History of preterm birth and subsequent cardiovascular disease: a systematic review

The association between maternal prenatal hair cortisol concentration and preterm birth: A systematic review and meta-analysis

BACKGROUND

The risk of preterm birth (PTB) increases when experiencing stress during pregnancy. Chronic stress has been associated with a dysregulation of the hypothalamic-pituitary-adrenal axis, for which hair cortisol concentration (HCC) is a promising biomarker. However, previous studies on the association between HCC and PTB yielded inconsistent results. This systematic review and meta-analysis synthesized previous studies on the association between maternal HCC before and during pregnancy and spontaneous PTB.

METHODS

Data was extracted from N = 11 studies with k = 19 effect sizes retrieved from PubMed, Embase, Web of Science, CINAHL and citation searching by hand in June 2023 and updated in October 2023. Standardized mean differences were calculated, and a random-effects three-level meta-analysis was conducted. Effect heterogeneity was assessed using Q and I2.

RESULTS

HCC during pregnancy was higher among PTB than term groups, but effects were not statistically significant (z = 0.11, 95% CI: - 0.28, 0.51, p = .54) and total heterogeneity was high (Q16 = 60.01, p < .001, I2Total = 92.30%). After leaving out two possible outlier studies in sensitivity analyses, HCC was lower among preterm compared to term delivering groups, although not statistically significant (z = - 0.06, 95% CI: - 0.20, 0.08, p = .39) but with a substantially reduced total heterogeneity (Q12 = 16.45, p = .17, I2Total = 42.15%). No moderators affected the estimates significantly, but an effect of trimester and gestational age at delivery is likely.

CONCLUSION

There is currently no evidence of prenatal HCC differences between PTB and term groups as effects were small, imprecise, and not significant. Low statistical power and methodological weaknesses of the small-scale studies challenge possible biological inferences from the small effects, but further research on HCC during pregnancy is highly encouraged.

The Association Between Pre-Pregnancy and First-Trimester Hair Cortisol and Preterm Birth: A Causal Inference Model

Background Adverse life events and chronic psychological distress before and during pregnancy have frequently been associated with preterm birth (PTB) but the biological underpinnings remain unclear. We investigated the association between corticosteroid levels in pre-pregnancy and first-trimester hair and the risk of PTB. Methods We followed 1,808 pregnant women from a prospective pre-birth cohort study in Lima, Perú. Hair samples were taken at the end of the first pregnancy trimester. The two most proximal 3cm segments to the scalp (representing pre-pregnancy and first-trimester) were analyzed to obtain hair cortisol and cortisone concentrations (HCC and HCNC). PTB was defined as birth < 37 completed gestational weeks. We constructed four generalized propensity scores for pre-pregnancy and first-trimester HCC and HCNC to create corresponding inverse probability weights before fitting marginal structural models for estimating the effect of HCC and HCNC on PTB risk. Results Pre-pregnancy Log HCC was not independently associated with PTB risk (RR = 0.97; 95%CI: 0.79, 1.19). In contrast, one SD increase from the mean first-trimester Log HCC was independently associated with a 37% (95%CI: 1.11, 1.69) increased risk of PTB. Although imprecise, pre-pregnancy Log HCNC was negatively associated with PTB risk (RR = 0.84; 95%CI: 0.58, 1.20), whereas the association between first-trimester Log HCNC and PTB risk was positive (RR = 1.20; 95%CI: 0.87, 1.65). Conclusions Our findings show that chronic corticosteroid levels in early pregnancy are causally linked to PTB risk in pregnant Peruvian women. This finding contributes to understanding the biological underpinnings of PTB better to enhance PTB prevention.

Hypertensive disorders of pregnancy and long-term maternal cardiovascular risk: Bridging epidemiological knowledge into personalized postpartum care and follow-up

Cardiovascular disease (CVD) is globally the leading cause of death and disability. Sex-specific causes of female CVD are under-investigated. Pregnancy remains an underinvestigated sex-specific stress test for future CVD and a hitherto missed opportunity to initiate prevention of CVD at a young age. Population-based studies show a strong association between female CVD and hypertensive disorders of pregnancy. This association is also present after other pregnancy complications that are associated with placental dysfunction, including fetal growth restriction, preterm delivery and gestational diabetes mellitus. Few women are, however, offered systematic cardio-preventive follow-up after such pregnancy complications. These women typically seek help from the health system at first clinical symptom of CVD, which may be decades later. By this time, morbidity is established and years of preventive opportunities have been missed out. Early identification of modifiable risk factors starting postpartum followed by systematic preventive measures could improve maternal cardiovascular health trajectories, promoting healthier societies. In this non-systematic review we briefly summarize the epidemiological associations and pathophysiological hypotheses for the associations. We summarize current clinical follow-up strategies, including some proposed by international and national guidelines as well as user support groups. We address modifiable factors that may be underexploited in the postpartum period, including breastfeeding and blood pressure management. We suggest a way forward and discuss the remaining knowledge gaps and barriers for securing the best evidence-based follow-up, relative to available resources after a hypertensive pregnancy complication in order to prevent or delay onset of premature CVD.

Developmental priming of early cerebrovascular ageing: Implications across a lifetime

INTRODUCTION

Neurological conditions such as Alzheimer's disease and stroke represent a substantial health burden to the world's ageing population. Cerebrovascular dysfunction is a key contributor to these conditions, affecting an individual's risk profile, age of onset, and severity of neurological disease. Recent data shows that early-life events, such as maternal health during pregnancy, birth weight and exposure to environmental toxins can 'prime' the vascular system for later changes. With age, blood vessels can become less flexible and more prone to damage. This can lead to reduced blood flow to the brain, which is associated with cognitive decline and an increased risk of stroke and other cerebrovascular diseases. These in turn increase the risk of vascular dementia and Alzheimer's disease.

OBJECTIVES

We aim to explore how early life factors influence cerebrovascular health, ageing and disease.

METHODS

We have reviewed recently published literature from epidemiological studies, clinical cases and basic research which explore mechanisms that contribute to cerebrovascular and blood-brain barrier dysfunction, with a particularly focus on those that assess contribution of early-life events or vascular priming to subsequent injury.

RESULTS

Perinatal events have been linked to acute cerebrovascular dysfunction and long-term structural reorganisation. Systemic disease throughout the lifetime that produce inflammatory or oxidative stress may further sensitise the cerebrovasculature to disease and contribute to neurodegeneration.

CONCLUSIONS

By identifying these early-life determinants and understanding their mechanisms, scientists aim to develop strategies for preventing or mitigating cerebrovascular ageing-related issues.

Determinants of prematurity in urban Indonesia: a meta-analysis

OBJECTIVES

Indonesia is the fifth country with the highest number of preterm births worldwide. More than a third of neonatal deaths in Indonesia were attributed to preterm birth. Residential areas affected the occurrence of preterm birth due to differing socioeconomic and environmental conditions. Many studies have investigated the determinants of prematurity in Indonesia, however, most of them were performed in rural areas. This study is the first meta-analysis describing the determinants of preterm birth in urban Indonesia, which aimed to become the foundation upon implementing the most suitable preventative measure and policy to reduce the rate of preterm birth.

METHODS

We collected all published papers investigating the determinants of preterm birth in urban Indonesia from PubMed MEDLINE and EMBASE, using keywords developed from the following key concepts: "preterm birth", "determinants", "risk factors", "Indonesia" and the risk factors, such as "high-risk pregnancy", "anemia", "pre-eclampsia", and "infections". Exclusion criteria were multicenter studies that did not perform a specific analysis on the Indonesian population or did not separate urban and rural populations in their analysis, and articles not available in English or Indonesian. The Newcastle Ottawa Scale was used to assess the risk of bias. This systematic review was registered in PROSPERO.

RESULTS

Sixteen articles were included in the analysis and classified into five categories: genetic factors, nutrition, smoking, pregnancy characteristics or complications, and disease-related characteristics.

CONCLUSIONS

Our meta-analysis revealed adolescent pregnancy, smoking, eclampsia, bacterial vaginosis, LC-PUFA, placental vitamin D, and several minerals as the significant determinants of preterm birth in urban Indonesia.

Mother's age at menarche is associated with odds of preterm delivery: A case-control study

OBJECTIVE

There is a secular trend towards earlier age of menarche in the US and globally. Earlier age at menarche (AAM) has been associated with metabolic disorders that increase risk for preterm delivery (PTD), yet no studies in the US have investigated whether AAM influences risk of PTD. This study tested the hypothesis that AAM is associated with PTD.

DESIGN

A case-control study.

SETTING

The Boston Medical Center (BMC) in Boston, Massachusetts.

POPULATION OR SAMPLE

8264 mother-newborn dyads enrolled at birth at BMC between 1998 and 2019, of which 2242 mothers had PTD (cases) and 6022 did not have PTD (controls).

METHODS

Multivariable-adjusted logistic regression models and restricted cubic splines were used to examine the association between AAM and risk of PTD. The combined impact of AAM and age at delivery on the risk of PTD was also examined.

MAIN OUTCOME MEASURES

Preterm delivery and gestational age (GA) was defined by maternal last menstrual period and early ultrasound documented in medical records.

RESULTS

Maternal age at delivery was 28.1 ± 6.5 years and AAM was 12.85 ± 1.86 years. Multivariable-adjusted cubic spline suggested an inverse dose-response association of AAM with odds of PTD and, consistently, a positive association with GA. A 1-year earlier AAM was associated with 5% (95% CI 2%-8%) higher odds of PTD, after adjustment for maternal year of birth, parity, maternal place of birth, education, smoking status and Mediterranean-style diet score. The association between AAM and PTD was stronger among older mothers whose age at delivery was ≥35 years.

CONCLUSIONS

Earlier AAM is associated with higher odds for PTD, and this association is stronger among women at advanced reproductive age.

Cardiovascular diseases in women - Consensus document of the Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Ginecologia, Sociedade Portuguesa de Obstetrícia e Medicina Materno-Fetal, Sociedade Portuguesa de Contraceção e Associação Portuguesa de Medicina Geral e Familiar

The main objective of this consensus statement from the Portuguese Society of Cardiology, the Portuguese Society of Gynecology, the Portuguese Society of Obstetrics and Maternal-Fetal Medicine, Portuguese Society of Contraception, Portuguese Association of General Practice and Family Medicine is to improve cardiovascular care for women. It includes a brief review of the state-of-the-art of cardiovascular diseases in women and of the links to other fields such as Gynaecology, Obstetrics and Endocrinology. It also provides final recommendations to help clinicians working in care of women's health.

Vaginal progesterone for preventing preterm birth and adverse perinatal outcomes in twin gestations: a systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of vaginal progesterone for the prevention of preterm birth and adverse perinatal outcomes in twin gestations.

DATA SOURCES

MEDLINE, Embase, LILACS, and CINAHL (from their inception to January 31, 2023), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared vaginal progesterone to placebo or no treatment in asymptomatic women with a twin gestation.

METHODS

The systematic review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was preterm birth <34 weeks of gestation. Secondary outcomes included adverse perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. We assessed the risk of bias in each included study, heterogeneity, publication bias, and quality of evidence, and performed subgroup and sensitivity analyses.

RESULTS

Eleven studies (3401 women and 6802 fetuses/infants) fulfilled the inclusion criteria. Among all twin gestations, there were no significant differences between the vaginal progesterone and placebo or no treatment groups in the risk of preterm birth <34 weeks (relative risk, 0.99; 95% confidence interval, 0.84-1.17; high-quality evidence), <37 weeks (relative risk, 0.99; 95% confidence interval, 0.92-1.06; high-quality evidence), and <28 weeks (relative risk, 1.00; 95% confidence interval, 0.64-1.55; moderate-quality evidence), and spontaneous preterm birth <34 weeks of gestation (relative risk, 0.97; 95% confidence interval, 0.80-1.18; high-quality evidence). Vaginal progesterone had no significant effect on any of the perinatal outcomes evaluated. Subgroup analyses showed that there was no evidence of a different effect of vaginal progesterone on preterm birth <34 weeks of gestation related to chorionicity, type of conception, history of spontaneous preterm birth, daily dose of vaginal progesterone, and gestational age at initiation of treatment. The frequencies of preterm birth <37, <34, <32, <30, and <28 weeks of gestation and adverse perinatal outcomes did not significantly differ between the vaginal progesterone and placebo or no treatment groups in unselected twin gestations (8 studies; 3274 women and 6548 fetuses/infants). Among twin gestations with a transvaginal sonographic cervical length <30 mm (6 studies; 306 women and 612 fetuses/infants), vaginal progesterone was associated with a significant decrease in the risk of preterm birth occurring at <28 to <32 gestational weeks (relative risks, 0.48-0.65; moderate- to high-quality evidence), neonatal death (relative risk, 0.32; 95% confidence interval, 0.11-0.92; moderate-quality evidence), and birthweight <1500 g (relative risk, 0.60; 95% confidence interval, 0.39-0.88; high-quality evidence). Vaginal progesterone significantly reduced the risk of preterm birth occurring at <28 to <34 gestational weeks (relative risks, 0.41-0.68), composite neonatal morbidity and mortality (relative risk, 0.59; 95% confidence interval, 0.33-0.98), and birthweight <1500 g (relative risk, 0.55; 95% confidence interval, 0.33-0.94) in twin gestations with a transvaginal sonographic cervical length ≤25 mm (6 studies; 95 women and 190 fetuses/infants). The quality of evidence was moderate for all these outcomes.

CONCLUSION

Vaginal progesterone does not prevent preterm birth, nor does it improve perinatal outcomes in unselected twin gestations, but it appears to reduce the risk of preterm birth occurring at early gestational ages and of neonatal morbidity and mortality in twin gestations with a sonographic short cervix. However, more evidence is needed before recommending this intervention to this subset of patients.

Long-term maternal mortality risk following spontaneous preterm birth: A retrospective cohort study

OBJECTIVE

To determine whether women with spontaneous preterm birth (PTB) have increased risks for long-term mortality.

DESIGN

Retrospective cohort.

SETTING

Births in Utah between 1939 and 1977.

POPULATION

We included women with a singleton live birth ≥20 weeks who survived at least 1 year following delivery. We excluded those who had never lived in Utah, had improbable birthweight/gestational age combinations, underwent induction (except for preterm membrane rupture) or had another diagnosis likely to cause PTB.

METHODS

Exposed women had ≥1 spontaneous PTB between 20+0  weeks and 37+0  weeks. Women with >1 spontaneous PTB were included only once. Unexposed women had all deliveries at or beyond 38+0  weeks. Exposed women were matched to unexposed women by birth year, infant sex, maternal age group and infant birth order. Included women were followed up to 39 years after index delivery.

MAIN OUTCOME MEASURES

Overall and cause-specific mortality risks were compared using Cox regression.

RESULTS

We included 29 048 exposed and 57 992 matched unexposed women. There were 3551 deaths among exposed (12.2%) and 6013 deaths among unexposed women (10.4%). Spontaneous PTB was associated with all-cause mortality (adjusted hazard ratio [aHR] 1.26, 95% confidence interval [CI] 1.21-1.31), death from neoplasms (aHR 1.10, 95% CI 1.02-1.18), circulatory disease (aHR 1.35, 95% CI 1.25-1.46), respiratory disease (aHR 1.73, 95% CI 1.46-2.06), digestive disease (aHR 1.33, 95% CI 1.12-1.58), genito-urinary disease (aHR 1.60, 95% CI 1.15-2.23) and external causes (aHR 1.39, 95% CI 1.22-1.58).

CONCLUSIONS

Spontaneous PTB is associated with modestly increased risks for all-cause and some cause-specific mortality.

Serum Cotinine and Adverse Cardiovascular Outcomes: A Cross-sectional Secondary Analysis of the nuMoM2b Heart Health Study

OBJECTIVE

We aimed to (1) compare serum cotinine with self-report for ascertaining smoking status among reproductive-aged women; (2) estimate the relative odds of adverse cardiovascular (CV) outcomes among women by smoking status; (3) assess whether the association between adverse pregnancy outcomes (APOs) and CV outcomes varies by smoking status.

STUDY DESIGN

We conducted a cross-sectional study of the nuMoM2b Heart Health Study. Women attended a study visit 2 to 7 years after their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine. Outcomes included incident chronic hypertension (HTN), metabolic syndrome (MetS), and dyslipidemia. Multivariable logistic regression estimated odds ratios (ORs) for each outcome by smoking status.

RESULTS

Of 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as secondhand smoke exposure, and 720 as smokers. Of 3,144 women who denied tobacco smoke exposure, serum cotinine was consistent with secondhand smoke exposure in 48 (1.5%) and current smoking in 131 (4.2%) After adjustment for APOs, smoking defined by serum cotinine was associated with MetS (adjusted OR [aOR] = 1.52, 95% confidence interval [CI]: 1.21, 1.91) and dyslipidemia (aOR = 1.28, 95% CI: 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR = 1.64, 95% CI: 1.32, 2.03) and stage 2 HTN (aOR = 2.92, 95% CI: 2.17, 3.93), MetS (aOR = 1.76, 95% CI: 1.42, 2.18), and dyslipidemia (aOR = 1.55, 95% CI: 1.25, 1.91) relative to women with no APO. Results were similar when smoking exposure was defined by self-report.

CONCLUSION

Whether determined by serum cotinine or self-report, smoking is associated with subsequent CV outcomes in reproductive-aged women. APOs are also independently associated with CV outcomes in women.

KEY POINTS

· Cotinine was detected in 5.7% of reported nonsmokers.. · Smoking and APOs were independently associated with CV health.. · Smoking was associated with MetS and dyslipidemia..

Pregnancy complications in last pregnancy and mothers' long-term cardiovascular mortality: does the relation differ from that of complications in first pregnancy? A population-based study

BACKGROUND

Women who experience complications in first pregnancy are at increased risk of cardiovascular disease (CVD) later in life. Little corresponding knowledge is available for complications in later pregnancies. Therefore, we assessed complications (preeclampsia, preterm birth, and offspring small for gestational age) in first and last pregnancies and the risk of long-term maternal CVD death, taking women´s complete reproduction into account.

DATA AND METHODS

We linked data from the Medical Birth Registry of Norway to the national Cause of Death Registry. We followed women whose first birth took place during 1967-2013, from the date of their last birth until death, or December 31st 2020, whichever occurred first. We analysed risk of CVD death until 69 years of age according to any complications in last pregnancy. Using Cox regression analysis, we adjusted for maternal age at first birth and level of education.

RESULTS

Women with any complications in their last or first pregnancy were at higher risk of CVD death than mothers with two-lifetime births and no pregnancy complications (reference). For example, the adjusted hazard ratio (aHR) for women with four births and any complications only in the last pregnancy was 2.85 (95% CI, 1.93-4.20). If a complication occurred in the first pregnancy only, the aHR was 1.74 (1.24-2.45). Corresponding hazard ratios for women with two births were 1.82 (CI, 1.59-2.08) and 1.41 (1.26-1.58), respectively.

CONCLUSIONS

The risk for CVD death was higher among mothers with complications only in their last pregnancy compared to women with no complications, and also higher compared to mothers with a complication only in their first pregnancy.

The association between spontaneous preterm birth and maternal hypertension in the fifth decade of life: a retrospective case-control study

OBJECTIVE

To investigate whether a history of spontaneous preterm birth (SPTB) predisposes to maternal hypertension.

DESIGN

Retrospective case-control study.

SETTING

Two affiliated university medical hospitals in Amsterdam, the Netherlands.

POPULATION

We included 350 women with a history of SPTB between 22 and 36⁺⁶  weeks and 166 women with a history of a term birth. Women with pregnancy complications that are known to be associated with cardiovascular disease were excluded.

METHODS

Both groups underwent cardiovascular risk assessment 9-16 years after pregnancy. We performed a subgroup analysis based upon the severity of SPTB.

MAIN OUTCOME MEASURES

Hypertension. Secondary outcomes - metabolic syndrome, mean blood pressure, anthropometrics, blood and urine sampling, Framingham Risk Score and Systematic Coronary Risk Evaluation.

RESULTS

A history of SPTB was significantly associated with hypertension; adjusted odds ratio 1.60 (95% confidence interval 1.04-2.46, p = 0.033). Abdominal obesity was more often diagnosed after SPTB (n = 163, 46.6% versus n = 54, 32.5%, p = 0.003) and was more pronounced with more severe preterm birth (p = 0.002).

CONCLUSIONS

The presence of hypertension 9-16 years after pregnancy was statistically significantly higher among women with a history of SPTB than among women with a history of uncomplicated term birth. Women with a history of SPTB were more often diagnosed with abdominal obesity, especially those with a history of extreme preterm birth.

Pregnancy-Related Complications and Incidence of Atrial Fibrillation: A Systematic Review

Pregnancy-related complications are associated with a higher risk of various incident cardiovascular diseases, but their specific potential relationship with incident atrial fibrillation (AF) is less clear. This systematic review summarises the available evidence from observational studies which have examined associations between pregnancy-related complications and the risk of AF. MEDLINE and EMBASE (Ovid) were searched for studies between 1990 to 10 February 2022. Pregnancy-related complications examined included hypertensive disorders of pregnancy (HDP), gestational diabetes, placental abruption, preterm birth, small-for-gestational-age and stillbirth. Study selection, data extraction and quality assessment were completed independently by two reviewers. Narrative synthesis was used to evaluate the results of the included studies. Nine observational studies were included, with eight eligible for narrative synthesis. Sample sizes ranged from 1839 to 2,359,386. Median follow-up ranged from 2 to 36 years. Six studies reported that pregnancy-related complications were associated with a significantly increased risk of incident AF. Hazard ratios (HRs) (95% confidence intervals) for the four studies that evaluated HDP ranged from 1.1 (0.8-1.6) to 1.9 (1.4-2.7). For the four studies that evaluated pre-eclampsia, HRs ranged from 1.2 (0.9-1.6) to 1.9 (1.7-2.2). Current evidence from observational studies suggests pregnancy-related complications are associated with a significantly higher risk of incident AF. However, only a small number of studies examining each pregnancy-related complication were identified, and considerable statistical heterogeneity was observed. Further large-scale prospective studies are required to confirm the association between pregnancy-related complications and incident AF.

Vaginal progesterone for the prevention of preterm birth: who can benefit and who cannot? Evidence-based recommendations for clinical use

Vaginal progesterone (VP) has been recommended to prevent preterm birth (PTB) in women at high-risk. However, there is controversy as to whether VP is efficacious in some subsets of high-risk women. In this review, we examined the current best evidence on the efficacy of VP to prevent PTB in several subsets of high-risk women and provided recommendations for its clinical use. Compelling evidence indicates that VP reduces the risk of PTB and improves perinatal outcomes in singleton gestations with a short cervix (≤25 mm), both with and without a history of spontaneous PTB. VP appears promising to reduce the risk of PTB in twin gestations with a short cervix (≤25 mm) and in singleton gestations conceived by assisted reproductive technologies, but further research is needed. There is no convincing evidence that supports prescribing VP to prevent PTB in singleton gestations based solely on the history of spontaneous preterm birth. Persuasive evidence shows that VP does not prevent PTB nor does it improve perinatal outcomes in unselected twin gestations and in singleton gestations with a history of spontaneous PTB and a cervical length >25 mm. There is no evidence supporting the use of VP to prevent PTB in triplet or higher-order multifetal gestations, singleton gestations with a positive fetal fibronectin test and clinical risk factors for PTB, and gestations with congenital uterine anomalies or uterine leiomyoma. In conclusion, current evidence indicates that VP should only be recommended in singleton gestations with a short cervix, regardless of the history of spontaneous PTB.

Association of pregnancy complications/risk factors with the development of future long-term health conditions in women: overarching protocol for umbrella reviews

INTRODUCTION

With good medical care, most pregnancy complications like pre-eclampsia, gestational diabetes, etc resolve after childbirth. However, pregnancy complications are known to be associated with an increased risk of new long-term health conditions for women later in life, such as cardiovascular disease. These umbrella reviews aim to summarise systematic reviews evaluating the association between pregnancy complications and five groups of long-term health conditions: autoimmune conditions, cancers, functional disorders, mental health conditions and metabolic health conditions (diabetes and hypertension).

METHODS AND ANALYSIS

We will conduct searches in Medline, Embase and the Cochrane database of systematic reviews without any language restrictions. We will include systematic reviews with or without meta-analyses that studied the association between pregnancy complications and the future risk of the five groups of long-term health conditions in women. Pregnancy complications were identified from existing core outcome sets for pregnancy and after consultation with experts. Two reviewers will independently screen the articles. Data will be synthesised with both narrative and quantitative methods. Where a meta-analysis has been carried out, we will report the combined effect size from individual studies. For binary data, pooled ORs with 95% CIs will be presented. For continuous data, we will use the mean difference with 95% CIs. The findings will be presented in forest plots to assess heterogeneity. The methodological quality of the studies will be evaluated with the AMSTAR 2 tool or the Cochrane risk of bias tool. The corrected covered area method will be used to assess the impact of overlap in reviews. The findings will be used to inform the design of prediction models, which will predict the risk of women developing these five group of health conditions following a pregnancy complication.

ETHICS AND DISSEMINATION

No ethical approvals required. Findings will be disseminated through publications in peer-reviewed journals and conference presentations.

Does vaginal progesterone prevent recurrent preterm birth in women with a singleton gestation and a history of spontaneous preterm birth? Evidence from a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of vaginal progesterone to prevent recurrent preterm birth and adverse perinatal outcomes in singleton gestations with a history of spontaneous preterm birth.

DATA SOURCES

MEDLINE, Embase, LILACS, and CINAHL (from their inception to February 28, 2022), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared vaginal progesterone to placebo or no treatment in asymptomatic women with a singleton gestation and a history of spontaneous preterm birth.

METHODS

The primary outcomes were preterm birth <37 and <34 weeks of gestation. The secondary outcomes included adverse maternal and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. We assessed the risk of bias in the included studies, heterogeneity (I2 test), small-study effects, publication bias, and quality of evidence; performed subgroup and sensitivity analyses; and calculated 95% prediction intervals and adjusted relative risks.

RESULTS

Ten studies (2958 women) met the inclusion criteria: 7 with a sample size <150 (small studies) and 3 with a sample size >600 (large studies). Among the 7 small studies, 4 were at high risk of bias, 2 were at some concerns of bias, and only 1 was at low risk of bias. All the large studies were at low risk of bias. Vaginal progesterone significantly decreased the risk of preterm birth <37 weeks (relative risk, 0.64; 95% confidence interval, 0.50-0.81; I2=75%; 95% prediction interval, 0.31-1.32; very low-quality evidence) and <34 weeks (relative risk, 0.62; 95% confidence interval, 0.42-0.92; I2=66%; 95% prediction interval, 0.23-1.68; very low-quality evidence), and the risk of admission to the neonatal intensive care unit (relative risk, 0.53; 95% confidence interval, 0.33-0.85; I2=67%; 95% prediction interval, 0.16-1.79; low-quality evidence). There were no significant differences between the vaginal progesterone and the placebo or no treatment groups in other adverse perinatal and maternal outcomes. Subgroup analyses revealed that vaginal progesterone decreased the risk of preterm birth <37 weeks (relative risk, 0.43; 95% confidence interval, 0.33-0.55; I2=0%) and <34 weeks (relative risk, 0.27; 95% confidence interval, 0.15-0.49; I2=0%) in the small but not in the large studies (relative risk, 0.98; 95% confidence interval, 0.88-1.09; I2=0% for preterm birth <37 weeks; and relative risk, 0.94; 95% confidence interval, 0.78-1.13; I2=0% for preterm birth <34 weeks). Sensitivity analyses restricted to studies at low risk of bias indicated that vaginal progesterone did not reduce the risk of preterm birth <37 weeks (relative risk, 0.96; 95% confidence interval, 0.84-1.09) and <34 weeks (relative risk, 0.90; 95% confidence interval, 0.71-1.15). There was clear evidence of substantial small-study effects in the meta-analyses of preterm birth <37 and <34 weeks of gestation because of funnel plot asymmetry and the marked differences in the pooled relative risks obtained from fixed-effect and random-effects models. The adjustment for small-study effects resulted in a markedly reduced and nonsignificant effect of vaginal progesterone on preterm birth <37 weeks (relative risk, 0.86; 95% confidence interval, 0.68-1.10) and <34 weeks (relative risk, 0.92; 95% confidence interval, 0.60-1.42).

CONCLUSION

There is no convincing evidence supporting the use of vaginal progesterone to prevent recurrent preterm birth or to improve perinatal outcomes in singleton gestations with a history of spontaneous preterm birth.

Adverse Pregnancy Outcomes and Postpartum Care as a Pathway to Future Health

Adverse pregnancy outcomes (APOs) collectively represent the leading causes of maternal and neonatal morbidity and mortality. Beyond the potentially devastating impact of APOs during pregnancy and the puerperium, women diagnosed with APOs have a 2-fold to 4-fold increased risk of future cardiovascular disease. Fortunately, APOs occur at an opportune time, in early-adulthood to mid-adulthood, when primary and secondary prevention strategies can alter the disease trajectory and improve long-term health outcomes. This chapter takes a life-course approach to (1) the epidemiology of APOs, (2) evidence-based strategies for clinicians to manage APOs, and (3) future directions for APO research and clinical practice.

Miscarriage syndrome: Linking early pregnancy loss to obstetric and age-related disorders

Upon embryo implantation, the uterine mucosa - the endometrium - transforms into a robust decidual matrix that accommodates the fetal placenta throughout pregnancy. This transition is driven by the differentiation of endometrial fibroblasts into specialised decidual cells. A synchronised influx of circulating natural killer (NK) cells and bone marrow-derived mesenchymal stem/progenitor cells (BM-MSC) is pivotal for decidual homeostasis and expansion in early pregnancy. We hypothesise that pathological signals interfering with the recruitment or activity of extrauterine cells at the maternal-fetal interface link miscarriage to subsequent adverse pregnancy outcomes, including further pregnancy losses and preterm labour. NK cells and BM-MSC are key homeostatic regulators in multiple tissues, pointing towards a shared aetiology between recurrent miscarriage and age-related disorders, including cardiometabolic disease. We propose the term ‘miscarriage syndrome’ to capture the health risks associated with miscarriage and discuss how this paradigm can inform clinical practice and accelerate the development of preventative strategies.

Association between aspirin use during pregnancy and cardiovascular risk factors 2-7 years after delivery: The nuMoM2b Heart Health Study

OBJECTIVES

To evaluate the association between aspirin use during first pregnancy and later maternal cardiovascular risk.

STUDY DESIGN

In this secondary analysis of a prospective cohort, we included participants who carried their first pregnancy to 20 + weeks, had data regarding aspirin use, and attended a study visit 2-7 years following delivery. The exposure was aspirin use during the first pregnancy. We calculated aspirin use propensity scores from logistic regression models including baseline variables associated with aspirin use in pregnancy and cardiovascular risk. Outcomes of interest were incident cardiovascular-related diagnoses 2-7 years following delivery. Robust Poisson regression calculated the risk of outcomes by aspirin exposure, adjusting for the aspirin use propensity score.

MAIN OUTCOME MEASURES

The primary outcome was a composite of incident cardiovascular diagnoses at the time of the study visit: cardiovascular events, chronic hypertension, metabolic syndrome, prediabetes or type 2 diabetes, dyslipidemia, and chronic kidney disease.

RESULTS

Of 4,480 women included, 84 (1.9%) reported taking aspirin during their first pregnancy. 52.6% of participants in the aspirin-exposed group and 43.0% in the unexposed group had the primary outcome. After adjusting for the aspirin use propensity scores, aspirin use during the first pregnancy was not associated with any of the outcomes.

CONCLUSION

We did not detect an association between aspirin use during the first pregnancy and cardiovascular-related diagnoses 2-7 years later. Our study was only powered to detect a large difference in relative risk, so we cannot rule out a smaller difference that may be clinically meaningful.

Nativity-Related Disparities in Preterm Birth and Cardiovascular Risk in a Multiracial U.S. Cohort

INTRODUCTION

Having a preterm birth is associated with future cardiovascular risk. Non-Hispanic Black women have higher rates of preterm birth than non-Hispanic White and Hispanic women, but nativity-related disparities in preterm birth are not well understood.

METHODS

Data from 6,096 women in the Boston Birth Cohort: non-Hispanic Black (2,699), non-Hispanic White (997), or Hispanic (2,400), were analyzed in June 2021. Differences in cardiovascular risk factors were assessed. The association of preterm birth with nativity and duration of U.S. residence were investigated using multivariable logistic regression.

RESULTS

U.S.-born women in all 3 racial-ethnic groups had a higher prevalence of obesity, smoking, and severe stress than foreign-born women. Foreign-born non-Hispanic Black and Hispanic women had lower odds of preterm birth than U.S.-born counterparts (non-Hispanic Black: AOR=0.79, 95% CI=0.65, 0.97; Hispanic: AOR=0.72, 95% CI=0.56, 0.93). In all the 3 groups, foreign-born women with shorter (<10 years) duration of U.S. residence had lower odds of preterm birth than the U.S.-born women (non-Hispanic Black: AOR=0.57, 95% CI=0.43, 0.75; Hispanic: AOR=0.72, 95% CI=0.55, 0.94; non-Hispanic White: AOR=0.46, 95% CI=0.25, 0.85), whereas the odds of preterm birth in foreign-born women with ≥10 years of residence were not significantly different.

CONCLUSIONS

Foreign-born women had better cardiovascular risk profiles in all groups and lower odds of preterm birth in non-Hispanic Black and Hispanic groups. In all the 3 groups, a shorter duration of U.S. residence was associated with lower odds of preterm birth. Further studies are needed to understand the biological and social determinants underlying these nativity-related disparities and the impact of acculturation.

The Assessment of Maternal and Fetal Intima-Media Thickness in Perinatology

Intima-media thickness (IMT) measurement is a non-invasive method of arterial wall assessment. An increased IMT is a common manifestation of atherosclerosis associated with endothelial dysfunction. In the course of pregnancy, various maternal organs, including the endothelium, are prepared for their new role. However, several pre-gestational conditions involving endothelial dysfunction, such as diabetes, chronic hypertension, and obesity, may impair the adaptation to pregnancy, whereas vascular changes may also affect fetal development, thus, influencing the fetal IMT. In the conducted studies, a correlation was found between an increased fetal abdominal aorta IMT (aIMT) and placental dysfunctions, which may subsequently impact both the mother and the fetus, and contribute to gestational hypertension, preeclampsia (PE), and fetal growth restriction (FGR). In fact, data indicate that following the delivery, the endothelial dysfunction persists and influences the future health of the mother and the newborn. Hypertensive disorders in pregnancy increase the maternal risk of chronic hypertension, obesity, and vascular events. Moreover, individuals born from pregnancies complicated by preeclampsia or fetal growth restriction are at high risk of obesity, diabetes, hypertension, and cardiovascular disease. Therefore, understanding the pathomechanism underlying an increased aIMT in preeclampsia and FGR, as well as subsequent placental dysfunctions, is essential for developing targeted therapies. This review summarizes recent publications regarding IMT and demonstrates how IMT measurements affect predicting perinatal complications.

The Association of Preterm Birth With Maternal Nativity and Length of Residence Among Non-Hispanic Black Women

Background

Preterm birth (PTB) is associated with future cardiovascular disease (CVD) risk and disproportionally affects non-Hispanic Black (NHB) women. Limited data exist on the influence of length of US residence on nativity-related disparities in PTB. We examined PTB by maternal nativity (US born vs foreign born) and length of US residence among NHB women.

Methods

We analyzed data from 2699 NHB women (1607 US born; 1092 foreign born) in the Boston Birth Cohort, originally designed as a case-control study. Using multivariable logistic regression, we investigated the association of PTB with maternal nativity and length of US residence.

Results

In the total sample, 29.1% of women delivered preterm (31.4% and 25.6% among US born and foreign born, respectively). Compared with foreign born, US-born women were younger (25.8 vs 29.5 years), had higher prevalence of obesity (27.6% vs 19.6%), smoking (20.5% vs 4.9%), alcohol use (13.2% vs 7.4%), and moderate to severe stress (73.5% vs 59.4%) (all P < 0.001). Compared with US-born women, foreign-born women had lower odds of PTB after adjusting for sociodemographic characteristics, alcohol use, stress, parity, smoking, body mass index, chronic hypertension, and diabetes (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI], 0.65-0.97). Foreign-born NHB women with < 10 years of US residence had 43% lower odds of PTB compared with US-born (aOR, 0.57; 95% CI, 0.43-0.75), whereas those with ≥ 10 years of US residence did not differ significantly from US-born women in their odds of PTB (aOR, 0.76; 95% CI, 0.54-1.07).

Conclusions

The prevalence of CVD risk factors and proportion of women delivering preterm were lower in foreign-born than US-born NHB women. The "foreign-born advantage" was not observed with ≥ 10 years of US residence. Our study highlights the need to intensify public health efforts in exploring and addressing nativity-related disparities in PTB.

Maternal LINE-1 DNA Methylation in Early Spontaneous Preterm Birth

Despite considerable effort aimed at decreasing the incidence of spontaneous preterm birth (SPTB), it remains the leading cause of infant mortality and morbidity. The aim of this study was to evaluate maternal LINE-1 DNA methylation (DNAm), along with DNMT polymorphisms and factors proposed to modulate DNAm, in patients who delivered early preterm. This case-control study included women who delivered spontaneously early preterm (23-33^6/7 weeks of gestation), and control women. DNAm was analyzed in peripheral blood lymphocytes by quantification of LINE-1 DNAm using the MethyLight method. There was no significant difference in LINE-1 DNAm between patients with early PTB and controls. Among the investigated predictors, only the history of previous PTB was significantly associated with LINE-1 DNAm in PTB patients (β = -0.407; R² = 0.131; p = 0.011). The regression analysis showed the effect of DNMT3B rs1569686 TT+TG genotypes on LINE-1 DNAm in patients with familial PTB (β = -0.524; R² = 0.275; p = 0.037). Our findings suggest novel associations of maternal LINE-1 DNA hypomethylation with DNMT3B rs1569686 T allele. These results also contribute to the understanding of a complex (epi)genetic and environmental relationship underlying the early PTB.

Cardiovascular risk factors before and during pregnancy: Does pregnancy unmask or initiate risk?

OBJECTIVES

To understand if pregnancy unmasks previously silent cardiovascular (CV) adverse factors, or initiates lasting injury.

METHODS

Pre-pregnancy and during pregnancy CV risk factors (blood pressure, fasting lipids, and glucose) from 296 women belonging to studies in the International Childhood Cardiovascular Cohort (i3C) Consortium, a group of studies assessing the relationship between child and adolescent CV risk factors and adult outcomes, were used. Correlation coefficients between the pre- and during pregnancy measures were calculated, and the mean difference between the measures was modeled with adjustment for age, body mass index, race, smoking, and study.

RESULTS

Measures were strongly correlated at pre- and during-pregnancy visits (p < 0.01), with r of between 0.30 and 0.55. In most cases, the difference between pre-pregnancy and during-pregnancy did not differ significantly from 0 after adjustment for confounders. Stratification by gestational age indicated stronger correlations with measurements obtained during the first and second trimesters than the third. The correlation did not differ by the time elapsed between the pre-pregnancy and pregnancy visits.

CONCLUSIONS

Pre- and during-pregnancy CV risk factors are moderately well correlated. This may indicate that susceptible women enter pregnancy with higher risk rather than pregnancy inducing new vascular or metabolic effects.

Death of an offspring and parental risk of ischemic heart diseases: A population-based cohort study

BACKGROUND

The death of a child is an extreme life event with potentially long-term health consequences. Knowledge about its association with ischemic heart diseases (IHDs) and acute myocardial infarction (AMI), however, is very limited. We investigated whether the death of an offspring is associated with the risk of IHD and AMI.

METHODS AND FINDINGS

We studied parents of live-born children recorded in the Danish (1973 to 2016) and the Swedish (1973 to 2014) Medical Birth Registers (n = 6,711,952; mean age at baseline 31 years, 53% women). We retrieved information on exposure, outcomes, and covariates by linking individual-level information from several nationwide registers. We analyzed the abovementioned associations using Poisson regression. A total of 126,522 (1.9%) parents lost at least 1 child during the study period. Bereaved parents had a higher risk of IHD and AMI than the nonbereaved [incidence rate ratios (IRRs) (95% confidence intervals (CIs)): 1.20 (1.18 to 1.23), P < 0.001 and 1.21 (1.17 to 1.25), P < 0.001, respectively]. The association was present not only in case of losses due to CVD or other natural causes, but also in case of unnatural deaths. The AMI risk was highest in the first week after the loss [IRR (95% CI): 3.67 (2.08 to 6.46), P < 0.001], but a 20% to 40% increased risk was observed throughout the whole follow-up period. Study limitations include the possibility of residual confounding by socioeconomic, lifestyle, or health-related factors and the potentially limited generalizability of our findings outside Scandinavia.

CONCLUSIONS

The death of an offspring was associated with an increased risk of IHD and AMI. The finding that the association was present also in case of losses due to unnatural causes, which are less likely to be confounded by cardiovascular risk factors clustering in families, suggests that stress-related mechanisms may also contribute to the observed associations.

Clinical and biochemical signs of polycystic ovary syndrome in young women born preterm

OBJECTIVE

It has been suggested that adverse early life exposures increase the risk of developing polycystic ovary syndrome (PCOS) in later life. We hypothesized that women born preterm would have more biochemical and clinical signs of PCOS than women born at term.

DESIGN

The ESTER Preterm Birth Study participants were born in Northern Finland and identified from the Northern Finland Birth Cohort and the Finnish Medical Birth Register. Altogether, 74 women born very or moderately preterm (<34 gestational weeks, VMPT), 127 born late preterm (at 34-36 weeks, LPT), and 184 born full term (≥37 weeks, controls) were included in the analysis (mean age: 23.2 years).

METHODS

We measured serum total testosterone and sex hormone-binding globulin (SHBG) and calculated the free androgen index (FAI). PCOS according to the clinical and biochemical signs was defined either as hirsutism and oligoamenorrhea (via questionnaire) or as oligoamenorrhea and elevated testosterone levels (>2.4 nmol/L).

RESULTS

Women born VMPT/LPT exhibited 33.0% (8.7, 62.8)/16.4% (-2.0, 38.1) higher testosterone, 28.5% (5.3, 45.9)/24.1% (5.6, 38.9) lower SHBG levels, and 64.6% (19.4, 127.1)/42.5% (11.1, 82.9) higher FAI than controls after adjusting for age and recruitment cohort, maternal BMI, smoking, and pregnancy disorders, parental education, history of hypertension, diabetes, myocardial infarction or stroke, and subject's birth weight s.d. Odds ratios for having PCOS were 1.67 (0.44, 6.23)/3.11 (1.26, 7.70).

CONCLUSIONS

Women born preterm have a more hyperandrogenic hormonal profile, and those born LPT are approximately three times more likely at risk to have PCOS compared to women born at term.

Use of cardiovascular imaging in risk restratification of the diabetic patient

PURPOSE OF REVIEW

Diabetes mellitus is no longer considered a cardiovascular disease (CVD) risk equivalent, but the optimal methods of risk stratification are a matter of debate. The coronary calcium score (CCS) is a measure of the burden of atherosclerosis and is widely used for CVD risk stratification in the general population. We review recently published data to describe the role of the CCS in people with diabetes mellitus.

RECENT FINDINGS

People with diabetes mellitus have 10-year event rates for CVD and CVD mortality that are considered high, at a much lower level of CCS than the general population. Different categories of CCS are pertinent to men and women with diabetes mellitus. CCS may be particularly useful in clinical settings when CVD risk is known to be increased but difficult to quantify, for example peri-menopausal women, young persons with diabetes, type 1 diabetic individuals and others. With modern techniques, the radiation dose of a CSS has fallen to levels wherein screening and surveillance could be considered.

SUMMARY

The CCS is able to quantify CVD risk in people with diabetes mellitus when there is clinical uncertainty and identifies those with very high event rates. Future research should aim to identify effective risk reduction strategies in this important group.

Challenges and Opportunities for the Prevention and Treatment of Cardiovascular Disease Among Young Adults: Report From a National Heart, Lung, and Blood Institute Working Group

Improvements in cardiovascular disease (CVD) rates among young adults in the past 2 decades have been offset by increasing racial/ethnic and gender disparities, persistence of unhealthy lifestyle habits, overweight and obesity, and other CVD risk factors. To enhance the promotion of cardiovascular health among young adults 18 to 39 years old, the medical and broader public health community must understand the biological, interpersonal, and behavioral features of this life stage. Therefore, the National Heart, Lung, and Blood Institute, with support from the Office of Behavioral and Social Science Research, convened a 2-day workshop in Bethesda, Maryland, in September 2017 to identify research challenges and opportunities related to the cardiovascular health of young adults. The current generation of young adults live in an environment undergoing substantial economic, social, and technological transformations, differentiating them from prior research cohorts of young adults. Although the accumulation of clinical and behavioral risk factors for CVD begins early in life, and research suggests early risk is an important determinant of future events, few trials have studied prevention and treatment of CVD in participants <40 years old. Building an evidence base for CVD prevention in this population will require the engagement of young adults, who are often disconnected from the healthcare system and may not prioritize long-term health. These changes demand a repositioning of existing evidence-based treatments to accommodate new sociotechnical contexts. In this article, the authors review the recent literature and current research opportunities to advance the cardiovascular health of today's young adults.

Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review

OBJECTIVE

To consolidate evidence from systematic reviews and meta-analyses investigating the association between reproductive factors in women of reproductive age and their subsequent risk of cardiovascular disease.

DESIGN

Umbrella review.

DATA SOURCES

Medline, Embase, and Cochrane databases for systematic reviews and meta-analyses from inception until 31 August 2019.

REVIEW METHODS

Two independent reviewers undertook screening, data extraction, and quality appraisal. The population was women of reproductive age. Exposures were fertility related factors and adverse pregnancy outcomes. Outcome was cardiovascular diseases in women, including ischaemic heart disease, heart failure, peripheral arterial disease, and stroke.

RESULTS

32 reviews were included, evaluating multiple risk factors over an average follow-up period of 7-10 years. All except three reviews were of moderate quality. A narrative evidence synthesis with forest plots and tabular presentations was performed. Associations for composite cardiovascular disease were: twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5-1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, ever parity, and early menopause. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The associations for ischaemic heart disease were twofold or greater for pre-eclampsia, recurrent pre-eclampsia, gestational diabetes, and preterm birth; 1.5-1.9-fold for current use of combined oral contraceptives (oestrogen and progesterone), recurrent miscarriage, premature ovarian insufficiency, and early menopause; and less than 1.5-fold for miscarriage, polycystic ovary syndrome, and menopausal symptoms. For stroke outcomes, the associations were twofold or more for current use of any oral contraceptive (combined oral contraceptives or progesterone only pill), pre-eclampsia, and recurrent pre-eclampsia; 1.5-1.9-fold for current use of combined oral contraceptives, gestational diabetes, and preterm birth; and less than 1.5-fold for polycystic ovary syndrome. The association for heart failure was fourfold for pre-eclampsia. No association was found between cardiovascular disease outcomes and current use of progesterone only contraceptives, use of non-oral hormonal contraceptive agents, or fertility treatment.

CONCLUSIONS

From menarche to menopause, reproductive factors were associated with cardiovascular disease in women. In this review, presenting absolute numbers on the scale of the problem was not feasible; however, if these associations are causal, they could account for a large proportion of unexplained risk of cardiovascular disease in women, and the risk might be modifiable. Identifying reproductive risk factors at an early stage in the life of women might facilitate the initiation of strategies to modify potential risks. Policy makers should consider incorporating reproductive risk factors as part of the assessment of cardiovascular risk in clinical guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120076.

Chlamydia trachomatis Infection, when Treated during Pregnancy, Is Not Associated with Preterm Birth in an Urban Safety-Net Hospital

Preterm birth is a major public health problem, occurring in more than half a million births per year in the United States. A number of maternal conditions have been recognized as risk factors for preterm birth, but for the majority of cases, the etiology is not completely understood. Chlamydia trachomatis is one of the most prevalent sexually transmitted infections in the world. However, its role in adverse pregnancy outcome in women is still debated. In order to determine if genitourinary tract infection with C. trachomatis during pregnancy was associated with preterm birth, we conducted a case-control study on women who delivered at Boston Medical Center, an urban "safety-net" hospital that serves a socioeconomically disadvantaged and racially diverse population. Women with known risk factors for preterm birth or immune suppression were excluded. Variables collected on enrolled subjects included demographics; diagnosis of C. trachomatis during or prior to pregnancy; tobacco, alcohol, and illicit substance use; gestational age; and birthweight and gender of the newborn. We also collected urine for chlamydia testing at the time of delivery and placental biopsies for nucleic acid amplification and histological studies. A total of 305 subjects were enrolled: 100 who delivered preterm and 205 who delivered full term. Among those subjects, we identified 19 cases of pregnancy-associated C. trachomatis infection: 6/100 preterm and 13/205 full term, a difference which was not statistically significant. Only two cases of untreated chlamydia infection were identified postpartum, and both occurred in women who delivered at term. We conclude that genitourinary tract infection with C. trachomatis during pregnancy, when appropriately treated, is not associated with preterm birth.

Associations between green space and preterm birth: Windows of susceptibility and interaction with air pollution

BACKGROUND

Recent studies have reported inconsistent associations between maternal residential green space and preterm birth (PTB, born < 37 completed gestational weeks). In addition, windows of susceptibility during pregnancy have not been explored and potential interactions of green space with air pollution exposures during pregnancy are still unclear.

OBJECTIVES

To evaluate the relationships between green space and PTB, identify windows of susceptibility, and explore potential interactions between green space and air pollution.

METHODS

Birth certificate records for all births in California (2001-2008) were obtained. The Normalized Difference Vegetation Index (NDVI) was used to characterized green space exposure. Gestational age was treated as a time-to-event outcome; Cox proportional hazard models were applied to estimate the association between green space exposure and PTB, moderately PTB (MPTB, gestational age < 35 weeks), and very PTB (VPTB, gestational age < 30 weeks), after controlling for maternal age, race/ethnicity, education, and median household income. Month-specific green space exposure was used to identify potential windows of susceptibility. Potential interactions between green space and air pollution [fine particulate matter < 2.5 µm (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃)] were examined on both additive and multiplicative scales.

RESULTS

In total, 3,753,799 eligible births were identified, including 341,123 (9.09%) PTBs, 124,631 (3.32%) MPTBs, and 22,313 (0.59%) VPTBs. A reduced risk of PTB was associated with increases in residential NDVI exposure in 250 m, 500 m, 1000 m, and 2000 m buffers. In the 2000 m buffer, the association was strongest for VPTB [adjusted hazard ratio (HR) per interquartile range increase in NDVI: 0.959, 95% confidence interval (CI): 0.942-0.976)], followed by MPTB (HR = 0.970, 95% CI: 0.962-0.978) and overall PTB (HR = 0.972, 95% CI: 0.966-0.978). For PTB, green space during the 3rd - 5th gestational months had stronger associations than those in the other time periods, especially during the 4th gestational month (NDVI 2000 m: HR = 0.970, 95% CI: 0.965-0.975). We identified consistent positive additive and multiplicative interactions between decreasing green space and higher air pollution.

CONCLUSION

This large study found that maternal exposure to residential green space was associated with decreased risk of PTB, MPTB, and VPTB, especially in the second trimester. There is a synergistic effect between low green space and high air pollution levels on PTB, indicating that increasing exposure to green space may be more beneficial for women with higher air pollution exposures during pregnancy.

The Role of Sex-Specific Risk Factors in the Risk Assessment of Atherosclerotic Cardiovascular Disease for Primary Prevention in Women

PURPOSE OF REVIEW

Robust evidence is emerging regarding the contribution of sex-specific risk factors to a woman's unique risk of atherosclerotic cardiovascular disease (ASCVD). This review summarizes the available literature regarding the association of sex-specific risk factors and ASCVD in women.

RECENT FINDINGS

The American College of Cardiology and American Heart Association Guidelines recommend estimation of 10-year risk of a first ASCVD event using the 2013 Pooled Cohort Equations. This can be further personalized by identifying sex-specific risk factors present in a woman's history. There are multiple vulnerable periods across a woman's life course that are associated with increased risk of ASCVD. Risk factors across the reproductive life course that have been shown to correlate with higher risk for future ASCVD include early menarche, adverse pregnancy outcomes (such as pre-eclampsia or preterm birth), and early natural or surgical menopause. In addition, certain conditions that are more common among women, including autoimmune diseases, history of chest irradiation, and certain chemotherapies, also need to be considered. Finally, risk assessment can be refined with subclinical disease imaging (coronary calcium score) if there remains uncertainty about clinical management with lipid-lowering therapies for primary prevention after inclusion of these risk enhancers. Risk assessment for ASCVD in women requires a personalized approach that incorporates sex-specific risk factors to guide primary prevention measures, such as lipid-lowering therapies. Coronary calcium score imaging may also help further refine risk assessment, but no clinical trials conducted to date have addressed this question.

Premature Atherosclerotic Cardiovascular Disease: What Have We Learned Recently?

PURPOSE OF REVIEW

In contrast to patients with non-premature atherosclerotic cardiovascular disease (ASCVD), patients with premature ASCVD have not observed a similar decline in cardiovascular mortality and recurrent adverse events. We sought to review the underlying risk factors, potential gaps in medical management, associated outcomes, and tools for risk prognostication among patients with premature ASCVD.

RECENT FINDINGS

In addition to traditional cardiovascular risk factors (i.e., diabetes, familial hypercholesterolemia), non-traditional risk factors such as chronic inflammatory conditions, recreational drug use, genetics, and pregnancy-related complications play a key role in development and progression of premature ASCVD. Patients with premature ASCVD, and especially women, receive less optimal medical management as compared to their non-premature counterparts. There is an increasing prevalence of cardiovascular risk factors among young adults. Hence, this population remains at an elevated risk for premature ASCVD and subsequent adverse cardiovascular events. Future studies evaluating different risk assessment tools and focusing on young patients across all three major domains of ASCVD are needed.

Cervical pessary to prevent preterm birth in asymptomatic high-risk women: a systematic review and meta-analysis

BACKGROUND

Randomized controlled trials that have assessed the efficacy of cervical pessary to prevent preterm birth in asymptomatic high-risk women have reported conflicting results.

OBJECTIVE

To evaluate the efficacy and safety of cervical pessary to prevent preterm birth and adverse perinatal outcomes in asymptomatic high-risk women.

DATA SOURCES

MEDLINE, EMBASE, POPLINE, CINAHL, and LILACS (from their inception to October 31, 2019), Cochrane databases, Google Scholar, bibliographies, and conference proceedings.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials that compared cervical pessary with standard care (no pessary) or alternative interventions in asymptomatic women at high risk for preterm birth.

STUDY APPRAISAL AND SYNTHESIS METHODS

The systematic review was conducted according to the Cochrane Handbook guidelines. The primary outcome was spontaneous preterm birth <34 weeks of gestation. Secondary outcomes included adverse pregnancy, maternal, and perinatal outcomes. Pooled relative risks with 95% confidence intervals were calculated. Quality of evidence was assessed using the GRADE methodology.

RESULTS

Twelve studies (4687 women and 7167 fetuses/infants) met the inclusion criteria: 8 evaluated pessary vs no pessary in women with a short cervix, 2 assessed pessary vs no pessary in unselected multiple gestations, and 2 compared pessary vs vaginal progesterone in women with a short cervix. There were no significant differences between the pessary and no pessary groups in the risk of spontaneous preterm birth <34 weeks of gestation among singleton gestations with a cervical length ≤25 mm (relative risk, 0.80; 95% confidence interval, 0.43-1.49; 6 trials, 1982 women; low-quality evidence), unselected twin gestations (relative risk, 1.05; 95% confidence interval, 0.79-1.41; 1 trial, 1177 women; moderate-quality evidence), twin gestations with a cervical length <38 mm (relative risk, 0.75; 95% confidence interval, 0.41-1.36; 3 trials, 1128 women; low-quality evidence), and twin gestations with a cervical length ≤25 mm (relative risk; 0.72, 95% confidence interval, 0.25-2.06; 2 trials, 348 women; low-quality evidence). Overall, no significant differences were observed between the pessary and no pessary groups in preterm birth <37, <32, and <28 weeks of gestation, and most adverse pregnancy, maternal, and perinatal outcomes (low- to moderate-quality evidence for most outcomes). There were no significant differences in the risk of spontaneous preterm birth <34 weeks of gestation between pessary and vaginal progesterone in singleton gestations with a cervical length ≤25 mm (relative risk, 0.99; 95% confidence interval, 0.54-1.83; 1 trial, 246 women; low-quality evidence) and twin gestations with a cervical length <38 mm (relative risk, 0.73; 95% confidence interval, 0.46-1.18; 1 trial, 297 women; very low-quality evidence). Vaginal discharge was significantly more frequent in the pessary group than in the no pessary and vaginal progesterone groups (relative risks, ∼2.20; high-quality evidence).

CONCLUSION

Current evidence does not support the use of cervical pessary to prevent preterm birth or to improve perinatal outcomes in singleton or twin gestations with a short cervix and in unselected twin gestations.

Reduced coronary flow velocity reserve in women with previous pre-eclampsia: link to increased cardiovascular disease risk

OBJECTIVES

To evaluate differences in coronary microvascular function approximately 12 years after delivery between women who had had early- (EO-PE) or late- (LO-PE) onset pre-eclampsia and those who had had a normotensive pregnancy, and to assess the relationship between microvascular function and myocardial deformation at follow-up in these women.

METHODS

This was a case-control study of 88 women who had delivered at the Department of Gynecology and Obstetrics, Randers Regional Hospital, Randers, Denmark, between 1998 and 2008. Coronary flow velocity reserve (CFVR) was assessed by Doppler echocardiography approximately 12 years after delivery. Women were grouped according to whether the pregnancy had been complicated by EO-PE (n = 29) or LO-PE (n = 20), or had been normotensive (controls) (n = 39). Study groups were matched for maternal age and time since delivery. CFVR at follow-up was compared between the study groups. Regression analysis was used to assess the association between gestational age at onset of PE and CFVR. The association between left ventricular global longitudinal strain (LV-GLS) and CFVR at follow-up was also evaluated.

RESULTS

Resting coronary flow velocity assessed 12 years after delivery was comparable between the study groups (P = 0.55), whereas peak hyperemic flow velocity was significantly lower in the EO-PE group than in the LO-PE group (P < 0.01) and controls (P < 0.0001). As such, mean CFVR at follow-up was significantly lower in the EO-PE group than in the LO-PE group (P < 0.01) and controls (P < 0.0001). CFVR was < 2.5 in 48% of women in the EO-PE group, 25% of those in the LO-PE group and 8% of controls (P < 0.01). There was a significant positive association between gestational age at diagnosis of PE and CFVR at 12-year follow-up (β1 = 1.8 (95% CI, 0.8-2.9); P < 0.01). This relationship remained significant after adjustment for cardiovascular risk factors, namely mean arterial blood pressure, glycated hemoglobin level, body mass index, low-density lipoprotein cholesterol level and smoking status (P < 0.05). There was a significant association between LV-GLS and CFVR in women who had had PE (β1 = -1.5 (95% CI, -2.2 to -0.9); R²  = 0.33, P < 0.0001).

CONCLUSIONS

Low gestational age at onset of PE, both as a continuous variable and when categorized as early onset, was associated with decreased CFVR 12 years after delivery. Nearly 50% of women who had had EO-PE had CFVR < 2.5 at follow-up. Reduced CFVR in women who had had PE was associated with subclinical myocardial dysfunction in terms of reduced LV-GLS. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Pregnancy and the Postpartum Period as an Opportunity for Cardiovascular Risk Identification and Management

Cardiovascular disease (CVD) is the leading cause of death in women. Because women generally present with more atypical symptoms of CVD than do men and because underlying CVD risk factors are often present for years before the onset of CVD, it is important to use innovative ways to identify women who should undergo CVD risk screening at a younger age. Pregnancy and the postpartum period afford us that opportunity, given that the development of certain pregnancy complications (hypertensive disorders of pregnancy, gestational diabetes, preterm birth, delivery of a neonate with fetal growth restriction, and significant placental abruption) can reliably identify women with underlying, often unrecognized, CVD risk factors. Women with one or more of these pregnancy complications should be identified at the time of delivery and referred for regular follow-up. This would ideally take the form of a multidisciplinary clinic including clinicians and allied health specialists to carry out physical and biochemical screening and counseling regarding lifestyle modification and possible therapeutic interventions. Longer-term follow-up and recommendations should be individualized based on findings and risks. There is also an opportunity for future pregnancy counseling and discussion about the importance of weight loss between pregnancies, initiation of a routine involving physical activity, use of preconception folic acid, and the potential initiation of low-dose aspirin for those women at risk for future preeclampsia and fetal growth restriction or the use of progesterone for women at risk for preterm labor. The link between pregnancy complications and future CVD affords us with the earliest opportunity for CVD risk assessment for health preservation and disease prevention.

Racial Disparities in Prematurity Persist among Women of High Socioeconomic Status

Objectives

Despite persistent racial disparities in preterm birth (PTB) in the US among non-Hispanic (NH) black women compared to NH white women, it remains controversial whether sociodemographic factors can explain these differences. We sought to evaluate whether disparities in PTB persist among NH black women with high socioeconomic status (SES).

Study Design

We conducted a population-based cohort study of all live births in the US from 2015-2017 using birth certificate data from the National Vital Statistics System. We included singleton, non-anomalous live births among women who were of high SES (defined as having ≥ 16 years of education, private insurance, and not receiving Women, Infants and Children [WIC] benefits) and who identified as NH white, NH black, or 'mixed' NH black and white race. The primary outcome was PTB <37 weeks; secondary outcomes included PTB <34 and <28 weeks. In addition, analyses were repeated considering birthweight <2500g as a surrogate for preterm birth <37 weeks, birthweight <1500g as a surrogate for preterm birth <34 weeks, and birthweight <750g as a surrogate for preterm birth <28 weeks' gestation. Data were analyzed with chi-square, t-test, and logistic regression.

Results

2,170,686 live births met inclusion criteria, with 92.9% NH white, 6.7% NH black, and 0.4% both NH white and black race. Overall, 5.9% delivered <37, 1.3% <34, and 0.3 % <28 weeks. In unadjusted analyses of women with high SES, the PTB rate at each gestational age cutoff was higher for women of 'mixed' NH white and black race, and highest for women who were NH black only compared to women who were NH white only. In regression models we further adjusted for women with insurance and prenatal care their entire pregnancy, maternal race was associated with higher odds of PTB at each GA cutoff, with the highest odds observed at <28 weeks. Finally, in further adjustement analysis including only the 1,934,912 women who received prenatal care in the first trimester, findings were similar. Rates of preterm birth at each gestational age cutoff remained highest for women who identified as non-Hispanic black, intermediate for women identifying as both non-Hispanic black and white race, and lowest for non-Hispanic white women at <37 weeks (9.9% vs. 6.1% vs. 5.5%, respectively; p<0.001), <34 weeks (3.5% vs. 1.5% vs. 1.1%, respectively; p<0.001), and <28 weeks' gestation (1.2% vs. 0.4% vs. 0.2%, respectively, p<0.001).

Conclusions

Even among college-educated women with private insurance who are not receiving WIC, racial disparities in prematurity persist. These national findings are consistent with prior studies that suggest factors other than socio-demographics are important in the underlying pathogenesis of PTB.

Maternal Cardiovascular Disease 3 Decades After Preterm Birth: Longitudinal Cohort Study of Pregnancy Vascular Disorders

Women who deliver preterm are at risk of cardiovascular disease, but the reason for the association is unclear. We determined whether vascular disorders during pregnancy explain the association between preterm delivery and future maternal cardiovascular disease. We analyzed a longitudinal cohort of 1 199 364 pregnant women with 19 186 983 person-years of follow-up in Quebec between 1989 and 2017. We calculated incidence rates of myocardial infarction, ischemic stroke, and other cardiovascular hospitalizations. We used multivariable Cox regression to estimate adjusted hazard ratios and 95% CIs for the association of very and moderate preterm delivery with maternal cardiovascular hospitalization. We determined the proportion of the association that was due to preeclampsia, acute cardiac events at delivery, antepartum/postpartum hemorrhage, and heart defects. The incidence of maternal cardiovascular hospitalization was greater for very (43.7 per 10 000 person-years) and moderate (39.4 per 10 000) preterm delivery compared with term delivery (26.2 per 10 000). Very preterm delivery was associated with 1.67× the risk of cardiovascular hospitalization (95% CI, 1.56-1.79), and moderate preterm delivery was associated with 1.51× the risk (95% CI, 1.46-1.56). Vascular disorders during pregnancy explained 26.2% of the association of very preterm delivery and 24.0% of the association of moderate preterm delivery, with cardiovascular hospitalization. Preeclampsia was the largest contributor to these proportions. We conclude that vascular disorders during pregnancy, especially preeclampsia, explain up to a quarter of the association between preterm delivery and future maternal cardiovascular hospitalization.

Association of antepartum depression, generalized anxiety, and posttraumatic stress disorder with infant birth weight and gestational age at delivery

BACKGROUND

Low- and middle-income countries bear a disproportionate burden of preterm birth (PTB) and low infant birth weight (LBW) complications where affective and anxiety disorders are more common in the antepartum period than in industrialized countries.

OBJECTIVE

To evaluate the extent to which early pregnancy antepartum depression, generalized anxiety disorder, and posttraumatic stress disorder (PTSD) are associated with infant birth weight and gestational age at delivery among a cohort of pregnant women in Peru.

METHODS

Our prospective cohort study consisted of 4408 pregnant women. Antepartum depression, generalized anxiety, and PTSD were assessed in early pregnancy using the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7 and PTSD Checklist - Civilian Version, respectively. Pregnancy outcome data were obtained from medical records. Multivariable linear and logistic regression procedures were used to estimate adjusted measures of association (β coefficients and odds ratios) and 95% confidence intervals (CI).

RESULTS

After adjusting for confounders, women with antepartum generalized anxiety (32.6% prevalence) had higher odds of LBW (adjusted odds ratio (OR)=1.47; 95%CI: 1.10-1.95) and were more likely to deliver small for gestational age (OR = 1.39; 95%CI: 1.01-1.92) infants compared to those without anxiety. Compared to those without PTSD, women with PTSD (34.5%) had higher odds of delivering preterm (OR = 1.28; 95%CI: 1.00-1.65) yet PTSD was not associated with LBW nor gestational age at delivery. Women with antepartum depression (26.2%) were at no increased risk of delivering a preterm, low-birth-weight or small-for-gestational-age infant.

LIMITATIONS

Our ability to make casual inferences from this observational study is limited; however, these findings are consistent with prior studies.

CONCLUSION

Generalized anxiety disorder during pregnancy appeared to increase odds of delivering a low-birth-weight or small-for-gestational-age infant, while PTSD was associated with increased odds of delivering preterm. Our findings, and those of others, suggest antenatal care should be tailored to screen for and provide additional mental health services to patients.

Chronic HPA activity in mothers with preterm delivery: A pilot nested case-control study

BACKGROUND

Chronic hypothalamic-pituitary-adrenal (HPA) axis activity role in the pathogenesis of preterm birth (PTB) remains unclear due to inconsistent measures with limited ability to monitor long-term cortisol concentrations. We explored this relationship using the novel method of assessing cortisol in hair, which is a valid and reliable measure of chronic HPA axis activity.

METHODS

137 participants (40 PTB cases and 97 controls from a birth cohort of pregnant women in Peru) were interviewed and invited to provide a 9-cm hair sample from the posterior vertex position of the scalp (mean = 13 weeks gestation). Hair cortisol concentration (HCC) was determined using luminescence immunoassay and values were natural-log transformed. PTB cases were defined as women who delivered before 37 gestational weeks. Case-control differences were assessed using multivariable linear and logistic regressions.

RESULTS

Overall, combined pre-conception and first-trimester HCC was 13% lower among cases as compared with controls (p-value = 0.01). Compared with controls, maternal HCC among PTB cases were 14% (p = 0.11), 10% (p = 0.22) and 14% (p = 0.08) lower for 3-6 months pre-conception, 0-3 months pre-conception, and first trimester, respectively. After adjusting for putative confounders, a 1-unit increase in HCC was associated with 55% reduced odds of PTB (aOR = 0.45; 95% CI: 0.17-1.17). For a 1-unit increase in HCC in the scalp-intermediate and scalp-distal segments (representing HCC concentrations in 0-3 months pre-conception and first trimester), the corresponding odds for PTB were 0.53 (95% CI: 0.19-1.48) and 0.39 (95% CI: 0.13-1.13), respectively.

CONCLUSIONS

Women who deliver preterm, as compared with those who deliver at term, have lower preconception and first trimester HCC. Our findings suggest that HPA axis activation, integral to the adaptive stress-response system, may be chronically dysregulated in women at increased risk of PTB.

Do self-reported pregnancy complications add to risk evaluation in older women with established cardiovascular disease?

Background

In postmenopausal women with established cardiovascular disease (CVD), it is unknown whether a history of pregnancy complications are related to multisite artery disease (MSAD), defined as atherosclerotic lesions in at least two major vascular beds. Pregnancy complications are an established risk factor for CVD. This study aimed to investigate the frequency of pregnancy complications and their association to specific atherosclerotic manifestations and prediction of MSAD in older women with and without CVD.

Methods

In total, 556 women were invited to participate in the study. Of these women 307 reported former pregnancy from a cohort of women with (n = 233) and without CVD (n = 74). The self-reported frequency of pregnancy complications were surveyed retrospectively by a questionnaire that included miscarriage, subfertility, gestational hypertension (GHT) and/or preeclampsia (PE), low birth weight, preterm birth, bleeding in late pregnancy, gestational diabetes mellitus and high birth weight. Three vascular beds were examined, the peripheral, carotid and coronary arteries.

Results

The mean age was 67.5 (SD 9.5) years. GHT and/or PE tended to be more common, but not significant, in women with CVD than in women without (20.3% vs 10.8%, p = 0.066). Among women with GHT and/or PE, hypertension later in life were more frequent than in women without (66.7% vs 47.4%, p = 0.010). GHT and/or PE were not associated with specific atherosclerotic manifestations or prediction of MSAD.

Conclusions

In older women with established CVD, pregnancy complications was not associated to specific atherosclerotic manifestations and may not provide additional value to the risk evaluation for MSAD.

Early pregnancy immune profile and preterm birth classified according to uteroplacental lesions

INTRODUCTION

Preterm birth is a heterogeneous phenotype, with placental abnormalities underlying many cases. The etiology of preterm births that occur in the absence of placental abnormalities, however, remain enigmatic and we considered that early pregnancy biomarkers may provide clues.

METHODS

Women from a hospital-based cohort (2008-2012, n = 397) were randomly selected within 6 strata of term and preterm birth with and without placental decidual vasculopathy (arteriopathy), intrauterine inflammation/infection (acute chorioamnionitis), or no lesions. Lipids and inflammatory markers were analyzed in first trimester samples (12.5 ± 0.6 weeks) and related to outcome groups (referent, term births with no lesions). Factor analysis then clustered analytes and related these to preterm birth groups, adjusted for covariates and stratified by pre-pregnancy obesity.

RESULTS

Three biomarker patterns were identified. Immune activation cytokines (33% of the variance) were associated with preterm birth with no lesions (aOR 1.5, 95%CI 1.1-2.1), particularly among obese women. In contrast, inflammatory chemokines (9% of variance) were associated with term and preterm vasculopathy among non-obese women (aOR 2.6 [1.3, 4.7] and 2.0 [1.1, 3.0], respectively).

DISCUSSION

The early pregnancy maternal immune profile is related to preterm births classified according to placental lesions, and these associations vary according to obesity status.

Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

Are Preeclampsia and Adverse Obstetrical Outcomes Predictors of Cardiovascular Disease? A Case-Control Study of Women With Heart Disease

OBJECTIVE

This study sought to determine whether preeclampsia; gestational diabetes; and adverse obstetrical outcomes such as placental abruption, intrauterine growth restriction, and preterm delivery are independent risk factors for cardiovascular disease later in life.

METHODS

This was a retrospective, age-matched, case-control study that surveyed 244 cases (women with confirmed coronary artery disease) and 246 controls (women who did not have coronary artery disease) on their obstetrical history and outcomes, as well as traditional cardiovascular risk factors. Analyses were performed using SAS software version 9.1.3. (Canadian Task Force Classification II-2).

RESULTS

Women with coronary artery disease had significantly higher rates of maternal complications such as gestational hypertension (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.03-10.9), as well as conventional vascular risk factors such as dyslipidemia (OR 5.38; 95% CI 2.70-10.7), hypertension (OR 2.40; 95% CI 1.23-4.70), diabetes (OR 2.32; 95% CI 1.07-5.01), and smoking (current smoker: OR; 4.82 95% CI 1.66-14.00; former smoker: OR 2.86; 95% CI 1.43-5.71). There were more cases with preeclampsia (9.8%, vs. 5.4% in controls); however, the difference was not statistically significant.

CONCLUSION

Among the adverse maternal conditions, there was more gestational hypertension in women with coronary artery disease. In this study, hypertensive disorders of pregnancy were the most important maternal risk factors for cardiovascular disease later in life and should be flagged early for close monitoring and/or intervention.

Does pregnancy complication history improve cardiovascular disease risk prediction? Findings from the HUNT study in Norway

AIM

To evaluate whether history of pregnancy complications [pre-eclampsia, gestational hypertension, preterm delivery, or small for gestational age (SGA)] improves risk prediction for cardiovascular disease (CVD).

METHODS AND RESULTS

This population-based, prospective cohort study linked data from the HUNT Study, Medical Birth Registry of Norway, validated hospital records, and Norwegian Cause of Death Registry. Using an established CVD risk prediction model (NORRISK 2), we predicted 10-year risk of CVD (non-fatal myocardial infarction, fatal coronary heart disease, and non-fatal or fatal stroke) based on established risk factors (age, systolic blood pressure, total and HDL-cholesterol, smoking, anti-hypertensives, and family history of myocardial infarction). We evaluated whether adding pregnancy complication history improved model fit, calibration, discrimination, and reclassification. Among 18 231 women who were parous, ≥40 years of age, and CVD-free at start of follow-up, 39% had any pregnancy complication history and 5% experienced a CVD event during a median follow-up of 8.2 years. While pre-eclampsia and SGA were associated with CVD in unadjusted models (HR 1.96, 95% CI 1.44-2.65 for pre-eclampsia and HR 1.46, 95% CI 1.18-1.81 for SGA), only pre-eclampsia remained associated with CVD after adjusting for established risk factors (HR 1.60, 95% CI 1.16-2.17). Adding pregnancy complication history to the established prediction model led to small improvements in discrimination (C-index difference 0.004, 95% CI 0.002-0.006) and reclassification (net reclassification improvement 0.02, 95% CI 0.002-0.05).

CONCLUSION

Pre-eclampsia independently predicted CVD after controlling for established risk factors; however, adding pre-eclampsia, gestational hypertension, preterm delivery, and SGA made only small improvements to CVD prediction among this representative sample of parous Norwegian women.