Preconception Blood Pressure and Its Change Into Early Pregnancy: Early Risk Factors for Preeclampsia and Gestational Hypertension

PRO-FIT-CARE study: the feasibility assessment of a pilot online exercise intervention for persons living with obesity and female infertility

Introduction

Moderate-to-high physical activity participation is associated with a reduced risk of infertility. Yet, exercise interventions that target cardiorespiratory fitness, independent of weight loss, are lacking in obesity and female fertility research.

Purpose

The primary objective of the PRO-FIT-CARE (PROmoting FITness for CArdiometabolic & REproductive Health) study was to assess the feasibility of a moderate-to-high-intensity online exercise program for persons with obesity and female infertility.

Methods

Feasibility, safety, acceptability, and efficacy were assessed by examining: (1) recruitment and consent rate, (2) study retention, (3) adverse events, (4) participant satisfaction, (5) adherence, and (6) cardiorespiratory fitness.

Results

Eleven of thirty-two women contacted agreed to participate in the program (34.4% consent rate). Eight participants (72.7%) completed the study. One musculoskeletal injury was reported. There was a 30% adherence rate based on prescribed exercise intensity (60%-80% of heart rate maximum). One of eleven participants attended 80% of the exercise intervention. Based on a weekly satisfaction survey, the program had an overall high level of satisfaction. Compared to sex and age normative data, post-intervention, two of eight participants improved their cardiorespiratory fitness percentile rank.

Conclusion

The study highlights challenges with adherence to an online exercise program. While the program was safe and participants reported high levels of program satisfaction, approaches to improve adherence must be incorporated.

Preconception Blood Pressure and Adverse Pregnancy Outcomes: A Population-Based Cohort Study

BACKGROUND

Adverse pregnancy outcomes (APOs) share clinical features and risk factors with cardiovascular disease and there is an increasing prevalence of hypertension among reproductive women. However, the associations between maternal preconception blood pressure (BP) and APOs remain controversial and inconclusive.

METHODS

This population-based cohort study used data of 567 127 mother-neonate-father triads from the National Free Preconception Checkup Project in Guangdong Province, China. Maternal BP levels within 1 year before pregnancy were classified using the American College of Obstetricians and Gynecologists definition of hypertension. The primary outcome was a composite of APOs, including preterm birth, small for gestational age, and perinatal infant death. Log-binomial and marginal structural binomial regressions were employed to estimate adjusted risk ratios and absolute risk differences, respectively.

RESULTS

Compared with women with normal BP, women with elevated BP (adjusted risk ratio, 1.07 [95% CI, 1.05-1.09]; absolute risk difference, 1.03% [95% CI, 0.72%-1.29%]), hypertension (adjusted risk ratio, 1.25 [95% CI, 1.18-1.32]; and absolute risk difference, 3.42% [95% CI, 1.97%-5.42%]) had a higher risk of a composite of APOs. Compared with women with normal BP, women with elevated BP and hypertension had higher risks of multiple APOs, preterm birth, small for gestational age, and perinatal infant death. However, these associations attenuated with increasing duration of pregnancy preparation and were not statistically significant beyond 90 days of pregnancy preparation.

CONCLUSIONS

Women with elevated BP or hypertension before pregnancy were associated with an increased risk of APOs. Preconception hypertension screening and control among women should not be ignored by policymakers, clinicians, and the general population.

A qualitative analysis of community health worker perspectives on the implementation of the preconception and pregnancy phases of the Bukhali randomised controlled trial

Community health workers (CHWs) play an important role in health systems in low- and middle-income countries, including South Africa. Bukhali is a CHW-delivered intervention as part of a randomised controlled trial, to improve the health trajectories of young women in Soweto, South Africa. This study aimed to qualitatively explore factors influencing implementation of the preconception and pregnancy phases of Bukhali, from the perspective of the CHWs (Health Helpers, HHs) delivering the intervention. As part of the Bukhali trial process evaluation, three focus group discussions were conducted with the 13 HHs employed by the trial. A thematic approach was used to analyse the data, drawing on elements of a reflexive thematic and codebook approach. The following six themes were developed, representing factors impacting implementation of the HH roles: interaction with the existing public healthcare sector; participant perceptions of health; health literacy and language barriers; participants' socioeconomic constraints; family, partner, and community views of trial components; and the HH-participant relationship. HHs reported uses of several trial-based tools to overcome implementation challenges, increasing their ability to implement their roles as planned. The relationship of trust between the HH and participants seemed to function as one important mechanism for impact. The findings supported a number of adaptations to the implementation of Bukhali, such as intensified trial-based follow-up of referrals that do not receive management at clinics, continued HH training and community engagement parallel to trial implementation, with an increased emphasis on health-related stigma and education. HH perspectives on intervention implementation highlighted adaptations across three broad strategic areas: navigating and bridging healthcare systems, adaptability to individual participant needs, and navigating stigma around disease. These findings provide recommendations for the next phases of Bukhali, for other CHW-delivered preconception and pregnancy trials, and for the strengthening of CHW roles in clinical settings with similar implementation challenges. Trial registration: Pan African Clinical Trials Registry; PACTR201903750173871, Registered March 27, 2019.

An investigation into the correlation between early-to-mid pregnancy exercise combined with cognitive behavioral therapy and anxiety levels and quality of life in patients

OBJECTIVE

The aim of this study was to investigate the effects of exercise combined with cognitive behavioral therapy (CBT) on anxiety and quality of life in pregnant women.

METHODS

This study adopted a prospective randomized controlled trial design, and divided 60 pregnant women in the first and second trimesters into two groups. The control group received routine prenatal education, and the experimental group added moderate exercise and CBT on the basis of routine prenatal education. All participants completed the Hamilton Anxiety Rating Scale (HARS) and World Health Organization Quality of Life-BREF (WHOQOL-BREF) at the start of the study (baseline) and at 6 weeks after the intervention.

RESULTS

Baseline data, scores on HARS, and scores on WHOQOL-BREF were found to be consistent among the two groups of patients prior to the intervention (all P > 0.05). Following the intervention, the implementation of exercise combined with CBT resulted in significant improvements in anxiety levels within the experimental group, particularly with respect to aspects such as anxious mood, tension, insomnia, cognitive function, cardiovascular symptoms, and gastrointestinal symptoms (all P < 0.05). Similarly, the combination of exercise and CBT led to significant enhancement in the quality of life in the experimental group, particularly in areas such as physical health, psychological health, and environmental factors (all P < 0.05). Nevertheless, no significant disparities were observed between the two groups in terms of fears, depressive mood, muscular and sensory somatic symptoms, respiratory symptoms, genitourinary symptoms, autonomic symptoms, behavior during the interview, and social relationships (all P > 0.05).

CONCLUSION

Exercise combined with CBT can effectively reduce the anxiety of pregnant women and improve their quality of life, which has important clinical significance for improving the mental health and quality of life of pregnant women in the first and second trimesters.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of maternal preconception blood pressure with preterm birth: a population-based cohort study

The association between maternal preconception blood pressure (BP) and preterm birth (PTB) is still unclear. The purpose of this study was to investigate the association between maternal preconception BP and PTB. This population-based cohort study included 715 984 Chinese women aged 20-49 years who participated in the National Free Preconception Health Examination Project and successfully had a singleton livebirth during 2014-2019 in Guangdong Province, China. Maternal preconception BP were measured by trained health workers. Multivariate logistic regression models and restricted cubic spline regressions were used to examine the association and dose-response relationship between maternal preconception BP and PTB, respectively. Maternal preconception hypertension was associated with the increased risk of PTB (adjusted odds ratios (aOR): 1.24; 95% CI: 1.14-1.34). Compared to women with normal preconception BP, the aORs for PTB were 1.09 (95% CI: 1.06-1.12), 1.24 (95% CI: 1.13-1.36), and 1.43 (95% CI: 1.15-1.79) for women with preconception elevated BP (120-139/ 80-89 mmHg, stage-1 hypertension (140-159/ 90-99 mmHg, and stage-2 hypertension (160-179/100-109 mmHg), respectively. According to the 2017 American College of Cardiology/American Heart Association criteria, maternal preconception elevated BP and hypertension were also significantly associated with an increased risk of PTB. Preconception systolic and diastolic BP showed a U-shaped (χ2 = 40.54; nonlinear P < 0.001) and linear (χ2 = 6.62; nonlinear P = 0.085) dose-response relationship with PTB, respectively. The association was modified by maternal age and preconception body mass index. These findings identify maternal preconception elevated BP and hypertension as a modifiable risk factor for PTB, providing evidence for future research studies, public health and clinical interventions.

Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review

AIMS

Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum.

METHODS AND RESULTS

Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum.

CONCLUSION

The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.

Associations of Preconception Body Weight, Body Mass Index, and Hypertension with Preeclampsia

Objective: Maximizing preconception health is an important strategy to prevent preeclampsia in pregnancy. Preeclampsia remains a significant cause of maternal and fetal morbidity and mortality. We examined the associations between preconception maternal body weight, body mass index (BMI), and blood pressure with preeclampsia and its related outcomes. Materials and Methods: We performed a retrospective review of 11,214 live births from 6 months preconception during 2009-2018 in the University of Washington medical system. Outcomes were analyzed using chi-square, analysis of variance, and t-tests. Binary logistic regression was performed to examine associations. Results: Of 11,214 births, 1,539 (13.7%) were complicated by preeclampsia. Individuals with preeclampsia weighed more and had higher blood pressure from 6 months preconception to at least 6 months of pregnancy compared with those without preeclampsia (p < 0.001). Persons with prepregnancy systolic blood pressure (SBP) ≥130 mmHg were 3.2 times more likely to develop preeclampsia than those with SBP <130 mmHg (adjusted odds ratio [aOR] = 3.24, 95% confidence interval [CI] = 2.37-4.43). Women with prepregnancy BMI ≥30 kg/m2 were 2.3 times more likely to develop preeclampsia (aOR = 2.31, 95% CI = 1.72-3.10) than those with BMI <30 kg/m2. Mothers with preeclampsia were more likely to deliver preterm (29% vs. 13.8%, p < 0.001) and have neonates with 5-minute Apgar scores <8 (22.1% vs. 12.1%, p = 0.02) and lower preterm birthweights (1,909 g, 95% CI = 1,813-2,004 g vs. 2,057 g, 95% CI = 1,989-2,123 g). Conclusions: Maternal obesity and elevated blood pressure from 6 months preconception to 6 months of pregnancy were associated with preeclampsia, resulting in maternal and fetal complications.

Body Mass Index, Adverse Pregnancy Outcomes, and Cardiovascular Disease Risk

BACKGROUND

Obesity is a well-established risk factor for both adverse pregnancy outcomes (APOs) and cardiovascular disease (CVD). However, it is not known whether APOs are mediators or markers of the obesity-CVD relationship. This study examined the association between body mass index, APOs, and postpartum CVD risk factors.

METHODS

The sample included adults from the nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be) Heart Health Study who were enrolled in their first trimester (6 weeks-13 weeks 6 days gestation) from 8 United States sites. Participants had a follow-up visit at 3.7 years postpartum. APOs, which included hypertensive disorders of pregnancy, preterm birth, small-for-gestational-age birth, and gestational diabetes, were centrally adjudicated. Mediation analyses estimated the association between early pregnancy body mass index and postpartum CVD risk factors (hypertension, hyperlipidemia, and diabetes) and the proportion mediated by each APO adjusted for demographics and baseline health behaviors, psychosocial stressors, and CVD risk factor levels.

RESULTS

Among 4216 participants enrolled, mean±SD maternal age was 27±6 years. Early pregnancy prevalence of overweight was 25%, and obesity was 22%. Hypertensive disorders of pregnancy occurred in 15%, preterm birth in 8%, small-for-gestational-age birth in 11%, and gestational diabetes in 4%. Early pregnancy obesity, compared with normal body mass index, was associated with significantly higher incidence of postpartum hypertension (adjusted odds ratio, 1.14 [95% CI, 1.10-1.18]), hyperlipidemia (1.11 [95% CI, 1.08-1.14]), and diabetes (1.03 [95% CI, 1.01-1.04]) even after adjustment for baseline CVD risk factor levels. APOs were associated with higher incidence of postpartum hypertension (1.97 [95% CI, 1.61-2.40]) and hyperlipidemia (1.31 [95% CI, 1.03-1.67]). Hypertensive disorders of pregnancy mediated a small proportion of the association between obesity and incident hypertension (13% [11%-15%]) and did not mediate associations with incident hyperlipidemia or diabetes. There was no significant mediation by preterm birth or small-for-gestational-age birth.

CONCLUSIONS

There was heterogeneity across APO subtypes in their association with postpartum CVD risk factors and mediation of the association between early pregnancy obesity and postpartum CVD risk factors. However, only a small or nonsignificant proportion of the association between obesity and CVD risk factors was mediated by any of the APOs, suggesting APOs are a marker of prepregnancy CVD risk and not a predominant cause of postpartum CVD risk.

Early Pregnancy Systolic Blood Pressure Patterns Predict Early- and Later-Onset Preeclampsia and Gestational Hypertension Among Ostensibly Low-to-Moderate Risk Groups

Background Clinical risk factors, a single blood pressure (BP) measurement, current biomarkers, and biophysical parameters can effectively identify risk of early-onset preeclampsia but have limited ability to predict later-onset preeclampsia and gestational hypertension. Clinical BP patterns hold promise to improve early risk stratification for hypertensive disorders of pregnancy. Methods and Results After excluding preexisting hypertension, heart, kidney, or liver disease, or prior preeclampsia, the retrospective cohort (n=249 892) all had systolic BP <140 mm Hg and diastolic BP <90 mm Hg or a single BP elevation ≤20 weeks' gestation, prenatal care at <14 weeks' gestation, and a still or live birth delivery at Kaiser Permanente Northern California hospitals (2009-2019). The sample was randomly split into development (N=174 925; 70%) and validation (n=74 967; 30%) data sets. Predictive performance of multinomial logistic regression models for early-onset (<34 weeks) preeclampsia, later-onset (≥34 weeks) preeclampsia, and gestational hypertension was evaluated in the validation data set. There were 1008 (0.4%), 10 766 (4.3%), and 11 514 (4.6%) patients with early-onset preeclampsia, later-onset preeclampsia, and gestation hypertension, respectively. Models with 6 systolic BP trajectory groups (0-20 weeks' gestation) plus standard clinical risk factors performed substantially better than risk factors alone to predict early- and later-onset preeclampsia and gestational hypertension, with C-statistics (95% CIs) of 0.747 (0.720-0.775), 0.730 (0.722-0.739), and 0.768 (0.761-0.776) versus 0.688 (0.659-0.717), 0.695 (0.686-0.704) and 0.692 (0.683-0.701), respectively, with excellent calibration (Hosmer-Lemeshow P=0.99, 0.99, and 0.74, respectively). Conclusions Early pregnancy BP patterns up to 20 weeks' gestation plus clinical, social, and behavioral factors more accurately discriminate hypertensive disorders of pregnancy risk among low-to-moderate risk pregnancies. Early pregnancy BP trajectories improve risk stratification to reveal higher-risk individuals hidden within ostensibly low-to-moderate risk groups and lower-risk individuals considered at higher risk by US Preventive Services Task Force criteria.

Preeclampsia up to date-What's going on?

Preeclampsia is a hypertensive disorder in pregnancy characterized by placental malperfusion and subsequent multi-organ injury. It accounts for approximately 14% of maternal deaths and 10-25% of perinatal deaths globally. In addition, preeclampsia has been attracting attentions for its association with risks for developing chronic diseases in later life for both mother and child. This mini-review discusses on latest knowledge on prediction, prevention, management, and long-term outcomes of preeclampsia and also touches on association between COVID-19 and preeclampsia. HTN hypertension, HDP hypertensive disorders of pregnancy, PE preeclampsia, BP blood pressure, cfDNA cell-free DNA, ST2 human suppression of tumorigenesis 2, sFlt-1 soluble fms-like tyrosine kinase-1, PIGF placental growth factor, VEGF vascular endothelial growth factor, VEGFR VEGF receptor, TGFβ transforming growth factor β, ENG endoglin, sENG soluble ENG, PRES posterior reversible encephalopathy syndrome, AKI acute kidney injury, CVD cardiovascular disease, ESKD end-stage kidney disease, ACE angiotensinogen converting enzyme, Ang angiotensin.

Maternal and Child Health, Non-Communicable Diseases and Metabolites

Mothers influence the health and disease trajectories of their children, particularly during the critical developmental windows of fetal and neonatal life reflecting the gestational-fetal and lactational-neonatal phases. As children grow and develop, they are exposed to various stimuli and insults, such as metabolites, that shape their physiology and metabolism to impact their health. Non-communicable diseases, such as diabetes, cardiovascular disease, cancer and mental illness, have high global prevalence and are increasing in incidence. Non-communicable diseases often overlap with maternal and child health. The maternal milieu shapes progeny outcomes, and some diseases, such as gestational diabetes and preeclampsia, have gestational origins. Metabolite aberrations occur from diets and physiological changes. Differential metabolite profiles can predict the onset of non-communicable diseases and therefore inform prevention and/or better treatment. In mothers and children, understanding the metabolite influence on health and disease can provide insights for maintaining maternal physiology and sustaining optimal progeny health over the life course. The role and interplay of metabolites on physiological systems and signaling pathways in shaping health and disease present opportunities for biomarker discovery and identifying novel therapeutic agents, particularly in the context of maternal and child health, and non-communicable diseases.

Clinical characteristics and treatment patterns of pregnant women with hypertension in primary care in the Federal Capital Territory of Nigeria: cross-sectional results from the hypertension treatment in Nigeria Program

BACKGROUND

Hypertensive disorders of pregnancy, including hypertension, are a leading cause of maternal mortality in Nigeria. However, there is a paucity of data on pregnant women with hypertension who receive care in primary health care facilities. This study presents the results from a cross-sectional analysis of pregnant women enrolled in the Hypertension Treatment in Nigeria Program which is aimed at integrating and strengthening hypertension care in primary health care centres.

METHODS

A descriptive analysis of the baseline results from the Hypertension Treatment in Nigeria Program was performed. Baseline blood pressures, treatment and control rates of pregnant women were analysed and compared to other adult women of reproductive age. A complete case analysis was performed, and a two-sided p value < 0.05 was considered statistically significant.

RESULTS

Between January 2020 to October 2022, 5972 women of reproductive age were enrolled in the 60 primary healthcare centres participating in the Hypertension Treatment in Nigeria Program and 112 (2%) were pregnant. Overall mean age (SD) was 39.6 years (6.3). Co-morbidities were rare in both groups, and blood pressures were similar amongst pregnant and non-pregnant women (overall mean (SD) first systolic and diastolic blood pressures were 157.4 (20.6)/100.7 (13.6) mm Hg and overall mean (SD) second systolic and diastolic blood pressures were 151.7 (20.1)/98.4 (13.5) mm Hg). However, compared to non-pregnant women, pregnant women had a higher rate of newly diagnosed hypertension (65.2% versus 54.4% p = 0.02) and lower baseline walk-in treatment (32.1% versus 42.1%, p = 0.03). The control rate was numerically lower among pregnant patients (6.3% versus 10.2%, p = 0.17), but was not statistically significant. Some pregnant patients (8.3%) were on medications contraindicated in pregnancy, and none of the pregnant women were on aspirin for primary prevention of preeclampsia.

CONCLUSIONS

These findings indicate significant gaps in care and important areas for future studies to improve the quality of care and outcomes for pregnant women with hypertension in Nigeria, a country with the highest burden of maternal mortality globally.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Optimizing Prepregnancy Cardiovascular Health to Improve Outcomes in Pregnant and Postpartum Individuals and Offspring: A Scientific Statement From the American Heart Association

This scientific statement summarizes the available preclinical, epidemiological, and clinical trial evidence that supports the contributions of prepregnancy (and interpregnancy) cardiovascular health to risk of adverse pregnancy outcomes and cardiovascular disease in birthing individuals and offspring. Unfavorable cardiovascular health, as originally defined by the American Heart Association in 2010 and revised in 2022, is prevalent in reproductive-aged individuals. Significant disparities exist in ideal cardiovascular health by race and ethnicity, socioeconomic status, and geography. Because the biological processes leading to adverse pregnancy outcomes begin before conception, interventions focused only during pregnancy may have limited impact on both the pregnant individual and offspring. Therefore, focused attention on the prepregnancy period as a critical life period for optimization of cardiovascular health is needed. This scientific statement applies a life course and intergenerational framework to measure, modify, and monitor prepregnancy cardiovascular health. All clinicians who interact with pregnancy-capable individuals can emphasize optimization of cardiovascular health beginning early in childhood. Clinical trials are needed to investigate prepregnancy interventions to comprehensively target cardiovascular health. Beyond individual-level interventions, community-level interventions must include and engage key stakeholders (eg, community leaders, birthing individuals, families) and target a broad range of antecedent psychosocial and social determinants. In addition, policy-level changes are needed to dismantle structural racism and to improve equitable and high-quality health care delivery because many reproductive-aged individuals have inadequate, fragmented health care before and after pregnancy and between pregnancies (interpregnancy). Leveraging these opportunities to target cardiovascular health has the potential to improve health across the life course and for subsequent generations.

Genetic Variations in Angiotensinogen Gene and Risk of Preeclampsia: A Pilot Study

Preeclampsia (PE) is a typical hypertensive disorders of pregnancy (HDP) which can cause substantial morbidity and mortality in both pregnant women and fetuses. The renin-angiotensin system (RAS) genes are the main HDP-causing genes, and Angiotensinogen (AGT) as the initial substrate can directly reflect the activity of the entire RAS. However, the association between AGT SNPs and PE risk has rarely been confirmed. This study was carried out to determine whether AGT SNPs could affect the risk of PE in 228 cases and 358 controls. The genotyping result revealed that the AGT rs7079 TT carrier was related to increased PE risk. Further stratified analysis illustrated that the rs7079 TT genotype significantly increased the PE risk in subgroups of Age < 35, BMI < 25, Albumin (ALB) ≥ 30 and Aspartate aminotransferase (AST) < 30. These findings demonstrated that the rs7079 might be a promising candidate SNP strongly associated with PE susceptibility.

Effects of fine ambient particulate matters on de novo hypertensive disorders of pregnancy and blood pressure before 20 weeks

The effects of fine particulate matter (PM) on de novo hypertensive disorders of pregnancy (HDP) were inconsistent during the first and second trimesters. This study aimed to assess the trimester-specific effects of PM_2.5 and PM₁ prior to diagnosis of de novo HDP. The exposure of fine PM was predicted by satellite remote sensing data according to maternal residential addresses. De novo HDP was defined as gestational hypertension and preeclampsia during the current pregnancy. A logistic regression model was performed to assess the association of PM_2.5 and PM₁ with HDP during the first and early second trimesters (0-13 weeks and 14-20 weeks). The generalized estimating equation model was conducted to assess the effect of PM_2.5 and PM₁ on blood pressure. The present study included 22,821 pregnant women (mean age, 29.1 years) from 2013 to 2017. PM_2.5 and PM₁ were significantly associated with an increased risk of de novo HDP during the first trimester (OR = 1.070, 95% CI: 1.013-1.130; OR = 1.264, 95% CI: 1.058-1.511 for per 10 μg/m³) and early second trimester (OR = 1.045, 95% CI: 1.003-1.088; OR = 1.170, 95% CI: 1.002-1.366 for per 10 μg/m³). Significant trends of increased de novo HDP risk was also observed with the increment of PM (all P for trend <0.05). The stratified analyses demonstrated that the associations between exposure to fine PM and the risk of HDP were more pronounced among the pregnant women with maternal age above 35 and low maternal education level (all OR >1.047). Each 10 μg/m³ increase of PM₁ and PM_2.5 before diagnosis of de novo HDP elevated 0.204 (95% CI: 0.098-0.310) and 0.058 (95%CI: 0.033-0.083) mmHg of systolic blood pressure. Exposure to PM_2.5 and PM₁ during the first and early second trimester were positively associated with the risk of de novo HDP. The fine PM before diagnosis of de novo HDP elevated the systolic blood pressure.

Even high normal blood pressure affects live birth rate in women undergoing fresh embryo transfer

STUDY QUESTION

Do differences in blood pressure within the normal range have any impacts on the live birth rate (primary outcome) or biochemical pregnancy rate (beta-hCG positivity), clinical pregnancy rate (heart beating in ultrasound), abortion rate and ectopic pregnancy rate (secondary outcomes) of fresh embryo transfer in women undergoing their IVF/ICSI treatment?

SUMMARY ANSWER

Even rather small differences in baseline blood pressure in women with normal blood pressure according to current guidelines undergoing fresh embryo transfer after IVF/ICSI affects substantially the live birth rate.

WHAT IS KNOWN ALREADY

Pre-pregnancy hypertension is a well-known risk factor for adverse pregnancy events such as preeclampsia, fetal growth restriction, placental abruption and adverse neonatal events. It is likewise well known that hypertension during pregnancy in women undergoing ART is associated with adverse pregnancy outcomes. However, whether blood pressure at the high end of the normal range has an impact on ART is unknown.

STUDY DESIGN, SIZE, DURATION

It is a prospective observational cohort study based on a single IVF center between January 2017 and December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two thousand four hundred and eighteen women with normal blood pressure undergoing fresh embryo transfer after IVF/ICSI at the Reproductive and Genetic Hospital of CITIC-Xiangya were enrolled in this study.

MAIN RESULTS AND THE ROLE OF CHANCE

Blood pressure was measured at the first visit when women consulted the IVF center due to infertility. In women with a successful pregnancy outcome (1487 live births out of 2418 women undergoing fresh embryo transfer after IVF/ICSI), systolic blood pressure (SBP) (114.1 ± 9.48 mmHg versus 115.4 ± 9.8 mmHg, P = 0.001) and diastolic blood pressure (DBP) (74.5 ± 7.5 mmHg versus 75.3 ± 7.34 mmHg, P = 0.006) were lower than in those who did not achieve live births. Multivariate logistic regression analysis revealed that SBP (OR: 0.987, 95% CI: 0.979–0.996, P = 0.004) and DBP (OR: 0.986, 95% CI: 0.975–0.998, P = 0.016) were negatively associated with live birth. Similarly, SBP was significantly negatively related to clinical pregnancy rate (OR: 0.990, 95% CI: 0.981–0.999, P = 0.033), while for DBP the association was not statistically significant (OR: 0.994, 95% CI: 0.982–1.006, P = 0.343). However, both SBP and DBP were positively associated with miscarriage OR: 1.021 (95% CI: 1.004–1.037, P = 0.013) and OR: 1.027 (95% CI: 1.005–1.049, P = 0.014), respectively. Both SBP and DBP were unrelated to biochemical pregnancy (hCG positivity), implantation and ectopic pregnancy rate.

LIMITATIONS, REASONS FOR CAUTION

Whether lowering blood pressure before initiating ART treatment in women with SBP or DBP higher than the thresholds defined in our study will confer a benefit is unknown. Also, we cannot exclude bias due to different ethnicities. Moreover, participants in our study only received fresh embryo transfer, whether the results could apply to frozen embryo transfer is unclear.

WIDER IMPLICATIONS OF THE FINDINGS

Our study challenges the current blood pressure goals in women undergoing fresh embryo transfer after IVF/ICSI. Further studies are needed to figure out the mechanism and effective approach to increase IVF/ICSI pregnancy outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

Hunan Provincial Grant for Innovative Province Construction (2019SK4012). The authors declare that there were no conflicts of interest in this study.

TRIAL REGISTRATION NUMBER

N/A.

The relationship between high-normal blood pressure in the first half of pregnancy and the risk of hypertensive disease of pregnancy

Early warning of hypertensive disorder in pregnancy (HDP) can improve maternal and infant outcomes. However, few studies had evaluated the warning value of high–normal blood pressure (BP) before the onset of HDP. This was a prospective cohort study to investigate the relationship between high‐normal BP in the first half of pregnancy and the risk of HDP. According to the maximum BP measured before 20⁺⁶ weeks of gestation, the cohort was divided into three groups: optimal BP (SBP < 120 mmHg and DBP < 80 mmHg), normal BP (120 mmHg ≤ SBP < 130 mmHg or 80 mmHg ≤ DBP < 85 mmHg), and high–normal BP (130 mmHg ≤ SBP < 140 mmHg or 85 mmHg ≤ DBP < 90 mmHg). The relationship between different BP levels in the first half of pregnancy and HDP risk was assessed by general linear models. Ten thousand one hundred and ninety‐three normotensive pregnant women with complete information were finally included for data analysis. Among them, 532 pregnant women were diagnosed with HDP, with a total HDP incidence of 5.2%. The incidences in the optimal, normal, and high–normal BP groups were 2.4%, 6.0%, and 21.8%, respectively. Compared to women with optimal BP in the first half of pregnancy, women with high‐normal BP had a 445% increased risk of HDP (aRR: 5.45, 95% CI: 4.24–7.00), and even women with normal BP had a 107% increased risk of HDP (aRR: 2.07, 95% CI: 1.68–2.56). This study demonstrated that among low‐risk healthy women, women with high–normal BP in the first half of pregnancy had a significantly higher risk of HDP.

Racial and Ethnic Disparities in Maternal and Neonatal Outcomes among Women with Chronic Hypertension

OBJECTIVE

The objective of this study was to compare maternal and neonatal outcomes in women with chronic hypertension by maternal race and ethnicity.

METHODS

A retrospective cohort study of women with chronic hypertension was performed from the Consortium on Safe Labor (2002-2008). Maternal self-reported race and ethnicity were analyzed as non-Hispanic White, non-Hispanic Black, and Hispanic. Maternal outcomes included cesarean birth, postpartum hemorrhage, blood transfusion, placental abruption, eclampsia, maternal intensive care unit admission, and death. Neonatal outcomes included preterm birth (PTB), low birth weight (LBW), small for gestational age (SGA), 5-minute Apgar <7, respiratory distress syndrome, hypoxic-ischemic encephalopathy, intraventricular hemorrhage, neonatal intensive care unit admission, sepsis, and death. Univariable and multivariable analyses were performed to examine the association between maternal race and ethnicity and perinatal outcomes.

RESULTS

A total of 2,729 women were included. In unadjusted analysis, non-Hispanic White women had higher rates of placental abruption and Hispanic women had higher rates of placental abruption and eclampsia. In multivariable analysis, non-Hispanic Black continued to have higher odds of placental abruption (adjusted odds ratio 4.16, 95% confidence interval 1.29-18.70), but the rest of the maternal outcomes did not differ between the groups. When comparing neonatal outcomes, PTB, SGA, and LBW were more frequent in, 5-minute Apgar <7 non-Hispanic Black and Hispanic women compared with non-Hispanic White women. In addition, 5-minute Apgar <7 and neonatal sepsis were more frequent in non-Hispanic Black neonates and neonatal death was more frequent in Hispanic neonates compared with non-Hispanic White women. In multivariable regression, neonates of non-Hispanic Black women had higher odds of PTB, SGA, LBW, 5-minute Apgar < 7, and sepsis compared with non-Hispanic White women. Similarly, neonates of Hispanic women had higher odds of SGA, LBW, and death.

CONCLUSION

Significant racial and ethnic disparities were identified mainly in neonatal outcomes of women with chronic hypertension.

KEY POINTS

· Non-Hispanic Black women with chronic hypertension had higher rates of placental abruption.. · Neonates of non-Hispanic Black women with chronic hypertension had higher odds of PTB, SGA, and LBW.. · Neonates of Hispanic women with chronic hypertension had higher odds of SGA, LBW, and neonatal death..

Association of Preconception Blood Pressure with the Risk of Anemia in Children under Five Years of Age: A Large Longitudinal Chinese Birth Cohort

Hypertension during pregnancy may increase the risk of anemia in the offspring. However, few studies have investigated the effects of elevated blood pressure during the preconception period on childhood anemia. This large population-based birth cohort study was performed to determine whether abnormal preconception blood pressure has long-term consequences for childhood health. Data were obtained from the China–US Collaborative Project for Neural Tube Defect Prevention. The study consisted of 40,638 women with singleton live births who were registered in a monitoring system before pregnancy in southern China during the period 1993–1996. Children were assessed by hemoglobin measurement at approximately 53 months of age. The incidences of childhood anemia were 19.80% in the hypertension group and 16.07% in the non-hypertension group. Compared with the non-hypertension group, the hypertension group had an increased risk of childhood anemia (adjusted risk ratio (RR): 1.25; 95% confidence interval (CI): 1.11–1.41). After categorization according to blood pressure, combined systolic and diastolic hypertension was associated with a significantly increased risk of childhood anemia, compared with normotension (adjusted RR: 1.37; 95% CI: 1.16–1.63). Compared with women who had normal blood pressure, the adjusted RRs for childhood anemia were 1.20 (95% CI: 1.13–1.28), 1.26 (95% CI: 1.08–1.47), and 1.38 (95% CI: 1.14–1.67) among women with prehypertension, stage-1 hypertension, and stage-2 hypertension, respectively. Our results suggest a linear association between prepregnancy hypertension and the risk of childhood anemia in the Chinese population. Interventions targeting preconception blood pressure may have a positive effect on childhood health.

Hypertension and contraceptive use among women of child-bearing age in the United States from 2001 to 2018

BACKGROUND

Hypertension (HTN) in pregnancy is a leading cause of maternal mortality in the United States. Contraception is widely used, and estrogen-based combined hormonal forms are known to increase blood pressure (BP). With nearly half of pregnancies unplanned and many antihypertensive medications teratogenic, appropriate contraception is critical in child-bearing age women with HTN.

METHODS

Using the National Health and Nutrition Examination Surveys (NHANES) from 2001 to 2018, we evaluated contraception and antihypertensive medication use in women of child-bearing age (20-50 years). Women who had undergone sterilization or menopause were excluded. HTN was defined based on a self-reported provider diagnosis and BP ≥130/80 mm Hg or antihypertensive medication use. Contraception included non-barrier methods (pills/patch/ring, injections, long-acting reversible contraceptives) or consistent condom use. Multivariable logistic regression was used to model the odds of contraception use. Temporal trends in contraception use were reported.

RESULTS

Of the 8726 women, 12.4% had HTN with mean age (standard error) 36.0 (0.3) years. In women with HTN, 9.2% used non-barrier contraception and 10.4% used condoms only. Over half (52.7%) of women with HTN on antihypertensive medications were taking medications contraindicated in pregnancy, with no difference seen by contraceptive status. In logistic regression models, contraceptive use was lower in the older-aged women. In women with HTN on non-barrier contraception, combined hormonal contraceptive use declined, from 100% (2001-2006) to 81.4% (2013-2018, P < 0.001).

CONCLUSIONS

Many women with self-reported HTN are not using adequate contraception. Of the small proportion on non-barrier contraceptives, the majority are using estrogen-based, BP-raising methods.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

MiR-125b-5p ameliorates hypoxia/reoxygenation-induced endothelial cell dysfunction and attenuates reduced uterine perfusion pressure-induced hypertension in pregnant rats via targeting BMF

BACKGROUND AND PURPOSE

MicroRNA-125b-5p (miR-125b-5p) is downregulated in patients with gestational hypertension signs. However, the role of miR-125b-5p in pregnancy-induced hypertension (PIH) remains unknown.

METHODS

The human placental microvascular endothelial cells (HPMECs) have undergone hypoxia and reoxygenation (H/R) treatment to establish PIH cellular model. Rats were performed with reduced uterine perfusion pressure (RUPP) operation to establish PIH animal model.

RESULTS

MiR-125b-5p promoted viability while inhibited the apoptosis of H/R-treated HPMECs by downregulating BMF. MiR-125b-5p alleviated hypertensive symptoms and improved pregnancy outcomes in RUPP rats.

CONCLUSION

MiR-125b-5p ameliorates H/R-induced HPMEC dysfunction and attenuates RUPP-induced hypertension in pregnant rats by downregulating BMF.

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.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Trends in Prepregnancy Obesity and Association With Adverse Pregnancy Outcomes in the United States, 2013 to 2018

Background

The prevalence of obesity in the population has increased in parallel with increasing rates of adverse pregnancy outcomes (APOs). Quantifying contemporary trends in prepregnancy obesity and associations with interrelated APOs (preterm birth, low birth weight, and pregnancy‐associated hypertension) together and individually can inform prevention strategies to optimize cardiometabolic health in women and offspring.

Methods and Results

We performed a serial, cross‐sectional study using National Center for Health Statistics birth certificate data including women aged 15 to 44 years with live singleton births between 2013 and 2018, stratified by race/ethnicity (non‐Hispanic White, non‐Hispanic Black, Hispanic, and non‐Hispanic Asian). We quantified the annual prevalence of prepregnancy obesity (body mass index ≥30.0 kg/m²; body mass index ≥27.5 kg/m² if non‐Hispanic Asian). We then estimated adjusted associations using multivariable logistic regression (odds ratios and population attributable fractions) for obesity‐related APOs compared with normal body mass index (18.5–24.9 kg/m²; 18.5–22.9 kg/m² if non‐Hispanic Asian). Among 20 139 891 women, the prevalence of prepregnancy obesity increased between 2013 and 2018: non‐Hispanic White (21.6%–24.8%), non‐Hispanic Black (32.5%–36.2%), Hispanic (26.0%–30.5%), and non‐Hispanic Asian (15.3%–18.6%) women (P‐trend < 0.001 for all). Adjusted odds ratios (95% CI) for APOs associated with obesity increased between 2013 and 2018, and by 2018, ranged from 1.27 (1.25–1.29) in non‐Hispanic Black to 1.94 (1.92–1.96) in non‐Hispanic White women. Obesity was most strongly associated with pregnancy‐associated hypertension and inconsistently associated with preterm birth and low birth weight. Population attributable fractions of obesity‐related APOs increased over the study period: non‐Hispanic White (10.6%–14.7%), non‐Hispanic Black (3.7%–6.9%), Hispanic (7.0%–10.4%), and non‐Hispanic Asian (7.4%–9.7%) women (P‐trend < 0.01 for all).

Conclusions

The prevalence of prepregnancy obesity and burden of obesity‐related APOs have increased, driven primarily by pregnancy‐associated hypertension, and vary across racial/ethnic subgroups.