Preeclampsia and gestational diabetes mellitus: pre-conception origins?

The association of interleukin-6, interleukin-27, and body roundness index with gestational diabetes mellitus

We aimed to investigate the relationship between GDM and IL-27, IL-6, and body roundness index (BRI), a new anthropometric measurement more sensitive than BMI in identifying obesity and predicting cardiometabolic outcomes. We enrolled 80 patients, 40 pregnant women with GDM and 40 healthy pregnant women at midgestation. The women's anthropometric measurements were recorded and serum markers and IL-6, IL-27 were analysed. At the time of delivery maternal, neonatal results were recorded. Women with GDM had significantly higher pregestational, midgestational and prepartum BMI and midgestational BRI; HOMA-IR; HbA1c; and IL-6 values and lower HDL values (p < .05). There was no statistically significant difference in IL-27 values between the groups (p = .939). In multivariate logistic regression analysis, HbA1c, IL-6 (>4.886 pg/mL), and BRI (>6.708) were found as independent risk factors associated with GDM (p < .05). Mean BRI was significantly associated with obesity (p < .001) and BRI higher than 6.708 was found to have 67.5% sensitivity and 80% specificity in the prediction of GDM. Women with GDM had elevated IL-6 levels, but no relationship was detected between IL-27 and GDM. BRI is a new anthropometric index that strongly correlated with BMI and seems to be a reliable alternative to BMI for the evaluation of obesity in GDM patients.IMPACT STATEMENTWhat's already known on this subject? Gestational diabetes mellitus (GDM) is the most common systemic disease in pregnancy. The risk of GDM was 3 times higher in obese pregnant women compared to normal weighted patients. IL-6 is an adipose-derived cytokine that was found to be associated with GDM. The body roundness index (BRI) is a new sensitive anthropometric index for detecting obesity and its secondary cardiometabolic results.What do the results of this study add? Our results showed that BRI was strongly correlated with obesity in GDM patients. HbA1c, IL-6 and BRI were found as independent risk factors associated with GDM. IL 27, a cytokine associated with inflammatory diseases, was not associated with GDM.What are the implications of these findings for clinical practice and/or further research? BRI could be a reliable alternative to BMI for the evaluation of obesity in pregnant women and predicting cardiometabolic outcomes.

Association between prenatal phthalate exposure and gestational metabolic syndrome parameters: a systematic review of epidemiological studies

The relationship of intrauterine phthalate exposure with gestational metabolic syndrome (GMS) parameters is inconsistently reported. We performed a systematic review to evaluate the association between prenatal phthalate exposure and GMS parameters. A literature search was performed in three databases. According to the defined PECOS statement, eligible studies were identified. The method and result for each study was qualitatively summarized with great emphasis on study design and exposure assessment. Fourteen studies were included in the present systematic review. Two studies used one-spot serum sample for evaluation of phthalate exposure, while others used 1-4 urine samples. Concentrations of phthalate metabolites varied substantially, and the levels in serum were greatly lower than those in urine. These studies observed no interstudy or intrastudy consistency for association between phthalates and GMS in pregnant women cross-sectionally or longitudinally, regardless of phthalates species or GMS indicator. Most reported associations were not significantly different from null result. Besides, positive and negative relationships also existed. The current epidemiological data do not support the hypothesis that prenatal exposure to phthalates increases GMS risk.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Therapeutic Potential of Regulatory T Cells in Preeclampsia-Opportunities and Challenges

Inflammation is a central feature and is implicated as a causal factor in preeclampsia and other hypertensive disorders of pregnancy. Inflammatory mediators and leukocytes, which are elevated in peripheral blood and gestational tissues, contribute to the uterine vascular anomalies and compromised placental function that characterize particularly the severe, early onset form of disease. Regulatory T (Treg) cells are central mediators of pregnancy tolerance and direct other immune cells to counteract inflammation and promote robust placentation. Treg cells are commonly perturbed in preeclampsia, and there is evidence Treg cell insufficiency predates onset of symptoms. A causal role is implied by mouse studies showing sufficient numbers of functionally competent Treg cells must be present in the uterus from conception, to support maternal vascular adaptation and prevent later placental inflammatory pathology. Treg cells may therefore provide a tractable target for both preventative strategies and treatment interventions in preeclampsia. Steps to boost Treg cell activity require investigation and could be incorporated into pregnancy planning and preconception care. Pharmacological interventions developed to target Treg cells in autoimmune conditions warrant consideration for evaluation, utilizing rigorous clinical trial methodology, and ensuring safety is paramount. Emerging cell therapy tools involving in vitro Treg cell generation and/or expansion may in time become relevant. The success of preventative and therapeutic approaches will depend on resolving several challenges including developing informative diagnostic tests for Treg cell activity applicable before conception or during early pregnancy, selection of relevant patient subgroups, and identification of appropriate windows of gestation for intervention.

Fasting glucose concentrations and associations with reproductive history over 40 years of follow-up

Gestational diabetes mellitus (GDM) is the onset or first recognition of diabetes that occurs during pregnancy. We aimed to assess for trends in fasting blood glucose levels across the life-course among a cohort of women by reproductive history: nulligravid women, gravid women with and without a history of GDM. Women who had participated in the Bogalusa Heart Study as children were interviewed about their reproductive history, including GDM (n = 358). We compared fasting blood glucose (mg/dL) measured after last pregnancy (or after age 40 among nulligravid women) across reproductive history groups in linear models adjusted for prepregnancy fasting blood glucose, body mass index, race, parity, and age at outcome measure. We fit a log-Poisson model to estimate the associations with prediabetes risk after age 40. After adjustments, mean fasting glucose after age 40 was not different between gravid women without GDM history and nulligravid women. However, women with a history of GDM had mean fasting glucose 27 mg/dL greater than nulligravid women (95% CI = 12.35, 41.64). Heterogeneity by race indicated Black women with a history of GDM had disproportionately elevated mean fasting glucose after age 40. Fasting blood glucose trends over the life-course differ among women by reproductive history and race.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Prepregnancy liver enzyme levels and risk of preeclampsia in a subsequent pregnancy: A population-based cohort study

BACKGROUND & AIMS

Preeclampsia is a serious multisystemic disorder leading to maternal and neonatal adverse outcomes. However, little is known about the early markers of this disease. The aim of this study was to investigate the association between prepregnancy liver function and the development of preeclampsia.

METHODS

We enrolled 192 571 Korean women who had their first delivery between January 1, 2008, and December 31, 2014, and had undergone a national health screening examination through the National Health Insurance Corporation during 1-2 years before delivery.

RESULTS

Preeclampsia developed in 3973 (2.0%) women. The rate of development of preeclampsia was higher in women with abnormal prepregnancy liver enzyme levels than in those with normal liver enzyme levels before pregnancy. On multivariate analysis, women with abnormal alanine aminotransferase level before pregnancy had a 1.21-fold increased risk of developing preeclampsia than those with normal alanine aminotransferase level before pregnancy, after adjusting for age, family history of hypertension, hepatitis B virus carrier status, smoking, alcohol status, prepregnancy body mass index and blood pressure. Prepregnancy γ-glutamyltransferase and aspartate aminotransferase levels were not associated with the risk of preeclampsia development.

CONCLUSION

Abnormal prepregnancy alanine aminotransferase level was associated with the development of preeclampsia in a subsequent pregnancy. Further studies are needed to evaluate whether early intervention for liver function before pregnancy can decrease the risk of preeclampsia.

Conjoint Associations of Gestational Diabetes and Hypertension With Diabetes, Hypertension, and Cardiovascular Disease in Parents: A Retrospective Cohort Study

The conjoint association of gestational diabetes mellitus (GDM) and gestational hypertension (GH) with cardiometabolic disease has not been well studied. We evaluated a combined GDM/GH risk indicator in both mothers and fathers because of shared spousal behaviors and environments. In the present population-based retrospective cohort study, GH was identified in matched pairs of mothers with GDM or without GDM (matched on age group, health region, and year of delivery) who had singleton live births in Quebec, Canada (1990–2007). A total of 64,232 couples were categorized based on GDM/GH status (neither, either, or both). Associations with diabetes, hypertension, and a composite of cardiovascular disease (CVD) and mortality were evaluated using Cox proportional hazard models (from 12 weeks postpartum to March 2012). Compared with having neither GDM nor GH, having either was associated with incident diabetes (hazard ratio (HR) = 14.7, 95% confidence interval (CI): 12.9, 16.6), hypertension (HR = 1.9, 95% CI: 1.8, 2.0), and CVD/mortality (HR = 1.4, 95% CI: 1.2, 1.7). We found associations of greater magnitude among participants who had both (for diabetes, HR = 36.9, 95% CI: 26.0, 52.3; for hypertension, HR = 5.7, 95% CI: 4.9, 6.7; and for CVD/mortality, HR = 2.4, 95% CI: 1.6, 3.5). Associations with diabetes were also observed in fathers (for either, HR = 1.2, 95% CI: 1.1, 1.3; for both, HR = 1.8, 95% CI: 1.4, 2.3). In conclusion, we found associations of a combined GDM/GH indicator with cardiometabolic disease in mothers and with diabetes in fathers, with stronger associations when both GDM and GH were present.

Maternal pre-gravid cardiometabolic health and infant birthweight: A prospective pre-conception cohort study

BACKGROUND AND AIMS

Both low birthweight and high birthweight have been associated with the development of cardiometabolic disease in adulthood, possibly reflecting the effect of intrauterine fetal programming. As developmental programming can begin before conception, pre-gravid factors that predict birthweight may be relevant in this context. However, little is known about such factors. Thus, we established a pre-conception cohort to identify maternal pre-gravid cardiometabolic determinants of infant birthweight.

METHODS AND RESULTS

In this prospective observational cohort study, 1484 newly-married women in Liuyang, China, underwent baseline (pre-gravid) evaluation and then were followed across a subsequent pregnancy. Pre-gravid cardiometabolic characterization consisted of clinical (anthropometry, blood pressure) and biochemical evaluation (total/LDL/HDL cholesterol, triglycerides, glucose) at median 20 weeks before a singleton pregnancy. Mean birthweight was 3294 ± 444 g, with 173 neonates large-for-gestational-age (LGA) and 110 small-for-gestational-age (SGA). On multiple linear regression analysis, positive determinants of birthweight were maternal age, pre-gravid body mass index (BMI), weight gain in pregnancy, length of gestation, and male infant (all p ≤ 0.0003). On logistic regression analysis, independent predictors of an LGA delivery were maternal age (OR = 1.10 per year, 95%CI 1.03-1.18), pre-gravid BMI (OR = 1.21 per kg/m², 1.07-1.37), and gestational weight gain (OR = 1.10 per kg, 1.06-1.14). The only independent predictor of SGA was gestational weight gain (OR = 0.93 per kg, 0.89-0.97).

CONCLUSION

Maternal weight before and during pregnancy is the predominant cardiometabolic determinant of infant birthweight, rather than pre-gravid blood pressure, glucose or lipid profile.

Role of Type 2 Diabetes in Determining Retinal, Renal, and Cardiovascular Outcomes in Women With Previous Gestational Diabetes Mellitus

OBJECTIVE

Women who have gestational diabetes mellitus (GDM) have elevated lifetime risks for the development of type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), compared with their peers. However, it is not known whether their risk of CVD is dependent upon the development of T2DM. Thus, we sought to evaluate the role of T2DM in determining vascular outcomes in women with previous GDM.

RESEARCH DESIGN AND METHODS

All women in Ontario, Canada, with a live-birth pregnancy between April 1994 and March 2014 (n = 1,515,079) were stratified into the following four groups: women with GDM in whom T2DM subsequently developed (n = 15,585, median age 32 years); those with GDM in whom T2DM did not develop (n = 41,299; median age 32 years); women who did not have GDM but in whom T2DM developed (n = 49,397; median age 31 years); and those with neither GDM nor T2DM (n = 1,408,798; median age 30 years). Women were followed over a median time of 10.0 years for the development of microvascular and macrovascular outcomes.

RESULTS

Among women who had GDM, only those in whom T2DM developed had an increased risk of vitrectomy/photocoagulation (hazard ratio [HR] 4.49, 95% CI 3.90-5.17), renal dialysis (HR 7.52, 5.24-10.81), and hospitalization for foot infection (HR 4.32, 3.42-5.46) (all P < 0.0001). However, for macrovascular outcomes, both women with GDM in whom T2DM developed and those in whom T2DM did not develop had increased risks of CVD (HR 2.82; 2.41-3.30; P < 0.0001; and HR 1.30; 1.07-1.59; P = 0.008, respectively) and coronary artery disease (HR 3.54; 2.96-4.23; P < 0.0001; and HR 1.41; 1.11-1.80; P = 0.005, respectively), although absolute event rates were very low.

CONCLUSIONS

Women with GDM have an elevated risk of cardiovascular outcomes, even in the absence of T2DM. In contrast, microvascular risk emerges only in those in whom T2DM develops.

Effects of vitamin D supplementation on metabolic indices and hs-CRP levels in gestational diabetes mellitus patients: a randomized, double-blinded, placebo-controlled clinical trial

BACKGROUND/OBJECTIVES

Vitamin D plays an important role in the etiology of gestational diabetes mellitus (GDM). This study evaluated the effect of vitamin D supplementation on metabolic indices and hs-C-reactive protein (CRP) levels in GDM patients.

SUBJECTS/METHODS

The study was a randomized, placebo-controlled, double-blinded clinical trial. Seventy-six pregnant women with GDM and gestational age between 24-28 weeks were assigned to receive four oral treatments consisting of 50,000 IU of vitamin D3 (n = 38) or placebo (n = 38) once every 2 weeks for 2 months. Fasting blood glucose (FG), insulin, HbA1c, 25-hydroxyvitamin D, lipid profile, hs-CRP, and homeostasis model assessment-insulin resistance (HOMA-IR) were measured before and after treatment. Independent and paired t-tests were used to determine intra- and intergroup differences, respectively. ANCOVA was used to assess the effects of vitamin D supplementation on biochemical parameters.

RESULTS

Compared with the placebo group, in the vitamin D group, the serum level of 25-hydroxyvitamin D increased (19.15 vs. -0.40 ng/ml; P < 0.01) and that of FG (-4.72 vs. 5.27 mg/dl; P = 0.01) as well as HbA1c (-0.18% vs. 0.17%; P = 0.02) decreased. Improvements in the lipid profiles were observed in the vitamin D group, but without statistical significance. Significant increases in concentrations of hs-CRP, FG, HbA1c, total cholesterol, and LDL cholesterol were observed in the placebo group. No significant change in fasting insulin and HOMA-IR was observed in either group.

CONCLUSIONS

In GDM patients, vitamin D supplementation improved FG and HbA1c but had no significant effects on lipid profile or hs-CRP.

Serum Folate Shows an Inverse Association with Blood Pressure in a Cohort of Chinese Women of Childbearing Age: A Cross-Sectional Study

Background

It has been reported that higher folate intake from food and supplementation is associated with decreased blood pressure (BP). The association between serum folate concentration and BP has been examined in few studies. We aim to examine the association between serum folate and BP levels in a cohort of young Chinese women.

Methods

We used the baseline data from a pre-conception cohort of women of childbearing age in Liuyang, China, for this study. Demographic data were collected by structured interview. Serum folate concentration was measured by immunoassay, and homocysteine, blood glucose, triglyceride and total cholesterol were measured through standardized clinical procedures. Multiple linear regression and principal component regression model were applied in the analysis.

Results

A total of 1,532 healthy normotensive non-pregnant women were included in the final analysis. The mean concentration of serum folate was 7.5 ± 5.4 nmol/L and 55% of the women presented with folate deficiency (< 6.8 nmol/L). Multiple linear regression and principal component regression showed that serum folate levels were inversely associated with systolic and diastolic BP, after adjusting for demographic, anthropometric, and biochemical factors.

Conclusions

Serum folate is inversely associated with BP in non-pregnant women of childbearing age with high prevalence of folate deficiency.

Metabolic syndrome in the non-pregnant state is associated with the development of preeclampsia

BACKGROUND

The aim of this study was to investigate the association between metabolic syndrome in the non-pregnant state and the development of preeclampsia.

METHODS

We enrolled 212,463 Korean women who had their first delivery between January, 2011 and December, 2012 and had undergone a national health screening examination through the National Health Insurance during the 1-2 years before their first delivery. Women who had hypertension in the non-pregnant state were excluded. The presence of metabolic syndrome was defined using the modified criteria published in National Cholesterol Education Program Adult Treatment Panel III criteria.

RESULTS

The prevalence of metabolic syndrome in non-pregnant state was 1.2%. Preeclampsia developed in 3.1% and its prevalence among women with and without metabolic syndrome was 7.3% and 3.0%, respectively. The pre-pregnancy prevalence of metabolic syndrome was higher in women who developed preeclampsia compared to that in those who had a normal pregnancy (1.1% vs. 2.8%; p<0.001). On multivariate regression analysis, women with metabolic syndrome had an increased risk of developing preeclampsia (odds ratio: 1.48; 95% CI: 1.26 to 1.74) compared to that in those without metabolic syndrome, after adjusting for age, family history of hypertension, smoking status, and pre-pregnancy body mass index. The risk of preeclampsia increased with a rise in the number of components of metabolic syndrome.

CONCLUSION

Metabolic syndrome in the non-pregnant state was associated with the development of preeclampsia. Further studies are needed to evaluate whether early intervention for metabolic syndrome before pregnancy can decrease the risk of developing preeclampsia.

Preeclampsia and diabetes

Preeclampsia is diagnosed in women presenting with new onset hypertension accompanied by proteinuria or other signs of severe organ dysfunction in the second half of pregnancy. Preeclampsia risk is increased 2- to 4-fold among women with type 1 or type 2 diabetes. The limited number of pregnant women with preexisting diabetes and the difficulties associated with diagnosing preeclampsia in women with proteinuria prior to pregnancy are significant barriers to research in this high-risk population. Gestational diabetes mellitus (GDM) also increases preeclampsia risk, although it is unclear whether these two conditions share a common pathophysiological pathway. Nondiabetic women who have had preeclampsia are more likely to develop type 2 diabetes later in life. Among women with type 1 diabetes, a history of preeclampsia is associated with an increased risk of retinopathy and nephropathy. More research examining the pathophysiology, treatment, and the long-term health implications of preeclampsia among women with preexisting and gestational diabetes is needed.

Impaired proliferation of pancreatic beta cells, by reduced placental growth factor in pre-eclampsia, as a cause for gestational diabetes mellitus

OBJECTIVES

Reduced increase in serum placental growth factor (PLGF) levels frequently occurs in patients with pre-eclampsia (PE) and thus has been used as a predictive factor for developing PE. However, it has remained elusive how shortage of PLGF could affect pancreatic endocrine homoeostasis and function in pregnancy to lead to development of gestational diabetes mellitus (GDM).

MATERIALS AND METHODS

We used l-NAME injection in mice, as a model of human PE, in which PLGF levels were significantly reduced.

RESULTS

We not only confirmed reduced serum PLGF levels in patients with PE but also detected strong correlation of serum PLGF levels and presence of GDM. We found that growth of beta cell mass during pregnancy was significantly impaired by l-NAME injection, as a result of reduced beta cell proliferation. This may explain the higher risk of developing GDM in patients with PE. Moreover, provision of exogenous PLGF in l-NAME-treated pregnant mice significantly rescued beta cell proliferation, with subsequent increase in beta cell mass, suggesting that shortage in PLGF may be responsible for impaired beta cell growth and higher occurrence of GDM in patients with PE.

CONCLUSIONS

Our study highlighted a pivotal role for PLGF in prevention and treatment of GDM in patients with PE.

Risks of gestational diabetes and preeclampsia over the last decade in a cohort of Alberta women

OBJECTIVES

The incidence of gestational diabetes mellitus (GDM) is increasing. However, less is known about the incidence of preeclampsia (PE) and whether it is affected by the presence of GDM. We sought to document the population-level incidence of GDM and PE during the last decade and examine the association between GDM and PE after accounting for established risk factors.

METHODS

We selected a population-based cohort retrospectively using data from the Alberta Perinatal Health Program registry. Logistic regression was used to examine the association between GDM and PE after adjusting for baseline characteristics.

RESULTS

Of 426 296 deliveries between 2000 and 2009, 422 672 were in women without pre-existing diabetes. Among these women, the incidence of GDM increased from 3.1% in 2000 to 4.6% in 2009 (P < 0.01), while the incidence of PE remained stable at approximately 1.3% per year. The incidence of PE was significantly higher in women with GDM than in those without GDM (2.6% vs. 1.2%; P < 0.01). After adjustment, women with GDM had a 90% higher risk of PE than those without GDM (OR 1.9; 95% CI 1.7 to 2.1). Other significant risk factors for PE were age, obesity, nulliparity, multifetal gestation, pre-existing hypertension, and chronic kidney disease.

CONCLUSION

In this contemporary population-based study spanning 10 years, there was a significant increase in the incidence of GDM over time. The higher incidence of PE in women with GDM than in normoglycemic women suggests a need for heightened surveillance and monitoring of women with GDM for the development of PE.

Gestational diabetes and hypertensive disorders of pregnancy as vascular risk signals: an overview and grading of the evidence

The occurrence of common pregnancy-related medical disorders identifies women at high risk of developing future vascular disease. Systematic reviews of cohort studies demonstrate that gestational diabetes confers a 7-fold risk increase for type 2 diabetes, and preeclampsia confers a 1.8-fold risk increase for type 2 diabetes and 3.4-fold risk increase for hypertension. Gestational diabetes and hypertensive disorders of pregnancy (HDP) increase the risk of premature vascular disease, but the 2-fold risk increase associated with preeclampsia is only partially explained by the development of traditional vascular risk factors. Despite the compelling evidence for gestational diabetes and HDP as vascular risk indicators, there are no published Canadian vascular prevention guidelines that recognize these postpartum women. In contrast, the 2011 American Heart Association guidelines on cardiovascular disease in women include gestational diabetes and HDP in their vascular risk assessment. Studies indicate that the importance surveillance of vascular risk factors in these women after pregnancy is underappreciated by the women themselves and their physicians. Although a prudent diet and physically active lifestyle were demonstrated to reduce diabetes risk in women with a gestational diabetes history in the American Diabetes Prevention Program trial, adoption of these health behaviours is low; qualitative studies confirm a need for tailored strategies that address barriers and provide social support. Further research is also needed on approaches to reduce vascular risk in women with a history of gestational diabetes and HDP. Otherwise, an early window of opportunity for chronic disease prevention in young, high-risk women will be missed.

MATERNAL CARDIAC TWIST PRE-PREGNANCY: POTENTIAL AS A NOVEL MARKER OF PRE-ECLAMPSIA

Healthy pregnancy is characterised by progressive physiological adaptation of the maternal cardiovascular (CV) system that facilitates optimal fetal development. The adaptations that constitute a healthy or normal progression are not always evident, and, in particular, CV adaptation to pregnancy is highly individualised. Some women develop pregnancy-related CV dysfunction such as pre-eclampsia (PE). Typically, PE is diagnosed by the development of hypertension and proteinuria after 20 weeks of pregnancy and is the leading cause of maternal and perinatal mortality and morbidity. Despite continued efforts to improve the understanding of the aetiology, pathophysiology and subsequently treatment for the disease, CV changes in PE are not well understood. PE before 34 weeks (early onset PE) is believed to differ in pathogenesis from late onset PE (>34 weeks) and can be characterised by a haemodynamic profile of increased systemic vascular resistance (SVR) and lower cardiac output (CO). Early onset PE is more often associated with uteroplacental insufficiency and significant adverse maternal and perinatal outcomes. In contrast, late onset PE (>34 weeks) involves an increased CO and lower SVR and is less likely to be associated with uteroplacental insufficiency and adverse perinatal outcomes. It is not known if PE develops secondary to the CV maladaptation in pregnancy or if a preexisting CV dysfunction predisposes some women to develop PE. Screening, diagnosis and disease management would be vastly improved if more were known about the onset of the maladaptive process associated with PE. To date, a combination of maternal factors including medical history, body mass index, age, parity and blood pressure (BP) have been used to predict the development of PE. In the first trimester, arterial stiffness is significantly increased in women who develop PE. Current hypotheses speculate that CV dysfunction is evident very early in pregnancy in PE and precedes the clinical manifestation at a later stage but whether CV dysfunction is present before pregnancy remains to be elucidated.

Effect of maternal gestational diabetes on the cardiovascular risk factor profile of infants at 1 year of age

BACKGROUND AND AIM

Offspring of women with gestational diabetes (GDM) exhibit an adverse cardiovascular risk factor profile by as early as age 5 years. Recently, maternal glycemia has been associated with epigenetic modification of genes on the fetal side of the placenta, including those encoding emerging risk factors (adiponectin, leptin), suggesting that vascular differences may emerge even earlier in life. Thus, we sought to evaluate cardiovascular risk factors and determinants thereof in 1-year-old infants of women with and without GDM.

METHODS AND RESULTS

Traditional (glucose, lipids) and emerging (C-reactive protein (CRP), adiponectin, leptin) risk factors were assessed in pregnancy in 104 women with (n = 36) and without GDM (n = 68), and at age 1-year in their offspring. In pregnancy, women with GDM had higher triglycerides (2.49 vs 2.10 mmol/L, p = 0.04) and CRP (5.3 vs 3.6 mg/L, p = 0.03), and lower adiponectin (7.3 vs 8.5 μg/mL, p = 0.04) than did their peers. At age 1-year, however, there were no differences in cardiovascular risk factors (including adiponectin) between the infants of women with and without GDM. Of note, maternal and infant adiponectin levels were associated in the non-GDM group (r = 0.39, p = 0.001) but not in the GDM group (r = 0.07, p = 0.67). Furthermore, on multiple linear regression analyses, maternal adiponectin emerged as an independent predictor of infant adiponectin in the non-GDM group only (beta = 776.1, p = 0.0065).

CONCLUSION

Infants of women with and without GDM have a similar cardiovascular risk factor profile at age 1-year. However, there are differences in their early-life determinants of adiponectin that may be relevant to the subsequent vascular risk of GDM offspring.