Pregnancy as the prodrome to vascular dysfunction and cardiovascular risk

Hypertension in pregnancy as an early sex-specific risk factor for cardiovascular diseases: evidence and awareness

Despite being a physiological condition, human pregnancy is known to cause numerous complications that can endanger the life of the mother and the fetus alike. While the majority of complications are mostly limited within the peripartum period, more and more information is available about persistently higher short- and long-term cardiovascular risk after a pregnancy complicated by a hypertensive disorder. There is evidence that women after gestational hypertension or preeclampsia are more likely to develop arterial hypertension, coronary atherosclerosis, myocardial infarction, stroke, peripheral artery disease, and even diabetes mellitus and venous thromboembolism years after the target pregnancy. This has urged some authors to view hypertensive disorders of pregnancy as a "stress test" for the maternal organism that unmasks latent endothelial dysfunction. An explanation is sought in the presence of common risk factors and underlying pathological pathways with cardiovascular diseases, although a certain etiological mechanism for the development of hypertensive disorders in pregnancy has not been established yet. More attention is needed towards the follow-up of women after a hypertensive pregnancy as it could be an opportunity for early prevention of cardiovascular diseases.

Premature Atherosclerotic Cardiovascular Disease: What Have We Learned Recently?

PURPOSE OF REVIEW

In contrast to patients with non-premature atherosclerotic cardiovascular disease (ASCVD), patients with premature ASCVD have not observed a similar decline in cardiovascular mortality and recurrent adverse events. We sought to review the underlying risk factors, potential gaps in medical management, associated outcomes, and tools for risk prognostication among patients with premature ASCVD.

RECENT FINDINGS

In addition to traditional cardiovascular risk factors (i.e., diabetes, familial hypercholesterolemia), non-traditional risk factors such as chronic inflammatory conditions, recreational drug use, genetics, and pregnancy-related complications play a key role in development and progression of premature ASCVD. Patients with premature ASCVD, and especially women, receive less optimal medical management as compared to their non-premature counterparts. There is an increasing prevalence of cardiovascular risk factors among young adults. Hence, this population remains at an elevated risk for premature ASCVD and subsequent adverse cardiovascular events. Future studies evaluating different risk assessment tools and focusing on young patients across all three major domains of ASCVD are needed.

Addressing the Gap in Physician Preparedness To Assess Cardiovascular Risk in Women: a Comprehensive Approach to Cardiovascular Risk Assessment in Women

PURPOSE OF REVIEW

Increased recognition of risk factors and improved knowledge of sex-specific presentations has led to improved clinical outcomes for women with cardiovascular disease (CVD) compared to two decades ago. Yet, CVD remains the leading cause of death for women in the USA. Women have unique risk factors for CVD that continue to go under-recognized by their physicians.

RECENT FINDINGS

In a nationwide survey of primary care physicians (PCPs) and cardiologists, only 22% of PCPs and 42% of cardiologists reported being extremely well prepared to assess CVD risk in women. A presidential advisory from the American Heart Association (AHA) and American College of Obstetrics and Gynecologist (ACOG) recommends that cardiologists and obstetricians and gynecologists (Ob/Gyns) collaborate to promote CVD risk identification and reduction throughout a woman's lifetime. We suggest a comprehensive approach to identify unique and traditional risk factors for CVD in women, address the gap in physician knowledge, and improve cardiovascular care for women.

Pregnancy complications and premature cardiovascular events among 1.6 million California pregnancies

Background

Cardiovascular complications of pregnancy present an opportunity to assess risk for subsequent cardiovascular disease. We sought to determine whether peripartum cardiomyopathy and hypertensive disorder of pregnancy subtypes predict future myocardial infarction, heart failure or stroke independent of one another and of other risks such as gestational diabetes, preterm birth and intrauterine growth restriction.

Methods and results

The California Healthcare Cost and Utilization Project database was used to identify all hospitalised pregnancies from 2005 to 2009, with follow-up through 2011, for a retrospective cohort study. Pregnancies, exposures, covariates and outcomes were defined by International Classification of Diseases, Ninth Revision codes. Among 1.6 million pregnancies (mean age 28 years; median follow-up time to event excluding censoring 2.7 years), 558 cases of peripartum cardiomyopathy, 123 603 hypertensive disorders of pregnancy, 107 636 cases of gestational diabetes, 116 768 preterm births and 23 504 cases of intrauterine growth restriction were observed. Using multivariable Cox proportional hazards models, peripartum cardiomyopathy was independently associated with a 39.2-fold increase in heart failure (95% CI 30.0 to 51.9), resulting in ~1 additional hospitalisation per 1000 person-years. There was a 13.0-fold increase in myocardial infarction (95% CI 4.1 to 40.9) and a 7.7-fold increase in stroke (95% CI 2.4 to 24.0). Hypertensive disorders of pregnancy were associated with 1.4-fold (95% CI 1.0 to 2.0) to 7.6-fold (95% CI 5.4 to 10.7) higher risk of myocardial infarction, heart failure and stroke, resulting in a maximum of ~1 additional event per 1000 person-years. Gestational diabetes, preterm birth and intrauterine growth restriction had more modest associations.

Conclusion

These findings support close monitoring of women with cardiovascular pregnancy complications for prevention of early cardiovascular events and study of mechanisms underlying their development.

Increased risk of cardiovascular disease in women with prior gestational diabetes: A systematic review and meta-analysis

This study aims to investigate the effect of gestational diabetes mellitus (GDM) on the long-term risk of cardiovascular disease (CVD). PubMed and other databases were searched up to August 31, 2017. Cohort studies evaluating risk of CVD postpartum in women with and without prior GDM were included. Random-effect model was used to estimate the pooled relative risk of CVD. Sensitivity and subgroup analyses were performed to check the consistency of the effect size and to explore sources of heterogeneity. Multivariable logistic regression was used to control for high heterogeneity. Seven cohort studies with 3,417,020 pregnant women including 14,146 incident CVD events were retrieved. In the pooled analysis, women with previous GDM had a higher risk of CVD than those without (RR: 1.74, 95%CI: 1.28-2.35, I² = 95.7%). Four studies reported the event of coronary artery disease (CAD) and two studies reported stroke. The overall RR for CAD was 2.09 (95%CI: 1.56-2.80, I² = 91.2%) and that for stroke was 1.25 (95%CI: 1.07-1.48). In view of the high level of heterogeneity, adjustments were made for this, with the resulting adjusted OR for CVD and CAD being 1.95 (95%CI: 1.83-2.08) and 1.59 (95%CI: 1.30-1.94). Women with prior GDM have increased risk of CVD.

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.

Preeclampsia and health risks later in life: an immunological link

Pregnancy represents a period of physiological stress, and although this stress is experienced for a very modest portion of life, it is now recognized as a window to women's future health, often by unmasking predispositions to conditions that only become symptomatic later in life. In normal pregnancy, the mother experiences mild metabolic syndrome-like condition through week 20 of gestation. A pronounced phenotype of metabolic syndrome may program pregnancy complications such as preeclampsia. Preeclampsia is a serious complication with a myriad of manifestations for mother and offspring. This pregnancy syndrome is a polygenic disease and has been now linked to higher incidence of cardiovascular disease, diabetes, and several other disorders associated with vulnerable organs. Furthermore, the offspring born to preeclamptic mothers also exhibit an elevated risk of cardiovascular disease, stroke, and mental disorders during adulthood. This suggests that preeclampsia not only exposes the mother and the fetus to complications during pregnancy but also programs chronic diseases in later life. The etiology of preeclampsia is thought to be primarily associated with poor placentation and entails excessive maternal inflammation and endothelial dysfunction. It is well established now that the maternal immune system and the placenta are involved in a highly choreographed cross-talk that underlies adequate spiral artery remodeling required for uteroplacental perfusion and free flow of nutrients to the fetus. Since normal pregnancy is associated with a sequence of events represented by temporal events of inflammation (implantation), anti-inflammation (gestation), and inflammation (parturition), it is quite possible that unscheduled alterations in these regulatory responses may lead to pathologic consequences. Although it is not clear whether immunological alterations occur early in pregnancy, it is proposed that dysregulated systemic and placental immunity contribute to impaired angiogenesis and the onset of preeclampsia. This review will focus on important aspects of the immune system that coordinate with placental dysfunction to program preeclampsia and influence health in later life.

Metabolic Syndrome and Framingham Risk Score: Observation from Screening of Low-Income Semi-Urban African Women

Background: The heightened cardiovascular risk associated with metabolic syndrome (MetS) has been documented by several researchers. The Framingham risk score (FRS) provides a simple and efficient method for identifying individuals at cardiovascular risk. The objective was to describe the prevalence of MetS and its association with FRS in predicting cardiovascular disease among a cohort of semi-urban women; Method: Clinical and laboratory parameters were evaluated among 189 healthy women. The International Diabetes Federation definition was used to diagnose metabolic syndrome. FRS was calculated for each participant; Result: About two thirds of the participant make less than $US 90 per month. The mean systolic blood pressure was 131.80 ± 30. Eighty (42.3%) participants were overweight with a mean waist circumference of 91.64 ± 11.19 cm. MetS was present in 46 (24.3%). Individuals with MetS were more likely to have increased FRS, p = 0.012. One hundred and eighty seven (98.9%) were in the low risk category according to FRS. There was a significant difference in the mean FRS between participants with and without MetS (13.52 versus 10.29 p = 0.025); Conclusion: Prevalence of MetS in this study was comparable to the global rate, despite a low economic status. Individuals with MetS were more likely to have cardiovascular disease than persons without MetS, thus emphasizing the need for risk stratification and prompt management.

Early cardiovascular events in women with a history of gestational diabetes mellitus

Background

The effect of gestational diabetes mellitus (GDM) on cardiovascular diseases (CVD) is not assessed within the first 10 years postpartum, regardless of subsequent diabetes. The aim of this study was to determine the risk of CVD events related to GDM within 7 years of postpartum.

Methods

This nationwide population-based study of deliveries in 2007 and 2008 with a follow-up of 7 years was based on data from the French medico-administrative database. Two groups were formed: women with a history of GDM and women without GDM or previous diabetes. CVD included angina pectoris, myocardial infarction, stroke, heart bypass surgery, coronary angioplasty, carotid endarterectomy and fibrinolysis. Hypertensive disease was assessed separately. Determinants studied included age, obesity, subsequent diabetes mellitus and hypertensive diseases during pregnancy. Adjusted odds ratios for outcomes were calculated using multiple logistic regressions.

Results

The hospital database recorded 1,518,990 deliveries in 2007 and 2008. Among these, 62,958 women had a history of GDM. After adjusting for age, DM, obesity and hypertensive disorders in pregnancy, GDM was significantly associated with a higher risk of CVD (adjusted Odds Ratio aOR = 1.25 [1.09–1.43]). Considering each variable in a separate model, GDM was associated with angina pectoris (aOR = 1.68 [1.29–2.20]), myocardial infarction (aOR = 1.92 [1.36–2.71]) and hypertension (aOR = 2.72 [2.58–2.88]) but not with stroke.

Conclusions

A history of GDM was identified as a risk factor of CVD, especially coronary vascular diseases, within the 7 years postpartum. A lifestyle changes from postpartum onwards can be recommended and supported.

Insulin reverses D-glucose-increased nitric oxide and reactive oxygen species generation in human umbilical vein endothelial cells

Vascular tone is controlled by the L-arginine/nitric oxide (NO) pathway, and NO bioavailability is strongly affected by hyperglycaemia-induced oxidative stress. Insulin leads to high expression and activity of human cationic amino acid transporter 1 (hCAT-1), NO synthesis and vasodilation; thus, a protective role of insulin on high D-glucose-alterations in endothelial function is likely. Vascular reactivity to U46619 (thromboxane A2 mimetic) and calcitonin gene related peptide (CGRP) was measured in KCl preconstricted human umbilical vein rings (wire myography) incubated in normal (5 mmol/L) or high (25 mmol/L) D-glucose. hCAT-1, endothelial NO synthase (eNOS), 42 and 44 kDa mitogen-activated protein kinases (p42/44mapk), protein kinase B/Akt (Akt) expression and activity were determined by western blotting and qRT-PCR, tetrahydrobiopterin (BH4) level was determined by HPLC, and L-arginine transport (0-1000 μmol/L) was measured in response to 5-25 mmol/L D-glucose (0-36 hours) in passage 2 human umbilical vein endothelial cells (HUVECs). Assays were in the absence or presence of insulin and/or apocynin (nicotinamide adenine dinucleotide phosphate-oxidase [NADPH oxidase] inhibitor), tempol or Mn(III)TMPyP (SOD mimetics). High D-glucose increased hCAT-1 expression and activity, which was biphasic (peaks: 6 and 24 hours of incubation). High D-glucose-increased maximal transport velocity was blocked by insulin and correlated with lower hCAT-1 expression and SLC7A1 gene promoter activity. High D-glucose-increased transport parallels higher reactive oxygen species (ROS) and superoxide anion (O2•-) generation, and increased U46619-contraction and reduced CGRP-dilation of vein rings. Insulin and apocynin attenuate ROS and O2•- generation, and restored vascular reactivity to U46619 and CGRP. Insulin, but not apocynin or tempol reversed high D-glucose-increased NO synthesis; however, tempol and Mn(III)TMPyP reversed the high D-glucose-reduced BH4 level. Insulin and tempol blocked the high D-glucose-increased p42/44mapk phosphorylation. Vascular dysfunction caused by high D-glucose is likely attenuated by insulin through the L-arginine/NO and O2•-/NADPH oxidase pathways. These findings are of interest for better understanding vascular dysfunction in states of foetal insulin resistance and hyperglycaemia.

Gestational diabetes mellitus and cardiovascular risk after pregnancy

Gestational diabetes mellitus (GDM) affects many women in pregnancy and is enhanced by epidemic conditions of obesity, increasing age at the time of the first pregnancy, stressful life conditions, a sedentary lifestyle with less physical activity and unhealthy nutrition with highly processed, high-calorie food intake. GDM does not affect the mother and offspring in pregnancy alone, as there is compelling evidence of the long-term effects of the hyperglycemic state in pregnancy postpartum. Type 2 diabetes mellitus, cardiovascular disease and metabolic syndrome are more common in GDM women, and even the offspring of GDM women are reported to have higher obesity rates and a higher risk for noncommunicable diseases. Early prevention of risk factors seems to be key to overcoming the vicious cycle of cardiometabolic disease onset.

Prevention of cardiovascular disease in women: highlights for the clinician of the 2011 American Heart Association Guidelines

The 2011 Update to the American Heart Association Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women is designed to assist women and health professionals in understanding the cardiovascular disease risk for women and undertaking the most effective preventive interventions. Although coronary heart disease remains the leading cause of mortality for women in the United States, cardiovascular mortality among U.S. women has decreased dramatically each year since 2000, with the decline in mortality being steeper for women than for men. Nonetheless, since 1984, more women than men continue to die annually from cardiovascular disease. Half of the decrement in cardiovascular mortality for women since 2000 reflects the improved management of their established cardiovascular disease; the other half is attributable to reductions in their major coronary risk factors, hence the importance of this prevention guideline.

Cardiovascular outcomes after preeclampsia or eclampsia complicated by myocardial infarction or stroke

OBJECTIVE

To assess the relationship between preeclampsia or eclampsia and stroke, myocardial infarction (MI), subsequent cardiovascular outcomes, and long-term survival.

METHODS

Using the Myocardial Infarction Data Acquisition System in New Jersey (1994-2009), we analyzed cardiovascular outcomes in women with and without preeclampsia or eclampsia and a first MI or stroke but with a hospitalization for a first MI or stroke (analysis 1: MI case group, n=57; MI control group, n=155; stroke case group, n=132; stroke control group, n=379). We also compared these outcomes in women with preeclampsia or eclampsia and a first MI or stroke during pregnancy with women with preeclampsia or eclampsia without MI or stroke during pregnancy (analysis 2: MI case group, n=23; MI control group, n=67; stroke case group, n=90; stroke control group, n=263). A subsequent occurrence of MI, stroke, and cardiovascular death, as well as a combined cardiovascular outcome, was ascertained.

RESULTS

In analysis 1, women with preeclampsia or eclampsia were at significantly lower risk for combined cardiovascular outcome with all deaths (frequency of outcome 16.7%) and with cardiovascular deaths (10.6%) compared with women without preeclampsia or eclampsia after a first stroke (33.8% and 23.5%, respectively). In analysis 2, women with preeclampsia or eclampsia and a first stroke during admission were at significantly higher risk of all death (11.1%) and the combined cardiovascular outcome with all deaths (11.1%) compared with women with preeclampsia or eclampsia without a stroke (1.9% and 2.7%, respectively) during that admission.

CONCLUSION

Our study indicates that preeclampsia or eclampsia not complicated by MI or stroke during pregnancy may not confer a very high risk for subsequent MI and stroke in up to 16 years of follow-up. Our data suggest that other known risk factors put women at greater risk for stroke than preeclampsia or eclampsia complicated by a stroke.

LEVEL OF EVIDENCE

II.

Need for insulin to control gestational diabetes is reflected in the ambulatory arterial stiffness index

BACKGROUND

The aim was to evaluate the metabolic profile in conjunction with vascular function using the ambulatory arterial stiffness index (AASI) in women with uncomplicated pregnancies and in women with gestational diabetes mellitus (GDM).

METHODS

Plasma glucose, lipids, HOMA -IR (homeostasis model assessment of insulin resistance) and AASI, as obtained from 24-hour ambulatory blood pressure monitoring in third trimester pregnancy and at three months postpartum, were measured in three groups of women: controls (N=32), women with GDM on diet (N=42) and women with GDM requiring insulin treatment (N=10).

RESULTS

Women with GDM had poorer glycemic control and higher HOMA-IR during and after pregnancy and their total and LDL (low density lipoprotein) cholesterol levels were significantly higher after pregnancy than in the controls. After delivery, there was an improvement in AASI from 0.26±0.10 to 0.17±0.09 (P=0.002) in women with GDM on diet, but not in women with GDM receiving insulin whose AASI tended to worsen after delivery from 0.30±0.23 to 0.33±0.09 (NS), then being significantly higher than in the other groups (P=0.001-0.047).

CONCLUSIONS

Women with GDM had more unfavorable lipid profile and higher blood glucose values at three months after delivery, the metabolic profile being worst in women requiring insulin. Interestingly, the metabolic disturbances at three months postpartum were accompanied by a tendency towards arterial stiffness to increase in women requiring insulin.

What do the 2011 American Heart Association guidelines tell us about prevention of cardiovascular disease in women?

The 2011 Update of the American Heart Association's Cardiovascular Disease Prevention Guideline for Women is designed to help women and their physicians understand cardiovascular Disease (CVD) risks and undertake practical steps that are most effective in preventing heart disease and stroke. Defining a woman's risk status and improving her adherence to preventive lifestyle behaviors and medications is the best strategy to lower the burden of CVD in women.

Increased risk of hypertension after gestational diabetes mellitus: findings from a large prospective cohort study

OBJECTIVE

Whether a history of gestational diabetes mellitus (GDM) is associated with an increased risk of hypertension after the index pregnancy is not well established.

RESEARCH DESIGN AND METHODS

We investigated the association between GDM and subsequent risk of hypertension after the index pregnancy among 25,305 women who reported at least one singleton pregnancy between 1991 and 2007 in the Nurses' Health Study II.

RESULTS

During 16 years of follow-up, GDM developed in 1,414 women (5.6%) and hypertension developed in 3,138. A multivariable Cox proportional hazards model showed women with a history of GDM had a 26% increased risk of developing hypertension compared with those without a history of GDM (hazard ratio 1.26 [95% CI 1.11-1.43]; P=0.0004). These results were independent of pregnancy hypertension or subsequent type 2 diabetes.

CONCLUSIONS

These results indicate that women with GDM are at a significant increased risk of developing hypertension after the index pregnancy.

Differences in the prevalence of metabolic syndrome and levels of C-reactive protein after puerperium in women with hypertensive disorders during pregnancy

To measure high-sensitivity C-reactive protein (hsCRP) levels and to assess the presence of metabolic syndrome (MS) after puerperium in women diagnosed with various hypertensive disorders during pregnancy (HDP), a consecutive, cross-sectional case study at the 15th week after gestation. The sample consisted of 264 women who were admitted to a women's hospital. The diagnoses consisted of transient gestational hypertension (TGH=43.2%), preeclampsia (PC=29.5%), chronic hypertension (CH=20.1%) and PC superimposed on CH (7.2%). A diagnosis of previous hypertension was present in 45.8% of the CH group. The prevalence of MS was 16.7% (CH=42.1%, TGH=13.9%, PC=4.1%, P<0.001). The average hsCRP levels for the CH, TGH and PC groups were 3.79 ± 2.76, 3.55 ± 3.15 and 2.89 ± 3.02, respectively (P=0.040). The levels of hsCRP were higher in women with MS (4.71 ± 3.15 vs. 3.01 ± 2.88 mg l(-1) in those without MS, P<0.001), and they increased when a higher number of MS criteria was fulfilled (P<0.001). The results demonstrated a positive correlation between hsCRP levels and body mass index (BMI) (r=0.46), waist circumference (r=0.50) or the number of fulfilled MS criteria (r=0.56). The results suggest differences in vascular risk that depend on the type of HDP and on the prevalence of MS. The prevalence of MS was notably higher in the CH group, intermediate among the TGH group and much lower in the PC group. Differences in hsCRP levels also depended on the type of HDP (higher levels in CH and TGH patients in comparison with PC patients). Women with MS had higher hsCRP levels compared with women without MS, and the levels correlated with the number of MS criteria fulfilled. This result suggests that subclinical inflammatory status is correlated with the number of MS components present. Furthermore, hsCRP levels increased with increasing BMIs and waist circumferences.

Glucose intolerance in pregnancy and postpartum risk of metabolic syndrome in young women

CONTEXT/OBJECTIVE

Gestational diabetes mellitus (GDM) and even mild glucose intolerance in pregnancy are both associated with increased risks of developing type 2 diabetes and cardiovascular disease in the future. Because the metabolic syndrome also identifies patients at risk of type 2 diabetes and cardiovascular disease, we hypothesized that gestational dysglycemia may be associated with an unrecognized latent metabolic syndrome. Thus, we sought to evaluate the relationship between gestational glucose tolerance status and postpartum risk of metabolic syndrome.

DESIGN/SETTING/PARTICIPANTS

In this prospective cohort study, 487 women underwent oral glucose tolerance testing in pregnancy and cardiometabolic characterization at 3 months postpartum. The antepartum testing defined three gestational glucose tolerance groups: GDM (n = 137); gestational impaired glucose tolerance (GIGT) (n = 91); and normal glucose tolerance (NGT) (n = 259).

MAIN OUTCOME MEASURE

The primary outcome was the presence of the metabolic syndrome at 3 months postpartum, as defined by International Diabetes Federation (IDF) and American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) criteria, respectively.

RESULTS

The postpartum prevalence of IDF metabolic syndrome progressively increased from NGT (10.0%) to GIGT (17.6%) to GDM (20.0%) (overall P = 0.016). The same progression was observed for AHA/NHLBI metabolic syndrome (NGT, 8.9%; GIGT, 15.4%; and GDM, 16.8%; overall P = 0.046). On logistic regression analysis, both GDM (odds ratio, 2.05; 95% confidence interval, 1.07-3.94) and GIGT (odds ratio, 2.16; 95% confidence interval, 1.05-4.42) independently predicted postpartum metabolic syndrome.

CONCLUSIONS

Both GDM and mild glucose intolerance in pregnancy predict an increased likelihood of metabolic syndrome at 3 months postpartum, supporting the concept that women with gestational dysglycemia may have an underlying latent metabolic syndrome.

Metabolic diseases and associated complications: sex and gender matter!

BACKGROUND

Clinicians and health professionals are increasingly challenged to understand and consider the different health needs of women and men. The increase of gender awareness and the expanding science of gender medicine will affect more and more clinical practice. This review addresses gender-specific aspects in metabolic disorders and related complications, which represent an increasing burden of this century and a great challenge to public health.

DESIGN

There is increasing evidence of gender-related differences in risk factors, clinical manifestation and sequelae of obesity and diabetes and increasing knowledge that prevention, detection and therapy of illness affect men and women differently.

RESULTS

Some gender-specific aspects, especially regarding cardiovascular disease, have been studied in more detail, but for many complications sex-related analyses of the results of both clinical trials and basic science are still missing or disregarded. Impaired glucose and lipid metabolism as well as dysregulation of energy balance and body fat distribution have a great impact on overall health via neuroendocrine changes and inflammatory pathways and deteriorate the course of many diseases with particular harm for women. Metabolic diseases dramatically affect life of men and women from infancy up to old age and are a major challenge for women during pregnancy. Great impact is attached to the intrauterine period and the lifelong implications of fetal programming.

CONCLUSIONS

Initiation of prospective studies on the impact of gender as primary outcome and investigation of gender-related pathophysiological mechanisms of chronic diseases will help to improve patient care and to implement evidence-based gender-specific prevention programs and clinical recommendations in future.

Mechanisms underlying developmental programming of elevated blood pressure and vascular dysfunction: evidence from human studies and experimental animal models

Cardiovascular-related diseases are the leading cause of death in the world in both men and women. In addition to the environmental and genetic factors, early life conditions are now also considered important contributing elements to these pathologies. The concept of 'fetal' or 'developmental' origins of adult diseases has received increased recognition over the last decade, yet the mechanism by which altered perinatal environment can lead to dysfunction mostly apparent in the adult are incompletely understood. This review will focus on the mechanisms and pathways that epidemiological studies and experimental models have revealed underlying the adult cardiovascular phenotype dictated by the perinatal experience, as well as the probable key causal or triggering elements. Programmed elevated blood pressure in the adult human or animal is characterized by vascular dysfunction and microvascular rarefaction. Developmental mechanisms that have been more extensively studied include glucocorticoid exposure, the role of the kidneys and the renin-angiotensin system. Other pathophysiological pathways have been explored, such as the role of the brain and the sympathetic nervous system, oxidative stress and epigenetic changes. As with many complex diseases, a unifying hypothesis linking the perinatal environment to elevated blood pressure and vascular dysfunction in later life cannot be presumed, and a better understanding of those mechanisms is critical before clinical trials of preventive or 'deprogramming' measures can be designed.