Cardiovascular and thromboembolic events following hypertensive pregnancy

Vascular health years after a hypertensive disorder of pregnancy: The EPOCH study

BACKGROUND

Preeclampsia is associated with a two-fold increase in a woman's lifetime risk of developing atherosclerotic cardiovascular disease (ASCVD), but the reasons for this association are uncertain. The objective of this study was to examine the associations between vascular health and a hypertensive disorder of pregnancy among women ≥ 2 years postpartum.

METHODS

Pre-menopausal women with a history of either a hypertensive disorder of pregnancy (cases: preeclampsia or gestational hypertension) or a normotensive pregnancy (controls) were enrolled. Participants were assessed for standard ASCVD risk factors and underwent vascular testing, including measurements of blood pressure, endothelial function, and carotid artery ultrasound. The primary outcomes were blood pressure, ASCVD risk, reactive hyperemia index measured by EndoPAT and carotid intima-medial thickness. The secondary outcomes were augmentation index normalized to 75 beats per minute and pulse wave amplitude measured by EndoPAT, and carotid elastic modulus and carotid beta-stiffness measured by carotid ultrasound.

RESULTS

Participants had a mean age of 40.7 years and were 5.7 years since their last pregnancy. In bivariate analyses, cases (N = 68) were more likely than controls (N = 71) to have hypertension (18% vs 4%, P = .034), higher calculated ASCVD risk (0.6 vs 0.4, P = .02), higher blood pressures (systolic: 118.5 vs 111.6 mm Hg, P = .0004; diastolic: 75.2 vs 69.8 mm Hg, P = .0004), and higher augmentation index values (7.7 vs 2.3, P = .03). They did not, however, differ significantly in carotid intima-media thickness (0.5 vs 0.5, P = .29) or reactive hyperemia index (2.1 vs 2.1, P = .93), nor in pulse wave amplitude (416 vs 326, P = .11), carotid elastic modulus (445 vs 426, P = .36), or carotid beta stiffness (2.8 vs 2.8, P = .86).

CONCLUSION

Women with a prior hypertensive disorder of pregnancy had higher ASCVD risk and blood pressures several years postpartum, but did not have more endothelial dysfunction or subclinical atherosclerosis.

Rates of Preeclampsia and Post-preeclamptic Cardiovascular Disease Among US Military Servicewomen: A Retrospective Case-cohort Study

INTRODUCTION

Preeclampsia (PE), a hypertensive-inflammatory disorder of pregnancy, poses acute risks of seizures, stroke, and heart attack during pregnancy and up to 6 weeks post-delivery. Recent data suggest that residual increased risks for cardiovascular disease (CVD) linger for much longer, possibly decades, after PE pregnancies. In civilian studies, PE and the major vascular events resulting from it disproportionately affect women from minority groups, especially African American women. The Military Health System (MHS) provides equal access to care for all active-duty servicewomen (ADSW), thus theoretically mitigating disparities. Racial/ethnic breakdown for PE and post PE CVD has not been studied in the MHS.

MATERIALS AND METHODS

We identified healthy pregnancies in the MHS electronic health records of ADSW in the years 2009/2010 and those with a PE diagnosis. Patients with preexisting conditions of PE or CVD based on a look-back period of two calendar years were excluded. Cases were matched to controls based on age at pregnancy within 5 years and race/ethnicity. Cohort was assessed for diagnosed CVDs, race, age, and service during 2011-2017. Time to first CVD event was assessed with Cox proportional hazards model, results reported as relative risks (95% CI). All variables were summarized using mean (SD) for normally distributed continuous variables; non-normal continuous variables were characterized by median [IQR] and categorical variables were summarized by counts and frequencies. All statistical testings were two-sided with a significance level of 5% and were completed using SAS-EG version 9.2 or R version 3.5.2.

RESULTS

From an analysis of 106,808 inpatient ADSW records, PE incidence by race is 11.8% for White, 12% for African American, 11.4% for Asian/Pacific Islander, 11.2% for Native American, 9.5% for Other, and 7.6% for unknown (not documented) race. Thus, in the US Military, African American women have comparable (0.2% higher) PE rate than White women in contrast with civilian studies that often report much higher incidence in the African American population. Using Asians as referent group, PE increases the risk of CVD. White women have a hazard ratio (HR) of 1.47 95%CI (1.15-1.88), African Americans a HR of 1.51 95% CI (1.18-1.93), and Other a HR of 1.39 95% CI (1.01-1.91).

CONCLUSION

In this study, we report overall higher incidence of PE in military women than what is published for civilian women in all races and across all services. Importantly, we do not find significantly higher numbers of PE and post-PE CVD for African American, compared to White women in the military. Our study is not designed to address differences between military and civilian PE epidemiology, but these results deserve further exploration. This study shines light on a health risk unique to women, which we found to be more prevalent in the US Military than published civilian population. Further study to determine the details of long-term morbidity, disability, and death attributable to PE (CVD, stroke, and kidney diseases) are needed to design optimal medical management protocols, ensure readiness for duty, and protect our Women Warfighters.

Early Mortality, Cardiovascular, and Renal Diseases in Women's Lives Following Hypertensive Disorders of Pregnancy: The Prospective Nationwide Study CONCEPTION

BACKGROUND

We aimed to evaluate the impact of hypertensive disorders of pregnancy occurrence, recurrence, onset time, and severity on mortality and on a wide range of cardiovascular outcomes in France.

METHODS AND RESULTS

CONCEPTION (Cohort of Cardiovascular Diseases in Pregnancy) is a French nationwide prospective cohort using data from the National Health Data System. We included all women in CONCEPTION with no history of a cardiovascular event who delivered in France for the first time between 2010 and 2018 (N=2 819 655). Hypertensive disorders of pregnancy and cardiovascular outcomes during the study follow-up were identified using algorithms combining International Classification of Diseases, Tenth Revision (ICD-10) coded diagnoses during hospitalization and purchases of medication between 2010 and 2021. We fitted Cox models with time-varying exposure to assess the associations of hypertensive disorders of pregnancy with mortality and cardiovascular events. Women with gestational hypertension had a 1.25- to 2-fold higher risk of stroke, acute coronary syndrome, peripheral arterial disease, pulmonary embolism, and chronic kidney disease, and a 2- to 4-fold higher risk of rhythm and conduction disorder and heart failure. Women with preeclampsia had a 1.35- to 2-fold higher risk of rhythm or conduction disorder and pulmonary embolism during follow-up; a 2- to 4-fold higher risk of stroke, acute coronary syndrome, and peripheral arterial disease; and a 7- to 9-fold higher risk of heart failure and chronic kidney disease. They were 1.8 times more likely to die and 4.4 times more likely to die of cardiovascular causes.

CONCLUSIONS

Hypertensive disorders of pregnancy drastically increase the risk of mortality, cardiovascular, and renal events early after pregnancy. Recurrent, severe, and early-onset preeclampsia further increases this risk.

Hypertensive pregnancy complications and maternal characteristics as predictors of cardiovascular health within ten years after delivery

OBJECTIVE

To identify the combination of maternal characteristics in women with hypertensive disorders of pregnancy (HDP) associated with hypertensive and other cardiovascular diseases (CVDs) within ten years following delivery. The aim is to understand who should receive the most intensive primary cardiovascular disease prevention.

STUDY DESIGN

A prospective cohort study.

MAIN OUTCOME

The population was the FINNPEC cohort (2008-2011), including women with (n = 1837) and without (n = 847) HDP. The main exposures were maternal hypertensive pregnancy complications linked with maternal pregnancy data from hospital records. The outcomes were hypertensive diseases and other CVDs (International Classification of Diseases, Tenth Revision).

RESULTS

Women with de novo pre-eclampsia (PE) had an elevated risk for hypertensive diseases within ten years following delivery. The risk of CVD was increased in women with superimposed PE and chronic hypertension (CHT) only. Women with de novo PE and hypertensive diseases were more often primiparous (41.4% vs. 23.0%, p = 0.020), had gestational diabetes (GDM) (31.0% vs. 11.7%, p = 0.002), and higher pre-pregnancy body mass index (BMI) (28.7 ± 5.8 vs. 24.6 ± 4.8 kg/m2, p = 0.001), compared with women who remained normotensive. Women with superimposed PE with CVD had more likely early-onset PE, preterm delivery and were older than women without later CVD.

CONCLUSIONS

Healthcare professionals should target early prevention of CVDs in women with chronic hypertension during pregnancy; of those who developed superimposed PE prior to 34th weeks of gestation and who delivered preterm. Women with de novo PE who are overweight/obese, primiparous, and with concurrent GDM need regular blood pressure monitoring.

Preeclampsia and Long-Term Risk of Venous Thromboembolism

Importance

As venous thromboembolism (VTE) remains one of the leading causes of maternal mortality, identifying women at increased risk of VTE is of great importance. Preeclampsia is a pregnancy-induced hypertensive disorder with generalized endothelial dysfunction. Some studies suggest that preeclampsia is associated with an increased risk of VTE, but much controversy exists.

Objective

To examine the association between preeclampsia and the risk of VTE during pregnancy, during the puerperium, and after the puerperium.

Design, Setting, and Participants

This observational cohort study used Danish nationwide registries to identify all eligible primiparous women who gave birth in Denmark from January 1, 1997, to December 31, 2016. The women were followed up from primiparous pregnancy to incident VTE, emigration, death, or the end of the study (December 31, 2016). Statistical analyses were carried out from January to May 2023.

Exposure

Preeclampsia during primiparous pregnancy.

Main Outcomes and Measure

The main outcome was incident VTE, and the secondary outcome was all-cause mortality.

Results

A total of 522 545 primiparous women (median age, 28 years [IQR, 25-31 years]) were included, and 23 330 (4.5%) received a diagnosis of preeclampsia. Women with preeclampsia were of similar age to women without preeclampsia but had a higher burden of comorbidities. During a median follow-up of 10.2 years (IQR, 5.2-15.4 years), preeclampsia was associated with a higher incidence of VTE compared with no preeclampsia (incidence rate, 448.8 [95% CI, 399.9-503.5] vs 309.6 [95% CI, 300.6-319.9] per 1000 patient-years, corresponding to an unadjusted hazard ratio [HR] of 1.45 [95% CI, 1.29-1.63] and an adjusted HR of 1.43 [95% CI, 1.27-1.61]). When stratified according to the subcategories of VTE, preeclampsia was associated with an increased rate of deep vein thrombosis (unadjusted HR, 1.51 [95% CI, 1.32-1.72] and adjusted HR, 1.49 [95% CI, 1.31-1.70]) as well as pulmonary embolism (unadjusted HR, 1.39 [95% CI, 1.09-1.76]; adjusted HR, 1.36 [95% CI, 1.08-1.73]). These findings held true in landmark analyses during pregnancy, during the puerperium, and after the puerperium.

Conclusions and Relevance

This cohort study suggests that preeclampsia was associated with a significantly increased risk of VTE during pregnancy, during the puerperium, and after the puerperium, even after thorough adjustment. Future studies should address how to improve the clinical management of women with a history of preeclampsia to prevent VTE.

Systematic review of validated case definitions to identify hypertensive disorders of pregnancy in administrative healthcare databases

BACKGROUND

Administrative data are frequently used to study cardiovascular disease (CVD) risk in women with hypertensive disorders of pregnancy (HDP). Little is known about the validity of case-finding definitions (CFDs, eg, disease classification codes/algorithms) designed to identify HDP in administrative databases.

METHODS

A systematic review of the literature. We searched MEDLINE, Embase, CINAHL, Web of Science and grey literature sources for eligible studies. Two independent reviewers screened articles for eligibility and extracted data. Quality of reporting was assessed using checklists; risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool, adapted for administrative studies. Findings were summarised descriptively.

RESULTS

Twenty-six studies were included; most (62%) validated CFDs for a variety of maternal and/or neonatal outcomes. Six studies (24%) reported reference standard definitions for all HDP definitions validated; seven reported all 2×2 table values for ≥1 CFD or they were calculable. Most CFDs (n=83; 58%) identified HDP with high specificity (ie, ≥98%); however, sensitivity varied widely (3%-100%). CFDs validated for any maternal hypertensive disorder had the highest median sensitivity (91%, range: 15%-97%). Quality of reporting was generally poor, and all studies were at unclear or high risk of bias on ≥1 QUADAS-2 domain.

CONCLUSIONS

Even validated CFDs are subject to bias. Researchers should choose the CFD(s) that best align with their research objective, while considering the relative importance of high sensitivity, specificity, negative predictive value and/or positive predictive value, and important characteristics of the validation studies from which they were derived (eg, study prevalence of HDP, spectrum of disease studied, methodological rigour, quality of reporting and risk of bias). Higher quality validation studies on this topic are urgently needed.

PROSPERO REGISTRATION NUMBER

CRD42021239113.

Cardiovascular and renal health: Preeclampsia as a risk marker

BACKGROUND

Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies.

MATERIALS AND METHODS

Review of PE and its association with future development of CVD and CKD.

RESULTS

Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage.

CONCLUSIONS

The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.

Pregnancy complications and later life women's health

There has been increasing recognition of the association between various pregnancy complications and development of chronic disease in later life. Pregnancy has come to be regarded as a physiological stress test, as the strain it places on a woman's body may reveal underlying predispositions to disease that would otherwise remain hidden for many years. Despite the increasing body of data, there is a lack of awareness among healthcare providers surrounding these risks. We performed a narrative literature review and have summarized the associations between the common pregnancy complications including gestational hypertension, pre-eclampsia, gestational diabetes, placental abruption, spontaneous preterm birth, stillbirth and miscarriage and subsequent development of chronic disease. Hypertensive disorders of pregnancy, spontaneous preterm birth, gestational diabetes, pregnancy loss and placental abruption are all associated with increased risk of various forms of cardiovascular disease. Gestational diabetes, pre-eclampsia, early miscarriage and recurrent miscarriage are associated with increased risk of diabetes mellitus. Pre-eclampsia, stillbirth and recurrent miscarriage are associated with increased risk of venous thromboembolism. Pre-eclampsia, gestational diabetes and stillbirth are associated with increased risk of chronic kidney disease. Gestational diabetes is associated with postnatal depression, and also with increased risk of thyroid and stomach cancers. Stillbirth, miscarriage and recurrent miscarriage are associated with increased risk of mental health disorders including depression, anxiety and post-traumatic stress disorders. Counseling in the postnatal period following a complicated pregnancy, and advice regarding risk reduction should be available for all women. Further studies are required to establish optimal screening intervals for cardiovascular disease and diabetes following complicated pregnancy.

Physical activity and pregnancy outcomes: an expert review

This expert review aimed to assess current literature on the effect and tracking of physical activity during pregnancy and associated outcomes. Self-reported physical activity may be inaccurate given the subjective nature of the questionnaires. The accelerometer ActiGraph is considered the "gold standard" to objectively measure physical activity. However, other more user-friendly wearable devices are now widely available and may accurately track physical activity. Conclusive data from both validated activity questionnaires and accelerometers indicate that physical activity is safe during pregnancy. In addition, studies of physical activity during pregnancy that evaluate pregnancy outcomes have found reduced risks of preterm birth, preeclampsia, and gestational diabetes mellitus and improved mental health among individuals who regularly engage in physical activity. In the United States, approximately 48% of pregnant individuals gain more than the recommended amount of weight during pregnancy; excessive gestational weight gain is associated with an increased risk of maternal and fetal complications, including preterm birth, preeclampsia, and gestational diabetes mellitus, and corresponding higher adverse short- and long-term maternal and offspring health outcomes. Although physical activity is safe during pregnancy and may reduce excessive gestational weight gain and resultant pregnancy complications, further research is needed to determine the frequency and duration of specific types of physical activity during pregnancy. Providers should encourage physical activity before and during pregnancy and educate patients regarding the benefits and safety of physical activity.

Preeclampsia and Fetal Growth Restriction as Risk Factors of Future Maternal Cardiovascular Disease-A Review

Cardiovascular diseases (CVDs) remain the leading cause of death in women worldwide. Although traditional risk factors increase later-life CVD, pregnancy-associated complications additionally influence future CVD risk in women. Adverse pregnancy outcomes, including preeclampsia and fetal growth restriction (FGR), are interrelated disorders caused by placental dysfunction, maternal cardiovascular maladaptation to pregnancy, and maternal abnormalities such as endothelial dysfunction, inflammation, hypercoagulability, and vasospasm. The pathophysiologic pathways of some pregnancy complications and CVDs might be linked. This review aimed to highlight the associations between specific adverse pregnancy outcomes and future CVD and emphasize the importance of considering pregnancy history in assessing a woman's CVD risk. Moreover, we wanted to underline the role of maternal cardiovascular maladaptation in the development of specific pregnancy complications such as FGR.

Risk of future cardiovascular diseases in different years postpartum after hypertensive disorders of pregnancy: A systematic review and meta-analysis

OBJECTIVE

There are limited data on the optimal timing and frequency of postpartum follow-up visits after hypertensive disorders of pregnancy (HDP) for primary prevention and early detection of cardiovascular diseases (CVDs) in high-risk women. We aimed to evaluate the risk of cardiovascular outcomes later in life in women with prior HDP in different years postpartum and in preeclamptic women with severe features, or early onset of preeclampsia.

METHODS

We searched MEDLINE, Cochrane Library, Web of Science, and Scopus without language restriction for relevant articles published from inception to March 16, 2022. We included prospective and retrospective cohort studies assessing hypertension, ischemic heart disease, heart failure, venous thromboembolism, peripheral vascular disease, stroke, dementia, composite cardiovascular and/or cerebrovascular diseases, and mortality after 6 weeks postpartum, in women with prior HDP compared with controls. Two authors independently selected and appraised the studies. Article quality was independently assessed using the Newcastle-Ottawa Scale (NOS). Random-effect models were used for meta-analysis. Stratified analyses based on years postpartum, severity, and onset of preeclampsia were performed.

RESULTS

We included 59 studies for qualitative review, of which 56 were included in quantitative meta-analysis, involving 1,262,726 women with prior HDP and 14,711,054 controls. Women with prior HDP had increased risks of hypertension (relative risk [RR] 3.46, 95% confidence interval [CI]: 2.67-4.49), ischemic heart disease (RR 2.06, 95% CI: 1.38-3.08), and heart failure (RR 2.53, 95% CI: 1.28-5.00) later in life, compared with those with normotensive pregnancies. The risk of hypertension was highest during 5 years postpartum (RR 5.34, 95% CI: 2.74-10.39). Compared with normotensive pregnancies, the risk of future CVDs significantly increased in preeclamptic women.

DISCUSSION

A history of HDP is associated with approximately 2- to 4-fold increase in the risk of CVDs. Screening for CVDs and their risk factors in women with prior HDP since delivery, especially the first 5 years after delivery is suggested for early detection and appropriate management. Evidence on the risks of CVDs in preeclampsia with severe features and early onset of preeclampsia is limited due to having few studies and high heterogeneity.

FUNDING

The Royal Golden Jubilee PhD Program-RGJ (PHD/0183/2561); Thailand Science Research and Innovation (TSRI) Research Career Development Grant-RSA (RSA6180009); Targeted Research Grants Program of the Faculty of Medicine, Prince of Songkla University, Thailand.

REGISTRATION

CRD42020191550.

Influence of Gestational Hypertension on Cardiovascular Health Behaviors and Factors

Objective

A survey was conducted to analyze the epidemiological differences in ideal cardiovascular health (CVH) behaviors and factors after delivery in females with and without gestational hypertension (GH) and evaluate the influence of GH on cardiovascular health behaviors and factors.

Methods

The present study adopted a cross-sectional design. A total of 4620 female workers who gave birth between 1976 and 2012 and received the annual health examination (2012 to 2013) at hospitals belonging to the Kailuan Medical Group were recruited. These subjects were divided into the GH group and non-GH (NGH) group, depending on whether they were combined with GH or not at delivery. The epidemiological differences in CVH behaviors and factors were compared between the two groups.

Result

In both groups, the percentage of subjects achieving ideal smoking status was the highest, while the percentage of subjects achieving an ideal level of physical activity was the lowest among all behaviors and factors. Compared with the NGH group, the percentages of subjects achieving each of the seven ideal CVH metrics decreased in the GH group. The percentages of subjects achieving ideal body mass index (BMI), blood pressure, blood glucose level, and cholesterol level were significantly lower in the GH group than in the NGH group (P < 0.05). The percentage of subjects with an ideal level of physical activity was higher in the NGH group than in the GH group. After stratification by age, the percentages of patients achieving ideal BMI, blood pressure, and blood glucose decreased with age regardless of the history of GH (P < 0.05). In the younger age group, the percentage of subjects with GH achieving ideal body mass index was significantly lower than that of those without GH.

Conclusion

Compared with females without GH, those with GH had higher BMI, blood pressure, blood glucose level, and cholesterol level among the seven CVH metrics surveyed.

Maternal Hypertension Increases Risk of Preeclampsia and Low Fetal Birthweight: Genetic Evidence From a Mendelian Randomization Study

BACKGROUND

Maternal cardiovascular risk factors have been associated with adverse maternal and fetal outcomes. Given the difficulty in establishing causal relationships using epidemiological data, we applied Mendelian randomization to explore the role of cardiovascular risk factors on risk of developing preeclampsia or eclampsia, and low fetal birthweight.

METHODS

Uncorrelated single-nucleotide polymorphisms associated systolic blood pressure (SBP), body mass index, type 2 diabetes, LDL (low-density lipoprotein) with cholesterol, smoking, urinary albumin-to-creatinine ratio, and estimated glomerular filtration rate at genome-wide significance in studies of 298 957 to 1 201 909 European ancestry participants were selected as instrumental variables. A 2-sample Mendelian randomization study was performed with primary outcome of preeclampsia or eclampsia (PET). Risk factors associated with PET were further investigated for their association with low birthweight.

RESULTS

Higher genetically predicted SBP was associated increased risk of PET (odds ratio [OR] per 1-SD SBP increase 1.90 [95% CI=1.45-2.49]; P=3.23×10-6) and reduced birthweight (OR=0.83 [95% CI=0.79-0.86]; P=3.96×10-18), and this was not mediated by PET. Body mass index and type 2 diabetes were also associated with PET (respectively, OR per 1-SD body mass index increase =1.67 [95% CI=1.44-1.94]; P=7.45×10-12; and OR per logOR increase type 2 diabetes =1.11 [95% CI=1.04-1.19]; P=1.19×10-3), but not with reduced birthweight.

CONCLUSIONS

Our results provide evidence for causal effects of SBP, body mass index, and type 2 diabetes on PET and identify that SBP is associated with reduced birthweight independently of PET. The results provide insight into the pathophysiological basis of PET and identify hypertension as a potentially modifiable risk factor amenable to therapeutic intervention.

The evolving role of coronary computed tomography in understanding sex differences in coronary atherosclerosis

Our understanding of sex differences in subclinical atherosclerosis and plaque composition and characteristics have greatly improved with the use of coronary computed tomography (CCTA) over the past years. CCTA has emerged as an important frontline diagnostic test for women, especially as we continue to understand the impact of non-obstructive atherosclerosis as well as diffuse, high risk plaque as precursors of acute cardiac events in women. Based on its ability to identify complex plaque morphology such as low attenuation plaque, high risk non calcified plaque, positive remodeling, fibrous cap, CCTA can be used to assess plaque characteristics. CCTA can avoid false positive of other imaging studies, if included earlier in assessment of ischemic symptoms. In the contemporary clinical setting, CCTA will prove useful in further understanding and managing cardiovascular disease in women and those without traditional obstructive coronary disease.

Maternal circulating concentrations of soluble Fas and Elabela in early- and late-onset preeclampsia

OBJECTIVE

The Fas/Fas ligand (FASL) system and Elabela-apelin receptor signaling pathways are implicated in the pathophysiology of preeclampsia. The aim of the current study was to investigate whether a model combining the measurement of sFas and Elabela in the maternal circulation may serve as a clinical biomarker for early- and/or late-onset preeclampsia more effectively than measures of each biomarker individually.

METHODS

Blood samples were collected from 214 women in the following groups: (1) normal pregnancy sampled <34 weeks of gestation (n = 56); (2) patients who developed early-onset preeclampsia (n = 54); (3) normal pregnancy sampled ≥34 weeks of gestation (n = 52); (4) patients who developed late-onset preeclampsia (n = 52). Maternal circulating soluble Fas and Elabela concentrations were determined using sensitive and validated immunoassays. Two sample t-tests, multivariate logistic regression, and receiver operating characteristic curves were used for analyses.

RESULTS

(1) Women with early-onset preeclampsia, and those with late-onset preeclampsia with placental lesions of maternal vascular malperfusion, had increased concentrations of sFas compared to their gestational age-matched normal controls; (2) women with late-onset preeclampsia, but not those with early-onset preeclampsia, had increased concentrations of Elabela compared to their gestational age-matched counterparts; and (3) an increase in both Elabela and sFas concentrations was more strongly associated with late-onset preeclampsia than early-onset preeclampsia relative to models including either of the markers alone.

CONCLUSIONS

A combined model of maternal sFas and Elabela concentrations provides a stronger association with late-onset preeclampsia than either protein alone. This finding demonstrates the possibility to improve the classification of late-onset preeclampsia by combining the results of both molecular biomarkers.

Maternal Cardiovascular Disease After Pre-Eclampsia and Gestational Hypertension: A Narrative Review

Previous literature has highlighted that women who have a pregnancy affected by gestational hypertension or preeclampsia are at higher risk of cardiovascular disease (CVD) in later life. However, CVD is a composite of multiple outcomes, including coronary heart disease, heart failure, and stroke, and the risk of both CVD and hypertensive disorders of pregnancy varies by the population studied. We conducted a narrative review of the risk of cardiovascular outcomes for women with prior gestational hypertension and pre-eclampsia. Previous literature is summarized by country and ethnicity, with a higher risk of CVD and coronary heart disease observed after gestational hypertension and a higher risk of CVD, coronary heart disease and heart failure observed after pre-eclampsia in most of the populations studied. Only one study was identified in a low- or middle-income country, and the majority of studies were conducted in white or mixed ethnicity populations. We discuss potential interventions to mitigate cardiovascular risk for these women in different settings and highlight the need for a greater understanding of the epidemiology of CVD risk after gestational hypertension and pre-eclampsia outside of high-income, white populations.

Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy

Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants' risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.

Nativity-Related Disparities in Preeclampsia and Cardiovascular Disease Risk Among a Racially Diverse Cohort of US Women

IMPORTANCE

Preeclampsia is an independent risk factor for future cardiovascular disease and disproportionally affects non-Hispanic Black women. The association of maternal nativity and duration of US residence with preeclampsia and other cardiovascular risk factors is well described among non-Hispanic Black women but not among women of other racial and ethnic groups.

OBJECTIVE

To examine differences in cardiovascular risk factors and preeclampsia prevalence by race and ethnicity, nativity, and duration of US residence among Hispanic, non-Hispanic Black, and non-Hispanic White women.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis of the Boston Birth Cohort included a racially diverse cohort of women who had singleton deliveries at the Boston Medical Center from October 1, 1998, to February 15, 2016. Participants self-identified as Hispanic, non-Hispanic Black, or non-Hispanic White. Data were analyzed from March 1 to March 31, 2021.

EXPOSURES

Maternal nativity and duration of US residence (<10 vs ≥10 years) were self-reported.

MAIN OUTCOME AND MEASURES

Diagnosis of preeclampsia, the outcome of interest, was retrieved from maternal medical records.

RESULTS

A total of 6096 women (2400 Hispanic, 2699 non-Hispanic Black, and 997 non-Hispanic White) with a mean (SD) age of 27.5 (6.3) years were included in the study sample. Compared with Hispanic and non-Hispanic White women, non-Hispanic Black women had the highest prevalence of chronic hypertension (204 of 2699 [7.5%] vs 65 of 2400 [2.7%] and 28 of 997 [2.8%], respectively), obesity (658 of 2699 [24.4%] vs 380 of 2400 [15.8%] and 152 of 997 [15.2%], respectively), and preeclampsia (297 of 2699 [11.0%] vs 212 of 2400 [8.8%] and 71 of 997 [7.1%], respectively). Compared with their counterparts born outside the US, US-born women in all 3 racial and ethnic groups had a significantly higher prevalence of obesity (Hispanic women, 132 of 556 [23.7%] vs 248 of 1844 [13.4%]; non-Hispanic Black women, 444 of 1607 [27.6%] vs 214 of 1092 [19.6%]; non-Hispanic White women, 132 of 776 [17.0%] vs 20 of 221 [9.0%]), smoking (Hispanic women, 98 of 556 [17.6%] vs 30 of 1844 [1.6%]; non-Hispanic Black women, 330 of 1607 [20.5%] vs 53 of 1092 [4.9%]; non-Hispanic White women, 382 of 776 [49.2%] vs 42 of 221 [19.0%]), and severe stress (Hispanic women, 76 of 556 [13.7%] vs 85 of 1844 [4.6%]; non-Hispanic Black women, 231 of 1607 [14.4%] vs 120 of 1092 [11.0%]; non-Hispanic White women, 164 of 776 [21.1%] vs 26 of 221 [11.8%]). After adjusting for sociodemographic and cardiovascular risk factors, birth status outside the US (adjusted odds ratio [aOR], 0.74 [95% CI, 0.55-1.00]) and shorter duration of US residence (aOR, 0.62 [95% CI, 0.41-0.93]) were associated with lower odds of preeclampsia among non-Hispanic Black women. However, among Hispanic and non-Hispanic White women, maternal nativity (aOR for Hispanic women, 1.07 [95% CI, 0.72-1.60]; aOR for non-Hispanic White women, 0.98 [95% CI, 0.49-1.96]) and duration of US residence (aOR for Hispanic women <10 years, 1.04 [95% CI, 0.67-1.59]; aOR for non-Hispanic White women <10 years, 1.20 [95% CI, 0.48-3.02]) were not associated with preeclampsia.

CONCLUSIONS AND RELEVANCE

Nativity-related disparities in preeclampsia persisted among non-Hispanic Black women but not among Hispanic and non-Hispanic White women after adjusting for sociodemographic and cardiovascular risk factors. Further research is needed to explore the interplay of factors contributing to nativity-related disparities in preeclampsia, particularly among non-Hispanic Black women.

Incident Heart Failure Within the First and Fifth Year after Delivery Among Women With Hypertensive Disorders of Pregnancy and Prepregnancy Hypertension in a Diverse Population

Background Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension are associated with increased morbidity and mortality for the mother. Our aim was to investigate the relationships between HDP and pre-pregnancy hypertension with maternal heart failure (HF) within 1 and 5 years of delivery and to examine racial/ethnic differences. Methods and Results We conducted a retrospective cohort study in South Carolina (2004-2016) involving 425 649 women aged 12 to 49 years (58.9% non-Hispanic White [NHW], 31.5% non-Hispanic Black [NHB], 9.6% Hispanic) with a live, singleton birth. Incident HF was defined by hospital/emergency department visit and death certificate data. Pre-pregnancy hypertension and HDP (preeclampsia, eclampsia, or gestational hypertension) were based on hospitalization/emergency department visit and birth certificate data (i.e., gestational hypertension for HDP). The 425 649 women had pre-pregnancy hypertension without superimposed HDP (pre-pregnancy hypertension alone; 0.4%), HDP alone (15.7%), pre-pregnancy hypertension with superimposed HDP (both conditions; 2.2%), or neither condition in any pregnancy (81.7%). Incident HF event rates per 1000 person-years were higher in NHB than NHW women with HDP (HDP: 2.28 versus 0.96; both conditions: 4.30 versus 1.22, respectively). After adjustment, compared with women with neither condition, incident HF risk within 5 years of delivery was increased for women with pre-pregnancy hypertension (HR,2.55, 95% CI: 1.31-4.95), HDP (HR,4.20, 95% CI: 3.66-4.81), and both conditions (HR,5.25, 95% CI: 4.24-6.50). Conclusions Women with HDP and pre-pregnancy hypertension were at higher HF risk (highest for superimposed preeclampsia) within 5 years of delivery. NHB women with HDP had higher HF risk than NHW women, regardless of pre-pregnancy hypertension.

Cardiovascular events following pregnancy complicated by pre-eclampsia with emphasis on comparison between early- and late-onset forms: systematic review and meta-analysis

OBJECTIVE

To elucidate whether pre-eclampsia (PE) and the gestational age at onset of the disease (early- vs late-onset PE) have an impact on the risk of long-term maternal cardiovascular complications.

METHODS

MEDLINE, EMBASE and Scopus databases were searched until 15 April 2020 for studies evaluating the incidence of cardiovascular events in women with a history of PE, utilizing combinations of the relevant MeSH terms, keywords and word variants for 'pre-eclampsia', 'cardiovascular disease' and 'outcome'. Inclusion criteria were cohort or case-control design, inclusion of women with a diagnosis of PE at the time of the first pregnancy, and sufficient data to compare each outcome in women with a history of PE vs women with previous normal pregnancy and/or in women with a history of early- vs late-onset PE. The primary outcome was a composite score of maternal cardiovascular morbidity and mortality, including cardiovascular death, major cardiovascular and cerebrovascular events, hypertension, need for antihypertensive therapy, Type-2 diabetes mellitus, dyslipidemia and metabolic syndrome. Secondary outcomes were the individual components of the primary outcome analyzed separately. Data were combined using a random-effects generic inverse variance approach. MOOSE guidelines and the PRISMA statement were followed.

RESULTS

Seventy-three studies were included. Women with a history of PE, compared to those with previous normotensive pregnancy, had a higher risk of composite adverse cardiovascular outcome (odds ratio (OR), 2.05 (95% CI, 1.9-2.3)), cardiovascular death (OR, 2.18 (95% CI, 1.8-2.7)), major cardiovascular events (OR, 1.80 (95% CI, 1.6-2.0)), hypertension (OR, 3.93 (95% CI, 3.1-5.0)), need for antihypertensive medication (OR, 4.44 (95% CI, 2.4-8.2)), dyslipidemia (OR, 1.32 (95% CI, 1.3-1.4)), Type-2 diabetes (OR, 2.14 (95% CI, 1.5-3.0)), abnormal renal function (OR, 3.37 (95% CI, 2.3-5.0)) and metabolic syndrome (OR, 4.30 (95% CI, 2.6-7.1)). Importantly, the strength of the associations persisted when considering the interval (< 1, 1-10 or > 10 years) from PE to the occurrence of these outcomes. When stratifying the analysis according to gestational age at onset of PE, women with previous early-onset PE, compared to those with previous late-onset PE, were at higher risk of composite adverse cardiovascular outcome (OR, 1.75 (95% CI, 1.0-3.0)), major cardiovascular events (OR, 5.63 (95% CI, 1.5-21.4)), hypertension (OR, 1.48 (95% CI, 1.3-1.7)), dyslipidemia (OR, 1.51 (95% CI, 1.3-1.8)), abnormal renal function (OR, 1.52 (95% CI, 1.1-2.2)) and metabolic syndrome (OR, 1.66 (95% CI, 1.1-2.5).

CONCLUSIONS

Both early- and late-onset PE represent risk factors for maternal adverse cardiovascular events later in life. Early-onset PE is associated with a higher burden of cardiovascular morbidity and mortality compared to late-onset PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Preeclampsia Emerging as a Risk Factor of Cardiovascular Disease in Women

The objective of this literature review was to explore the long-term cardiovascular effects of preeclampsia in women. The primary goal was to determine which organs were most commonly affected in this population. Although it was previously believed that preeclampsia is cured after the delivery of the fetus and the placenta current evidence supports an association between preeclampsia and cardiovascular disease later in life, many years after the manifestation of this hypertensive pregnancy related disorder. Therefore preeclampsia may be emerging as a novel cardiovascular risk factor for women, which requires long-term follow up.

Maternal Coronary Heart Disease, Stroke, and Mortality Within 1, 3, and 5 Years of Delivery Among Women With Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension

Background Pre-pregnancy hypertension and hypertensive disorders of pregnancy (HDP; preeclampsia, eclampsia, gestational hypertension) are major health risks for maternal morbidity and mortality. However, it is unknown if racial/ethnic differences exist. We aimed to determine the impact of HDP and pre-pregnancy hypertension on maternal coronary heart disease, stroke, and mortality risk ≤1, 3, and 5 years post-delivery and by race/ethnicity ≤5 years. Methods and Results This retrospective cohort study included women aged 12 to 49 years with a live, singleton birth between 2004 to 2016 (n=254 491 non-Hispanic White; n=137 784 non-Hispanic Black; n=41 155 Hispanic). Birth and death certificates and International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) diagnosis codes in hospitalization/emergency department visit data defined HDP, pre-pregnancy hypertension, incident coronary heart disease and stroke, and all-cause mortality. During at least 1 pregnancy of the 433 430 women, 2.3% had pre-pregnancy hypertension with superimposed HDP, 15.7% had no pre-pregnancy hypertension with HDP, and 0.4% had pre-pregnancy hypertension without superimposed HDP, whereas 81.6% had neither condition. Maternal deaths from coronary heart disease, stroke, and all causes totaled 2136. Within 5 years of delivery, pre-pregnancy hypertension, and HDP were associated with all-cause mortality (hazard ratio [HR], 2.21; 95% CI, 1.61-3.03), incident coronary heart disease (HR, 3.79; 95% CI, 3.09-4.65), and incident stroke (HR, 3.10; 95% CI, 2.09-4.60). HDP alone was related to all outcomes. Race/ethnic differences were observed for non-Hispanic Black and non-Hispanic White women, respectively, in the associations of pre-pregnancy hypertension and HDP with all-cause mortality within 5 years of delivery (HR, 2.34 [95% CI, 1.58-3.47]; HR, 2.11 [95% CI, 1.23-3.65]; P interaction=0.001). Conclusions Maternal cardiovascular outcomes including mortality were increased ≤5 years post-delivery in HDP, pre-pregnancy hypertension, or pre-pregnancy hypertension with superimposed HDP. The race/ethnic interaction for all-cause mortality ≤5 years of delivery warrants further research.

Hypertensive Disorders of Pregnancy and Risk of Cardiovascular Disease-Related Morbidity and Mortality: A Systematic Review and Meta-Analysis

INTRODUCTION

Several studies have demonstrated that there is a higher risk of cardiovascular disease (CVD) in women with a history of hypertensive disorders of pregnancy (HDP). However, effect sizes varied greatly between these studies, and a complete overview of the existing data in the literature is lacking. We aimed to evaluate the association between HDP and the risk of CVD-related morbidity and mortality.

METHODS

Systematic literature searches were conducted in several electronic databases from inception to July 2019. Exposure of interest was any type of HDP. Outcomes of interest included any CVD, CVD-related mortality, and hypertension.

RESULTS

Sixty-six cohort and 7 case-control studies involving >13 million women were included. The overall combined relative risks (RRs) for women with a history of HDP compared with the reference group were 1.80 (95% confidence interval [CI] 1.67-1.94) for any CVD, 1.66 (1.49-1.84) for coronary artery heart disease, 2.87 (2.14-3.85) for heart failure, 1.60 (1.29-2.00) for peripheral vascular disease, 1.72 (1.50-1.97) for stroke, 1.78 (1.58-2.00) for CVD-related mortality, and 3.16 (2.74-3.64) for hypertension. Significant heterogeneity was partially explained by all or part of the variables including type of exposure, follow-up time, geographic region, and sample source.

CONCLUSIONS

Women with a history of HDP are at an increased risk of future CVD-related morbidity and mortality. Our study highlights the importance of life-long monitoring of cardiovascular risk factors in women with a history of HDP.

Future Cardiovascular Disease Risk for Women With Gestational Hypertension: A Systematic Review and Meta-Analysis

Background Inconsistent findings have been found among studies evaluating the risk of cardiovascular disease for women who have had pregnancies complicated by gestational hypertension (the new onset of high blood pressure without proteinuria during pregnancy). We provide a comprehensive review of studies to quantify the association between gestational hypertension and cardiovascular events in women. Methods and Results We conducted a systematic search of PubMed, Embase, and Web of Science in March 2019 for studies examining the association between gestational hypertension and any cardiovascular event. Two reviewers independently assessed the abstracts and full-text articles. Study characteristics and the relative risk (RR) of cardiovascular events associated with gestational hypertension were extracted from the eligible studies. Where appropriate, the estimates were pooled with inverse variance weighted random-effects meta-analysis. A total of 21 studies involving 3 60 1192 women (127 913 with gestational hypertension) were identified. Gestational hypertension in the first pregnancy was associated with a greater risk of overall cardiovascular disease (RR, 1.45; 95% CI, 1.17-1.80) and coronary heart disease (RR, 1.46; 95% CI, 1.23-1.73), but not stroke (RR, 1.26; 95% CI, 0.96-1.65) or thromboembolic events (RR, 0.88; 95% CI, 0.73-1.07). Women with 1 or more pregnancies affected by gestational hypertension were at greater risk of cardiovascular disease (RR, 1.81; 95% CI, 1.42-2.31), coronary heart disease (RR, 1.83; 95% CI, 1.33-2.51), and heart failure (RR, 1.77; 95% CI, 1.47-2.13), but not stroke (RR, 1.50; 95% CI, 0.75-2.99). Conclusions Gestational hypertension is associated with a greater risk of overall cardiovascular disease, coronary heart disease, and heart failure. More research is needed to assess the presence of a dose-response relationship between gestational hypertension and subsequent cardiovascular disease. Registration URL: https://www.crd.york.ac.uk/prosp​ero/; Unique identifier: CRD42018119031.

Comparing Perceived Social Support and Perceived Stress in Healthy Pregnant Women and Pregnant Women with Preeclampsia

Background

Preeclampsia is a prevalent side effect of pregnancy. Different studies have reported different results about the relationship between mental stress and blood pressure disorders. In addition, social support is highly important to help women who experience risky pregnancy in adapting to the stressors they experience. This study aimed to compare perceived social support and perceived stress in women with and without preeclampsia.

Methods and Materials

Fifty pregnant women definitely diagnosed with preeclampsia and 50 healthy pregnant women visiting public hospitals including Hazrat Masoumeh, Motazedi, and Imam Reza in Kermanshah-Iran took part in a descriptiveanalytical study from June 2017 to January 2018. Data gathering tools included demographics questionnaire, social support appraisals scale and perceived stress scale. The collected data was analyzed with SPSS (v.20) using independent t-test.

Results

The mean score of perceived social support in the preeclampsia and non-preeclampsia groups were 69.88±7.3 and 76.80±7.6 respectively (P<0.01). The mean score of perceived stress in the preeclampsia and non-preeclampsia groups were 35.6±8.7 and 26.01±5.56 respectively (P<0.01). This means that compared with healthy women, women with preeclampsia perceived more stress and less social support.

Conclusion

In comparison with healthy pregnant women, women with preeclampsia perceived more stress and less social support. Healthcare providers should recommended to pay more attention to improving social support and attenuating stress in pregnant women.

Maternal and birth cohort studies in the Gulf Cooperation Council countries: a systematic review and meta-analysis

BACKGROUND

We systematically reviewed and chronicled exposures and outcomes measured in the maternal and birth cohort studies in the Gulf Cooperation Council (GCC) countries and quantitatively summarized the weighted effect estimates between maternal obesity and (1) cesarean section (CS) and (2) fetal macrosomia.

METHODS

We searched MEDLINE-PubMed, Embase, Cochrane Library, Scopus, and Web of Science electronic databases up to 30 June 2019. We considered all maternal and birth cohort studies conducted in the six GCC countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE)). We categorized cohort studies on the basis of the exposure(s) (anthropometric, environmental, medical, maternal/reproductive, perinatal, or socioeconomic) and outcome(s) (maternal or birth) being measured. Adjusted weighted effect estimates, in the form of relative risks, between maternal obesity and CS and fetal macrosomia were generated using a random-effects model.

RESULTS

Of 3502 citations, 81 published cohort studies were included. One cohort study was in Bahrain, eight in Kuwait, seven in Qatar, six in Oman, 52 in Saudi Arabia, and seven in the UAE. Majority of the exposures studied were maternal/reproductive (65.2%) or medical (39.5%). Birth and maternal outcomes were reported in 82.7% and in 74.1% of the cohort studies, respectively. In Saudi Arabia, babies born to obese women were at a higher risk of macrosomia (adjusted relative risk (aRR), 1.15; 95% confidence interval (CI), 1.10-1.20; I2 = 50%) or cesarean section (aRR, 1.21; 95% CI, 1.15-1.26; I2 = 62.0%). Several cohort studies were only descriptive without reporting the magnitude of the effect estimate between the assessed exposures and outcomes.

CONCLUSIONS

Cohort studies in the GCC have predominantly focused on reproductive and medical exposures. Obese pregnant women are at an increased risk of undergoing CS delivery or macrosomic births. Longer-term studies that explore a wider range of environmental and biological exposures and outcomes relevant to the GCC region are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017068910.

Hypertensive Disorders of Pregnancy and Future Cardiovascular Health

Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations. These women are known to have higher cardiovascular morbidity and mortality later in life in comparison with parous controls who had normotensive pregnancies. Several studies have demonstrated that women with preeclampsia present in a state of segmental impaired myocardial function, biventricular chamber dysfunction, adverse biventricular remodeling, and hypertrophy, a compromised hemodynamic state and indirect echocardiographic signs of localized myocardial ischemia and fibrosis. These cardiac functional and geometric changes are known to have strong predictive value for cardiovascular disease in non-pregnant subjects. A "dose effect" response seems to regulate this relationship with severe HDP, early-onset HDP, coexistence of fetal growth disorders, and recurrence of HDP resulting in poorer cardiovascular measures. The mechanism underlying the relationship between HDP in younger women and cardiovascular disease later in life is unclear but could be explained by sharing of pre-pregnancy cardiovascular risk factors or due to a direct impact of HDP on the maternal cardiovascular system conferring a state of increased susceptibility to future metabolic or hemodynamic insults. If so, the prevention of HDP itself would become all the more urgent. Shortly after delivery, women who experienced HDP express an increased risk of classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile, and diabetes with higher frequency than controls. Within one or two decades after delivery, this group of women are more likely to experience premature cardiovascular events, such as symptomatic heart failure, myocardial ischemia, and cerebral vascular disease. Although there is general agreement that women who suffered from HDP should undertake early screening for cardiovascular risk factors in order to allow for appropriate prevention, the exact timing and modality of screening has not been standardized yet. Our findings suggest that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, stop smoking, healthy diet, and daily exercise which are well-established and cost-effective prevention strategies.

Association between cardiovascular diseases and pregnancy-induced hypertensive disorders in a population of Cameroonian women at Yaoundé: A case-control study

Background

Positive associations have been found between Hypertensive Disorders of Pregnancy gestational hypertension, preeclampsia and cardiovascular diseases within non-African populations, no data exist from sub-Saharan Africa. We aimed to assess this association in Cameroonian mothers.

Methods

We used a case-control study. Cases were women diagnosed with any arteriosclerotic cardiovascular disease between 2012 and 2017 at two major hospitals of Yaoundé. Controls were mothers of children who sought pediatric care at the Gyneco-obstetric hospital of Yaoundé, with no diagnosis of cardiovascular disease. We abstracted data from patient files to assess cardiovascular disease and used phone-based questionnaires to assess a prior history of Hypertensive Disorders of Pregnancy. We used logistic regression and propensity scores for data analysis.

Results

Out of 1228 individuals selected, 173 cases and 339 controls participated in the study. We found no increased risk of cardiovascular diseases for women with a history of Hypertensive Disorders of Pregnancy (OR = 0.83, 95% CI, 0.51 to 1.34). Women with gestational hypertension had 2.33 (95% CI, 0.99 to 5.50) times the risk of women with no history of Hypertensive Disorders of Pregnancy, an inverse association was observed between preeclampsia and cardiovascular diseases (OR = 0.28, 95% CI, 0.10 to 0.72).

Conclusions

Cameroonian women with a history of gestational hypertension may have a higher risk of cardiovascular diseases. However, population-based studies with more accurate data on the exposure are needed.

Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

Preeclampsia and Cardiovascular Disease in a Large UK Pregnancy Cohort of Linked Electronic Health Records

Background:

The associations between pregnancy hypertensive disorders and common cardiovascular disorders have not been investigated at scale in a contemporaneous population. We aimed to investigate the association between preeclampsia, hypertensive disorders of pregnancy, and subsequent diagnosis of 12 different cardiovascular disorders.

Methods:

We used linked electronic health records from 1997 to 2016 to recreate a UK population-based cohort of 1.3 million women, mean age at delivery 28 years, with nearly 1.9 million completed pregnancies. We used multivariable Cox models to determine the associations between hypertensive disorders of pregnancy, and preeclampsia alone (term and preterm), with 12 cardiovascular disorders in addition to chronic hypertension. We estimated the cumulative incidence of a composite end point of any cardiovascular disorder according to preeclampsia exposure.

Results:

During the 20-year study period, 18 624 incident cardiovascular disorders were observed, 65% of which had occurred in women under 40 years. Compared to women without hypertension in pregnancy, women who had 1 or more pregnancies affected by preeclampsia had a hazard ratio of 1.9 (95% confidence interval 1.53–2.35) for any stroke, 1.67 (1.54–1.81) for cardiac atherosclerotic events, 1.82 (1.34–2.46) for peripheral events, 2.13 (1.64–2.76) for heart failure, 1.73 (1.38–2.16) for atrial fibrillation, 2.12 (1.49–2.99) for cardiovascular deaths, and 4.47 (4.32–4.62) for chronic hypertension. Differences in cumulative incidence curves, according to preeclampsia status, were apparent within 1 year of the first index pregnancy. Similar patterns of association were observed for hypertensive disorders of pregnancy, while preterm preeclampsia conferred slightly further elevated risks.

Conclusions:

Hypertensive disorders of pregnancy, including preeclampsia, have a similar pattern of increased risk across all 12 cardiovascular disorders and chronic hypertension, and the impact was evident soon after pregnancy. Hypertensive disorders of pregnancy should be considered as a natural screening tool for cardiovascular events, enabling cardiovascular risk prevention through national initiatives.

Are Preeclampsia and Adverse Obstetrical Outcomes Predictors of Cardiovascular Disease? A Case-Control Study of Women With Heart Disease

OBJECTIVE

This study sought to determine whether preeclampsia; gestational diabetes; and adverse obstetrical outcomes such as placental abruption, intrauterine growth restriction, and preterm delivery are independent risk factors for cardiovascular disease later in life.

METHODS

This was a retrospective, age-matched, case-control study that surveyed 244 cases (women with confirmed coronary artery disease) and 246 controls (women who did not have coronary artery disease) on their obstetrical history and outcomes, as well as traditional cardiovascular risk factors. Analyses were performed using SAS software version 9.1.3. (Canadian Task Force Classification II-2).

RESULTS

Women with coronary artery disease had significantly higher rates of maternal complications such as gestational hypertension (odds ratio [OR] 3.34; 95% confidence interval [CI] 1.03-10.9), as well as conventional vascular risk factors such as dyslipidemia (OR 5.38; 95% CI 2.70-10.7), hypertension (OR 2.40; 95% CI 1.23-4.70), diabetes (OR 2.32; 95% CI 1.07-5.01), and smoking (current smoker: OR; 4.82 95% CI 1.66-14.00; former smoker: OR 2.86; 95% CI 1.43-5.71). There were more cases with preeclampsia (9.8%, vs. 5.4% in controls); however, the difference was not statistically significant.

CONCLUSION

Among the adverse maternal conditions, there was more gestational hypertension in women with coronary artery disease. In this study, hypertensive disorders of pregnancy were the most important maternal risk factors for cardiovascular disease later in life and should be flagged early for close monitoring and/or intervention.

Persistent cardiac dysfunction on echocardiography in African American women with severe preeclampsia

BACKGROUND

Cardiovascular disease (CVD) and preeclampsia both disproportionally affect African American women. Evidence continues to grow linking a history of preeclampsia to future CVD. Therefore, we sought to determine whether abnormalities in cardiac function, as determined by echocardiography, could be identified at the time of preeclampsia diagnosis in African American women, and if they persist into the early postpartum period.

STUDY DESIGN

This prospective blinded longitudinal cohort study was performed from April 2015 to May 2017. We identified African American women diagnosed with preterm (<37 weeks) preeclampsia with severe features and compared them to control normotensive pregnant women matched on race, gestational age, maternal age, and body mass index. We obtained transthoracic echocardiograms on cases and controls at time of diagnosis and again 4-12 weeks postpartum. We quantified the systolic function with longitudinal strain, ventricular-arterial coupling parameters and diastolic function.

RESULTS

There were 29 matched (case-control) pairs of African American women for a total of 58 women. At time of preeclampsia diagnosis, there was more abnormal cardiac function as evidenced by worse cardiac systolic function (longitudinal strain), increased chamber stiffness (end systolic elastance), and worse diastolic function (E/e') in preeclampsia cases compared to controls. These findings persisted 4-12 weeks postpartum. There were additional notable abnormalities in E/A, and Ea (arterial load) postpartum, indicative of potentially worse diastolic function and increased arterial stiffness in the postpartum period.

CONCLUSIONS

Among African American women, we found notable cardiac function differences between women with severe preeclampsia and healthy pregnant controls that persist postpartum.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention

Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.

Electronic Algorithm Is Superior to Hospital Discharge Codes for Diagnoses of Hypertensive Disorders of Pregnancy in Historical Cohorts

OBJECTIVES

To develop and validate criteria for the retrospective diagnoses of hypertensive disorders of pregnancy that would be amenable to the development of an electronic algorithm, and to compare the accuracy of diagnoses based on both the algorithm and diagnostic codes with the gold standard, of physician-made diagnoses based on a detailed review of medical records using accepted clinical criteria.

PATIENTS AND METHODS

An algorithm for hypertensive disorders of pregnancy was developed by first defining a set of criteria for retrospective diagnoses, which included relevant clinical variables and diagnosis of hypertension that required blood pressure elevations in greater than 50% of readings ("the 50% rule"). The algorithm was validated using the Rochester Epidemiology Project (Rochester, Minnesota). A stratified random sample of pregnancies and deliveries between January 1, 1976, and December 31, 1982, with the algorithm-based diagnoses was generated for review and physician-made diagnoses (normotensive, gestational hypertension, and preeclampsia), which served as the gold standard; the targeted cohort size for analysis was 25 per diagnosis category according to the gold standard. Agreements between (1) algorithm-based diagnoses and (2) diagnostic codes and the gold standard were analyzed.

RESULTS

Sensitivities of the algorithm for 25 normotensive pregnancies, 25 with gestational hypertension, and 25 with preeclampsia were 100%, 88%, and 100%, respectively, and specificities were 94%, 100%, and 100%, respectively. Diagnostic code sensitivities were 96% for normotensive pregnancies, 32% for gestational hypertension, and 96% for preeclampsia, and specificities were 78%, 96%, and 88%, respectively.

CONCLUSION

The electronic diagnostic algorithm was highly sensitive and specific in identifying and classifying hypertensive disorders of pregnancy and was superior to diagnostic codes.

Preeclampsia-eclampsia and future cardiovascular risk among women in Taiwan

OBJECTIVE

This study aims to examine the long-term cardiovascular and cerebrovascular risks in a large cohort of women with past history of preeclampsia and/or eclampsia.

MATERIALS AND METHODS

This is a retrospective longitudinal study using National Health Insurance Research Database from 1996 to 2010. We identified 1295 women with preeclampsia and eclampsia. The control group was 5180 pregnant women without preeclampsia/eclampsia, who were matched for age and date of delivery. The incidences of diabetes, dyslipidemia, hypertension and cardiovascular events after pregnancy were identified from medical records after the date of delivery to the date of an event or the end of the study.

RESULTS

The median follow-up duration was 9.8 years (interquartile 5.1-12.7 years). The incidences of diabetes, dyslipidemia, hypertension, congestive heart failure and cerebrovascular disease events were significantly greater in women with eclampsia or preeclampsia than those in controls. Eclampsia or preeclampsia increased the risk of diabetes, dyslipidemia, hypertension, congestive heart failure and cerebrovascular disease events (hazard ratio [HR] 3.84 and 5.42, P < 0.0001; HR 2.75 and 3.40, P < 0.0001; HR 6.52 and 7.31, P < 0.0001; HR 9.07, P = 0.0060 and 7.39, P < 0.0001; HR 10.71, P < 0.0001 and 3.47, P = 0.0048, respectively). The survival curves for the development of congestive heart failure and cerebrovascular disease in women with eclampsia/preeclampsia and in control differed significantly (Log-rank test P < 0.0001). From the curve, we can find dramatic increases of congestive heart failure and cerebrovascular disease incidences at roughly 3 years and 10 years since the diagnosis of eclampsia/preeclampsia.

CONCLUSIONS

Our study revealed that women with a history of preeclampsia/eclampsia were at increased risks for subsequent diagnoses of diabetes, dyslipidemia, hypertension, congestive heart failure and cerebrovascular disease. Preventive counseling, more vigilant screening and management for the modifiable risks should be provided to the affected women. Clinicians should closely monitor these patients in the first three years postpartum and continuously for up to at least a decade.

Gene-Centric Analysis of Preeclampsia Identifies Maternal Association at PLEKHG1

The genetic susceptibility to preeclampsia, a pregnancy-specific complication with significant maternal and fetal morbidity, has been poorly characterized. To identify maternal genes associated with preeclampsia risk, we assembled 498 cases and 1864 controls of European ancestry from preeclampsia case-control collections in 5 different US sites (with additional matched population controls), genotyped samples on a cardiovascular gene-centric array composed of variants from ≈2000 genes selected based on prior genetic studies of cardiovascular and metabolic diseases and performed case-control genetic association analysis on 27 429 variants passing quality control. In silico replication testing of 9 lead signals with P<10-4 was performed in independent European samples from the SOPHIA (Study of Pregnancy Hypertension in Iowa) and Inova cohorts (212 cases, 456 controls). Multiethnic assessment of lead signals was then performed in samples of black (26 cases, 136 controls), Hispanic (132 cases, 468 controls), and East Asian (9 cases, 80 controls) ancestry. Multiethnic meta-analysis (877 cases, 3004 controls) revealed a study-wide statistically significant association of the rs9478812 variant in the pleiotropic PLEKHG1 gene (odds ratio, 1.40 [1.23-1.60]; Pmeta=5.90×10-7). The rs9478812 effect was even stronger in the subset of European cases with known early-onset preeclampsia (236 cases diagnosed <37 weeks, 1864 controls; odds ratio, 1.59 [1.27-1.98]; P=4.01×10-5). PLEKHG1 variants have previously been implicated in genome-wide association studies of blood pressure, body weight, and neurological disorders. Although larger studies are required to further define maternal preeclampsia heritability, this study identifies a novel maternal risk locus for further investigation.

Association Between Gestational Hypertension and Risk of Cardiovascular Disease Among 617 589 Norwegian Women

Background

Preeclampsia and gestational hypertension (GH) are the most common hypertensive pregnancy disorders. Preeclampsia has been linked to increased risk of cardiovascular disease (CVD), but a similar association for GH has not been established. We aimed to determine the association between GH and subsequent CVD, and explore the additional role of small‐for‐gestational‐age infants, preterm delivery, and parity.

Methods and Results

Data from the Medical Birth Registry of Norway were linked to the Cardiovascular Disease in Norway project and the Norwegian Cause of Death Registry. Hazard ratios and 95% confidence intervals were computed using Cox proportional hazard regression, comparing women with and without GH during their first and/or second pregnancy. We included all women with a first delivery from 1980 through 2009 (n=617 589) and followed them for a median of 14.3 (quartile 1–quartile 3: 6.9–21.5) years. Women with GH in the first pregnancy had 1.8‐fold (95% confidence interval, 1.7–2.0) higher risk of subsequent CVD compared with women without any hypertensive pregnancy disorder. When GH occurred in combination with small‐for‐gestational‐age infants and/or preterm delivery, the hazard ratio was 2.6 (95% confidence interval, 2.3–3.0). When women with GH were compared with women with preeclampsia, the risk of CVD was comparable when the pregnancy complications occurred in either the first or second pregnancy but was significantly higher for preeclampsia without complications when the disorder occurred in both pregnancies.

Conclusions

GH was associated with increased risk of subsequent CVD, and the highest risk was observed when GH was combined with small‐for‐gestational‐age infants and/or preterm delivery.

Maternal and birth cohort studies in the Gulf Cooperation Council countries: protocol for a systematic review and narrative evaluation

INTRODUCTION

Cohort studies have revealed that genetic, socioeconomic, communicable and non-communicable diseases, and environmental exposures during pregnancy may influence the mother and her pregnancy, birth delivery and her offspring. Numerous studies have been conducted in the Gulf Cooperation Council (GCC) countries to examine maternal and birth health. The objectives of this protocol for a systematic review are to systematically review and characterise the exposures and outcomes that have been examined in the mother and birth cohort studies in the GCC region, and to summarise the strength of association between key maternal exposures during pregnancy (ie, body mass index) and different health-related outcomes (ie, mode of birth delivery). The review will then synthesise and characterise the consequent health implications and will serve as a platform to help identify areas that are overlooked, point out limitations of studies and provide recommendations for future cohort studies.

METHODS AND ANALYSIS

Medline, Embase, Cochrane Library and Web of Science electronic databases will be comprehensively searched. Two reviewers will independently screen each study for eligibility, and where discrepancies arise they will be discussed and resolved; otherwise a third reviewer will be consulted. The two reviewers will also independently extract data into a predefined Excel spreadsheet. The included studies will be categorised on the basis of whether the participant is a mother, infant or mother-infant dyad. Outcome variables will be divided along two distinctions: mother or infant. Exposure variables will be divided into six domains: psychosocial, biological, environmental, medical/medical services, maternal/reproductive and perinatal/child. Studies are expected to be of heterogeneous nature; therefore, quantitative syntheses might be limited.

ETHICS AND DISSEMINATION

There is no primary data collection; therefore, ethical review is not necessary. The findings of this review will be disseminated in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017068910.

Pre-Eclampsia and Eclampsia: An Update on the Pharmacological Treatment Applied in Portugal

Pre-eclampsia and eclampsia are two hypertensive disorders of pregnancy, considered major causes of maternal and perinatal death worldwide. Pre-eclampsia is a multisystemic disease characterized by the development of hypertension after 20 weeks of gestation, with the presence of proteinuria or, in its absence, of signs or symptoms indicative of target organ injury. Eclampsia represents the consequence of brain injuries caused by pre-eclampsia. The correct diagnosis and classification of the disease are essential, since the therapies for the mild and severe forms of pre-eclampsia are different. Thus, this review aims to describe the most advisable antepartum pharmacotherapy for pre-eclampsia and eclampsia applied in Portugal and based on several national and international available guidelines. Slow-release nifedipine is the most recommended drug for mild pre-eclampsia, and labetalol is the drug of choice for the severe form of the disease. Magnesium sulfate is used to prevent seizures caused by eclampsia. Corticosteroids are used for fetal lung maturation. Overall, the pharmacological prevention of these diseases is limited to low-dose aspirin, so it is important to establish the safest and most effective available treatment.

Environmental contaminants and preeclampsia: a systematic literature review

Preeclampsia is a medical condition specific to pregnancy characterized by high blood pressure and protein in the woman's urine, indicating kidney damage. It is one of the most serious reproductive conditions, posing substantial risks to the baby and potentially fatal for the mother. The causes of preeclampsia are largely unknown and environmental contaminants merit further investigation. The aim of this review was to determine the association between environmental chemical exposures and preeclampsia. PubMed was searched for articles examining a priori chemical exposures and preeclampsia through April 2018. Studies were included in our review if they included at least 10 cases, evaluated preeclampsia independent of gestational hypertension, and used either measured or modeled exposure assessments. Our review contained 28 investigations examining persistent organic pollutants (POP) (6 studies), drinking water contaminants (1 study), atmospheric pollutants (11 studies), metals and metalloids (6 studies), and other environmental contaminants (4 studies). There were an insufficient number of investigations on most chemicals to draw definitive conclusions, but strong evidence existed for an association between preeclampsia and cadmium (Cd). There is suggestive evidence for associations between nitrogen dioxide (NO₂), particulate matter (PM)_2.5, and traffic exposure with preeclampsia. There is evidence for an association between preeclampsia and Cd but insufficient literature to evaluate many other environmental chemicals. Additional studies using repeated measures, appropriate biological matrices, and mixtures methods are needed to expand this area of research and address the limitations of previous studies.

Quality measures in high-risk pregnancies: Executive Summary of a Cooperative Workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists

Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.

Risk Factors for Pregnancy-Associated Stroke in Women With Preeclampsia

BACKGROUND AND PURPOSE

Preeclampsia affects 3% to 8% of pregnancies and increases risk of pregnancy-associated stroke (PAS). Data are limited on which women with preeclampsia are at highest risk for PAS.

METHODS

Using billing data from the 2003 to 2012 New York State Department of Health inpatient database, we matched women with preeclampsia and PAS 1:3 to preeclamptic controls based on age and race/ethnicity. Pre-defined PAS risk factors included pregnancy complications, infection present on admission, vascular risk factors, prothrombotic states, and coagulopathies. We constructed multivariable conditional logistic regression models to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for independent risk factors for PAS.

RESULTS

Among women aged 12 to 55 years admitted to New York State hospitals for any reason during the study period (n=3 373 114), 88 857 had preeclampsia, and 197 of whom (0.2%) had PAS. In multivariable analysis, women with preeclampsia and stroke were more likely than controls to have severe preeclampsia or eclampsia (OR, 7.2; 95% confidence interval [CI], 4.6-11.3), infections present on admission (OR, 3.0; 95% CI, 1.6-5.8), prothrombotic states (OR, 3.5; 95% CI, 1.3-9.2), coagulopathies (OR, 3.1; 95% CI, 1.3-7.1), or chronic hypertension (OR, 3.2; 95% CI, 1.8-5.5). Additional analyses matched and stratified by severity of preeclampsia confirmed these results.

CONCLUSIONS

Infections, chronic hypertension, coagulopathies, and underlying prothrombotic conditions increase PAS risk in women with preeclampsia. These women may warrant closer monitoring.