Preterm Delivery and Long-term Risk of Hypertension in Women

Patterns of Gestational Hypertension or Preeclampsia Across 2 Pregnancies in Relationship to Chronic Hypertension Development: A Retrospective Cohort Study

BACKGROUND

Gestational hypertension (GHTN) and preeclampsia are established risk indicators for chronic hypertension. While recurrence is associated with a greater risk, it is unclear whether there are differences in risk when these gestational complications occur for the first time in an earlier pregnancy versus first occurrence in a subsequent one. We hypothesized that the absence of recurrence reflects a transition toward a lower hypertension risk trajectory, whereas a new occurrence in a later pregnancy indicates a transition toward elevated risk.

METHODS AND RESULTS

We analyzed linked data in Quebec, Canada, from public health care insurance administrative databases and birth, stillbirth, and death registries. Our retrospective cohort study included mothers with 2 singleton deliveries between April 1990 and December 2012. The primary exposure was patterns of GHTN or preeclampsia across 2 pregnancies (GHTN/preeclampsia in neither, first only, second only, or both). The outcome was incident chronic hypertension. We performed an adjusted multivariable Cox regression analysis. Among 431 980 women with 2 singleton pregnancies, 27 755 developed hypertension during the follow-up period. Compared with those without GHTN/preeclampsia, those with GHTN/preeclampsia only in the first pregnancy had a 2.7-fold increase in hazards (95% CI, 2.6-2.8), those with GHTN/preeclampsia only in the second had a 4.9-fold increase (95% CI, 4.6-5.1), and those with GHTN/preeclampsia in both pregnancies experienced a 7.3-fold increase (95% CI, 6.9-7.6). Patterns and estimates were similar when we considered GHTN and preeclampsia separately.

CONCLUSIONS

The magnitude of hypertension risk is associated with the number and sequence of GHTN/preeclampsia-affected pregnancies. Considering both allows more personalized risk estimates.

Adverse Pregnancy Outcomes and Long-Term Mortality in Women

Importance

Women with adverse pregnancy outcomes, such as preterm delivery or preeclampsia, have higher future risks of cardiometabolic disorders; however, little is known about their long-term mortality risks. A better understanding of such risks is needed to facilitate early identification of high-risk women and preventive actions.

Objective

To determine long-term mortality risks associated with 5 major adverse pregnancy outcomes in a large population-based cohort of women.

Design, Setting, and Participants

This national cohort study in Sweden used the Swedish Medical Birth Register, containing prenatal and birth information for nearly all deliveries in Sweden since 1973, to identify women who had a singleton delivery during 1973 to 2015. All 2 195 667 such women with information for pregnancy duration and infant birth weight were included in the study. Data were analyzed from March to September 2023.

Exposure

Adverse pregnancy outcomes (preterm delivery, small for gestational age, preeclampsia, other hypertensive disorders, and gestational diabetes), identified from nationwide birth records.

Main Outcome and Measures

All-cause and cause-specific mortality through December 31, 2018. Cox regression was used to compute hazard ratios (HRs) for mortality associated with specific adverse pregnancy outcomes, adjusted for other maternal factors. Cosibling analyses assessed for confounding by shared familial (genetic or environmental) factors.

Results

In 56 million person-years of follow-up to a median (IQR) age of 52 (42-61) years, 88 055 women (4%) died (median [IQR] age at death, 59 [50-67] years). All 5 adverse pregnancy outcomes were independently associated with increased mortality. Across the entire follow-up (≤46 years after delivery), adjusted HRs for all-cause mortality associated with specific adverse pregnancy outcomes were as follows: gestational diabetes, 1.52 (95% CI, 1.46-1.58); preterm delivery, 1.41 (95% CI, 1.37-1.44); small for gestational age, 1.30 (95% CI, 1.28-1.32); other hypertensive disorders, 1.27 (95% CI, 1.19-1.37); and preeclampsia, 1.13 (95% CI, 1.10-1.16). All HRs remained significantly elevated even 30 to 46 years after delivery. These effect sizes were only partially (0%-45%) reduced after controlling for shared familial factors in cosibling analyses. Women who experienced multiple adverse pregnancy outcomes had further increases in risk. Several major causes of death were identified, including cardiovascular and respiratory disorders and diabetes.

Conclusions and Relevance

In this large national cohort study, women who experienced any of 5 major adverse pregnancy outcomes had increased mortality risks that remained elevated more than 40 years later. Women with adverse pregnancy outcomes need early preventive evaluation and long-term follow-up for detection and treatment of chronic disorders associated with premature mortality.

Adverse pregnancy outcomes and long-term risk of chronic kidney disease in women: national cohort and co-sibling study

BACKGROUND

Women with adverse pregnancy outcomes may have higher subsequent risk of chronic kidney disease, but the long-term independent risks and potential causality are unclear.

OBJECTIVE

This study aimed to determine long-term risks of chronic kidney disease associated with 5 major adverse pregnancy outcomes in a large population-based cohort, and to assess for familial confounding using co-sibling analyses.

STUDY DESIGN

A national cohort study was conducted of all 2,201,279 women with a singleton delivery in Sweden from 1973 to 2015, followed up for chronic kidney disease identified from nationwide diagnoses through 2018. Cox regression was used to compute hazard ratios for chronic kidney disease associated with preterm delivery, small for gestational age, preeclampsia, other hypertensive disorders, and gestational diabetes, adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for potential confounding by shared familial (genetic or environmental) factors.

RESULTS

In 56 million person-years of follow-up, 11,572 (0.5%) women were diagnosed with chronic kidney disease (median age, 61 years). All 5 adverse pregnancy outcomes were independently associated with increased chronic kidney disease risk. Within 10 years following delivery, adjusted hazard ratios associated with specific adverse pregnancy outcomes were: 7.12 for other hypertensive disorders (95% confidence interval, 5.88-8.62), 4.38 for preeclampsia (3.72-5.16), 3.50 for preterm delivery (2.95-4.15), 3.15 for gestational diabetes (2.53-3.92), and 1.22 for small for gestational age (1.02-1.44). All hazard ratios remained significantly elevated even 30 to 46 years after delivery (gestational diabetes, 3.32 [95% confidence interval, 2.96-3.72]; other hypertensive disorders, 2.44 [1.91-3.11]; preeclampsia, 2.03 [1.90-2.16]; preterm delivery, 1.56 [1.44-1.68]; and small for gestational age, 1.24 [1.16-1.31]). These findings were only partially (0%-45%) explained by shared familial factors. Women with multiple adverse pregnancy outcomes had further increases in risk.

CONCLUSION

In this large national cohort, women who experienced any of 5 major adverse pregnancy outcomes had increased risk for chronic kidney disease up to 46 years later. Women with adverse pregnancy outcomes need early preventive actions and long-term monitoring to reduce risk of chronic kidney disease.

Are fetal microchimerism and circulating fetal extracellular vesicles important links between spontaneous preterm delivery and maternal cardiovascular disease risk?

Trafficking and persistence of fetal microchimeric cells (fMCs) and circulating extracellular vesicles (EVs) have been observed in animals and humans, but their consequences in the maternal body and their mechanistic contributions to maternal physiology and pathophysiology are not yet fully defined. Fetal cells and EVs may help remodel maternal organs after pregnancy-associated changes, but the cell types and EV cargos reaching the mother in preterm pregnancies after exposure to various risk factors can be distinct from term pregnancies. As preterm delivery-associated maternal complications are rising, revisiting this topic and formulating scientific questions for future research to reduce the risk of maternal morbidities are timely. Epidemiological studies report maternal cardiovascular risk as one of the major complications after preterm delivery. This paper suggests a potential link between fMCs and circulating EVs and adverse maternal cardiovascular outcomes post-pregnancies, the underlying mechanisms, consequences, and methods for and how this link might be assessed.

The risk for venous thromboembolism and cardiometabolic disorders in offspring from thrombosis-prone pedigrees

BACKGROUND

Most family studies on venous thromboembolism (VTE) have focused on first-degree relatives.

OBJECTIVES

We took a pedigree-based approach and examined the risk of VTE and cardiometabolic disorders in offspring from extended pedigrees according to the densities of VTE in pedigrees.

METHODS

From the Swedish population, we identified a total of 482 185 pedigrees containing a mean of 14.2 parents, aunts/uncles, grandparents, and cousins of a core full sibship that we termed the pedigree offspring (n = 751 060). We then derived 8 empirical classes of these pedigrees based on the density of cases of VTE. The risk was determined in offspring for VTE and cardiometabolic disorders as a function of VTE density in their pedigrees. Bonferroni correction for multiple comparisons was performed.

RESULTS

VTE was unevenly distributed in the population; the Gini coefficient was 0.59. Higher VTE density in pedigrees was associated in the offspring with a higher risk of different VTE manifestations (deep venous thrombosis, pulmonary embolism, pregnancy-related VTE, unusual thrombosis, and superficial thrombophlebitis), thrombophilia, and lower age of first VTE event. Moreover, VTE density in pedigrees was significantly associated in the offspring with obesity, diabetes, gout, varicose veins, and arterial embolism and thrombosis (excluding brain and heart). No significant associations were observed for retinal vein occlusion, hypercholesterolemia, hypertension, coronary heart disease, myocardial infarction, ischemic stroke, atrial fibrillation, heart failure, primary pulmonary hypertension, cerebral hemorrhage, aortic aneurysm, peripheral artery disease, and overall mortality.

CONCLUSION

Offspring of pedigrees with a high density of VTE are disadvantaged regarding VTE manifestations and certain cardiometabolic disorders.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Association between preterm delivery and subsequent maternal risk of hypertension and type 2 diabetes mellitus in a UK population-based retrospective cohort study

OBJECTIVES

Women with a history of preterm delivery (PTD) are at higher risk of developing cardiovascular diseases (CVD) later in life. However, it is not well established whether PTD is associated with CVD risk factors, hypertension and type 2 diabetes mellitus (T2DM). Therefore, in this study, we examined the associations between PTD compared with term delivery and subsequent risk of hypertension and T2DM.

DESIGN

Retrospective matched population-based open cohort study.

SETTING

Clinical Practice Research Datalink GOLD data in the UK.

PARTICIPANTS

A total of 3335 18-49-year-old women with preterm delivery were matched by age and region to 12 634 without a record of preterm delivery.

PRIMARY OUTCOME MEASURES

Outcomes of interest were newly diagnosed hypertension or T2DM at least 6 months after delivery. During the study period (January 2000-December 2019), hypertension or T2DM events in the medical records of women with (exposed) and without (unexposed) preterm delivery were compared. HR and 95% CI were estimated using Cox proportional hazards models adjusted for potential confounders.

RESULTS

Over a median follow-up period of 5.11 (IQR 2.15-9.56) years, the HRs for hypertension in women who delivered preterm compared with women who delivered at term were 1.42 (95%CI 1.09 to 1.80) and 1.18 (95%CI 0.90 to 1.56) in the unadjusted and adjusted models, respectively. For T2DM, over a median follow-up period of 5.17 (IQR 2.18-9.67) years, the HRs in women who delivered preterm compared with those who delivered at term were 1.67 (95%CI 1.12 to 2.48) and 1.10 (95%CI 0.72 to 1.68) in the unadjusted and adjusted models, respectively.

CONCLUSION

We found no independent effect of preterm delivery on risk of hypertension or type 2 diabetes in this study. While significant associations were observed in unadjusted analyses, associations were lost after adjustment and may be attributable to other reproductive complications. Additional studies are needed to confirm these findings.

County-Level Maternal Vulnerability and Preterm Birth in the US

Importance

Appreciation for the effects of neighborhood conditions and community factors on perinatal health is increasing. However, community-level indices specific to maternal health and associations with preterm birth (PTB) have not been assessed.

Objective

To examine the association of the Maternal Vulnerability Index (MVI), a novel county-level index designed to quantify maternal vulnerability to adverse health outcomes, with PTB.

Design, Setting, and Participants

This retrospective cohort study used US Vital Statistics data from January 1 to December 31, 2018. Participants included 3 659 099 singleton births at 22 plus 0/7 to 44 plus 6/7 weeks of gestation born in the US. Analyses were conducted from December 1, 2021, through March 31, 2023.

Exposure

The MVI, a composite measure of 43 area-level indicators, categorized into 6 themes reflecting physical, social, and health care landscapes. Overall MVI and theme were stratified by quintile (very low to very high) by maternal county of residence.

Main Outcomes and Measures

The primary outcome was PTB (gestational age <37 weeks). Secondary outcomes were PTB categories: extreme (gestational age ≤28 weeks), very (gestational age 29-31 weeks), moderate (gestational age 32-33 weeks), and late (gestational age 34-36 weeks). Multivariable logistic regression quantified associations of MVI, overall and by theme, with PTB, overall and by PTB category.

Results

Among 3 659 099 births, 298 847 (8.2%) were preterm (male, 51.1%; female, 48.9%). Maternal race and ethnicity included 0.8% American Indian or Alaska Native, 6.8% Asian or Pacific Islander, 23.6% Hispanic, 14.5% non-Hispanic Black, 52.1% non-Hispanic White, and 2.2% with more than 1 race. Compared with full-term births, MVI was higher for PTBs across all themes. Very high MVI was associated with increased PTB in unadjusted (odds ratio [OR], 1.50 [95% CI, 1.45-1.56]) and adjusted (OR, 1.07 [95% CI, 1.01-1.13]) analyses. In adjusted analyses of PTB categories, MVI had the largest association with extreme PTB (adjusted OR, 1.18 [95% CI, 1.07-1.29]). Higher MVI in the themes of physical health, mental health and substance abuse, and general health care remained associated with PTB overall in adjusted models. While the physical health and socioeconomic determinant themes were associated with extreme PTB, physical health, mental health and substance abuse, and general health care themes were associated with late PTB.

Conclusions and Relevance

The findings of this cohort study suggest that MVI was associated with PTB even after adjustment for individual-level confounders. The MVI is a useful measure for county-level PTB risk that may have policy implications for counties working to lower preterm rates and improve perinatal outcomes.

Women's Reproductive Milestones and Cardiovascular Disease Risk: A Review of Reports and Opportunities From the CARDIA Study

In 1985 to 1986, the CARDIA (Coronary Artery Risk Development in Young Adults) study enrolled 5115 Black or White participants, including 2788 women, aged 18 to 30 years. Over the following 35 years, the CARDIA study amassed extensive longitudinal data on women's reproductive milestones, spanning menarche to menopause. Although not initially conceived as a study of women's health, >75 CARDIA study publications address relationships between reproductive factors and events with cardiovascular and metabolic risk factors, subclinical and clinical cardiovascular disease, and social determinants of health. The CARDIA study was one of the earliest population-based reports to note Black-White differences in age at menarche and associations with cardiovascular risk factors. Adverse pregnancy outcomes, particularly gestational diabetes and preterm birth, have been assessed along with postpartum behaviors, such as lactation. Existing studies have examined risk factors for adverse pregnancy outcomes and lactation, as well as their relationship to future cardiovascular and metabolic risk factors, diagnoses, and subclinical atherosclerosis. Ancillary studies examining components of polycystic ovary syndrome and ovarian biomarkers, such as anti-Müllerian hormone, have facilitated examination of reproductive health in a population-based cohort of young adult women. As the cohort transitioned through menopause, examination of the importance of premenopausal cardiovascular risk factors along with menopause has improved our understanding of shared mechanisms. The cohort is now aged in the 50s to mid-60s, and women will begin to experience a greater number of cardiovascular events as well as other conditions, such as cognitive impairment. Thus, in the next decade, the CARDIA study will provide a unique resource for understanding how the women's reproductive life course epidemiology informs cardiovascular risk, as well as reproductive and chronological aging.

Markers of Cardiovascular Risk Associated with Pregnancy

PURPOSE OF REVIEW

The purpose of the review is to summarize the unique cardiovascular disease (CVD) risk factors encountered during pregnancy and to provide the reader with a framework for acquiring a comprehensive obstetric history during the cardiovascular (CV) assessment of women.

RECENT FINDINGS

Individuals with a history of pregnancies complicated by hypertensive disorders of pregnancy (HDP), gestational diabetes (GDM), preterm delivery, low birth weight, and fetal growth restriction during pregnancy are at a higher risk of developing short- and long-term CV complications compared to those without adverse pregnancy outcomes (APOs). Women with a history of APOs can be at increased risk of CVD even after achieving normoglycemia and normal blood pressure control postpartum. Risk assessment and stratification in women must account for these APOs as recommended by the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the primary prevention of CVD. Early recognition, monitoring, and treatment of APOs are key to limiting CVD complications late in maternal life. Recognition of APOs as female-specific cardiovascular risk factors is critical for risk stratification for women and birthing persons. Further research is needed to understand the complex interplay between genetics, environmental, behavioral, and maternal vascular health, and the association between APOs and CVD risk.

Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers: national cohort and co-sibling study

OBJECTIVE

To examine the associations between five major adverse pregnancy outcomes and long term risks of ischemic heart disease in mothers.

DESIGN

National cohort study.

SETTING

Sweden.

PARTICIPANTS

All 2 195 266 women with a first singleton delivery in Sweden during 1973-2015.

MAIN OUTCOME MEASURES

The main outcome measure was incidence of ischemic heart disease from delivery to 2018, identified from nationwide inpatient and outpatient diagnoses. Cox regression was used to calculate hazard ratios for ischemic heart disease associated with preterm delivery, small for gestational age, pre-eclampsia, other hypertensive disorders of pregnancy, and gestational diabetes, adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and environmental) factors.

RESULTS

During 53.6 million person years of follow-up, ischemic heart disease was diagnosed in 83 881 (3.8%) women. All five adverse pregnancy outcomes were independently associated with increased risk of ischemic heart disease. In the 10 years after delivery, adjusted hazard ratios for ischemic heart disease associated with specific adverse pregnancy outcomes were 2.09 (95% confidence interval 1.77 to 2.46) for other hypertensive disorders of pregnancy, 1.72 (1.55 to 1.90) for preterm delivery, 1.54 (1.37 to 1.72) for pre-eclampsia, 1.30 (1.09 to 1.56) for gestational diabetes, and 1.10 (1.00 to 1.21) for small for gestational age. The hazard ratios remained significantly increased even 30-46 years after delivery: 1.47 (1.30 to 1.66) for other hypertensive disorders of pregnancy, 1.40 (1.29 to 1.51) for gestational diabetes, 1.32 (1.28 to 1.36) for pre-eclampsia, 1.23 (1.19 to 1.27) for preterm delivery, and 1.16 (1.13 to 1.19) for small for gestational age. These findings were only partially (<45%) explained by shared familial (genetic or environmental) factors. Women who experienced multiple adverse pregnancy outcomes showed further increases in risk (eg, <10 years after delivery, adjusted hazard ratios associated with 1, 2, or ≥3 adverse pregnancy outcomes were 1.29 (1.19 to 1.39), 1.80 (1.59 to 2.03), and 2.26 (1.89 to 2.70), respectively)).

CONCLUSIONS

In this large national cohort, women who experienced any of five major adverse pregnancy outcomes showed an increased risk for ischemic heart disease up to 46 years after delivery. Women with adverse pregnancy outcomes should be considered for early preventive evaluation and long term risk reduction to help prevent the development of ischemic heart disease.

Sociodemographic disparities in preterm birth and low birthweight in the State of Georgia: Results from the 2017-2018 Pregnancy Risk Assessment Monitoring System

PURPOSE

To update the overall prevalence of preterm birth (PTB) (<37 weeks gestation) and low birthweight (LBW) (<2,500 g) in the State of Georgia, including rural and urban counties.

METHODS

A sample was drawn from the 2017-2018 Georgia Pregnancy Risk Assessment Monitoring System (PRAMS). In the complete-case data of singleton births (n=1,258), we estimated the weighted percentage prevalence of PTB, LBW, early/late PTB, and moderately/very LBW subcategories in association with maternal sociodemographic characteristics, and the prevalence stratified by rural/urban county of residence. Univariate and multivariate logistic regression models were fitted to estimate the odds ratios (ORs) of PTB and LBW adjusting for selected covariates. Logistic regression results from multiple imputation by chained equations (MICE) were used for comparison.

FINDINGS

The overall rate for PTB was 9.3% and 6.8% for LBW and among them, 2.3% were early PTB, 7.0% were late PTB, 5.4% were moderately LBW (MLBW), and 1.3% were very LBW (VLBW). Non-Hispanic Black women had the highest prevalence of PTB, LBW, early PTB, MLBW, and VLBW, as well as PTB and LBW in urban counties and LBW in rural counties. The odds of PTB (aOR 1.38; 95% CI: 0.81, 2.35) and LBW (aOR 2.68; 95% CI: 1.32, 5.43) were also higher among non-Hispanic Black relative to non-Hispanic White women and among women who received adequate-plus prenatal care compared to inadequate prenatal care.

CONCLUSIONS

Socioeconomic and health disparities created by disadvantage should be a focus of state policy to improve neonatal outcomes in the State of Georgia.

Adverse Maternal and Delivery Outcomes in Children and Very Young (Age ≤13 Years) US Adolescents Compared With Older Adolescents and Adults

This study uses a US claims database to compare morbidity and delivery outcomes among pregnant 10- to 13-year-olds vs 14- to 17-year-olds and 18- to 19-year-olds.

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

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

Preterm Delivery Is a Lifelong Risk Factor for Hypertension

According to this study: Compared with women who delivered full term, those who had a preterm delivery or an extremely preterm delivery had a more than 1.6-fold risk and 2.2-fold risk of hypertension, respectively, within the next 10 years, even after adjustment for potential confounders.Early evaluation and long-term risk reduction and monitoring for hypertension are recommended for women who have a history of preterm delivery.