their health. These stressors disproportionately affect socially disadvantaged and minority populations. Pregnancy is a physiologically stressful state that can unmask underlying CVD risk factors and lead to adverse pregnancy outcomes (APOs). Disparities in APOs are particularly pronounced among individuals of color and those from economically disadvantaged backgrounds. This variation underscores healthcare inequity and access, a failure of the healthcare system. Besides short-term negative effects, APOs also are associated strongly with long-term CVDs. APOs therefore must be identified as a cue for early intervention, for the prevention and management of CVD risk factors. This review explores the intricate relationship among maternal morbidity and mortality, SDoH, and cardiovascular health, and the implementation of health policy efforts to reduce the negative impact of SDoH in this patient population. The review emphasizes the importance of comprehensive strategies to improve maternal health outcomes.

Hypertensive disorders of pregnancy & vascular dysfunction

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and fetal morbidity and mortality. One of the more severe HDP diagnoses is preeclampsia, which is recognized as a sex-specific cardiovascular risk enhancer with long-term implications for women's health, increasing lifetime risk of ischemic heart disease, stroke, and heart failure. Though the mechanisms accounting for the increased risk of cardiovascular disease following HDP are not yet well understood, vascular dysfunction has been implicated. In this perspective piece, we summarize the existing evidence for vascular dysfunction in HDP with a focus on non-invasive assessments, highlight advances in the field, and suggest future directions for improving risk stratification of women with HDP.

Impact of body mass index on markers of vascular health in normotensive women with history of pre-eclampsia

OBJECTIVE

Obesity and pre-eclampsia (PE) are both associated with vascular dysfunction, which translates into an increased risk for cardiovascular disease in later life. The aim of this study was to investigate whether there is an interaction between body mass index (BMI) and a history of PE in their effects on vascular health.

METHODS

This was an observational case-control study of 30 women with a history of PE who were compared with 31 age- and BMI-matched controls who had an uncomplicated pregnancy. Flow-mediated dilation (FMD), carotid intima-media thickness (cIMT) and carotid distensibility (CD) were measured 6-12 months postpartum. To evaluate the impact of physical fitness, maximum oxygen uptake capacity was assessed using a standardized maximum exhaustion cycling test using breath-by-breath analysis. To specify further BMI subgroups, metabolic syndrome constituents were assessed in all individuals.

RESULTS

Formerly pre-eclamptic women had significantly lower FMD (5.1 ± 2.1% vs 9.4 ± 3.4%; P < 0.01), higher cIMT (0.59 ± 0.09 vs 0.49 ± 0.07 µm; P < 0.01) and lower CD (1.54 ± 0.37%/10 mmHg vs 1.80 ± 0.39%/10 mmHg; P < 0.01) compared with controls. In our study, population BMI correlated negatively with FMD (P = 0.04) but not with cIMT or CD. BMI and PE did not exhibit an interaction effect on these vascular parameters. Physical fitness was lower in women with a history of PE and in women with higher BMI. Constituents of the metabolic syndrome, including insulin, homeostasis model assessment for insulin resistance (HOMA-ir), triglyceride, microalbuminuria and systolic and diastolic blood pressure, were significantly higher in formerly pre-eclamptic women. BMI affected glucose metabolism but not lipids or blood pressure. BMI and PE positively interacted in their effect on insulin (P = 0.04) and HOMA-ir (P = 0.02).

CONCLUSIONS

Both BMI and a history of PE have negative effects on endothelial function, insulin resistance and physical fitness. In formerly pre-eclamptic women, the effect of BMI on insulin resistance was particularly high, suggesting a synergistic effect. Additionally, independently of BMI, a history of PE was associated with reduced FMD and CD and increased cIMT and blood pressure. Recognizing the cardiovascular risk profile is important for informing patients and encouraging targeted lifestyle modifications. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Risk and trajectory of premature ischaemic cardiovascular disease in women with a history of pre-eclampsia: a nationwide register-based study

AIMS

Pre-eclampsia increases women's lifetime risk of cardiovascular disease (CVD). Little is known about the trajectory of CVD after pre-eclampsia, limiting the usefulness of this knowledge for informing screening, prevention, and interventions. We investigated when the risk of CVD increases after pre-eclampsia and how the risk changes over time since pregnancy.

METHODS AND RESULTS

This register-based study included 1 157 666 women with >1 pregnancy between 1978 and 2017. Cumulative incidences of acute myocardial infarction (AMI) and ischaemic stroke were estimated, as well as hazard ratios (HRs) by attained age and time since delivery. Up to 2% [95% confidence interval (CI): 1.46-2.82%] of women with pre-eclampsia in their first pregnancy had an AMI or stroke within two decades of delivery, compared with up to 1.2% (95% CI: 1.08-1.30%) of pre-eclampsia-free women; differences in cumulative incidences were evident 7 years after delivery. Ten years after delivery, women with pre-eclampsia had four- and three-fold higher rates of AMI (HR = 4.16, 95% CI: 3.16-5.49) and stroke (HR = 2.59, 95% CI 2.04-3.28) than women without pre-eclampsia; rates remained doubled >20 years later. Women with pre-eclampsia aged 30-39 years had five-fold and three-fold higher rates of AMI (HR = 4.88, 95% CI 3.55-6.71) and stroke (HR = 2.56, 95% CI 1.95-3.36) than women of similar age without pre-eclampsia.

CONCLUSIONS

Women with a history of pre-eclampsia have high rates of AMI and stroke at early ages and within a decade after delivery. The findings suggest that pre-eclampsia history could be useful in identifying women at increased risk of CVD and that targeted interventions should be initiated soon after delivery.

A High Cholesterol Diet During Late Pregnancy Impairs Long-Term Maternal Vascular Function in Mice

BACKGROUND

Gestational dyslipidemia is associated with pregnancy complications including preeclampsia. However, whether gestational dyslipidemia leads postpartum vascular dysfunction, which could increase the risk for cardiovascular complications later in life, is not known. Here, we aimed to determine whether a gestational dyslipidemia affects postpartum vascular health and induces early signs of atherosclerosis.

METHODS

Pregnant C57BL/6 mice received a high cholesterol diet or control diet from gestational day 13.5 until term. After delivery, all mice received the control diet for ≈3 months postpartum (PP). Age-matched nulliparous females were on the same diets for equal periods. After 3 months, all mice were euthanized, serum was collected, and aortas were isolated to assess vascular function (wire myography) and markers of oxidative stress and early atherosclerosis.

RESULTS

PP-high cholesterol diet females had increased circulating cholesterol levels compared with PP-control diet mice, without effect of the diet in nulliparous mice. Methacholine-induced vasodilation was impaired, and nitric oxide contribution reduced, by the high cholesterol diet in aortas of PP mice, but not in nulliparous mice. Exposure to oxidized low-density-protein cholesterol further impaired methylcholine-induced vasodilation in PP-high cholesterol diet aortas only. Compared with PP-control diet mice, aortic inducible nitric oxide synthase expression, reactive oxygen species and nitrotyrosine levels were increased in aortas from PP-high cholesterol diet mice. No differences in aortic lipid deposition and macrophage infiltration were found.

CONCLUSIONS

Exposure to a high cholesterol diet in pregnancy impairs vascular function postpartum. Our results support the hypothesis that gestational dyslipidemia impacts maternal vascular function after pregnancy, which could potentially predispose these women to future cardiovascular complications.

Comparison of carotid intima media thickness between women with history of preeclampsia and normal pregnancy: a meta-analysis of systematic review

Background

On a clinical level, preeclampsia and atherosclerotic cardiovascular disease share common risk factors. Carotid intima media thickness (CIMT) is ultrasound-based imaging, non-invasive, simple, and reproducible method of subclinical atherosclerosis evaluation. Nowadays, there were studies concerning of CIMT among preeclamptic women, although the results were different.

Objective

To prove that CIMT among women with histories of preeclampsia was greater compared to normal pregnancy.

Methods

We conducted a meta-analysis of studies that reported CIMT, in women who had preeclampsia and had normal pregnancy. Studies were identified through three databases: PubMed, Google Scholar, and SAGE Journals with publication year of 2010–2020. Heterogeneity was assessed using the I2 statistic. Standardized mean difference was used as measured of effect size.

Results

Nine eligible studies were included in the meta-analysis. This meta-analysis consisted of 439 women with preeclampsia histories and 526 women with normal pregnancy histories. Women who had preeclampsia had significantly higher CIMT compared to those with normal pregnancy with standardized mean difference −0.38 and 95% confidence interval (CI) −0.68 to −0.07 (p=0.02).

Conclusion

CIMT was greater among women with histories of preeclampsia compared to normal pregnancy.

Trial registration

PROSPERO CRD42021228825

Resveratrol protects against atherosclerosis by downregulating the PI3K/AKT/mTOR signaling pathway in atherosclerosis model mice

Atherosclerosis is a cardiovascular disease, which is characterized by the interaction between carbohydrates, lipids, cells and various other molecules and genetic factors. Previous studies have demonstrated that resveratrol (RV) served protective roles in numerous types of human disease by regulating different signaling pathways. The aim of the present study was to investigate the therapeutic effects of RV and analyze the potential RV-mediated mechanism in umbilical vein endothelial cells (UVECS) in atherosclerosis model mice. Reverse transcription-quantitative PCR, western blotting and immunohistochemistry were used to analyze the therapeutic effects of RV both in vitro and in vivo. The results demonstrated that total cholesterol, triglycerides, low-density lipoprotein cholesterin and high-density lipoprotein cholesterin levels were significantly decreased in the RV group compared with the control group. RV demonstrated significant anti-atherosclerotic activity, which was determined through the atherogenic index, 3-hydroxy-3-methyl-glutaryl-Coa (HMG-CoA) reductase activity and marker enzymes, such as lactate dehydrogenase, creatine phosphokinase, aspartate transaminase, alanine transaminase and alkaline phosphatase. It was also observed that RV treatment significantly decreased the area of the arteriosclerotic lesion in the RV group compared with the control, as well as significantly decreasing the expression levels of matrix metalloproteinase-9 and CD40 ligand (CD40L) in arterial lesion tissue compared with the control group. Serum expression levels of tumor necrosis factor-α and C-reactive protein were also significantly decreased by RV treatment compared with the control group. Furthermore, RV treatment significantly decreased the expression levels of PI3K, AKT and mTOR in UVECS in vitro. In conclusion, these results suggested that the anti-atherosclerotic activity of RV may be due to its modulatory activity over the PI3K/AKT/mTOR signaling pathway. These findings suggested a potential novel treatment option for patients with atherosclerosis.

Acute Atherosis Lesions at the Fetal-Maternal Border: Current Knowledge and Implications for Maternal Cardiovascular Health

Decidua basalis, the endometrium of pregnancy, is an important interface between maternal and fetal tissues, made up of both maternal and fetal cells. Acute atherosis is a uteroplacental spiral artery lesion. These patchy arterial wall lesions containing foam cells are predominantly found in the decidua basalis, at the tips of the maternal arteries, where they feed into the placental intervillous space. Acute atherosis is prevalent in preeclampsia and other obstetric syndromes such as fetal growth restriction. Causal factors and effects of acute atherosis remain uncertain. This is in part because decidua basalis is challenging to sample systematically and in large amounts following delivery. We summarize our decidua basalis vacuum suction method, which facilitates tissue-based studies of acute atherosis. We also describe our evidence-based research definition of acute atherosis. Here, we comprehensively review the existing literature on acute atherosis, its underlying mechanisms and possible short- and long-term effects. We propose that multiple pathways leading to decidual vascular inflammation may promote acute atherosis formation, with or without poor spiral artery remodeling and/or preeclampsia. These include maternal alloreactivity, ischemia-reperfusion injury, preexisting systemic inflammation, and microbial infection. The concept of acute atherosis as an inflammatory lesion is not novel. The lesions themselves have an inflammatory phenotype and resemble other arterial lesions of more extensively studied etiology. We discuss findings of concurrently dysregulated proteins involved in immune regulation and cardiovascular function in women with acute atherosis. We also propose a novel hypothesis linking cellular fetal microchimerism, which is prevalent in women with preeclampsia, with acute atherosis in pregnancy and future cardiovascular and neurovascular disease. Finally, women with a history of preeclampsia have an increased risk of premature cardiovascular disease. We review whether presence of acute atherosis may identify women at especially high risk for premature cardiovascular disease.

Long-Term Consequences of Placental Vascular Pathology on the Maternal and Offspring Cardiovascular Systems

Over the last thirty years, evidence has been accumulating that Hypertensive Disorders of Pregnancy (HDP) and, specifically, Preeclampsia (PE) produce not only long-term effects on the pregnant woman, but have also lasting consequences for the fetus. At the core of these consequences is the phenomenon known as defective deep placentation, being present in virtually every major obstetrical syndrome. The profound placental vascular lesions characteristic of this pathology can induce long-term adverse consequences for the pregnant woman's entire arterial system. In addition, placental growth restriction and function can, in turn, cause a decreased blood supply to the fetus, with long-lasting effects. Women with a history of HDP have an increased risk of Cardiovascular Diseases (CVD) compared with women with normal pregnancies. Specifically, these subjects are at a future higher risk of: Hypertension; Coronary artery disease; Heart failure; Peripheral vascular disease; Cerebrovascular accidents (Stroke); CVD-related mortality. Vascular pathology in pregnancy and CVD may share a common etiology and may have common risk factors, which are unmasked by the "stress" of pregnancy. It is also possible that the future occurrence of a CVD may be the consequence of endothelial dysfunction generated by pregnancy-induced hypertension that persists after delivery. Although biochemical and biophysical markers of PE abound, information on markers for a comparative evaluation in the various groups is still lacking. Long-term consequences for the fetus are an integral part of the theory of a fetal origin of a number of adult diseases, known as the Barker hypothesis. Indeed, intrauterine malnutrition and fetal growth restriction represent significant risk factors for the development of chronic hypertension, diabetes, stroke and death from coronary artery disease in adults. Other factors will also influence the development later in life of hypertension, coronary and myocardial disease; they include parental genetic disposition, epigenetic modifications, endothelial dysfunction, concurrent intrauterine exposures, and the lifestyle of the affected individual.

Pre-eclampsia and long-term health outcomes for mother and infant: an umbrella review

BACKGROUND

Pre-eclampsia is a pregnancy-associated condition with complex disease mechanisms and a risk factor for various long-term health outcomes for the mother and infant.

OBJECTIVE

To summarise evidence on the association of pre-eclampsia with long-term health outcomes arising in women and/or infants.

SEARCH STRATEGY

PubMed, EMBASE, Scopus and ISI Web of Science were searched from inception to July 2020.

SELECTION CRITERIA

Systematic reviews and meta-analyses examining associations between pre-eclampsia and long-term health outcomes in women and their infants.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. We re-estimated the summary effect size by random-effects and fixed-effects models, the 95% confidence interval, the 95% prediction interval, the between-study heterogeneity, any evidence of small-study effects and excess significance bias.

RESULTS

Twenty-one articles were included (90 associations). Seventy-nine associations had nominally statistically significant findings (P < 0.05). Sixty-five associations had large or very large heterogeneity. Evidence for small-study effects and excess significance bias was found in seven and two associations, respectively. Nine associations: cerebrovascular disease (cohort studies), cerebrovascular disease (overall), cardiac disease (cohort studies), dyslipidaemia (all studies), risk of death (late-onset pre-eclampsia), fatal and non-fatal ischaemic heart disease, cardiovascular mortality (cohort studies), any diabetes or use of diabetic medication (unadjusted), and attention deficit/hyperactivity disorder (ADHD) (adjusted) were supported with robust evidence.

CONCLUSION

Many of the meta-analyses in this research field have caveats casting doubts on their validity. Current evidence suggests an increased risk for women to develop cardiovascular-related diseases, diabetes and dyslipidaemia after pre-eclampsia, while offspring exposed to pre-eclampsia are at higher risk for ADHD.

TWEETABLE ABSTRACT

Cardiovascular and cerebrovascular diseases were supported with convincing evidence for long-term health outcomes after pre-eclampsia.

Placental morphology and the prediction of underlying cardiovascular risk factors

OBJECTIVE

Pre-eclampsia is associated with an increased risk of future cardiovascular disease. Maladaptive placentation or malperfusion, as well as predisposing cardiovascular or metabolic risk for endothelial dysfunction, contribute to the systemic inflammatory response that establishes the origins of the disease. The purpose of this study was to investigate the relationship between placental size and cardiovascular risk when assessed at six months postpartum in women who experienced pre-eclampsia.

STUDY DESIGN

Maternal clinical and biochemical cardiovascular risk factors were used to categorize preeclamptic women into high vs. low lifetime cardiovascular disease risk profiles at six months postpartum. A multivariable logistic regression model was then used to identify the association between placental weight to birth weight ratio and high lifetime cardiovascular disease risk, adjusting for maternal age, pre-pregnancy BMI, and severity of pre-eclampsia. A p-value of < 0.05 was deemed statistically significant.

RESULTS

186/216 women with pre-eclampsia who attended the Maternal Health Clinic met inclusion criteria. No significant differences were observed for placental morphometric measurements between women who screened as having a high vs. low lifetime risk profile for cardiovascular disease at six months postpartum. However, using multivariable modelling that controlled for maternal age, pre-pregnancy body mass index, gestational age at delivery, and severity of pre-eclampsia, a low placenta to birth weight ratio (<15%) was associated with an increased odds of high lifetime cardiovascular disease risk (p < 0.009).

CONCLUSION

The findings of the current study identify clinical measurements that can be collected at the time of delivery which may help identify specific women who may benefit most from postpartum cardiovascular risk screening and intervention.

Cardiovascular events following pregnancy complicated by pre-eclampsia with emphasis on comparison between early- and late-onset forms: systematic review and meta-analysis

OBJECTIVE

To elucidate whether pre-eclampsia (PE) and the gestational age at onset of the disease (early- vs late-onset PE) have an impact on the risk of long-term maternal cardiovascular complications.

METHODS

MEDLINE, EMBASE and Scopus databases were searched until 15 April 2020 for studies evaluating the incidence of cardiovascular events in women with a history of PE, utilizing combinations of the relevant MeSH terms, keywords and word variants for 'pre-eclampsia', 'cardiovascular disease' and 'outcome'. Inclusion criteria were cohort or case-control design, inclusion of women with a diagnosis of PE at the time of the first pregnancy, and sufficient data to compare each outcome in women with a history of PE vs women with previous normal pregnancy and/or in women with a history of early- vs late-onset PE. The primary outcome was a composite score of maternal cardiovascular morbidity and mortality, including cardiovascular death, major cardiovascular and cerebrovascular events, hypertension, need for antihypertensive therapy, Type-2 diabetes mellitus, dyslipidemia and metabolic syndrome. Secondary outcomes were the individual components of the primary outcome analyzed separately. Data were combined using a random-effects generic inverse variance approach. MOOSE guidelines and the PRISMA statement were followed.

RESULTS

Seventy-three studies were included. Women with a history of PE, compared to those with previous normotensive pregnancy, had a higher risk of composite adverse cardiovascular outcome (odds ratio (OR), 2.05 (95% CI, 1.9-2.3)), cardiovascular death (OR, 2.18 (95% CI, 1.8-2.7)), major cardiovascular events (OR, 1.80 (95% CI, 1.6-2.0)), hypertension (OR, 3.93 (95% CI, 3.1-5.0)), need for antihypertensive medication (OR, 4.44 (95% CI, 2.4-8.2)), dyslipidemia (OR, 1.32 (95% CI, 1.3-1.4)), Type-2 diabetes (OR, 2.14 (95% CI, 1.5-3.0)), abnormal renal function (OR, 3.37 (95% CI, 2.3-5.0)) and metabolic syndrome (OR, 4.30 (95% CI, 2.6-7.1)). Importantly, the strength of the associations persisted when considering the interval (< 1, 1-10 or > 10 years) from PE to the occurrence of these outcomes. When stratifying the analysis according to gestational age at onset of PE, women with previous early-onset PE, compared to those with previous late-onset PE, were at higher risk of composite adverse cardiovascular outcome (OR, 1.75 (95% CI, 1.0-3.0)), major cardiovascular events (OR, 5.63 (95% CI, 1.5-21.4)), hypertension (OR, 1.48 (95% CI, 1.3-1.7)), dyslipidemia (OR, 1.51 (95% CI, 1.3-1.8)), abnormal renal function (OR, 1.52 (95% CI, 1.1-2.2)) and metabolic syndrome (OR, 1.66 (95% CI, 1.1-2.5).

CONCLUSIONS

Both early- and late-onset PE represent risk factors for maternal adverse cardiovascular events later in life. Early-onset PE is associated with a higher burden of cardiovascular morbidity and mortality compared to late-onset PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Role of arterial impairment in preeclampsia: should the paradigm shift?

Preeclampsia is a worldwide pregnancy complication with serious short- and long-term maternal and neonatal consequences. Our understanding of preeclampsia pathophysiology has significantly evolved over the last decades with the recognition that impaired arterial function and structure may occur early in the course of pregnancy, preceding the clinic-humoral syndrome and driving long-term cardiovascular disease risk in the future of these patients. Although an early abnormal placentation may be the inciting event for a large proportion of cases, there is growing evidence that challenges the placental hypothesis in all affected women, since placental histopathology lesions thought to be characteristic are neither sensitive nor specific markers for the disorder. Recent hemodynamic investigations and studies on left ventricular function and structure in women with preeclampsia further challenge this universal paradigm and propose that placental dysfunction could be secondary to a maternal cardiovascular maladaptation to pregnancy in certain patients. Supporting this hypothesis, certain vascular features, which are characteristically enhanced in normal pregnancy allowing a healthy vascular adaptation, are absent in preeclampsia and comparable to the nonpregnant population. However, arterial biomechanics in preeclampsia may only not cope with hemodynamic demands of pregnancy but also impose additional detrimental loads to the maternal heart ("impaired left-ventricle-aorta coupling") and transmit pressure and flow disturbances into the fetoplacental circulation ("impaired large arteries-microcirculation coupling"). In this review, we analyze the major role of the arterial dysfunction in the cardiovascular maladaptation hypothesis of preeclampsia, shed light on its potential etiopathogenic link, and discuss the complementary nature of the placental and cardiovascular theories.

Increased of the carotid intima media thickness in preeclampsia

Objectives The aim of the study was to determine carotid intima-media thickness (CIMT) values in patients who developed and did not develop preeclampsia (PE), and to determine whether CIMT values could be predictors of PE development. Methods The study included pregnant women who were examined by regular ultrasound examination at the Materno-Infantil Presidente Vargas Hospital (HMIPV) in Porto Alegre, Brazil, from April 2016 to September 2017. The examinations were performed every three months. Patients were divided into two groups. The first group included patients diagnosed with PE (n=21) and second group included patients who did not have PE (n=199). A high frequency ultrasound device (12 MHz) with a semi-automatic method was used to estimate CIMT. Results CIMT was significantly higher in pregnant women with PE than in women without PE (55±0.11 vs. 0.44±0.06, respectively; p<0.001). Using a cut-off value of 0.51 mm, CIMT had a specificity of 77.9% and sensitivity of 81% in the diagnosis of PE. With CIMT ≥0.6 mm, the probability of a patient developing PE was 44.4%; with CIMT >0.42 mm, the probability was only 4.2%. Conclusions An increase in CIMT was associated with the onset of PE. CIMT values were significantly higher in patients who develop PE.

The pathogenic role of coronary microvascular dysfunction in the setting of other cardiac or systemic conditions

Coronary microvascular dysfunction (CMD) plays a pathogenic role in cardiac and systemic conditions other than microvascular angina. In this review, we provide an overview of the pathogenic role of CMD in the setting of diabetes mellitus, obesity, hypertensive pregnancy disorders, chronic inflammatory and autoimmune rheumatic disorders, chronic kidney disease, hypertrophic cardiomyopathy, and aortic valve stenosis. In these various conditions, CMD results from different structural, functional, and/or dynamic alterations in the coronary microcirculation associated with the primary disease process. CMD is often detectable very early in the course of the primary disease, before clinical symptoms or signs of myocardial ischaemia are present, and it portrays an increased risk for cardiovascular events.

Nanoparticle-Mediated Simultaneous Downregulation of Placental Nrf2 and sFlt1 Improves Maternal and Fetal Outcomes in a Preeclampsia Mouse Model

Preeclampsia has impacted 3-5% pregnancies among the world and its complications lead to both maternal and fetal morbidity and mortality. However, management of preeclampsia is limited. Nanoparticles targeting chondroitin sulfate A (CSA) can deliver drugs to placenta. Inactivation of soluble fms-like tyrosine kinase (sFlt-1) and nuclear factor-erythroid 2-like 2 (Nrf2) has been proved to alleviate preeclampsia and improve maternal and fetal outcomes. Carboxyl-polyethylene glycol-poly (d,l-lactide) (COOH-PEG5K-PLA8K), cationic lipid DOTAP, and siNrf2 and sisFlt-1 were used to construct the nanoparticles and conjugating peptides targeting CSA was fabricated to it. The expression levels of proteins and RNAs were estimated by qRT-PCR and Western blot assays. ELISA assays were performed to evaluate levels of circulating sFlt-1. The nanoparticles containing siNrf2 and sisFlt-1 are targeted to the placenta trophoblasts and downregulated the expression levels of Nrf2 and sFlt-1 as well as their downstream genes in the placental cells of model mice. Treatment of nanoparticles induced the expression of angiogenic factors in placenta. Knocking down Nrf2 and sFlt-1 synchronously alleviated the preeclampsia and increased the maternal and fetal outcomes in preeclampsia model mice. Nanoparticle-mediated simultaneous downregulation of placental Nrf2 and sFlt1 improved maternal and fetal outcomes in a preeclampsia mouse model.

Pregnancy-induced Cardiovascular Pathologies: Importance of Structural Components and Lipids

Pregnancy leads to adaptations for maternal and fetal energy needs. The cardiovascular system bears the brunt of the adaptations as the heart and vessels enable nutrient supply to maternal organs facilitated by the placenta to the fetus. The components of the cardiovascular system are critical in the balance between maternal homeostatic and fetus driven homeorhetic regulation. Since lipids intersect maternal cardiovascular function and fetal needs with growth and in stress, factors affecting lipid deposition and mobilization impact risk outcomes. Here, the cardiovascular components and functional derangements associated with cardiovascular pathology in pregnancy, vis-à-vis lipid deposition, mobilization and maternal and/or cardiac and fetal energy needs are detailed. Most reports on the components and associated pathology in pregnancy, are on derangements affecting the extracellular matrix and epicardial fat, followed by the endothelium, vascular smooth muscle, pericytes and myocytes. Targeted studies on all cardiovascular components and pathological outcomes in pregnancy will enhance targeted interventions.

Wave intensity analysis of maternal arterial stiffness: augmentation index and pulse wave velocity in pregnancies complicated by diabetes or hypertension

PURPOSE

The aim of our study was to compare the maternal arterial stiffness in pregnant women with diabetic disease, hypertension and those with normal pregnancies.

METHODS

A cross-sectional study was performed involving 65 pregnant women with diabetic disease (DD group), 26 pregnant women with hypertension (RR group) and 448 women with normal pregnancies (control group). The augmentation index (AIx) and the pulse wave velocity (PWV) of the right carotid artery were assessed using non-invasive sonographic wave intensity analysis. Furthermore, the reliability of the measurements was evaluated in 21 healthy women.

RESULTS

Compared with the controls, the AIx and PWV were increased in the DD group [11.0 (interquartile range, IQR 7.3, 15.2) vs. 5.7 (IQR 2.4, 9.3), P < 0.001; 5.7 (IQR 5.1, 6.4) vs. 5.2 (IQR 4.6, 6.1), P = 0.001; respectively] and the RR group [9.3 (IQR 6.6, 11.5) vs. 5.7 (IQR 2.4, 9.3), P < 0.001; 7.1 (6.3, 7.9) vs. 5.2 (IQR 4.6, 6.1), P < 0.001; respectively]. The intraclass and interclass correlation coefficients were good to excellent for the AIx (ICC: 0.91, P < 0.001 and 0.74, P < 0.002; respectively) and PWV measurements (ICC: 0.71, P < 0.004 and 0.70, P < 0.005; respectively).

CONCLUSION

Pregnancies complicated by diabetic disease or hypertension are associated with increased maternal arterial stiffness. The importance of wave intensity analysis needs to be verified and larger studies are needed to establish both normal and cutoff values that may be relevant for clinical decisions.

Preeclampsia Is Associated With Increased Preclinical Carotid Atherosclerosis in Women With Type 1 Diabetes

PURPOSE

Although preeclampsia (PE) is a well-established cardiovascular risk factor (CVRF) in the general population, its role in type 1 diabetes (T1D) has been scarcely studied. We assessed the association between PE and preclinical atherosclerosis in T1D.

METHODS

We recruited 112 women without cardiovascular disease and last pregnancy ≥5 years before: (1) T1D and previous PE (T1D+/PE+; n = 28); (2) T1D without preeclampsia (T1D+/PE-; n = 28); (3) previous PE without T1D (T1D-/PE+; n = 28); and (4) controls (without T1D or PE; T1D-/PE-; n = 28). Groups were matched by age, several CVRFs, and diabetes duration and retinopathy (in T1D participants). Carotid intima-media thickness (IMT) and the presence of plaque (IMT ≥ 1.5 mm) were assessed by standardized ultrasonography protocol.

RESULTS

Mean age of the participants was 44.9 ± 7.8 years (14.3% hypertension and 21.4% active smokers). Groups including T1D (T1D+/PE+ and T1D+/PE-) more frequently presented hypertension and statin treatment (23.2% vs 5.4% and 37.5% vs 8.9%; respectively; P < 0.01), without differences in other CVRFs. Carotid plaques were observed in 20.5%. In multivariate models adjusted for age, CVRF, and statins, both T1D and PE showed a similar impact on the presence of plaque, with odds ratios (95% confidence interval), 5.45 (1.36-21.9) and 4.24 (1.04-17.3), respectively. Both entities showed an additive effect when combined, both in common carotid-IMT (T1D+/PE- or T1D-/PE+, β = 0.198; T1D+/PE+, β = 0.297) and in the presence of plaque (8.53 [1.07-68.2] and 28.1 [2.67-296.4], respectively).

CONCLUSIONS

Previous PE was independently associated with preclinical atherosclerosis in T1D. Further studies are needed to ascertain its usefulness for stratifying risk in T1D women.

Hypertensive Disorders of Pregnancy and Future Maternal Health: How Can the Evidence Guide Postpartum Management?

PURPOSE OF REVIEW

To review the postpartum management of hypertensive disorders of pregnancy.

RECENT FINDINGS

Hypertensive disorders are associated with an increased risk of future cardiovascular disease; however, there is a poor understanding of the underlying mechanisms and few recommendations to guide care in the postpartum period. Recent studies have shown high rates of masked hypertension and home blood pressure monitoring in the first year postpartum may be a promising opportunity to monitor health given evidence of high maternal adherence to this approach. In longer term, women with a history of a hypertensive disorder of pregnancy have higher blood pressures, increased risk of metabolic syndrome, and perhaps excess diastolic dysfunction. Triaging risk and improving handoff from the obstetrician to the primary care provider or subspecialist should be a priority in this population. Hypertensive disorders of pregnancy remain an untapped opportunity to identify excess cardiovascular risk in affected women at a time when mitigating that risk during the reproductive years has the potential to improve future pregnancy health as well as improve women's long-term cardiometabolic health.

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

Hypertensive disorders of pregnancy (HDP), such as gestational hypertension and pre-eclampsia, affect up to 10% of all pregnancies. These women have on average a twofold higher risk to develop cardiovascular disease (CVD) later in life as compared with women with normotensive pregnancies. This increased risk might result from an underlying predisposition to CVD, HDP itself or a combination of both. After pregnancy women with HDP show an increased risk of classical cardiovascular risk factors including chronic hypertension, renal dysfunction, dyslipidemia, diabetes and subclinical atherosclerosis. The prevalence and onset of cardiovascular risk factors depends on the severity of the HDP and the coexistence of other pregnancy complications. At present, guidelines addressing postpartum cardiovascular risk assessment for women with HDP show a wide variation in their recommendations. This makes cardiovascular follow-up of women with a previous HDP confusing and non-coherent. Some guidelines advise to initiate cardiovascular follow-up (blood pressure, weight and lifestyle assessment) 6-8 weeks after pregnancy, whereas others recommend to start 6-12 months after pregnancy. Concurrent blood pressure monitoring, lipid and glucose assessment is recommended to be repeated annually to every 5 years until the age of 50 years when women will qualify for cardiovascular risk assessment according to all international cardiovascular prevention guidelines.

Early Pregnancy Cardiovascular Health and Subclinical Atherosclerosis

Background Assessing and optimizing cardiovascular health (CVH) early in life, such as in pregnancy, could lead to a longer lifetime spent in better CVH and reduce the risk of cardiovascular disease. This might especially benefit women with a hypertensive disorder of pregnancy (HDP) who are more likely to develop atherosclerosis and cardiovascular disease. We hypothesized that CVH in pregnancy is related to later life CVH and carotid intima-media thickness (CIMT), and that these associations differ between women with a normotensive pregnancy and women with an HDP. Methods and Results This study was conducted within the prospective population-based Generation R Study. CVH in pregnancy was based on 5 metrics (blood pressure, total-cholesterol, glucose, smoking, and body mass index). Postpartum CVH additionally included physical activity and diet scores, according to the American Heart Association classification. Postpartum CVH and CIMT were measured 10 years after pregnancy. Results were analyzed for women with a normotensive pregnancy and those with an HDP. Women with a normotensive pregnancy (n=1786) and women with an HDP (n=138) were evaluated from early pregnancy until 10 years postpartum. Better CVH in early pregnancy was associated with a smaller CIMT and better postpartum CVH in all women, especially in those with an HDP (CIMT: -9.82 μm [95% CI: -17.98, -1.67]). Conclusions Already in pregnancy, better CVH is associated with a smaller CIMT and better CVH 10 years postpartum, especially in women with an HDP. As pregnancy is an incentive for women to improve lifestyle, assessing CVH in pregnancy might help improve postpartum CVH and reduce cardiovascular disease risk.

Association between reproductive factors and carotid atherosclerosis in post-menopausal women

OBJECTIVES

Assessment of cardiovascular risk in women is specific and hormonal factors should be considered to avoid its underestimation. So far, studies on this issue are lacking and the impact of reproductive factors on cardiovascular risk has yet to be determined. We study the association between reproductive factors and carotid atherosclerosis, a non-invasive marker of cardiovascular diseases, in post-menopause.

STUDY DESIGN

In this cross-sectional study, data were analyzed from post-menopausal women with at least one cardiovascular risk factor followed through a dedicated healthcare pathway at the Lille University Hospital between January 1st, 2013 and December 31st, 2016.

MAIN OUTCOME AND MEASURES

The primary outcome was the presence of plaque or stenosis at carotid ultrasound.

RESULTS

We included 370 post-menopausal women with a mean age of 63.4 ± 0.5 years. Carotid atherosclerosis was found in 161 (43,3%) women. Women with 3 or more children had higher odds of having carotid atherosclerosis than women with fewer than 3 children after adjustment for age, OR 1,69 [CI 95% 1,09-2,61], p = 0,019, and after further adjustment for anthropometric measures, traditional cardiovascular risk factors and pregnancy-related complications: OR 1,65 [CI 95% 1,05-2,62], p = 0,031. No other reproductive factor was significantly associated with carotid atherosclerosis.

CONCLUSIONS

A higher parity was associated with higher odds of carotid atherosclerosis independently of age, traditional risk factors, anthropometric measures and gestational diseases among post-menopausal women at risk of cardiovascular diseases. This suggests the importance of considering the number of children when assessing cardiovascular risk in women.

Preeclampsia: Acute Complications and Management Priorities

Acute complications of preeclampsia contribute substantially to maternal and fetal morbidity and mortality. The considerable variation in onset, clinical presentation, and severity of this hypertensive disease that is unique to pregnancy creates challenges in identifying risk factors for clinical deterioration. Delivery of the fetus remains the only definitive treatment for preeclampsia. Surveillance of signs and symptoms and laboratory parameters consistent with progression in severity requires an appreciation of the dynamic and progressive nature of the disease. This article provides a comprehensive overview of the pathophysiology of preeclampsia, setting the foundation for discussion of management priorities for acute complications that pose the greatest risks to maternal health.

Cardiovascular origins of preeclampsia

PURPOSE OF REVIEW

To review the current data on maternal cardiovascular adaptation in normal pregnancy and preeclampsia.

RECENT FINDINGS

Defective placentation causes early-onset preeclampsia, a disease entity that is considered more or less distinct from late-onset preeclampsia. The latter has been attributed as 'maternal' preeclampsia. There are inconsistencies with the placental origins hypothesis, especially when considering the lack of a causative association with abnormal placental histology or impaired fetal growth. An alternative explanation is that placental dysfunction is secondary to maternal cardiovascular maladaptation in pregnancy. The concept that placental dysfunction is secondary to a maternal disorder is not new when one considers the clinical similarities between preeclampsia and gestational diabetes - both pregnancy-specific conditions that are cured by birth. It is accepted that gestational diabetes develops when the maternal pancreas is unable to manage the increasing glucose load of pregnancy. It is now apparent that pregnancy presents a substantial cardiovascular load on the maternal heart, and that cardiovascular dysfunction precedes the disorder, predominates in the clinical syndrome and persists for several decades postpartum. It is time to consider the evidence that failure of the maternal cardiovascular system to adapt to pregnancy may well be the primary mechanism leading to secondary placental dysfunction in preeclampsia.

SUMMARY

Many of the existing paradoxes of preeclampsia challenge the placental origin hypothesis and are explained if one considered preeclampsia to be a cardiovascular syndrome.

Cardiovascular Sequels During and After Preeclampsia

Preeclampsia is a pregnancy-specific disorder complicating 2%-8% of pregnancies worldwide and characterized by de novo development of hypertension and proteinuria. Current understanding of the pathophysiology of preeclampsia is limited. A main feature is disrupted spiral artery remodeling in the placenta, which restricts the blood flow to the placenta, which in turn leads to decreased uteroplacental perfusion. Impaired blood flow through the placenta might result in fetal growth restriction and secretion of several factors by the placenta-mainly pro-inflammatory cytokines and anti-angiogenic factors-which spread into the maternal circulation, leading to endothelial dysfunction, which subsequently results in disrupted maternal hemodynamics. To date, no treatment options are available apart from termination of pregnancy. Despite normalization of the maternal vascular disturbances after birth, it has become apparent that formerly preeclamptic women experience an increased risk to develop cardiovascular and kidney disease later in life. One well-accepted concept is that the development of preeclampsia is an indicator of maternal susceptibility to develop future cardiovascular conditions, although the increased risk might also be the result of organ damage caused during preeclampsia. Given the associations between preeclampsia and long-term complications, preeclampsia is acknowledged as woman-specific risk factor for cardiovascular disease. Current research focuses on finding effective screening and prevention strategies for the reduction of cardiovascular disease in women with a history of preeclampsia.

The placental bed vascular pathology revisited: a risk indicator for cardiovascular disease

AIM

The present paper intends in the first place to clarify the confusing terminology for describing the vascular pathology of the placental bed in relation to long-term risk of cardiovascular disease.

METHODS

Systematic review of relevant topics.

RESULTS

The maternal blood supply to the placenta is achieved by some 100 utero-placental spiral arteries with an outside diameter varying between 200 and 600 microns. Defective physiological changes of the myometrial segment of utero-placental spiral arteries and, particularly in preeclampsia associated to hypertensive disease, the presence of atherosclerosis in their proximal segment are a cause of obstructive vascular pathology. On the other hand, basal arteries which supply the inner myometrium and basal decidua are not affected by physiological change and maintain their musculoelastic structure. They can be identified by their external diameter of less than 120 microns. Acute atherosis is an aspecific vascular lesion that occurs in basal as well as spiral arteries inside, as well as outside, the placental bed in association with a variety of obstetrical conditions.

CONCLUSIONS

An increased risk of future cardiovascular disease, should be linked to atherosis or, at a later stage, atherosclerosis of utero-placental spiral arteries, rather than to that of decidual basal arteries.

Characterization of intravascular cellular activation in relationship to subclinical atherosclerosis in postmenopausal women

Objective

Mechanisms and interactions among intravascular cells contributing to development of subclinical atherosclerosis are poorly understood. In women, both menopausal status and pregnancy history influence progression of atherosclerosis. This study examined activation and interactions among blood elements with subclinical atherosclerosis in menopausal women with known pregnancy histories.

Methods

Carotid intima-media thickness (CIMT), as a marker of subclinical atherosclerosis, was measured using B-mode ultrasound in age- and parity-matched women [40 with and 40 without a history of preeclampsia] 35 years after the index pregnancy. Interactions among intravascular cells (38 parameters) were measured by flow cytometry in venous blood. Data analysis was by principal component which retained 7 independent dimensions accounting for 63% of the variability among 38 parameters.

Results

CIMT was significantly greater in women with a history of preeclampsia (P = 0.004). Platelet aggregation and platelet interactions with granulocytes and monocytes positively associated with CIMT in postmenopausal women independent of their pregnancy history (ρ = 0.258, P< 0.05). However, the association of the number of platelets, platelet activation and monocyte-platelet interactions with CIMT differed significantly depending upon pregnancy history (test for interaction, P<0.001).

Conclusion

Interactions among actived intravascular cells and their association with subclinical atherosclerosis differ in women depending upon their pregnancy histories.

Preeclampsia and coronary plaque erosion: Manifestations of endothelial dysfunction resulting in cardiovascular events in women

Atherosclerosis is the major underlying pathology of cardiovascular disease (CVD). The risk for CVD is increased in women with a history of preeclampsia. Multiple studies have indicated that accelerated atherosclerosis underlies this increased CVD risk. Furthermore, it has been suggested that endothelial dysfunction and inflammation play an important role in the increased CVD risk of women with preeclampsia. Rupture or erosion of atherosclerotic plaques can induce the formation of thrombi that underlie the onset of acute clinical CVD such as myocardial infarction and stroke. In relatively young women, cardiovascular events are mainly due to plaque erosions. Eroded plaques have a distinct morphology compared to ruptured plaques, but have been understudied as a substrate for CVD. The currently available evidence points towards lesions with features of stability such as high collagen content and smooth muscle cells and with distinct mechanisms that further promote the pro-thrombotic environment such as Toll Like Receptor (TLR) signaling and endothelial apoptosis. These suggested mechanisms, that point to endothelial dysfunction and intimal thickening, may also play a role in preeclampsia. Pregnancy is considered a stress test for the cardiovascular system with preeclampsia as an additional pathological substrate for earlier manifestation of vascular disease. This review provides a summary of the possible common mechanisms involved in preeclampsia and accelerated atherosclerosis in young females and highlights plaque erosion as a likely substrate for CVD events in women with a history of preeclampsia.

Carotid Artery Intima-Media Thickness and Subclinical Atherosclerosis in Women With Remote Histories of Preeclampsia: Results From a Rochester Epidemiology Project-Based Study and Meta-analysis

OBJECTIVE

To measure carotid artery intima-media thickness (CIMT), a marker of subclinical atherosclerosis, in postmenopausal women with and without histories of preeclampsia and to synthesize these results with those from prior studies of CIMT performed 10 or more years after preeclamptic pregnancies.

PATIENTS AND METHODS

Forty women (median age, 59 years) with histories of preeclampsia and 40 with histories of normotensive pregnancy (confirmed by medical record review) were selected from women who resided and gave birth in Olmsted County, Minnesota, between January 1, 1976, and December 31, 1982. The participants were identified and recruited in 2014-2015, and CIMT was measured by B-mode ultrasonography. Meta-analysis included CIMT studies that were performed 10 or more years after preeclamptic pregnancies and which were identified through PubMed, EMBASE, and Web of Science. Heterogeneity was assessed using the I² statistic. Standardized mean difference was used as a measure of effect size.

RESULTS

Carotid artery intima-media thickness, expressed as a median (interquartile range), was greater in the preeclamptic than in the normotensive group (0.80 mm [0.75-0.85 mm] vs 0.73 mm [0.70-0.78]; P=.004); the odds of having CIMT higher than threshold (0.77 mm) was statistically significant after adjusting for confounding factors (odds ratio, 3.17; 95% CI, 1.10-9.14). A meta-analysis of 10 studies conducted 10 or more years post partum included 813 women with and 2874 without histories of preeclampsia. Carotid artery intima-media thickness was greater among women with histories of preeclampsia, with a standardized mean difference of 0.18 and 95% CI of 0.05 to 0.30 mm (P=.004).

CONCLUSION

Among women with histories of preeclampsia, CIMT may identify those with subclinical atherosclerosis, thus offering an opportunity for early intervention.