Understanding the Link Between the Placenta and Future Cardiovascular Disease

Adverse Pregnancy Outcomes and Long-Term Mortality in Women

Importance

Women with adverse pregnancy outcomes, such as preterm delivery or preeclampsia, have higher future risks of cardiometabolic disorders; however, little is known about their long-term mortality risks. A better understanding of such risks is needed to facilitate early identification of high-risk women and preventive actions.

Objective

To determine long-term mortality risks associated with 5 major adverse pregnancy outcomes in a large population-based cohort of women.

Design, Setting, and Participants

This national cohort study in Sweden used the Swedish Medical Birth Register, containing prenatal and birth information for nearly all deliveries in Sweden since 1973, to identify women who had a singleton delivery during 1973 to 2015. All 2 195 667 such women with information for pregnancy duration and infant birth weight were included in the study. Data were analyzed from March to September 2023.

Exposure

Adverse pregnancy outcomes (preterm delivery, small for gestational age, preeclampsia, other hypertensive disorders, and gestational diabetes), identified from nationwide birth records.

Main Outcome and Measures

All-cause and cause-specific mortality through December 31, 2018. Cox regression was used to compute hazard ratios (HRs) for mortality associated with specific adverse pregnancy outcomes, adjusted for other maternal factors. Cosibling analyses assessed for confounding by shared familial (genetic or environmental) factors.

Results

In 56 million person-years of follow-up to a median (IQR) age of 52 (42-61) years, 88 055 women (4%) died (median [IQR] age at death, 59 [50-67] years). All 5 adverse pregnancy outcomes were independently associated with increased mortality. Across the entire follow-up (≤46 years after delivery), adjusted HRs for all-cause mortality associated with specific adverse pregnancy outcomes were as follows: gestational diabetes, 1.52 (95% CI, 1.46-1.58); preterm delivery, 1.41 (95% CI, 1.37-1.44); small for gestational age, 1.30 (95% CI, 1.28-1.32); other hypertensive disorders, 1.27 (95% CI, 1.19-1.37); and preeclampsia, 1.13 (95% CI, 1.10-1.16). All HRs remained significantly elevated even 30 to 46 years after delivery. These effect sizes were only partially (0%-45%) reduced after controlling for shared familial factors in cosibling analyses. Women who experienced multiple adverse pregnancy outcomes had further increases in risk. Several major causes of death were identified, including cardiovascular and respiratory disorders and diabetes.

Conclusions and Relevance

In this large national cohort study, women who experienced any of 5 major adverse pregnancy outcomes had increased mortality risks that remained elevated more than 40 years later. Women with adverse pregnancy outcomes need early preventive evaluation and long-term follow-up for detection and treatment of chronic disorders associated with premature mortality.

EGCG, a Green Tea Compound, Increases NO Production and Has Antioxidant Action in a Static and Shear Stress In Vitro Model of Preeclampsia

Preeclampsia (PE) is a gestational hypertensive disease characterized by endothelial dysfunction. Epigallocatechin-3-gallate (EGCG), the main compound in green tea, is a promising therapeutic target for the disease. By activating eNOS, EGCG increased NO production and exerted an important antioxidant action, but its specific impact in the context of PE remains understudied. The aim of this study is to evaluate the effects of EGCG on endothelial function in static and shear stress in in vitro models of PE. Endothelial cells were incubated with healthy (HP) and preeclamptic (PE) pregnant women's plasma, and the latter group was treated with EGCG. Additionally, NOS (L-NAME) and PI3K protein (LY249002) inhibitors were also used. The levels of NO, ROS, and O2•- were evaluated, as well as the antioxidant potential. These investigations were also carried out in a shear stress model. We found that EGCG increases the NO levels, which were reduced in the PE group. This effect was attenuated with the use of L-NAME and LY249002. Furthermore, EGCG increased the antioxidant capacity of PE, but its action decreased with LY294002. In cells subjected to shear stress, EGCG increased nitrite levels in the PE group and maintained its action on the antioxidant capacity. This is the first study of the effects of EGCG in this experimental model, as well as the investigation of its effects along with shear stress. Our findings suggest that EGCG improves parameters of endothelial dysfunction in vitro, making it a promising target in the search for treatments for the disease.

The significance of mitochondrial haplogroups in preeclampsia risk

OBJECTIVE

To determine whether mitochondrial haplogroups function as disease-modifiers or as susceptibility factors in preeclampsia using a traditional haplogroup association model.

METHODS

This retrospective study haplotyped 235 control and 78 preeclamptic pregnancies from Denmark using either real-time PCR or Sanger sequencing depending on the rarity of the haplogroup.

RESULTS

No significant association between haplogroups and the risk of preeclampsia was found, nor was any role for haplogroups in disease severity uncovered.

CONCLUSION

Mitochondrial haplogroups are not associated with preeclampsia or the severity of preeclampsia in the Danish population. However, this study cannot exclude a role for less common mtDNA variation. Models that can examine these should be applied in preeclamptic patients.

Adverse pregnancy outcomes and long term risk of ischemic heart disease in mothers: national cohort and co-sibling study

OBJECTIVE

To examine the associations between five major adverse pregnancy outcomes and long term risks of ischemic heart disease in mothers.

DESIGN

National cohort study.

SETTING

Sweden.

PARTICIPANTS

All 2 195 266 women with a first singleton delivery in Sweden during 1973-2015.

MAIN OUTCOME MEASURES

The main outcome measure was incidence of ischemic heart disease from delivery to 2018, identified from nationwide inpatient and outpatient diagnoses. Cox regression was used to calculate hazard ratios for ischemic heart disease associated with preterm delivery, small for gestational age, pre-eclampsia, other hypertensive disorders of pregnancy, and gestational diabetes, adjusting for other adverse pregnancy outcomes and maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and environmental) factors.

RESULTS

During 53.6 million person years of follow-up, ischemic heart disease was diagnosed in 83 881 (3.8%) women. All five adverse pregnancy outcomes were independently associated with increased risk of ischemic heart disease. In the 10 years after delivery, adjusted hazard ratios for ischemic heart disease associated with specific adverse pregnancy outcomes were 2.09 (95% confidence interval 1.77 to 2.46) for other hypertensive disorders of pregnancy, 1.72 (1.55 to 1.90) for preterm delivery, 1.54 (1.37 to 1.72) for pre-eclampsia, 1.30 (1.09 to 1.56) for gestational diabetes, and 1.10 (1.00 to 1.21) for small for gestational age. The hazard ratios remained significantly increased even 30-46 years after delivery: 1.47 (1.30 to 1.66) for other hypertensive disorders of pregnancy, 1.40 (1.29 to 1.51) for gestational diabetes, 1.32 (1.28 to 1.36) for pre-eclampsia, 1.23 (1.19 to 1.27) for preterm delivery, and 1.16 (1.13 to 1.19) for small for gestational age. These findings were only partially (<45%) explained by shared familial (genetic or environmental) factors. Women who experienced multiple adverse pregnancy outcomes showed further increases in risk (eg, <10 years after delivery, adjusted hazard ratios associated with 1, 2, or ≥3 adverse pregnancy outcomes were 1.29 (1.19 to 1.39), 1.80 (1.59 to 2.03), and 2.26 (1.89 to 2.70), respectively)).

CONCLUSIONS

In this large national cohort, women who experienced any of five major adverse pregnancy outcomes showed an increased risk for ischemic heart disease up to 46 years after delivery. Women with adverse pregnancy outcomes should be considered for early preventive evaluation and long term risk reduction to help prevent the development of ischemic heart disease.

Preterm Delivery and Increased Risk of Recurrent Cardiovascular Events in Australian Women

Background: Women with a history of preterm delivery (PTD) have significantly increased risk of experiencing cardiovascular disease (CVD) later in life. However, the risk of long-term recurrence of CVD in this population remains unknown. Materials and Methods: The study was based on a cohort of Victorian women who had a singleton birth between 1999 and 2008. The primary outcome was a CVD event resulting in an Emergency Department visit/hospitalization or death. Women who do not have a PTD during the study period were adopted as the comparator. The Andersen and Gill model, which generalizes the Cox proportional hazards regression model, was used for the analysis of recurrent CVD, while adjusting for covariates, including indigenous status. Results: After excluding cases not meeting the inclusion criteria, 34,128 Victoria women who had a history of PTD and 374,538 women who had deliveries at terms were analyzed. A history of PTD was shown to be associated with significantly increased risk of recurrent CVD, while adjusting for all covariates, including indigenous status, with an adjusted hazard ratio (aHR) of 1.70 (95% confidence interval [CI]: 1.54-1.86, p < 0.0001). Aboriginal and Torres Strait Islander women had substantially increased risk of experiencing recurrent CVD after birth over their lifetime (aHR: 3.22, 95% CI: 2.39-4.35, p < 0.0001). Conclusions: Recognizing PTD as a nontraditional risk factor of CVD may play a role in the formulation of care plans for primary and secondary CVD prevention in women with such a history.

Hyperinsulinaemia in pregnancy and gestational outcomes: A case series

Background: Pathological insulin resistance in pregnancy is associated with an increased risk for complications such as gestational diabetes mellitus and pre-eclampsia. Individuals with pathological insulin resistance also exhibit hyperinsulinaemia. Currently, there are no diagnostic criteria for pathological hyperinsulinaemia in pregnancy that may be used to indicate risk of adverse outcomes.Aim: This case series aimed to explore the relationship between first trimester insulin response patterns and gestational outcomes.Setting: Auckland, New Zealand.Methods: Participants included four pregnant women with prepregnancy body mass index ≥ 25 kg/m2 and aged 25–35 years. Glucose and insulin response patterns were examined following a 120 min oral glucose tolerance test (OGTT) at 12–15 weeks of gestation using a modified Kraft methodology. Outcomes assessed at 25 and 35 weeks of gestation included gestational weight gain (GWG), blood pressure, fasting capillary blood glucose and foetal growth. Lifestyle and medical information were collected at each trimester. After delivery, total GWG, infant size, delivery method and clinical outcomes were recorded.Results: Kraft pattern IIB hyperinsulinaemia was identified in two cases. Amongst them, Case #1 experienced excessive GWG, induction of labour and surgically assisted delivery. Case #4 delivered by emergency caesarean, and the neonate required intensive care admission for 17 h. No cases developed hyperglycaemia or hypertension. Infant weights were between 3.75 kg and 3.86 kg.Conclusion: Dynamic insulin assay provides a promising template to assess metabolic risk in the first trimester of pregnancy. Diagnosing hyperinsulinaemia early in pregnancy means that lifestyle-based initiatives could be introduced earlier to mitigate excess GWG and potential adverse outcomes.

Adverse Pregnancy Outcomes and Incident Heart Failure in the Women's Health Initiative

IMPORTANCE

Some prior evidence suggests that adverse pregnancy outcomes (APOs) may be associated with heart failure (HF). Identifying unique factors associated with the risk of HF and studying HF subtypes are important next steps.

OBJECTIVE

To investigate the association of APOs with incident HF overall and stratified by HF subtype (preserved vs reduced ejection fraction) among postmenopausal women in the Women's Health Initiative (WHI).

DESIGN, SETTING, AND PARTICIPANTS

In 2017, an APO history survey was administered in the WHI study, a large multiethnic cohort of postmenopausal women. The associations of 5 APOs (gestational diabetes, hypertensive disorders of pregnancy [HDP], low birth weight, high birth weight, and preterm delivery) with incident adjudicated HF were analyzed. In this cohort study, the association of each APO with HF was assessed using logistic regression models and with HF subtypes using multinomial regression, adjusting for age, sociodemographic characteristics, smoking, randomization status, reproductive history, and other APOs. Data analysis was performed from January 2020 to September 2021.

EXPOSURES

APOs (gestational diabetes, HDP, low birth weight, high birth weight, and preterm delivery).

MAIN OUTCOMES AND MEASURES

All confirmed cases of women hospitalized with HF and HF subtype were adjudicated by trained physicians using standardized methods.

RESULTS

Of 10 292 women (median [IQR] age, 60 [55-64] years), 3185 (31.0%) reported 1 or more APO and 336 (3.3%) had a diagnosis of HF. Women with a history of any APO had a higher prevalence of hypertension, diabetes, coronary heart disease, or smoking. Of the APOs studied, only HDP was significantly associated with HF with a fully adjusted odds ratio (OR) of 1.75 (95% CI, 1.22-2.50), and with HF with preserved ejection fraction in fully adjusted models (OR, 2.06; 95% CI, 1.29-3.27). In mediation analyses, hypertension explained 24% (95% CI, 12%-73%), coronary heart disease 23% (95% CI, 11%-68%), and body mass index 20% (95% CI, 10%-64%) of the association between HDP and HF.

CONCLUSIONS AND RELEVANCE

In this large cohort of postmenopausal women, HDP was independently associated with incident HF, particularly HF with preserved ejection fraction, and this association was mediated by subsequent hypertension, coronary heart disease, and obesity. These findings suggest that monitoring and modifying these factors early in women presenting with HDP may be associated with reduced long-term risk of HF.

Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study

PURPOSE

The association between placental detachment disorders and risk of chronic disease is unclear. We determined the association of placenta accreta and retained placenta with risk of future maternal cardiovascular disease and cancer.

METHODS

We tracked a longitudinal cohort of 541,051 pregnant women over a period of 13 years (2006-2019) in Quebec, Canada. The main exposure measures were placenta accreta and retained placenta in any pregnancy. Outcomes included future hospitalizations for cardiovascular disease and cancer. Using Cox regression models adjusted for maternal characteristics, we estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of accreta and retained placenta with cardiovascular disease and cancer at 13 years.

RESULTS

The incidence of cardiovascular hospitalization was 21.2 per 10,000 person-years for accreta and 23.4 per 10,000 for retained placenta with postpartum hemorrhage, compared with 20.3 per 10,000 for neither placental disorder. Cancer incidence followed a similar pattern, with rates highest for retained placenta with hemorrhage. Retained placenta with hemorrhage was associated with 1.19 times the risk of cardiovascular disease (95% CI 1.03-1.38) and 1.27 times the risk of cancer (95% CI 1.06-1.53). Retained placenta with hemorrhage was associated with heart failure (HR 1.84, 95% CI 1.04-3.27), cardiomyopathy (HR 1.88, 95% CI 1.03-3.43), and cervical cancer (HR 2.03, 95% CI 1.17-3.52). Accreta and retained placenta without hemorrhage were not associated with these outcomes.

CONCLUSION

Retained placenta with hemorrhage may be a risk marker for cardiovascular disease and certain cancers later in life.

A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum

The rates of maternal overweight and obesity, but also excess gestational weight gain, are increasing. Pregnancy complications, including gestational diabetes mellitus, gestational hypertension, pre-eclampsia and delivery of a preterm or growth restricted baby, are higher for both women with overweight and obesity and women who gain excess weight during their pregnancy. Other conditions such as polycystic ovary syndrome are also strongly linked to overweight and obesity and worsened pregnancy complications. All of these conditions place women at increased risk for future cardiometabolic diseases. If overweight and obesity, but also excess gestational weight gain, can be reduced in women of reproductive age, then multiple comorbidities associated with pregnancy complications may also be reduced in the years after childbirth. This narrative review highlights the association between maternal overweight and obesity and gestational weight gain, with gestational diabetes, pre-eclampsia, polycystic ovary syndrome and delivery of a preterm or growth restricted baby. This review also addresses how these adverse conditions are linked to cardiometabolic diseases after birth. We report that while the independent associations between obesity and gestational weight gain are evident across many of the adverse conditions assessed, whether body mass index or gestational weight gain is a stronger driving factor for many of these is currently unclear. Mechanisms linking gestational diabetes mellitus, gestational hypertension, pre-eclampsia, preterm delivery and polycystic ovary syndrome to heightened risk for cardiometabolic diseases are multifactorial but relate to cardiovascular and inflammatory pathways that are also found in overweight and obesity. The need for post-partum cardiovascular risk assessment and follow-up care remains overlooked. Such early detection and intervention for women with pregnancy-related complications will significantly attenuate risk for cardiovascular disease.

Association of Adverse Pregnancy Outcomes With Risk of Atherosclerotic Cardiovascular Disease in Postmenopausal Women

Importance

Atherosclerotic cardiovascular disease (ASCVD) may have unique risk factors in women. Most women have a history of pregnancy; common adverse pregnancy outcomes (APOs) appear to be associated with ASCVD, but prior studies have limitations.

Objective

To assess whether APOs are associated with increased ASCVD risk independently of traditional risk factors.

Design, Setting, and Participants

The APO history among participants in the Women's Health Initiative, a large multiethnic cohort of postmenopausal women, was assessed. The associations of 5 self-reported APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight [ie, birth weight less than 2.49 kg], high birth weight [ie, birth weight greater than 4.08 kg], and preterm delivery by 3 weeks or more) with ASCVD were analyzed, adjusting for traditional ASCVD risk factors. Data were collected and analyzed in 2017.

Exposures

APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight, high birth weight, and preterm delivery).

Main Outcomes and Measures

Adjudicated ASCVD.

Results

A total of 48 113 Women's Health Initiative participants responded to the survey; the median (interquartile range) age at time of enrollment was 60.0 (55.0-64.0) years. A total of 13 482 participants (28.8%) reported 1 or more APOs. Atherosclerotic cardiovascular disease was more frequent in women who reported an APO compared with those without APOs (1028 of 13 482 [7.6%] vs 1758 of 30 522 [5.8%]). Each APO, analyzed separately, was significantly associated with ASCVD, and gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and preterm delivery remained significant after adjustment for traditional ASCVD risk factors. When all APOs were analyzed together, hypertensive disorders of pregnancy (odds ratio, 1.27; 95% CI, 1.15-1.40) and low birth weight (odds ratio, 1.12; 95% CI, 1.00-1.26) remained independently associated with ASCVD. All findings were materially unchanged by additional adjustment for parity, body mass index, and socioeconomic factors.

Conclusions and Relevance

In this large multiethnic cohort of women, hypertensive disorders of pregnancy and low birth weight were independently associated with ASCVD after adjustment for risk factors and other APOs.

Prepregnancy obesity: a risk factor for future development of ovarian and breast cancer

The aim of this study was to investigate the association between a history of prepregnancy obesity and a woman's future long-term risk for the development of female malignancies. A population-based study compared the incidence of long-term female malignancies in a cohort of consecutive women with and without a diagnosis of prepregnancy obesity. Deliveries occurred between the years 1988 and 2013, with a mean follow-up duration of 11.6 years. Women with known malignancies before the index pregnancy and known genetic predisposition for malignancy were excluded from the study. Female malignancies were divided according to specific type (ovary, uterine, breast, and uterine cervix). A Kaplan-Meier survival curve was used to estimate the cumulative incidence of malignancies. A Cox proportional hazards model was used to estimate the adjusted hazard ratios for female malignancy. During the study period, 106 251 deliveries fulfilled the inclusion criteria; 2.2% (n=2360) occurred in patients with a history of prepregnancy obesity. During the follow-up period, patients with prepregnancy obesity had a significantly increased risk for hospitalization because of female malignancies as a group and specifically ovarian and breast cancer. Using a Kaplan-Meier survival curve, patients with a previous diagnosis of prepregnancy obesity had a significantly higher cumulative incidence of female malignancies. Using a Cox proportional hazards model, adjusted for confounders such as gestational diabetes mellitus and maternal age, prepregnancy obesity remained independently associated with long-term risk for female malignancies (adjusted hazard ratio: 1.4; 95% confidence interval: 1.1-1.9; P=0.045). Prepregnancy obesity is an independent risk factor for long-term female malignancies such as ovarian and breast cancer.

Preterm Delivery and Future Risk of Maternal Cardiovascular Disease: A Systematic Review and Meta-Analysis

Background

Preterm delivery (<37 weeks gestational age) affects 11% of all pregnancies, but data are conflicting whether preterm birth is associated with long‐term adverse maternal cardiovascular outcomes. We aimed to systematically evaluate and summarize the evidence on the relationship between preterm birth and future maternal risk of cardiovascular diseases.

Methods and Results

A systematic search of MEDLINE and EMBASE was performed to identify relevant studies that evaluated the association between preterm birth and future maternal risk of composite cardiovascular disease, coronary heart disease, stroke, and death caused by cardiovascular or coronary heart disease and stroke. We quantified the associations using random effects meta‐analysis. Twenty‐one studies with over 5.8 million women, including over 338 000 women with previous preterm deliveries, were identified. Meta‐analysis of studies that adjusted for potential confounders showed that preterm birth was associated with an increased risk of maternal future cardiovascular disease (risk ratio [RR] 1.43, 95% confidence interval [CI], 1.18, 1.72), cardiovascular disease death (RR 1.78, 95% CI, 1.42, 2.21), coronary heart disease (RR 1.49, 95% CI, 1.38, 1.60), coronary heart disease death (RR 2.10, 95% CI, 1.87, 2.36), and stroke (RR 1.65, 95% CI, 1.51, 1.79). Sensitivity analysis showed that the highest risks occurred when the preterm deliveries occurred before 32 weeks gestation or were medically indicated.

Conclusions

Preterm delivery is associated with an increase in future maternal adverse cardiovascular outcomes, including a 2‐fold increase in deaths caused by coronary heart disease. These findings support the assessment of preterm delivery in cardiovascular risk assessment in women.

Maternal dietary free or bound fructose diversely influence developmental programming of lipogenesis

Background

Maternal dietary choices throughout preconception, pregnancy, and lactation irreversibly affect the development of fetal tissues and organs, known as fetal programming. Recommendations tend to emphasize reducing added sugars. However, the impact of maternal dietary free or bound fructose in added sugars on developmental programming of lipogenesis is unknown.

Methods

Virgin Sprague-Dawley rats were randomly divided into five groups. Rats were given feed and plain water (control) or water containing maltodextrin (vehicle), fructose, high-fructose corn syrup (HFCS) containing 55% fructose, sucrose (20% w/v) for 12 weeks before mating and throughout the pregnancy and lactation periods. Body weight, water, and feed intake were measured throughout the study. At the end of the lactation period, blood was drawn to determine the fasting levels of glucose, insulin, triglycerides, and non-esterified fatty acids (NEFA) in blood. Triglycerides and acetyl Co-A Carboxylase-1 (ACC1) levels in livers were analyzed, and insulin resistance was calculated.

Results

The energy intake of dams in the HFCS group was higher than in the fructose group, while weight gain was less in the HFCS group than in the fructose group. HFCS resulted in greater insulin resistance in dams, whereas free fructose had a robust effect on the fetal programming of insulin resistance. Free fructose and HFCS in the maternal diet increased blood and liver triglycerides and NEFA content in pups. Furthermore, fructose and HFCS exposure increased phosphorylated ACC1 as compared to maltodextrin and control, indicating greater fatty acid synthesis in pups and dams.

Conclusion

Different types of added sugar in the maternal diet have different metabolic effects on the developmental programming of lipogenesis. Consequently, high fructose intake via processed foods may increase the risk for chronic diseases, and free fructose might contribute to developmental programming of chronic diseases more than bound fructose.

Angiopoietin 2 in placentation and tumor biology: The yin and yang of vascular biology

There are several parallels between placental and tumor biology. Both require rapid acquisition of a blood supply to supply oxygen and nutrients, the placenta through neoangiogenesis and tumors by co-opting the existing vasculature. In addition, successful pregnancy also requires remodeling of the maternal uterine spiral arteries. Angiopoietins (Angs) are a family of angiogenic growth factors, the best studied being Ang-1 and Ang-2, which signal through the membrane tyrosine kinase receptor Tie2, and in simple terms have opposite effects with Ang-1 acting to stabilize newly formed blood vessels and Ang-2 having a destabilizing effect. The roles of Ang-1, and in particular Ang-2 in placental and tumor biology are discussed in this review.

Hyperemesis gravidarum and placental dysfunction disorders

Background

Evidence about the consequence of hyperemesis gravidarum (HG) on pregnancy outcomes is still inconclusive. In this study, we evaluated if occurrence of hyperemesis gravidarum is associated with placental dysfunction disorders and neonatal outcomes.

Methods

A prospective cohort study was conducted in a maternal and child health primary care referral center, Budi Kemuliaan Hospital and its branch, in Jakarta, Indonesia. 2252 pregnant women visiting the hospital for regular antenatal care visits from July 2012 until October 2014 were included at their first clinic visit. For women without, with mild and with severe hyperemesis, placental dysfunction disorders (gestational hypertension, preeclampsia (PE), stillbirth, miscarriage), neonatal outcomes (birth weight, small for gestational age (SGA), low birth weight (LBW), Apgar score at 5 min, gestational age at delivery) and placental outcomes (placental weight and placental-weight-to-birth-weight ratio (PW/BW ratio)) were studied.

Results

Compared to newborns of women without hyperemesis, newborns of women with severe hyperemesis had a 172 g lower birth weight in adjusted analysis (95%CI -333.26; -10.18; p = 0.04). There were no statistically significant effects on placental dysfunction disorders or other neonatal outcome measures.

Conclusions

The results of our study suggest that hyperemesis gravidarum does not seem to induce placental dysfunction disorders, but does, if severe lead to lower birth weight.

Altered cardiovascular function at birth in growth-restricted preterm lambs

BACKGROUND

Cardiovascular dysfunction at birth may underlie poor outcomes after fetal growth restriction (FGR) in neonates. We compared the cardiovascular transition between FGR and appropriately grown (AG) preterm lambs and examined possible mechanisms underlying any cardiovascular dysfunction in FGR lambs.

METHODS

FGR was induced in ewes bearing twins at 0.7 gestation; the twin was used as an internal control (AG). At 0.8 gestation, lambs were delivered and either euthanized with their arteries isolated for in vitro wire myography, or ventilated for 2 h. At 60 min, inhaled nitric oxide (iNO) was administered in a subgroup for 30 min. Molecular assessment of the nitric oxide (NO) pathway within lung tissue was conducted.

RESULTS

FGR lambs had lower left ventricular output and cerebral blood flow (CBF) and higher systemic vascular resistance compared with AG lambs. INO administration to FGR lambs rapidly improved cardiovascular and systemic hemodynamics but resulted in decreased CBF in AG lambs. Isolated arteries from FGR lambs showed impaired sensitivity to NO donors, but enhanced vasodilation to Sildenafil and Sodium nitroprusside, and altered expression of components of the NO pathway.

CONCLUSION

Cardiovascular dysfunction at birth may underlie the increased morbidity and mortality observed in preterm FGR newborns. Impaired NO signaling likely underlies the abnormal vascular reactivity.

Is preterm delivery an independent risk factor for long-term maternal kidney disease?. J Matern Fetal Neonatal Med 2016;30:1102-1107. [PMID: 27334094 DOI: 10.1080/14767058.2016.1205022]

OBJECTIVE

To investigate whether women who had a preterm delivery (PTD) are at an increased risk of subsequent long term maternal kidney disease.

STUDY DESIGN

A population-based study compared the incidence of long-term maternal kidney disease in a cohort of women with and without previous PTD. Deliveries occurred during a 25 years period, with a mean follow-up duration of 11.2 years.

RESULTS

Of 99 338 deliveries of women, 16 364 (16.4%) occurred in patients who had at least one PTD. A significant dose response was found between the number of previous PTDs and the gestational age at birth of the PTDs and future risk for renal-related hospitalizations. Patients with either spontaneous or indicated PTD had higher rates of renal-related hospitalizations (0.2% versus 0.1% OR= 2.6; 95%CI: 1.7-3.9, p  <0.001 and 0.5% versus 0.2% OR 3.41; 95%CI: 1.7-6.5, p  < 0.001, respectively). In a Cox proportional hazards model, PTD was independently associated with long-term maternal renal-related hospitalizations.

CONCLUSIONS

PTD is an independent risk factor for long-term maternal kidney disease.

Gene expression in term placentas is regulated more by spinal or epidural anesthesia than by late-onset preeclampsia or gestational diabetes mellitus

Pre-eclampsia (PE) and gestational diabetes mellitus (GDM) are common complications of pregnancy, but the mechanisms underlying these disorders remain unclear. The aim was to identify the extent of altered gene expression in term placentas from pregnant women with late-onset PE and GDM compared to controls. RNAseq identified few significantly differentially regulated genes in placental biopsies between PE, GDM, or uncomplicated pregnancy (n = 10 each group). Five genes were altered in placentas from PE including 4 non-coding genes and Angiopoietin 2 (ANGPT2). No genes were significantly regulated by GDM. In contrast, many genes were significantly regulated by fetal, maternal and delivery-specific variables, particularly spinal and epidural anesthesia. We selected ANGPT2 and Chemokine (C-X-C motif) ligand 14 (CXCL14) to test with qPCR in a larger set of placentas (n = 475) and found no differences between the groups. However, regression analysis revealed a stronger association between placental ANGPT2 and CXCL14 mRNA expression and fetal, maternal and delivery-specific variables than diagnostic group. To conclude, the gene expression in term placentas are highly affected by fetal, maternal and delivery specific variables. Few regulated genes were found in late-onset PE and GDM placentas, which may suggest that these conditions could be more affected by maternal factors.

Recurrent pregnancy loss: a risk factor for long-term maternal atherosclerotic morbidity?

OBJECTIVE

We sought to investigate whether patients with a history of recurrent pregnancy loss (RPL) have an increased risk for future maternal atherosclerotic morbidity.

STUDY DESIGN

A population-based study compared the incidence of long-term atherosclerotic morbidity (renal and cardiovascular) in a cohort of women with and without a diagnosis of RPL. Patients had a mean follow-up duration of more than a decade. Women with known atherosclerotic disease were excluded from the study. Cardiovascular morbidity was divided into 4 categories according to severity and type including simple and complex cardiovascular events and invasive and noninvasive cardiac procedures. Kaplan-Meier survival curves were used to estimate cumulative incidence of cardiovascular and renal hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazard ratios for cardiovascular and renal morbidity.

RESULTS

During the study period 99,285 patients were included; of these 6.7% (n = 6690) had a history of RPL. Patients with RPL had higher rates of renal and cardiovascular morbidity including cardiac invasive and noninvasive diagnostic procedures, simple as well as complex cardiovascular events, and hospitalizations due to cardiovascular causes. Using Kaplan-Meier survival curves, patients with a previous diagnosis of RPL had a significantly higher cumulative incidence of cardiovascular but not renal hospitalizations. Using a Cox proportional hazards model, adjusted for confounders such as preeclampsia, diabetes mellitus, obesity, and smoking, a history of RPL remained independently associated with cardiovascular hospitalizations (adjusted hazard ratio, 1.6; 95% confidence interval, 1.4-1.8; P = .001).

CONCLUSION

RPL is an independent risk factor for long-term maternal cardiovascular complications.

Beyond pregnancy: modulation of trophoblast invasion and its consequences for fetal growth and long-term children's health

Invasion of extravillous trophoblast cells (EVTs) into the maternal tissues is a key step in the development of a successful pregnancy, excessive and insufficient EVT invasion being associated with pregnancy complications. These pregnancy complications include preeclampsia and fetal growth restriction, both of which are associated with maternal and fetal morbidity and mortality at the time of birth and with increased risk of cardiovascular disease, diabetes and obesity in adult life for infants born from these conditions. In addition, women who develop preeclampsia are also at a greater risk of cardiovascular disease in later life. Many factors, protein and environmental, have been shown to both up- and down-regulate this process in vitro via different mechanisms. The redundancy observed in the regulation of this system suggests that dysregulation of one factor may not contribute to the pathological conditions of EVT invasion and that the relative local concentrations of many different factors may be more important. This review article explores the possibility that the modulation of EVT invasion as a therapeutic target for pregnancies affected by preeclampsia and fetal growth restriction may not be possible or needs to concentrate on the modulation of cell activity as a whole and not of one particular factor.

An association between preterm delivery and long-term maternal cardiovascular morbidity

OBJECTIVE

The purpose of this study was to investigate whether a history of preterm delivery (PTD) poses a risk for subsequent maternal long-term cardiovascular morbidity.

STUDY DESIGN

A population-based study compared the incidence of cardiovascular morbidity in a cohort of women who delivered preterm (<37 weeks' gestation) and those who gave birth at term at the same period. Deliveries occurred during the years 1988-1999 with follow up until 2010. Kaplan-Meier survival curves were used to estimate cumulative incidence of cardiovascular hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazard ratios for cardiovascular hospitalizations.

RESULTS

During the study period 47,908 women met the inclusion criteria; 12.5% of the patients (n = 5992) delivered preterm. During a follow-up period of >10 years, patients with PTD had higher rates of simple and complex cardiovascular events and higher rates of total cardiovascular-related hospitalizations. A linear association was found between the number of previous PTD and future risk for cardiovascular hospitalizations (5.5% for ≥2 PTDs; 5.0% for 1 PTD vs 3.5% in the comparison group; P < .001). The association remained significant for spontaneous vs induced PTD and for early (<34 weeks) and late (34 weeks to 36 weeks 6 days' gestation) PTD. In a Cox proportional hazards model that adjusted for pregnancy confounders such as labor induction, diabetes mellitus, preeclampsia, and obesity, PTD was associated independently with cardiovascular hospitalizations (adjusted hazard ratio, 1.4; 95% confidence interval, 1.2-1.6).

CONCLUSION

PTD is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than a decade.

Intrauterine growth restriction: screening, diagnosis, and management

BACKGROUND

Intrauterine growth restriction (IUGR) is an obstetrical complication, which by definition would screen in 10% of fetuses in the general population. The challenge is to identify the subset of pregnancies affected with pathological growth restriction in order to allow intervention that would decrease morbidity and mortality.

OBJECTIVE

The purpose of this guideline is to provide summary statements and recommendations and to establish a framework for screening, diagnosis, and management of pregnancies affected with IUGR.

METHODS

Affected pregnancies are compared with pregnancies in which the fetus is at an appropriate weight for its gestational age. History, physical examination, and laboratory investigations including biochemical markers and ultrasound characteristics of IUGR are reviewed, and a management strategy is suggested.

EVIDENCE

Published literature in English was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in January 2013 using appropriate controlled vocabulary via MeSH terms (fetal growth restriction and small for gestational age) and key words (fetal growth, restriction, growth retardation, IUGR, low birth weight, small for gestational age). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table).

BENEFITS, HARMS, AND COSTS

Implementation of the recommendations in this guideline should increase clinician recognition of IUGR and guide intervention where appropriate. Optimal long-term follow-up of neonates diagnosed as IUGR may improve their long-term health.