Cardiovascular effects of aerobic exercise training in formerly preeclamptic women and healthy parous control subjects

Arteries and Hearts in Motion: Sex Differences in Exercise-Mediated Protection Against Atherosclerotic Cardiovascular Disease Risk

PURPOSE OF REVIEW

This review summarizes the current knowledge on the benefits of various exercise training modalities on subclinical atherosclerotic cardiovascular disease (ASCVD) risk factors (i.e., endothelial dysfunction, large artery stiffening, carotid artery intima-media thickening) across the adult lifespan and the moderating role of biological sex, with the goal of informing/being to inform research gaps and future research directions.

RECENT FINDINGS

Regular exercise is an effective intervention to counter subclinical risk factors for ASCVD. However, sex-specific variation has been observed in exercise training benefits. For example, aerobic exercise improves large artery stiffening in both middle-aged/older men and women and enhances endothelial function in middle-aged/older men; however, similar exercise-mediated improvements in endothelial function are not consistently observed in postmenopausal women Sex differences in exercise benefits may be related to differences in the sex hormone environment across the adult lifespan that influence cellular-molecular mechanisms, disconnecting favorable signaling in the vasculature induced by exercise training. Moreover, differences could be explained by social and/or psychological factors that make women more susceptible, on average, to barriers to exercise training compared to age-matched men.

Impact of postpartum physical activity on cardiometabolic health, breastfeeding, injury and infant growth and development: a systematic review and meta-analysis

OBJECTIVE

To examine the relationship between postpartum physical activity and maternal postnatal cardiometabolic health, breastfeeding, injury, and infant growth and development.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Eight online databases were searched up until 12 January 2024.

ELIGIBILITY CRITERIA

Studies of all designs in all languages were eligible (except case studies and reviews) if they contained information on the population (postpartum people), intervention (frequency, intensity, duration, volume, or type of exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+co-intervention'), comparator (no or low volumes of physical activity), and outcomes: hypertension, diabetes, cardiometabolic risk factors (systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, high density lipoproteins, low density lipoproteins, and triglycerides, glycated hemoglobin (HbA1C), glucose and insulin concentration), breastfeeding (breast milk quality and volume), infant growth (length and weight) and development, or postpartum injury.

RESULTS

46 unique studies (n=8766 participants) from 20 countries were included. Moderate certainty of evidence showed exercise+co-interventions reduced the odds of developing diabetes by 28% (7 randomised controlled trials (RCTs), n=2496; OR 0.72 95% CI 0.54, 0.98, I2 12%), reduced SBP (10 RCTs, n=2753; mean difference (MD) -2.15 95% CI -3.89 to -0.40, I2 73%) and DBP (9 RCTs, n=2575; MD -1.38 95% CI -2.60 to -0.15, I2 66%) compared with controls. Infant growth and development, breast milk quality and quantity, and risk of injury were not different between exercise and control groups.

CONCLUSIONS

Physical activity improves cardiometabolic health without adversely impacting breast milk supply or quality, infant growth or maternal injury.

An aerobe exercise intervention for optimizing metabolic, cardiovascular and immune status: protocol of an intervention study with a multi-systemic approach for women with unexplained recurrent pregnancy loss

Women confronted with recurrent pregnancy loss (RPL) are often desperately searching for a possible explanation and hoping they will someday fulfill a healthy pregnancy. Unfortunately, in more than 50% of these women no cause for their losses can be identified after clinical investigations and therefore clinicians have no treatment options to help these women. Although adaptations in several systems such as the metabolic, the cardiovascular, and the immune system are highly important to support early pregnancy, especially the contribution of a specific subset of immune cells in the uterus known as CD56bright Natural Killer (NK) cells has gained a lot of interest, investigating separate RPL associated factors might not be the way forward. Moreover, a readily available and non-invasive exercise intervention might optimize all systems simultaneously, reducing metabolic, cardiovascular and immunological risk factors contributing to RPL. Therefore, we propose an aerobe exercise intervention and study the influence on the cardiovascular, the metabolic, and the immune system, with a particular focus on endometrial CD56bright NK cells, in women with unexplained RPL. In this exercise intervention study, women with unexplained RPL will receive two questionnaires to assess baseline characteristics. Moreover, they will receive (1) an immunological assessment (by sampling menstrual blood, peripheral blood and a vaginal swab) (2) an assessment of the cardiovascular system (by transvaginal ultrasound to assess uterine artery perfusion, by measuring hemodynamic and autonomic nerve system responses during a tilt test and by maximum stress test on a cycle ergometer) and (3) a metabolic assessment (by sampling peripheral blood, urine and by measuring body characteristics) before and after intervention. The intervention consists of 12-weeks moderate exercise training based on 50-65% of heart rate reserve. One year after the end of the intervention women will receive a final questionnaire regarding possible subsequent pregnancy outcome. This clinical trial with a multi-systemic approach can not only provide new insights by studying contribution and associations of the immune system, the cardiovascular system and the metabolic system in women with unexplained RPL, it also can support shared decision-making between clinicians and patients by evaluating the importance of a ready available exercise intervention strategy.

Intensive postpartum antihypertensive treatment (IPAT) and healthy lifestyle education: Study protocol for a pilot randomized controlled trial for patients with hypertensive disorders of pregnancy

BACKGROUND

Hypertensive disorders of pregnancy (HDP) complicate about 10 % of pregnancies and lead to postpartum hospital readmissions and cardiovascular complications. Following HDP, vascular dysfunction could persist and accelerate the trajectory of cardiovascular disease risk. The benefits of intensive blood pressure (BP) control following HDP have not been adequately investigated. Therefore, no standard guidelines exist to guide the management of mild-to-moderate hypertension in the postpartum period, leading to a wide variation in clinical practice. The present study will investigate the effect of intensive BP control and healthy lifestyle education on maternal cardiovascular health (CVH) and vascular function following HDP.

METHODS

The Intensive Postpartum Antihypertensive Treatment (IPAT) study is a randomized controlled, two-arm, single-site, pilot trial where 60 postpartum HDP patients will be randomized 1:1 to one of two groups: 1) Intensive postpartum BP control - nifedipine initiation at BP ≥140/90 mmHg to maintain BP <140/90 mmHg; or 2) Less intensive postpartum BP control - nifedipine initiation at BP ≥150/100 mmHg to maintain BP <150/100 mmHg. All participants will also undergo vascular function assessments and receive healthy lifestyle education. The study will primarily test feasibility of all study procedures. It will secondarily examine changes in BP and CVH scores from baseline to 12 months postpartum.

CONCLUSION

This pilot trial will study whether the BP threshold of 140/90 is superior to 150/100 for initiation of pharmacotherapy and evaluate feasibility to ultimately conduct a trial capable of generating robust evidence to standardize clinical practice and guidelines in postpartum HDP management.

TRIAL REGISTRATION NUMBER

NCT05687344.

Encouraging New Moms to Move More-Are We Missing the Mark? A Systematic Review With Meta-Analysis of the Effect of Exercise Interventions on Postpartum Physical Activity Levels and Cardiorespiratory Fitness

OBJECTIVE: To determine if current exercise interventions were effective at improving physical activity (PA) levels and/or cardiorespiratory fitness (CRF) in postpartum women. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: CINAHL, Embase, Medline, PsycINFO, and SPORTDiscus were searched from inception to March 2024. STUDY SELECTION CRITERIA: Participants: postpartum women; intervention: exercise; control: standard care; outcomes: PA levels and/or CRF. DATA SYNTHESIS: Random effects meta-analysis using standardized mean differences (SMDs). Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) and Risk of Bias in Non-Randomized Studies - Intervention (ROBINS-I). RESULTS: A total of 6041 studies were screened, and 29 were eligible for inclusion. Nineteen studies with adequate control data included outcomes related to PA levels (n = 12) or CRF (n = 7) and were pooled in meta-analyses. There was a small to moderate improvement in CRF (SMD, 0.65; 95% CI [confidence interval]: 0.20, 1.10; I2 = 61%). There was no improvement in PA levels (SMD, -0.13; 95% CI: -0.53, 0.26; I2 = 90%). Frequency, intensity, type, and time of the exercise interventions varied. Twenty-three studies were at high or serious risk of bias. CONCLUSIONS: Postpartum exercise interventions may improve CRF but have an unclear effect on PA levels. Despite numerous exercise interventions to improve health outcomes postpartum, parameters were inconsistent. J Orthop Sports Phys Ther 2024;54(11):687-701. Epub 9 October 2024. doi:10.2519/jospt.2024.12666.

Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Preeclampsia and Italian Society of Perinatal Medicine

OBJECTIVE

 The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art.

STUDY DESIGN

 AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version.

RESULTS

 More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life.

CONCLUSION

 Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications.

KEY POINTS

· Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..

Can short- and long-term maternal and infant risks linked to hypertension and diabetes during pregnancy be reduced by therapy?

Hypertensive disorders of pregnancy (HDP), especially preeclampsia, and diabetes during pregnancy pose significant risks for both maternal and infant health, extending to long-term outcomes such as early-onset cardiovascular disease and metabolic disorders. Current strategies for managing HDP focus on screening, prevention, surveillance, and timely intervention. No disease-modifying therapies exist so far for established preeclampsia; delivery remains the definitive resolution. Preventive measures-including early pregnancy screening, exercise, and low-dose aspirin-show promise. Antihypertensive treatments reduce severe hypertension risks, whereas magnesium sulfate remains the standard for preventing eclampsia. Planned delivery from gestational week 37 can balance maternal benefits and neonatal risks in women with established preeclampsia. Delivery between 34 and 37 weeks gestation in women with preeclampsia has to balance risks for mother and infant. Lifestyle interventions-particularly diet and physical activity-are pivotal in managing gestational diabetes mellitus and type 2 diabetes. The oral antidiabetic metformin has shown benefits in glycaemic control and reducing maternal weight gain, although its long-term effects on offspring remain uncertain. The safety of other peroral antidiabetics in pregnancy is less studied. Advancements in glucose monitoring and insulin administration present encouraging prospects for enhancing outcomes in women with diabetes types 1 and 2. Both HDP and diabetes during pregnancy necessitate vigilant management through a combination of lifestyle modifications, pharmacological interventions, and timely obstetric care. Although certain treatments such as low-dose aspirin and metformin show efficacy in risk reduction, further research is ongoing to ensure safety for both mothers and their offspring to reduce short- and long-term adverse effects.

Blood pressure responses to handgrip exercise but not apnea or mental stress are enhanced in women with a recent history of preeclampsia

Preeclampsia is a risk factor for future cardiovascular diseases. However, the mechanisms underlying this association remain unclear, limiting effective prevention strategies. Blood pressure responses to acute stimuli may reveal cardiovascular dysfunction not apparent at rest, identifying individuals at elevated cardiovascular risk. Therefore, we compared blood pressure responsiveness with acute stimuli between previously preeclamptic (PPE) women (34 ± 5 yr old, 13 ± 6 mo postpartum) and women following healthy pregnancies (Ctrl; 29 ± 3 yr old, 15 ± 4 mo postpartum). Blood pressure (finger photoplethysmography calibrated to manual sphygmomanometry-derived values; PPE: n = 12, Ctrl: n = 12) was assessed during end-expiratory apnea, mental stress, and isometric handgrip exercise protocols. Integrated muscle sympathetic nerve activity (MSNA) was assessed in a subset of participants (peroneal nerve microneurography; PPE: n = 6, Ctrl: n = 8). Across all protocols, systolic blood pressure (SBP) was higher in PPE than Ctrl (main effects of group all P < 0.05). Peak changes in SBP were stressor specific: peak increases in SBP were not different between PPE and Ctrl during apnea (8 ± 6 vs. 6 ± 5 mmHg, P = 0.32) or mental stress (9 ± 5 vs. 4 ± 7 mmHg, P = 0.06). However, peak exercise-induced increases in SBP were greater in PPE than Ctrl (11 ± 5 vs. 7 ± 7 mmHg, P = 0.04). MSNA was higher in PPE than Ctrl across all protocols (main effects of group all P < 0.05), and increases in peak MSNA were greater in PPE than Ctrl during apnea (44 ± 6 vs. 27 ± 14 burst/100 hb, P = 0.04) and exercise (25 ± 8 vs. 13 ± 11 burst/100 hb, P = 0.01) but not different between groups during mental stress (2 ± 3 vs. 0 ± 5 burst/100 hb, P = 0.41). Exaggerated pressor and sympathetic responses to certain stimuli may contribute to the elevated long-term risk for cardiovascular disease in PPE.NEW & NOTEWORTHY Women with recent histories of preeclampsia demonstrated higher systolic blood pressures across sympathoexcitatory stressors relative to controls. Peak systolic blood pressure reactivity was exacerbated in previously preeclamptic women during small muscle-mass exercises, although not during apneic or mental stress stimuli. These findings underscore the importance of assessing blood pressure control during a variety of experimental conditions in previously preeclamptic women to elucidate mechanisms that may contribute to their elevated cardiovascular disease risk.

Unexplained recurrent pregnancy loss and markers of arterial vascular health: An experimental case-control study

OBJECTIVE

To investigate whether women with unexplained recurrent pregnancy loss have impaired arterial vascular health compared with controls, and to evaluate whether this is modifiable by exercise.

DESIGN

Experimental case-control pilot study.

SETTING

University medical centre in the Netherlands.

POPULATION

Twelve women with unexplained recurrent pregnancy loss, 11 nulliparous women and 19 primiparous women with a history of uncomplicated pregnancies.

METHODS

In all three groups we measured baseline characteristics, metabolic components and arterial vascular health, and repeated this in women with unexplained recurrent pregnancy loss after 1 month of protocolled and supervised cycle training.

MAIN OUTCOME MEASURES

Differences in arterial vascular health between women with unexplained recurrent pregnancy loss and controls, and the effect of exercise on arterial vascular health in women with unexplained recurrent pregnancy loss.

RESULTS

Women with unexplained recurrent pregnancy loss have a significantly increased carotid intima media thickness in comparison with both controls (both P < 0.01), a significantly decreased brachial endothelial dependent flow-mediated vasodilation in comparison with both controls (nulliparous: P < 0.01; primiparous: P = 0.05) and a significantly decreased femoral endothelial dependent flow-mediated vasodilation in comparison with primiparous women (P = 0.01). The endothelium independent glyceryl trinitrate response was similar in all groups. With 1 month of exercise, the carotid intima media thickness decreased significantly by 7% (P = 0.05) and the femoral FMD increased significantly by 10% (P = 0.01) in women with unexplained recurrent pregnancy loss.

CONCLUSIONS

Women with unexplained recurrent pregnancy loss have an impaired vascular health in comparison with controls. This impaired arterial vascular health can be improved by exercise.

Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association

Adverse pregnancy outcomes are common among pregnant individuals and are associated with long-term risk of cardiovascular disease. Individuals with adverse pregnancy outcomes also have an increased incidence of cardiovascular disease risk factors after delivery. Despite this, evidence-based approaches to managing these patients after pregnancy to reduce cardiovascular disease risk are lacking. In this scientific statement, we review the current evidence on interpregnancy and postpartum preventive strategies, blood pressure management, and lifestyle interventions for optimizing cardiovascular disease using the American Heart Association Life's Essential 8 framework. Clinical, health system, and community-level interventions can be used to engage postpartum individuals and to reach populations who experience the highest burden of adverse pregnancy outcomes and cardiovascular disease. Future trials are needed to improve screening of subclinical cardiovascular disease in individuals with a history of adverse pregnancy outcomes, before the onset of symptomatic disease. Interventions in the fourth trimester, defined as the 12 weeks after delivery, have great potential to improve cardiovascular health across the life course.

Pregnancy-associated cardiovascular risks and postpartum care; an opportunity for interventions aiming at health preservation and disease prevention

Cardiovascular disease (CVD) is the leading cause of premature death and disability for female individuals around the world and the rates are increasing in those aged 35-44 years. Certain pregnancy complications (Pregnancy-associated Cardiovascular Risks (P-CVR))are linked to an increased risk of future CVD making pregnancy and the postpartum period as an ideal time to screen individuals for underlying, often unrecognized, cardiovascular risk factors. Pregnancy complications associated with an increased risk of future CVD including the hypertensive disorders of pregnancy, gestational diabetes, idiopathic preterm birth, delivery of a growth restricted baby and a placental abruption that leads to delivery. A number of guidelines and research groups recommend postpartum CVR screening, counseling and lifestyle intervention for all those who have had one or more of P-CVRs starting within the first six months postpartum. An individualized plan for postpartum screening should be created with the individual and lifestyle interventions discussed.

The effect of postpartum lifestyle interventions on blood pressure: a systematic literature review

Postpartum lifestyle modification is recommended to hypertension risk. We conducted a systematic literature review to assess the evidence for postpartum lifestyle interventions to reduce blood pressure. We searched for relevant publications from 2010 through November 2022. Two authors independently conducted article screening and data extraction; a third resolved discrepancies. Ultimately, nine studies met inclusion criteria. Most were randomized controlled trials and had sample sizes <100. In all but one of the eight studies reporting race data, nearly all participants identified as White. None of the studies reported a significant intervention effect on blood pressure. However, most interventions were associated with improvements in other outcomes, such as physical activity. Overall, the evidence for postpartum lifestyle interventions to reduce blood pressure is limited to a handful of studies characterized by small sample sizes and a lack of racial diversity. Additional research with larger samples, more diverse populations, and intermediate outcomes is warranted.

[Follow-up Routine in Primary Care of Women after Hypertensive Disorders in Pregnancy - a Single-Center, Survey-Based Study]

INTRODUCTION

Women with a history of a hypertensive disorders of pregnancy have a significantly higher risk of future cardiovascular diseases and are therefore recommended to participate in screening examinations and counseling on primary prevention. To understand the current routine of postpartum care, we examined how many women engage in follow-up examinations and whether counseling takes place.

METHODOLOGY

Single-center, survey-based study of 113 women affected by hypertensive disorders of pregnancy between 2014 and 2019. Descriptive analysis was used to analyze the responses.

RESULTS

A total of 54% of the women engaged in follow-up. Of the participants, 47% were informed about their diagnosis in a personal conversation and possible consequences were pointed out. Of the 67 women with a BMI≥25 kg/m2, 23% received a recommendation to increase physical activity, and 13% of these women were advised to reduce their weight. Significantly more women with a higher burden of disease (BMI, p=0.027; arterial hypertension, p=0.016) and a severe form of hypertensive pregnancy disorder (eclampsia, intensive care treatment, each p=0.016) engaged in follow-up care.

CONCLUSIONS

The present results suggest that the strategies to prevent cardiovascular diseases and detect cardiovascular risk factors have not been consistently pursued. After a hypertensive disorder of pregnancy, every woman should receive a recommendation to engage in follow-up examinations.

Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice

Hypertensive disorders of pregnancy (HDP) are the most common causes of maternal and perinatal morbidity and mortality. They are responsible for 16% of maternal deaths in high-income countries and approximately 25% in low- and middle-income countries. The impact of HDP can be lifelong as they are a recognized risk factor for future cardiovascular disease. During pregnancy, the cardiovascular system undergoes significant adaptive changes that ensure adequate uteroplacental blood flow and exchange of oxygen and nutrients to nurture and accommodate the developing fetus. Failure to achieve normal cardiovascular adaptation is associated with the development of HDP. Hemodynamic alterations in women with a history of HDP can persist for years and predispose to long-term cardiovascular morbidity and mortality. Therefore, pregnancy and the postpartum period are an opportunity to identify women with underlying, often unrecognized, cardiovascular risk factors. It is important to develop strategies with lifestyle and therapeutic interventions to reduce the risk of future cardiovascular disease in those who have a history of HDP.

Acute systemic inhibition of inflammation augments endothelium-dependent dilation in women with a history of preeclamptic pregnancy

Women who have had preeclampsia demonstrate microvascular endothelial-dysfunction, mediated in part by reduced nitric oxide (NO)-dependent dilation. Preeclamptic pregnancies are associated with elevated inflammation, and inhibition of inflammation attenuates endothelial damage in animal models of preeclampsia. However, it is unclear if inhibition of vascular inflammation improves endothelial function in women after a preeclamptic pregnancy. Using the cutaneous microcirculation as a model, we hypothesized that acute systemic inhibition of vascular inflammation (oral salsalate; 1500 mg/twice daily, 4 days) would improve endothelium- and NO-dependent vasodilation in women with a history of preeclampsia (PE) but not in women with a history of uncomplicated pregnancy (HC). Twelve HC (30 ± 1yrs, 10 ± 2 months postpartum) and 10 PE (30 ± 2yrs, 8 ± 2 months postpartum) participated in a double-blind placebo-controlled study. Following each treatment, 2 intradermal microdialysis fibers were placed in the skin of the ventral forearm for graded infusion of acetylcholine (Ach, 10^-7-10²mM) or Ach + 15 mM L-NAME (NO synthase antagonist). Red blood cell flux was measured over each site by laser-Doppler flowmetry (LDF). Cutaneous vascular conductance was calculated (CVC = LDF/mean arterial pressure) and normalized to maximum (%CVC_max; 28 mM SNP + local heat 43 °C). ACh-induced (77 ± 3 vs. 92 ± 3%CVC_max; p = 0.01) and NO-dependent (20 ± 6 vs. 33 ± 4%; p = 0.02) vasodilation were attenuated in PE compared to HC. Salsalate augmented ACh-induced (95 ± 2%CVC_max; p = 0.002) and NO-dependent (39 ± 3%; p = 0.009) dilation in PE compared to placebo but had no effect in HC (all p > 0.05). Salsalate treatment augmented endothelium-dependent vasodilation via NO-mediated pathways in women who have had preeclampsia, suggesting that inflammatory signaling mediates persistent endothelial dysfunction following preeclampsia.

Preeclampsia has two phenotypes which require different treatment strategies

The opinion on the mechanisms underlying the pathogenesis of preeclampsia still divides scientists and clinicians. This common complication of pregnancy has long been viewed as a disorder linked primarily to placental dysfunction, which is caused by abnormal trophoblast invasion, however, evidence from the previous two decades has triggered and supported a major shift in viewing preeclampsia as a condition that is caused by inherent maternal cardiovascular dysfunction, perhaps entirely independent of the placenta. In fact, abnormalities in the arterial and cardiac functions are evident from the early subclinical stages of preeclampsia and even before conception. Moving away from simply observing the peripheral blood pressure changes, studies on the central hemodynamics reveal two different mechanisms of cardiovascular dysfunction thought to be reflective of the early-onset and late-onset phenotypes of preeclampsia. More recent evidence identified that the underlying cardiovascular dysfunction in these phenotypes can be categorized according to the presence of coexisting fetal growth restriction instead of according to the gestational period at onset, the former being far more common at early gestational ages. The purpose of this review is to summarize the hemodynamic research observations for the two phenotypes of preeclampsia. We delineate the physiological hemodynamic changes that occur in normal pregnancy and those that are observed with the pathologic processes associated with preeclampsia. From this, we propose how the two phenotypes of preeclampsia could be managed to mitigate or redress the hemodynamic dysfunction, and we consider the implications for future research based on the current evidence. Maternal hemodynamic modifications throughout pregnancy can be recorded with simple-to-use, noninvasive devices in obstetrical settings, which require only basic training. This review includes a brief overview of the methodologies and techniques used to study hemodynamics and arterial function, specifically the noninvasive techniques that have been utilized in preeclampsia research.

Women with a history of preeclampsia have preserved sensory nerve-mediated dilatation in the cutaneous microvasculature

NEW FINDINGS

What is the central question of this study? Are sensory nerve-mediated vasodilatation and the NO-dependent contribution to that response attenuated in the cutaneous microvasculature of women who have had preeclampsia? What is the main finding and its importance? Women who have had preeclampsia demonstrate attenuated microvascular endothelium-dependent dilatation compared to women with a history of uncomplicated pregnancy. However, there are no differences in sensory nerve-mediated vasodilatation between groups. This suggests that the neurogenic response is not altered following preeclampsia, and that the NO-dependent vasodilatation of the neurogenic response is not related to endothelium-dependent NO-mediated dilatation in these women.

ABSTRACT

Women who have had preeclampsia (PE) demonstrate microvascular endothelial dysfunction, mediated in part by reduced nitric oxide (NO)-dependent mechanisms. Localized heating of the skin induces a biphasic vasodilatation response: a sensory nerve-mediated initial peak, followed by a sustained endothelium-dependent plateau. We have previously shown that the endothelium-dependent plateau is attenuated in PE. However, it is unknown if the sensory nerve-mediated initial peak is similarly attenuated. Therefore, the purpose of this study was to examine the effect of PE history on sensory nerve-mediated vasodilatation and the NO-dependent contribution to that response. We hypothesized that PE would have an attenuated initial peak and a reduced NO-dependent contribution to that response compared to women with a history of normotensive pregnancy (healthy controls, HC). Nine HC (31 ± 4 years) and nine PE (28 ± 6 years) underwent a standard local heating protocol (42°C; 0.1°C s^-1 ). Two intradermal microdialysis fibres were placed in the skin of the ventral forearm for the continuous local delivery of lactated Ringer solution alone (control) or 15-mM N^G -nitro-l-arginine methyl ester for nitric oxide synthase (NOS) inhibition. Red blood cell flux was measured at each site by laser Doppler flowmetry (LDF). Cutaneous vascular conductance was calculated (CVC = LDF/mean arterial pressure) and normalized to maximum (%CVC_max ; 28-mM SNP + local heat 43°C). There were no differences in the initial peak between groups (HC: 79 ± 8 vs. PE: 80 ± 10%CVC_max ; P = 0.936). NOS inhibition attenuated the initial peak in both HC (57 ± 18% CVC_max ; P = 0.003) and PE (54 ± 10%CVC_max ; P = 0.002). However, there were no differences in the NO-dependent portion of the initial peak (HC: 23 ± 16 vs. PE: 24 ± 9%; P = 0.777). The local heating plateau (HC: 99 ± 4 vs. PE: 88 ± 7%CVC_max ; P = 0.001) and NO contribution to the plateau (HC: 31 ± 9 vs. PE: 17 ± 14%; P = 0.02) were attenuated in PE. There was no relation between NO-dependent dilatation in the initial peak and NO-dependent dilatation in the plateau across groups (R²  = 0.005; P = 0.943). Women who have had PE demonstrate attenuated microvascular endothelium-dependent dilatation. However, there are no differences in sensory nerve-mediated vasodilatation following PE, suggesting that the NO-dependent vasodilatation of the neurogenic response is not related to endothelium-dependent NO-mediated dilatation in these women.

Response of endothelial function and oxidative stress after supervised aerobic exercise training in formerly preeclamptic women

We sought to investigate effects of aerobic exercise in women with preeclampsia history. 42 women were enrolled. After 16 weeks, we found improvement in endothelial function index and oxidative stress biomarkers in the exercise group. Moreover, the change of endothelial function index was significantly associated with the change of total antioxidant capacity in the exercise group. Our findings showed aerobic exercise improved exercise capacity, endothelial function and oxidative stress in formerly preeclamptic women, and favorable modification of oxidative stress might be a vital pathway of endothelial function's melioration in those women, which deserves further exploration.

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review

Importance

A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs.

Observations

A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians.

Conclusions and Relevance

These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.

Maternal myocardial dysfunction after hemolysis, elevated liver enzymes, and low platelets syndrome: a speckle-tracking study

OBJECTIVES

Pregnancy complicated by pre-eclampsia (PE) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome is associated with an increased risk of cardiovascular (CV) diseases later in life. Subclinical cardiac alterations precede eminent CV diseases. Speckle-tracking echocardiography (STE) is an effective method to assess subclinical myocardial dysfunction. We performed a myocardial speckle tracking study to investigate the prevalence of subclinical myocardial dysfunction in former PE patients (with and without HELLP syndrome) compared to normotensive women affected by HELLP syndrome.

METHODS

In this cross-sectional retrospective study, women with a history of normotensive HELLP (n = 32), PE without HELLP (n = 59), and PE with HELLP (n = 101) underwent conventional and STE as part of the clinical CV work-up after their complicated pregnancies from 6 months to 4 years postpartum. We excluded women with comorbidities, including chronic hypertension, hypercholesterolemia, and obesity.

RESULTS

Women with a history of PE with HELLP syndrome were characterized by a higher prevalence of altered left ventricular circumferential and global longitudinal two-dimensional (2D) strain (74 and 20%, respectively), altered right ventricular longitudinal 2D strain (37%), and left atrial (LA) 2D strain (57%). Moreover, a higher proportion of alterations of biventricular and LA strains was also present in former PE without HELLP as well as in the normotensive HELLP group.

CONCLUSIONS

In the first years after a pregnancy complicated by HELLP syndrome, irrespective of whether there was concomitant PE, a higher rate of abnormal STE myocardial function is observed. Therefore, these women may benefit from CV risk management.

Physical Activity and Cardiovascular Risk Factor Outcomes in Women with a History of Hypertensive Disorders of Pregnancy: Integrative Review

BACKGROUND

Hypertensive disorders of pregnancy increase a woman's risk for developing cardiovascular disease, with risk factors manifested as early as one year postpartum. Researchers are examining how physical activity may help to mitigate cardiovascular risk factors in this population.

AIM

Review the existing scientific literature on the impact of physical activity in women with a history of hypertensive disorders of pregnancy related to physical activity and cardiovascular risk factor outcomes.

METHODS

This integrative review examined research studies addressing physical activity in women with a history of preeclampsia or other hypertensive disorders of pregnancy. Using four databases, the search strategy included published studies through December 31, 2019. Identified studies were assessed using Joanna Briggs Institute critical appraisal tools.

RESULTS

The initial search identified 1,166 publications. Seven studies including two observational, four quasi-experimental, and one experimental study were included in the review. Although the studies had limitations, none of these limitations were deemed significant enough to eliminate a study from the review. Studies were conducted in four countries, and participants were predominantly White. Physical activity interventions primarily consisted of delivery of educational content, and data were primarily obtained by self-report. Of the five studies utilizing intervention strategies, three reported positive findings including increased physical activity, enhanced physiologic adaptations, and decreased physical inactivity. One study reported mixed findings of improved physical fitness in both groups, while another reported no change in intent to change exercise behavior associated with the intervention.

LINKING EVIDENCE TO ACTION

Physical activity promotion among women with a history of hypertensive disorders of pregnancy has been studied by a small group of researchers. Current literature on the topic is characterized by limited sample diversity, lack of exercise-based interventions, and over reliance on self-report to measure physical activity. It is imperative that further research be conducted to facilitate improved cardiovascular outcomes.

Cardiovascular Risk Reduction in Women Following Hypertensive Disorders of Pregnancy - a Prospective, Randomised, Controlled Interventional Study

Background Women have a markedly increased lifetime risk for cardiovascular morbidity and mortality following hypertensive disorders of pregnancy. Arterial stiffness is regarded as a target parameter for reducing cardiovascular risk and can be modified by lifestyle changes.

Methods In a prospective, randomised, controlled interventional study, starting 6 weeks postpartum, the effect of nutritional intervention combined with an intensive 6-month cardiovascular exercise programme on arterial stiffness was investigated by means of pulse wave velocity (PWV) in 38 women with severe hypertensive disorder of pregnancy (preeclampsia with or without pre-existing hypertension and/or HELLP syndrome). A reference group was formed with postpartum women without pregnancy complications or known cardiovascular risk and the arterial stiffness was studied by means of PWV at the time of delivery. The PWV was measured in the intervention and control groups within a week after delivery and after 32 weeks (6 weeks + 6 months). A feasibility analysis was performed in addition.

Results 29 of 38 women with severe hypertensive disorder of pregnancy and 38 postpartum women in the reference group were included in the analysis (intervention group n = 14; control group n = 15; reference group n = 38). Adherence to a) the nutritional counselling and b) the intensive cardiovascular exercise programme was 73% and 79% respectively. A clinically significant difference (d = 0.65) in pulse wave velocity between the intervention and control groups was found after 6 months (6.36 ± 0.76 vs. 7.33 ± 2.25 m/s; group × time: p = 0.632). The PWV of the intervention group corresponded to that of the reference group at the end of the study (6.36 ± 0.76 m/s vs. 6.5 ± 0.70; d = 0.19), while the results in the control group differed markedly from this (7.33 ± 2.25 m/s; d = 0.56).

Conclusion The study documents the feasibility of lifestyle intervention with physical exercise after delivery (starting 6 weeks postpartum). The intervention showed a significant clinical effect by reducing arterial stiffness to the level of the reference group. Before this intervention can be included in the standard of care and prevention, follow-up studies must confirm these results and the medium-term effects on cardiovascular risk.

The impact of repeated, local heating-induced increases in blood flow on lower limb endothelial function in young, healthy females

PURPOSE

The purpose of the present study was to examine the effect of repeated, single leg heating on lower limb endothelial function.

METHODS

Macrovascular function was assessed with superficial femoral artery (SFA) reactive hyperemia flow-mediated dilation (RH-FMD) and sustained stimulus FMD (SS-FMD). Calf microvascular function was assessed as the peak and area under the curve of SFA reactive hyperemia (RH). Participants (n = 13 females, 23 ± 2 yrs) had one leg randomized to the single leg heating intervention (EXP; other leg: control (CON)). The EXP leg underwent 8 weeks of single leg heating via immersion in 42.5 ℃ water for five 35-min sessions/week. At weeks 0, 2, 4, 6, and 8, SFA RH-FMD, SS-FMD (shear stress increased via plantar flexion exercise), and SFA RH flow were measured.

RESULTS

None of the variables changed with repeated, single leg heating (interaction week*limb RH-FMD: p = 0.076; SS-FMD: p = 0.958; RH flow p = 0.955). Covariation for the shear stress stimulus did not alter the FMD results.

CONCLUSION

Eight weeks of single leg heating did not change SFA endothelial or calf microvascular function. These results are in contrast with previous findings that limb heating improves upper limb endothelial function.

Perindopril Reduces Arterial Pressure and Does Not Inhibit Exercise-Induced Angiogenesis in Spontaneously Hypertensive Rats

ABSTRACT

Sympathetic activity, arteriolar structure, and angiogenesis are important mechanisms modulating hypertension and this study aimed to analyze the effects of perindopril treatment, associated or not with exercise training, on the mechanisms that control blood pressure (BP) in hypertensive rats. Spontaneously hypertensive rats (SHR) were allocated into 4 groups: 1/sedentary (S); 2/perindopril (P, 3.0 mg/kg/d); 3/trained (T); and 4/trained + perindopril (TP). Wistar rats were used as normotensive sedentary control group. SHR were assigned to undergo a treadmill training (T) or were kept sedentary. Heart rate, BP, sympathetic activity to the vessels (LF-SBP), and skeletal muscle and myocardial morphometric analyses were performed. BP was significantly lower after all 3 strategies, compared with S and was accompanied by lower LF-SBP (-76%, -53%, and -44%, for P, T, and TP, respectively). Arteriolar vessel wall cross-sectional area was lower after treatments (-56%, -52%, and -56%, for P, T, and TP, respectively), and only TP presented higher arteriolar lumen area. Capillary rarefaction was present in soleus muscle and myocardium in S group and both trained groups presented higher vessel density, although perindopril attenuated this increase in soleus muscle. Although myocyte diameter was not different between groups, myocardial collagen deposition area, higher in S group, was lower after 3 strategies. In conclusion, we may suggest that perindopril could be an option for the hypertensive people who practice exercise and need a specific pharmacological treatment to reach a better BP control, mainly because training-induced angiogenesis is an important response to facilitate blood flow perfusion and oxygen uptake and perindopril did not attenuate this response.

Recognizing Cardiovascular Risk After Preeclampsia: The P4 Study

Background

There is increased risk of hypertension, early cardiovascular disease, and premature mortality in women who have had preeclampsia. This study was undertaken to determine the upper limit of normal blood pressure (BP) 6 months postpartum and the frequency of women with prior preeclampsia who had BP above these limits, as part of the P4 (Post‐Partum Physiology, Psychology and Pediatric) follow‐up study.

Methods and Results

BP was measured by sphygmomanometer, 24‐hour ambulatory BP monitoring, and non‐invasive central BP at 6 months postpartum in 302 women who had normotensive pregnancy and 90 who had preeclampsia. The upper limit of normal BP (mean+2 SD) for women with normotensive pregnancy was 122/79 mm Hg for routine BP, 115/81 mm Hg for central BP, and 121/78 mm Hg for 24‐hour ambulatory BP monitoring. Traditional normal values detected only 3% of women who had preeclampsia as having high BP 6 months postpartum whereas these new values detected between 13% and 19%. Women with preeclampsia had greater body mass index (27.8 versus 25.0, P<0.001) and left ventricular wall thickness but similar augmentation index. They also had lower high‐density lipoprotein (59±15 versus 65±16 mg/dL, P=0.002), higher triglycerides (77±51 versus 61±35 mg/dL, P=0.005), and higher homeostatic model assessment score (2.1±1.8 versus 1.3±1.9, P<0.001).

Conclusions

Clinicians wishing to detect high BP in these women should be aware of the lower than usual upper limit of normal for this young cohort and where possible should use 24‐hour ambulatory BP monitoring to detect these changes. This may define a subgroup of women who had preeclampsia for whom targeted BP lowering therapy would be successful.

Registration

URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365295&isReview=true; Unique identifier: ACTRN12613001260718.

California Cardiovascular Screening Tool: Findings from Initial Implementation

Objective  American College of Obstetricians and Gynecologists (ACOG) recently published the California (CA) cardiovascular disease (CVD) screening algorithm for pregnant and postpartum women. We aim to prospectively determine screen-positive and true-positive rates of CVD among women across two populations. Study Design  This is a prospective cohort study of obstetrical patients from April 2018 to July 2019 at academic medical centers in CA and New York (NY). We attempted to screen all patients at least once during their pregnancy care (prenatal or postpartum). Women who screened positive ("Red Flags," >3-4 moderate risk factors, abnormal physical examination, and persistent symptoms) underwent further testing. The primary outcome was the screen-positive rate. Secondary outcomes included the true-positive rate and the strength of each moderate factor in predicting a positive CVD screen. Results  We screened 846 women. The overall screen-positive rate was 8% (5% in CA vs. 19% in NY). The sites differed in ethnicity, that is, African American women (2.7% in CA vs. 35% in NY, p  < 0.01) and substance use (2.7 vs. 5.6%, p  < 0.04). The true-positive rate was 1.5% at both sites. The percentage of screen-positive patients who did not complete follow-up studies was higher in NY (70%) than in CA (27%). CVD was confirmed in 30% with positive screens with complete follow-up. Combinations of moderate factors were the main driver of screen-positive rates in both populations. Conclusion  This is the first data describing the performance of the CVD screening algorithm in a general obstetric population. Factors, such as proportion of African American women affect the likelihood of a positive screen. The screening algorithm highlights patients at higher lifetime risk of CVD and may identify a group that could be targeted for more direct care transitions postpartum. Data may be used to design a larger validation study.

Missed opportunities to prevent cardiovascular disease in women with prior preeclampsia

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women in every major developed country and in most emerging nations. Complications of pregnancy, including preeclampsia, indicate a subsequent increase in cardiovascular risk. There may be a primary care provider knowledge gap regarding preeclampsia as a risk factor for CVD. The objective of our study is to determine how often internists at an academic institution inquire about a history of preeclampsia, as compared to a history of smoking, hypertension and diabetes, when assessing CVD risk factors at well-woman visits. Additional aims were (1) to educate internal medicine primary care providers on the significance of preeclampsia as a risk factor for CVD disease and (2) to assess the impact of education interventions on obstetric history documentation and screening for CVD in women with prior preeclampsia.

METHODS

A retrospective chart review was performed to identify women ages 18-48 with at least one prior obstetric delivery. We evaluated the frequency of documentation of preeclampsia compared to traditional risk factors for CVD (smoking, diabetes, and chronic hypertension) by reviewing the well-woman visit notes, past medical history, obstetric history, and the problem list in the electronic medical record. For intervention, educational teaching sessions (presentation with Q&A session) and education slide presentations were given to internal medicine physicians at clinic sites. Changes in documentation were evaluated post-intervention.

RESULTS

When assessment of relevant pregnancy history was obtained, 23.6% of women were asked about a history preeclampsia while 98.9% were asked about diabetes or smoking and 100% were asked about chronic hypertension (p < 0.001). Education interventions did not significantly change rates of screening documentation (p = 0.36).

CONCLUSION

Our study adds to the growing body of literature that women with a history of preeclampsia might not be identified as having increased CVD risk in the outpatient primary care setting. Novel educational programming may be required to increase provider documentation of preeclampsia history in screening.

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.

Physical exercise and metformin in the prevention of pre-eclampsia: systematic review

Abstract Introduction: Pre-eclampsia is a disorder that may occur during pregnancy but is still unknown and / or multifactorial causes. Objective: To verify whether physical exercise and metformin may be helpful in preventing preeclampsia. Method: This is a systematic review of the literature in PubMed / MEDLINE, Web of Science, Scopus, LILACS and Cochrane. This review followed the critiques of the PRISMA checklist. Bias assessment was used for the Cochrane Handbook for Systematical Reviews of Interventions (Version 5.1.0) for clinical trials and the Downs and Black scale for cohort and case-control studies. Results: 17 studies were within the established criteria. The subjects evaluated were: pre-eclampsia, cardiovascular metabolic factors, physiotherapeutic therapies and the effects of physical exercise and metformin on the circulatory system. Conclusion: There is a need for adapted techniques and new protocols according to the contingencies and complications of pregnancy. During pregnancy, it is suggested a greater interdisciplinarity of knowledge among professionals and that the therapy receives adjustments against the metabolic alterations of the reproductive system. In order to prevent preeclampsia, the study suggests a program of individual exercises that include greater assistance, verification and / or comprehension of possible changes and their limits during pregnancy. As well as, the adjuvant use of metformin of 1000 mg/d in the initial phase, with the purpose of maintaining the effects of the drug due to renal clearance during pregnancy, until reaching a maximum of 1500 mg/d, to avoid side effects of the drug.

A Systematic Review of Vascular Structure and Function in Pre-eclampsia: Non-invasive Assessment and Mechanistic Links

Hypertensive disorders of pregnancy, such as pre-eclampsia, are known to be independently associated with the development of premature cardiovascular disease (CVD) in women. In pre-eclampsia, the placenta secretes excess anti-angiogenic factors into the maternal circulation, leading to widespread endothelial damage, and inflammation. This endothelial damage is evidenced to persist beyond the acute illness. However, whether it is permanent and responsible for the elevated rates of premature CVD seen in this at-risk group remains unclear. A systematic review of the available literature with respect to vascular structure and function prior to, during and after a pregnancy complicated by pre-eclampsia was performed. Studies non-invasively assessing vascular structure using carotid intima-media thickness (CIMT), retinal microvasculature caliber, CT coronary angiogram, or coronary calcium scores were included. Vascular function was assessed using brachial flow-mediated dilation (FMD), pulse wave analysis (PWA), and peripheral arterial tonometry (PAT). In total 59 articles were included (13 CIMT, 5 CTCA/Ca score, five retinal microvasculature, 27 FMD, 7 PAT, and 14 PWV/PWA), consisting of prospective and retrospective cohort, and case-control studies. Change in vascular structure was evidenced with significant increases in CIMT by 73-180 μm greater than that of non-affected women. This is tempered by other studies reporting resolution of structural changes postpartum, highlighting the need for further research. Accelerated coronary calcification and plaque deposition was identified, with greater rates of increased calcium scores and subclinical coronary artery disease shown by CTCA in women with a history of pre-eclampsia at 30 years postpartum. Impaired endothelial function was consistently reported prior to, during and immediately after pregnancy as evidenced by differences in FMD of 1.7-12.2% less than non-affected women, an increase in PWV by 13.2-26%, and reduced retinal microvascular caliber and arterial elasticity indices. The evidence was less conclusive for the persistence of long-term endothelial dysfunction. Understanding the underlying mechanistic links between pre-eclampsia and CVD is a key step to identifying targeted therapies aimed at "repairing the endothelium" and attenuating risk. This review has highlighted the need for a greater understanding of vascular structure and function following pre-eclampsia through high quality studies with large sample sizes, particularly in the longer postpartum period when clinical CVD disease starts to manifest.

A Systematic Review of Vascular Structure and Function in Pre-eclampsia: Non-invasive Assessment and Mechanistic Links

Hypertensive disorders of pregnancy, such as pre-eclampsia, are known to be independently associated with the development of premature cardiovascular disease (CVD) in women. In pre-eclampsia, the placenta secretes excess anti-angiogenic factors into the maternal circulation, leading to widespread endothelial damage, and inflammation. This endothelial damage is evidenced to persist beyond the acute illness. However, whether it is permanent and responsible for the elevated rates of premature CVD seen in this at-risk group remains unclear. A systematic review of the available literature with respect to vascular structure and function prior to, during and after a pregnancy complicated by pre-eclampsia was performed. Studies non-invasively assessing vascular structure using carotid intima-media thickness (CIMT), retinal microvasculature caliber, CT coronary angiogram, or coronary calcium scores were included. Vascular function was assessed using brachial flow-mediated dilation (FMD), pulse wave analysis (PWA), and peripheral arterial tonometry (PAT). In total 59 articles were included (13 CIMT, 5 CTCA/Ca score, five retinal microvasculature, 27 FMD, 7 PAT, and 14 PWV/PWA), consisting of prospective and retrospective cohort, and case-control studies. Change in vascular structure was evidenced with significant increases in CIMT by 73–180 μm greater than that of non-affected women. This is tempered by other studies reporting resolution of structural changes postpartum, highlighting the need for further research. Accelerated coronary calcification and plaque deposition was identified, with greater rates of increased calcium scores and subclinical coronary artery disease shown by CTCA in women with a history of pre-eclampsia at 30 years postpartum. Impaired endothelial function was consistently reported prior to, during and immediately after pregnancy as evidenced by differences in FMD of 1.7–12.2% less than non-affected women, an increase in PWV by 13.2–26%, and reduced retinal microvascular caliber and arterial elasticity indices. The evidence was less conclusive for the persistence of long-term endothelial dysfunction. Understanding the underlying mechanistic links between pre-eclampsia and CVD is a key step to identifying targeted therapies aimed at “repairing the endothelium” and attenuating risk. This review has highlighted the need for a greater understanding of vascular structure and function following pre-eclampsia through high quality studies with large sample sizes, particularly in the longer postpartum period when clinical CVD disease starts to manifest.

Evidence of a limb- and shear stress stimulus profile-dependent impact of high-intensity cycling training on flow-mediated dilation

Lower limb endurance training can improve conduit artery flow-mediated dilation (FMD) in response to transient increases in shear stress (reactive hyperemia; RH-FMD) in both the upper and lower limbs. Sustained increases in shear stress recruit a partially distinct transduction pathway and elicit a physiologically relevant FMD response (SS-FMD) that provides distinct information regarding endothelial function. However, the impact of training on SS-FMD is not well understood. The purpose of this study was to determine the impact of cycling training on handgrip exercise-induced brachial artery (BA) FMD (BA SS-FMD) and calf plantar-flexion-induced superficial femoral artery (SFA) FMD (SFA SS-FMD). RH-FMD was also assessed in both arteries. Twenty-eight young males were randomized to control (n = 12) or training (n = 16) groups. The training group cycled 30 min/day, 3 days/week for 4 weeks at 80% heart rate reserve. FMD was assessed in the BA and SFA before and after the intervention via Duplex ultrasound. Results are means ± SD. Training did not impact SS-FMD in either artery, and SFA RH-FMD was also unchanged (p > 0.05). When controlling for the shear rate stimulus via covariate analysis, BA RH-FMD improved in the training group (p = 0.05) (control - pre-intervention: 5.7% ± 2.4%, post-intervention: 5.3% ± 2.4%; training - pre-intervention: 5.4% ± 2.5%, post-intervention: 7.2% ± 2.4%). Thus, endurance training resulted in nonuniform adaptations to endothelial function, with an isolated impact on the BA's ability to transduce a transient increase in shear stress. Novelty Training did not alter SS-FMD in the arm or leg. RH-FMD was augmented in the arm only. Thus training adaptations were limb- and shear stress profile-specific.

Is preeclampsia itself a risk factor for the development of metabolic syndrome after delivery?

Objective

This study aimed to determine the association between preeclampsia and the postpartum development of metabolic syndrome based on the pre-pregnancy status.

Methods

Korean women who delivered their first child between January 1, 2011, and December 31, 2012, were enrolled. All subjects underwent a national health screening examination conducted by the National Health Insurance Corporation 1 or 2 years prior to their first delivery and within 2 years after their first delivery.

Results

Among the 49,065 participants, preeclampsia developed in 3,391 participants (6.9%). The prevalence of metabolic syndrome was higher postpartum in women with preeclampsia than in those without preeclampsia (4.9% vs. 2.7%, respectively, P<0.001). Through the pre-pregnancy to postpartum period, women with preeclampsia had a greater increase in gestational weight retention, body mass index, waist circumference, systolic blood pressure, and triglyceride levels and a greater decrease in high-density lipoprotein cholesterol levels than women without preeclampsia. Preeclampsia was associated with an increased risk of the postpartum development of metabolic syndrome in women without pre-pregnancy metabolic syndrome (odds ratio, 1.28; 95% confidence interval, 1.05–1.56). However, preeclampsia was not associated with postpartum metabolic syndrome in women with pre-pregnancy metabolic syndrome or 2 components of metabolic syndrome.

Conclusion

In this study, preeclampsia was associated with the postpartum development of metabolic syndrome in women without pre-pregnancy metabolic syndrome. However, the effects were attenuated by predisposing risk factors in the pre-pregnancy period.

Decreased heart rate recovery in women with a history of pre-eclampsia

BACKGROUND

A growing body of literature has reported that a history of pre-eclampsia (PE) increases a woman's long-term risk of cardiovascular diseases (CVD). Autonomic nervous system dysfunction was found to be significant in this specific population, but most studies observed the role of sympathetic over-activation. The aim of this study was to assess whether parasympathetic impairment was involved in women 1 year after PE, and heart rate recovery (HRR) was used to represent parasympathetic tone.

STUDY DESIGN

47 women with previous PE (PE group) and 58 women with a healthy pregnancy (control group) were examined. Blood pressure levels, lipid profiles, homeostasis model assessment of insulin resistance (HOMA-IR), inflammatory biomarkers and HRR were compared between the two groups, and the association between the biochemical parameters and HRR in the PE group was evaluated.

RESULTS

Compared with the Control group, body mass index, 24-h mean diastolic blood pressure, low-density lipoprotein cholesterol and Ln(HOMA-IR) were higher, and HRR was slower in the PE group. Furthermore, body mass index, total cholesterol, and Ln(HOMA-IR) were independent determinants of HRR in the PE group according to multiple regression analysis.

CONCLUSIONS

Our findings suggest that parasympathetic impairment is involved in this specific female population, and its close association with body mass index, total cholesterol and insulin resistance might contribute to an increased risk of CVD development in women with PE history.

Residual vascular dysfunction in women with a history of preeclampsia

Preeclampsia is a hypertensive disorder of pregnancy characterized by new-onset hypertension, proteinuria, and edema occurring after 20 wk of gestation, with a prevalence of ~7-10% of pregnancies in the United States and ~8 million pregnancies worldwide. Despite the postpartum remission of preeclamptic symptoms, women who have had preeclampsia are two to four times more likely to develop cardiovascular disease (CVD) and are significantly more likely to die of CVD compared with women with a history of normal pregnancy. Although the relation between history of preeclampsia and elevated CVD risk is well documented, the mechanism(s) underlying this association remains unclear. One hypothesis explaining this association is that the initial vascular damage and dysfunction sustained during the preeclamptic pregnancy persist chronically. Indeed, even in the absence of, or in advance of, overt CVD women who have had preeclampsia have compromised vascular endothelial function. Emerging mechanistic studies in these women have provided some insight into the underlying mechanisms of this persistent vascular dysfunction and have begun to identify potential therapeutic targets for the prevention or mitigation of CVD progression in this vulnerable population. This review summarizes the existing literature examining vascular function and dysfunction in women with a history of preeclampsia and highlights future directions for mechanistic investigations and development of novel intervention strategies aimed at halting or slowing the progression of CVD in these women.

Decreased endothelial function and increased subclinical heart failure in women several years after pre-eclampsia

OBJECTIVES

Pre-eclampsia (PE) is associated with both postpartum endothelial dysfunction and asymptomatic structural heart alterations consistent with heart failure Stage B (HF-B). In this study, we assessed the relationship between endothelial function, measured by flow-mediated dilation (FMD), and HF-B in women with a history of PE.

METHODS

This was an observational study in which 67 formerly pre-eclamptic women (≥ 4 years postpartum) and 37 healthy parous controls were assessed ultrasonographically for cardiac function and geometry, as well as for endothelial function by means of brachial artery FMD. HF-B was diagnosed as left ventricular hypertrophy (left ventricular mass index (LVMi) > 95 g/m² ), concentric remodeling (relative wall thickness > 0.42 and LVMi ≤ 95 g/m² ), mild systolic dysfunction (left ventricular ejection fraction > 40% and < 55%) or asymptomatic valvular disease. Cardiovascular and metabolic syndrome variables were compared between women with history of PE and controls, as well as between those in the formerly pre-eclamptic group who had HF Stage A, HF-B or no HF. Logistic regression analysis was performed to assess the associations of FMD with PE, metabolic syndrome risk factors and obstetric parameters.

RESULTS

The prevalence of HF-B amongst formerly pre-eclamptic women was three-fold higher than that observed for controls (25% vs 8%, P < 0.05), while FMD was lower in formerly pre-eclamptic women compared with controls (6.12% vs 8.22%, P < 0.01); history of PE remained associated independently with lower FMD after adjusting for metabolic syndrome risk factors and obstetric parameters (β, -1.88; 95% CI, -3.59 to -0.18). However, HF-B did not relate to low FMD in formerly pre-eclamptic women.

CONCLUSIONS

Years after pregnancy, formerly pre- eclamptic women have lower FMD and have HF-B more often compared with healthy parous controls. Nonetheless, HF-B was not related to reduced FMD. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of venous hemodynamics and volume homeostasis during pregnancy: recommendations of the International Working Group on Maternal Hemodynamics

Venous hemodynamics and volume homeostasis are important aspects of cardiovascular physiology. However, today their relevance is still very much underappreciated. Their most important role is maintenance and control of venous return and, as such, cardiac output. A high-flow/low-resistance circulation, remaining constant under physiological circumstances, is mandatory for an uncomplicated course of pregnancy. In this article, characteristics of normal and abnormal venous and volume regulating functions are discussed with respect to normal and pathologic outcomes of pregnancy, and current (non-invasive) methods to assess these functions are summarized. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Improvements in fitness are not obligatory for exercise training-induced improvements in CV risk factors

The purpose of this study was to assess whether changes in physical fitness relate to changes in cardiovascular risk factors following standardized, center-based and supervised exercise training programs in subjects with increased cardiovascular risk. We pooled data from exercise training studies of subjects with increased cardiovascular risk (n = 166) who underwent 8-52 weeks endurance training. We determined fitness (i.e., peak oxygen uptake) and traditional cardiovascular risk factors (body mass index, blood pressure, total cholesterol, high-density lipoprotein cholesterol), before and after training. We divided subjects into quartiles based on improvement in fitness, and examined whether these groups differed in terms of risk factors. Associations between changes in fitness and in cardiovascular risk factors were further tested using Pearson correlations. Significant heterogeneity was apparent in the improvement of fitness and individual risk factors, with nonresponder rates of 17% for fitness, 44% for body mass index, 33% for mean arterial pressure, 49% for total cholesterol, and 49% for high-density lipoprotein cholesterol. Neither the number, nor the magnitude, of change in cardiovascular risk factors differed significantly between quartiles of fitness change. Changes in fitness were not correlated with changes in cardiovascular risk factors (all P > 0.05). Our data suggest that significant heterogeneity exists in changes in peak oxygen uptake after training, while improvement in fitness did not relate to improvement in cardiovascular risk factors. In subjects with increased cardiovascular risk, improvements in fitness are not obligatory for training-induced improvements in cardiovascular risk factors.

Maternal hemodynamics: a method to classify hypertensive disorders of pregnancy

BACKGROUND

The classification of hypertensive disorders of pregnancy is based on the time at the onset of hypertension, proteinuria, and other associated complications. Maternal hemodynamic interrogation in hypertensive disorders of pregnancy considers not only the peripheral blood pressure but also the entire cardiovascular system, and it might help to classify the different clinical phenotypes of this syndrome.

OBJECTIVE

This study aimed to examine cardiovascular parameters in a cohort of patients affected by hypertensive disorders of pregnancy according to the clinical phenotypes that prioritize fetoplacental characteristics and not the time at onset of hypertensive disorders of pregnancy.

STUDY DESIGN

At the fetal-maternal medicine unit of Ziekenhuis Oost-Limburg (Genk, Belgium), maternal cardiovascular parameters were obtained through impedance cardiography using a noninvasive continuous cardiac output monitor with the patients placed in a standing position. The patients were classified as pregnant women with hypertensive disorders of pregnancy who delivered appropriate- and small-for-gestational-age fetuses. Normotensive pregnant women with an appropriate-for-gestational-age fetus at delivery were enrolled as the control group. The possible impact of obesity (body mass index ≥30 kg/m²) on maternal hemodynamics was reassessed in the same groups.

RESULTS

Maternal age, parity, body mass index, and blood pressure were not significantly different between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and hypertensive disorders of pregnancy/small-for-gestational-age groups. The mean uterine artery pulsatility index was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group. The cardiac output and cardiac index were significantly lower in the hypertensive disorders of pregnancy/small-for-gestational-age group (cardiac output 6.5 L/min, cardiac index 3.6) than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group (cardiac output 7.6 L/min, cardiac index 3.9) but not between the hypertensive disorders of pregnancy/appropriate-for-gestational-age and control groups (cardiac output 7.6 L/min, cardiac index 4.0). Total vascular resistance was significantly higher in the hypertensive disorders of pregnancy/small-for-gestational-age group than in the hypertensive disorders of pregnancy/appropriate-for-gestational-age group and the control group. All women with hypertensive disorders of pregnancy showed signs of central arterial dysfunction. The cardiovascular parameters were not influenced by gestational age at the onset of hypertensive disorders of pregnancy, and no difference was observed between the women with appropriate-for-gestational-age fetuses affected by preeclampsia or by gestational hypertension with appropriate-for-gestational-age fetuses. Women in the obese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and obese/hypertensive disorders of pregnancy/small-for-gestational-age groups showed a significant increase in cardiac output, as well as significant changes in other parameters, compared with the nonobese/hypertensive disorders of pregnancy/appropriate-for-gestational-age and nonobese/hypertensive disorders of pregnancy/small-for-gestational-age groups.

CONCLUSION

Significantly low cardiac output and high total vascular resistance characterized the women with hypertensive disorders of pregnancy associated with small for gestational age due to placental insufficiency, independent of the gestational age at the onset of hypertension. The cardiovascular parameters were not significantly different in the women with appropriate-for-gestational-age or small-for-gestational-age fetuses affected by preeclampsia or gestational hypertension. These findings support the view that maternal hemodynamics may be a candidate diagnostic tool to identify hypertensive disorders in pregnancies associated with small-for-gestational-age fetuses. This additional tool matches other reported evidence provided by uterine Doppler velocimetry, low vascular growth factors in the first trimester, and placental pathology. Obesity is associated with a significantly higher cardiac output and outweighs other determinants of hemodynamics in pregnancy; therefore, in future studies on hypertensive disorders, obesity should be studied as an additional disease and not simply as a demographic characteristic.

Physiological adaptation of endothelial function to pregnancy: systematic review and meta-analysis

OBJECTIVES

To establish reference values for flow-mediated dilatation (FMD) and brachial artery diameter (BAD) in pregnancy and to provide insight into the physiological and pathological course of endothelial adaptation throughout human singleton pregnancy.

METHODS

A meta-analysis was performed following a systematic review of current literature on FMD, as a derivative for endothelial function, and BAD, throughout uncomplicated and complicated pregnancy. PubMed (NCBI) and EMBASE (Ovid) electronic databases were used for the literature search, which was performed from inception to 9 June 2016. To allow judgment of changes in comparison with the non-pregnant state, studies were required to report both non-pregnant mean reference of FMD (matched control group, prepregnancy or postpartum measurement) and mean FMD at a predetermined and reported gestational age. Pooled mean differences between the reference and pregnant FMD values were calculated for predefined intervals of gestational age.

RESULTS

Fourteen studies that enrolled 1231 participants met the inclusion criteria. Publication dates ranged from 1999 to 2014. In uncomplicated pregnancy, FMD was increased in the second and third trimesters. Between 15 and 21 weeks of gestation, absolute FMD increased the most, by a mean (95% CI) of 1.89% (0.25-3.53%). This was a relative increase of 22.5% (3.0-42.0%) compared with the non-pregnant reference. BAD increased progressively, in a steady manner, by the second trimester but not significantly in the first half of the second trimester. We could not discern differences in FMD and BAD between complicated and uncomplicated pregnancies at 29-35 weeks' gestation, reported in the three studies that met our inclusion criteria. Despite the increase in FMD and BAD throughout gestation, both reference curves were characterized by wide 95% CIs.

CONCLUSION

During healthy pregnancy, endothelium-dependent vasodilatation and BAD increase. Women with a complicated pregnancy had FMD values within the lower range when compared with those with uncomplicated pregnancy but, as a group, did not differ from each other. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Effects of 24-Week Aerobic and Resistance Training on Carotid Artery Intima-Media Thickness and Flow Velocity in Elderly Women with Sarcopenic Obesity

Aim: Sarcopenic obesity (SO) is closely associated with cardiovascular disease (CVD) in elderly women. Increases in body fat and decreases in muscle mass are closely associated with increased carotid intima-media thickness (CIMT). The aim of this study was to examine the influence of a 24-week aerobic and resistance training program on carotid parameters in SO.

Methods: Fifty elderly women (74.1 ± 6.1 years) with SO were randomly divided into an exercise group and a control group. The exercise group performed combined exercise over 24 weeks, consisting of resistance and aerobic training for 50–80 min, 5 times a week. Carotid variables were measured using B-mode ultrasound. The differences in the carotid variables and the relative changes between baseline and after 24 weeks were evaluated.

Results: In the analysis of variance (ANOVA) results, CIMT (p = 0.013), systolic flow velocity (p = 0.007), diastolic flow velocity (p = 0.006), and wall shear rate (p = 0.010) showed significant interactions. In paired t-test results of the exercise group, CIMT significantly decreased (p < 0.01) and systolic flow velocity (p < 0.01), diastolic flow velocity (p < 0.001), and wall shear rate (p < 0.05) significantly increased after 24 weeks.

Conclusion: The 24-week combined exercise effectively decreased CIMT and increased carotid flow velocity and wall shear ratio. Therefore, combined exercise is thought to contribute to the improvement of the risk of CVD in elderly women with SO.

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

OBJECTIVES

Pre-eclampsia (PE) is a pregnancy-specific hypertensive disorder that has been associated with cardiovascular risk factors and vascular changes, such as acute atherosis in placental blood vessels, similar to early-stage atherosclerosis. The objective of this study was to determine whether women with PE have increased atherosclerotic burden, as determined by the carotid intima-media thickness (CIMT), compared with women without PE.

METHODS

We conducted a systematic review and meta-analysis of studies that reported CIMT, a non-invasive, ultrasound-based measure of subclinical atherosclerosis, in women who did vs those who did not have PE. Studies were eligible if they had been conducted during pregnancy or during the first decade postpartum, and if CIMT was measured in the common carotid artery. Studies published before 7 March 2016 were identified through PubMed, EMBASE and Web of Science. Two reviewers used predefined forms and protocols to evaluate independently the eligibility of studies based on titles and abstracts and to perform full-text screening, data abstraction and quality assessment. Heterogeneity was assessed using the I2 statistic. Standardized mean difference (SMD) was used as a measure of effect size.

RESULTS

Fourteen studies were included in the meta-analysis. Seven studies were carried out during pregnancy complicated by PE, 10 were carried out up to 10 years postpartum and three included measurements obtained at both time periods. Women who had PE had significantly higher CIMT than did those who did not have PE, both at the time of diagnosis (SMD, 1.10 (95% CI, 0.73-1.48); P < 0.001) and in the first decade postpartum (SMD, 0.58 (95% CI, 0.36-0.79); P < 0.001).

CONCLUSIONS

Atherosclerotic load is present at the time of PE and may be a mechanism associated with the disease. Measurement of CIMT may offer an opportunity for the early identification of premenopausal women with atherosclerotic burden after a PE pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Impaired Flow-Mediated Dilation Before, During, and After Preeclampsia: A Systematic Review and Meta-Analysis

Endothelial dysfunction is believed to play a critical role in preeclampsia; however, it is unclear whether this dysfunction precedes the pregnancy or is caused by pathophysiological events in early pregnancy. It is also unclear for how long vascular dysfunction may persist postpartum and whether it represents a mechanism linking preeclampsia with future cardiovascular disease. Our objective was to determine whether women with preeclampsia had worse vascular function compared with women who did not have preeclampsia by performing a systematic review and meta-analysis of studies that examined endothelial dysfunction using flow-mediated dilation. We included studies published before May 29, 2015, that examined flow-mediated dilation before, during, or after preeclampsia. Differences in flow-mediated dilation between study groups were evaluated by standardized mean differences. Out of 610 abstracts identified through PubMED, EMBASE, and Web of Science, 37 studies were eligible for the meta-analysis. When compared with women who did not have preeclampsia, women who had preeclampsia had lower flow-mediated dilation before the development of preeclampsia (≈20-29 weeks gestation), at the time of preeclampsia, and for 3 years postpartum, with the estimated magnitude of the effect ranging between 0.5 and 3 standard deviations. Similar effects were observed when the analysis was limited to studies that excluded women with chronic hypertension, smokers, or both. Vascular dysfunction predates preeclampsia and may contribute to its pathogenesis. Future studies should address whether vascular changes that persist after preeclamptic pregnancies may represent a mechanistic link with increased risk for future cardiovascular disease.

Effective strategies for weight loss in post-partum women: a systematic review and meta-analysis

Post-partum weight loss is critical to preventing and managing obesity in women, but the results from lifestyle interventions are variable and the components associated with successful outcomes are not yet clearly identified. This study aimed to identify lifestyle intervention strategies associated with weight loss in post-partum women. MEDLINE, EMBASE, PubMed, CINAHL and four other databases were searched for lifestyle intervention studies (diet or exercise or both) in post-partum women (within 12 months of delivery) published up to July 2014. The primary outcome was weight loss. Subgroup analyses were conducted for self-monitoring, individual or group setting, intervention duration, intervention types, the use of technology as a support, and home- or centre-based interventions. From 12,673 studies, 46 studies were included in systematic review and 32 randomized controlled trials were eligible for meta-analysis (1,892 women, age 24-36 years). Studies with self-monitoring had significantly greater weight lost than those without (-4.61 kg [-7.08, -2.15] vs. -1.34 kg [-1.66, -1.02], P = 0.01 for subgroup differences). Diet and physical activity when combined were significantly more effective on weight loss compared with physical activity alone (-3.24 kg [-4.59, -1.90] vs. -1.63 kg [-2.16, -1.10], P < 0.001 for subgroup differences). Lifestyle interventions that use self-monitoring and take a combined diet-and-exercise approach have significantly greater weight loss in post-partum women.

Reduced Heart Rate Variability and Altered Cardiac Conduction after Pre-Eclampsia

Pre-eclampsia is a hypertensive disorder of pregnancy that is associated with elevated maternal risk for cardiovascular disease. The aims of this study were to determine the effect of normal pregnancy on postpartum parameters of the electrocardiogram, and furthermore to determine how a history of pre-eclampsia may affect these parameters. Ten-minute high-resolution (1000 Hz) orthogonal Holter electrocardiogram (ECG) recordings were used to measure heart rate variability (HRV). Signal-averaged P-wave and QRS complex durations were determined. Participants included non-pregnant controls, normotensive parous controls and women with a recent history of PE. While reductions in HRV induced by uncomplicated pregnancy returned to non-pregnant levels by 6–8 months postpartum HRV remained reduced in women with a history of PE compared to control groups. In addition, P-Wave and QRS complex durations were prolonged in PE subjects at 6–8 months postpartum compared to control groups. Only QRS duration was independent of differences in blood pressure. These results suggest increased sympathetic cardiac activity, and delayed myocardial conduction in women after PE; alterations consistent with cardiac remodeling and increased risk for arrhythmia. In examining the association between PE and cardiovascular disease, identification of ECG abnormalities soon after pregnancy in women with a history of PE highlights a unique opportunity for early identification and screening in this population before other risk factors become apparent.

Low Plasma Volume in Normotensive Formerly Preeclamptic Women Predisposes to Hypertension

Formerly preeclamptic women are at risk for cardiovascular disease. Low plasma volume may reflect latent hypertension and potentially links preeclampsia with chronic cardiovascular disease. We hypothesized that low plasma volume in normotensive formerly preeclamptic women predisposes to hypertension. We longitudinally studied n=104 formerly preeclamptic women in whom plasma volume was measured 3 to 30 months after the preeclamptic pregnancy. Cardiovascular variables were assessed at 2 points in time (3-30 months postpartum and 2-5 years thereafter). Study population was divided into low plasma volume (≤1373 mL/m(2)) and normal plasma volume (>1373 mL/m(2)). Primary end point was hypertension at the second visit: defined as ≥140 mm Hg systolic or ≥90 mm Hg diastolic. Secondary outcome of this study was change in traditional cardiovascular risk profile between visits. Variables correlating univariately with change in blood pressure between visits were introduced in regression analysis. Eighteen of 104 (17%) formerly preeclamptic women who were normotensive at first visit had hypertension at second evaluation 2 to 5 years later. Hypertension developed more often in women with low plasma volume (10/35 [29%]) than in women with normal plasma volume (8/69 [12%]; odds ratio, 3.2; 95% confidence interval, 1.4-8.6). After adjustments, relationship between plasma volume status and subsequent hypertension persisted (adjusted odds ratio, 3.0; 95% confidence interval, 1.1-8.5). Mean arterial pressure at second visit correlated inverse linearly with plasma volume (r=-0.49; P<0.01). Initially normotensive formerly preeclamptic women have 17% chance to develop hypertension within 5 years. Women with low plasma volume have higher chance to develop hypertension than women with normal plasma volume. Clinically, follow-up of blood pressure seems warranted in women with history of preeclampsia, even when initially normotensive.

Intraabdominal fat, insulin sensitivity, and cardiovascular risk factors in postpartum women with a history of preeclampsia

OBJECTIVE

Women who develop preeclampsia have a higher risk of future cardiovascular disease and diabetes compared to women who have uncomplicated pregnancies. We hypothesized that women with prior preeclampsia would have increased visceral adiposity that would be a major determinant of their metabolic and cardiovascular risk factors.

STUDY DESIGN

We compared intraabdominal fat (IAF) area, insulin sensitivity index (SI), fasting lipids, low-density lipoprotein relative flotation rate, and brachial artery flow-mediated dilatation in 49 women with prior preeclampsia and 22 controls who were at least 8 months postpartum and matched for age, parity, body mass index, and months postpartum. Women were eligible if they did not smoke tobacco, use hormonal contraception, have chronic hypertension, or have a history of gestational diabetes.

RESULTS

The groups were similar for age (mean ± SD: prior preeclampsia 33.4 ± 6.6 vs control 34.6 ± 4.3 years), parity (median: 1 for both), body mass index (26.7 ± 5.9 vs 24.0 ± 7.3 kg/m(2)), and months postpartum (median [25th-75th percentile]: 16 [13-38] vs 16.5 [13-25]). There were no significant differences in IAF area and SI. Despite this, women with preeclampsia had lower high-density lipoprotein (46.0 ± 10.7 vs 51.3 ± 9.3 mg/dL; P < .05), smaller/denser low-density lipoprotein relative flotation rate (0.276 ± 0.022 vs 0.289 ± 0.016; P = .02), higher systolic (114.6 ± 10.9 vs 102.3 ± 7.5 mm Hg) and diastolic (67.6 ± 7.5 vs 60.9 ± 3.6 mm Hg; P < .001) blood pressures, and impaired flow-mediated dilatation (4.5 [2-6.7] vs 8.8 [4.5-9.1] percent change, P < .05) compared to controls. In a subgroup analysis, women with nonsevere preeclampsia (n = 17) had increased IAF (98.3 [60.1-122.2]) vs 63.1 [40.1-70.7] cm(2); P = .02) and decreased SI (4.18 [2.43-5.25] vs 5.5 [3.9-8.3] × 10(-5) min(-1)/pmol/L; P = .035) compared to the controls, whereas women with severe preeclampsia (n = 32) were not different for IAF and SI. IAF was negatively associated with SI and positively associated with cardiovascular risk factors even after adjusting for the matching variables and total body fat.

CONCLUSION

Women with prior preeclampsia have an atherogenic lipid profile and endothelial dysfunction compared to matched control subjects despite having similar adiposity and insulin sensitivity, suggesting that there are mechanisms separate from obesity and insulin resistance that lead to their cardiovascular risk factors. Visceral adiposity may have a role in contributing to these risk factors in the subgroup of women who have preeclampsia without severe features.