Cardiovascular risk factors in women who had hypertensive disorders late in pregnancy: a cohort study

Discover overlooked complications after preeclampsia using electronic health records

Background

Preeclampsia (PE) is a severe pregnancy complication characterized by hypertension and end-organ damage such as proteinuria. PE poses a significant threat to women's long-term health, including an increased risk of cardiovascular and renal diseases. Most previous studies have been hypothesis-based, potentially overlooking certain significant complications. This study conducts a comprehensive, non-hypothesis-based analysis of PE-complicated diagnoses after pregnancies using multiple large-scale electronic health records (EHR) datasets.

Method

From the University of Michigan (UM) Healthcare System, we collected 4,348 PE patients for the cases and 27,377 patients with pregnancies not complicated by PE or related conditions for the controls. We first conducted a non-hypothesis-based analysis to identify any long-term adverse health conditions associated with PE using logistic regression with adjustments to demographics, social history, and medical history. We confirmed the identified complications with UK Biobank data which contain 443 PE cases and 14,870 non-PE controls. We then conducted a survival analysis on complications that exhibited significance in more than 5 consecutive years post-PE. We further examined the potential racial disparities of identified complications between Caucasian and African American patients.

Findings

Uncomplicated hypertension, complicated diabetes, congestive heart failure, renal failure, and obesity exhibited significantly increased risks whereas hypothyroidism showed decreased risks, in 5 consecutive years after PE in the UM discovery data. UK Biobank data confirmed the increased risks of uncomplicated hypertension, complicated diabetes, congestive heart failure, renal failure, and obesity. Further survival analysis using UM data indicated significantly increased risks in uncomplicated hypertension, complicated diabetes, congestive heart failure, renal failure, and obesity, and significantly decreased risks in hypothyroidism. There exist racial differences in the risks of developing hypertension and hypothyroidism after PE. PE protects against hypothyroidism in African American postpartum women but not Cacausians; it also increases the risks of uncomplicated hypertension but less severely in African American postpartum women as compared to Cacausians.

Interpretation

This study addresses the lack of a comprehensive examination of PE's long-term effects utilizing large-scale EHR and advanced statistical methods. Our findings underscore the need for long-term monitoring and interventions for women with a history of PE, emphasizing the importance of personalized postpartum care. Notably, the racial disparities observed in the impact of PE on hypertension and hypothyroidism highlight the necessity of tailored aftercare based on race.

Flow-mediated Dilation of the Brachial Artery in Women with Hypertensive Disorders of Pregnancy

Background

Hypertensive disorder of pregnancy (HDP) comprise chronic hypertension, gestational hypertension, preeclampsia/eclampsia, and preeclampsia superimposed on chronic hypertension. HDP complicate up to 10% of pregnancies worldwide and carry significant risks of maternal and perinatal morbidity and mortality. The aim of this study was to evaluate the derangement and characteristics of brachial artery flow-mediated dilation (BAFMD) in women with HDP.

Methods

The BAFMD of the right brachial artery of 80 women with HDP (pregnant HDP), 80 normotensive pregnant women (pregnant non-HDP), and 80 healthy nonpregnant women (nonpregnant controls) was evaluated with B-mode ultrasound. The age, blood pressure, body mass index (BMI), brachial artery diameter, and BAFMD of the participants were compared. P ≤ 0.05 was statistically significant.

Results

The pregnant HDP group had significantly lower mean BAFMD compared to pregnant non-HDP and nonpregnant controls (6.9% ± 2.53% vs. 8.32% ± 3.4% vs. 9.4% ± 2.68%; P < 0.001). There was no significant difference between the mean BAFMD of the pregnant HDP subgroups: preeclampsia (5.81% ± 1.7%) versus gestational hypertension (6.43% ± 3.02%); P = 0.57. BAFMD diminished with advancing gestational age in both the pregnant HDP and pregnant non-HDP groups. On regression analysis, BAFMD was a poor marker for HDP, while BMI was an independent predictor for HDP.

Conclusion

Even though HDP were associated with significantly diminished BAFMD, it was not a good marker for HDP.

Childhood growth outcomes 2 years after hypertensive versus normotensive pregnancy: a P4 study

BACKGROUND

Intrauterine exposure to hypertensive disorders of pregnancy, including gestational hypertension (GH) and preeclampsia (PE), may influence infant growth and have long-term health implications. This study aimed to compare growth outcomes of infants exposed to a normotensive pregnancy (NTP), GH, or PE from birth to 2 years.

METHODS

Infants were children of women enroled in the prospective Postpartum Physiology, Psychology and Paediatric (P4) cohort study who had NTP, GH or PE. Birth, 6-month (age-corrected) and 2-year (age-corrected) weight z-scores, change in weight z-scores, rapid weight gain (≥0.67 increase in weight z-score) and conditional weight gain z-scores were calculated to assess infant growth (NTP = 240, GH = 19, PE = 66).

RESULTS

Infants exposed to PE compared to NTP or GH had significantly lower birth weight and length z-scores, but there were no differences in growth outcomes at 6 months or 2 years. GH and PE-exposed infants had significantly greater weight z-score gain [95% CI] (PE = 0.93 [0.66-1.18], GH = 1.03 [0.37-1.68], NTP = 0.45 [0.31-0.58], p < 0.01) and rapid weight gain (GH = 63%, PE = 59%, NTP = 42%, p = 0.02) from birth to 2 years, which remained significant for PE-exposed infants after confounder adjustment.

CONCLUSION

In this cohort, GH and PE were associated with accelerated infant weight gain that may increase future cardiometabolic disease risk.

IMPACT

Preeclampsia exposed infants were smaller at birth, compared with normotensive pregnancy and gestational hypertension exposed infants, but caught up in growth by 2 years of age. Both preeclampsia and gestational hypertension exposed infants had significantly accelerated weight gain from birth to 2 years, which remained significant for preeclampsia exposed infants after adjustment for confounders including small for gestational age. Monitoring of growth patterns in infants born following exposure to a hypertensive disorder of pregnancy may be indicated to prevent accelerated weight gain trajectories and obesity.

Are Overweight and Obesity Risk Factors for Developing Metabolic Syndrome or Hypertension after a Preeclamptic Event?

OBJECTIVE

To identify the determinants and risks associated with developing hypertension and metabolic syndrome in the first year postpartum in women who experienced preeclampsia.

METHODS

A cohort study was conducted, involving women who had experienced preeclampsia (PE) recently. The control group was women with the same characteristics but a healthy pregnancy. The variables analyzed were somatometry, disease history, pre-pregnancy body mass index (Pre-BMI), and Third Adult Treatment Panel updated (ATP III) metabolic syndrome (MS) data (blood pressure, obesity, triglycerides, high-density lipoproteins, and fasting glucose). These variables were measured at 3, 6, and 12 months postpartum.

RESULTS

Women with a history of PE exhibited higher systolic and diastolic blood pressure than women without PE. The risk of developing isolated diastolic arterial hypertension at 3 and 12 months of follow-up was two to eight times greater in women with a history of PE. Factors associated with having higher blood pressure levels were preeclampsia, insulin resistance, age, and BMI. Neither the pre-BMI index nor gestational weight gain (GWG) had any effect on blood pressure in any of the three assessments. Women with preeclampsia had a 5- to 8-fold increased risk of developing MS (which could be explained not only by the history of preeclampsia but also by the history of pre-pregnancy obesity). However, PE was not identified as a risk factor at the six-month evaluation and was only explained by pre-pregnancy obesity and overweight.

CONCLUSIONS

Obesity and overweight, as well as preeclampsia, were strongly associated with the development of hypertension and metabolic syndrome during the first year following childbirth.

Preeclampsia and the Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is characterized by venous or arterial thrombosis and/or adverse pregnancy outcome in the presence of persistent laboratory evidence of antiphospholipid antibodies (aPLs). Preeclampsia complicates about 10-17% of pregnancies with APS. However, only early onset preeclampsia (<34 weeks of gestation) belongs to the clinical criteria of APS. The similarities in the pathophysiology of early onset preeclampsia and APS emphasize an association of these two syndromes. Overall, both are the result of a defective trophoblast invasion and decidual transformation at early gestation. Women with APS are at increased risk for prematurity; the reasons are mostly iatrogenic due to placental dysfunction, such as preeclampsia or FGR. Interestingly, women with APS have also an increased risk for preterm delivery, even in the absence of FGR and preeclampsia, and therefore it is not indicated but spontaneous. The basic treatment of APS in pregnancy is low-dose aspirin and low-molecular-weight heparin. Nevertheless, up to 20-30% of women develop complications at early and late gestation, despite basic treatment. Several additional treatment options have been proposed, with hydroxychloroquine (HCQ) being one of the most efficient. Additionally, nutritional interventions, such as intake of vitamin D, have shown promising beneficial effects. Curcumin, due to its antioxidant and anti-inflammatory properties, might be considered as an additional intervention as well.

Cardiovascular risk profile after a complicated pregnancy across ethnic groups: The HELIUS study

AIMS

Little is known about how pregnancy complications and cardiovascular disease (CVD) risk are associated, specifically among ethnic minorities. In this study we examined this association in women from six ethnic groups, and the potential value of pregnancy complications as eligibility criterion for CVD risk screening.

METHODS

We conducted a cross-sectional study combining obstetric history from the Dutch perinatal registry with data on cardiovascular risk up to 15 years after pregnancy from the multi-ethnic HELIUS study. We included 2,466 parous women of Dutch, South-Asian Surinamese, African Surinamese, Ghanaian, Turkish and Moroccan origin. Associations were studied across ethnicities and predictive value of pregnancy complications for CVD risk factors above traditional eligibility criteria for CVD risk screening was assessed using Poisson regression.

RESULTS

History of hypertensive disorders of pregnancy and preterm birth were associated with higher prevalence of chronic hypertension and chronic kidney disease across most groups (prevalence ratio 1.6-1.9). Gestational diabetes mellitus was associated with increased type 2 diabetes mellitus risk, particularly in ethnic minority groups (prevalence ratio 4.5-7.7). Associations did not significantly differ across ethnic groups. The prediction models did not improve substantially after adding pregnancy complications to traditional eligibility criteria for CVD risk screening.

CONCLUSION

History of hypertensive disorders of pregnancy, preterm birth and gestational diabetes mellitus is associated with CVD risk factors in parous women, without evidence of a differential association across ethnic groups. However, addition of pregnancy complications to traditional eligibility criteria for CVD risk screening does not substantially improve the prediction of prevalent CVD risk factors.

Impact of preeclampsia/eclampsia on hemorrhagic and ischemic stroke risk: A 17 years follow-up nationwide cohort study

Background and purposes

The long-term risk of stroke in women with preeclampsia/eclampsia is a concerning issue. In this study we further investigated different stroke subtypes and differentiated follow-up time intervals.

Methods

Between 2000 and 2017, 1,384,427 pregnant women were registered in the National Health Insurance Research Database in Taiwan. After excluding women with previous stroke history and exact matching with all confounders, 6,053 women with preeclampsia/eclampsia and 24,212 controls were included in the analysis sample.

Results

Over the 17-year follow-up, the adjusted hazard ratio (aHR) for stroke in women with preeclampsia/eclampsia was 2.05 (95% confidence interval, CI = 1.67–2.52, p<0.001). The 17 years overall aHR of both ischemic and hemorrhagic stroke were 1.98 and 3.45, respectively (p<0.001). The stroke subtypes, hemorrhagic and ischemic, had different time trend risks, and hemorrhagic stroke risks kept higher than that of ischemic stroke. The aHR of ischemic stroke reached a peak during 1–3 years after childbirth (aHR = 3.09). The aHR of hemorrhagic stroke reached a peak during 3–5 years (aHR = 7.49).

Conclusions

Stroke risk persisted even after decades, for both ischemic and hemorrhagic subtypes. Women with preeclampsia/eclampsia history should be aware of the long-term risk of stroke.

Effectiveness of a nurse practitioner-led cardiovascular prevention clinic at reduction of metabolic syndrome following maternal complications of pregnancy: a preliminary analysis

AIM

Maternal complications of pregnancy, including hypertensive disorders of pregnancy, gestational diabetes mellitus, intrauterine growth restriction, preterm labour, and placental abruption, are associated with increased risk of future cardiometabolic disease. Lifestyle interventions that focus on preventative strategies for this young, high-risk population of women may assist in cardiometabolic disease risk reduction. The aim of this preliminary registry analysis was to observe the change in maternal metabolic syndrome status after receiving a nurse practitioner-led lifestyle intervention delivered soon after a complicated pregnancy.

METHOD

This preliminary analysis included 64 eligible women who had attended both baseline (approximately 6 months postpartum) and review (approximately eighteen months postpartum) appointments at the postpartum lifestyle clinic after an index pregnancy complicated by at least one maternal complication of pregnancy. Metabolic syndrome status at both appointments was assessed.

RESULTS

At the baseline appointment, 22 (34.4%) women met the criteria for metabolic syndrome. This number reduced at the review appointment to 19 (29.7%). This difference was not statistically significant. There were some modest improvements in the individual cardiometabolic risk factors, as well as marked improvements in the women who had recovered from metabolic syndrome over twelve months.

CONCLUSION

There was a high percentage of metabolic syndrome present early in the postpartum period. The results of this preliminary analysis highlight the importance of continuing preventative care and ongoing research for this group of high-risk women.

A review of infant growth and psychomotor developmental outcomes after intrauterine exposure to preeclampsia

Preeclampsia is a hypertensive disorder of pregnancy with serious health implications for mother and their offspring. The uteroplacental vascular insufficiency caused by preeclampsia is associated with epigenetic and pathological changes in the mother and fetus. However, the impact of preeclampsia in infancy (birth to 2 years), a time of rapid development influenced by pre- and postnatal factors that can predict future health outcomes, remains inconclusive. This narrative review of 23 epidemiological and basic science studies assessed the measurement and impact of preeclampsia exposure on infant growth and psychomotor developmental outcomes from birth to 2 years. Studies assessing infant growth report that preeclampsia-exposed infants have lower weight, length and BMI at 2 years than their normotensive controls, or that they instead experience accelerated weight gain to catch up in growth by 2 years, which may have long-term implications for their cardiometabolic health. In contrast, clear discrepancies remain as to whether preeclampsia exposure impairs infant motor and cognitive development, or instead has no impact. It is additionally unknown whether any impacts of preeclampsia are independent of confounders including shared genetic factors that predispose to both preeclampsia and childhood morbidity, perinatal factors including small for gestational age or preterm birth and their sequelae, and postnatal environmental factors such childhood nutrition. Further research is required to account for these variables in larger cohorts born at term, to help elucidate the independent pathophysiological impact of this clinically heterogenous and dangerous disease.

Prevalence of Metabolic Syndrome in Women After Maternal Complications of Pregnancy: An Observational Cohort Analysis

Introduction

Certain complications of pregnancy, including hypertensive disorders of pregnancy, gestational diabetes mellitus, intrauterine growth restriction, spontaneous preterm birth, and placental abruption, are established independent risk factors for premature cardiovascular disease in women. Metabolic syndrome, which is associated with an increased risk of cardiovascular disease, may be a suitable alternative to traditional cardiovascular risk calculators that underestimate risk in young women. This study aimed to investigate the prevalence of metabolic syndrome in women who experienced a complicated pregnancy 6 months earlier.

Methods

This observational study investigated the prevalence of metabolic syndrome as defined by the International Diabetes Federation in all eligible participants (n = 247) attending a postpartum lifestyle intervention clinic from August 2018 to June 2021 at the Lyell McEwin Hospital in Adelaide, South Australia.

Results

A total of 89 (36%) participants met the criteria for metabolic syndrome at a mean follow up time of 7 months postpartum. Almost 90% of the cohort were abdominally obese, and over two thirds of the total cohort met at least two of the criteria for metabolic syndrome.

Conclusions

Women with a prior history of one of the common major pregnancy complications are at high risk of future cardiovascular and metabolic disease, with many showing either metabolic syndrome or multiple risk factors at only 7 months postpartum. The results indicate that follow-up within 1 year postpartum is an appropriate time to commence preventative strategies, as many women are already showing early signs of disease.

Adverse Pregnancy Outcomes and Maternal Chronic Diseases in the Future: A Cross-Sectional Study Using KoGES-HEXA Data

Adverse pregnancy outcomes (APOs) are associated with an increased risk of chronic diseases, including cardiovascular disease (CVD) and metabolic syndrome (MS), in the future. We designed a large-scale cohort study to evaluate the influence of APOs (preeclampsia, gestational diabetes mellitus (GDM), stillbirth, macrosomia, and low birth weight) on the incidence of chronic diseases, body measurements, and serum biochemistry in the future and investigate whether combinations of APOs had additive effects on chronic diseases. We used health examinee data from the Korean Genome and Epidemiology Study (KoGES-HEXA) and extracted data of parous women (n = 30,174; mean age, 53.02 years) for the analysis. Women with APOs were more frequently diagnosed with chronic diseases and had a family history of chronic diseases compared with women without APOs. Composite APOs were associated with an increased risk of hypertension, diabetes mellitus, hyperlipidemia, angina pectoris, stroke, and MS (adjusted odds ratio: 1.093, 1.379, 1.269, 1.351, 1.414, and 1.104, respectively) after adjustment for family history and social behaviors. Preeclampsia and GDM were associated with an increased risk of some chronic diseases; however, the combination of preeclampsia and GDM did not have an additive effect on the risk. APOs moderately influenced the future development of maternal CVD and metabolic derangements, independent of family history and social behaviors.

Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy

Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants' risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.

Women and babies are dying from inertia: a collaborative framework for obstetrical drug development is urgently needed

Obstetrical complications, often referred to as the "great obstetrical syndromes," are among the most common global causes of mortality and morbidity in young women and their infants. However, treatments for these syndromes are underdeveloped compared with other fields of medicine and are urgently needed. This current paucity of treatments for obstetrical complications is a reflection of the challenges of drug development in pregnancy. The appetite of pharmaceutical companies to invest in research for obstetrical syndromes is generally reduced by concerns for maternal, fetal, and infant safety, poor definition, and high-risk regulatory paths toward product approval. Notably, drug candidates require large investments for development with an unguaranteed return on investment. Furthermore, the discovery of promising drug candidates is hampered by a poor understanding of the pathophysiology of obstetrical syndromes and their uniqueness to human pregnancies. This limits translational extrapolation and de-risking strategies in preclinical studies, as available for other medical areas, compounded with limited fetal safety monitoring to capture early prenatal adverse reactions. In addition, the ethical review committees are reluctant to approve the inclusion of pregnant women in trials, and in the absence of regulatory guidance in obstetrics, clinical development programs are subject to unpredictable regulatory paths. To develop effective and safe drugs for pregnancy complications, substantial commitment, and investment in research for innovative therapies are needed in parallel with the creation of an enabling ethical, legislative, and guidance framework. Solutions are proposed to enable stakeholders to work with a common set of expectations to facilitate progress in this medical discipline. Addressing this significant unmet need to advance maternal and possibly perinatal health requires the involvement of all stakeholders and specifically patients, couples, and clinicians facing pregnancy complications in the dearth of appropriate therapies. This paper focused on the key pharmaceutical research and development challenges to achieve effective and safe treatments for obstetrical syndromes.

Considering environmental exposures to per- and polyfluoroalkyl substances (PFAS) as risk factors for hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP), including preeclampsia and gestational hypertension, lead to significant maternal morbidity and in some cases, maternal mortality. Environmental toxicants, especially those that disrupt normal placental and endothelial function, are emerging as potential risk factors for HDP. Per- and polyfluoroalkyl substances (PFAS) are a large group of ubiquitous chemicals found in consumer products, the environment, and increasingly in drinking water. PFAS have been associated with a multitude of adverse health effects, including dyslipidemia, hypertension, and more recently, HDP. In this review, we present epidemiological and mechanistic evidence for the link between PFAS and HDP and recommend next steps for research and prevention efforts. To date, epidemiological studies have assessed associations between only ten of the thousands of PFAS and HDP. Positive associations between six PFAS (PFOA, perfluorooctanoic acid; PFOS, perfluorooctane sulfonic acid; PFHxS, perfluorohexane sulfonic acid; PFHpA, perfluoroheptanoic acid; PFBS, perfluorobutanesulfonic acid; and PFNA, perfluoronanoic acid) and risk for HDP have been reported in some, but not all, studies. PFAS disrupt placental and immune function, cause oxidative stress, and disrupt lipid metabolism. These physiological disruptions may be mechanisms through which PFAS can lead to HDP. Overall, limited epidemiological evidence and plausible mechanisms support PFAS as risk factors for HDP. More research is needed in diverse, well-powered cohorts that assess exposures to as many PFAS as possible. Such research should consider not only individual PFAS but also the totality of exposures to PFAS and other environmental chemicals. Pregnant women may be a group that is vulnerable to PFAS exposure, and as such HDP risk should be considered by policymakers setting PFAS exposure limits. In the interim, medical and public health professionals in regions with PFAS contamination could provide short-term solutions in the form of patient-level prevention, increased monitoring, and early intervention for HDP.

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.

The Pregravid Vascular Risk Factor Profile of Low-Risk Women Who Develop Pregnancy Outcomes That Predict Future Cardiovascular Disease

Background: Women with a history of certain adverse outcomes in pregnancy (preterm birth, delivery of a small-for-gestational age [SGA] infant, preeclampsia, and gestational diabetes mellitus [GDM]) have an elevated lifetime prevalence of metabolic syndrome (MetS) and cardiovascular disease, compared with their peers. However, it is not known if MetS precedes the index pregnancy in young, nulliparous women who experience these antepartum outcomes. Thus, we sought to evaluate the relationship between pregravid cardiovascular risk factor profile and these pregnancy outcomes in low-risk women.

Methods: In this prospective preconception cohort study, 1183 newly married women underwent systematic assessment of cardiovascular risk factors (anthropometry, blood pressure, lipids, glucose) at median 24.7 weeks before pregnancy, whereupon they were followed for the outcomes of preterm birth, SGA delivery, preeclampsia, and GDM.

Results: Women who had pregravid MetS (harmonized definition) (n = 49) were more likely to have a Caesarean delivery than their peers (61.4% vs. 38.6%, p = 0.003). However, they did not have a higher incidence of preterm delivery, SGA, preeclampsia, or GDM. Similarly, women who had at least one of these adverse pregnancy outcomes (n = 141) did not have a higher prevalence of MetS or any of its component disorders before pregnancy. Indeed, before pregnancy, there were no significant differences between these women and their peers in waist circumference, body mass index, blood pressure, fasting glucose, triglycerides, low-density-lipoprotein, or high-density-lipoprotein cholesterol.

Conclusions: The adverse cardiovascular risk factor profile that is seen in women with a history of preterm birth, SGA, preeclampsia, or GDM does not necessarily manifest before their pregnancy.

Comparison of three definitions of metabolic syndrome and relation to risk of recurrent preeclampsia

Objective. To determine the prevalence of metabolic syndrome in formerly preeclamptic women according to three definitions of metabolic syndrome (World Health Organization [WHO], International Diabetes Federation [IDF], and Third Adult Treatment Panel updated [ATPIII]), to evaluate agreement amongst definitions and to compare the risk of recurrent preeclampsia. Methods. In 197 women with a history of preeclampsia, we determined presence of metabolic syndrome using WHO, IDF, and ATPIII criteria. We evaluated agreement amongst definitions by using Kappa statistics. The prevalence of recurrent preeclampsia was compared between women with and without inter-pregnancy metabolic syndrome, according to the three definitions. Results. A total of 40 (20%), 46 (23%), and 31 (16%) of women with previous preeclampsia were classified as having metabolic syndrome postpartum according to WHO, IDF, and ATPIII criteria, respectively. Agreement among criteria was considered substantial between WHO and IDF (κ = 0.64, 95% CI 0.53-0.79), WHO and ATPIII (κ = 0.74, 95% CI 0.62-0.86), and IDF and ATPIII (κ = 0.66, 95% CI 0.51-0.77). The prevalence of recurrent preeclampsia was 45% versus 17% in women with and without inter-pregnancy metabolic syndrome according to the WHO definition (P < 0.001), 26% versus 21% according to the IDF criteria (P = 0.16), and 39% versus 20% according to the ATPIII definition (P = 0.02). Conclusions. Agreement among WHO, IDF, and ATPIII criteria of metabolic syndrome in women after preeclampsia is considered substantial. The risk of recurrent preeclampsia is almost one out of two in women with inter-pregnancy metabolic syndrome according to the WHO criteria.

Low Plasma Volume and Increased Pressure Load Relate to Concentric Left Ventricular Remodeling After Preeclampsia: A Longitudinal Study

Background During uncomplicated pregnancy, left ventricular remodeling occurs in an eccentric way. In contrast, during preeclamptic gestation, the left ventricle hypertrophies concentrically, concurrent with loss in circulatory volume and increased blood pressure. Concentric cardiac structure persists in a substantial proportion of women and may be associated with pressure and volume load after preeclampsia. We hypothesize that low volume load, as indicated by plasma volume (PV) after preeclampsia and increased pressure load, is associated with remote concentric remodeling. Methods and Results In this longitudinal cohort study, we included 100 formerly preeclamptic women. Two visits were performed: at 0.8 years postpartum and at 4.8 years postpartum. During visit 1, we measured blood pressure and PV (I125 dilution technique, low PV ≤48 mL/kg lean body mass). During the second visit, we assessed cardiac geometry by cardiac ultrasound. Concentric remodeling was defined as relative wall thickness >0.42 and left ventricular mass index ≤95 g/m2. We adjusted multivariable analysis for primiparity, systolic blood pressure, PV mL/kg lean body mass, and antihypertensive medication at visit 1. Low PV is associated with remote concentric remodeling (odds ratio [OR], 4.37; 95% CI, 1.06-17.40; and adjusted OR, 4.67; 95% CI, 1.02-21.42). Arterial pressure load (systolic, diastolic, and mean arterial pressure) is also associated with development of concentric remodeling (OR, 1.15 [95% CI, 0.99-1.35]; OR, 1.24 [95% CI, 0.98-1.58]; and OR, 1.20 [95% CI, 0.98-1.47], respectively). Conclusions In former preeclamptic women, development toward left ventricular concentric remodeling is associated with low volume load and increased pressure load.

Dietary patterns and gestational hypertension in nulliparous pregnant Chinese women: A CONSORT report

It has been well established that dietary patterns play important roles in the pathogenesis and development of hypertension. Our aim was to investigate the association between pregnancy dietary patterns and the risk of hypertension among nulliparous pregnant Chinese women.A cross-sectional, case-control study.Three hospitals in Haikou, the capital of Hainan Province, South China.A total of 2580 participants who reported dietary intake using a validated food frequency questionnaire (FFQ).Four primary dietary patterns were identified by principal component factor analysis and labeled as traditional Chinese, animal food, Western food, and salty snacks patterns. Women with high scores on pattern characterized by salty snacks were at increased risk.This study suggests that dietary pattern characterized by salty snack increases the risk of hypertension during pregnancy.

Cardiovascular risk after hypertensive disorders of pregnancy in women with and without inheritable Thrombophilia

Aim of this study was to compare cardiovascular risk in women with and without inheritable thrombophilia after hypertensive disorders of pregnancy (HDP). Blood pressure, anthropometrics and blood samples were measured 9-13 years after early-onset (<34 weeks) HDP. Amongst the 114 women included, no differences in hypertension (31.1% vs. 33.7%, OR 0.90 95% CI (0.29-2.79)), body mass index > 25 kg/m² (43.8% vs. 53.1%, OR 0.69 95% CI (0.24-2.00)) or metabolic syndrome (18.8% vs. 13.3%, OR 1.51 95% CI (0.38-6.02)) were found. These data show similar cardiovascular risk profile in women with and without inheritable thrombophilia.

Cardiovascular effects of severe late-onset preeclampsia are reversed within six months postpartum

OBJECTIVES

Preeclampsia (PE) is a common pregnancy-related disorder associated with cardiovascular long-term disease. Eighty percent are late-onset PE, occurring after 34 gestational weeks, and can present with severe symptoms. Magnitude and reversibility rate of maternal cardiovascular changes after severe late-onset PE have not been characterized. This study therefore evaluated longitudinal dynamics of maternal cardiovascular changes after severe late-onset PE.

STUDY DESIGN

Six previously normotensive women with severe late-onset PE and eight pregnant controls were included. Severe PE was defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 110 mmHg and proteinuria with/without evidence of end-organ dysfunction, or SBP ≥ 140 mmHg or DBP ≥ 90 mmHg with/without proteinuria and with evidence of end-organ dysfunction. Cardiovascular function was assessed by magnetic resonance imaging at 1-3 days, one week and six months postpartum.

RESULTS

Left ventricular mass at 1-3 days postpartum was higher after severe late-onset PE (57 g/m²) compared to after normal pregnancy (48 g/m²; p = 0.01). Pulse wave velocity (PWV) decreased between 1 and 3 days and six months postpartum after PE (6.1 to 5.0 m/s; p = 0.028). There was no difference in PWV 1-3 days postpartum after severe PE compared after normal pregnancy (6.1 versus 5.6 m/s; p = 0.175). Blood pressure normalized within six months in all but one patient.

CONCLUSIONS

Cardiac effects after severe late-onset PE were small and transient. This indicates that left ventricular hypertrophy after severe late-onset PE may be a secondary physiologic response to increased peripheral resistance in PE. Vascular mechanisms rather than persistent cardiac hypertrophy postpartum may be the culprit for increased long-term cardiovascular risk after PE.

A Protocol for Nurse-Practitioner Led Cardiovascular Follow-Up After Pregnancy Complications in a Socioeconomically Disadvantaged Population

Background: Women who experience pregnancy complications have an increased risk of future cardiovascular disease when compared to their healthy counterparts. Despite recommendations, there is no standardized cardiovascular follow-up in the postpartum period for these women, and the Australian follow-up protocols that have been previously described are research-based. This study proposes a new model of care for a nurse practitioner-led postpartum intervention clinic for women who experience severe hypertensive disorders of pregnancy, gestational diabetes mellitus requiring medication, severe intrauterine growth restriction, idiopathic preterm delivery, or placental abruption, in a socioeconomically disadvantaged population.

Methods: All women receiving antenatal care or who deliver at the Lyell McEwin Hospital, a tertiary acute care facility located in the northern Adelaide metropolitan area, following a severe complication of pregnancy are referred to the intervention clinic for review at 6 months postpartum. A comprehensive assessment is conducted from demographics, medical history, diet and exercise habits, psychosocial information, health literacy, pathology results, and physical measurements. Subsequently, patient-specific education and clinical counseling are provided by a specialized nurse practitioner. Clinic appointments are repeated at 18 months and 5 years postpartum. All data is also collated into a registry, which aims to assess the efficacy of the intervention at improving modifiable cardiovascular risk factors and reducing cardiovascular risk.

Discussion: There is limited information on the efficacy of postpartum intervention clinics in reducing cardiovascular risk in women who have experienced pregnancy complications. Analyses of the data collected in the registry will provide essential information about how best to reduce cardiovascular risk in women in socioeconomically disadvantaged and disease-burdened populations.

Potential confounders and a modified Framingham risk score for the prediction of pregnancy-related medical conditions occurrence among pregnant women: A retrospective study from Baghdad, Iraq

Background:

The incidence of pregnancy-related medical conditions relied on a set of potential factors that could be available even before the term of pregnancy and may be associated with poor outcomes later in life. This study aimed to investigate the association between some potential predictive factors related to maternal, gestational, and clinical parameters and the incidence of pregnancy-related medical conditions in a sample of Iraqi pregnant women.

Materials and Methods:

A retrospective, observational, single-center study was carried out on 92 pregnant women during their routine visit to the obstetric clinic in a certain distinct of Baghdad province, Iraq. Demographic, gestational, and clinical records of the participants were collected and analyzed to detect the predictive factors for pregnancy-related medical conditions.

Results:

56.5% of the participants were at a gestational age of 25–37 weeks. 32.6% complained of pregnancy-related medical conditions, mainly gestational hypertension and diabetes mellitus. Pregnant women with pregnancy-related medical conditions were significantly correlated with a family history (P < 0.0001), previous gestational medical conditions (P < 0.001), diastolic blood pressure (P = 0.0011), different lipid panels (P = 0.0001), and maternal blood phenotype O (P = 0.0001).

Conclusion:

Some predictive factors related to maternal, gestational, and health characteristics are correlated with the incidence of pregnancy-related medical conditions. Interventions to adjust and recognize these confounders are essentials even before pregnancy which could improve maternal health and reduce the overall risk of pregnancy-related medical conditions.

The effect of parity on longitudinal maternal hemodynamics

BACKGROUND

Parous women have a lower risk for pregnancy complications, such as preeclampsia or delivery of small-for-gestational-age neonates. However, parous women are a heterogeneous group of patients because they contain a low-risk cohort with previously uncomplicated pregnancies and a high-risk cohort with previous pregnancies complicated by preeclampsia and/or small for gestational age. Previous studies examining the effect of parity on maternal hemodynamics, including cardiac output and peripheral vascular resistance, did not distinguish between parous women with and without a history of preeclampsia or small for gestational age and reported contradictory results.

OBJECTIVE

The objective of the study was to compare maternal hemodynamics in nulliparous women and in parous women with and without previous preeclampsia and/or small for gestational age.

STUDY DESIGN

This was a prospective, longitudinal study of maternal hemodynamics, assessed by a bioreactance method, measured at 11⁺⁰ to 13⁺⁶, 19⁺⁰ to 24⁺⁰, 30⁺⁰ to 34⁺⁰, and 35⁺⁰ to 37⁺⁰ weeks' gestation in 3 groups of women. Group 1 was composed of parous women without a history of preeclampsia and/or small for gestational age (n = 632), group 2 was composed of nulliparous women (n = 829), and group 3 was composed of parous women with a history of preeclampsia and/or small for gestational age (n = 113). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal characteristics, medical history, and development of preeclampsia or small for gestational age in the current pregnancy.

RESULTS

In groups 1 and 2, cardiac output increased with gestational age to a peak at 32 weeks and peripheral vascular resistance showed a reversed pattern with its nadir at 32 weeks; in group 1, compared with group 2, there was better cardiac adaptation, reflected in higher cardiac output and lower peripheral vascular resistance. In group 3 there was a hyperdynamic profile of higher cardiac output and lower peripheral vascular resistance at the first trimester followed by an earlier sharp decline of cardiac output and increase of peripheral vascular resistance from midgestation. The incidence of preeclampsia and small for gestational age was highest in group 3 and lowest in group 1.

CONCLUSION

There are parity-specific differences in maternal cardiac adaptation in pregnancy.

Elevated soluble-St2 concentrations in preeclampsia correlate with echocardiographic parameters of diastolic dysfunction and return to normal values one year after delivery

Objectives: To compare soluble-ST2 (sST2) concentrations in patients with severe features of preeclampsia and healthy pregnant controls before as well as 1 year after delivery. Another objective was to assess potential correlation between sST2 concentrations and myocardial function.Methods: Patients with singleton pregnancy complicated by severe features of preeclampsia and healthy controls were included in a prospective observational study. Plasma sST2 concentrations were measured within 24 h before delivery and 1 year after delivery. Standard two-dimensional and Doppler echocardiography was performed at the time of first sST2 measurement before delivery. Mann-Whitney U test was used to compare sST2 values in preeclamptic patients versus controls. Kendall's tau was used to assess correlation between sST2 values and echocardiographic measures of left ventricular systolic and diastolic function (p < .05 significant).Results: We included 24 patients with severe preeclampsia and 29 controls. One year after delivery, sST2 concentrations were available for 24 (45%) participants (13 in preeclampsia group and 11 controls). Concentrations of sST2 were markedly elevated in patients with severe preeclampsia compared to healthy controls before delivery (p = .04), but not 1 year after delivery (p = .80). There was no significant correlation between sST2 and parameters of systolic function. In preeclamptic patients, we found a significant inverse correlation between sST2 and markers of diastolic function: peak early mitral inflow velocity E (Kendall's tau = -0.40; p = .02), peak early diastolic myocardial velocities at septal and lateral mitral annulus (e') (Kendall's tau = -0.354, p = .04) and ratio between e' and peak systolic myocardial velocities at the septal and lateral mitral annulus (e'/s') (Kendall's tau = -0.362, p = .04).Conclusions: Preeclampsia with severe features is associated with increased maternal plasma concentrations of sST2, which return to normal values in the first year after delivery. Higher sST2 levels in preeclamptic patients correlate with impaired parameters of left ventricular diastolic function.

Maternal lipid profiles in women with and without gestational diabetes mellitus

To determine the longitude lipid profiles in women with and without gestational diabetes mellitus (GDM), and to investigate the relationship between lipid disturbances in the 1st trimester and GDM.Blood samples were collected from 1283 normal pregnant women and 300 women with GDM. Serum lipids which include total cholesterol (TC), triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were measured and the TG/HDL-C ratio was calculated in the 1st, 2nd, and 3rd trimesters of pregnancy and then we got the longitudinal lipid profiles. We compared the differences of lipid profiles between patients with GDM and normal pregnant women using 2-way repeated measures analysis of variance. Also additional propensity-based subgroup analyses were performed. The logistic regression analysis was used to determine the relationship between the lipid disturbances in the 1st trimester and GDM.TG, TC, LDL-C concentrations, and TG/HDL-C ratio increased progressively throughout pregnancy; while HDL-C amounts increased from the 1st to the 2nd trimester with a slight decrease in the 3rd trimester. The GDM group showed higher TG concentrations, higher TG/HDL-C ratio, and lower HDL-C concentrations throughout pregnancy. There were no significant differences in TC and LDL-C concentrations in the 1st, 2nd, and 3rd trimesters (P > .05), between the GDM group and the control group. Logistic regression analysis showed that maternal age, prepregnancy body mass index (BMI), and TG/HDL ratio in the 1st trimester were associated with an increased risk of GDM.The lipid profile alters significantly in patients with GDM, and maternal age, prepregnancy BMI, and TG/HDL ratio in the 1st trimester were associated with an increased risk of GDM.

Gestational Hypoxia and Developmental Plasticity

Hypoxia is one of the most common and severe challenges to the maintenance of homeostasis. Oxygen sensing is a property of all tissues, and the response to hypoxia is multidimensional involving complicated intracellular networks concerned with the transduction of hypoxia-induced responses. Of all the stresses to which the fetus and newborn infant are subjected, perhaps the most important and clinically relevant is that of hypoxia. Hypoxia during gestation impacts both the mother and fetal development through interactions with an individual's genetic traits acquired over multiple generations by natural selection and changes in gene expression patterns by altering the epigenetic code. Changes in the epigenome determine "genomic plasticity," i.e., the ability of genes to be differentially expressed according to environmental cues. The genomic plasticity defined by epigenomic mechanisms including DNA methylation, histone modifications, and noncoding RNAs during development is the mechanistic substrate for phenotypic programming that determines physiological response and risk for healthy or deleterious outcomes. This review explores the impact of gestational hypoxia on maternal health and fetal development, and epigenetic mechanisms of developmental plasticity with emphasis on the uteroplacental circulation, heart development, cerebral circulation, pulmonary development, and the hypothalamic-pituitary-adrenal axis and adipose tissue. The complex molecular and epigenetic interactions that may impact an individual's physiology and developmental programming of health and disease later in life are discussed.

Increased cardiovascular disease risk in women with a history of recurrent miscarriage

INTRODUCTION

Cardiovascular disease is the leading cause of death in women. Observational studies suggest that women with a history of recurrent miscarriage have an increased risk of cardiovascular disease.

MATERIAL AND METHODS

Women who visited the recurrent miscarriage clinic at Leiden University Medical Center between 2000 and 2010 and who had their third consecutive miscarriage before the age of 31 years, were invited to participate in this follow-up study (between 2012 and 2014). The reference group consisted of women with at least one uncomplicated pregnancy and no miscarriage, matched by zip code, age, and date of pregnancy. All women were invited for risk factor screening, including physical examination and blood collection. Main outcome measures were the (extrapolated) 10- and 30-year cardiovascular risk scores using the Framingham risk score. A subanalysis was performed for women with idiopathic recurrent miscarriage.

RESULTS

Thirty-six women were included in both groups. Mean follow up was 7.5 years. Women with recurrent miscarriage had a significantly higher extrapolated 10-year cardiovascular risk score (mean 6.24%, SD 5.44) compared with women with no miscarriage (mean 3.56%, SD 1.82, P = .007) and a significantly higher 30-year cardiovascular risk score (mean 9.86%, SD 9.10) compared with women with no miscarriage (mean 6.39%, SD 4.20, P = .04). Similar results were found in women with idiopathic recurrent miscarriage (n = 28).

CONCLUSIONS

Women with a history of recurrent miscarriage differ in cardiovascular risk profile at a young age compared with women with no miscarriage. The findings support an opportunity to identify women at risk of cardiovascular disease later in life and a possible moment for intervention.

Cardiovascular biomarkers in the years following pregnancies complicated by hypertensive disorders or delivered preterm

BACKGROUND

Women with a history of hypertensive disorders of pregnancy and preterm delivery have an increased risk of cardiovascular disease (CVD). Chronic inflammation, endothelial dysfunction, and dyslipidemia may link pregnancy outcomes with CVD.

OBJECTIVE

We evaluated whether women with a history of HDP or normotensive preterm delivery had adverse CVD biomarker profiles after pregnancy.

STUDY DESIGN

We identified parous women from the Nurses' Health Study II with C-reactive protein (CRP; n = 2614), interleukin-6 (IL-6; n = 2490), glycated hemoglobin (n = 885), intracellular adhesion molecule-1 (n = 1231), high density lipoprotein cholesterol (n = 931), low density lipoprotein cholesterol (n = 931), triglycerides (n = 1428), or total cholesterol (n = 2940) assessed in stored blood samples. Multivariable-adjusted robust linear regression models evaluated percent differences and 95% confidence intervals (CIs) in each biomarker associated with a history of HDP or preterm delivery.

RESULTS

Ten percent of women had a history of HDP, while 11% with normotensive pregnancies had at least one preterm delivery. Median time from first pregnancy to blood draw was 17 years (interquartile range: 12, 22). Plasma levels of CRP and IL-6 were 34.4% (95% CI: 17.2, 54.1), and 11.6% higher (95% CI: 2.1, 21.9) respectively, among women with a history of HDP compared to those with only normotensive pregnancies. Altered CVD biomarker levels were otherwise not present in women with a history of HDP or preterm delivery.

CONCLUSION

CRP and IL-6, but not other CVD biomarkers, were elevated in women with a history of HDP in the years following pregnancy, suggesting inflammation may be a pathway linking HDP with future CVD risk.

Detergent-Insoluble Proteome Analysis Revealed Aberrantly Aggregated Proteins in Human Preeclampsia Placentas

Preeclampsia (PE) is a placenta disease, featured by hypertension, proteinuria, and other multiorgan dysfunctions, and its etiology is unclear. We and others have shown that intensive endoplasmic reticulum (ER) stress and unfolded protein response (UPR) occur in the PE placenta. In this study, we isolated detergent-insoluble proteins (DIPs) from human placenta tissues, which were enriched with protein aggregates, to characterize the placenta UPR in PE. With data-independent acquisition (DIA) mass spectrometry, we identified 2066 DIPs across all normal (n = 10) and PE (n = 10) placenta samples, among which 110 and 108 DIPs were significantly up- and down-regulated in PE, respectively. Per clustering analysis, differential DIPs could generally distinguish PE from normal placentas. We verified the MS quantitation of endoglin and vimentin by immunoblotting. In addition, we observed that PE placenta tissues have remarkably more endoglin in the cytoplasm. Furthermore, we found that DIPs were evenly distributed across different chromosomes and could be enriched in diversified gene ontology terms, while differential DIPs avoided to distribute on X-chromosome. Significantly up-regulated DIPs in PE were focused on the top functions of lipid metabolism, while 23 of these DIPs could form the top network regulating cellular movement, development, growth, and proliferation. Our results implicate that human PE placentas have disease-relevant differential DIPs, which reflect aberrantly aggregated proteins of placental tissues. The mass spectrometry proteomics data have been deposited to ProteomeXchange consortium with the data set identifier PXD006654, and iProX database (accession number: IPX0000948000).

Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when

Background

Women with a history of a hypertensive disorder during pregnancy (HDP) have an increased risk of cardiovascular events. Guidelines recommend assessment of cardiovascular risk factors in these women later in life, but provide limited advice on how this follow-up should be organized.

Design

Systematic review and meta-regression analysis.

Methods

The aim of our study was to provide an overview of existing knowledge on the changes over time in three major modifiable components of cardiovascular risk assessment after HDP: blood pressure, glucose homeostasis and lipid levels. Data from 44 studies and up to 6904 women with a history of a HDP were compared with risk factor levels reported for women of corresponding age in the National Health And Nutrition Examination Survey, Estudio Epidemiólogico de la Insuficiencia Renal en España and Hong Kong cohorts (N = 27,803).

Results

Compared with the reference cohort, women with a HDP presented with higher mean blood pressure. Hypertension was present in a higher rate among women with a previous HDP from 15 years postpartum onwards. At 15 years postpartum (±age 45), one in five women with a history of a HDP suffer from hypertension. No differences in glucose homeostasis parameters or lipid levels were observed.

Conclusions

Based on our analysis, it is not possible to point out a time point to commence screening for cardiovascular risk factors in women after a HDP. We recommend redirection of future research towards the development of a stepwise approach identifying the women with the highest cardiovascular risk.

Effect of early-onset preeclampsia on cardiovascular risk in the fifth decade of life

BACKGROUND

Women with hypertensive disorders in pregnancy, in particular early-onset preeclampsia, are at increased risk of developing cardiovascular disease later in life. These women have a more than 2-fold increased risk of dying from cardiovascular diseases. Most studies have focused on identification of risk factors shortly after pregnancy. Less is known on the prevalence of risk factors or actual signs of cardiovascular disease 5-20 years later. The presence of hypertension or metabolic syndrome can be seen as an opportunity for preventive interventions to reduce the development of severe cardiovascular diseases like myocardial infarction and stroke.

OBJECTIVE

To assess cardiovascular risk factors and established cardiovascular disease in women after early-onset preeclampsia, in the fifth decade of life. As a consequence, we can assess whether there is still a window of opportunity for preventive measures and to establish in what proportion of women cardiovascular disease already has developed.

STUDY DESIGN

In a prospective observational study, cardiovascular risk assessment was performed in women with early-onset preeclampsia (<34 weeks' gestation) and normotensive controls (≥37 weeks' gestation) 9-16 years after their index pregnancy. Medical records of 2 tertiary hospitals in Amsterdam, The Netherlands, were screened consecutively, and all eligible women were invited. Cardiovascular risk assessment consisted of a questionnaire, blood pressure measurement, anthropometrics, and blood and urine for fasting lipids, lipoproteins, glucose levels, glycated hemoglobin, renal function, N-terminal brain natriuretic peptide, and albuminuria. History of cardiovascular diseases (ie, myocardial infarction and stroke) was determined. Prevalence of women presenting in an optimal window of opportunity for preventive measures was defined by the presence of cardiovascular risk factors (ie, hypertension and metabolic syndrome) but in the absence of established cardiovascular diseases (ie, myocardial infarction and stroke).

RESULTS

Women with a history of early-onset preeclampsia (n = 131) had significantly greater systolic and diastolic blood pressure, greater body mass index, more often had an abnormal lipid profile (lower high-density lipoprotein levels, higher triglycerides), greater glycated hemoglobin, and greater levels of albuminuria compared to controls (n = 56). None of the women with a history of early-onset preeclampsia was diagnosed with cardiovascular disease; 38.2% were diagnosed with hypertension; and 18.2% were diagnosed with metabolic syndrome. A total of 42% met the criteria for the window of opportunity for preventive measures. In women with a history of an uncomplicated pregnancy, no women were diagnosed with cardiovascular disease; 14.3% were diagnosed with hypertension; 1.8% with metabolic syndrome. In this cohort, 14.3% met the criteria for the window of opportunity for preventive measures.

CONCLUSION

A large proportion of women who experienced early-onset preeclampsia had major cardiovascular risk factors in the fifth decade of life, compared with healthy controls. These women are currently outside the scope of most preventive programs due to their relatively young age, but have important modifiable risk factors for cardiovascular diseases.

Failure of physiologic transformation of spiral arteries, endothelial and trophoblast cell activation, and acute atherosis in the basal plate of the placenta

BACKGROUND

Failure of physiologic transformation of spiral arteries has been reported in preeclampsia, fetal growth restriction, fetal death, and spontaneous preterm labor with intact or ruptured membranes. Spiral arteries with failure of physiologic transformation are prone to develop atherosclerotic-like lesions of atherosis. There are striking parallels between preeclampsia and atherosclerotic disease, and between lesions of atherosis and atherosclerosis. Endothelial activation, identified by intercellular adhesion molecule-1 expression, is present in atherosclerotic-like lesions of heart transplantation, and is considered a manifestation of rejection. Similarly, endothelial activation/dysfunction has been implicated in the pathophysiology of atherosclerosis and preeclampsia. Intercellular adhesion molecule-1-overexpressing-activated endothelial cells are more resistant to trophoblast displacement than nonactivated endothelium, and may contribute to shallow spiral artery trophoblastic invasion in obstetrical syndromes having failure of physiologic transformation.

OBJECTIVE

We sought to determine whether failure of spiral artery physiologic transformation was associated with activation of interstitial extravillous trophoblasts and/or spiral artery endothelium and presence of acute atherosis in the placental basal plate.

STUDY DESIGN

A cross-sectional study of 123 placentas (19-42 weeks' gestation) obtained from normal pregnancies (n = 22), preterm prelabor rupture of membranes (n = 26), preterm labor (n = 23), preeclampsia (n = 27), intrauterine fetal death (n = 15), and small for gestational age (n = 10) was performed. Failure of spiral artery physiologic transformation and presence of cell activation was determined using immunohistochemistry of placental basal plates containing a median of 4 (minimum: 1; maximum: 9) vessels per placenta. Endothelial/trophoblast cell activation was defined by the expression of intercellular adhesion molecule-1. Investigators examining microscopic sections were blinded to clinical diagnosis. Pairwise comparisons among placenta groups were performed with Fisher exact test and Wilcoxon rank sum test using a Bonferroni-adjusted level of significance (.025).

RESULTS

We found that 87% (94/108) of placentas having spiral arteries with failure of physiologic transformation (actin-positive and cytokeratin-negative) in the basal plate, and 0% (0/15) of placentas having only spiral arteries with complete physiologic transformation (cytokeratin-positive and actin-negative), had arterial endothelial and/or interstitial extravillous trophoblasts reactive with the intercellular adhesion molecule-1 activation marker (P < .001). A significant correlation (R² = 0.84) was found between expression of spiral artery endothelial and interstitial extravillous trophoblast intercellular adhesion molecule-1 (P < .001) in activated placentas. Lesions of atherosis were found in 31.9% (30/94) of placentas with complete and/or partial failure of physiologic transformation of spiral arteries that were intercellular adhesion molecule-1-positive, in none of the 14 placentas with failure of physiologic transformation that were intercellular adhesion molecule-1-negative, and in none of the 15 placentas with complete spiral artery physiologic transformation without failure (P = .001). All placentas (30/30, 100%) with atherosis were identified in placentas having concomitant spiral artery endothelial and interstitial extravillous trophoblast activation.

CONCLUSION

Failure of spiral artery physiologic transformation in the placental basal plate is associated with interstitial extravillous trophoblast and arterial endothelial activation along with increased frequency of spiral artery atherosis. These findings may be used to improve the characterization of different disorders of the placental bed such as in refining the existing tools for the early prediction of risk for preterm, preeclamptic, and other abnormal pregnancies.

Associations of lipid levels during gestation with hypertensive disorders of pregnancy and gestational diabetes mellitus: a prospective longitudinal cohort study

OBJECTIVE

To assess associations of elevated lipid levels during gestation with hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM).

METHODS

This prospective cohort study was conducted in a tertiary maternal hospital in Shanghai, China from February to November 2014. Lipid constituents, including triglycerides (TGs), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c) and high-density lipoprotein cholesterol (HDL-c) of 1310 eligible women were assessed in the first (10-13+ weeks), second (22-28 weeks) and third (30-35 weeks) trimesters consecutively. Associations of lipid profiles with HDP and/or GDM outcomes were assessed.

RESULTS

Compared with the normal group, maternal TG concentrations were higher in the HDP/GDM groups across the three trimesters (p<0.001); TC and LDL-c amounts were only higher in the first trimester for the HDP and GDM groups (p<0.05). HDL-c levels were similar in the three groups. Compared with intermediate TG levels (25-75th centile), higher TG amounts (>75th centile) were associated with increased risk of HDP/GDM in each trimester with aORs (95% CI) of 2.04 (1.41 to 2.95), 1.81 (1.25 to 2.63) and 1.78 (1.24 to 2.54), respectively. High TG elevation from the first to third trimesters (>75th centile) was associated with increased risk of HDP, with an aOR of 2.09 (1.16 to 3.78). High TG elevation before 28 weeks was associated with increased risk of GDM, with an aOR of 1.67 (1.10 to 2.54). TG elevation was positively correlated with weight gain during gestation (R=0.089, p=0.005).

CONCLUSIONS

Controlling weight gain during pregnancy could decrease TG elevation and reduce the risk of HDP/GDM. TGs could be used as follow-up parameters during complicated pregnancy, while other lipids are meaningful only in the first trimester.

Preeclampsia; short and long-term consequences for mother and neonate

Preeclampsia is a common pregnancy specific disease, that presents with hypertension and a variety of organ failures, including malfunction of kidneys, liver and lungs. At present, the only definitive treatment of preeclampsia is end the pregnancy and deliver the neonate and placenta. For women with mild preeclampsia in the preterm phase of pregnancy, expectant management is generally indicated to improve fetal maturity, often requiring maternal medical treatment. Last decades, more evidence is available that the underlying mechanism of preeclampsia, endothelial disease, is not limited to pregnancy but increases cardiovascular risk in later life. In this review, we present the most recent insight in preeclampsia with focus on impact on the fetus, short and long-term outcome of offspring's, and long-term outcome of women with a history of preeclampsia.

Adrenal, metabolic and cardio-renal dysfunction develops after pregnancy in rats born small or stressed by physiological measurements during pregnancy

KEY POINTS

Women born small are at an increased risk of developing pregnancy complications. Stress may further increase a woman's likelihood for an adverse pregnancy. Adverse pregnancy adaptations can lead to long-term diseases even after her pregnancy. The current study investigated the effects of stress during pregnancy on the long-term adrenal, metabolic and cardio-renal health of female rats that were born small. Stress programmed increased adrenal Mc2r gene expression, a higher insulin secretory response to glucose during intraperitoneal glucose tolerance test (+36%) and elevated renal creatinine clearance after pregnancy. Females that were born small had increased homeostatic model assessment-insulin resistance and elevated systolic blood pressure after pregnancy, regardless of stress exposure. These findings suggest that being born small or being stressed during pregnancy programs long-term adverse health outcomes after pregnancy. However, stress in pregnancy does not exacerbate the long-term adverse health outcomes for females that were born small.

ABSTRACT

Females born small are more likely to experience complications during their pregnancy, including pregnancy-induced hypertension, pre-eclampsia and gestational diabetes. The risk of developing complications is increased by stress exposure during pregnancy. In addition, pregnancy complications may predispose the mother to diseases after pregnancy. We determined whether stress during pregnancy would exacerbate the adrenal, metabolic and cardio-renal dysfunction of growth-restricted females in later life. Late gestation bilateral uterine vessel ligation was performed in Wistar Kyoto rats to induce growth restriction. At 4 months, growth-restricted and control female offspring were mated with normal males. Those allocated to the stressed group had physiological measurements [metabolic cage, tail cuff blood pressure, intraperitoneal glucose tolerance test (IPGTT)] conducted during pregnancy whilst the unstressed groups were unhandled. After the completion of pregnancy, dams were aged to 12 months and blood pressure, and metabolic and renal function were assessed. At 13 months, adrenal glands, pancreases and plasma were collected at post-mortem. Females stressed during pregnancy had increased adrenal Mc2r gene expression (+22%), higher insulin secretory response to glucose during IPGTT (+36%) and higher creatinine clearance (+29%, indicating increased estimated glomerular filtration rate). In contrast, females that were born small had increased homeostatic model assessment-insulin resistance (+54%), increased water intake (+23%), urine output (+44%) and elevated systolic blood pressure (+7%) regardless of exposure to stress. Our findings suggest that low maternal birth weight and maternal stress exposure during pregnancy are both independently detrimental for long-term adrenal, metabolic and cardio-renal health of the mother, although their effects were not exacerbated.

Programming of maternal and offspring disease: impact of growth restriction, fetal sex and transmission across generations

Babies born small are at an increased risk of developing myriad adult diseases. While growth restriction increases disease risk in all individuals, often a second hit is required to unmask 'programmed' impairments in physiology. Programmed disease outcomes are demonstrated more commonly in male offspring compared with females, with these sex-specific outcomes partly attributed to different placenta-regulated growth strategies of the male and female fetus. Pregnancy is known to be a major risk factor for unmasking a number of conditions and can be considered a 'second hit' for women who were born small. As such, female offspring often develop impairments of physiology for the first time during pregnancy that present as pregnancy complications. Numerous maternal stressors can further increase the risk of developing a maternal complication during pregnancy. Importantly, these maternal complications can have long-term consequences for both the mother after pregnancy and the developing fetus. Conditions such as preeclampsia, gestational diabetes and hypertension as well as thyroid, liver and kidney diseases are all conditions that can complicate pregnancy and have long-term consequences for maternal and offspring health. Babies born to mothers who develop these conditions are often at a greater risk of developing disease in adulthood. This has implications as a mechanism for transmission of disease across generations. In this review, we discuss the evidence surrounding long-term intergenerational implications of being born small and/or experiencing stress during pregnancy on programming outcomes.

Pregnancy-Associated Hypertension in Glucose-Intolerant Pregnancy and Subsequent Metabolic Syndrome

OBJECTIVE

To evaluate whether pregnancy-associated hypertension (preeclampsia or gestational hypertension) among women with varying degrees of glucose intolerance during pregnancy is associated with maternal metabolic syndrome 5-10 years later.

METHODS

This was an observational cohort study of women previously enrolled in a treatment trial of mild gestational diabetes mellitus or an observational study of lesser degrees of glucose intolerance evaluated 5-10 years after their index pregnancy. At follow-up, women underwent anthropometric and blood pressure measurements and analysis of fasting glucose and serum lipids.

RESULTS

A total of 825 women (47% of eligible women from the original study) were included in this analysis and evaluated at a median 7 years after their index pregnancy at a median age of 35 years. Overall, 239 (29%) had subsequent metabolic syndrome. The frequency of metabolic syndrome and its components was highest in the women who had pregnancy-associated hypertension and delivered preterm. After adjusting for confounding factors, pregnancy-associated hypertension in women who delivered preterm was associated with subsequent hypertension (130/85 mm Hg or greater; relative risk 3.06, 95% confidence interval [CI] 1.95-4.80, P<.001), high triglycerides (150 mg/dL or greater; relative risk 1.82, 95% CI 1.06-3.14, P=.03), and metabolic syndrome (per the American Heart Association and National Heart Lung and Blood Institute Scientific Statement; relative risk 1.78, 95% CI 1.14-2.78, P=.01) compared with women who remained normotensive throughout their index pregnancy and were delivered at term.

CONCLUSION

Women with varying degrees of glucose intolerance who experienced pregnancy-associated hypertension and then delivered preterm had a higher frequency of subsequent hypertension, high triglycerides, and metabolic syndrome 5-10 years later.