Hypertensive disorders during pregnancy and risk of type 2 diabetes in later life: a systematic review and meta-analysis

Adverse pregnancy outcomes, familial predisposition, and cardiovascular risk: a Swedish nationwide study

BACKGROUND AND AIMS

Adverse pregnancy outcomes (APOs) are recognized as significant female-specific risk factors for cardiovascular disease (CVD). A potential shared familial susceptibility between APOs and CVD has been proposed, but not thoroughly explored. This study employs a quasi-experimental family comparison design to investigate shared familial predisposition between APOs and CVD, by assessing risk of CVD in APO-exposed women and their APO-free sisters.

METHODS

Nationwide population-based cohort study encompassing primiparous women, without prior CVD, with registered singleton births in the Swedish Medical Birth Register between 1992 and 2019, grouped into: women with ≥1 APO (165 628), APO-free sisters (60 769), and unrelated APO-free comparator women (992 108). All study participants were followed longitudinally, through linkage with national health registers, from delivery until 2021, for primary endpoint major adverse cardiac events, and its individual components: ischaemic heart disease, heart failure, and cerebrovascular events.

RESULTS

Over a median follow-up of 14 years, APO-exposed women exhibited increased rates of CVDs compared with APO-free comparators. Adverse pregnancy outcome-free sisters exhibited elevated adjusted hazard ratios (aHRs) of major adverse cardiac event {aHR 1.39 [95% confidence interval (CI) 1.13-1.71]}, heart failure [aHR 1.65 (95% CI 1.14-2.39)], and cerebrovascular events [aHR 1.37 (1.04-1.72)] compared with the APO-free comparators, while no significant increase in ischaemic heart disease was observed. Within-family analysis revealed lower CVD rates in APO-free sisters compared with their APO-exposed counterparts, except for no significant difference in cerebrovascular events.

CONCLUSIONS

Sisters of women with APOs face a moderately increased risk of CVD, suggesting a genetic and/or environmental influence on the association between APOs and CVDs. These findings underscore the need for evaluating the effectiveness of targeted preventive measures in women with APOs and their sisters.

Long-Term Risk of Type 2 Diabetes After Preterm Delivery or Hypertensive Disorders of Pregnancy

OBJECTIVE

To examine long-term diabetes risk after preterm delivery or hypertensive disorders of pregnancy in a large population-based cohort.

METHODS

This retrospective cohort study included all women with a singleton delivery in Sweden during 1973-2015 and no preexisting diabetes mellitus. Participants were followed up for development of type 2 diabetes identified from nationwide outpatient and inpatient diagnoses through 2018. Cox regression was used to compute hazard ratios (HRs) for the association between preterm delivery or hypertensive disorders of pregnancy and type 2 diabetes with adjustment for gestational diabetes and other maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic or environmental) factors.

RESULTS

Overall, 2,184,417 women were included. Within 10 years after delivery, adjusted HRs for type 2 diabetes associated with specific pregnancy outcomes were as follows: any preterm delivery (before 37 weeks of gestation), 1.96 (95% CI, 1.83-2.09); extremely preterm delivery (22-27 weeks), 2.53 (95% CI, 2.03-3.16); and hypertensive disorders of pregnancy, 1.52 (95% CI, 1.43-1.63). All HRs remained significantly elevated (1.1-1.7-fold) 30-46 years after delivery. These findings were largely unexplained by shared familial factors.

CONCLUSION

In this large national cohort, preterm delivery and hypertensive disorders of pregnancy were associated with increased risk for type 2 diabetes up to 46 years later. Women with these pregnancy complications are candidates for early preventive actions and long-term monitoring for type 2 diabetes.

Impact of different types of hypertensive disorders of pregnancy and their duration on incident post-partum risk of diabetes mellitus: Results from the French nationwide study CONCEPTION

AIMS

To evaluate the impact of onset time, duration, and severity of various types of hypertensive disorders of pregnancy (HDP) on the risk of incident DM.

METHODS

We used data from the ongoing French nationwide prospective cohort study CONCEPTION. We included all primiparous women in CONCEPTION who delivered between 2010 and 2018 (n = 2,816,793 women). Follow-up spanned from childbirth to 31 December 2021. HDP and incident DM onset during follow-up were identified using algorithms combining ICD-10 coded diagnoses during hospitalization and/or medication dispensing. We used Cox models to assess the associations between incident DM and preexisting chronic hypertension, gestational hypertension (GH), and various phenotypes of pre-eclampsia.

RESULTS

Pre-eclampsia and GH alone occurred in 2.6 % and 4.6 % of the population, respectively. During follow-up (mean = 4.5 years), 16,670 women had incident DM. The cumulative incidences of DM were 15.8 % and 1.8 % in women who had pre-eclampsia during pregnancy with and without concomitant gestational diabetes, respectively. The risk of DM was higher after HDP (all types) irrespective of gestational diabetes status during pregnancy. In women without gestational diabetes, compared with those who had no HDP, the risk of incident DM was higher in women who had GH (adjusted hazard ratio, aHR = 1.97 [1.81-2.16]), pre-eclampsia (aHR = 2.42 [2.21-2.65]), and preexisting chronic hypertension prior to pregnancy (aHR = 3.35 [3.03-3.70]). Pre-eclampsia duration was significantly associated with a higher risk of DM.

CONCLUSION

Women who experienced an HDP had twice the risk of developing DM. Early blood glucose assessment and blood pressure monitoring should be more widely recommended after HDP diagnosis.

Preeclampsia-Associated Cardiovascular Risk Factors 6 Months and 2 Years After Pregnancy: The P4 Study

BACKGROUND

Increased cardiovascular risk following preeclampsia is well established and there are signs of early cardiovascular aging 6 months postpartum. This study assessed whether blood pressure (BP) and other cardiovascular measures are abnormal 2 years postpartum in the same cohort to determine ongoing risk markers.

METHODS

Six months and 2 years postpartum, BP was measured using sphygmomanometry, 24-hour ambulatory BP monitoring, and noninvasive central BP. Anthropometric measures, blood, and urine biochemistry were performed. Cross-sectional comparisons between preeclampsia and normotensive pregnancy (NP) groups and longitudinal comparisons within each group were made at 6 months and 2 years.

RESULTS

Two years postpartum, 129 NP, and 52 preeclampsia women were studied who also had 6 months measures. At both time points, preeclampsia group had significantly higher BP (office BP 2 years, 112±12/72±8 versus 104±9/67±7 mm Hg NP; [P<0.001]; mean ambulatory BP monitoring 116±9/73±8 versus 106±8/67±6 mm Hg NP; [P<0.001]). No significant BP changes noted 6 months to 2 years within either group. Office BP thresholds of 140 mm Hg systolic and 90 mm Hg diastolic classified 2% preeclampsia and 0% NP at 2 years. American Heart Association 2017 criteria (above normal, >120/80 mm Hg) classified 25% versus 8% (P<0.002), as did our reference range threshold of 122/79 mm Hg. American Heart Association criteria classified 60% post-preeclampsia versus 16% after NP with above-normal ambulatory BP monitoring (P<0.001). Other cardiovascular risk markers more common 2 years post-preeclampsia included higher body mass index (median 26.6 versus 23.1, P=0.003) and insulin resistance.

CONCLUSIONS

After preeclampsia, women have significantly higher BP 6 months and 2 years postpartum, and have higher body mass index and insulin-resistance scores, increasing their future cardiovascular risk. Regular cardiovascular risk screening should be implemented for all who have experienced preeclampsia.

Association between pregnancy-related complications and development of type 2 diabetes and hypertension in women: an umbrella review

BACKGROUND

Despite many systematic reviews and meta-analyses examining the associations of pregnancy complications with risk of type 2 diabetes mellitus (T2DM) and hypertension, previous umbrella reviews have only examined a single pregnancy complication. Here we have synthesised evidence from systematic reviews and meta-analyses on the associations of a wide range of pregnancy-related complications with risk of developing T2DM and hypertension.

METHODS

Medline, Embase and Cochrane Database of Systematic Reviews were searched from inception until 26 September 2022 for systematic reviews and meta-analysis examining the association between pregnancy complications and risk of T2DM and hypertension. Screening of articles, data extraction and quality appraisal (AMSTAR2) were conducted independently by two reviewers using Covidence software. Data were extracted for studies that examined the risk of T2DM and hypertension in pregnant women with the pregnancy complication compared to pregnant women without the pregnancy complication. Summary estimates of each review were presented using tables, forest plots and narrative synthesis and reported following Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines.

RESULTS

Ten systematic reviews were included. Two pregnancy complications were identified. Gestational diabetes mellitus (GDM): One review showed GDM was associated with a 10-fold higher risk of T2DM at least 1 year after pregnancy (relative risk (RR) 9.51 (95% confidence interval (CI) 7.14 to 12.67) and although the association differed by ethnicity (white: RR 16.28 (95% CI 15.01 to 17.66), non-white: RR 10.38 (95% CI 4.61 to 23.39), mixed: RR 8.31 (95% CI 5.44 to 12.69)), the between subgroups difference were not statistically significant at 5% significance level. Another review showed GDM was associated with higher mean blood pressure at least 3 months postpartum (mean difference in systolic blood pressure: 2.57 (95% CI 1.74 to 3.40) mmHg and mean difference in diastolic blood pressure: 1.89 (95% CI 1.32 to 2.46) mmHg). Hypertensive disorders of pregnancy (HDP): Three reviews showed women with a history of HDP were 3 to 6 times more likely to develop hypertension at least 6 weeks after pregnancy compared to women without HDP (meta-analysis with largest number of studies: odds ratio (OR) 4.33 (3.51 to 5.33)) and one review reported a higher rate of T2DM after HDP (hazard ratio (HR) 2.24 (1.95 to 2.58)) at least a year after pregnancy. One of the three reviews and five other reviews reported women with a history of preeclampsia were 3 to 7 times more likely to develop hypertension at least 6 weeks postpartum (meta-analysis with the largest number of studies: OR 3.90 (3.16 to 4.82) with one of these reviews reporting the association was greatest in women from Asia (Asia: OR 7.54 (95% CI 2.49 to 22.81), Europe: OR 2.19 (95% CI 0.30 to 16.02), North and South America: OR 3.32 (95% CI 1.26 to 8.74)).

CONCLUSIONS

GDM and HDP are associated with a greater risk of developing T2DM and hypertension. Common confounders adjusted for across the included studies in the reviews were maternal age, body mass index (BMI), socioeconomic status, smoking status, pre-pregnancy and current BMI, parity, family history of T2DM or cardiovascular disease, ethnicity, and time of delivery. Further research is needed to evaluate the value of embedding these pregnancy complications as part of assessment for future risk of T2DM and chronic hypertension.

Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.

Effect of hypertensive disorders of pregnancy on pubertal development in daughters and sons: a systematic review and meta-analysis

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal and offspring morbidity and mortality worldwide. Several studies in recent years have focused on the link between HDP and pubertal development in offspring. The goal of this study was to synthesize the published literature on the effect of HDP on pubertal development in offspring by a systematic review and meta-analysis (PROSPERO 2021: CRD42020148736). A systematic literature search of several databases was conducted through December 2021, focusing on studies reporting pubertal development in offspring of women with and without HDP exposure. Primary outcomes of interest included offspring body mass index (BMI), height, waist and hip circumference, fat mass, pubarche, thelarche, and age at menarche. A total of 21 studies were finally included. Significantly higher values of BMI (SMD: 0.16 [0.11, 0.22]; p < 0.01) and waist circumference (SMD: 0.21 [0.14, 0.29]; p < 0.01) were found in offspring exposed to maternal HDP. In addition, a tendency of the early development of secondary sexual characteristics only in daughters was presented in offspring whose mothers were diagnosed with HDP. The findings imply a possible effect of HDP on pubertal development in offspring, especially for their BMI and waist circumference, which highlights the importance of focusing on adolescent developmental abnormalities in offspring exposed to HDP.

Economic Evaluation of Prenatal and Postpartum Care in Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review

OBJECTIVES

This study aimed to summarize evidence on the economic outcomes of prenatal and postpartum interventions for the management of gestational diabetes mellitus and hypertensive disorders of pregnancy (HDP), assess the quality of each study, and identify research gaps that may inform future research.

METHODS

Electronic databases including PubMed/MEDLINE, Embase, the Cochrane Library, and Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to October 1, 2021. Selected studies were included in narrative synthesis and extracted data were presented in narrative and tabular forms. The quality of each study was assessed using the Consolidated Health Economic Evaluation Reporting Standards and Consensus on Health Economic Criteria list.

RESULTS

Among the 22 studies identified through the systematic review, 19 reported favorable cost-effectiveness of the intervention. For prenatal management of HDP, home blood pressure monitoring was found to be cost-effective compared with in-person visits in improving maternal and neonatal outcomes. For postpartum care, regular screening for hypertension or metabolic syndrome followed by subsequent treatment was found to be cost-effective compared with no screening in women with a history of gestational diabetes mellitus or HDP.

CONCLUSIONS

Existing economic evaluation studies showed that prenatal home blood pressure monitoring and postpartum screening for hypertension or metabolic syndrome were cost-effective. Nevertheless, limitations in the approach of the current economic evaluations may dampen the quality of the evidence and warrant further investigation.

Gestational diabetes mellitus and hypertensive disorder of pregnancy play as spouse-pair risk factors of diabetes and hypertension: Insights from Tehran Lipid and Glucose Study

BACKGROUND

Complicated pregnancies by gestational diabetes mellitus (GDM) and hypertensive disorder of pregnancy (HDP) are relatively common worldwide. The evidence is still inconclusive regarding the role of GDM and HDP as spousal risk factor of diabetes (DM) and hypertension (HTN). This study aimed to determine the spousal risk of development of DM and/or HTN in the context of GDM and/or HDP.

METHODS

This population-based cohort study involved couples who participated in Tehran Lipid and Glucose Study. A total of 3650 pairs of spouses were identified, and among them, 2820 met the inclusion criteria. Included participants, followed up 3-year intervals visits from 1999 to 2018. All pairs underwent standard data collection. GDM and HDP were the main exposure of interest in females, and DM and HTN were the main outcomes in both females and their spouses. Cox proportional hazard regression models were used for both females and their spouses, adjusting for age, consanguinity, waist-to-height ratio, physical activity, smoking, and parity.

RESULTS

Of 2820 females, 558 (19.79 %) had histories of GDM or HDP, and 72 (2.55 %) experienced both. Among females who experienced GDM and HDP, 24 (33 %) and 31 (33 %) developed DM and HTN during the follow-up. The corresponding numbers were 89 (16 %) and 191 (34 %) for those who experienced GDM or HPD, and 274 (13 %) and 623 (28 %) for the non-risk factors group. The incidences of DM were 9 (12 %), 100 (18 %), and 373 (17 %) for males whose spouses experienced both GDM and HDP, either one or none of them, respectively. Among males in these groups, 20 (28 %), 150 (27 %), and 630 (29 %) developed HTN, respectively. Females who never had history of GDM and HDP have 34 % (95 % CI: 21, 45) less hazard of being diabetic than their spouses if they have the same age and waist to hip ratio. In cases with histories of both GDM and HDP, the risk of females increases to 3.05 (95 % CI: 1.43, 6.52) times of their spouses. Also, females who had experienced GDM (HR: 3.51, 95 % CI: 2.23, 5.53), or HDP (HR: 2.80, 95 % CI: 1.72, 4.56) were at higher risk of developing DM compared with females who never had GDM or HDP. We found that females with neither GDM nor HDP were more likely than males to be hypertensive in the future by the hazard ratio of 1.21 (95 % CI: 1.06, 1.39).

CONCLUSIONS

Complicated pregnancies by GDM and/or HDP were associated with increased risk of development DM and HTN in later life of females and their spouses. Further studies are required to confirm these results. Preventive care programs should be considered pregnancy complications as couple-based risk factors for subsequent DM and HTN.

Sex differences in hypertension. Do we need a sex-specific guideline?

Hypertension is the most prevalent cardiovascular disorder and the leading cause of death worldwide in both sexes. The prevalence of hypertension is lower in premenopausal women than in men of the same age, but sharply increases after the menopause, resulting in higher rates in women aged 65 and older. Awareness, treatment, and control of hypertension are better in women. A sex-pooled analysis from 4 community-based cohort studies found increasing cardiovascular risk beginning at lower systolic blood pressure thresholds for women than men. Hormonal changes after the menopause play a substantial role in the pathophysiology of hypertension in postmenopausal women. Female-specific causes of hypertension such as the use of contraceptive agents and assisted reproductive technologies have been identified. Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality, as well as with a greater risk of developing cardiovascular disease later in life. Hypertension-mediated organ damage was found to be more prevalent in women, thus increasing the cardiovascular risk. Sex differences in pharmacokinetics have been observed, but their clinical implications are still a matter of debate. There are currently no sufficient data to support sex-based differences in the efficacy of antihypertensive treatment. Adverse drug reactions are more frequently reported in women. Women are still underrepresented in large clinical trials in hypertension, and not all of them report sex-specific results. Therefore, it is of utmost importance to oblige scientists to include women in clinical trials and to consider sex as a biological variable.

Sodium ozagrel and atorvastatin for type 2 diabetes patients with lacunar cerebral infarction

BACKGROUND

The main pathological factor of cerebral infarction is atherosclerosis, which is the pathological process of chronic inflammatory diseases such as vascular smooth muscle hyperplasia, inflammatory cell infiltration, extracellular matrix increase, and thrombosis. At present, the focus of clinical treatment is anti-platelet aggregation and improving blood status, and current research is limited to improving symptoms only.

AIM

To observe the effect of sodium ozagrel and atorvastatin on type 2 diabetes patients with lacunar cerebral infarction.

METHODS

Eighty-two patients with type 2 diabetes and lacunar cerebral infarction admitted to our hospital from January 2018 to February 2020 were equally categorized into two groups according to their treatment method. The control group was administered atorvastatin, and the observation group was administered sodium ozagrel combined with atorvastatin. The National Institutes of Health stroke scale (NIHSS) score, activities of daily living (ADL) score, blood glucose, lipid levels, inflammatory factors, high-mobility group box 1 (HMGB1) levels, paraoxonase-1 (PON-1) levels, erythrocyte sedimentation rate (ESR), and macrophage migration inhibitory factor (MIF) levels were recorded before and after treatment. The total effective rate and adverse reaction rate of the two groups were analyzed.

RESULTS

The total effective rate of the observation group (94.00%) was significantly higher than that of the control group (80.00%) (χ² = 3.998; P = 0.046). The blood glucose indexes, total cholesterol levels, triglyceride levels, low-density lipoprotein cholesterol levels, high-sensitivity C-reactive protein levels, interleukin-1β levels, tumor necrosis factor-α levels, HMGB1 Levels, ESR, MIF levels, platelet aggregation rates, and plasma viscosity of the two groups decreased after treatment; however, high-density lipoprotein cholesterol and PON-1 Levels increased after treatment. After treatment, the blood glucose indexes; blood lipid indexes; inflammatory factors; HMGB1, PON-1, and MIF levels; ESR; platelet aggregation rate; and plasma viscosity of the observation group were better than those of the control group (P < 0.05). After treatment, all patients in the observation group had higher ADL scores and lower NIHSS scores than those in the control group (P < 0.05).

CONCLUSION

Sodium ozagrel with atorvastatin can reduce inflammatory reactions; regulate ESR and HMGB1, PON-1, and MIF levels; control blood glucose and lipid indexes; and alleviate nerve injury without increasing adverse effects of atorvastatin alone.

Long-term consequences of previous preeclampsia and complicated pregnancy: analysis of echocardiographic aspects

AIM

To evaluated echocardiographic aspects in women with history of preeclampsia or preeclampsia-related complications in their previous pregnancies.

MATERIALS AND METHODS

Consecutive women receiving echocardiography during daily clinical echolab activity were studied using complete echocardiographic examination data and anamnestic data collection of hypertension, diabetes, dyslipidemia, and rheumatic diseases. Studied women should have at least one pregnancy in more than the 10 past years, and were subdivided into two groups according to the history of complicated or physiological pregnancy. Complicated pregnancies were defined by preeclampsia or preeclampsia-related complication, such as preterm delivery or small-for-gestational age newborn. Echocardiographic parameters and prevalence of hypertension, diabetes, dyslipidemia, and rheumatic disease were compared between the two groups of studied women.

RESULTS

From March 2016 to May 2020, 545 women were studied, of whom 218 had a history of complicated pregnancy (mean age 60.81 ± 11.109 years vs. 62.78 ± 9.758 years of not complicated pregnancy; P = 0.03). Compared with physiological pregnancy women, complicated pregnancy ones were shorter (159.97 ± 6.608 vs. 161.42 ± 6.427 cm; P = 0.012) with lower body surface area (1.678 ± 0.1937 vs. 1.715 ± 0.1662 m2; P = 0.02), had higher prevalence of diabetes (6.9 vs. 3.1%; P = 0.04; odds ratio = 2.34; CI 1.0323--5.3148) and rheumatic diseases (33 vs. 22.3%; P = 0.006; odds ratio = 1.72; CI 1.1688--2.5191), and showed a slight, not significant higher prevalence of hypertension. As for echocardiographic parameters, they showed significantly higher values of end-diastolic left ventricular posterior wall (LPWd) (P = 0.034), a trend toward a more concentric geometry, and a worse longitudinal systolic left and right ventricle performance, represented by lower tissue Doppler systolic waves (septal: 7.41 ± 1.255 vs. 7.69 ± 1.376 cm/s; P = 0.018; and tricuspidalic: 12.64 ± 2.377 vs. 13.32 ± 2.548 cm/s; P = 0.003).

CONCLUSION

Patients with previous preeclampsia present an increased risk of hypertension, diabetes, and rheumatic diseases, suggesting that these women could share a specific predisposition to a high-risk profile. Furthermore, they show a higher prevalence of classically considered echocardiographic hypertensive-derived cardiac damage, suggesting structural and functional left ventricular modifications as subclinical aspects of long-term worse cardiovascular prognosis for these women.

Delivering Coordinated Cardio-Obstetric Care from Preconception through Postpartum

Coordinated preconception through postpartum cardio-obstetrics care is necessary to optimize both maternal and fetal health. Maternal mortality in the United States is increasing, largely driven by increasing cardiovascular (CV) disease burden during pregnancy and needs to be addressed emergently. Both for women with congenital and acquired heart disease, CV complications during pregnancy are associated with increased future risk of CV disease. Comprehensive cardio-obstetrics care is a powerful way of ensuring that women's CV risks before and during pregnancy are appropriately identified and treated and that they remain engaged in CV care long term to prevent future CV complications.

Pre-eclampsia and long-term health outcomes for mother and infant: an umbrella review

BACKGROUND

Pre-eclampsia is a pregnancy-associated condition with complex disease mechanisms and a risk factor for various long-term health outcomes for the mother and infant.

OBJECTIVE

To summarise evidence on the association of pre-eclampsia with long-term health outcomes arising in women and/or infants.

SEARCH STRATEGY

PubMed, EMBASE, Scopus and ISI Web of Science were searched from inception to July 2020.

SELECTION CRITERIA

Systematic reviews and meta-analyses examining associations between pre-eclampsia and long-term health outcomes in women and their infants.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. We re-estimated the summary effect size by random-effects and fixed-effects models, the 95% confidence interval, the 95% prediction interval, the between-study heterogeneity, any evidence of small-study effects and excess significance bias.

RESULTS

Twenty-one articles were included (90 associations). Seventy-nine associations had nominally statistically significant findings (P < 0.05). Sixty-five associations had large or very large heterogeneity. Evidence for small-study effects and excess significance bias was found in seven and two associations, respectively. Nine associations: cerebrovascular disease (cohort studies), cerebrovascular disease (overall), cardiac disease (cohort studies), dyslipidaemia (all studies), risk of death (late-onset pre-eclampsia), fatal and non-fatal ischaemic heart disease, cardiovascular mortality (cohort studies), any diabetes or use of diabetic medication (unadjusted), and attention deficit/hyperactivity disorder (ADHD) (adjusted) were supported with robust evidence.

CONCLUSION

Many of the meta-analyses in this research field have caveats casting doubts on their validity. Current evidence suggests an increased risk for women to develop cardiovascular-related diseases, diabetes and dyslipidaemia after pre-eclampsia, while offspring exposed to pre-eclampsia are at higher risk for ADHD.

TWEETABLE ABSTRACT

Cardiovascular and cerebrovascular diseases were supported with convincing evidence for long-term health outcomes after pre-eclampsia.

Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association

This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman's later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.

Team-Based Care of Women With Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 1/5

The specialty of cardio-obstetrics has emerged in response to the rising rates of maternal morbidity and mortality related to cardiovascular disease (CVD) during pregnancy. Women of childbearing age with or at risk for CVD should receive appropriate counseling regarding maternal and fetal risks of pregnancy, medical optimization, and contraception advice. A multidisciplinary cardio-obstetrics team should ensure appropriate monitoring during pregnancy, plan for labor and delivery, and ensure close follow-up during the postpartum period when CVD complications remain common. The hemodynamic changes throughout pregnancy and during labor and delivery should be considered with respect to the individual cardiac disease of the patient. The fourth trimester refers to the 12 weeks after delivery and is a key time to address contraception, mental health, cardiovascular risk factors, and identify any potential postpartum complications. Women with adverse pregnancy outcomes are at increased risk of long-term CVD and should receive appropriate education and longitudinal follow-up.

Risk of type 2 diabetes mellitus in women with prior hypertensive disorders of pregnancy: a systematic review and meta-analysis

AIMS/HYPOTHESIS

The association between a history of hypertensive disorders of pregnancy (HDP) and subsequent type 2 diabetes (referred to throughout as diabetes) remains inconclusive. We reviewed the most recent evidence to quantify the association of previous HDP with incident diabetes.

METHODS

A systematic search of MEDLINE, Embase and CINAHL was performed up to 17 February 2020 to identify observational studies of the association between HDP (pre-eclampsia or gestational hypertension) and incident diabetes. Studies of women with pre-pregnancy diabetes were excluded. Two independent reviewers screened citations and abstracted results. Study quality was assessed in duplicate using the Newcastle-Ottawa Scale. Random-effects models were used to pool effect estimates. Heterogeneity was assessed using the I² statistic.

RESULTS

After screening 4617 citations, 16 cohort studies with a total of 3,095,457 participants were included (unspecified HDP n = 5, pre-eclampsia only n = 4, gestational hypertension and pre-eclampsia n = 7). Risks of subsequent diabetes were significantly higher in women with a history of any HDP (HDP: adjusted hazard ratio [aHR] 2.24, 95% CI 1.95, 2.58; gestational hypertension: aHR 2.19 [95% CI 1.69, 2.84]; pre-eclampsia: aHR 2.56 [95% CI 2.02, 3.24]; preterm pre-eclampsia: aHR 3.05 [95% CI 2.05, 4.56]). The association between HDP and diabetes persisted in studies that adjusted for gestational diabetes mellitus (aHR 2.01 [95% CI 1.77, 2.28]).

CONCLUSIONS/INTERPRETATION

HDP are independently associated with a higher risk of diabetes. Further study is needed to determine how HDP contribute to diabetes risk prediction to develop evidence-based screening and prevention strategies. Graphical abstract.

Hypertension and diabetes mellitus: highlights of a complex relationship

PURPOSE OF REVIEW

Herein, we provide a review of the recent literature on the epidemiological and pathophysiological relationship between hypertension (HTN) and diabetes mellitus, along with prognostic implications and current treatment concepts.

RECENT FINDINGS

Diabetes mellitus affects ∼10% of US adults. The prevalence of HTN in adults with diabetes mellitus was 76.3% or 66.0% based on the definitions used by guidelines. There exist differences among major society guidelines regarding the definition of HTN and target blood pressure (BP) levels. Recent basic and clinical research studies have shed light on pathophysiologic and genetic links between HTN and diabetes mellitus. Randomized controlled trials over the past 5 years have confirmed the favorable BP and cardiovascular risk reduction by antidiabetic agents.

SUMMARY

HTN and diabetes mellitus are 'silent killers' with rising global prevalence. The development of HTN and diabetes mellitus tracks each other over time. The coexistence of both clinical entities synergistically contributes to micro- and macro-vasculopathy along with cardiovascular and all-cause mortality. Various shared mechanisms underlie the pathophysiological relationship between HTN and diabetes mellitus. Moreover, BP reduction with lifestyle interventions and antihypertensive agents is a primary target for reducing cardiovascular risk among patients with HTN and diabetes mellitus.

Association between neonatal birthweight and risk of maternal glucose intolerance after gestational diabetes mellitus

Aims/Introduction

To evaluate whether the neonatal birthweight (NBW) is associated with early postpartum glucose intolerance in women with gestational diabetes mellitus.

Materials and Methods

A total of 1,113 women diagnosed with gestational diabetes mellitus who completed an oral glucose tolerance test at 6–9 weeks postpartum between 1 April 2014 and 8 January 2020 were included in this observational prospective cohort study. They were grouped by neonatal birthweight quartiles, and the odds ratios of postpartum glucose intolerance for different levels of neonatal birthweight were assessed.

Results

A lower NBW quartile was associated with an increased maternal risk of postpartum glucose intolerance after gestational diabetes mellitus. The adjusted odds ratios for maternal glucose intolerance were 1.69 (95% confidence interval 1.13–2.51) in the lowest NBW quartile (NBW 1,980–2,930 g) when compared with the highest NBW quartile (NBW 3,410–4,610 g). The association between lower NBW and maternal glucose intolerance was significantly stronger in women who delivered a girl. Additionally, NBW ≥3,100 g appears to be associated with a lower risk of maternal glucose intolerance postpartum.

Conclusions

Our findings suggest that low NBW is a previously unrecognized risk factor for maternal glucose intolerance after gestational diabetes in early postpartum in South China.

Fasting blood glucose level and hypertension risk in aging benign prostatic hyperplasia patients

Evidence suggests there maybe an association among abnormal fasting blood glucose, hypertension and benign prostatic hyperplasia. In this study, we investigated whether abnormal fasting blood glucose correlates with hypertension in aging benign prostatic hyperplasia patients. Ultimately, 612 benign prostatic hyperplasia patients, including 230 hypertensive patients and 382 normotensive patients, were included. Univariate and multivariate logistic regression analyses were used to evaluate the associations. The results indicated that neither impaired fasting glucose/high risk of type 2 diabetes mellitus nor high risk of type 2 diabetes mellitus were associated with an increased risk of hypertension. When patients were stratified based on the severity of their hypertension, similar results were obtained (all P> 0.05). After adjusting for confounding factors, the nonsignificant tendencies for high risk of type 2 diabetes mellitus and impaired fasting glucose/high risk of type 2 diabetes mellitus to associate with hypertension persisted (all P> 0.05). Unlike earlier studies, the present study suggests that the level of fasting blood glucose may not be significantly related to hypertension in aging patients with benign prostatic hyperplasia.

Dietary patterns and gestational hypertension in nulliparous pregnant Chinese women: A CONSORT report

It has been well established that dietary patterns play important roles in the pathogenesis and development of hypertension. Our aim was to investigate the association between pregnancy dietary patterns and the risk of hypertension among nulliparous pregnant Chinese women.A cross-sectional, case-control study.Three hospitals in Haikou, the capital of Hainan Province, South China.A total of 2580 participants who reported dietary intake using a validated food frequency questionnaire (FFQ).Four primary dietary patterns were identified by principal component factor analysis and labeled as traditional Chinese, animal food, Western food, and salty snacks patterns. Women with high scores on pattern characterized by salty snacks were at increased risk.This study suggests that dietary pattern characterized by salty snack increases the risk of hypertension during pregnancy.

Involvement of Receptor for Advanced Glycation Endproducts in Hypertensive Disorders of Pregnancy

Preeclampsia/hypertensive disorders of pregnancy (PE/HDP) is a serious and potentially life-threatening disease. Recently, PE/HDP has been considered to cause adipose tissue inflammation, but the detailed mechanism remains unknown. We exposed human primary cultured adipocytes with serum from PE/HDP and healthy controls for 24 h, and analyzed mRNA expression of several adipokines, cytokines, and ligands of the receptor for advanced glycation endproducts (RAGE). We found that the mRNA levels of interleukin-6 (IL-6), C-C motif chemokine ligand 2 (CCL2), high mobility group box 1 (HMGB1), and RAGE were significantly increased by the addition of PE/HDP serum. Among RAGE ligands, advanced glycation endproducts (AGE) and HMGB1 increased mRNA levels of IL-6 and CCL2 in SW872 human adipocytes and mouse 3T3-L1 cells. The introduction of small interfering RNA for RAGE (siRAGE) into SW872 cells abolished the AGE- and HMGB1-induced up-regulation of IL-6 and CCL2. In addition, lipopolysaccharide (LPS), a ligand of RAGE, increased the expression of IL-6 and CCL2 and siRAGE attenuated the LPS-induced expression of IL-6 and CCL2. These results strongly suggest that the elevated AGE, HMGB1, and LPS in pregnant women up-regulate the expression of IL-6 and CCL2 via the RAGE system, leading to systemic inflammation such as PE/HDP.

Risks of Dysglycemia Over the First 4 Years After a Hypertensive Disorder of Pregnancy

BACKGROUND

Women with the hypertensive disorders of pregnancy (HDP) (preeclampsia [PE] and gestational hypertension [GHTN]) have increased risks of future diabetes. Postpartum glycemic testing offers early identification and treatment of dysglycemia, but evidence-based recommendations for this high-risk population are lacking. The objective of this study was to describe the risks of developing dysglycemia in women with normotensive and hypertensive pregnancies over the first 4 years postpartum.

METHODS

The Discharge Abstract Database was used to identify women who delivered singleton live-born infants in Calgary, Alberta, Canada, between January 2010 and December 2012 (N=27,300). This was linked with Calgary Laboratory Services (for glycemic tests) and the Pharmaceutical Information Network databases (for antidiabetes medication prescriptions) over the first 4 years postpartum. Logistic regression analyses compared glycemic testing and results were adjusted for maternal age, gestational age, parity and the Pampalon deprivation index.

RESULTS

Women with HDP had more glycemic testing (GHTN 67.8% and PE 69.9% vs normotensive 60.9%; p<0.001) and significantly higher results for fasting plasma glucose (GHTN 4.82±0.51 mmol/L and PE 4.84±0.54 mmol/L vs normotensive 4.73±0.49 mmol/L; p<0.001), random plasma glucose (GHTN 5.20±0.96 mmol/L and PE 5.39±1.71 mmol/L vs normotensive 5.00±0.87 mmol/L; p<0.001) and glycated hemoglobin levels (PE 5.62±0.53% vs normotensive 5.49±0.32%; p<0.001). Women with HDP had a higher adjusted odds (95% confidence interval) of developing type 2 diabetes compared with normotensive women (GHTN: 2.26, 1.50 to 13.4; PE: 2.02, 0.91 to 4.46).

CONCLUSIONS

The high prevalence of early dysglycemia highlights the importance of targeted postpartum glycemic testing in women after HDP. Further research on optimal glycemic testing (specific tests and timing) in these high-risk women is needed.

Hypertensive disorders of pregnancy increase the risk of developing neovascular age-related macular degeneration in later life

Background: Hypertensive disorders of pregnancy (HDP) and short-term adverse outcomes have long been recognized; however, survivors remain at risk of long-term complications. We investigated whether HDP is associated with the development of choroidal neovascular age-related macular degeneration (CNV AMD). Methods: We identified 31,454 women who experienced HDP based on Utah birth certificates and 62,908 unexposed women matched 2:1 to the exposed. Risk of CNV AMD was estimated using Cox models. Findings: Women with HDP exhibited an 80% higher risk for early CNV AMD (age < 70 y; 95%CI 1.23-2.58). Conclusion: Our findings may have implications forearlier CNV AMD screening and detection.

Preventing type 2 diabetes and cardiovascular disease in women with gestational diabetes - The evidence and potential strategies

Gestational Diabetes Mellitus is a condition strongly related to the development of type 2 diabetes later in life, although the risk and the onset have not been fully identified yet. Although glucose tolerance returns to normal levels after delivery in the majority of women with GDM, this condition represents an early stage in the natural history of T2DM. In addition, women with previous GDM exhibit an increased cardiovascular risk profile and a raised incidence of cardiovascular diseases. Lifestyle changes and pharmacological interventions might be able to reduce the incidence of type 2 diabetes in pGDM women, although results are still not conclusive. Long term continuous programs specifically addressed to women with pGDM should be implemented, with the ambitious target to encourage them to regularly check glucose tolerance, lipid profile and other parameters related to cardiovascular diseases, aimed at improving women's health. In this paper, we review the relationship between type 2 diabetes, cardiovascular diseases and a history of GDM.

Midlife development of type 2 diabetes and hypertension in women by history of hypertensive disorders of pregnancy

BACKGROUND

Women with history of hypertensive disorders of pregnancy (HDP) are at increased risk of early onset cardiovascular disease and type 2 diabetes (T2D). We aimed to investigate the extent to which HDP is also associated with midlife development of T2D and hypertension above and beyond established risk factors.

METHODS

We included parous women who attended population-based structured clinical visits at age 50 and 60 years in Sweden 1991-2013 (N = 6587). Women with prior diabetes mellitus, stroke, or ischemic heart disease at age 50 years were excluded. Data on reproductive history were collected from registries. To study the association between history of HDP and the between-visits development of T2D, hypertension, and clinical risk factors of cardiometabolic disease (body mass index (BMI), blood pressure, and total cholesterol), we utilized multivariable adjusted regression models (logistic, log binomial, and linear regression, respectively). Models included data on outcome risk factors at age 50 years, e.g. BMI, 75 g 2 h oral glucose tolerance test result, and mean arterial pressure, respectively.

RESULTS

Between ages 50 and 60 years, 5.8% of initially disease-free women developed T2D and 31.6% developed hypertension. History of HDP was associated with increased risk of developing T2D between age 50 and 60 years even when adjusting for risk factors, including BMI, at age 50 years (odds ratio (OR) 1.96, 95% confidence interval (CI) 1.29-2.98). By contrast, the higher risk of developing hypertension observed in women with history of HDP (relative risk (RR) 1.47, 95% CI 1.22-1.78) was attenuated when adjusted for risk factors (RR 1.09, 95% CI 0.94-1.25). Participants with a history of HDP had higher mean BMI and blood pressure at age 50 years, with levels roughly corresponding to those observed at age 60 years in unaffected women.

CONCLUSIONS

Women with history of HDP are not only at higher risk of cardiometabolic disease during their reproductive years, but HDP is also associated with midlife T2D development above and beyond established risk factors.

Persistence of risk factors associated with maternal cardiovascular disease following aberrant inflammation in rat pregnancy

Introduction

Pre-eclampsia is associated with increased risk of subsequent cardiovascular and metabolic disease in the affected mothers. While aberrant inflammation contributes to the pathophysiology of pre-eclampsia, it is unclear whether maternal inflammation contributes to the increased risk of disease. Here, we determined the effect of aberrant inflammation in pregnancy on cardiovascular and metabolic disease risk factors.

Methods

Wistar rats were administered low doses of lipopolysaccharide (LPS) on gestational days (GD) 13.5-16.5 to induce inflammation. Controls included pregnant rats treated with saline and nonpregnant rats treated with LPS or saline. We previously showed that LPS-treated pregnant rats exhibit key features of pre-eclampsia. Echocardiographic parameters, heart weight, blood pressure, blood lipids, pulse-wave velocity, and glucose tolerance, were assessed at 16 weeks postpartum. Messenger RNA levels of transcription factors associated with cardiac growth were measured in left ventricular tissue; histone modifications and global DNA methylation were determined in hearts and livers at GD 17.5 and at 16 weeks postpartum.

Results

Compared with saline-treated pregnant rats and nonpregnant rats treated with LPS or saline, LPS-treated pregnant rats exhibited left ventricular hypertrophy and increased blood cholesterol and low-density lipoprotein levels at 16 weeks postdelivery. LPS-treated rats had increased left ventricular mRNA levels of hypertrophy-associated transcription factors at GD 17.5 and increased levels of modified histones in hearts and livers at GD 17.5 and 16 weeks postpartum. Other parameters remained unchanged.

Conclusion

Aberrant inflammation during pregnancy results in persistent alterations in maternal physiological parameters and epigenetic modifications that could contribute to the pathophysiology of cardiovascular disease.

Postpartum glucose intolerance: an updated overview

The prevalence of type 2 diabetes mellitus has increased worldwide over the past three decades, as a consequence of the more westernized lifestyle, which is responsible for the increasing obesity rate in the modern adult's life. Concomitant with this increase there has been a gradual rise in the overall prevalence of gestational diabetes mellitus, a condition that strongly predisposes to overt diabetes later in life. Many women with previous gestational diabetes mellitus show glucose intolerance in the early postpartum period. Although the best screening strategy for postpartum glucose intolerance is still debated, numerous evidences indicate that identification of these women at this time is of critical importance, as efforts to initiate early intensive lifestyle modification, including hypocaloric diet and physical activity, and to ameliorate the metabolic profile of these high-risk subjects can prevent or delay the onset of type 2 diabetes mellitus. Nevertheless, less than one fifth of women attend the scheduled postpartum screening following gestational diabetes mellitus and they are at increased risk to develop type 2 diabetes mellitus later in their lives. Unsatisfying results have also come from early intervention strategies and tools that have been developed during the last few years to help improving the rate of adherence to postpartum glycemic testing, thereby indicating that more effective strategies are needed to improve women's participation in postpartum screening.

Postpartum Sequelae of the Hypertensive Diseases of Pregnancy: A Pilot Study

Background

Hypertensive disorders are one of the most common medical conditions that may complicate pregnancy. Postpartum blood pressure (BP) pattern is, however, less clear in affected women and decision to discharge them is usually decided arbitrarily.

Materials and Methods

A cohort study conducted at Lagos University Teaching Hospital, Lagos, Nigeria, aimed at determining the proportion of pregnant women with pregnancy-induced hypertension (PIH) and preeclampsia (PE) whose BP remains elevated 6 weeks postdelivery and factors associated with the persistent rise. Fifteen women each with PIH and PE were studied in different phases of pregnancy and followed up until 6 weeks postdelivery. Fifteen normotensive pregnant women served as controls. BP patterns were monitored and fasting lipid levels, serum creatinine, fasting glucose profile (FGP), and FGP/insulin ratio were assayed. Data were analyzed with IBM SPSS version 20.

Results

Proportion of women with PIH or PE who had persistent hypertension at 6 weeks postpartum was 3/29 (10.3%), risk ratio of 1.1. No statistically significant association was found between mean arterial BP at 6 weeks postpartum and age, parity, gestational age at delivery, body mass index, and family history of hypertension. Serum creatinine level showed moderate correlation with persistent hypertension at 6 weeks postpartum (r = 0.441,P = 0.006), with sensitivity of 100% and specificity of 81.8% at cutoff value of 1.2 mg/dL in detecting pregnant women with hypertensive disorders who will likely remain hypertensive at 6 weeks postpartum.

Conclusion

There is a need for long-term follow-up of women with PIH/PE beyond puerperium.