Hypertensive Disorders of Pregnancy and Subsequent Risk of Premature Mortality

Echocardiographic assessment of left atrial mechanics in women with hypertensive disorders of pregnancy: A systematic review and meta-analysis

OBJECTIVE

The influence of hypertensive disorders of pregnancy (HDP) on left atrial (LA) mechanics assessed by speckle tracking echocardiography (STE) has been poorly investigated. Accordingly, we performed a meta-analysis to summarize the main findings of STE studies who measured LA reservoir (LASr), conduit (LAScd) and contractile (LASct) strain in HDP women.

STUDY DESIGN

All echocardiographic studies assessing LA strain parameters in HDP women vs. healthy controls, selected from PubMed and EMBASE databases, were included. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment of Case-Control Studies. Continuous data (LASr, LAScd and LASct) were pooled as standardized mean difference (SMD) comparing HDP group with healthy controls. The overall SMDs of LASr, LAScd and LASct were calculated using the random-effect model.

RESULTS

The full-texts of 8 studies with 566 HDP women and 420 healthy pregnant women were analyzed. Average LASr (34.3 ± 6.4 vs 42.7 ± 5.3 %, P = 0.01) and LAScd (23.4 ± 6.3 vs 32.5 ± 6.0 %, P < 0.001) were significantly lower in HDP women than controls, whereas LASct (-13.0 ± 5.4 vs -13.7 ± 4.5 %, P = 0.18) was similar in the two groups of women. Substantial heterogeneity was detected among the studies evaluating LASr (I2 = 94.3 %), LAScd (I2 = 64.9 %) and LASct (I2 = 86.4 %). SMDs were large and statistically significant for LASr (-1.70, 95 %CI -2.34,-1.06, P < 0.001) and LAScd (-1.35, 95 %CI -1.69,-1.00, P < 0.001), small and not statistically significant for LASct (-0.11, 95 %CI -0.60,0.39, P = 0.678) assessment. Egger's test gave P-values of 0.10, 0.34 and 0.75 for LASr, LAScd and LASct measurement respectively, indicating no publication bias. On meta-regression analysis, none of the moderators was significantly associated with effect modification for LASr and its components (all P < 0.05).

CONCLUSIONS

HDPs are independently associated with LASr impairment in pregnancy. STE allows to identify, among HDP women, those who might benefit from a more aggressive antihypertensive treatment and/or a closer clinical follow-up, aimed at reducing the risk of adverse maternal outcome and cardiovascular complications later in life.

Cardiovascular Risk Profile Among Reproductive-Aged Women in the U.S.: The Behavioral Risk Factor Surveillance System, 2015-2020

Introduction

Suboptimal cardiovascular health is associated with adverse pregnancy outcomes and long-term cardiovascular risk. The authors examined trends in cardiovascular risk factors and correlates of suboptimal cardiovascular risk profiles among reproductive-aged U.S. women.

Methods

With data from 335,959 women in the Behavioral Risk Factor Surveillance System (2015-2020), the authors conducted serial cross-sectional analysis among nonpregnant reproductive-aged women (18-44 years) without cardiovascular disease who self-reported information on 8 cardiovascular risk factors selected on the basis of Life's Essential 8 metrics. The authors estimated the prevalence of each risk factor and suboptimal cardiovascular risk profile (≥2 risk factors) and examined trends overall and by age and race/ethnicity. Using multivariable Poisson regression, the authors assessed the sociodemographic correlates of suboptimal cardiovascular risk profile.

Results

The weighted prevalence of women aged <35 years was approximately 64% in each survey year. The prevalence of suboptimal cardiovascular risk profile increased modestly from 72.4% (71.6%-73.3%) in 2015 to 75.9% (75.0%-76.7%) in 2019 (p<0.001). This increase was mainly driven by increases in overweight/obesity (53.1%-58.4%; p<0.001). Between 2015 and 2019, significant increases in suboptimal cardiovascular risk profile were observed among non-Hispanic White (69.8%-72.6%; p<0.001) and Hispanic (75.1%-80.3%; p<0.001) women but not among non-Hispanic Black (82.7%-83.7%; p=0.48) or Asian (68.1%-73.2%; p=0.09) women. Older age, rural residence, and non-Hispanic Black and Hispanic race and ethnicity were associated with a higher prevalence of suboptimal cardiovascular risk profile.

Conclusions

There has been a modest but significant increase in suboptimal cardiovascular risk profile among U.S. women of reproductive age. Urgent preventive efforts are needed to reverse this trend and improve cardiovascular health, particularly among subgroups at increased risk, to mitigate its implications.

Left Atrial Mechanics Following Preeclamptic Pregnancy

BACKGROUND

Preterm preeclampsia is a pregnancy complication associated with myocardial dysfunction and premature cardiovascular disease morbidity and mortality. Left atrial (LA) strain is a noninvasive index of left ventricular end diastolic pressure and an early marker of heart failure risk. This study aimed to evaluate LA strain during the postpartum period in participants with and without preterm preeclampsia and to assess whether this varied in the presence of hypertension, cardiac dysfunction or both.

METHODS

In this longitudinal cohort study, 321 women from 28 hospitals with preterm preeclampsia (cases) underwent cardiovascular assessment 6 months postpartum. This is a secondary analysis of the PHOEBE study (ISRCTN01879376). An uncomplicated pregnancy control group (n=30) was recruited from a single center for comparison. A full cross-sectional transthoracic echocardiogram was performed, and from these images, the myocardial strain of the left atrium, including reservoir, conduit, and contractile strain, as well as LA stiffness, were calculated.

RESULTS

At 6 months postpartum, compared with controls, prior preeclampsia was associated with a significantly attenuated LA reservoir, conduit, and contractile strain, as well as increased LA stiffness (all P<0.001). LA strain was further reduced in preeclamptic women who had and had not developed hypertension, systolic, or diastolic dysfunction at 6 months postpartum (all P<0.05).

CONCLUSIONS

LA mechanics were significantly attenuated at 6 months postpartum in participants with preterm preeclampsia, whether or not they remained hypertensive or had evidence of ventricular dysfunction. Further studies are needed to determine whether postnatal LA strain may identify women at greater risk for future cardiovascular disease.

Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging: A Randomized Clinical Trial

Importance

More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.

Objective

To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.

Design, Setting, and Participants

An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record.

Intervention

A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.

Main Outcome and Measures

Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient's electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted.

Results

A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%).

Conclusions and Relevance

The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being.

Trial Registration

ClinicalTrials.gov Identifier: NCT05543265.

Maternal Mental Health, COVID-19-Related Distress, and Disruptions in Lifestyle Behaviors Among Postpartum Mothers With a Previous Hypertensive Disorder of Pregnancy

BACKGROUND

Many perinatal people experienced pandemic-related distress and changes in health behaviors at the onset of the COVID-19 pandemic, but less is known about how the pandemic continued to impact their health.

OBJECTIVE

The authors of this study examined the influence of pandemic-related distress and maternal mental health on postpartum lifestyle behaviors of mothers with a previous hypertensive disorder of pregnancy.

METHODS

Between September 2021 and March 2022, 82 postpartum (19.2 ± 5.5 months) mothers with a hypertensive disorder of pregnancy completed measures of pandemic-related distress and pandemic-related disruption in lifestyle behaviors from the Coronavirus Perinatal Experiences Impact Survey. A Patient Health Questionnaire-9 score ≥ 10 and a score ≥ 3 on the Breslau scale indicated significant depressive and posttraumatic stress disorder (PTSD) symptoms, respectively.

RESULTS

Twenty-two (27.2%) and 30 (36.6%) participants had significant depressive or PTSD symptoms, respectively. In models adjusted for education, income, parity, delivery prepandemic or peripandemic, intervention group, and prepregnancy mental health history, both PTSD symptoms ( B = 0.229, P = .029) and pandemic-related distress ( B = 0.492, P < .001) associated with greater disruption in health behaviors. Depressive symptoms did not associate with greater disruption in health behaviors ( B = 0.169, P = .135).

CONCLUSION

Monitoring PTSD symptoms may be vital in supporting mothers with hypertensive disorders of pregnancy in making lifestyle changes to prevent cardiovascular disease.

Increasing Postpartum Primary Care Engagement through Default Scheduling and Tailored Messaging: A Randomized Clinical Trial

Importance

Over 30% of pregnant people have at least one chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face significant barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.

Objective

To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.

Design

Individual-level randomized controlled trial conducted from November 3, 2022 to October 11, 2023.

Setting

One hospital-based and five community-based outpatient obstetric clinics affiliated with a large academic medical center.

Participants

Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes mellitus, chronic hypertension, gestational diabetes, or pregnancy-related hypertension, and a primary care practitioner (PCP) listed in their electronic health record (EHR).

Intervention

A behavioral economics-informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.

Main Outcome

Completion of a PCP visit for routine or chronic condition care within 4 months of delivery.

Results

360 patients were randomized (Control: N=176, Intervention: N=184). Individuals had mean (SD) age 34.1 (4.9) years and median gestational age of 36.3 weeks (interquartile range (IQR) 34.0-38.6 weeks) at enrollment. The distribution of self-reported races was 7.4% Asian, 6.8% Black, 15.0% multiple races or "Other," and 68.6% White. Most (75.8%) participants had anxiety or depression, 15.9% had a chronic or pregnancy-related hypertensive disorder, 19.8% had pre-existing or gestational diabetes, and 40.4% had a pre-pregnancy BMI ≥30 kg/m2. Medicaid was the primary payer for 21.9% of patients. PCP visit completion within 4 months occurred in 22.0% in the control group and 40.0% in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95%CI 10.7-29.1). Intervention participants also had fewer postpartum readmissions (1.7 vs. 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8 vs. 28.3%), weight assessment (42.8 vs. 27.7%), and depression screening (32.8 vs. 16.8%).

Conclusions and Relevance

In this randomized trial of pregnant individuals with or at risk for chronic health conditions, default PCP visit scheduling, tailored messages, and reminders substantially improved postpartum primary care engagement. The current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual's short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and wellbeing.

Trial Registration

NCT05543265.

Incident Cardiovascular Disease in Women With Type 1 or Type 2 Diabetes Following a Hypertensive Disorder of Pregnancy

BACKGROUND

The extent to which a history of hypertensive disorders of pregnancy is associated with incident cardiovascular disease also among women with diabetes is unknown.

METHODS

In this nationwide register-based cohort study, parous women aged 18 to 69 years with a first delivery in the Swedish Medical Birth Register, regardless of diabetic status at that time, and a subsequent clinical visit in the Swedish National Diabetes Register were included. Time to first cardiovascular disease event (myocardial infarction, stroke, or heart failure) before age 70 years by hypertensive disorders of pregnancy history was separately analyzed by diabetes type using Cox regression models that included conventional risk factors.

RESULTS

In total, 1748 (18.9%) of 9230 women with type 1 and 5904 (10.6%) of 55 773 women with type 2 diabetes had their first delivery complicated by a hypertensive disorder of pregnancy. Median time (25-75th percentile) between first delivery and start of follow-up was 3.3 (1.4-13.0) years for women with type 1 and 29.8 (22.4-35.6) years for women with type 2 diabetes. In modeling, the risk for any cardiovascular disease event among women with a history of hypertensive disorders of pregnancy was generally 10% to 20% higher, with main models estimating hazard ratios to 1.20 (95% CI, 0.99-1.47) for women with type 1 and 1.15 (95% CI, 1.02-1.29) for women with type 2 diabetes.

CONCLUSIONS

In women with diabetes, a history of hypertensive disorders of pregnancy was associated with an increased risk of incident cardiovascular disease and should be considered as a risk enhancer.

Heterogeneity in the risk of cardiovascular disease mortality after the hypertensive disorders of pregnancy across mothers' lifetime reproductive history

BACKGROUND

Prior studies on maternal cardiovascular disease (CVD) mortality and hypertensive disorders of pregnancy (HDP) have focused only on a woman's first birth and have not accounted for successive affected pregnancies.

OBJECTIVES

The objective of this study is to identify mothers' risk of CVD mortality considering lifetime reproductive history.

METHODS

We used data from the Medical Birth Registry of Norway, the Norwegian Cause of Death Registry, and the Norwegian National Population Register to identify all mothers who gave birth from 1967 to 2020. Our outcome was mothers' CVD death before age 70. The primary exposure was the lifetime history of HDP. The secondary exposure was the order of HDP and gestational age at delivery of pregnancies with HDP. We used Cox regression models to estimate hazard ratio (HR) and 95% confidence interval (CI), adjusting for education, mother's age, and year of last birth. These models were stratified by the lifetime number of births.

RESULTS

Among 987,378 mothers, 86,294 had HDP in at least one birth. The highest CVD mortality, relative to mothers without HDP, was among those with a pre-term HDP in their first two births, although this represented 1.0% of mothers with HDP (HR 5.12, 95% CI 2.66, 9.86). Multiparous mothers with term HDP in their first birth only had no increased risk of CVD relative to mothers without HDP (36.9% of all mothers with HDP; HR 1.12, 95% CI 0.95, 1.32). All other mothers with HDP had a 1.5- to 4-fold increased risk of CVD mortality.

CONCLUSIONS

This study identified heterogeneity in the risk of CVD mortality among mothers with a history of HDP. A third of these mothers are not at higher risk compared to women without HDP, while some less common patterns of HDP history are associated with severe risk of CVD mortality.

Genetic Associations of Circulating Cardiovascular Proteins With Gestational Hypertension and Preeclampsia

Importance

Hypertensive disorders of pregnancy (HDPs), including gestational hypertension and preeclampsia, are important contributors to maternal morbidity and mortality worldwide. In addition, women with HDPs face an elevated long-term risk of cardiovascular disease.

Objective

To identify proteins in the circulation associated with HDPs.

Design, Setting, and Participants

Two-sample mendelian randomization (MR) tested the associations of genetic instruments for cardiovascular disease-related proteins with gestational hypertension and preeclampsia. In downstream analyses, a systematic review of observational data was conducted to evaluate the identified proteins' dynamics across gestation in hypertensive vs normotensive pregnancies, and phenome-wide MR analyses were performed to identify potential non-HDP-related effects associated with the prioritized proteins. Genetic association data for cardiovascular disease-related proteins were obtained from the Systematic and Combined Analysis of Olink Proteins (SCALLOP) consortium. Genetic association data for the HDPs were obtained from recent European-ancestry genome-wide association study meta-analyses for gestational hypertension and preeclampsia. Study data were analyzed October 2022 to October 2023.

Exposures

Genetic instruments for 90 candidate proteins implicated in cardiovascular diseases, constructed using cis-protein quantitative trait loci (cis-pQTLs).

Main Outcomes and Measures

Gestational hypertension and preeclampsia.

Results

Genetic association data for cardiovascular disease-related proteins were obtained from 21 758 participants from the SCALLOP consortium. Genetic association data for the HDPs were obtained from 393 238 female individuals (8636 cases and 384 602 controls) for gestational hypertension and 606 903 female individuals (16 032 cases and 590 871 controls) for preeclampsia. Seventy-five of 90 proteins (83.3%) had at least 1 valid cis-pQTL. Of those, 10 proteins (13.3%) were significantly associated with HDPs. Four were robust to sensitivity analyses for gestational hypertension (cluster of differentiation 40, eosinophil cationic protein [ECP], galectin 3, N-terminal pro-brain natriuretic peptide [NT-proBNP]), and 2 were robust for preeclampsia (cystatin B, heat shock protein 27 [HSP27]). Consistent with the MR findings, observational data revealed that lower NT-proBNP (0.76- to 0.88-fold difference vs no HDPs) and higher HSP27 (2.40-fold difference vs no HDPs) levels during the first trimester of pregnancy were associated with increased risk of HDPs, as were higher levels of ECP (1.60-fold difference vs no HDPs). Phenome-wide MR analyses identified 37 unique non-HDP-related protein-disease associations, suggesting potential on-target effects associated with interventions lowering HDP risk through the identified proteins.

Conclusions and Relevance

Study findings suggest genetic associations of 4 cardiovascular disease-related proteins with gestational hypertension and 2 associated with preeclampsia. Future studies are required to test the efficacy of targeting the corresponding pathways to reduce HDP risk.

Pregnancy-associated mortality due to cardiovascular disease: Impact of hypertensive disorders of pregnancy

BACKGROUND

Reported rates of maternal mortality in the United States have been staggeringly high and increasing, and cardiovascular disease (CVD) is a chief contributor to such deaths. However, the impact of hypertensive disorders of pregnancy (HDP) on the short-term risk of cardiovascular death is not well understood.

OBJECTIVES

To evaluate the association between HDP (chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and superimposed preeclampsia) and pregnancy-associated mortality rates (PMR) from all causes, CVD-related causes both at delivery and within 1 year following delivery.

METHODS

We used the Nationwide Readmissions Database (2010-2018) to examine PMRs for females 15-54 years old. International Classification of Disease 9 and 10 diagnosis codes were used to identify pregnancy-associated deaths due to HDP and CVD. Discrete-time Cox proportional hazards regression models were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for mortality at delivery (0 days) and at <30, <60, <90, <180, and <365 days after delivery in relation to HDP.

RESULTS

Of 33,417,736 hospital deliveries, the rate of HDP was 11.0% (n = 3,688,967), and the PMR from CVD was 6.4 per 100,000 delivery hospitalisations (n = 2141). Compared with normotensive patients, HRs for CVD-related PMRs increased with HDP severity, reaching over 58-fold for eclampsia patients. HRs were higher for stroke-related (1.2 to 170.9) than heart disease (HD)-related (0.99 to 39.8) mortality across all HDPs. Except for gestational hypertension, the increased risks of CVD mortality were evident at delivery and persisted 1 year postpartum for all HDPs.

CONCLUSIONS

HDPs are strong risk factors for pregnancy-associated mortality due to CVD at delivery and within 1 year postpartum; the risks are stronger for stroke than HD-related PMR. While absolute PMRs are low, this study supports the importance of extending postpartum care beyond the traditional 42-day postpartum visit for people whose pregnancies are complicated by hypertension.

Cardiovascular disease prevention in women - the current state in 2023

PURPOSE OF REVIEW

Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality for women globally. The purpose of this review is to provide an updated overview of CVD prevention in women, focusing on what is currently understood about female-specific or female-predominant CVD risk factors and the importance of tailored strategies for risk assessment and medical interventions.

RECENT FINDINGS

Recent studies have demonstrated the need to account for risk factors specific to women in current risk assessment models for CVD, including early menarche, polycystic ovary syndrome, adverse pregnancy outcomes, early menopause, and chronic inflammatory conditions. Incorporation of these findings has led to advancements in sex-specific guidelines, diagnostic tools, and treatment approaches that have led to improvement in the precision of CVD prevention strategies. At-risk women benefit similarly to lipid-lowering and other preventive therapies as men but are less likely to be treated.

SUMMARY

CVD prevention in women has made substantial progress over the past decade, marked by increasing awareness among clinicians, improved understanding of sex-specific risk-enhancing factors, and incorporation of sex-specific guidelines for management. However, there remain knowledge gaps that warrant ongoing efforts to optimize CVD prevention strategies in women, which will ultimately lead to improved cardiovascular health outcomes.

Association of Gestational Diabetes With Subsequent Long-Term Risk of Mortality

Importance

Gestational diabetes has been associated with numerous chronic diseases. However, few studies have examined the association of gestational diabetes with long-term mortality risk.

Objective

To investigate the associations between gestational diabetes and long-term risks of total and cause-specific mortality.

Design, Setting, and Participants

This cohort study analyzed participants of the Nurses' Health Study II who were followed for 30 years (1989-2019). Participants included US female nurses aged 25 to 42 years who reported at least 1 pregnancy (≥6 months) at 18 years or older across their reproductive life span. Data were analyzed from May 1, 2022, to May 25, 2023.

Exposure

Gestational diabetes across the reproductive life span.

Main Outcomes and Measures

Hazard ratios (HRs with 95% CIs) for total and cause-specific mortality were estimated by Cox proportional hazards regression models.

Results

A total of 91 426 parous participants were included, with a mean (SD) age of 34.9 (4.7) years and a body mass index of 24.1 (4.7) at baseline. During a follow-up period of 2 609 753 person-years, 3937 deaths were documented, including 255 deaths from cardiovascular disease and 1397 from cancer. Participants with a history of gestational diabetes had a higher crude mortality rate than those without a history of gestational diabetes (1.74 vs 1.49 per 1000 person-years; absolute difference = 0.25 per 1000 person-years). The corresponding HR for total mortality was 1.28 (95% CI, 1.13-1.44), which did not materially change after additional adjustment for potential confounders and lifestyle factors during the reproductive life span (HR, 1.25; 95% CI, 1.11-1.41). The association persisted regardless of the subsequent development of type 2 diabetes and was more robust among participants who adopted less healthy lifestyles; experienced gestational diabetes in 2 or more pregnancies (HR, 1.48; 95% CI, 0.99-2.19); had gestational diabetes both in the initial and subsequent pregnancies (HR, 1.71; 95% CI, 1.11-2.63); and concurrently reported hypertensive disorders in pregnancy (HR, 1.80; 95% CI, 1.21-2.67), preterm birth (HR, 2.46; 95% CI, 1.66-3.64), or low birth weight (HR, 2.11; 95% CI, 1.21-3.68). Cause-specific mortality analyses revealed that gestational diabetes was directly associated with the risk of mortality due to cardiovascular disease (HR, 1.59; 95% CI, 1.03-2.47). Additionally, gestational diabetes was inversely associated with cancer mortality (HR, 0.76; 95% CI, 0.59-0.98); however, it was only evident among participants who later developed type 2 diabetes.

Conclusions and Relevance

Results of this cohort study suggest that participants who reported a history of gestational diabetes exhibited a small but elevated risk of subsequent mortality over 30 years. The findings emphasize the importance of considering gestational diabetes as a critical factor in later-life mortality risk.

Determinants of vascular structure and function in at-risk children born to mothers managed for pre-eclampsia (FINNCARE study)

Background and aim

Pre-eclampsia (PE) is related to elevated blood pressure (BP) in children. The study aims to investigate if elevated BP is reflected in child arterial health and how anthropometrics, body composition, and gestational and perinatal factors influenced this.

Methods

In this prospective cohort study, we assessed the arteries of 182 children exposed (46 had an early onset, with a diagnosis before 34 gestational weeks, and 136 had a late onset) and 85 children unexposed (non-PE) to PE at 8-12 years from delivery using ultra-high-frequency ultrasound in addition to ambulatory and central BPs, body composition and anthropometrics, and tonometry-derived pulse wave velocity (PWV).

Results

No differences were found in intima-media thickness (IMT), adventitia thickness (AT), lumen diameter (LD), local carotid artery stiffness, distensibility, or wall stress between PE-exposed and non-PE-exposed children. All children's brachial, radial, and femoral artery IMTs were associated with 24-h systolic BP (SBP) and pulse pressure, carotid-femoral PWV, and anthropometric measures. The 24-h SBP and anthropometrics, notably lean body mass, were independent predictors of peripheral artery IMTs (brachial R2 = 0.217, radial R2 = 0.208, femoral R2 = 0.214; p < 0.001). Head circumference predicted carotid artery IMT and LD (β = 0.163, p = 0.009; β = 0.417, p < 0.001, respectively), but carotid artery IMT was not associated with BP. No independent associations were found for peripheral artery ATs. Local carotid artery stiffness, distensibility, and wall stress were independently associated with adiposity. No significant associations were found between gestational or perinatal factors and child vascular health parameters.

Conclusions

The peripheral artery IMT of PE-exposed children is identical to that of non-PE-exposed children, but associated with BP. Adiposity is related to local carotid artery stiffness. These adverse associations in arterial health may reflect the early progression of cardiovascular disease in PE-exposed children.

Symptom Presentation among Women with Suspected Ischemia and No Obstructive Coronary Artery Disease (INOCA)

Identifying ischemic heart disease (IHD) in women based on symptoms is challenging. Women are more likely to endorse non-cardiac symptoms. More than 50% of women with suspected ischemia have no obstructive coronary disease (and thus, INOCA) and impaired outcomes during follow-up. We aimed to identify symptoms having predictive capacity for INOCA in women with clinical evidence of coronary ischemia. We included 916 women from the original WISE cohort (NCT00000554) who had coronary angiography performed for suspected ischemia and completed a 65-item WISE symptom questionnaire. Sixty-two percent (n = 567) had suspected INOCA. Logistic regression models using a best subsets approach were examined to identify the best predictive model for INOCA based on Score χ2 and AICc. A 10-variable, best-fit model accurately predicted INOCA (AUC 0.72, 95% CI 0.68, 0.75). The model indicated that age ≤ 55 years, left side chest pain, chest discomfort, neck pain, and palpitations had independent, positive relationship (OR > 1) to INOCA (p < 0.001 to 0.008). An inverse relationship (OR < 1) was observed for impending doom, and pain in the jaw, left or bilateral arm, and right hand, interpreted as INOCA associated with the absence of these symptoms (p ≤ 0.001 to 0.023). Our best-fit model accurately predicted INOCA based on age and symptom presentation ~72% of the time. While the heterogeneity of symptom presentation limits the utility of this unvalidated 10-variable model, it has promise for consideration of symptom inclusion in future INOCA prediction risk modeling for women with evidence of symptomatic ischemia.

Is There a Relationship between Adverse Pregnancy Outcomes and Future Development of Atherosclerosis?

Cardiovascular disease is one of the main death causes globally. Effective cardiovascular risk management requires a thorough understanding of the mechanisms underlying the disorder. Establishing early markers of the disease allows a timely intervention and prevention of further atherosclerosis development. Multiple studies confirm the correlation between pregnancy disorders and cardiovascular disease in the postpartum period. Moreover, over 30% of women experience adverse pregnancy outcomes. Thus, the examination of the links between these conditions and atherosclerotic cardiovascular disease may help to identify gender-specific risk factors. In this review, we will explore the association between several adverse pregnancy outcome conditions and atherosclerosis. The current analysis is based on the data from several recent studies on the mechanisms behind gestational diabetes, hypertensive disorders of pregnancy, miscarriages, and stillbirths and their implications for the female cardiovascular system.

Pregnancy complications in last pregnancy and mothers' long-term cardiovascular mortality: does the relation differ from that of complications in first pregnancy? A population-based study

BACKGROUND

Women who experience complications in first pregnancy are at increased risk of cardiovascular disease (CVD) later in life. Little corresponding knowledge is available for complications in later pregnancies. Therefore, we assessed complications (preeclampsia, preterm birth, and offspring small for gestational age) in first and last pregnancies and the risk of long-term maternal CVD death, taking women´s complete reproduction into account.

DATA AND METHODS

We linked data from the Medical Birth Registry of Norway to the national Cause of Death Registry. We followed women whose first birth took place during 1967-2013, from the date of their last birth until death, or December 31st 2020, whichever occurred first. We analysed risk of CVD death until 69 years of age according to any complications in last pregnancy. Using Cox regression analysis, we adjusted for maternal age at first birth and level of education.

RESULTS

Women with any complications in their last or first pregnancy were at higher risk of CVD death than mothers with two-lifetime births and no pregnancy complications (reference). For example, the adjusted hazard ratio (aHR) for women with four births and any complications only in the last pregnancy was 2.85 (95% CI, 1.93-4.20). If a complication occurred in the first pregnancy only, the aHR was 1.74 (1.24-2.45). Corresponding hazard ratios for women with two births were 1.82 (CI, 1.59-2.08) and 1.41 (1.26-1.58), respectively.

CONCLUSIONS

The risk for CVD death was higher among mothers with complications only in their last pregnancy compared to women with no complications, and also higher compared to mothers with a complication only in their first pregnancy.

Hypertensive disorders of pregnancy and risk of asthma and chronic obstructive pulmonary disease: a prospective cohort study

Background

Hypertensive disorders of pregnancy (HDPs) have been associated with respiratory dysfunction during pregnancy and postpartum. In this study, we explored the associations between HDPs (gestational hypertension and preeclampsia) and the risk of incident asthma and chronic obstructive pulmonary disease (COPD) during adulthood and the potential mediating role of chronic hypertension.

Methods

We included parous nurses in the Nurses' Health Study II reporting a pregnancy lasting no less than 6 months. The associations between HDPs and asthma and COPD were estimated using Cox proportional hazards models with adjustment for confounders.

Findings

We included 73,807 nurses [92.5% (68,246 of 73,807) White] in asthma analyses and 79,843 [92.4% (73,746 of 79,843) White] in COPD analyses, whose mean (SD, range) age, at baseline, were both 34.8 (4.7, 25.0-44.0) years. During 24 years of follow-up, we identified 2663 incident cases of asthma and 537 COPD. Compared with nurses without HDPs, nurses reporting HDPs had an increased HR for incident asthma and COPD of 1.22 (95% CI 1.10-1.36) and 1.39 (95% CI 1.11-1.74), respectively. The risk of asthma was similar when gestational hypertension and preeclampsia were assessed separately [HR = 1.25 (95% CI 1.08-1.43) and 1.24 (95% CI 1.11-1.38), respectively]. However, only nurses with preeclampsia had a higher risk of COPD (HR = 1.41, 95% CI 1.11-1.78). Mediation analyses estimated that chronic hypertension explained 18.6% (95% CI 8.9-35.0%) and 10.7% (95% CI 2.9-32.4%) of the associations between HDPs and asthma and COPD, respectively.

Interpretation

HDPs may serve as useful markers of increased susceptibility to chronic respiratory diseases during adulthood.

Funding

The National Institutes of Health grants.

Preventing Adverse Cardiovascular Outcomes in Pregnancy Complicated by Obesity

Purpose of review

Obesity is a chronic disease that is becoming increasingly prevalent, and more individuals of reproductive age have obesity prior to becoming pregnant. Obesity in pregnancy is associated with short- and long-term adverse consequences for both the birthing person and their offspring which have been associated with increased long-term cardiovascular morbidity and mortality. The goal of this review is to discuss what is currently understood about the relationship between maternal obesity and adverse pregnancy outcomes (APOs), the association between APOs and future cardiovascular disease (CVD) risk, and what evidence-based interventions can be implemented to prevent adverse outcomes in this population.

Recent findings

Maternal obesity has been associated with an increased risk of APOs such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth as well as an increased risk of future CVD, such as metabolic syndrome, chronic hypertension, coronary heart disease, and stroke. The impact of maternal obesity also extends beyond the pregnant individual to the offspring, increasing the risk of fetal, neonatal, and infant mortality, as well as of congenital malformations, prematurity, and long-term health problems such as insulin resistance and childhood obesity. Prevention guidelines are incorporating the increased risk of adverse outcomes from maternal obesity into formalized risk assessments to guide both prenatal and postpartum care. It is becoming evident that a multidisciplinary cardio-obstetrics team is an important part of providing comprehensive care for pregnant individuals with obesity and other cardiovascular risk factors, including preexisting CVD and a history of prior APOs. There remains a need for further studies to better understand the mechanisms underlying the relationship between maternal obesity and APOs, as well as the racial and ethnic disparities that have been noted in the prevalence of APOs and associated CVD risk and mortality.

Summary

There is increasing awareness that obesity in pregnancy is associated with various short- and long-term adverse maternal and offspring outcomes. There are multiple screening and prevention strategies that may be implemented before, during, and after pregnancy to prevent these adverse outcomes.

How much does hypertension in pregnancy affect the risk of future cardiovascular events?

Hypertensive disorders in pregnancy (HDP) include essential (or secondary) hypertension occurring before 20 weeks of gestation or in women already on antihypertensive therapy prior to pregnancy, gestational hypertension, developing after 20 weeks of gestation without significant proteinuria, and pre-eclampsia or AH onset after 20 weeks of pregnancy in the presence of proteinuria. The development of HDP is associated with a higher incidence of long-term cardiovascular (CV) adverse events, such as myocardial infarction, heart failure, stroke, and CV death. Women who develop high blood pressure in their first pregnancy have an increased risk of complication in a subsequent pregnancy. In the years following delivery, pregnant women with hypertensive disorders develop subclinical atherosclerosis and alterations of cardiac structure and function that may lead to CV disease and heart failure. Thus, it is recommended to monitor these changes over time and subject in pregnant women with these characteristics to CV surveillance through structured and multidisciplinary interventions for CV prevention.

Management of blood pressure in pregnancy: new perspectives from the CHAP trial

PURPOSE OF REVIEW

Chronic hypertension affects up to 10% of pregnancies in the United States and the incidence of hypertensive diseases of pregnancy has more than doubled in the past decade, affecting minority women at disproportionate rates. Recent data show potential benefit by lowering the threshold of blood pressure treatment for pregnant women to >140/90 mmHg.

RECENT FINDINGS

In April 2022, the results of the Chronic Hypertension and Pregnancy (CHAP) trial was published and demonstrated that lower thresholds (>140/90 vs. >160/110 mmHg) for the initiation of antihypertensive therapy during pregnancy resulted in better pregnancy outcomes without negative impacts to foetal growth. In addition, professional societies, such as the American College of Obstetrics and Gynecology (ACOG) and the Society of Maternal Fetal Medicine (SMFM), have released statements supporting the initiation of antihypertensive therapy at elevations above 140/90 mmHg for pregnant women with chronic hypertension based upon these recent reports.

SUMMARY

Treatment of hypertension in pregnant women is controversial, but recent data are emerging that treatment at lower blood pressure thresholds may be associated with improved perinatal outcomes without an increased risk of poor foetal growth. Although these recommendations may be applied to women with chronic hypertension, more research is needed to determine how these guidelines should be applied to other hypertensive diseases of pregnancy.

Adverse pregnancy outcomes and future risk of heart failure

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death in women. Women with history of adverse pregnancy outcomes (APOs) have approximately two-fold risk of future CVD, but until recently the association with future heart failure (HF) was unclear. Here, we summarize evidence for associations of APOs with HF, potential underlying mechanisms, and future directions for clinical translation.

RECENT FINDINGS

Women with history of hypertensive disorders of pregnancy (HDPs) have roughly two-fold risk of future HF compared with other parous women even after accounting for interval development of coronary artery disease. The HDPs portend heightened risk of HF with both reduced and preserved ejection fraction. Gestational diabetes mellitus (GDM) and other APOs such as preterm delivery, small-for-gestational-age delivery, and placental abruption may also confer additional risk for HF development. Possible underlying mechanisms linking APOs to HF include shared upstream risk factors and genetics, accelerated development of cardiometabolic risk factors postpartum, persistent endothelial and microvascular dysfunction, and impaired natriuretic peptide signaling.

SUMMARY

History of APOs, including HDPs and GDM, confer increased risk for development of HF years after delivery. Further research is needed to define strategies to optimize prepregnancy and postpartum cardiovascular health toward HF prevention.

Identification and Management of Atherosclerotic Cardiovascular Disease Risk in South Asian Populations in the U.S

South Asians (SAs, individuals with ancestry from Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka) are among the fastest growing ethnic subgroups in the United States. SAs typically experience a high prevalence of diabetes, abdominal obesity, and hypertension, among other cardiovascular disease risk factors, which are often under recognized and undermanaged. The excess coronary heart disease risk in this growing population must be critically assessed and managed with culturally appropriate preventive services. Accordingly, this scientific document prepared by a multidisciplinary group of clinicians and investigators in cardiology, internal medicine, pharmacy, and SA-centric researchers describes key characteristics of traditional and nontraditional cardiovascular disease risk factors, compares and contrasts available risk assessment tools, discusses the role of blood-based biomarkers and coronary artery calcium to enhance risk assessment and prevention strategies, and provides evidenced-based approaches and interventions that may reduce coronary heart disease disparities in this higher-risk population.

Maternal hypertensive disorders during pregnancy and the risk of offspring diabetes mellitus in childhood, adolescence, and early adulthood: a nationwide population-based cohort study

BACKGROUND

Maternal hypertensive disorders during pregnancy (HDP) have been suggested to contribute to the development of offspring cardiovascular disease later in life, but empirical evidence remains inconsistent. This study was aimed to assess the association of maternal overall and type-specific HDPs with diabetes in offspring from childhood to early adulthood.

METHODS

Using Danish national health registers, a total of 2,448,753 individuals born in Denmark from 1978 to 2018 were included in this study. Maternal HDP included chronic hypertension, gestational hypertension, and preeclampsia. The outcome of interest was diabetes in offspring (including type 1, type 2, and gestational diabetes). The follow-up of offspring started at birth and ended at the first diagnosis of diabetes, emigration from Denmark, death, or time end on 31 December 2018, whichever came first. Cox proportional hazards regression was used to evaluate the hazard ratios (HRs) with 95% confidence intervals (CIs) of the association between maternal HDP and diabetes (including type 1, type 2, and gestational diabetes) in offspring from birth to young adulthood (up to 41 years), with the offspring's age as the time scale.

RESULTS

During a follow-up of up to 41 (median: 19.3) years, 1247 offspring born to mothers with HDP and 23,645 offspring born to mothers without HDP were diagnosed with diabetes. Compared with offspring born to mothers without HDP, those born to mothers with HDP had an increased risk for overall diabetes (HR=1.27, 95% CI=1.20-1.34), as well as for type 2 diabetes (HR=1.57, 95% CI=1.38-1.78) and gestational diabetes (HR=1.37, 95% CI=1.25-1.49). We did not observe obvious increased risk for type 1 diabetes (HR=1.08, 95% CI=0.98-1.18). Offspring of mothers with gestational hypertension (HR=1.37, 95% CI=1.00-1.88) or preeclampsia (HR=1.62, 95% CI=1.41-1.87) had higher risks of type 2 diabetes. The strongest association was observed for severe preeclampsia, with a 2-fold risk of type 2 diabetes (HR=2.00, 95% CI=1.42-2.82). The association between maternal HDP and type 1 diabetes did not reach statistical significance, except for maternal gestational hypertension (HR=1.41, 95%CI=1.17-1.71). In addition, we found that offspring born to mothers with any subtypes of maternal HDP had higher risk of gestational diabetes, and the corresponding HRs (95%CIs) for chronic hypertension, gestational hypertension, and preeclampsia were 1.60 (1.06-2.41), 1.29 (1.04-1.59), and 1.38 (1.24-1.53), respectively. We also observed stronger associations among offspring of mothers with HDP and comorbid diabetes (HR=4.64, 95%CI=3.85-5.60) than offspring of mothers with HDP or diabetes alone.

CONCLUSIONS

Offspring of mothers with HDP, especially mothers with comorbid diabetes, had an increased risk of diabetes later in their life. Our findings suggest that timely and effective prevention of HDP in women of childbearing age should be taken into consideration as diabetes prevention and control strategies for their generations.

Peripartum and Long-Term Maternal Cardiovascular Health After Preeclampsia

There is widespread acceptance of the increased prevalence of cardiovascular diseases occurring within 1 to 2 decades in women following a preeclamptic pregnancy. More recent evidence suggests that the deranged biochemical and echocardiographic findings in women do not resolve in the majority of preeclamptic women following giving birth. Many women continue to be hypertensive in the immediate postnatal period with some exhibiting occult signs of cardiac dysfunction. There is now promising evidence that with close monitoring and effective control of blood pressure control in the immediate postnatal period, women may have persistently lower blood pressures many years after stopping their medication. This review highlights the evidence that delivering effective medical care in the fourth trimester of pregnancy can improve the long-term cardiovascular health after a preeclamptic birth.

Maternal Mortality in the United States: Trends and Opportunities for Prevention

Maternal mortality is unusually high in the United States compared to other wealthy nations and is characterized by major disparities in race/ethnicity, geography, and socioeconomic factors. Similar to other developed nations, the United States has seen a shift in the underlying causes of pregnancy-related death, with a relative increase in mortality resulting from diseases of the cardiovascular system and preexisting medical conditions. Improved continuity of care aimed at identifying reproductive-age women with preexisting conditions that may heighten the risk of maternal death, preconception management of risk factors for major adverse pregnancy outcomes, and primary care visits within the first year after delivery may offer opportunities to address gaps in medical care contributing to the unacceptable rates of maternal mortality in the United States.

Long-term cardiovascular mortality in women with twin pregnancies by lifetime reproductive history

BACKGROUND

Women with one lifetime singleton pregnancy have increased risk of cardiovascular disease (CVD) mortality compared with women who continue reproduction particularly if the pregnancy had complications. Women with twins have higher risk of pregnancy complications, but CVD mortality risk in women with twin pregnancies has not been fully described.

OBJECTIVES

We estimated risk of long-term CVD mortality in women with naturally conceived twins compared to women with singleton pregnancies, accounting for lifetime number of pregnancies and pregnancy complications.

METHODS

Using linked data from the Medical Birth Registry of Norway and the Norwegian Cause of Death Registry, we identified 974,892 women with first pregnancy registered between 1967 and 2013, followed to 2020. Adjusted hazard ratios (aHR) with 95% confidence intervals (CI) for maternal CVD mortality were estimated by Cox regression for various reproductive history (exposure categories): (1) Only one twin pregnancy, (2) Only one singleton pregnancy, (3) Only two singleton pregnancies, (4) A first twin pregnancy and continued reproduction, (5) A first singleton pregnancy and twins in later reproduction and (6) Three singleton pregnancies (the referent group). Exposure categories were also stratified by pregnancy complications (pre-eclampsia, preterm delivery or perinatal loss).

RESULTS

Women with one lifetime pregnancy, twin or singleton, had increased risk of CVD mortality (adjusted hazard [HR] 1.72, 95% confidence interval [CI] 1.21, 2.43 and aHR 1.92, 95% CI 1.78, 2.07, respectively), compared with the referent of three singleton pregnancies. The hazard ratios for CVD mortality among women with one lifetime pregnancy with any complication were 2.36 (95% CI 1.49, 3.71) and 3.56 (95% CI 3.12, 4.06) for twins and singletons, respectively.

CONCLUSIONS

Women with only one pregnancy, twin or singleton, had increased long-term CVD mortality, however highest in women with singletons. In addition, twin mothers who continued reproduction had similar CVD mortality compared to women with three singleton pregnancies.

Breastfeeding duration and subsequent risk of mortality among US women: A prospective cohort study

BACKGROUND

Breastfeeding has been associated with a reduced maternal long-term risk of chronic diseases, but its association with mortality is poorly known.

METHODS

We included 166,708 female United States (US) nurses from the Nurses' Health Study (1986-2016) and the Nurses' Health Study II (1989-2019) who experienced at least one pregnancy lasting at least six months across their reproductive lifespan. Hazard ratios and 95% confidence intervals (CI) for mortality according to lifetime breastfeeding duration were estimated with time-dependent Cox proportional hazards regression models.

FINDINGS

During 4,705,160 person-years of follow-up, 36,634 deaths were documented in both cohorts, including 9880 from cancer and 7709 from cardiovascular disease (CVD). Lifetime total breastfeeding duration was associated with a lower subsequent risk of all-cause mortality in a non-linear manner (p-value for non-linearity=0.0007). The pooled multivariable-adjusted hazard ratios of all-cause mortality were 0.95 (95% CI: 0.92 to 0.98), 0.94 (95% CI: 0.91 to 0.98), 0.93 (95% CI: 0.90 to 0.97), and 0.93 (95% CI: 0.89 to 0.97), respectively, for women reporting lifetime total breastfeeding duration of 4-6, 7-11, 12-23, and ≥24 months, compared to women who breastfed for ≤3 months over their reproductive lifespan. Cause-specific analysis showed a similar pattern of non-linear inverse associations between lifetime total breastfeeding duration and CVD and cancer mortality (both p-values for non-linearity <0.01). There was no evidence of interactions between breastfeeding duration and pre-pregnancy lifestyle factors on mortality risk.

INTERPRETATION

Parous women with longer lifetime breastfeeding duration had a modestly lower risk of mortality.

FUNDING

The National Institutes of Health grants.

Birth weight and long-term risk of mortality among US men and women: Results from three prospective cohort studies

Background

Weight at birth has been associated with the development of various adult diseases, but its association with mortality remains unclear.

Methods

We included 22,389 men from the Health Professionals Follow-up Study (1994-2018) and 162,231 women from the Nurses' Health Study (1992-2018) and the Nurses' Health Study II (1991-2019). The hazard ratios (HRs) of mortality according to birth weight were estimated by Cox proportional hazards regression models with adjustment for potential confounders.

Findings

Compared to women reporting a birth weight of 3.16-3.82 kg, the pooled HRs for all-cause mortality were 1.13 (95% CI, 1.08 to 1.17), 0.99 (95% CI, 0.96 to 1.02), 1.04 (95% CI, 1.00 to 1.08), and 1.03 (95% CI, 0.96 to 1.10), respectively, for women with a birth weight of <2.5, 2.5-3.15, 3.83-4.5, and >4.5 kg. In cause-specific mortality analyses, women reporting birth weight >4.5 kg had a higher risk of cancer mortality (HR=1.15, 95% CI: 1.00 to 1.31), whereas women with a birth weight <2.5 kg had an elevated risk of mortality from cardiovascular diseases (HR=1.15; 95% CI, 1.05 to 1.25) and respiratory diseases (HR=1.35; 95% CI, 1.18 to 1.54). Birth weight was unrelated to all-cause mortality among men, but cause-specific mortality analyses showed an inverse association with cardiovascular disease mortality and a positive association with cancer mortality (p for linear trend = 0.012 and 0.0039, respectively).

Interpretation

low birth weight was associated with a greater risk of cardiovascular and respiratory disease mortality among women, while large birth weight was associated with a greater cancer mortality risk in both men and women.

Funding

The National Institutes of Health grants U01-HL145386, U01-CA176726, R01-HL034594, R01-HL088521, UM-CA186107, P01-CA87969, R01-CA49449, R01-CA67262, U01-HL145386, U01-CA167552, R01-HL35464, and R24-ES028521-01 support this study.

Gestational Hypertensive Disorders and Maternal Breast Cancer Risk in a Nationwide Cohort of 40,720 Parous Women

BACKGROUND

Preeclampsia and gestational hypertension are hypothesized to be associated with reduced maternal breast cancer risk, but the epidemiologic evidence is inconclusive. Our objective was to examine associations between gestational hypertensive disorders and breast cancer in a nationwide cohort of women with a family history of breast cancer.

METHODS

Women ages 35-74 years who had a sister previously diagnosed with breast cancer, but had never had breast cancer themselves, were enrolled in the Sister Study from 2003 to 2009 (N = 50,884). At enrollment, participants reported diagnoses of eclampsia, preeclampsia, or gestational hypertension in each pregnancy. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between history of a gestational hypertensive disorder and incident invasive breast cancer or ductal carcinoma in situ among 40,720 parous women. We used age as the time scale and adjusted for birth cohort, race-ethnicity, and reproductive, socioeconomic, and behavioral factors. We examined effect measure modification by risk factors for gestational hypertensive disease and breast cancer and assessed possible etiologic heterogeneity across tumor characteristics.

RESULTS

The prevalence of gestational hypertensive disease was 12%. During follow-up (mean = 10.9 years), 3,198 eligible women self-reported a breast cancer diagnosis. History of a gestational hypertensive disorder was not associated with breast cancer risk (HR = 1.0; 95% CI = 0.90, 1.1). We did not observe clear evidence of effect measure modification or etiologic heterogeneity.

CONCLUSIONS

History of a gestational hypertensive disorder was not associated with breast cancer risk in a cohort of women with a first-degree family history of breast cancer.

Versorgungsrealität von Frauen nach hypertensiver Schwangerschaftserkrankung – eine monozentrische fragebogenbasierte Analyse

Einleitung Frauen nach einer hypertensiven Schwangerschaftserkrankung wird aufgrund ihres signifikant erhöhten kardiovaskulären Risikos zu Screeninguntersuchungen und primärer Prävention geraten. Diese Studie soll einen Beitrag zur Ermittlung der aktuellen Nachsorgepraxis leisten und aufzeigen, wie viele Frauen an den empfohlenen Nachsorgeuntersuchungen mit Beratung zur Reduktion von Risikofaktoren teilnehmen.

Material und Methoden Monozentrische Patientinnenbefragung von 113 Frauen, welche im Zeitraum von 2014 bis 2019 von einer hypertensiven Schwangerschaftserkrankung betroffen waren. Es erfolgte eine deskriptive statistische Auswertung.

Ergebnisse Eine Nachsorgeuntersuchung erfolgte bei 54% der Frauen. Es wurden 47% der Patientinnen im persönlichen Gespräch über ihre Erkrankung informiert und auf mögliche langfristige gesundheitliche Konsequenzen hingewiesen. Von 67 übergewichtigen Frauen (BMI≥25 kg/m2) erhielten 23% eine Empfehlung zur Steigerung der körperlichen Aktivität und 13% wurde zur Gewichtsreduktion geraten. Es stellten sich signifikant mehr Frauen mit höherer Krankheitslast (BMI, p=0,027; arterieller Hypertonus, p=0,016) und gravierender Ausprägung der Erkrankung (Eklampsie, Aufenthalt auf einer Intensivstation, jeweils p=0,049) zu weiteren Untersuchungen vor.

Schlussfolgerung Die vorliegenden Ergebnisse legen nahe, dass die Maßnahmen zur Prävention und Früherkennung von kardiovaskulären Erkrankungen in unserem Patientinnenkollektiv nicht ausgeschöpft wurden. Unabhängig des Ausprägungsgrades der Erkrankung sollten alle Frauen eine Empfehlung zur Teilnahme an Nachsorgeuntersuchung erhalten.

Design, implementation, and evaluation of an innovative intelligence information management system for premature infants

Introduction

Low birth weight is the most important condition of neonatal community health and the main cause of neonates' mortality. Identifying the indexes associated with this condition, and factors to prevent, and managing related data can help reduce the birth of premature infants to reduce the mortality rate due to this condition. The goal of present study was to design, implement and evaluate an innovative intelligence information management system for premature infants.

Material and method

The present study was a multidisciplinary research that was done in 2019 to 2021 in four integrated phases in Iran. The first phase aimed to compare the current status of registration systems of premature infants through a systematic review and semi-structured interviews by using the Delphi model Then the minimum data set was determined and was designed a proposed model based on it. In the second phase, the structure and how the user interacts with the system were determined, and, using Microsoft Visio software, Unified Modeling Language diagrams were drawn to define the logical relationship of data. In the third phase, the system was developed, and finally in the last phase, in three methods, users' views on the usability of the system were evaluated.

Results

The findings of this study included 233 essential data elements that were placed in two main groups of essential data, and the system was approved by end users for 87.73% consent and 67.19% satisfaction for SUMI (Software Usability Measurement Inventory) and 7.97 of 9 in QUIS questionnaire.

Conclusion

This research's results can be beneficial and functional such as a complete sample for design and development of other systems concerned to health systems.

Menstrual Cycle Regularity and Length Across the Reproductive Lifespan and Risk of Cardiovascular Disease

Importance

Menstrual cycle characteristics may be associated with an increased risk of cardiovascular disease (CVD). However, existing studies are limited, and few have explored the mediating role of established CVD risk factors.

Objective

To explore the associations of menstrual cycle characteristics across the reproductive lifespan with the risk of CVD and to what extent these associations were mediated by hypercholesterolemia, chronic hypertension, and type 2 diabetes.

Design, Setting, and Participants

This cohort study prospectively followed Nurses' Health Study II participants between 1993 and 2017 who reported menstrual cycle regularity and length for ages 14 to 17 years and 18 to 22 years at enrollment in 1989 and updated current cycle characteristics in 1993 (at ages 29 to 46 years). Data analysis was performed from October 1, 2019, to January 1, 2022.

Exposures

Menstrual cycle regularity and length across the reproductive lifespan.

Main Outcomes and Measures

Incident CVD events of interest, including fatal and nonfatal coronary heart disease (CHD; myocardial infarction [MI] or coronary revascularization) and stroke.

Results

A total of 80 630 Nurses' Health Study II participants were included in the analysis, with a mean (SD) age of 37.7 (4.6) years and body mass index of 25.1 (5.6) at baseline. Over 24 years of prospective follow-up, 1816 women developed their first CVD event. Multivariable Cox proportional hazards models showed that, compared with women reporting very regular cycles at the same ages, women who had irregular cycles or no periods at ages 14 to 17, 18 to 22, or 29 to 46 years had hazard ratios for CVD of 1.15 (95% CI, 0.99-1.34), 1.36 (95% CI, 1.06-1.75), and 1.40 (95% CI, 1.14-1.71), respectively. Similarly, compared with women reporting a cycle length of 26 to 31 days, women reporting a cycle length 40 days or more or a cycle too irregular to estimate from ages 18 to 22 or 29 to 46 years had hazard ratios for CVD of 1.44 (95% CI, 1.13-1.84) and 1.30 (95% CI, 1.09-1.57), respectively. Mediation analyses showed that subsequent development of hypercholesteremia, chronic hypertension, and type 2 diabetes only explained 5.4% to 13.5% of the observed associations.

Conclusions and Relevance

In this cohort study, both irregular and long menstrual cycles were associated with increased rates of CVD, which persisted even after accounting for subsequently established CVD risk factors.

Pre-pregnancy fat intake in relation to hypertensive disorders of pregnancy

BACKGROUND

Many studies have linked intakes of fat and of specific fatty acids during pregnancy with preeclampsia; however, information on the association of intake before pregnancy with hypertensive disorders of pregnancy (HDP) is scant.

OBJECTIVES

We evaluated the associations of intakes of major and specific types of fat before pregnancy with the risks of HDP, including preeclampsia and gestational hypertension (GHTN).

METHODS

We followed 11,535 women without chronic disease participating in the Nurses' Health Study II from 1991 and 2009. Pre-pregnancy dietary fat was assessed by an FFQ. Intakes of total fat, saturated fat, trans fatty acid (TFA), MUFAs, PUFAs, and fat subtypes (omega-3 and omega-6) were categorized into quintiles of intake. HDP were self-reported. The RRs (95% CIs) of HDP were estimated by log-binomial generalized estimating equation regression models, with an exchangeable correlation matrix to account for repeated pregnancies while adjusting for potential confounders.

RESULTS

During 19 years of follow-up, there were 495 cases of preeclampsia (2.9%) and 561 (3.3%) cases of GHTN in 16,892 singleton pregnancies. The mean age at pregnancy was 34.6 years (SD, 3.9 years). Among major fat types, only pre-pregnancy TFA was related to a higher risk of HDP (RR, 1.32; 95% CI: 1.05-1.66), and only for preeclampsia (RR, 1.50; 95% CI: 1.07-2.10) but not for GHTN (RR, 1.21; 95% CI: 0.87-1.70). Among specific types of PUFAs, intake of arachidonic acid was positively related with GHTN (RR, 1.43; 95% CI: 1.00-2.04) but not preeclampsia (RR, 1.08; 95% CI: 0.75-1.57). In analyses restricted to pregnancies 1 year after the diet assessment, women with the highest intake of long-chain omega-3 fatty acids had a 31% lower risk of HDP (95% CI: 3%-51%), which was driven by preeclampsia (RR, 0.55; 95% CI: 0.33-0.92).

CONCLUSIONS

Pre-pregnancy intakes of total fat, saturated fat, and MUFA were unrelated to HDP, whereas TFA was positively related to HDP. These findings highlight the importance of ongoing efforts to eliminate TFA from the global food supply.

Associations of birth weight and later life lifestyle factors with risk of cardiovascular disease in the USA: A prospective cohort study

BACKGROUND

Low birth weight has been associated with a greater risk of cardiovascular disease (CVD). However, the interaction between low birth weight and adult lifestyle factors on the risk of CVD remains unclear.

METHODS

We included 20,169 men from the Health Professionals Follow-up Study (HPFS, 1986-2016), 52,380 women from the Nurses' Health Study (NHS, 1980-2018), and 85,350 women from the Nurses' Health Study II (NHS II, 1991-2017) in the USA who reported birth weight and updated data on adult body weight, smoking status, physical activity, and diet every 2-4 years. Incident cases of CVD, defined as a combined endpoint of fatal and nonfatal coronary heart disease (CHD) and stroke, were self-reported and confirmed by physicians through reviewing medical records.

FINDINGS

During 4,370,051 person-years of follow-up, 16,244 incident CVD cases were documented, including 12,126 CHD and 4118 stroke cases. Cox proportional hazards regression models revealed an increased risk of CHD during adulthood across categories of decreasing birth weight in all cohorts (all P for linear trend <0.001). Additionally, we found an additive interaction between decreasing birth weight and unhealthy lifestyles on the risk of CHD among women, with a pooled relative excess risk due to interaction of 0.06 (95% CI: 0.04-0.08). The attributable proportions of the joint effect were 23.0% (95% CI: 11.0-36.0%) for decreasing birth weight alone, 67.0% (95% CI: 58.0-75.0%) for unhealthy lifestyle alone, and 11.0% (95% CI: 5.0-17.0%) for their additive interaction. Lower birth weight was associated with a greater stroke risk only among women, which was independent of later-life lifestyle factors.

INTERPRETATION

Lower birth weight may interact synergistically with unhealthy lifestyle factors in adulthood to further increase the risk of CHD among women.

FUNDING

The National Institutes of Health grants.

Clinical Analysis of Echocardiography and Serum IL-6 and TNF-α Changes in Pregnant Women with Hypertension

In order to explore the changes and clinical significance of serum TNF-α and IL-6 and ET levels in the pathogenesis of hypertensive disorders of pregnancy (HDIP), echocardiography, and serum IL-6 and TNF-α changes in pregnant women with a hypertensive disorder, a clinical analysis method was proposed. A retrospective analysis of 59 pregnant women who visited the obstetrics department of a provincial hospital was divided into 2 groups. The normal control group consisted of 32 normal, uncomplicated pregnant women; the preeclampsia group included 27 patients with systolic blood pressure > 140 mmHg and/or diastolic blood pressure > 90 mmHg who developed proteinuria after 20 weeks of gestation. The levels of TNF-α and IL-6 in serum of normal pregnant women and pregnant women with preeclampsia were detected by enzyme-linked immunosorbent assay (ELISA). The results showed that compared with normal pregnant women, the serum levels of TNF-α and IL-6 in the early pregnant women of Zizhi were significantly increased, and the trend of increased TNF-α and IL-6 levels was related to the severity of complications. With the mean pulmonary arterypressure > 50 mmHg, the serum TNF-α level of pregnant women was significantly higher than that of pregnant women with mean pulmonary arterypressure < 50 mmHg. The analysis found that the serum levels of TNF-α and IL-6 in patients with hypoxic gestational hypertension were significantly increased, and the results of lung tissue immunohistochemistry also showed that serum TNF-α and IL-6 levels in patients with hypoxic gestational hypertension were significantly increased. And serum TNF-α and IL-6 levels were positively correlated with right ventricular systolic blood pressure (RVSP). Conclusion. This study revealed that the elevated levels of serum TNF-α and IL-6 are closely related to the pathophysiological process of gestational hypertension. Serum levels of TNF-α and IL-6 and ET were significantly increased, and the changes of serum TNF-α and IL-6 and ET levels had important clinical value for closely monitoring the severity of the disease and the development of the disease.

Early-pregnancy plasma per- and polyfluoroalkyl substance (PFAS) concentrations and hypertensive disorders of pregnancy in the Project Viva cohort

BACKGROUND

Hypertensive disorders of pregnancy (HDP), defined here as hypertensive disorders with onset in pregnancy (i.e., gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension), affect up to 10% of pregnancies in the United States and are associated with substantial maternal and neonatal morbidity and mortality. Per- and polyfluoroalkyl substances (PFAS) are associated with adverse cardiometabolic outcomes during pregnancy, but associations between PFAS and HDP are inconsistent and joint effects of PFAS mixtures have not been evaluated.

METHODS

We studied 1,558 pregnant individuals from the Project Viva cohort, recruited during 1999-2002. We quantified concentrations of eight PFAS in plasma samples (median 9.7 weeks of gestation). Using clinical records, we calculated trimester-specific mean systolic (SBP) and diastolic (DBP) blood pressure and categorized HDP status [no HDP (normotensive & chronic hypertension), gestational hypertension, preeclampsia]. We estimated associations of individual PFAS with HDP using multinomial logistic regression and estimated associations with blood pressure using linear regression. We used Bayesian kernel machine regression (BKMR) and quantile g-computation to assess joint effects of the PFAS mixture on HDP and blood pressure measures.

RESULTS

Four percent of participants developed preeclampsia and 7% developed gestational hypertension. We observed higher odds of gestational hypertension, but not preeclampsia, per doubling of perfluorooctanoate (PFOA) [OR = 1.51 (95% confidence interval: 1.12, 2.03)], perfluorooctane sulfonate (PFOS) [OR = 1.38 (1.04, 1.82)], and perfluorohexane sulfonate [OR = 1.28 (1.06, 1.54)] concentrations. We observed higher mean DBP per doubling of PFOA [2nd trimester (T2): 0.39 mmHg (-0.01, 0.78); 3rd trimester (T3): 0.56 mmHg (0.14, 0.98)] and PFOS [T2: 0.46 mmHg (0.11, 0.82); T3: 0.43 mmHg (0.05, 0.80)]. The PFAS mixture was positively associated with odds of gestational hypertension [75th vs. 50th percentile: OR = 1.14 (95% credible interval:1.03, 1.25), BKMR] and mean DBP [T2 = 0.17 mmHg (-0.06, 0.40); T3 = 0.22 mmHg (-0.03, 0.48), BKMR].

CONCLUSIONS

These findings suggest that exposure to certain PFAS may increase the odds of gestational hypertension during pregnancy, with potential implications for subsequent maternal and child health outcomes.

Temporal Trends in Adverse Pregnancy Outcomes in Birthing Individuals Aged 15 to 44 Years in the United States, 2007 to 2019

Background Adverse pregnancy outcomes (APOs) (hypertensive disorders of pregnancy [HDP], preterm delivery [PTD], or low birth weight [LBW]) are associated adverse maternal and offspring cardiovascular outcomes. Therefore, we sought to describe nationwide temporal trends in the burden of each APO (HDP, PTD, LBW) from 2007 to 2019 to inform strategies to optimize maternal and offspring health outcomes. Methods and Results We performed a serial cross-sectional analysis of APO subtypes (HDP, PTD, LBW) from 2007 to 2019. We included maternal data from all live births that occurred in the United States using the National Center for Health Statistics Natality Files. We quantified age-standardized and age-specific rates of APOs per 1000 live births and their respective mean annual percentage change. All analyses were stratified by self-report of maternal race and ethnicity. Among 51 685 525 live births included, 15% were to non-Hispanic Black individuals, 24% Hispanic individuals, and 6% Asian individuals. Between 2007 and 2019, age standardized HDP rates approximately doubled, from 38.4 (38.2-38.6) to 77.8 (77.5-78.1) per 1000 live births. A significant inflection point was observed in 2014, with an acceleration in the rate of increase of HDP from 2007 to 2014 (+4.1% per year [3.6-4.7]) to 2014 to 2019 (+9.1% per year [8.1-10.1]). Rates of PTD and LBW increased significantly when co-occurring in the same pregnancy with HDP. Absolute rates of APOs were higher in non-Hispanic Black individuals and in older age groups. However, similar relative increases were seen across all age,racial and ethnic groups. Conclusions In aggregate, APOs now complicate nearly 1 in 5 live births. Incidence of HDP has increased significantly between 2007 and 2019 and contributed to the reversal of favorable trends in PTD and LBW. Similar patterns were observed in all age groups, suggesting that increasing maternal age at pregnancy does not account for these trends. Black-White disparities persisted throughout the study period.

Cardiovascular Risk Factors Mediate the Long-Term Maternal Risk Associated With Hypertensive Disorders of Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy (HDP), including gestational hypertension and preeclampsia, are associated with an increased risk of CVD.

OBJECTIVES

The purpose of this study was to evaluate associations between HDP and long-term CVD and identify the proportion of the association mediated by established CVD risk factors.

METHODS

Parous participants without CVD in the Nurses' Health Study II (n = 60,379) were followed for incident CVD from first birth through 2017. Cox proportional hazards models estimated HRs and 95% CIs for the relationship between HDP and CVD, adjusting for potential confounders, including prepregnancy body mass index, smoking, and parental history of CVD. To evaluate the proportion of the association jointly accounted for by chronic hypertension, hypercholesterolemia, type 2 diabetes, and changes in body mass index, we used the difference method.

RESULTS

Women with HDP in first pregnancy had a 63% higher rate of CVD (95% CI: 1.37-1.94) compared with women with normotensive pregnancies. This association was mediated by established CVD risk factors (proportion mediated = 64%). The increased rate of CVD was higher for preeclampsia (HR: 1.72; 95% CI: 1.42-2.10) than gestational hypertension (HR: 1.41; 95% CI: 1.03-1.93). Established CVD risk factors accounted for 57% of the increased rate of CVD for preeclampsia but 84% for gestational hypertension (both P < 0.0001).

CONCLUSIONS

Established CVD risk factors arising after pregnancy explained most (84%) of the increased risk of CVD conferred by gestational hypertension and 57% of the risk among women with preeclampsia. Screening for chronic hypertension, hypercholesterolemia, type 2 diabetes, and overweight/obesity after pregnancy may be especially helpful in CVD prevention among women with a history of HDP.

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman's reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.

Antihypertensive Medications for Severe Hypertension in Pregnancy: A Systematic Review and Meta-Analysis

Background: Hypertension in pregnancy causes significant maternal and fetal mortality and morbidity. A comprehensive assessment of the effectiveness of antihypertensive drugs for severe hypertension during pregnancy is needed to make informed decisions in clinical practice. This systematic review aimed to assess the efficacy and safety of antihypertensive drugs in severe hypertension during pregnancy. Methods: A systematic review using the electronic databases MEDLINE (PubMed) and Cochrane Library was performed until August 2021. The risk-of-bias 2 tool was used to assess the risk-of-bias in each study included. Meta-analysis was conducted to assess heterogeneity and to estimate the pooled effects size. Results: Seventeen studies fulfilled the inclusion criteria and 11 were included in the meta-analysis. Nifedipine was estimated to have a low risk in persistent hypertension compared to hydralazine (RR 0.40, 95% CI 0.23–0.71) and labetalol (RR 0.71, 95% CI 0.52–0.97). Dihydralazine was associated with a lower risk of persistent hypertension than ketanserin (RR 5.26, 95% CI 2.01–13.76). No difference was found in the risk of maternal hypotension, maternal and fetal outcomes, and adverse effects between antihypertensive drugs, except for dihydralazine, which was associated with more adverse effects than ketanserin. Conclusions: Several drugs can be used to treat severe hypertension in pregnancy, including oral/sublingual nifedipine, IV/oral labetalol, oral methyldopa, IV hydralazine, IV dihydralazine, IV ketanserin, IV nicardipine, IV urapidil, and IV diazoxide. In addition, nifedipine may be preferred as the first-line agent. There was no difference in the risk of maternal hypotension, maternal and fetal outcomes, and adverse effects between the drugs, except for adverse effects in IV dihydralazine and IV ketanserin.

Maternal Vascular Lesions in the Placenta Predict Vascular Impairments a Decade After Delivery

Women with adverse pregnancy outcomes later experience excess hypertension and cardiovascular disease, but how the events are linked is unknown. Examination of the placenta may provide clues to vascular impairments after delivery. Maternal vascular malperfusion lesions (MVMs) were abstracted from clinical reports, validated and characterized using clinical guidelines and severity score. A total of 492 women (170 with MVMs and 322 without MVMs) participated in a study visit 8 to 10 years after delivery to assess blood pressure, cardiometabolic factors, and sublingual microvascular features using sidestream dark field imaging. Covariates included age, race, adverse pregnancy outcomes (preeclampsia, small for gestational age, and preterm birth), and health behaviors. Women with versus without MVM had a distinct sublingual microvascular profile comprised of (1) lower microvascular density (-410 μm/mm², P=0.015), (2) higher red blood cell filling as a marker of perfusion (2%, P=0.004), and (3) smaller perfused boundary region (-0.07 µm, P=0.025) as a measure of glycocalyx integrity, adjusted for covariates including adverse pregnancy outcomes. Women with MVM also had higher adjusted diastolic blood pressure (+2.6 mm Hg, P=0.021), total and LDL (low-density lipoprotein)-cholesterol (+11.2 mg/dL, P=0.016; +8.7 mg/dL, P=0.031). MVM associations with subsequent cardiovascular measures did not vary by type of adverse pregnancy outcome, except among women with preterm births where blood pressure was higher only among those with MVM. Results were similar when evaluated as MVM severity. A decade after delivery, women with placental vascular lesions had an adverse cardiovascular profile comprised of microvascular rarefaction, higher blood pressure and more atherogenic lipids. Placental histopathology may reveal a woman's early trajectory toward subsequent vascular disease.

Calcium supplementation for the prevention of hypertensive disorders of pregnancy: current evidence and programmatic considerations

Most low‐ and middle‐income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500‐mg doses/day). WHO recommends 1.5–2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low‐dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost‐effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron‐containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food‐based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation.

Physical activity before pregnancy and the risk of hypertensive disorders of pregnancy

BACKGROUND

It is unclear whether pre-pregnancy physical activity influences the risk of hypertensive disorders of pregnancy and whether any impact is similar for preeclampsia or gestational hypertension.

OBJECTIVE

To evaluate the relation between pre-pregnancy physical activity with hypertensive disorders of pregnancy and its alignment with current recommendations for physical activity for the general population.

METHODS

We studied 28,147 singleton pregnancies from 18,283 women participating in the Nurses' Health Study-II without chronic hypertension, cardiovascular disease, or cancer, between 1989 and 2010. Women self-reported physical activity before pregnancy and pregnancy complications, including preeclampsia and gestational hypertension. Logistic regression models using generalized estimating equations to account for within-woman correlations across pregnancies were used to estimate the relative risk (95%CI) of preeclampsia and gestational hypertension across quartiles of pre-pregnancy physical activity, adjusting for age at pregnancy, parity, smoking, multivitamin use, infertility history, marital status, race, year of pregnancy, and history of preeclampsia.

RESULTS

We identified 842 (3.0%) pregnancies with preeclampsia and 905 (3.2%) pregnancies with gestational hypertension. Physical activity before pregnancy was related to a lower risk of hypertensive disorders of pregnancy (RR=0.75 [95%CI: 0.65, 0.87] for women in the highest quartile compared to the lowest quartile). This relation was driven by a 39% lower risk of gestational hypertension (RR=0.61; 95%CI:0.50,0.76) comparing women in the highest quartile of physical activity (≥ 30.6 MET-h/wk) vs. women in the lowest quartile (<6.0 MET-h/wk). Women whose moderate physical activity levels exceeded those recommended in the Physical Activity Guidelines for Americans (>5 h/wk) had a 50% lower (RR=0.50; 95%CI:0.36,0.69) risk of gestational hypertension than women who did not meet this recommendation (<2.5h/wk). For vigorous physical activity, the risk of gestational hypertension was lower among women who met (1.25-2.5 h/wk; RR=0.77; 95%CI: 0.64, 0.93) or exceeded (>2.5h/wk; RR=0.76; 95%CI: 0.62,0.92) the recommendations than women whose activity levels were below those recommended. Physical activity was not related to the risk of preeclampsia (RR=0.93; 95%CI:0.76,1.14).

CONCLUSIONS

Physical activity before pregnancy may lower the risk of developing gestational hypertension but not preeclampsia.