Association of Birth Year of Pregnant Individuals With Trends in Hypertensive Disorders of Pregnancy in the United States, 1995-2019

IMPORTANCE

Hypertensive disorders of pregnancy are leading causes of morbidity and mortality among pregnant individuals as well as newborns, with increasing incidence during the past decade. Understanding the individual associations of advancing age of pregnant individuals at delivery, more recent delivery year (period), and more recent birth year of pregnant individuals (cohort) with adverse trends in hypertensive disorders of pregnancy could help guide public health efforts to improve the health of pregnant individuals.

OBJECTIVE

To clarify the independent associations of delivery year and birth year of pregnant individuals, independent of age of pregnant individuals, with incident rates of hypertensive disorders of pregnancy.

DESIGN, SETTING, AND PARTICIPANTS

This serial cross-sectional study of 38 141 561 nulliparous individuals aged 15 to 44 years with a singleton, live birth used 1995-2019 natality data from the National Vital Statistics System.

EXPOSURES

Year of delivery (period) and birth year (cohort) of pregnant individuals.

MAIN OUTCOMES AND MEASURES

Rates of incident hypertensive disorders of pregnancy, defined as gestational hypertension, preeclampsia, or eclampsia, recorded on birth certificates. Generalized linear mixed models were used to calculate adjusted rate ratios (aRRs) comparing the incidence of hypertensive disorders of pregnancy in each delivery period (adjusted for age and cohort) and birth cohort (adjusted for age and period) with the baseline group as the reference for each. Analyses were additionally stratified by the self-reported racial and ethnic group of pregnant individuals.

RESULTS

Of 38 141 561 individuals, 20.2% were Hispanic, 0.8% were non-Hispanic American Indian or Alaska Native, 6.5% were non-Hispanic Asian or Pacific Islander, 13.9% were non-Hispanic Black, and 57.8% were non-Hispanic White. Among pregnant individuals who delivered in 2015 to 2019 compared with 1995 to 1999, the aRR for the incidence of hypertensive disorders of pregnancy was 1.59 (95% CI, 1.57-1.62), adjusted for age and cohort. Among pregnant individuals born in 1996 to 2004 compared with 1951 to 1959, the aRR for the incidence of hypertensive disorders of pregnancy was 2.61 (95% CI, 2.41-2.84), adjusted for age and period. The incidence was higher among self-identified non-Hispanic Black individuals in each birth cohort, with similar relative changes for period (aRR, 1.76 [95% CI, 1.70-1.81]) and cohort (aRR, 3.26 [95% CI, 2.72-3.91]) compared with non-Hispanic White individuals (period: aRR, 1.60 [95% CI, 1.57-1.63]; cohort: aRR, 2.53 [95% CI, 2.26-2.83]).

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that more recent birth cohorts of pregnant individuals have experienced a doubling of rates of hypertensive disorders of pregnancy, even after adjustment for age and delivery period. Substantial racial and ethnic disparities persisted across generations.

Sleep-disordered Breathing in Pregnancy and after Delivery: Associations with Cardiometabolic Health

Rationale: Knowledge gaps exist regarding health implications of sleep-disordered breathing (SDB) identified in pregnancy and/or after delivery. Objectives: To determine whether SDB in pregnancy and/or after delivery is associated with hypertension (HTN) and metabolic syndrome (MS). Methods: nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be Heart Health Study) (N = 4,508) followed participants initially recruited during their first pregnancy. Participants returned for a visit 2-7 years after pregnancy. This study examined a subgroup who underwent SDB assessments during their first pregnancy (n = 1,964) and a repeat SDB assessment after delivery (n = 1,222). Two SDB definitions were considered: 1) apnea-hypopnea index (AHI) ⩾ 5 and 2) oxygen desaturation index (ODI) ⩾ 5. Associations between SDB and incident HTN and MS were evaluated with adjusted risk ratios (aRRs). Measurements and Main Results: The aRR for MS given an AHI ⩾ 5 during pregnancy was 1.44 (95% confidence interval [CI], 1.08-1.93), but no association with HTN was found. ODI ⩾ 5 in pregnancy was associated with both an increased risk for HTN (aRR, 2.02; 95% CI, 1.30-3.14) and MS (aRR, 1.53; 95% CI, 1.19-1.97). Participants with an AHI ⩾ 5 in pregnancy that persisted after delivery were at higher risk for both HTN (aRR, 3.77; 95% CI, 1.84-7.73) and MS (aRR, 2.46; 95% CI, 1.59-3.76). Similar associations were observed for persistent ODI ⩾ 5 after delivery. Conclusions: An AHI ⩾ 5 in pregnancy was associated with an increased risk of MS. An ODI ⩾ 5 in pregnancy was significantly associated with both HTN and MS. Participants with persistent elevations in AHI and ODI during pregnancy and at 2-7 years after delivery were at the highest risk for HTN and MS. Clinical trial registered with www.clinicaltrials.gov (NCT02231398).

Latent class analysis of placental histopathology: a novel approach to classifying early and late preterm births

BACKGROUND

Neonatal morbidity attributable to prematurity predominantly occurs among early preterm births (<32 weeks) rather than late preterm births (32 to <37 weeks). Methods to distinguish early and late preterm births are lacking given the heterogeneity in pathophysiology and risk factors, including maternal obesity. Although preterm births are often characterized by clinical presentation (spontaneous or clinically indicated), classifying deliveries by placental features detected on histopathology reports may help identify subgroups of preterm births with similar etiology and risk factors. Latent class analysis is an empirical approach to characterize preterm births on the basis of observed combinations of placental features.

OBJECTIVE

To identify histopathologic markers that can distinguish early (<32 weeks) and late preterm births (32 to <37 weeks) that are also associated with maternal obesity and neonatal outcomes.

STUDY DESIGN

Women with a singleton preterm birth at University of Pittsburgh Medical Center Magee-Womens Hospital (Pittsburgh, PA) from 2008 to 2012 and a placental evaluation (89% of preterm births) were stratified into early (n=900, 61% spontaneous) and late preterm births (n=3362, 57% spontaneous). Prepregnancy body mass index was self-reported at first prenatal visit and 16 abstracted placental features were analyzed. Placental subgroups (ie, latent classes) of early and late preterm births were determined separately by latent class analysis of placental features. The optimal number of latent classes was selected by comparing fit statistics. The probability of latent class membership across prepregnancy body mass indexes was estimated in early preterm births and in late preterm births by an extension of multinomial regression called pseudo-class regression, adjusting for race, smoking, education, and parity. The frequencies of severe neonatal morbidity (composite outcome: respiratory distress, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia, patent ductus arteriosus, and retinopathy of prematurity), small-for-gestational-age, and length of neonatal intensive care unit stay were compared across latent classes by chi-square and Kruskal-Wallis tests.

RESULTS

Early preterm births were grouped into 4 latent classes based on placental histopathologic features: acute inflammation (38% of cases), maternal vascular malperfusion with inflammation (29%), maternal vascular malperfusion (25%), and fetal vascular thrombosis with hemorrhage (8%). As body mass index increased from 20 to 50kg/m², the probability of maternal vascular malperfusion and fetal vascular thrombosis with hemorrhage increased, whereas the probability of maternal vascular malperfusion with inflammation decreased. There was minimal change in the probability of acute inflammation with increasing body mass index. Late preterm births also had 4 latent classes: maternal vascular malperfusion (22%), acute inflammation (12%), fetal vascular thrombosis with hemorrhage (9%), and low-risk pathology (58%). Body mass index was not associated with major changes in likelihood of the latent classes in late preterm births. Associations between body mass index and likelihood of the latent classes were not modified by type of delivery (spontaneous or indicated) in early or late preterm births. Maternal malperfusion and fetal vascular thrombosis with hemorrhage were associated with greater neonatal morbidity than the other latent classes in early and late preterm births.

CONCLUSION

Obesity may predispose women to early but not late preterm birth through placental vascular impairment. Latent class analysis of placental histopathologic data provides an evidence-based approach to group preterm births with shared underlying etiology and risk factors.

Abstract 073: A Mediterranean Diet Pattern Is Associated With Lower Risk Of Adverse Pregnancy Outcomes In US Women: Results From The NuMoM2b Cohort

Introduction: Adverse pregnancy outcomes (APOs) are associated with an increased risk of developing cardiovascular disease (CVD). While the Mediterranean diet pattern has been inversely related to CVD outcomes, its association with APOs in US women has not been previously evaluated.

Hypothesis: Adherence to a Mediterranean diet pattern during the periconception period is associated with lower risk of APOs.

Methods: Racially and ethnically diverse women (n=8075, mean age: 27±6y) from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort were enrolled across 8 US medical centers from 2010-13. An Alternate Mediterranean Diet (aMed) score was computed from data on habitual diet in the 3 months around conception, assessed using a semi-quantitative food frequency questionnaire in the first trimester. APOs were prospectively ascertained and defined as developing 1 or more of the following: gestational hypertension, preeclampsia/eclampsia, gestational diabetes, preterm delivery, small for gestational age, or stillbirth. Multivariable logistic regression was used to examine associations of the aMed score and its components with any APO and individual APOs.

Results: Women in the highest vs. lowest quintile of the aMed score had 21% lower odds of developing any APO, and 36% and 52% lower odds of preeclampsia/eclampsia and gestational diabetes, respectively; a linear trend across aMed score categories was detected (p-trend<0.05) ( Figure ). When aMed score components were examined separately, higher intakes of vegetables, fruits, legumes, and fish and lower intakes of red meat were related to up to 26% lower odds of APOs.

Conclusions: Greater adherence to a Mediterranean diet pattern is related to lower risk of APOs, with evidence of a dose-response relationship, highlighting the potential of this diet pattern in CVD primordial prevention efforts in US women. Long-term studies are needed to assess whether dietary modification in the periconception period can reduce risk of APOs and future CVD.

Association of N-Terminal Pro-Brain Natriuretic Peptide Concentration in Early Pregnancy With Development of Hypertensive Disorders of Pregnancy and Future Hypertension

IMPORTANCE

Hypertensive disorders of pregnancy are associated with future cardiovascular disease, perhaps because of subclinical cardiac dysfunction before pregnancy leading to impaired adaptation to pregnancy. Natriuretic peptides are promising biomarkers for detecting subclinical cardiac dysfunction outside of pregnancy.

OBJECTIVE

To investigate whether higher concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) in early pregnancy would be associated with hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be Heart Health Study, a prospective multicenter observational study. A total of 4103 nulliparous women with complete data and no prepregnancy hypertension or diabetes who were treated at 8 clinical sites were included. Women were followed up with for 2 to 7 years after pregnancy. Data were collected from October 2010 to October 2017, and data were analyzed from August 2020 to November 2021.

EXPOSURES

NT-proBNP concentration, measured using an electrochemiluminescence immunoassay from a first-trimester blood sample.

MAIN OUTCOMES AND MEASURES

Hypertensive disorders of pregnancy and incident hypertension (systolic blood pressure of 130 mm Hg or diastolic blood pressure of 80 mm Hg or use of antihypertensive agents) at follow-up visit.

RESULTS

A total of 4103 women met inclusion criteria; the mean (SD) age was 27.0 (5.6) years. Among these women, 909 (22.2%) had an adverse pregnancy outcome, and 817 (19.9%) had hypertension at the follow-up visit. Higher NT-proBNP concentrations were associated with a lower risk of hypertensive disorders of pregnancy (adjusted odds ratio per doubling, 0.81; 95% CI, 0.73-0.91), which persisted after adjustment for age, self-reported race and ethnicity, early-pregnancy body mass index, smoking, and aspirin use. Similarly, higher NT-proBNP concentration in early pregnancy was also associated with a lower risk of incident hypertension 2 to 7 years after delivery (adjusted odds ratio per doubling, 0.84; 95% CI, 0.77-0.93), an association that persisted after controlling for confounders, including hypertensive disorders of pregnancy.

CONCLUSIONS AND RELEVANCE

In this cohort study, higher NT-proBNP concentrations in early pregnancy were associated with a lower risk of hypertensive disorders of pregnancy and hypertension 2 to 7 years post partum. These findings suggest that normal early-pregnancy cardiovascular physiology, as assessed by NT-proBNP concentration, may provide biologic insights into both pregnancy outcome and cardiovascular disease risk.

Prepregnancy weight change associated with high gestational weight gain

OBJECTIVE

Gestational weight gain (GWG) above recommendations is a risk factor for adverse maternal, perinatal, and long-term outcomes. This study hypothesized that prepregnancy weight gain may portend excess GWG.

METHODS

Among 1,126 women (51% of whom were of Black race) in the Coronary Artery Risk Development in Young Adults (CARDIA) study with post-baseline births, the prepregnancy annual rate of BMI change per woman was estimated (slope; 5 years before pregnancy) and was related to the risk of GWG above Institute of Medicine recommendations using mixed-effects models (binary) and GWG z score (continuous), adjusting for confounders, and stratified by prepregnancy overweight/obesity status.

RESULTS

A total of 626 women (56%) had excess GWG. Each standard deviation increase in prepregnancy BMI (0.16 kg/m² per year) was associated with an 18% increased risk of excess GWG (95% CI: 1.13-1.23), adjusted for covariates. Stratified results showed an association for women without overweight or obesity (adjusted relative risk = 1.71 [95% CI: 1.38-2.13]) but not among those with overweight or obesity (adjusted relative risk = 0.98 [95% CI: 0.91-1.05]). When evaluated as a z score, prepregnancy weight gain was associated with higher GWG among women with and without overweight or obesity (mean = 0.24 [0.10] and 0.28 [0.12] z score, respectively).

CONCLUSIONS

Weight gain before pregnancy is associated with higher GWG during pregnancy. Assessment of prepregnancy weight changes may identify those at risk for high GWG.

Maternal Vascular Lesions in the Placenta Predict Vascular Impairments a Decade After Delivery

Women with adverse pregnancy outcomes later experience excess hypertension and cardiovascular disease, but how the events are linked is unknown. Examination of the placenta may provide clues to vascular impairments after delivery. Maternal vascular malperfusion lesions (MVMs) were abstracted from clinical reports, validated and characterized using clinical guidelines and severity score. A total of 492 women (170 with MVMs and 322 without MVMs) participated in a study visit 8 to 10 years after delivery to assess blood pressure, cardiometabolic factors, and sublingual microvascular features using sidestream dark field imaging. Covariates included age, race, adverse pregnancy outcomes (preeclampsia, small for gestational age, and preterm birth), and health behaviors. Women with versus without MVM had a distinct sublingual microvascular profile comprised of (1) lower microvascular density (-410 μm/mm², P=0.015), (2) higher red blood cell filling as a marker of perfusion (2%, P=0.004), and (3) smaller perfused boundary region (-0.07 µm, P=0.025) as a measure of glycocalyx integrity, adjusted for covariates including adverse pregnancy outcomes. Women with MVM also had higher adjusted diastolic blood pressure (+2.6 mm Hg, P=0.021), total and LDL (low-density lipoprotein)-cholesterol (+11.2 mg/dL, P=0.016; +8.7 mg/dL, P=0.031). MVM associations with subsequent cardiovascular measures did not vary by type of adverse pregnancy outcome, except among women with preterm births where blood pressure was higher only among those with MVM. Results were similar when evaluated as MVM severity. A decade after delivery, women with placental vascular lesions had an adverse cardiovascular profile comprised of microvascular rarefaction, higher blood pressure and more atherogenic lipids. Placental histopathology may reveal a woman's early trajectory toward subsequent vascular disease.

Association of Physical Activity and Sedentary Time with Cardio-Autonomic Regulation in Women

Background: Low moderate-to-vigorous-intensity physical activity (MVPA) and high sedentary time (ST) may contribute to cardiovascular disease (CVD) risk in women, perhaps via cardiac autonomic dysregulation. We examined associations of total, leisure, and occupational MVPA and ST with cardiac autonomic regulation in women. Methods: Data were from 522 women (age = 37.7 ± 5.7 years; 59%white) who participated in the follow-up study of the Pregnancy Outcomes and Community Health Study (between 2011 and 2014). MVPA and ST (hours/day) were self-reported using the Modifiable Activity Questionnaire. Cardiac autonomic regulation was assessed by calculating heart rate variability (HRV) indices (resting heart rate, natural logarithm standard deviation of normal R-R intervals; lnSDNN [total variability], natural logarithm root mean square of the successive differences; lnRMSSD [cardiac parasympathetic activity]) with Kubios software from a 5-minute, seated electrocardiogram. Progressive generalized linear models evaluated associations of total, leisure, and occupational MVPA and ST with HRV indices while adjusting for confounders (demographics, health-related factors), and then potential mediators (clinical variables). A final model evaluated the relationship between ST and HRV stratified by MVPA level. Results: Adjusting for confounders, total and leisure MVPA were associated with favorable lnSDNN (B = 0.027 [p = 0.014] and B = 0.074 [p = 0.009], respectively) and lnRMSSD (B = 0.036 [p = 0.015] and B = 0.075 [p = 0.043], respectively). Adjustment for mediators tended to strengthen the observed significant associations. No associations were found between occupational MVPA or any ST measure with HRV indices (p > 0.05). Neither MVPA nor ST were associated with heart rate. When stratified by MVPA level, leisure ST was associated with unfavorable lnRMSSD (B = -0.041, [p = 0.042]) only among women who did not meet leisure MVPA recommendations. Conclusion: Cardiac autonomic dysregulation may be a mechanism through which low leisure MVPA and, among low-active women, high leisure ST contribute to CVD risk among women.

Mindfulness in Pregnancy: A Brief Intervention for Women at Risk

INTRODUCTION

The U.S. has the highest rate of preterm birth (PTB), of all developed countries, especially among African American women. Social determinants of health and inequalities in health outcomes are understudied areas. The intersectionality of race and socioeconomic status has been shown to contribute to chronic stress, stress has been shown to be associated with PTB, yet the mechanisms that affect pregnancy outcomes have not been explicit. Mindfulness-based Interventions that address stress reduction during pregnancy may improve quality of life during pregnancy, perhaps enhancing resilience, and be on the pathway to reducing the risk of negative pregnancy outcomes such as PTB.

METHODS

We over-enrolled African American women and those covered by Medicaid to reach women at higher risk for PTB and included women in substance use treatment. Participants were enrolled in a 6-week mindfulness in pregnancy (MIP) intervention at the obstetric clinic. Sociodemographic characteristics and psychosocial assessments were obtained at three time points.

RESULTS

We enrolled 35 women who self-identified as: non-white, Medicaid recipients, aged 25-35 years, with high school or less education. We found reductions in perceived stress, pregnancy specific stress, trait anxiety and depression and increases in mindfulness that sustained post-intervention at 2 and 7 months.

DISCUSSION

Social determinants and stress in particular have been associated with negative birth outcomes. This paper describes a brief intervention and results of MIP tailored to women who have significantly more stress due to race, poverty, homelessness, substance use treatment and other comorbid health risks including PTB.

DNA Methylation GrimAge and Incident Diabetes: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

DNA methylation (DNAm)-based biological age (epigenetic age) has been suggested as a useful biomarker of age-related conditions including type 2 diabetes (T2D), and its newest iterations (GrimAge measurements) have shown early promise. In this study, we explored the association between epigenetic age and incident T2D in the context of their relationships with obesity. A total of 1,057 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study were included in the current analyses. We stratified the participants into three groups: normal weight, overweight, and obese. A 1-year increase of GrimAge was associated with higher 10-year (study years 15-25) incidence of T2D (odds ratio [OR] 1.06, 95% CI 1.01-1.11). GrimAge acceleration, which represents the deviation of GrimAge from chronological age, was derived from the residuals of a model of GrimAge and chronological age, and any GrimAge acceleration (positive GrimAA: having GrimAge older than chronological age) was associated with significantly higher odds of 10-year incidence of T2D in obese participants (OR 2.57, 95% CI 1.61-4.11). Cumulative obesity was estimated by years since obesity onset, and GrimAge partially mediated the statistical association between cumulative obesity and incident diabetes or prediabetes (proportion mediated = 8.0%). In conclusion, both older and accelerated GrimAge were associated with higher risk of T2D, particularly among obese participants. GrimAge also statistically mediated the associations between cumulative obesity and T2D. Our findings suggest that epigenetic age measurements with DNAm can potentially be used as a risk factor or biomarker associated with T2D development.

A pathway level analysis of PFAS exposure and risk of gestational diabetes mellitus

Per- and polyfluoroalkyl substances (PFAS) have been found to be associated with gestational diabetes mellitus (GDM) development, a maternal health disorder in pregnancy with negative effects that can extend beyond pregnancy. Studies that report on this association are difficult to summarize due to weak associations and wide confidence intervals. One way to advance this field is to sharpen the biologic theory on a causal pathway behind this association, and to measure it directly by way of molecular biomarkers. The aim of this review is to summarize the literature that supports a novel pathway between PFAS exposure and GDM development. Epidemiological studies demonstrate a clear association of biomarkers of thyroid hormones and glucose metabolism with GDM development. We report biologic plausibility and epidemiologic evidence that PFAS dysregulation of maternal thyroid hormones and thyrotropin (TSH) may disrupt glucose homeostasis, increasing the risk of GDM. Overall, epidemiological studies demonstrate that PFAS were positively associated with TSH and negatively with triiodothyronine (T3) and thyroxine (T4). PFAS were generally positively associated with glucose and insulin levels in pregnancy. We propose dysregulation of thyroid function and glucose metabolism may be a critical and missing component in the accurate estimation of PFAS on the risk of GDM.

Cognition and Cerebrovascular Reactivity in Midlife Women With History of Preeclampsia and Placental Evidence of Maternal Vascular Malperfusion

Background: Preeclampsia is emerging as a sex-specific risk factor for cerebral small vessel disease (SVD) and dementia, but the reason is unknown. We assessed the relationship of maternal vascular malperfusion (MVM), a marker of placental SVD, with cognition and cerebral SVD in women with and without preeclampsia. We hypothesized women with both preeclampsia and MVM would perform worst on information processing speed and executive function.

Methods: Women (n = 45; mean 10.5 years post-delivery; mean age: 41 years; 42.2% Black) were classified as preeclampsia-/MVM-, preeclampsia+/MVM-, or preeclampsia+/MVM+. Information processing speed, executive function, and memory were assessed. In a pilot sub-study of cerebrovascular reactivity (CVR; n = 22), cerebral blood flow during room-air breathing and breath-hold induced hypercapnia were obtained via arterial spin labeling MRI. Non-parametric tests and regression models were used to test associations.

Results: Between-group cognitive differences were significant for information processing speed (p = 0.02); preeclampsia+/MVM+ had the lowest scores. Cerebral blood flow increased from room-air to breath-hold, globally and in all regions in the three groups, except the preeclampsia+/MVM+ parietal region (p = 0.12). Lower parietal CVR (less change from room-air breathing to breath-holding) was correlated with poorer information processing speed (partial ρ = 0.63, p = 0.005) and executive function (ρ = 0.50, p = 0.03) independent of preeclampsia/MVM status.

Conclusion: Compared to women without preeclampsia and MVM, midlife women with both preeclampsia and MVM have worse information processing speed and may have blunted parietal CVR, an area important for information processing speed and executive function. MVM in women with preeclampsia is a promising sex-specific indicator of cerebrovascular integrity in midlife.

Sedentary behaviour and physical activity across pregnancy and birth outcomes

BACKGROUND

Shorter gestation or smaller birth size are indicators of a suboptimal fetal environment and negatively impact short- and long-term offspring health. Understanding how modifiable maternal behaviours, such as moderate-to-vigorous intensity physical activity (MVPA) or sedentary behaviour (SED), improve fetal outcomes could inform strategies to improve health across the lifespan.

OBJECTIVES

The objective of this study was to examine the association of MVPA and SED across pregnancy trimesters on gestational age at delivery and newborn anthropometrics.

METHODS

The MoM Health Study measured SED (thigh-mounted activPAL3 micro) and MVPA (waist-worn Actigraph GTX3) in each trimester of pregnancy. Birth outcomes (gestational age at delivery, birthweight, birth length, and head circumference) were abstracted from medical records and used to calculate ponderal index (grams*100/cm³ ) and size-for-gestational age percentiles. Associations of group-based trajectories and trimester-specific SED and MVPA with birth outcomes were analysed using regression models.

RESULTS

Low, medium, and high trajectory groups were generated SED and MVPA in 103 and 99 pregnant women, respectively. High vs low SED trajectory was associated with earlier gestational age at delivery (β -1.03 weeks, 95% CI -2.01, -0.06), larger head circumference (β 0.83 cm, 95% CI 0.24, 1.63), longer birth length (β 1.37 cm, 95% CI 0.09, 2.64), and lower ponderal index (β -0.24 g*100/cm³ , 95% CI -0.42, -0.06), after adjustment for demographics, pre-pregnancy BMI, and (for newborn anthropometric outcomes) gestational age. The association of high SED with lower ponderal index was the most robust across progressively adjusted models (β -0.25 g*100/cm³ , 95% CI -0.44, -0.07). SED trajectory was not associated with birthweight or size-for-gestational age. High vs low MVPA trajectory was only associated with smaller head circumference (β -0.86 cm, 95% CI -1.70, -0.02).

CONCLUSIONS

Higher SED during pregnancy may result in shorter gestation and inhibited fetal growth. Further research evaluating the effect of reducing SED during pregnancy on birth outcomes is warranted.

Gestational Diabetes History and Glucose Tolerance After Pregnancy Associated With Coronary Artery Calcium in Women During Midlife: The CARDIA Study

BACKGROUND

Gestational diabetes (GD) leads to earlier onset and heightened risk of type 2 diabetes, a strong risk factor for cardiovascular disease (CVD). However, it is unclear whether attaining normoglycemia can ameliorate the excess CVD risk associated with GD history. This study sought to evaluate GD history and glucose tolerance after pregnancy associated with coronary artery calcification (CAC) in women, a manifestation of atherosclerotic CVD and a predictor of CVD clinical events.

METHODS

Data were obtained from the CARDIA study (Coronary Artery Risk Development in Young Adults), a US multicenter, community-based prospective cohort of young Black (50%) and White adults aged 18 to 30 years at baseline (1985-1986). The sample included 1133 women without diabetes at baseline, who had ≥1 singleton births (n=2066) during follow-up, glucose tolerance testing at baseline and up to 5 times during 25 years (1986-2011), GD status, and CAC measurements obtained from 1 or more follow up examinations at years 15, 20, and 25 (2001-2011). CAC was measured by noncontrast cardiac computed tomography; dichotomized as Any CAC (score>0) or No CAC (score=0). Complementary log-log models for interval-censored data estimated adjusted hazard ratios of CAC and 95% confidence intervals for GD history and subsequent glucose tolerance groups (normoglycemia, prediabetes, or incident diabetes) on average 14.7 years after the last birth adjusted for prepregnancy and follow-up covariates.

RESULTS

Of 1133 women, 139 (12.3%) reported GD and were 47.6 years of age (4.8 SD) at follow-up. CAC was present in 25% (34/139) of women with GD and 15% (149/994) of women with no GD. In comparison with no GD/normoglycemia, adjusted hazard ratios (95% CIs) were 1.54 (1.06-2.24) for no GD/prediabetes and 2.17 (1.30-3.62) for no GD/incident diabetes, and 2.34 (1.34-4.09), 2.13 (1.09-4.17), and 2.02 (0.98-4.19) for GD/normoglycemia, GD/prediabetes, and GD/incident diabetes, respectively (overall P=0.003).

CONCLUSIONS

Women without previous GD showed a graded increase in the risk of CAC associated with worsening glucose tolerance. Women with a history of GD had a 2-fold higher risk of CAC across all subsequent levels of glucose tolerance. Midlife atherosclerotic CVD risk among women with previous GD is not diminished by attaining normoglycemia.

Association of Hypertensive Disorders of Pregnancy With Left Ventricular Remodeling Later in Life

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with short-term cardiac structure and function abnormalities, but later life changes are not well studied.

OBJECTIVES

This study aimed to determine if HDP history is associated with echocardiographic differences 8 to 10 years after delivery, and if subgroups with placental maternal vascular malperfusion (MVM) lesions or current hypertension may be particularly affected.

METHODS

Women with pregnancies delivered from 2008 to 2009 were selected from a clinical cohort with abstracted pregnancy and placental pathology data to undergo transthoracic echocardiography (2017 to 2020). Medical history, blood pressure, and weight were measured at the study visit.

RESULTS

The authors enrolled 132 women (10 ± 1 years post-delivery, age 38 ± 6 years): 102 with normotensive pregnancies and 30 with HDP: pre-eclampsia (n = 21) or gestational hypertension (n = 9). Compared with women with normotensive pregnancies, those with HDP history were more likely to have current hypertension (63% vs. 26%; p < 0.001). After adjusting for age, race, MVM lesions, body mass index, current hypertension, and hemoglobin A1c, women with HDP history had higher interventricular septal thickness (β = 0.08; p = 0.04) and relative wall thickness (β = 0.04; p = 0.04). In subgroup analyses, those with both HDP history and current hypertension had a higher proportion of left ventricular remodeling (79.0%) compared with all other groups (only HDP [36.4%; p = 0.01], only current hypertension [46.2%; p = 0.02], and neither HDP nor hypertension [38.2%; p < 0.001]), and lower mitral inflow E/A and annular e'. Accounting for placental MVM lesions did not impact results.

CONCLUSIONS

Women with both HDP history and current hypertension have pronounced differences in left ventricular structure and function a decade after pregnancy, warranting continued surveillance and targeted therapies for cardiovascular disease prevention.

Early Pregnancy Atherogenic Profile in a First Pregnancy and Hypertension Risk 2 to 7 Years After Delivery

Background

Cardiovascular risk in young adulthood is an important determinant of lifetime cardiovascular disease risk. Women with adverse pregnancy outcomes (APOs) have increased cardiovascular risk, but the relationship of other factors is unknown.

Methods and Results

Among 4471 primiparous women, we related first‐trimester atherogenic markers to risk of APO (hypertensive disorders of pregnancy, preterm birth, small for gestational age), gestational diabetes mellitus (GDM) and hypertension (130/80 mm Hg or antihypertensive use) 2 to 7 years after delivery. Women with an APO/GDM (n=1102) had more atherogenic characteristics (obesity [34.2 versus 19.5%], higher blood pressure [systolic blood pressure 112.2 versus 108.4, diastolic blood pressure 69.2 versus 66.6 mm Hg], glucose [5.0 versus 4.8 mmol/L], insulin [77.6 versus 60.1 pmol/L], triglycerides [1.4 versus 1.3 mmol/L], and high‐sensitivity C‐reactive protein [5.6 versus 4.0 nmol/L], and lower high‐density lipoprotein cholesterol [1.8 versus 1.9 mmol/L]; P<0.05) than women without an APO/GDM. They were also more likely to develop hypertension after delivery (32.8% versus 18.1%, P<0.05). Accounting for confounders and factors routinely assessed antepartum, higher glucose (relative risk [RR] 1.03 [95% CI, 1.00–1.06] per 0.6 mmol/L), high‐sensitivity C‐reactive protein (RR, 1.06 [95% CI, 1.02–1.11] per 2‐fold higher), and triglycerides (RR, 1.27 [95% CI, 1.14–1.41] per 2‐fold higher) were associated with later hypertension. Higher physical activity was protective (RR, 0.93 [95% CI, 0.87‐0.99] per 3 h/week). When evaluated as latent profiles, the nonobese group with higher lipids, high‐sensitivity C‐reactive protein, and insulin values (6.9% of the cohort) had increased risk of an APO/GDM and later hypertension. Among these factors, 7% to 15% of excess RR was related to APO/GDM.

Conclusions

Individual and combined first‐trimester atherogenic characteristics are associated with APO/GDM occurrence and hypertension 2 to 7 years later.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02231398.

Association of sedentary time with blood pressure in women of reproductive age

While the beneficial impact of moderate-vigorous physical activity (MVPA) on blood pressure is well-understood, the relationship between sedentary time (ST) and blood pressure is less clear. We aimed to evaluate the associations between ST and BP in reproductive-age women. This cross-sectional analysis consisted of 431 women enrolled in the Placenta as a Window to Maternal Microvascular Disease Risk study at Magee-Womens Hospital. Blood pressure and self-reported physical activity and ST were collected 8–10 years after delivery at study enrollment. Logistic and linear regression models examined associations between ST and blood pressure and adjusted for MVPA. Women with the highest amount of ST were less likely to be normotensive and more likely to have elevated blood pressure and Stage II hypertension (p = 0.02). Each additional hour of ST was associated with an increased risk of Stage II hypertension (OR 1.12 [1.01–1.24]) and higher systolic blood pressure (0.45 mmHg [0.08–0.82]), diastolic blood pressure (0.29 mmHg [0.02–0.56]), and mean arterial pressure (0.34 mmHg [0.05–0.63]), after adjustment for covariates. This relationship was more apparent in women who participated in less MVPA (bottom 50th percentile) versus more MVPA (top 50th percentile). ST is associated with higher blood pressure, particularly in women who engage in less aerobic activity, and could serve as an important intervention target for reducing blood pressure and hypertension during the reproductive years.

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

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

Maternal risk of hypertension 7-15 years after pregnancy: clues from the placenta

OBJECTIVE

To assess whether pre-eclampsia (PE)-related placental/extraplacental membrane findings are linked to moderately elevated blood pressure (BP) in pregnancy and later-life hypertension.

DESIGN

Prospective cohort.

SETTING

52 prenatal clinics, 5 Michigan communities.

SAMPLE

The POUCH Study recruited women at 16-27 weeks' gestation (1998-2004) and studied a sub-cohort in depth. This sample (n = 490) includes sub-cohort women with detailed placental assessments and cardiovascular health evaluations 7-15 years later in the POUCHmoms follow-up study.

METHODS

PE-related placental/extraplacental membrane findings (i.e. mural hyperplasia, unaltered/abnormal vessels or atherosis in decidua; infarcts) were evaluated in relation to pregnancy BP and odds of Stage 2 hypertension at follow up using weighted polytomous regression. Follow-up hypertension odds also were compared in three pregnancy BP groups: normotensives (referent) and moderately elevated BP with or without PE-related placental/extraplacental membrane findings.

MAIN OUTCOME MEASURES

Stage 2 hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg, or using antihypertensive medications) at follow up.

RESULTS

After excluding women with pregnancy hypertension (i.e. chronic, PE, gestational), mural hyperplasia and unaltered/abnormal decidual vessels were each associated with Stage 2 hypertension at follow up: adjusted odds ratio (aOR) = 2.7, 95% CI 1.1-6.6, and aOR = 1.7 (95% CI 0.8-3.4), respectively. Women with moderately elevated BP in pregnancy and evidence of mural hyperplasia or unaltered/abnormal decidual vessels had greater odds of Stage 2 hypertension at follow up: aOR = 4.5 (95% CI 1.6-12.5 and aOR = 2.6, 95% CI 1.1-5.9, respectively.

CONCLUSIONS

PE-related placental/extraplacental membrane findings help risk-stratify women with moderately elevated BP in pregnancy for later development of hypertension.

TWEETABLE ABSTRACT

Placental findings associated with mother's risk of later-life hypertension.

Abstract 3: Preeclampsia-induced T Helper-associated Cytokine Imbalances Persist Postpartum

Preeclampsia (PreE), a hypertensive disorder in pregnancy, contributes to long-term maternal cardiovascular disease risk. By 2025, it is estimated that more women than men will have hypertension (HTN), yet the mechanisms contributing to the development of HTN in women are less understood. One potential mechanism underlying HTN in women is a persistent imbalance of anti- and pro- inflammatory T H cells following PreE. Consistent with this, anti-inflammatory T helper (T H ) cytokines are reduced and pro-inflammatory T H cytokines are increased during a PreE pregnancy.

De-identified and coded plasma samples and clinical data were obtained from the Magee-Women’s Research Institute & Foundation or the University of Iowa Maternal-Fetal Tissue Bank (IRB 201808705) from women 1-3 (N=93) or 8-10 (N=58) years (yrs) following a normotensive (CTL) or PreE-affected pregnancy. Postpartum (PP) HTN was defined as having stage 1 or higher HTN as designated in the updated 2017 ACC/AHA guidelines. Women with PreE had higher rates of HTN at 1-3 years and at 8-10 years PP, (24% vs. 5% and 65% vs. 17%, all p<0.05) compared to women with a normotensive pregnancy.

To determine if T H cells play a role in the future development of HTN, we investigated if the T H cytokine changes observed in PreE persist 1-3 yrs and 8-10 yrs PP. Cytokine concentrations were determined via ELISAs and normalized to total protein. Average cytokine concentrations are reported in pg/g. At 1-3 yrs PP, concentrations of anti-inflammatory cytokines IL-4 (47 vs. 6819, p<0.05), IL-10 (1204 vs. 15042, p<0.05) and TGFβ (8.2x10 5 vs. 4.4x10 6 , p<0.05) were reduced in women with a prior PreE pregnancy vs. women with a CTL pregnancy. At 8-10 yrs PP, pro-inflammatory IL-6 (86 vs. 18, p<0.05) and TNFα (298 vs. 53, p<0.05) were both significantly increased in women with prior PreE compared to women with a CTL pregnancy.

Here, we confirm women with a prior PreE pregnancy present with a higher prevalence of HTN early (1-3 yrs) and later (8-10 yrs) PP compared to women with a normotensive pregnancy. Further, we show an altered T H cytokine milieu persists following delivery in women with PreE. This pro-inflammatory milieu is associated with increased rates of HTN and thus, may underlie the future development of HTN in women with a history of PreE.

Changes in Cardiometabolic Risk Factors Before and After Gestational Diabetes: A Prospective Life-Course Analysis in CARDIA Women

OBJECTIVE

This study hypothesized that both preconception and postchildbearing patterns of cardiometabolic risk factors may be different for women with gestational diabetes mellitus (GDM) compared with women without GDM.

METHODS

Among 1,302 (51% black) women in the Coronary Artery Risk Development in Young Adults (CARDIA) study with births and followed for 30 years, this study evaluated changes in cardiometabolic factors (BMI, waist circumference [WC], lipids, blood pressure) during prechildbearing (prior to the first postbaseline birth) and postchildbearing periods (after the last birth) by GDM status using piecewise linear mixed models adjusted for sociodemographics, parity, and time-varying covariates.

RESULTS

Compared with women who did not develop GDM, weight and WC increases in women who developed GDM (n = 152, 12%) were faster (BMI difference: +0.12 kg/m² /y, P = 0.04; WC difference: +0.28 cm/y, P = 0.04) during the prechildbearing period, accounting for covariates. This translated to an average of 1.3 kg of excess weight gain across 4 years among women with subsequent GDM versus non-GDM births. In contrast, slopes after childbearing did not differ by GDM status, nor were there other cardiometabolic differences.

CONCLUSIONS

Women with GDM exhibited an increasing prepregnancy pattern of weight gain and central adiposity. Absolute postchildbearing weight was also higher in GDM-affected women, but the slope of gain after GDM was not.

Life Course Changes in Cardiometabolic Risk Factors Associated With Preterm Delivery: The 30-Year CARDIA Study

Background

Women who deliver preterm infants (<37 weeks) have excess cardiovascular risk; however, it is unclear whether the unfavorable changes in the cardiometabolic profile associated with preterm delivery initiate before, during, or after childbearing.

Methods and Results

We identified 1306 women (51% Black) with births between baseline (1985–1986) and year 30 in the CARDIA (Coronary Artery Risk Development in Young Adults) study. We compared life course changes in blood pressure, body mass index, waist circumference, and lipids in women with preterm deliveries (n=318) with those with all term deliveries (n=988), using piecewise linear mixed‐effects models. Specifically, we evaluated group differences in rates of change before and after the childbearing period and change in level across the childbearing period. After adjusting for the covariates, women with preterm deliveries had a higher change in diastolic blood pressure across the childbearing period than those with all term deliveries (1.59 versus −0.73 mm Hg, P<0.01); the rates of change did not differ by group, both prechildbearing and postchildbearing. Women with preterm deliveries had a larger body mass index increase across the childbearing period (1.66 versus 1.22 kg/m², P=0.03) compared with those with all term deliveries, followed by a steeper increase after the childbearing period (0.22 versus 0.17 kg/m² per year, P=0.02).

Conclusions

Preterm delivery was associated with unfavorable patterns of change in diastolic blood pressure and adiposity that originate during the childbearing years and persist or exacerbate later in life. These adverse changes may contribute to the elevated cardiovascular risk among women with preterm delivery.

Associations of perceived prenatal stress and adverse pregnancy outcomes with perceived stress years after delivery

Maternal stress is a risk factor for adverse pregnancy outcomes (APOs). This study evaluates the associations of prenatal stress and APOs with maternal stress years after pregnancy. The 10-item Perceived Stress Scale (PSS) (0-40 range) was completed in the first and third trimesters, and 2-7 years after delivery among a subsample (n = 4161) of nulliparous women enrolled at eight US medical centers between 2010 and 2013 in a prospective, observational cohort study. Demographics, medical history, and presence of APOs (gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), preeclampsia (PE), and medically indicated or spontaneous preterm birth (miPTB, sPTB)) were obtained. The associations of prenatal PSS and the presence of APOs with PSS scores years after delivery were estimated using multivariable linear regression. Mean PSS scores were 12.5 (95% CI 12.3, 12.7) and 11.3 (95% CI 11.1, 11.5) in the first and third trimesters respectively and 14.9 (95% CI 14.7, 15.1) 2-7 years later, an average increase of 2.4 points (95% CI 2.2, 2.6) from the start of pregnancy. Regressing PSS scores after delivery on first-trimester PSS and PSS increase through pregnancy showed positive associations, with coefficients (95% CI) of 2.8 (2.7, 3.0) and 1.5 (1.3, 1.7) per 5-point change, respectively. Adding APO indicator variables separately showed higher PSS scores for women with HDP (0.7 [0.1, 1.3]), PE (1.3 [0.6, 2.1]), and miPTB (1.3 [0.2, 2.4]), but not those with GDM or sPTB. In this geographically and demographically diverse sample, prenatal stress and some APOs were positively associated with stress levels 2-7 years after pregnancy.ClinicalTrials.gov Registration number NCT02231398.