Pregnancy complications and maternal risk of ischaemic heart disease: a retrospective cohort study of 129,290 births

A life course approach to cardiovascular aging

A life course approach in epidemiology investigates the biological, behavioral and social pathways that link physical and social exposures and experiences during gestation, childhood, adolescence and adult life, and across generations, to later-life health and disease risk. We illustrate how a life course approach has been applied to cardiovascular disease, highlighting the evidence in support of the early origins of disease risk. We summarize how trajectories of cardiometabolic risk factors change over the life course and suggest that understanding underlying 'normal' or 'healthy' trajectories and the characteristics that drive deviations from such trajectories offer the potential for early prevention and for identifying means of preventing future disease.

Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort

BACKGROUND

Few studies have investigated the combination of pregnancy complications that predict risk for cardiovascular disease (CVD) death and how risk changes with age. This report presents a comprehensive investigation of the relation of the occurrence of multiple pregnancy complications to CVD death over 5 decades in a large pregnancy cohort.

METHODS AND RESULTS

We examined pregnancy events (1959-1967) and CVD death through 2011 in 14 062 women from the Child Health and Development Studies. CVD death was determined by linkage to California Vital Statistics and National Death Index. Women were a median age of 26 years at enrollment and 66 years in 2011. Preexisting hypertension (hazard ratio, 3.5; 95% confidence interval, 2.4-5.1); glycosuria (hazard ratio, 4.2; confidence interval, 1.3-13.1); late-onset preeclampsia (after week 34, hazard ratio, 2.0; confidence interval, 1.2-3.5); and hemoglobin decline over the second and third trimesters (hazard ratio, 1.7; confidence interval, 1.2-2.7) predicted CVD death. Delivery of a small-for-gestation or preterm infant and early-onset preeclampsia (by week 34) significantly predicted premature CVD death (P<0.05 for age dependence). Preterm birth combined with hemorrhage, gestational hypertension, or preexisting hypertension identified women with a 4- to 7-fold increased risk of CVD death. Preeclampsia in combination with preexisting hypertension conferred a significant nearly 6-fold risk in comparison with a 4-fold risk for preexisting hypertension alone.

CONCLUSIONS

We observed combinations of pregnancy complications that predict high risk of death and 2 new risk markers, glycosuria and hemoglobin decline. Obstetricians serve as primary care physicians for many young women and can readily use these complications to identify high-risk women to implement early prevention.

Potential role of folate in pre-eclampsia

Dietary deficiencies of folate and other B vitamin cofactors involved in one-carbon metabolism, together with genetic polymorphisms in key folate-methionine metabolic pathway enzymes, are associated with increases in circulating plasma homocysteine, reduction in DNA methylation patterns, and genome instability events. All of these biomarkers have also been associated with pre-eclampsia. The aim of this review was to explore the literature and identify potential knowledge gaps in relation to the role of folate at the genomic level in either the etiology or the prevention of pre-eclampsia. A systematic search strategy was designed to identify citations in electronic databases for the following terms: folic acid supplementation AND pre-eclampsia, folic acid supplementation AND genome stability, folate AND genome stability AND pre-eclampsia, folic acid supplementation AND DNA methylation, and folate AND DNA methylation AND pre-eclampsia. Forty-three articles were selected according to predefined selection criteria. The studies included in the present review were not homogeneous, which made pooled analysis of the data very difficult. The present review highlights associations between folate deficiency and certain biomarkers observed in various tissues of women at risk of pre-eclampsia. Further investigation is required to understand the role of folate in either the etiology or the prevention of pre-eclampsia.

Maternal metabolic syndrome, preeclampsia, and small for gestational age infancy

OBJECTIVE

We sought to explore to what extent the presence of cardiometabolic and cardiovascular risk constitutions differ between pregnancies complicated by small-for-gestational-age (SGA) infancy, preeclampsia (PE), or a combination of both.

STUDY DESIGN

We conducted a cohort study in women after pregnancies complicated by placental syndrome with fetal manifestations (SGA infancy [n = 113]), maternal manifestations (PE [n = 729]), or both (n = 461). Independent sample t test was used to compare cardiometabolic and cardiovascular risk factors between groups. Logistic regression was used to calculate odds ratios and adjusted odds ratios of the prevalence of the metabolic syndrome and its constituents between groups. Adjustments were made for maternal age, parity, smoking, interval between delivery and measurements, and intrauterine fetal demise.

RESULTS

The metabolic syndrome was present in 7.5% of women who delivered SGA infants, 15.6% of former PE women, and 19.8% of women after pregnancy complicated by both SGA and PE. Hypertension was observed in 25% of former PE women and 15% of women with solely SGA. Women who delivered a SGA infant had lower global vascular compliance compared to former PE women without SGA.

CONCLUSION

Cardiometabolic risk factors consistent with metabolic syndrome relate to the maternal rather than to the fetal presentation of placental syndrome. Nonetheless, highest incidence of metabolic syndrome was observed in women with both PE and SGA. PE relates to chronic hypertension, whereas increased arterial stiffness seems to be associated with women who deliver a SGA infant.

Upregulation of the Tim-3/Gal-9 pathway and correlation with the development of preeclampsia

OBJECTIVE

It is well documented that an imbalance in immune tolerance at the maternal-fetal interface is likely to play an essential role in the etiology of preeclampsia. However, the mechanisms underlying immune tolerance during preeclampsia are still poorly understood. Tim-3, a Th1-specific cell surface molecule, is a relatively newly described molecule with important immunological functions. It can regulate Th1 responses with its ligand galectin-9 (Gal-9), and has become an attractive candidate for exploring the pathogenesis of preeclampsia.

STUDY DESIGN

Twenty normal pregnancies and 20 preeclamptic pregnancies were enrolled in the present study. We examined the expression and function of Tim-3/Gal-9 in decidual tissue at the RNA and protein levels. In order to analyze their correlation with the development of preeclampsia, we measured the expression of Tim-3 on peripheral blood leukocytes using flow cytometry. IFN-γ, IL-10, and IL-17 in the peripheral blood plasma were measured by ELISA.

RESULTS

Tim-3/Gal-9 was upregulated in decidual tissue of preeclamptic vs. normotensive pregnancies. There was a significantly increased Th1 and Th17 response in PE as demonstrated by the upregulated levels of IFN-γ/IL-17, whereas IL-10 secreted by Th2 cells was sharply reduced.

CONCLUSIONS

The present study showed that an abnormal Tim-3/Gal-9 pathway was able to facilitate the development of preeclampsia. Our data uncovered a novel mechanism by which the Tim-3/Gal-9 pathway regulates immune responses, and we now identify this pathway as a potential therapeutic target in preeclampsia.

Molecular Mechanisms of Preeclampsia

Preeclampsia is a pregnancy-specific disease characterized by new onset hypertension and proteinuria after 20 wk of gestation. It is a leading cause of maternal and fetal morbidity and mortality worldwide. Exciting discoveries in the last decade have contributed to a better understanding of the molecular basis of this disease. Epidemiological, experimental, and therapeutic studies from several laboratories have provided compelling evidence that an antiangiogenic state owing to alterations in circulating angiogenic factors leads to preeclampsia. In this review, we highlight the role of key circulating antiangiogenic factors as pathogenic biomarkers and in the development of novel therapies for preeclampsia.

Association between miscarriage and cardiovascular disease in a Scottish cohort

OBJECTIVE

To assess if miscarriage, whether consecutive or not, is associated with an increased risk of subsequent cardiovascular disease.

METHODS

A cohort study was performed using women with at least one miscarriage or live birth recorded from 1950 to 2010 in the Aberdeen Maternity and Neonatal Databank. The exposed groups consisted of women with non-consecutive, two consecutive or three or more consecutive miscarriages; the unexposed group consisted of all women with at least one live birth and no miscarriages. Women were linked to Scottish Morbidity Records for hospital admissions for cardiovascular conditions, cardiac surgery and death registrations. Main outcome measures were ischaemic heart disease, cerebrovascular disease and a composite outcome of any disease of circulatory system. A sensitivity analysis was performed dividing the women into those who had one, two or three or more miscarriages irrespective of whether these events were consecutive or not.

RESULTS

After excluding women with pre-existing hypertension, type 1 diabetes mellitus, kidney disease and 'disease of circulatory system', 60,105 women were analysed; 9419 with non-consecutive, 940 with two consecutive, 167 with three or more consecutive miscarriages and 49,579 with no miscarriage. In the multivariate analyses, a significant association was found between ischaemic heart disease and women with two (HRs 1.75 (95% CI 1.22 to 2.52)) or three or more (HR 3.18 (95% CI 1.49 to 6.80)) consecutive miscarriages. Similar patterns of risk were observed in the sensitivity analysis.

CONCLUSION

Women with a history of two or more miscarriages, irrespective of whether consecutive or not, appear to have an increased risk of ischaemic heart disease.

Determinants of future cardiovascular health in women with a history of preeclampsia

Women who develop preeclampsia have an increased risk of cardiovascular disease (CVD) later in life. However, current guidelines on cardiovascular risk assessment and prevention are unclear on how and when to screen these women postpartum, and about the role of a positive history of preeclampsia in later-life CVD risk management. The aim of this review is to discuss the present knowledge on commonly used cardiovascular screening modalities available to women with a history of preeclampsia, and to discuss recent developments in early detection of CVD using cardiovascular imaging. Furthermore, we explore how female-specific risk factors may have additional value in cardiovascular screening, in particular in relatively young women, although their implementation in clinical practice is challenged by inconsistent results and lack of long-term outcome data. Non-invasive imaging techniques, e.g., coronary artery intima-media thickness (CIMT), can be helpful to detect subclinical atherosclerotic disease, and coronary artery calcium scoring (CACS) has shown to be effective in early detection of cardiovascular damage. However, while more short-term and long-term follow-up studies are becoming available, few studies have investigated women with a history of preeclampsia in the fourth and fifth decade of life, when early signs of premature CVD are most likely to become apparent. Further studies are needed to inform new and improved clinical practice guidelines, and provide long-term strategies to effectively prevent CVD, specifically targeted at women with a history of preeclampsia. Additionally, evaluation of feasibility, cost-effectiveness, and implementation of CVD screening and prevention initiatives targeted at former preeclampsia patients are needed.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

DNA methylation provides insight into intergenerational risk for preterm birth in African Americans

African Americans are at increased risk for spontaneous preterm birth (PTB). Though PTB is heritable, genetic studies have not identified variants that account for its intergenerational risk, prompting the hypothesis that epigenetic factors may also contribute. The objective of this study was to evaluate DNA methylation from maternal leukocytes to identify patterns specific to PTB and its intergenerational risk. DNA from peripheral leukocytes from African American women that delivered preterm (24-34 weeks; N = 16) or at term (39-41 weeks; N = 24) was assessed for DNA methylation using the HumanMethylation450 BeadChip. In maternal samples, 17,829 CpG sites associated with PTB, but no CpG site remained associated after correction for multiple comparisons. Examination of paired maternal-fetal samples identified 5,171 CpG sites in which methylation of maternal samples correlated with methylation of her respective fetus (FDR < 0.05). These correlated sites were enriched for association with PTB in maternal leukocytes. The majority of correlated CpG sites could be attributed to one or more genetic variants. They were also significantly more likely to be in genes involved in metabolic, cardiovascular, and immune pathways, suggesting a role for genetic and environmental contributions to PTB risk and chronic disease. The results of this study may provide insight into the factors underlying intergenerational risk for PTB and its consequences.

Tissue factor and tissue factor pathway inhibitor in women with a past history of preeclampsia: implication for a hypercoagulable state postpregnancy

Preeclampsia (P-EC) is a multisystem disorder of pregnancy whose cause and pathogenesis remain poorly understood. However, abnormal haemostasis and endothelial dysfunction are thought to be implicated. Women with a past medical history of P-EC have a baseline hypercoagulable state postpregnancy. The aim of this study is to examine the relationship between tissue factor (TF) and TF pathway inhibitor (TFPI) in women who have had P-EC within the last 3 years (more than 6 months postpartum) and their normal counterparts. Blood specimens were collected from women known to have had P-EC within the last 3 years (n = 26) and aged-matched healthy women without past history of P-EC in previous pregnancy (n = 26). Plasma TF and TFPI levels were measured using ELISAs. Women who have had P-EC showed increased TF levels compared with their normal counterparts, whereas TFPI levels were reduced. Neither parameter differed significantly when the groups were tested against each other. Interestingly, the TF/TFPI ratio was significantly increased (P = 0.024) when the two groups were compared. In summary, there was a trend towards increased TF and reduced TFPI levels in the P-EC group. Such a tendency was not statistically significant. However, the TF/TFPI ratio was significantly increased when the groups were compared. Our findings suggest an imbalance between TF/TFPI levels in women with past history of P-EC postpregnancy. This may contribute to the development of maternal hypercoagulable states and may predispose women with a history of P-EC to cardiovascular risks later in life.

The Maternal Health Clinic: Improving women's cardiovascular health

Women's cardiovascular health is a national priority that should be addressed through improving cardiovascular awareness and prevention. Given the costs of treating cardiovascular disease and screening for it, novel and innovative ways to identify women who should undergo risk screening and intervention, including lifestyle modification, is critical to achieve this goal. Pregnancy is seen as a vascular stress test in that the development of common pregnancy complications has been shown to predict a woman's risk of premature cardiovascular disease and cardiovascular disease-related mortality. Therefore, pregnancy and the postpartum period provide a new early window of opportunity to identify risk factors for the majority of women to improve their long-term health. We have translated the research findings into the Maternal Health Clinic for health maintenance and disease prevention. Women who develop one of the pregnancy-related cardiovascular risk indicators are referred for screening, counseling, and lifestyle modification. We have reported that over half of the women referred to the Maternal Health Clinic, in comparison to women who have a normal pregnancy outcome, have a high lifetime cardiovascular disease risk and three times the risk to meet the criteria for the metabolic syndrome. If these women had not attended our clinic and received early screening and intervention, they may not have been identified as having underlying risk factors until much later in life. Intervening and management later in life, when there is a potentially greater burden of atherosclerosis, does not reduce cardiovascular disease risk to the same extent as maintaining favorable risk factor levels throughout adulthood. Pregnancy complications and the postpartum period are a new early window of opportunity to reliably identify women who should undergo cardiovascular risk screening, and management that may improve subsequent pregnancy outcomes and prevent cardiovascular disease.

Cardiovascular disease screening

Cardiovascular disease is the leading cause of death amongst women worldwide. Cardiovascular risk assessment and primary prevention are important strategies to improve morbidity and mortality. In additional to the traditional risk factors, pregnancy complications such as pre-eclampsia and gestational diabetes increment future risk of developing cardiovascular complications. Additionally, several serum biomarkers are valuable measures for both risk assessment and predictors of clinical outcomes in women. The purpose of this review is to describe current risk stratification schemes as well as outline the role of obstetric history and serum biomarkers in adjusting risk stratification in women.

Preeclampsia and future cardiovascular disease in women: How good are the data and how can we manage our patients?

Women with a history of preeclampsia have double the risk of future heart disease and stroke, and elevated risks of hypertension and diabetes. The American Heart Association (AHA) and the American College of Obstetrics and Gynecology now include preeclampsia as a risk factor for future cardiovascular disease (CVD) with the recommendation of obtaining a history of preeclampsia and improving lifestyle behaviors for women with such a history. Research has progressed from asking whether preeclampsia is associated with CVD to how preeclampsia is associated with CVD, and the implications for prevention of CVD among women with a history of preeclampsia. A history of preeclampsia "unmasks" future CVD risk; research is inconclusive whether it also causes vascular damage that leads to CVD. For women with prior preeclampsia, the AHA recommends CVD risk reduction actions similar to those for other "at risk" groups: cessation of cigarette smoking, physical activity, weight reduction if overweight or obese and counseling to follow a "DASH" like diet. The efficacy of these lifestyle modifications to lower risk of CVD in women with prior preeclampsia remains to be determined. Barriers exist to implementing lifestyle improvement measures in this population, including lack of awareness of both patients and clinicians of this link between preeclampsia and CVD. We review patient, provider, and systems level barriers and solutions to leverage this information to prevent CVD among women with a history of preeclampsia.

Neutrophil functions in morbidly obese subjects

The present study aimed to determine different peripheral blood neutrophil functions in 18 morbidly obese subjects with body mass index (BMI) ranging between 35 and 69 kg/m(2) in parallel with age- and gender-matched lean controls. Peripheral blood neutrophil functions of obese subjects and matched lean controls were determined. Neutrophils of obese subjects showed significant elevation of the release of basal superoxides (P < 0.0001), formyl-methionyl-leucyl-phenylalanine (fMLP)-stimulated superoxides (P < 0.0001) and opsonized zymosan (OZ)-stimulated superoxides (P < 0.045) compared with lean controls. Interestingly, there were no differences in phorbol myristate acetate (PMA)-stimulated superoxide production by neutrophils of the obese subjects and controls. There was also a significant elevation of chemotactic (P < 0.0003) and random (P < 0.0001) migration of neutrophils from obese subjects compared with lean controls. Phagocytosis, CD11b surface expression and adherence of neutrophils from obese subjects were not significantly different from those of the lean controls. The elevated superoxide production and chemotactic activity, together with the normal phagocytosis and adherence, suggest that neutrophils from obese subjects are primed and have the capability to combat infections. However, neutrophils in the priming state may participate in the pathogenesis of obesity-related diseases.

Cardiovascular disease in women: the significance of hypertension and gestational diabetes during pregnancy

PURPOSE OF REVIEW

Cardiovascular disease (CVD) remains the major killer of women around the globe. Complications during pregnancy, including hypertensive disorders of pregnancy and gestational diabetes mellitus, are now recognized as risk factors for future CVD.

RECENT FINDINGS

Studies of diverse populations demonstrate the links between these complications of pregnancy and a woman's future risk of CVD including atherosclerosis, hypertension, stroke, coronary artery disease, and heart failure. Markers that persist in these women following pregnancy continue to be identified and include microalbuminuria, proteinuria, elevated homocysteine levels, C-reactive protein, and salt sensitivity. Efforts are now being placed on establishing specialized clinics to monitor women beyond pregnancy to help reduce the burden of future disease.

SUMMARY

Pregnancy offers a unique window through which women at risk of future CVD may be identified. Clinicians have an opportunity to implement health monitoring, lifestyle modifications, and other interventions during this period, and beyond, that will help reduce the burden of CVD. Research should continue to focus on identifying and understanding the mechanisms that lead to future CVD in these women; deciphering whether pregnancy unmasks an existing predisposition to disease, compounds the risk of future disease, or is the direct cause of future disease.

How does preeclampsia predispose to future cardiovascular disease?

Over the last few decades, there has been increasing emphasis on cardiovascular disease in women and study of female-specific cardiovascular risk factors. Hypertension in pregnancy, and specifically preeclampsia, has been identified as one such risk factor. In this review, we explore the epidemiological evidence for preeclampsia as a risk factor for cardiovascular disease. We propose reasons for this association, giving evidence for potential pathways linking preeclampsia with future cardiovascular disease.

Sleep-disordered breathing during pregnancy: future implications for cardiovascular health

IMPORTANCE

Cardiovascular disease (CVD) is a common condition in postreproductive females. Key risk factors for later-life CVD include gestational hypertension (GHTN) and preeclampsia (PE). Although several risk factors of hypertension in pregnancy are well recognized, a novel risk factor that has emerged recently is sleep-disordered breathing (SDB), a condition characterized by repeated closure of the upper airway during sleep with disrupted ventilation and sleep fragmentation. In the nonpregnant population, SDB is now known to play a causal role in future CVD.

OBJECTIVE

The aim of this study was to propose the hypothesis that occult SDB during pregnancy may play a role in long-term CVD in women who had hypertensive disorders of pregnancy.

EVIDENCE ACQUISITION

This study is a review and synthesis of empirical evidence that links SDB to GHTN/PE and GHTN/PE to future CVD.

RESULTS

An increasing body of evidence supports the relationship between SDB and hypertensive disorders of pregnancy via mechanisms of inflammation, oxidative stress, and endothelial dysfunction. It is well established that hypertensive disorders of pregnancy are associated with long-term risk for CVD via similar mechanisms. However, no studies have addressed the potential role of SDB in long-term outcomes of women with GHTN/PE during pregnancy.

CONCLUSIONS

Given the suggested mechanisms that explain these associations, it is plausible that SDB during pregnancy may increase long-term cardiovascular morbidity and mortality.

RELEVANCE

Pregnancy may offer a window of opportunity for identification and treatment of SDB, which could provide substantial health benefit for many years to come.

Alteration of Delta-like ligand 1 and Notch 1 receptor in various placental disorders with special reference to early onset preeclampsia

Notch signaling pathway has been shown to be dysregulated in placentas with preeclampsia, but there has been a lack of studies on methylation of Notch family genes in this disorder. We therefore executed methylation-specific polymerase chain reaction and immunostaining for Notch 1 receptor and the activating ligand, Delta-like (DLL) 1, with placental tissues from cases of preeclampsia (early onset, n = 18; late-onset, n = 19) and other placental disorders, including maternal complications such as diabetes mellitus and collagen disease (n = 10), fetal growth restriction (n = 17), fetal anomaly (n = 23), preterm birth (n = 15), miscarriage (n = 25), and hydatidiform moles (n = 9) as well as term births (n = 12). The frequency of DLL1 methylation was higher in early onset preeclamptic placentas (61%) than the other subjects (0%-36%; P ≤ .016). Appreciable samples (36%) of miscarriage also represented DLL1 methylation. None of the samples studied showed Notch 1 methylation. On gestational period-matched analysis, the rate of DLL1 methylation was higher in early onset preeclampsia (83.3%) than preterm birth (13.3%; P < .001), with no significant differences in clinical backgrounds between the two. In this analysis, increase of syncytial knots and accelerated villous maturation were most prominent in DLL1-methylated placentas with early onset preeclampsia. Notch 1 and DLL1 expressions in villous trophoblasts and endothelial cells were significantly lower in early onset preeclamptic placentas as compared with preterm birth controls. In conclusion, altered Notch signaling via methylation of DLL1 is likely involved in possible disease-related mechanisms of early onset preeclampsia. Alternatively, DLL1 methylation in early onset preeclampsia could be a manifestation of a lack of placental maturation, similar to miscarriage.

Prevention of cardiovascular risk in women who had hypertension during pregnancy after 36 weeks gestation

OBJECTIVE

To analyse preventive interventions of women with cardiovascular risk factors postpartum.

METHODS

3.5 years postpartum, women with history of hypertension in pregnancy were invited for a questionnaire, 1 year after a cardiovascular risk assessment.

RESULTS

Two hundred and fifty-seven women completed the questionnaire. At risk factor analyses, 35% had hypertension, 37% abnormal lipid- or glucose levels, 63% BMI ≥ 25 and 19% smoked. One year later, 36% of women with hypertension used anti-hypertensives, 0% of women with abnormal laboratory findings used anti-cholesterol and 1% anti-diabetes medication, 31% of the obese women achieved BMI reduction (≥ 5%), 42% of the women who smoked, quit.

CONCLUSION

A minority improved their risk profile.

Present status of clinical care for postpartum patients with hypertensive disorders of pregnancy in Japan: findings from a nationwide questionnaire survey

OBJECTIVE

To assess the present status of clinical care for postpartum patients with hypertensive disorders of pregnancy (HDP) in Japan.

METHODS

We conducted a nationwide questionnaire survey of obstetricians, internists and hypertension specialists and analyzed 686 valid responses.

RESULTS

Though HDP is widely known as a risk factor for subsequent hypertension and cardiovascular disease, over one-third of obstetricians terminated their postpartum follow-up of HDP patients without referring them to other departments.

CONCLUSION

It is important to establish an effective referral system, whereby patients with HDP can be smoothly transferred to primary care or a specialist physician after childbirth for long-term monitoring and management of blood pressure.

Moving beyond silos: How do we provide distributed personalized medicine to pregnant women everywhere at scale? Insights from PRE-EMPT

While we believe that pre-eclampsia matters-because it remains a leading cause of maternal and perinatal morbidity and mortality worldwide-we are convinced that the time has come to look beyond single clinical entities (e.g. pre-eclampsia, postpartum hemorrhage, obstetric sepsis) and to look for an integrated approach that will provide evidence-based personalized care to women wherever they encounter the health system. Accurate outcome prediction models are a powerful way to identify individuals at incrementally increased (and decreased) risks associated with a given condition. Integrating models with decision algorithms into mobile health (mHealth) applications could support community and first level facility healthcare providers to identify those women, fetuses, and newborns most at need of facility-based care, and to initiate lifesaving interventions in their communities prior to transportation. In our opinion, this offers the greatest opportunity to provide distributed individualized care at scale, and soon.

Exposure to experimental preeclampsia in mice enhances the vascular response to future injury

Cardiovascular disease (CVD) remains the leading killer of women in developed nations. One sex-specific risk factor is preeclampsia, a syndrome of hypertension and proteinuria that complicates 5% of pregnancies. Although preeclampsia resolves after delivery, exposed women are at increased long-term risk of premature CVD and mortality. Pre-existing CVD risk factors are associated with increased risk of developing preeclampsia but whether preeclampsia merely uncovers risk or contributes directly to future CVD remains a critical unanswered question. A mouse preeclampsia model was used to test the hypothesis that preeclampsia causes an enhanced vascular response to future vessel injury. A preeclampsia-like state was induced in pregnant CD1 mice by overexpressing soluble fms-like tyrosine kinase-1, a circulating antiangiogenic protein that induces hypertension and glomerular disease resembling human preeclampsia. Two months postpartum, soluble fms-like tyrosine kinase-1 levels and blood pressure normalized and cardiac size and function by echocardiography and renal histology were indistinguishable in preeclampsia-exposed compared with control mice. Mice were then challenged with unilateral carotid injury. Preeclampsia-exposed mice had significantly enhanced vascular remodeling with increased vascular smooth muscle cell proliferation (180% increase; P<0.01) and vessel fibrosis (216% increase; P<0.001) compared with control pregnancy. In the contralateral uninjured vessel, there was no difference in remodeling after exposure to preeclampsia. These data support a new model in which vessels exposed to preeclampsia retain a persistently enhanced vascular response to injury despite resolution of preeclampsia after delivery. This new paradigm may contribute to the substantially increased risk of CVD in woman exposed to preeclampsia.

Pre-eclampsia: an update

Pre-eclampsia remains the second leading direct cause of maternal death, >99 % of which occurs in less developed countries. Over 90 percent of the observed reduction in pre-eclampsia-related maternal deaths in the UK (1952-2008) occurred with antenatal surveillance and timed delivery. In this review, we discuss the pathogenesis, diagnostic criteria, disease prediction models, prevention and management of pre-eclampsia. The Pre-eclampsia Integrated Estimate of RiSk (PIERS) models and markers of angiogenic imbalance identify women at incremental risk for severe pre-eclampsia complications. For women at high risk of developing pre-eclampsia, low doses of aspirin (especially if started <17 weeks) and calcium are evidence-based preventative strategies; heparin is less so. Severe hypertension must be treated and the Control of Hypertension In Pregnancy (CHIPS) Trial (reporting: 2014) will guide non-severe hypertension management. Magnesium sulfate prevents and treats eclampsia; there is insufficient evidence to support alternative regimens. Pre-eclampsia predicts later cardiovascular disease; however, at this time we do not know what to do about it.

Higher filtration fraction in formerly early-onset preeclamptic women without comorbidity

Formerly preeclamptic women have an increased risk for developing end-stage renal disease, which has been attributed to altered renal hemodynamics and abnormalities in the renin-angiotensin-aldosterone system. Whether this is due to preeclampsia itself or to comorbid conditions is unknown. Renal hemodynamics and responsiveness to ANG II during low Na(+) intake (7 days, 50 mmol Na(+)/24 h) and high Na(+) (HS) intake (7 days, 200 mmol Na(+)/24 h) were studied in 18 healthy normotensive formerly early-onset preeclamptic women (fPE women) and 18 healthy control subjects (fHP women), all selected for absence of comorbidity. At the end of each diet, renal hemodynamics and blood pressure were measured before and during graded ANG II infusion. Both HS intake and former preeclampsia increased filtration fraction (FF) without an interaction between the two. FF was highest during HS intake in fPE women [0.31 ± 0.12 vs. 0.29 ± 0.11 in fHP women, generalized estimating equation analysis (body mass index corrected), P = 0.03]. The renal response to ANG II infusion was not different between groups. In conclusion, fPE women have a higher FF compared with fHP women. As this was observed in the absence of comorbidity, preeclampsia itself might exert long-term effects on renal hemodynamics. However, we cannot exclude the presence of prepregnancy alterations in renal function, which, in itself, lead to an increased risk for preeclampsia. In experimental studies, an elevated FF has been shown to play a pathogenic role in the development of hypertension and renal damage. Future studies, however, should evaluate whether the subtle differences in renal hemodynamics after preeclampsia contribute to the increased long-term renal risk after preeclampsia.

Cardiovascular disease risk in women with a history of spontaneous preterm delivery: A systematic review and meta-analysis

BACKGROUND

Increasing evidence suggests a relation between having had spontaneous preterm delivery and cardiovascular disease in the future. We performed a systematic review and meta-analysis to assess the relation between a history of spontaneous preterm delivery and risk of ischaemic heart disease (IHD), stroke or overall cardiovascular disease (CVD).

METHODS

We carried out a systematic search in Medline (from 1966 to 17 July 2014) and Embase (from 1980 to 17 July 2014). We included studies with a cohort design assessing the relation between spontaneous preterm delivery and fatal or nonfatal IHD, stroke, or overall CVD. IHD, stroke and CVD were assessed through linkage with national registries. Hazard ratios (HRs) were pooled using a random-effects model.

RESULTS

Of the 10 cohort studies included; sample sizes ranged from 3706 to 923,686 women and follow-up ranged from 12-35 years. Spontaneous preterm delivery was related to an increased risk of developing or dying from IHD (HR 1.38, 95% confidence interval (CI) 1.22-1.57), stroke (HR 1.71, 95% CI 1.53-1.91) and overall CVD (relative risk (HR) 2.01, 95% CI 1.52-2.65). All studies found a positive effect, although substantial between-study heterogeneity was found for IHD and CVD.

CONCLUSION

Spontaneous preterm delivery is an independent risk factor for the development of IHD, stroke and overall CVD.

Longitudinal changes in maternal corin and mid-regional proatrial natriuretic peptide in women at risk of pre-eclampsia

OBJECTIVE

Corin, an atrial natriuretic peptide-converting enzyme, has been found to promote trophoblast invasion and spiral artery remodeling. Yet, elevated maternal plasma atrial natriuretic peptide (ANP) and corin levels have been reported in pregnancies complicated by pre-eclampsia (PE). The aim of this study was to investigate longitudinal changes in maternal plasma levels of corin and mid-regional proatrial natriuretic peptide (MR-PANP) in pregnancies that develop PE and gestational hypertension (GH).

METHODS

This was a nested case-control study drawn from a larger prospective longitudinal study in singleton pregnancies identified as being at high risk for PE by screening at 11 + 0 to 13 + 6 weeks' gestation. Blood samples were taken every 4 weeks until delivery. Values were compared in pregnancies that developed preterm PE (requiring delivery before 37 weeks' gestation), term PE, GH and those that remained normotensive.

RESULTS

A total of 471 samples were analyzed from 122 women, including 85 that remained normotensive, 12 that developed GH, 13 term PE and 12 preterm PE. In the normotensive group, log10 corin levels were associated with gestational age (P < 0.01), whereas log10 MR-PANP levels were not. In the preterm-PE group, compared with the normotensive group, corin was significantly lower until 20 weeks' gestation (P = 0.001). In the GH and term-PE groups, corin did not differ significantly from the normotensive group (P = 0.637 and P = 0.161, respectively). Compared with the normotensive group, MR-PANP levels were significantly higher in the pregnancies that developed preterm PE and GH (P = 0.046 and P = 0.019, respectively), but not term PE (P = 0.467).

CONCLUSION

Maternal-plasma corin and MR-PANP could potentially be useful biomarkers for the prediction of preterm PE.

Anti-Müllerian Hormone as a marker of ovarian reserve in relation to cardio-metabolic health: a narrative review

The final hallmark of diminishing ovarian reserve is menopause, a state known to be inextricably linked to the deterioration of female cardiovascular health. The menopausal transition is associated with an increased risk of future cardiovascular morbidity and mortality, irrespective of chronological age. The aim of this narrative review is to identify studies investigating the association between Anti-Müllerian Hormone (AMH), a marker of ovarian reserve status, and factors of cardio-metabolic risk. Both for regularly cycling women and women with polycystic ovary syndrome (PCOS), current reports are conflicting and heterogeneous, with some indicating presence and others absence of a correlation between AMH and cardio-metabolic risk factors. The occurrence of hypertensive complications in pregnancy, known to increase the risk of later cardiovascular sequelae, is associated with reduced AMH levels in various study populations. Further research remains a prerequisite in order to further elucidate a possible common mechanism for ovarian and cardiovascular decline. More knowledge of the temporal or causal association between ovarian and cardiovascular decline may enable timely identification of women with increased risk of cardiovascular disease or early onset ovarian aging. Following this, AMH may in the future play a role beyond the scope of female reproduction.

Metabolic syndrome in preeclampsia women in gorgan

The aim of study was to assess the metabolic syndrome in preeclampsia women. The study was performed on 50 women. The metabolic syndrome prevalence was 66%. Serum glucose, triglyceride and LDL-cholesterol levels significantly were increased and HDL- cholesterol level significantly was decreased in metabolic syndrome patients. These patients showed high prevalence of components of the syndrome. Our results show the importance of dyslipidemia in preeclampsia in overweight and obese women. Preeclampsia and cardiovascular disease are important problems for the health of women. It may be useful to give a treat to people with a high-normal blood pressure in early pregnancy.

Leisure time physical activity and the risk of pre-eclampsia: a systematic review

Today, pre-eclampsia (PE) is one of the leading causes of maternal and perinatal morbidity and mortality. It has been proposed that leisure time physical activity (LTPA) is associated with a decreased risk of PE. The objective of this study was to perform a systematic literature review examining the association between LTPA before and/or during pregnancy and the risk of PE. A systematic search of the EMBASE and PUBMED databases from inception to November 17, 2011 was conducted by two independent reviewers. Only studies describing the association between the intensity or amount of LTPA before and/or during pregnancy and the risk of PE were included. A narrative synthesis of the results was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A quality assessment was performed using the Newcastle Ottawa Scale. Eleven studies were included. None of the studies found light- or moderate-intensity LTPA to be associated with PE. Three studies reported that vigorous-intensity LTPA before and/or during pregnancy may reduce the risk of PE. One study reported a reduced risk among women who participated in LTPA at least 25 times per month or more than 4 h per week. However, one study found an elevated risk of severe PE with high amounts of LTPA, defined as 4.5 h per week or more. Results are mixed, but high intensity LTPA before and/or during pregnancy or more than 4 h per week of LTPA may reduce the risk of PE. However, an urgent need remains for high-quality studies including different ethnicities to further explore this relationship.

Gene expression profile in cardiovascular disease and preeclampsia: a meta-analysis of the transcriptome based on raw data from human studies deposited in Gene Expression Omnibus

INTRODUCTION

Cardiovascular disease (CVD) and preeclampsia (PE) share common clinical features. We aimed to identify common transcriptomic signatures involved in CVD and PE in humans.

METHODS

Meta-analysis of individual raw microarray data deposited in GEO, obtained from blood samples of patients with CVD versus controls and placental samples from women with PE versus healthy women with uncomplicated pregnancies. Annotation of cases versus control samples was taken directly from the microarray documentation. Genes that showed a significant differential expression in the majority of experiments were selected for subsequent analysis. Hypergeometric gene list analysis was performed using Bioconductor GOstats package. Bioinformatic analysis was performed in PANTHER.

RESULTS

Seven studies in CVD and 5 studies in PE were eligible for meta-analysis. A total of 181 genes were found to be differentially expressed in microarray studies investigating gene expression in blood samples obtained from patients with CVD compared to controls and 925 genes were differentially expressed between preeclamptic and healthy placentas. Among these differentially expressed genes, 22 were common between CVD and PE.

DISCUSSION

Bioinformatic analysis of these genes revealed oxidative stress, p-53 pathway feedback, inflammation mediated by chemokines and cytokines, interleukin signaling, B-cell activation, PDGF signaling, Wnt signaling, integrin signaling and Alzheimer disease pathways to be involved in the pathophysiology of both CVD and PE. Metabolism, development, response to stimulus, immune response and cell communication were the associated biologic processes in both conditions. Gene set enrichment analysis showed the following overlapping pathways between CVD and PE: TGF-β-signaling, apoptosis, graft-versus-host disease, allograft rejection, chemokine signaling, steroid hormone synthesis, type I and II diabetes mellitus, VEGF signaling, pathways in cancer, GNRH signaling, Huntingtons disease and Notch signaling.

CONCLUSION

CVD and PE share same common traits in their gene expression profile indicating common pathways in their pathophysiology.

Synergistic effect of gestational hypertension and postpartum incident hypertension on cardiovascular health: a nationwide population study

BACKGROUND

Gestational hypertension (GH) is a common complication of pregnancy and is associated with increased risk of incident hypertension in later life (IH) and cardiovascular events. However, the interactive effect of GH and IH on postpartum cardiovascular health remains unclear.

METHODS AND RESULTS

A nationwide population-based study was conducted using 1 million individuals from the Taiwan National Health Insurance database. Records from 1998 to 2009 were used to identify 1260 pregnant women with GH and without previous cardiovascular disease. The control group comprised 5040 pregnant women without GH, matched for age and date of delivery. During the follow-up period (median duration, 5.8 years), 182 cardiovascular events developed. Women with GH had significantly higher risk of cardiovascular events (hazard ratio [95% CI], 2.44 [1.80 to 3.31]) and IH (8.29 [6.30 to 10.91]) than controls. Compared with women without GH and IH, there was a significantly higher risk of cardiovascular events for women without GH but with IH (relative risk [95% CI], 2.89 [1.27-6.58]), women with GH but without IH (1.66 [1.16-2.39]), and women with GH and IH (8.11 [5.36-12.30]). The synergy index was 2.91 (95% CI 1.11 to 7.59), suggesting a positive interaction between GH and IH.

CONCLUSIONS

GH increased the risk of subsequent IH. Women with both GH and IH were at a substantially higher cardiovascular risk than were women with either GH or IH. The synergistic adverse effect of GH and IH on postpartum cardiovascular health indicates that more attention should be paid to this special population.

Placental Nkx2-5 and target gene expression in early-onset and severe preeclampsia

OBJECTIVE

Preeclampsia (PE) affects 2-8% of pregnancies worldwide and is a significant source of maternal and neonatal morbidity and mortality. However, the mechanisms underlying PE are poorly understood and major questions regarding etiology and risk factors remain to be addressed. Our objective was to examine whether abnormal expression of the cardiovascular developmental transcription factor, Nkx2-5, was associated with early onset and severe preeclampsia (EOSPE).

METHODS

Using qPCR and immunohistochemical assay, we examined expression of Nkx2-5 and target gene expression in EOSPE and control placental tissue. We tested resulting mechanistic hypotheses in cultured cells using shRNA knockdown, qPCR, and western blot.

RESULTS

Nkx2-5 is highly expressed in racially disparate fashion (Caucasians > African Americans) in a subset of early EOSPE placentae. Nkx2-5 mRNA expression is highly correlated (Caucasians > African Americans) to mRNA expression of the preeclampsia marker sFlt-1, and of the Nkx2-5 target and RNA splicing factor, Sam68. Knockdown of Sam68 expression in cultured cells significantly impacts sFlt-1 mRNA isoform generation in vitro, supporting a mechanistic hypothesis that Nkx2-5 impacts EOSPE severity in a subset of patients via upregulation of Sam68 to increase sFlt-1 expression. Expression of additional Nkx2-5 targets potentially regulating metabolic stress response is also elevated in a racially disparate fashion in EOSPE.

CONCLUSIONS

Expression of Nkx2-5 and its target genes may directly influence the genesis and racially disparate severity, and define a mechanistically distinct subclass of EOSPE.

Preterm birth and long-term maternal cardiovascular health

PURPOSE

To investigate whether preterm birth (PTB) is associated with greater cardiovascular disease (CVD) risk in a longitudinal cohort.

METHODS

We examined differences in systolic blood pressure (SBP), diastolic blood pressure, insulin resistance (Homeostatic model assessment of insulin resistance), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein, triglycerides, C-reactive protein, and interleukin 6 at 3 years postpartum between women who delivered preterm (gestation <37 weeks; n = 54) versus term (≥37 weeks; n = 751) using multivariable linear regression. We also assessed relations with body mass index, weight change from prepregnancy, and waist circumference at 3 and 7 years postpartum.

RESULTS

Median age at enrollment was 33.9 years (range: 16.4-44.9). After adjusting for age, race, prepregnancy body mass index, parity, marital status, education, and SBP during early pregnancy, women with PTB had 3.99 mm Hg (95% confidence interval, 0.82-7.16) higher SBP and 7.01 mg/dL (1.54-12.50) lower HDL than those who delivered at term. The association with SBP was attenuated after accounting for hypertension before or during pregnancy (2.78 mm Hg [-0.30 to 5.87]). PTB was not related to other postpartum outcomes.

CONCLUSIONS

PTB is related to greater CVD risk by 3 years postpartum as indicated by higher SBP and lower HDL. Although these associations may be due to preexisting conditions exacerbated during pregnancy, PTB may flag high-risk women for more vigilant CVD monitoring and lifestyle interventions.

The mother--the long-term implications on metabolic and cardiovascular complications

There is cumulating evidence linking the occurrence of pregnancy complications, including miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, and fetal growth restriction, with increased future risk of type 2 diabetes mellitus, and hospitalization and death due to cardiovascular and cerebrovascular diseases. Such association is largely related to genetic predisposition and shared pathophysiological mechanisms and changes, which may precede the index pregnancy. Awareness of this association would allow identification of the at-risk women for implementation of preventive measures to reduce the recurrence risk of these complications and mitigate the future development of metabolic and cardiovascular diseases worldwide.

Concentrations of endothelial nitric oxide synthase, angiotensin-converting enzyme, vascular endothelial growth factor and placental growth factor in maternal blood and maternal metabolic status in pregnancy complicated by hypertensive disorders

Hypertensive disorders of pregnancy (HDPs) are associated with altered maternal metabolism, impaired perinatal outcome and increased risk for remote maternal complications. The aim of our study was to analyse associations between circulating levels of angiogenic factors and markers of oxidative stress and metabolic status in women with HDP. Forty-six women in singleton pregnancies complicated by HDP and 30 healthy controls were enrolled in a prospective observational study. Serum concentrations of endothelial nitric oxide synthase (eNOS), angiotensin-converting enzyme, vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) were measured in the third trimester and correlated with maternal anthropometrics and metabolic status. We found significantly lower eNOS levels in patients with severe hypertension vs controls, a strong association between eNOS and PlGF in the study group, a significant association between maternal prepregnancy body mass index (BMI) and VEGF levels and an inverse correlation between VEGF and PlGF. Maternal prepregnancy BMI was the only independent predictor for VEGF concentrations. We noted reduced levels of PlGF and eNOS and increased VEGF levels in women with severe hypertension/preeclampsia. First, different forms of HDP are associated with different alteration patterns in concentrations of angiogenic factors and markers of oxidative stress. Second, maternal prepregnancy BMI, but not body weight, is a significant predictor for VEGF levels in late pregnancy.

Concentrations of eNOS, VEGF, ACE and PlGF in maternal blood as predictors of impaired fetal growth in pregnancy complicated by gestational hypertension/preeclampsia

OBJECTIVES

To investigate into an association between circulating levels of vascular factors (VF: ACE, eNOS, PlGF and VEGF) and impaired fetal growth measured as a small for gestational age newborn (SGA) in women with gestational hypertension/preeclampsia.

METHODS

A prospective observational trial in 46 patients in singleton pregnancies. Concentrations of VF were compared between participants who delivered SGA versus non-SGA newborns.

RESULTS

only low levels of ACE were associated with significantly increased risk for SGA (for a cut-off value, LR: 1.4-3.6).

CONCLUSIONS

Circulating levels of VF are not sufficient predictors of SGA in pregnancies complicated by gestational hypertension/preeclampsia.

Baixo peso ao nascer em adolescentes e adultas jovens na Região Nordeste do Brasil

Objetivos: avaliar a associação entre as características sociodemográficas, do pré-natal e do parto de mães adolescentes e adultas jovens com o baixo peso ao nascer, em capitais e outros municípios da Região Nordeste do Brasil, no período de 2011 e 2012. Métodos: estudo transversal, de base hospitalar e nível regional, realizado em 2011 e 2012. As informações foram obtidas por meio de entrevista com a puérpera no pós-parto imediato e coletados dados dos prontuários maternos e dos recém-nascidos. Um modelo teórico conceitual foi estabelecido com três níveis de hierarquia e a variável dependente foi o baixo peso ao nascer (BPN). Resultados: do total de 3009 puérperas entrevistadas, 9,7% apresentaram conceptos com baixo peso. As puérperas que realizaram menos que seis consultas no pré-natal apresentaram uma chance 1,7 vezes maior de ter RN com baixo peso; ser primigesta aumentou a chance da ocorrência do BPN em 1,5 vezes; assim como a prematuridade que representou o principal fator de exposição, elevando em 21 vezes a chance desse desfecho. Conclusões: o estudo demonstrou alta frequência de baixo peso ao nascer entre mães adolescentes e adultas jovens, tendo como principais fatores associados o número insuficiente de consultas pré-natal, primigestação e prematuridade.

Biological indicators of the in-utero environment and their association with birth weight for gestational age

Birth weight for gestational age (BW/GA) has been associated with a risk of adverse health outcomes. Biological indices of pregnancy complications, maternal mid-pregnancy serum biomarkers and placental pathology may shed light on these associations, but at present, they are most often examined as single entities and offer little insight about overlap. In addition, these indices are typically assessed in relation to the extremes of the BW/GA distribution, leaving open the question of how they relate to the entire BW/GA distribution. Addressing issues such as these may help elucidate why postnatal health outcomes vary across the BW/GA continuum. In this study, we focused on a subset of women who participated in the Pregnancy Outcomes and Community Health Study (n = 1371). We examined BW/GA (i.e. gestational age and sex-referenced z-scores) in relation to obstetric complications, second trimester maternal serum screening results and histologic evidence of placental pathology along with maternal demographics, anthropometrics and substance use. In adjusted models, mean reductions in BW/GA z-scores were associated with preeclampsia (β = -0.70, 95% CI -1.04, -0.36), high maternal serum alpha fetoprotein (β = -0.28, 95% CI -0.43, -0.13), unconjugated estriol (β = -0.31/0.5 multiples of the median decrease, 95% CI -0.41, -0.21) and high levels of maternal obstructive vascular pathology in the placenta (β = -0.46, 95% CI -0.67, -0.25). The findings were similar when preterm infants, small-for-gestational age or large-for-gestational age infants were excluded. More research is needed to examine how the factors studied here might directly mediate or mark risk when evaluating the associations between BW/GA and postnatal health outcomes.