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Guan C, Rodriguez C, Elder-Odame P, Minhas AS, Zahid S, Baker VL, Shufelt CL, Michos ED. Assisted reproductive technology: what are the cardiovascular risks for women? Expert Rev Cardiovasc Ther 2023; 21:663-673. [PMID: 37779500 PMCID: PMC10615881 DOI: 10.1080/14779072.2023.2266355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/29/2023] [Indexed: 10/03/2023]
Abstract
INTRODUCTION Infertility affects 15% of women of reproductive age in the United States. The use of assisted reproductive technology (ART) has been rising globally, as well as a growing recognition of reproductive factors that increase risk for cardiovascular disease (CVD). AREAS COVERED Women with infertility who use ART are more likely to have established CVD risk factors, such as obesity, dyslipidemia, hypertension, and diabetes. They are also more likely to experience adverse pregnancy outcomes, which are associated with both peripartum and long-term cardiovascular complications. ART may lead to increased cardiometabolic demands due to ovarian stimulation, pregnancy itself, and higher rates of multifetal gestation. Preeclampsia risk appears greater with frozen rather than fresh embryo transfers. EXPERT OPINION The use of ART and its association with long term CVD has not been well-studied. Future prospective and mechanistic studies investigating the association of ART and CVD risk may help determine causality. Nevertheless, CVD risk screening is critical pre-pregnancy and during pregnancy to reduce pregnancy complications that elevate future CVD risk. This also offers a window of opportunity to connect patients to longitudinal care for early management of cardiometabolic risk profile and initiation of preventive lifestyle and pharmacotherapy interventions tailored toward patient-specific risk factors.
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Affiliation(s)
- Carolyn Guan
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Carla Rodriguez
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Petal Elder-Odame
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Anum S. Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Salman Zahid
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR
| | - Valerie L. Baker
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine
| | | | - Erin D. Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Lucia M, Viviana M, Alba C, Giulia D, Carlo DR, Grazia PM, Luca T, Federica VM, Immacolata VA, Grazia PM. Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis. J Clin Med 2023; 12:jcm12082994. [PMID: 37109329 PMCID: PMC10141482 DOI: 10.3390/jcm12082994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/06/2023] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.
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Affiliation(s)
- Merlino Lucia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Matys Viviana
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Crognale Alba
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - D'Ovidio Giulia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Della Rocca Carlo
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, 04100 Latina, Italy
| | - Porpora Maria Grazia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Titi Luca
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Viscardi Maria Federica
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Volpicelli Agnese Immacolata
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
| | - Piccioni Maria Grazia
- Department of Maternal, Infantile and Urological Sciences, University of Rome La Sapienza, Viale del Policlinico 155, 00161 Rome, Italy
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Appiah D, Kim C, Fuquay T, de Riese C, Ebong IA, Nwabuo CC. Maternal age at birth of last child and cardiovascular disease mortality later in life among a national cohort of postmenopausal women from the United States. Menopause 2023; 30:393-400. [PMID: 36749913 DOI: 10.1097/gme.0000000000002158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Abstract
Maternal age at last birth of child is increasing in the United States, and it has been reported to influence future chronic diseases. In this study of nationally-representative sample of postmenopausal women, there was no conclusive association between maternal age at last birth of child and cardiovascular disease mortality later in life.
Objective
Maternal age at last birth (ALB) of child is increasing in the United States, and it has been reported to influence future chronic diseases. However, the relationship of ALB and cardiovascular disease (CVD) events later in life has not been widely studied. We evaluated the association of ALB with CVD mortality.
Methods
Data were from 7,971 parous postmenopausal women older than 45 years who participated in the US National Health and Nutritional Examination Survey from 1999 to 2018 and had mortality follow-up data through to December 31, 2019. ALB was self-reported, whereas CVD mortality was assessed using International Classification of Diseases codes. Cox regression was used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI).
Results
The mean age of participants was 63 ± 9.8 years, with 9.5% being non-Hispanic Black, 9.7% being Hispanic women, and 21% reporting ALB ≥35 years. During a median follow-up of 8.1 years, 443 participants died from CVD. In age-adjusted models, CVD mortality was elevated for women with ALB of <25 years (HR, 1.68; 95% CI, 1.23-2.29) and ALB of ≥35 years (HR, 1.37; 95% CI, 1.00-1.88). However, after additional adjustment for race and ethnicity, foreign born, education, marital status, poverty income ratio, parity, smoking status, age at menarche, oral contraceptive pills use and family history of myocardial infarction, these estimates were attenuated resulting in no association between ALB and CVD mortality.
Conclusions
In this study of nationally representative sample of postmenopausal women, there was no conclusive association between maternal ALB and CVD mortality later in life.
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Affiliation(s)
- Duke Appiah
- From the Department of Public Health, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Catherine Kim
- Department of Obstetrics & Gynecology, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Taylor Fuquay
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Cornelia de Riese
- Departments of Medicine and Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Imo A Ebong
- Division of Cardiovascular Sciences, University of California, Davis, Sacramento, CA
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4
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Stroke in Pregnancy. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023. [DOI: 10.1007/s13669-023-00351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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5
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Paternal age impairs in vitro embryo and in vivo fetal development in murine. Sci Rep 2022; 12:13031. [PMID: 35906367 PMCID: PMC9338298 DOI: 10.1038/s41598-022-16469-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Abstract
The association between advanced paternal age and impaired reproductive outcomes is still controversial. Several studies relate decrease in semen quality, impaired embryo/fetal development and offspring health to increased paternal age. However, some retrospective studies observed no alterations on both seminal status and reproductive outcomes in older men. Such inconsistency may be due to the influence of intrinsic and external factors, such as genetics, race, diet, social class, lifestyle and obvious ethical issues that may bias the assessment of reproductive status in humans. The use of the murine model enables prospective study and owes the establishment of homogeneous and controlled groups. This study aimed to evaluate the effect of paternal age on in vitro embryo development at 4.5 day post conception and on in vivo fetal development at 16 days of gestation. Murine females (2–4 months of age) were mated with young (4–6 months of age) or senile (18–24 months of age) males. We observed decreased in vitro cleavage, blastocyst, and embryo development rates; lighter and shorter fetuses in the senile compared to the young group. This study indicated that advanced paternal age negatively impacts subsequent embryo and fetal development.
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Pregnancy After 40: Recommendations for Counseling, Evaluation, and Management From Preconception to Delivery. Obstet Gynecol Surv 2022; 77:111-121. [DOI: 10.1097/ogx.0000000000000967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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7
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Jalnapurkar S, Xu KH, Zhang Z, Bairey Merz CN, Elkayam U, Pai RG. Changing Incidence and Mechanism of Pregnancy-Associated Myocardial Infarction in the State of California. J Am Heart Assoc 2021; 10:e021056. [PMID: 34668401 PMCID: PMC8751836 DOI: 10.1161/jaha.121.021056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The objective of this study was to evaluate the temporal trends in pregnancy-associated myocardial infarction (PAMI) in the State of California and explore potential risk factors and mechanisms. Methods and Results The California State Inpatient Database was analyzed from 2003 to 2011 for patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for acute myocardial infarction and pregnancy or postpartum admissions; risk factors were analyzed and compared with pregnant patients without myocardial infarction. A total of 341 patients were identified with PAMI from a total of 5 266 380 pregnancies (incidence of 6.5 per 100 000 pregnancies). Inpatient maternal mortality rate was 7%, and infant mortality rate was 3.5% among patients with PAMI. There was a nonsignificant trend toward an increase in PAMI incidence from 2003 to 2011, possibly attributable to higher incidence of spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome. PAMI, when compared with pregnant patients without myocardial infarction, was significant for older age (aged >30 years in 72% versus 37%, P<0.0005), higher preponderance of Black race (12% versus 6%, P<0.00005), lower socioeconomic status (median household income in lowest quartile 26% versus 20%, P=0.04), higher prevalence of hypertension (26% versus 7%, P<0.0005), diabetes (7% versus 1%, P<0.0005), anemia (31% versus 7%, P<0.0001), amphetamine use (1% versus 0%, P<0.00005), cocaine use (2% versus 0.2%, P<0.0001), and smoking (6% versus 1%, P=0.0001). Conclusions There has been a trend toward an increase in PAMI incidence in California over the past decade, with an increasing trend in spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome as mechanisms. These findings warrant further investigation.
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Affiliation(s)
- Sawan Jalnapurkar
- Department of Internal Medicine and CardiologyUniversity of California Riverside School of MedicineRiversideCA
| | - Karen Huaying Xu
- Department of StatisticsUniversity of California RiversideLos AngelesCA
| | - Zhiwei Zhang
- Department of StatisticsUniversity of California RiversideLos AngelesCA
| | | | - Uri Elkayam
- University of Southern CaliforniaLos AngelesCA
| | - Ramdas G. Pai
- Department of Internal Medicine and CardiologyUniversity of California Riverside School of MedicineRiversideCA
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8
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Abstract
Pregnancy confers a substantially increased risk of stroke, especially during the third trimester and until 6 weeks postpartum. Hypertensive disorders of pregnancy and gestational hypercoagulability are important contributors to obstetric stroke. Preeclampsia and eclampsia confer risk for future cardiovascular disease. Hemorrhagic stroke is the most common type of obstetric stroke. Ischemic stroke can result from cardiomyopathy, paradoxical embolism, posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and dissections. Cerebral venous sinus thrombosis is a frequent complication of pregnancy.
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Affiliation(s)
- Erica C Camargo
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 729-C, Boston, MA 02114, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 729-C, Boston, MA 02114, USA.
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Never too late? Quadruplets at the age of 65 years. Arch Gynecol Obstet 2021; 304:851-854. [PMID: 34146145 PMCID: PMC8429373 DOI: 10.1007/s00404-021-06127-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/12/2021] [Indexed: 11/25/2022]
Abstract
Background We discuss the challenges of multiple pregnancy at very advanced reproductive age. Case presentation We present the case of a quadruplet pregnancy at the maternal age of 65 following in-vitro fertilization (IVF) with donor eggs and sperm, involving cross-border reproductive care. All children born were at 25 weeks’ gestation and survived; however, poor neurodevelopmental outcome remains a major concern in one child. Conclusions The use of reproductive technology to achieve a multiple pregnancy at such an advanced post-menopausal age generated a debate on ethical, psychosocial and medical questions. We share this debate and highlight the need to reconsider international guidelines for women of advanced reproductive age.
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10
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Correa-de-Araujo R, Yoon SS(S. Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age. J Womens Health (Larchmt) 2021; 30:160-167. [PMID: 33185505 PMCID: PMC8020515 DOI: 10.1089/jwh.2020.8860] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Although the influence of advanced maternal age (AMA) and delayed childbearing on adverse maternal and perinatal outcomes has been studied extensively, no universal consensus on the definition of AMA exists. This terminology currently refers to the later years of a woman's reproductive life span and generally applies to women age ≥35 years. AMA increases the risk of pregnancy complications, including ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, congenital anomalies, placenta previa and abruption, gestational diabetes, preeclampsia, and cesarean delivery. Such complications could be the cause of preterm birth and increase the risk of perinatal mortality. For women who have a chronic illness, pregnancy may lead to additional risk that demands increased monitoring or surveillance. The management of pregnant women of AMA requires understanding the relationship between age and preexisting comorbidities. The outcomes from pregnancy in AMA may have a negative impact on women's health as they age because of both the changes from the pregnancy itself and the increased risk of pregnancy-related complications. Postpartum depression affects women of AMA at higher rates. Links between preeclampsia and the risk of future development of cardiovascular disease require follow-up surveillance. The association between hypertensive pregnancy disorders and cognitive and brain functions needs further investigation of sex-specific risk factors across the life span. Educating providers and women of AMA is crucial to facilitate clinical decision making and such education should consider cultural influences, risk perception, and women's health literacy, as well as providers' biases and system issues.
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Affiliation(s)
- Rosaly Correa-de-Araujo
- Division of Geriatrics and Clinical Gerontology, U.S. Department of Health and Human Services, National Institute on Aging, National Institutes of Health, Bethesda, Maryland, USA
| | - Sung Sug (Sarah) Yoon
- Division of Extramural Science Programs, U.S. Department of Health and Human Services, National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
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11
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O’Kelly AC, Scott NS. Cardiovascular Evaluation and Considerations for Women of Advanced Maternal Age Desiring Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00857-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Katsuragi S, Tanaka H, Hasegawa J, Kurasaki A, Nakamura M, Kanayama N, Nakata M, Hayata E, Murakoshi T, Yoshimatsu J, Osato K, Tanaka K, Oda T, Sekizawa A, Shimaoka T, Ishiwata I, Takahashi J, Ikeda T. Perinatal outcome in case of maternal death for cerebrovascular acute disorders: a nationwide study in Japan. J Matern Fetal Neonatal Med 2020; 35:2429-2434. [PMID: 32674694 DOI: 10.1080/14767058.2020.1786511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The goal of this study is to find clues to improve perinatal outcomes in the case of cerebrovascular acute disorders during pregnancy. STUDY DESIGN We analyzed 35 cases of cerebrovascular diseases related to maternal deaths in Japan those that occurred during pregnancy and reported to the Committee of the Ministry of Health, Labor, and Welfare from 2010 to 2018. RESULTS Cerebrovascular acute disorders occurred at 34.6 ± 6.6 gestational weeks. There were seven intrauterine fetal deaths (IUFD), and eight cases showed neonatal asphyxia with umbilical arterial pH between 6.7 and 7.0 (asphyxia cases, n = 15). In two of eight newborns, brain hypothermia therapy was given, and all survived without neurological sequelae. Maternal dyspnea was significantly related to severe prolonged decelerations of the fetus (p < .05), and asphyxia cases (p < .005). Median time from maternal onset to delivery (OD time) was significantly longer in asphyxia cases than in the non-asphyxia cases (84 vs 29 min, p < .05). OD time over 30 min was significantly related to the antepartum occurrence, cervical dilatation <5 cm (p < .05), onset outside of the hospital (p < .001), and maternal transfer before delivery (p < .001). CONCLUSION More than 40% of cases experienced fetal asphyxia, and 20% ended in IUFD in maternal deaths related to cerebrovascular acute disorders. Maternal respiratory support and rapid delivery would be the keys to improve perinatal outcomes in case of cerebrovascular acute disorders during pregnancy.
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Affiliation(s)
- Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Akiko Kurasaki
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masamitsu Nakamura
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University, Tokyo, Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral Cardiovascular Center, Osaka, Japan
| | - Kazuhiro Osato
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
| | - Tomoaki Oda
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Takako Shimaoka
- Department of Obstetrics and Gynecology, Sagamihara National Hospital, Kanagawa, Japan
| | - Isamu Ishiwata
- Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
| | - Jun Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Mie, Japan
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Meeks JR, Bambhroliya AB, Alex KM, Sheth SA, Savitz SI, Miller EC, McCullough LD, Vahidy FS. Association of Primary Intracerebral Hemorrhage With Pregnancy and the Postpartum Period. JAMA Netw Open 2020; 3:e202769. [PMID: 32286658 PMCID: PMC7156993 DOI: 10.1001/jamanetworkopen.2020.2769] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Intracerebral hemorrhage (ICH) during pregnancy and the postpartum period results in catastrophic maternal outcomes. There is a paucity of population-based estimates of pregnancy-related ICH risk, including risk during the extended postpartum period. OBJECTIVE To evaluate ICH risk during pregnancy and an extended 24-week postpartum period in a population-level cohort and to determine fetal and maternal outcomes as well as demographic and comorbidity factors associated with ICH during pregnancy and post partum. DESIGN, SETTING, AND PARTICIPANTS This study used a cohort-crossover design in which patients serve as their own controls when no longer exposed (pregnant or post partum). Administrative data were obtained from all hospital admissions for New York, California, and Florida for a 7- to 10-year period. Participants included all women admitted for labor and delivery who were older than 12 years and did not have a prior diagnosis of ICH. Conditional Poisson regression models were used to evaluate ICH risk, and data were reported as rate ratios and 95% CIs. Data analysis was performed from August 2018 to February 2020. EXPOSURES Women were tracked using hospitalization records for the duration of pregnancy (40 weeks), for 24 weeks post partum, and for an additional 64 weeks when no longer exposed. MAIN OUTCOMES AND MEASURES Diagnosis of ICH during both 64-week observation periods was determined using validated International Classification of Diseases, Ninth Revision codes. RESULTS A total of 3 314 945 pregnant women were included (mean [SD] age, 28.17 [6.47] years; 1 451 780 white [43.79%], 474 808 black [14.32%], 246 789 Asian [7.44%], and 835 917 Hispanic [25.22%]). The risk of ICH was significantly higher during the third trimester (2.9 vs 0.7 cases per 100 000 pregnancies; rate ratio, 4.16; 95% CI, 2.52-6.86) and remained elevated during the first 12 weeks post partum (4.4 vs 0.5 cases per 100 000 pregnancies; rate ratio, 9.15; 95% CI, 5.16-16.23). Advanced maternal age (adjusted odds ratio [OR], 1.08; 95% CI, 1.05-1.10), nonwhite race (adjusted ORs, 2.44 [95% CI, 1.73-3.44] for black patients, 2.12 [95% CI, 1.34-3.35] for Asian patients, and 1.59 [95% CI, 1.12-2.26] for Hispanic patients), hypertension (adjusted OR, 2.02; 95% CI, 1.19-3.42), coagulopathy (adjusted OR, 14.17; 95% CI, 9.17-21.89), preeclampsia or eclampsia (adjusted OR, 9.23; 95% CI, 6.99-12.19), and tobacco use (adjusted OR, 2.83; 95% CI, 1.53-5.23) were independently associated with ICH during pregnancy and the postpartum period. Pregnancy-related ICH was associated with a higher risk of maternal (relative risk difference, 792.6; absolute risk difference, 0.18) and fetal (relative risk difference, 5.3; absolute risk difference, 0.03) death, compared with pregnancies without ICH. CONCLUSIONS AND RELEVANCE These findings suggest that the risk of ICH is significantly higher during the third trimester of pregnancy and the first 12 weeks post partum. There are age and race disparities in ICH risk that are associated with devastating maternal and fetal outcomes. These data illustrate the critical need for continuous monitoring and aggressive management of ICH-associated risk factors. These findings suggest that extended postpartum monitoring of high-risk women may be warranted.
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Affiliation(s)
- Jennifer R. Meeks
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
| | | | - Katie M. Alex
- Department of Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Sunil A. Sheth
- Department of Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Sean I. Savitz
- Department of Neurology, McGovern Medical School, UTHealth, Houston, Texas
| | - Eliza C. Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | | | - Farhaan S. Vahidy
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas
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14
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Cauldwell M, Steer PJ, von Klemperer K, Kaler M, Grixti S, Hale J, O'Heney J, Warriner D, Curtis S, Mohan AR, Dockree S, Mackillop L, Head CEG, Sterrenberg M, Wallace S, Freeman LJ, Patridge G, Baalman JH, McAuliffe FM, Simpson M, Walker N, Girling J, Siddiqui F, Bolger AP, Bredaki F, Walker F, Vause S, Gatzoulis MA, Johnson MR, Roberts A. Maternal and neonatal outcomes in women with history of coronary artery disease. Heart 2019; 106:380-386. [DOI: 10.1136/heartjnl-2019-315325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/25/2019] [Accepted: 08/05/2019] [Indexed: 01/12/2023] Open
Abstract
BackgroundPregnancy outcomes in women with pre-existing coronary artery disease (CAD) are poorly described. There is a paucity of data therefore on which to base clinical management to counsel women, with regard to both maternal and neonatal outcomes.MethodWe conducted a retrospective multicentre study of women with established CAD delivering at 16 UK specialised cardiac obstetric clinics. We included pregnancies of 24 weeks’ gestation or more, delivered between January 1998 and October 2018. Data were collected on maternal cardiovascular, obstetric and neonatal events.Results79 women who had 92 pregnancies (94 babies including two sets of twins) were identified. 35.9% had body mass index >30% and 24.3% were current smokers. 18/79 (22.8%) had prior diabetes, 27/79 (34.2%) had dyslipidaemia and 21/79 (26.2%) had hypertension. The underlying CAD was due to atherosclerosis in 52/79 (65.8%), spontaneous coronary artery dissection (SCAD) in 11/79 (13.9%), coronary artery spasm in 7/79 (8.9%) and thrombus in 9/79 (11.4%).There were six adverse cardiac events (6.6% event rate), one non-ST elevation myocardial infarction at 23 weeks’ gestation, two SCAD recurrences (one at 26 weeks’ gestation and one at 9 weeks’ postpartum), one symptomatic deterioration in left ventricular function and two women with worsening angina. 14% of women developed pre-eclampsia, 25% delivered preterm and 25% of infants were born small for gestational age.ConclusionWomen with established CAD have relatively low rates of adverse cardiac events in pregnancy. Rates of adverse obstetric and neonatal events are greater, highlighting the importance of multidisciplinary care.
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Abstract
Pregnancy confers a substantially increased risk of stroke in women. The period of highest risk of stroke is the peripartum/postpartum phase, coinciding with the highest risk for hypertensive disorders of pregnancy and peak gestational hypercoagulability. Hemorrhagic stroke is the most common type of obstetric stroke. Hypertensive disorders of pregnancy are important contributors to obstetric stroke and predispose women to premature cardiovascular disease. The rate of stroke associated with hypertensive disorders of pregnancy has increased in the United States. Other conditions associated with obstetric stroke include posterior reversible encephalopathy, reversible cerebral vasoconstriction syndrome, and cerebral venous sinus thrombosis.
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Affiliation(s)
- Erica C Camargo
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Steven K Feske
- Stroke Division, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 729-C, Boston, MA 02114, USA.
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16
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Cooke CLM, Davidge ST. Advanced maternal age and the impact on maternal and offspring cardiovascular health. Am J Physiol Heart Circ Physiol 2019; 317:H387-H394. [PMID: 31199185 DOI: 10.1152/ajpheart.00045.2019] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Delaying pregnancy, which is on the rise, may increase the risk of cardiovascular disease in both women and their children. The physiological mechanisms that lead to these effects are not fully understood but may involve inadequate adaptations of the maternal cardiovascular system to pregnancy. Indeed, there is abundant evidence in the literature that a fetus developing in a suboptimal in utero environment (such as in pregnancies complicated by fetal growth restriction, preterm birth, and/or preeclampsia) is at an increased risk of cardiovascular disease in adulthood, the developmental origins of health and disease theory. Although women of advanced age are at a significantly increased risk of pregnancy complications, there is limited information as to whether advanced maternal age constitutes an added stressor on the prenatal environment of the fetus, and whether or not this is secondary to impaired cardiovascular function during pregnancy. This review summarizes the current literature available on the impact of advanced maternal age on cardiovascular adaptations to pregnancy and the role of maternal age on long-term health risks for both the mother and offspring.
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Affiliation(s)
- Christy-Lynn M Cooke
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada.,Women and Children's Health Research Institute and the Cardiovascular Research Centre, Edmonton, Alberta, Canada
| | - Sandra T Davidge
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada.,Department of Physiology, University of Alberta, Edmonton, Alberta, Canada.,Women and Children's Health Research Institute and the Cardiovascular Research Centre, Edmonton, Alberta, Canada
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17
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Chung E, Haizlip KM, Leinwand LA. Pregnancy late in rodent life has detrimental effects on the heart. Am J Physiol Heart Circ Physiol 2018; 315:H482-H491. [PMID: 29750565 DOI: 10.1152/ajpheart.00020.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
During pregnancy, the heart undergoes significant and numerous changes, including hypertrophy, that are usually described as physiological and reversible. Two aspects of the cardiac response to pregnancy are relatively understudied: advanced maternal age and multiple pregnancies (multiparity). Repeated breeder (RB) mice that have undergone five to seven consecutive pregnancies were euthanized 21 days after the weaning of their last pups and compared with age-matched primiparous, one-time pregnant (O1P) mice. The ages of the older mouse groups were similar (12 ± 1 mo). Pregnancy at a later age resulted in reduced fertility (40%); resorption was 29%, maternal mortality was 10%, and mortality of the pups was 17%. Contractile function as indicated by percent fractional shortening was significantly decreased in O1P and RB groups compared with the old nonpregnant control (ONP) group. There was no pathological induction of the fetal program of gene expression, with the exception of β-myosin heavy chain mRNA, which was induced in O1P compared with ONP mice ( P < 0.05) but not in RB mice. MicroRNA-208a was significantly increased in O1P compared with ONP mice ( P < 0.05) but significantly decreased in RB compared with ONP mice ( P < 0.05). mRNA of genes regulating angiogenesis (i.e., vascular endothelial growth factor-A) were significantly downregulated, whereas proinflammatory genes [i.e., interleukin-6, chemokine (C-C motif) ligand 2, and Cd36] were significantly upregulated in O1P ( P < 0.05) but not in RB mice. Overall, our results suggest that rather than multiparity, pregnancy in advanced age is a much more stressful event in both pregnant dams and fetuses, as evidenced by increased mortality, lower fertility, downregulation of angiogenesis, upregulation of inflammation, and cardiac dysfunction. NEW & NOTEWORTHY Pregnancy in older mice significantly decreases cardiac function, although repeated breeder mice demonstrated increased wall hypertrophy and dilated chamber size compared with one-time pregnant mice. Interestingly, many of the molecular changes were altered in one-time pregnant mice but not in repeated breeder mice, which may contribute to adverse pregnancy outcomes in a first pregnancy at a later age.
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Affiliation(s)
- Eunhee Chung
- Department of Kinesiology, Health, and Nutrition, University of Texas at San Antonio , San Antonio, Texas
| | - Kaylan M Haizlip
- Department of Molecular, Cellular, and Developmental Biology and BioFrontiers Institute, University of Colorado , Boulder, Colorado
| | - Leslie A Leinwand
- Department of Molecular, Cellular, and Developmental Biology and BioFrontiers Institute, University of Colorado , Boulder, Colorado
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18
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Dayan N, Filion KB, Okano M, Kilmartin C, Reinblatt S, Landry T, Basso O, Udell JA. Cardiovascular Risk Following Fertility Therapy. J Am Coll Cardiol 2017; 70:1203-1213. [DOI: 10.1016/j.jacc.2017.07.753] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/30/2022]
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