Maternal risk of ischaemic heart disease following elective and spontaneous pre-term delivery: retrospective cohort study of 750 350 singleton pregnancies

Biomarkers associated with cardiovascular disease in women with spontaneous preterm birth: A case-control study

INTRODUCTION

Women with spontaneous preterm birth have an increased risk of cardiovascular disease later in life. Studies suggest potential pathophysiological mechanisms in common, but whether these could be identified by measurement of soluble circulating protein biomarkers in women with spontaneous preterm birth is unknown. The aim of this study was to determine if protein biomarkers associated with cardiovascular disease distinguish women with spontaneous preterm birth from healthy controls, both at pregnancy and at follow up.

MATERIAL AND METHODS

Study participants were identified in the population-based Uppsala biobank of pregnant women in Sweden, where plasma samples were collected in mid-pregnancy. In a first screening phase, we identified participants who subsequently experienced spontaneous preterm birth (<37 weeks) in the index pregnancy (N = 13) and controls (N = 6). In these samples, differences in protein expression were examined by comparative mass spectrometry. In a second validation phase, we invited 100 cases with previous spontaneous preterm birth in the index pregnancy and 100 controls (matched for age, body mass index, and year of delivery) from the same source population, to a follow-up visit 4-15 years after pregnancy. At follow up, we collected plasma samples and data on cardiovascular risk factors. We measured concentrations of selected biomarkers identified in the screening phase, as well as lipid profiles in samples both from pregnancy (biobank) and follow up.

CLINICALTRIALS

gov registration NCT05693285.

RESULTS

In the screening phase, fibrinogen, cadherin-5, complement C5, factor XII, plasma kallikrein, apolipoprotein M, and vitamin D-binding protein differed significantly at pregnancy. In the validation phase, 65 women agreed to participate (35 cases and 30 controls), with a median follow-up time of 11.8 years since pregnancy. The concentration of fibrinogen (p = 0.02) and triglycerides (p = 0.03) were slightly higher in cases compared with matched controls at follow up.

CONCLUSIONS

Compared with women without preterm birth, those with spontaneous preterm birth had slightly higher concentrations of fibrinogen, both at mid-pregnancy and a decade after pregnancy. Additionally, we found slightly higher concentration of triglycerides at follow up in women with previous spontaneous preterm birth. The relevance of this finding is uncertain but might indicate potential pathophysiological mechanisms in common between spontaneous preterm birth and cardiovascular disease.

Birth Weight in Consecutive Pregnancies and Maternal Cardiovascular Disease Mortality Among Spontaneous and Iatrogenic Term Births: A Population-Based Cohort Study

Knowledge on the association between offspring birth weight and long-term risk of maternal cardiovascular disease (CVD) mortality is often based on firstborn infants without consideration of women's consecutive births. We studied long-term CVD mortality according to offspring birth weight patterns among women with spontaneous and iatrogenic term deliveries in Norway (1967-2020). We constructed birth weight quartiles (Qs) by combining standardized birth weight with gestational age in quartiles (Q1, Q2/Q3, and Q4) for the women's first 2 births. Mortality was estimated using Cox regression and expressed as hazard ratios (HRs) with 95% confidence intervals (CIs). Changes in offspring birth weight quartiles were associated with long-term maternal CVD mortality. Compared with women who had 2 term infants in Q2/Q3, women with a first offspring in Q2/Q3 and a second in Q1 had higher mortality risk (HR = 1.33, 95% CI: 1.18, 1.50), while risk was lower if the second offspring was in Q4 (HR = 0.78, 95% CI: 0.67, 0.91). The risk increase associated with having a first infant in Q1 was eliminated if the second offspring was in Q4 (HR = 0.99, 95% CI: 0.75, 1.31). These patterns were similar for women with iatrogenic and spontaneous deliveries. Inclusion of information from subsequent births revealed heterogeneity in maternal CVD mortality which was not captured when using only information based on the first offspring.

Prepregnancy Cardiovascular Disease Risk Factors and Adverse Pregnancy Outcomes in a Safety-Net Hospital

Background: Many adverse pregnancy outcomes (APOs) are associated with elevated cardiovascular disease (CVD) risk. However, APO data in the context of pre-existing CVD risk factors, and from diverse populations, are limited. We assessed the occurrence of APOs among individuals with and without prepregnancy CVD risk factors, overall and by race/ethnicity. Methods: We conducted a retrospective study using electronic medical record data from a large urban safety-net hospital. Individuals with prenatal care and delivery between 2016 and 2018 at the hospital were included, and data from prenatal intake through the delivery hospitalization were captured. The exposure, prepregnancy CVD risk factors (hypertension, diabetes, tobacco use, and obesity), and the outcome, APOs (hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, low birth weight, and stillbirth), were identified from electronic medical records. Results: We identified 3760 unique delivering individuals, of whom 55.1% self-identified as Black non-Hispanic and 17% as Hispanic. Prepregnancy CVD risk factor prevalence was 45.6%, most commonly obesity (26.6%). APO prevalence was 35.6%, most commonly a hypertensive disorder of pregnancy (20.1%). Overall, 45.7% of APOs occurred in the absence of recognized prepregnancy CVD risk factors, representing 16.3% of the total sample. Among individuals without prepregnancy CVD risk factors, APO prevalence was 30.0% and did not vary by race/ethnicity. Conclusions: In this racially and ethnically diverse hospital-based sample, APOs were present in one in three parous individuals without prepregnancy CVD risk factors-a group with potentially elevated CVD risk who might otherwise be missed by traditional CVD risk factor screening.

Pregnancy Complications and Long-Term Mortality in a Diverse Cohort

BACKGROUND

Pregnancy complications are associated with increased risk of development of cardiometabolic diseases and earlier mortality. However, much of the previous research has been limited to White pregnant participants. We aimed to investigate pregnancy complications in association with total and cause-specific mortality in a racially diverse cohort and evaluate whether associations differ between Black and White pregnant participants.

METHODS

The Collaborative Perinatal Project was a prospective cohort study of 48 197 pregnant participants at 12 US clinical centers (1959-1966). The Collaborative Perinatal Project Mortality Linkage Study ascertained participants' vital status through 2016 with linkage to the National Death Index and Social Security Death Master File. Adjusted hazard ratios (aHRs) for underlying all-cause and cause-specific mortality were estimated for preterm delivery (PTD), hypertensive disorders of pregnancy, and gestational diabetes/impaired glucose tolerance (GDM/IGT) using Cox models adjusted for age, prepregnancy body mass index, smoking, race and ethnicity, previous pregnancies, marital status, income, education, previous medical conditions, site, and year.

RESULTS

Among 46 551 participants, 45% (21 107 of 46 551) were Black, and 46% (21 502 of 46 551) were White. The median time between the index pregnancy and death/censoring was 52 years (interquartile range, 45-54). Mortality was higher among Black (8714 of 21 107 [41%]) compared with White (8019 of 21 502 [37%]) participants. Overall, 15% (6753 of 43 969) of participants had PTD, 5% (2155 of 45 897) had hypertensive disorders of pregnancy, and 1% (540 of 45 890) had GDM/IGT. PTD incidence was higher in Black (4145 of 20 288 [20%]) compared with White (1941 of 19 963 [10%]) participants. The following were associated with all-cause mortality: preterm spontaneous labor (aHR, 1.07 [95% CI, 1.03-1.1]); preterm premature rupture of membranes (aHR, 1.23 [1.05-1.44]); preterm induced labor (aHR, 1.31 [1.03-1.66]); preterm prelabor cesarean delivery (aHR, 2.09 [1.75-2.48]) compared with full-term delivery; gestational hypertension (aHR, 1.09 [0.97-1.22]); preeclampsia or eclampsia (aHR, 1.14 [0.99-1.32]) and superimposed preeclampsia or eclampsia (aHR, 1.32 [1.20-1.46]) compared with normotensive; and GDM/IGT (aHR, 1.14 [1.00-1.30]) compared with normoglycemic. P values for effect modification between Black and White participants for PTD, hypertensive disorders of pregnancy, and GDM/IGT were 0.009, 0.05, and 0.92, respectively. Preterm induced labor was associated with greater mortality risk among Black (aHR, 1.64 [1.10-2.46]) compared with White (aHR, 1.29 [0.97-1.73]) participants, while preterm prelabor cesarean delivery was higher in White (aHR, 2.34 [1.90-2.90]) compared with Black (aHR, 1.40 [1.00-1.96]) participants.

CONCLUSIONS

In this large, diverse US cohort, pregnancy complications were associated with higher mortality nearly 50 years later. Higher incidence of some complications in Black individuals and differential associations with mortality risk suggest that disparities in pregnancy health may have life-long implications for earlier mortality.

Early mortality among aboriginal and non-aboriginal women who had a preterm birth in Western Australia: A population-based cohort study

BACKGROUND

Having a preterm (<37 weeks' gestation) birth may increase a woman's risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women.

OBJECTIVES

We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status.

METHODS

This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cause-specific mortality.

RESULTS

There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95% CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95% CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95% CI 1.32, 1.66) and 1.35 (95% CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes.

CONCLUSIONS

Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening.

Elevated cardiovascular disease risk in low-income women with a history of pregnancy loss

OBJECTIVE

Pregnancy is associated with elevated risk of cardiovascular diseases (CVD), but little is known regarding the association between CVD and specific types of pregnancy losses. The aim of this study is to investigate the effects of pregnancy loss on the risk of subsequent CVD of any type.

METHODS

This prospective longitudinal study examines medical records between 1999 and 2014 for Medicaid beneficiaries born after 1982 who lived in a state that funds all reproductive health services, including induced abortion. Unique pregnancy outcomes, history of diabetes, hyperlipidaemia or CVD (International Classification of Diseases, Ninth Revision (ICD-9): 401-459) prior to their first pregnancy outcome for each woman. Cumulative incidence rates of a first CVD diagnosis following a first pregnancy were calculated for the observed period, exceeding 12 years.

RESULTS

A history of pregnancy loss was associated with 38% (OR=1.38; 95% CI=1.37 to 1.40) higher risk of a CVD diagnosis in the period observed. After controlling for history of diabetes, hyperlipidaemia, age, year of first pregnancy, race, state of residence, months of eligibility, number of pregnancies, births, number of losses before and after the first live birth, exposure to any pregnancy loss was associated with an 18% (adjusted OR=1.18; 95% CI=1.15 to 1.21) increased risk of CVD. Our analyses also reveal an important temporal relationship between the CVD and pregnancy loss. Immediate and short-term increased CVD risk is more characteristic for women whose first pregnancy ended in live birth while a delayed and more prolonged increased risk of CVD is associated with a first pregnancy loss.

CONCLUSIONS

Our findings corroborate previous research showing that pregnancy loss is an independent risk factor for CVD, especially for diseases more chronic in nature. Our research contributes to understanding the specific needs for cardiovascular health monitoring for pregnant women and developing a consistent, evidence-based screening tools for both short-term and long-term follow-up.

First Trimester Prediction of Preterm Delivery in the Absence of Other Pregnancy-Related Complications Using Cardiovascular-Disease Associated MicroRNA Biomarkers

The aim of the study was to determine if aberrant expression profile of cardiovascular disease associated microRNAs would be able to predict within 10 to 13 weeks of gestation preterm delivery such as spontaneous preterm birth (PTB) or preterm prelabor rupture of membranes (PPROM) in the absence of other pregnancy-related complications (gestational hypertension, preeclampsia, fetal growth restriction, or small for gestational age). In addition, we assessed if aberrant expression profile of cardiovascular disease associated microRNAs would be able to predict preterm delivery before and after 34 weeks of gestation. The retrospective study was performed within the period November 2012 to March 2020. Whole peripheral blood samples were collected from 6440 Caucasian individuals involving 41 PTB and 65 PPROM singleton pregnancies. A control group, 80 singleton term pregnancies, was selected on the base of equal sample storage time. Gene expression of 29 selected cardiovascular disease associated microRNAs was studied using real-time RT-PCR. Downregulation of miR-16-5p, miR-20b-5p, miR-21-5p, miR-24-3p, miR-26a-5p, miR-92a-3p, miR-126-3p, miR-133a-3p, miR-145-5p, miR-146a-5p, miR-155-5p, miR-210-3p, miR-221-3p and miR-342-3p was observed in pregnancies with preterm delivery before 37 (≤36 + 6/7) weeks of gestation. Majority of downregulated microRNAs (miR-16-5p, miR-24-3p, miR-26a-5p, miR-92a-3p, miR-133a-3p, miR-145-5p, miR-146a-5p, miR-155-5p, miR-210-3p, and miR-342-3p) was associated with preterm delivery occurring before 37 (≤36 + 6/7) weeks of gestation. The only miR-210-3p was downregulated in pregnancies with preterm delivery before 34 (≤33 + 6/7) weeks of gestation. The type of preterm delivery also had impact on microRNA gene expression profile. Downregulation of miR-24-3p, miR-92a-3p, miR-155-5p, and miR-210-3p was a common feature of PTB and PPROM pregnancies. Downregulation of miR-16-5p, miR-20b-5p, miR-26a-5p, miR-126-3p, miR-133a-3p, miR-146a-5p, miR-221-3p, and miR-342-3p appeared just in PTB pregnancies. No microRNA was uniquely dysregulated in PPROM pregnancies. The combination of 12 microRNAs (miR-16-5p, miR-20b-5p, miR-21-5p, miR-24-3p, miR-26a-5p, miR-92a-3p, miR-133a-3p, miR-145-5p, miR-146a-5p, miR-155-5p, miR-210-3p, and miR-342-3p, AUC 0.818, p < 0.001, 74.53% sensitivity, 75.00% specificity, cut off > 0.634) equally as the combination of 6 microRNAs (miR-16-5p, miR-21-5p, miR-24-3p, miR-133a-3p, miR-155-5p, and miR-210-3p, AUC 0.812, p < 0.001, 70.75% sensitivity, 78.75% specificity, cut off > 0.652) can predict preterm delivery before 37 weeks of gestation in early stages of gestation in 52.83% pregnancies at 10.0% FPR. Cardiovascular disease associated microRNAs represent promising biomarkers with very good diagnostical potential to be implemented into the current routine first trimester screening programme to predict preterm delivery.

Maternal LINE-1 DNA Methylation in Early Spontaneous Preterm Birth

Despite considerable effort aimed at decreasing the incidence of spontaneous preterm birth (SPTB), it remains the leading cause of infant mortality and morbidity. The aim of this study was to evaluate maternal LINE-1 DNA methylation (DNAm), along with DNMT polymorphisms and factors proposed to modulate DNAm, in patients who delivered early preterm. This case-control study included women who delivered spontaneously early preterm (23-33^6/7 weeks of gestation), and control women. DNAm was analyzed in peripheral blood lymphocytes by quantification of LINE-1 DNAm using the MethyLight method. There was no significant difference in LINE-1 DNAm between patients with early PTB and controls. Among the investigated predictors, only the history of previous PTB was significantly associated with LINE-1 DNAm in PTB patients (β = -0.407; R² = 0.131; p = 0.011). The regression analysis showed the effect of DNMT3B rs1569686 TT+TG genotypes on LINE-1 DNAm in patients with familial PTB (β = -0.524; R² = 0.275; p = 0.037). Our findings suggest novel associations of maternal LINE-1 DNA hypomethylation with DNMT3B rs1569686 T allele. These results also contribute to the understanding of a complex (epi)genetic and environmental relationship underlying the early PTB.

Contributions of Preterm Delivery to Cardiovascular Disease Risk Prediction in Women

Background: Preterm delivery is associated with a 1.4- to 2-fold increased risk of cardiovascular disease (CVD), but inclusion of preterm delivery in CVD risk prediction algorithms has not been tested. We evaluated whether including preterm delivery and parity in CVD risk scores improved identification of women at high risk versus scores based on traditional risk factors. Methods: We predicted 10-year CVD risk using 119,587 observations contributed by 76,512 women ≥40 years of age and 20-year CVD risk with 72,533 women ≥40 years of age and 72,872 women ≥30 years of age from the Nurses' Health Study II. Cox proportional hazards models were fit with established CVD risk factors (Model 1) and established risk factors plus preterm delivery and parity (Model 2). We evaluated model fit, calibration, discrimination, and risk reclassification. Results: Very preterm delivery (<32 weeks) was associated with CVD in all 10- and 20-year models that included the established CVD risk factors (e.g., hazard ratio: 1.61, 95% confidence interval: 1.19 to 2.20 in 10-year risk model). Model 2 had improved fit relative to Model 1, but discrimination was not improved in Model 2 based on the C-difference or net reclassification index. Similar models for 20-year CVD risk prediction at age ≥30 years indicated improved discrimination when including preterm delivery and parity. Conclusions: Incorporating preterm delivery and parity into CVD risk scores appears most useful when women are young, before they develop established CVD risk factors. Observed improvements in risk prediction were small and warrant further investigation to confirm our findings and assess utility in a clinical setting.

A History of Preterm Delivery Is Associated with Aberrant Postpartal MicroRNA Expression Profiles in Mothers with an Absence of Other Pregnancy-Related Complications

This prospective cross-sectional case-control study investigated the postpartal gene expression of microRNAs associated with diabetes/cardiovascular/cerebrovascular diseases in the peripheral white blood cells of women with anamnesis of preterm prelabor rupture of membranes (n = 58), spontaneous preterm birth (n = 55), and term delivery (n = 89) by a quantitative reverse transcription polymerase chain reaction. After pregnancies complicated by preterm prelabor rupture of membranes or spontaneous preterm birth, mothers showed diverse expression profiles for 25 out of 29 tested microRNAs (miR-1-3p, miR-16-5p, miR-17-5p, miR-20a-5p, miR-20b-5p, miR-21-5p, miR-23a-3p, miR-24-3p, miR-26a-5p, miR-29a-3p, miR-100-5p, miR-103a-3p, miR-125b-5p, miR-126-3p, miR-130b-3p, miR-133a-3p, miR-143-3p, miR-145-5p, miR-146a-5p, miR-181a-5p, miR-195-5p, miR-199a-5p, miR-221-3p, miR-499a-5p, and miR-574-3p). The earliest gestational ages at delivery and the lowest birth weights of newborns were associated with the highest postpartal levels of the previously mentioned microRNAs in maternal peripheral white blood cells. Administration of tocolytic drugs in order to prolong pregnancy, used in order to administer and complete a full course of antenatal corticosteroids, was associated with alterations in postpartal microRNA expression profiles to a lesser extent than in women with imminent delivery, where there was insufficient time for administration of tocolytics and antenatal corticosteroids. Overall, mothers who did not receive tocolytic therapy (miR-24-3p and miR-146a-5p) and mothers who did not receive corticosteroid therapy (miR-1-3p, miR-100-5p, and miR-143-3p) had increased or showed a trend toward increased postpartal microRNA expression when compared with mothers given tocolytic and corticosteroid therapy. In addition, mothers with serum C-reactive protein levels above 20 mg/L, who experienced preterm labour, showed a trend toward increased postpartal expression profiles of miR-143-3p and miR-199a-5p when compared with mothers with normal serum C-reactive protein levels. On the other hand, the occurrence of maternal leukocytosis, the presence of intra-amniotic inflammation (higher levels of interleukin 6 in the amniotic fluid), and the administration of antibiotics at the time of preterm delivery had no impact on postpartal microRNA expression profiles in mothers with a history of preterm delivery. Likewise, the condition of the newborns at the moment of birth, determined by Apgar scores at 5 and 10 min and the pH of cord arterial blood, had no influence on the postpartal expression profiles of mothers with a history of preterm delivery. These findings may contribute to explaining the increased cardiovascular risk in mothers with anamnesis of preterm delivery, and the greater increase of maternal cardiovascular risk with the decrease of gestational age at delivery. Women with preterm delivery in their anamnesis represent a high-risk group with special needs on a long-term basis, with a need to apply preventive and therapeutic interventions as early as possible.

Pre-Term Delivery and Risk of Ischemic Heart Disease in Women

BACKGROUND

Women who deliver pre-term have been reported to have increased future risks of cardiometabolic disorders. However, their long-term risks of ischemic heart disease (IHD) and whether such risks are due to shared familial factors are unclear. A better understanding of these risks may help improve long-term clinical follow-up and interventions to prevent IHD in women.

OBJECTIVES

The purpose of this study was to determine the long-term risks of IHD in women by pregnancy duration.

METHODS

A national cohort study was conducted of all 2,189,190 women with a singleton delivery in Sweden from 1973 to 2015, who were followed up for IHD through the end of 2015. Cox regression was used to compute adjusted hazard ratios (aHRs) for IHD associated with pregnancy duration, and cosibling analyses assessed the influence of shared familial (genetic and/or environmental) factors.

RESULTS

In 47.5 million person-years of follow-up, 49,955 (2.3%) women were diagnosed with IHD. In the 10 years following delivery, the aHR for IHD associated with pre-term delivery (<37 weeks) was 2.47 (95% confidence interval [CI]: 2.16 to 2.82), and further stratified was 4.04 (95% CI: 2.69 to 6.08) for extremely pre-term (22 to 27 weeks), 2.62 (95% CI: 2.09 to 3.29) for very pre-term (28 to 33 weeks), 2.30 (95% CI: 1.97 to 2.70) for late pre-term (34 to 36 weeks), and 1.47 (95% CI: 1.30 to 1.65) for early-term (37 to 38 weeks), compared with full-term (39 to 41 weeks). These risks declined but remained significantly elevated after additional follow-up (pre-term vs. full-term, 10 to 19 years: aHR: 1.86; 95% CI: 1.73 to 1.99; 20 to 29 years: aHR: 1.52; 95% CI: 1.45 to 1.59; 30 to 43 years: aHR: 1.38; 95% CI: 1.32 to 1.45). These findings did not appear attributable to shared genetic or environmental factors within families. Additional pre-term deliveries were associated with further increases in risk.

CONCLUSIONS

In this large national cohort, pre-term delivery was a strong independent risk factor for IHD. This association waned over time but remained substantially elevated up to 40 years later. Pre-term delivery should be recognized as a risk factor for IHD in women across the life course.

Pregnancy Complications, Cardiovascular Risk Factors, and Future Heart Disease

Heart disease is the leading cause of mortality in adult women. Beyond the traditional risk factors of obesity, diabetes, and hypercholesterolemia, women with the pregnancy complications of preeclampsia, gestational diabetes, prematurity, and low birth weight for gestational age (fetal growth restriction) are at higher risk for later development of cardiovascular disease. Education of women and providers about the association of pregnancy complications and cardiovascular disease should begin in the postpartum period. Postpartum cardiovascular risk screening and lifestyle modifications should be considered standard of care and are essential to improving cardiac health as a preventive strategy.

How Does Preterm Delivery Contribute to the Increased Burden of Cardiovascular Disease? Quantifying the Economic Impact of Cardiovascular Disease in Women with a History of Preterm Delivery

Background: The association between preterm delivery (PTD) and maternal risk of cardiovascular disease (CVD) was demonstrated, but the economic burden of CVD in these women was unknown. Methods: A Markov microsimulation model, comprising no event, postacute coronary event (ACE, including acute myocardial infarction and unstable angina), poststroke, post-ACE and stroke, postheart failure, and death, was constructed to quantify the CVD burden in women with PTD from 2017 to 2066 using the Australian health care system perspective. Both first-ever and recurrent CVD events were accounted for in the model. Population with PTD histories was sourced from Australian Bureau of Statistics and costs of acute hospitalization and long-term management from government websites. Nonmonetary burden as years of life lost (YLL) was compared between women with and without PTD histories. Both dynamic (i.e., new cohort added every cycle) and static (i.e., population was stabilized) approaches were used to measure the CVD burden, with sensitivity analyses examining the robustness of results. Results: The dynamic model showed the total CVD burden caused by PTD as AUD11.4 billion for the next 50 years and the YLL as 0.34/capita, while the static model generated a cost of AUD4.5 billion and the YLL as 0.52/capita. Long-term management cost was the primary cost determinant (AUD9.4 billion and AUD3.7 billion, respectively) in the two models, with the results most sensitive to the discount rate and time horizon. Conclusions: Considering the substantial economic burden, recognizing PTD as a potential risk factor and encouraging women with PTD histories to participate in primary prevention programs would potentially curb the ever-increasing CVD burden.

Medically assisted reproduction and the risk of preterm birth: a case-control study using data from the Quebec Pregnancy Cohort

BACKGROUND

The use of fertility treatments has been growing over the past decade, but these treatments are not without risk. We aimed to quantify the risk of preterm birth associated with the use of ovarian stimulators (OS) and assisted reproductive technologies (ART) overall and by type of fertility treatment.

METHODS

We conducted a case-control analysis of data from the Quebec Pregnancy Cohort. We included singleton pregnancies ending in a live birth during the time when Quebec operated a universal reimbursement program for assisted reproduction (2010-2015). Fertility treatments were defined dichotomously, and pregnancies resulting from spontaneous conception were used as the reference. We categorized fertility treatments into subgroups: ovarian stimulators alone, ART alone and OS and ART combined. Preterm birth was defined as birth before 37 weeks' gestation. We estimated odds ratios (ORs) for the association between type of assisted reproduction and preterm birth using generalized estimating equation models and adjusted ORs for potential confounders.

RESULTS

A total of 57 624 pregnancies were included in the study. During the study period, 2055 pregnancies were conceived through the use of OS, ART or both: 419 involved OS alone, 150 involved ART alone and 1486 involved both OS and ART. When we adjusted for potential confounders, conception with OS, ART or both was associated with an increased risk of preterm birth (adjusted OR 1.46, 95% confidence interval [CI] 1.25-1.72, 182 exposed cases). All types of assisted reproduction were associated with an increased risk of preterm birth compared with pregnancies conceived spontaneously (OS alone: adjusted OR 1.47, 95% CI 1.04-2.07; ART alone: adjusted OR 1.76, 95% CI 1.01-3.06; OS and ART combined: adjusted OR 1.43, 95% CI 1.19-1.73). Use of OS or ART or both was associated with an increased risk of late, moderate and extremely preterm birth (extremely preterm birth: adjusted OR 2.39, 95% CI 1.30-4.39).

INTERPRETATION

Compared with pregnancies conceived spontaneously, pregnancies conceived through the use of OS, ART or both were associated with a 46% increased risk of preterm birth. Physicians should advise patients of the increased risks of late, moderate and extremely preterm birth so that they can make informed choices.

Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications

BACKGROUND

Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD.

METHODS

We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI).

RESULTS

Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage.

CONCLUSIONS

Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

Effect of premature birth on long-term systolic blood pressure variability in women

Objective:

To investigate the effect of premature birth (PTB) on long-term systolic blood pressure (SBP) variability (SBPV) in women.

Methods:

A total of 1974 pregnant women were divided into PTB group and non-PTB (NPTB) group. The SBP standard deviation (SSD) was calculated by four annual SBP values measured in 2006–2007, 2008–2009, 2010–2011, and 2012–2013. SBP coefficient of variation (SCV) was calculated by dividing SSD with mean SBP. Multivariate logistic regression analysis was used to analyze the influence of PTB on long-time SSD and SCV in women.

Results:

SSD and SCV of the PTB group (10.95 mm Hg and 9.05%, respectively) were higher than those of the NPTB group (9.81 mm Hg and 8.23%, respectively), but there were no significant differences (p>0.05). The number of patients with SSD >9.87 mm Hg and SCV >8.28% in the PTB and NPTB groups was 57 (51.40%) and 62 (55.90%) and 747 (40.10%) and 841 (45.10%), respectively. The number of patients with SSD >9.87 mm Hg and SCV >8.28% in the PTB group was significantly higher than that in the NPTB group (p<0.05). Multiple logistic regression analysis showed that after adjusting other risk factors, the PTB group was at a risk of SSD and SCV elevations with OR values of 1.60 (95% CI: 1.06–2.40) and 1.64 (95% CI: 1.10–2.45), respectively.

Conclusion:

PTB is a risk factor of long-time SBPV in women, which might be a potential reason for cardiovascular events. Pregnancy may be an important opportunity for early identification of women at an increased risk of cardiovascular disease later in life.

Pregnancy Complications as a Window to Future Cardiovascular Disease

Pregnancy is a time of significant hemodynamic, metabolic, and hormonal stress that can unmask underlying subclinical cardiovascular abnormalities, and pregnancy-related complications may serve as early warning signs for future risk of cardiovascular disease. The increased recognition of these sex-specific risk factors could identify women who may benefit from more intensive risk factor modification to reduce morbidity and mortality later in life. In this review, we describe several pregnancy-related complications that have been associated with the risk of cardiovascular disease, including hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm delivery, and pregnancy loss. Pregnancy-associated risk factors must be identified to fully assess a woman's future cardiovascular risk and may influence strategies for risk reduction.

Women with Preterm Birth Have Evidence of Subclinical Atherosclerosis a Decade After Delivery

Background: Women with preterm birth (PTB) have excess risk of cardiovascular disease (CVD) and metabolic dysregulation after delivery, but vascular mechanisms are poorly understood. We considered that women with PTB may have evidence of subclinical atherosclerosis after delivery, perhaps related to cardiometabolic risk factors. Materials and Methods: The Pregnancy Outcomes and Community Health Moms (POUCHmoms) study followed women from pregnancy through 7 to 15 years after delivery (n = 678). Women underwent B-mode ultrasound to measure the average intima-media thickness (IMT) across the common carotid, bulb, and internal carotid artery segments at follow-up (n = 605). Linear regression estimated the overall and segment-specific difference in IMT between women with preterm and term births. Results: Women were, on average, 38 years old (SD 5.7) at the follow-up visit. Those with a prior preterm versus term birth had thicker mean IMT (average of eight segments, 0.592 mm vs. 0.575, p = 0.04). Differences persisted after accounting for age, race, smoking, and body mass index (difference = +0.018 mm, p = 0.019) and were attenuated after adjustment for blood pressure, medication use, and total cholesterol (difference = +0.014, p = 0.052). Thicker mean bulb IMT in women with PTB was robust to cardiovascular risk factor adjustments (fully adjusted difference = +0.033, p = 0.029). Excluding cases of prepregnancy hypertension or preeclampsia did not change results. Conclusions: Mechanisms leading to subclinical atherosclerosis may link PTB with future CVD. PTB differences in maternal vessel remodeling in the carotid bulb, an arterial segment more prone to early development of atherosclerosis, were independent of traditional risk factors suggesting that novel processes may be involved.

Preterm Delivery and Maternal Cardiovascular Disease Risk Factors: The Nurses' Health Study II

Background: Preterm delivery has been linked to future maternal cardiovascular disease (CVD); however, research investigating clinical CVD risk factors is limited. We evaluated whether women who have delivered an infant preterm are at higher risk of developing CVD risk factors after adjustment for prepregnancy confounders. Materials and Methods: We examined the association between preterm delivery and incident chronic hypertension, type 2 diabetes mellitus (T2DM), and hypercholesterolemia among 57,904 parous women in the Nurses' Health Study II. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between preterm delivery in first pregnancy and each CVD risk factor; adjusted cumulative incidence curves were computed using the Breslow estimator. Results: Preterm delivery (<37 weeks) was associated with HRs of 1.11 (95% CI: 1.06-1.17) for chronic hypertension, 1.17 (95% CI: 1.03-1.33) for T2DM, and 1.07 (95% CI: 1.03-1.11) for hypercholesterolemia, adjusting for age, race/ethnicity, parental education, and prepregnancy confounders (e.g., body mass index, smoking, and family history). HRs were higher in women who delivered very preterm (<32 weeks) and in the first 10 years after first birth. The cumulative incidence of each risk factor was highest in women who delivered very preterm. Conclusions: Women with a history of preterm delivery are at higher risk of developing chronic hypertension, T2DM, and hypercholesterolemia in the years after pregnancy. This increased risk was particularly pronounced in the first 10 years after a preterm delivery, indicating that it may be an important time period to implement lifestyle interventions.

Cardiovascular biomarkers in the years following pregnancies complicated by hypertensive disorders or delivered preterm

BACKGROUND

Women with a history of hypertensive disorders of pregnancy and preterm delivery have an increased risk of cardiovascular disease (CVD). Chronic inflammation, endothelial dysfunction, and dyslipidemia may link pregnancy outcomes with CVD.

OBJECTIVE

We evaluated whether women with a history of HDP or normotensive preterm delivery had adverse CVD biomarker profiles after pregnancy.

STUDY DESIGN

We identified parous women from the Nurses' Health Study II with C-reactive protein (CRP; n = 2614), interleukin-6 (IL-6; n = 2490), glycated hemoglobin (n = 885), intracellular adhesion molecule-1 (n = 1231), high density lipoprotein cholesterol (n = 931), low density lipoprotein cholesterol (n = 931), triglycerides (n = 1428), or total cholesterol (n = 2940) assessed in stored blood samples. Multivariable-adjusted robust linear regression models evaluated percent differences and 95% confidence intervals (CIs) in each biomarker associated with a history of HDP or preterm delivery.

RESULTS

Ten percent of women had a history of HDP, while 11% with normotensive pregnancies had at least one preterm delivery. Median time from first pregnancy to blood draw was 17 years (interquartile range: 12, 22). Plasma levels of CRP and IL-6 were 34.4% (95% CI: 17.2, 54.1), and 11.6% higher (95% CI: 2.1, 21.9) respectively, among women with a history of HDP compared to those with only normotensive pregnancies. Altered CVD biomarker levels were otherwise not present in women with a history of HDP or preterm delivery.

CONCLUSION

CRP and IL-6, but not other CVD biomarkers, were elevated in women with a history of HDP in the years following pregnancy, suggesting inflammation may be a pathway linking HDP with future CVD risk.

Association of Spontaneous Preterm Delivery and Future Maternal Cardiovascular Disease

Cardiovascular disease (CVD) risk factors are well established. However, little is known about a woman's cardiovascular response to pregnancy, which appears to be an early marker of future maternal CVD risk. Spontaneous preterm delivery (sPTD) has been associated with a ≤3-fold increased risk of maternal CVD death later in life compared with having a term delivery. This review focuses on 3 key areas to critically assess the association of sPTD and future maternal CVD risk: (1) CVD risk factors, (2) inflammatory biomarkers of interest, and (3) specific forms of vascular dysfunction, such as endothelial function and arterial stiffness, and mechanisms by which each may be linked to sPTD. The association of sPTD with subsequent future maternal CVD risk suggests that a woman's abnormal response to pregnancy may serve as her first physiological stress test. These findings suggest that future research is needed to understand why women with sPTD may be at risk for CVD to implement effective interventions earlier in a woman's life.

The profiles of soluble adhesion molecules in the "great obstetrical syndromes". J Matern Fetal Neonatal Med 2018;32:2113-2136. [PMID: 29320948 DOI: 10.1080/14767058.2018.1427058]

OBJECTIVE

The objective of this study was to determine the profiles of maternal plasma soluble adhesion molecules in patients with preeclampsia, small-for-gestational-age (SGA) fetuses, acute pyelonephritis, preterm labor with intact membranes (PTL), preterm prelabor rupture of the membranes (preterm PROM), and fetal death.

MATERIALS AND METHODS

A cross-sectional study was conducted to determine maternal plasma concentrations of sE-selectin, sL-selectin, and sP-selectin as well as sICAM-1, sVCAM-1, and sPECAM-1 in patients with (1) an uncomplicated pregnancy (control, n = 100); (2) preeclampsia (n = 94); (3) SGA fetuses (in women without preeclampsia/hypertension, n = 45); (4) acute pyelonephritis (n = 25); (5) PTL (n = 53); (6) preterm PROM (n = 24); and (7) fetal death (n = 34). Concentrations of soluble adhesion molecules and inflammatory cytokines (tumor necrosis factor (TNF)-α and interleukin (IL)-8) were determined with sensitive and specific enzyme-linked immunoassays.

RESULTS

In comparison to women with a normal pregnancy, (1) women with preeclampsia had higher median concentrations of sE-selectin, sP-selectin, and sVCAM-1, and a lower concentration of sL-selectin (all p values < .001); (2) patients with SGA fetuses had higher median concentrations of sE-selectin, sP-selectin, and sVCAM-1 (all p values < .05); (3) patients with a fetal death had higher median concentrations of sE-selectin and sP-selectin (all p values < .05); (4) patients with acute pyelonephritis had higher median plasma concentrations of sE-selectin, sICAM-1, and sVCAM-1 (all p values < .001); (5) patients with preeclampsia and acute pyelonephritis, plasma concentrations of sVCAM-1, sE-selectin, and sP-selectin correlated with those of the proinflammatory cytokines TNF-α and interleukin (IL)-8 (all p values < .05); (6) patients with PTL had a higher median concentration of sP-selectin and a lower median concentration of VCAM-1 (all p values < .05); and (7) women with preterm PROM had lower median concentrations of sL-selectin and sVCAM-1 (all p values < .05).

CONCLUSIONS

The results of this study show that endothelial cell activation/dysfunction reflected by the plasma concentration of sE-selectin is not specific to preeclampsia but is present in pregnancies complicated by SGA fetuses, acute pyelonephritis, and fetal death. Collectively, we report that each obstetrical syndrome appears to have a stereotypical profile of soluble adhesion molecules in the peripheral circulation.

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.

History of Adverse Pregnancy Outcomes, Blood Pressure, and Subclinical Vascular Measures in Late Midlife: SWAN (Study of Women's Health Across the Nation)

BACKGROUND

Adverse pregnancy outcomes, such as preterm birth (PTB), have been associated with elevated risk of maternal cardiovascular disease, but their effect on late midlife blood pressure (BP) and subclinical vascular measures remains understudied.

METHODS AND RESULTS

We conducted a cross-sectional analysis with 1220 multiethnic parous women enrolled in SWAN (Study of Women's Health Across the Nation) to evaluate the impact of self-reported history of adverse pregnancy outcomes (PTB, small-for-gestational-age, stillbirth), on maternal BP, mean arterial pressure, and subclinical vascular measures (carotid intima-media thickness, plaque, and pulse wave velocity) in late midlife. We also examined whether these associations were modified by race/ethnicity. Associations were tested in linear and logistic regression models adjusting for sociodemographics, reproductive factors, cardiovascular risk factors, and medications. Women were on average aged 60 years and 255 women reported a history of an adverse pregnancy outcome. In fully adjusted models, history of PTB was associated with higher BP (systolic: β=6.40; SE, 1.62 [P<0.0001] and diastolic: β=3.18; SE, 0.98 [P=0.001]) and mean arterial pressure (β=4.55; SE 1.13 [P<0.0001]). PTB was associated with lower intima-media thickness, but not after excluding women with prevalent hypertension. There were no significant associations with other subclinical vascular measures.

CONCLUSIONS

Findings suggest that history of PTB is associated with higher BP and mean arterial pressure in late midlife. Adverse pregnancy outcomes were not significantly related to subclinical cardiovascular disease when excluding women with prevalent hypertension. Future studies across the menopause transition may be important to assess the impact of adverse pregnancy outcomes on midlife progression of BP.

Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis

OBJECTIVES

Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities.

METHODS

MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies.

RESULTS

Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors.

CONCLUSIONS

Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.

Preterm Delivery and Maternal Cardiovascular Disease in Young and Middle-Aged Adult Women

BACKGROUND

Preterm delivery has been shown to be associated with increased risk of cardiovascular disease (CVD), but it is unknown whether this risk remains after adjustment for prepregnancy lifestyle and CVD risk factors.

METHODS

We examined the association between history of having delivered an infant preterm (<37 weeks) and CVD in 70 182 parous women in the Nurses' Health Study II. Multivariable Cox proportional-hazards models were used to estimate hazards ratios (HRs) and 95% confidence intervals (CIs) for CVD events (myocardial infarction and stroke, n=949); we also adjusted for intermediates to determine the proportion of the association between preterm and CVD accounted for by postpartum development of CVD risk factors.

RESULTS

After adjusting for age, race, parental education, and prepregnancy lifestyle and CVD risk factors, preterm delivery in the first pregnancy was associated with an increased risk of CVD (HR, 1.42; 95% CI, 1.16-1.72) in comparison with women with a term delivery (≥37 weeks) in the first pregnancy. When preterm delivery was split into moderate preterm (≥32 to <37 weeks) and very preterm (<32 weeks), the HRs were 1.22 (95% CI, 0.96-1.54) and 2.01 (95% CI, 1.47-2.75), respectively. The increased rate of CVD in the very preterm group persisted even among women whose first pregnancy was not complicated by hypertensive disorders of pregnancy (HR, 2.01; 95% CI, 1.38-2.93). In comparison with women with at least 2 pregnancies, all of which were delivered at term, women with a preterm first birth and at least 1 later preterm birth had a HR of CVD of 1.65 (95% CI, 1.20-2.28). The association between moderate preterm first birth and CVD was accounted for in part by the development of postpartum chronic hypertension, hypercholesterolemia, type 2 diabetes mellitus, and changes in body mass index (proportion accounted for, 14.5%; 95% CI, 4.0-41.1), as was the very-preterm-CVD relationship (13.1%; 95% CI, 9.0-18.7).

CONCLUSIONS

Preterm delivery is independently predictive of CVD and may be useful for CVD prevention efforts. Because only a modest proportion of the preterm-CVD association was accounted for by development of conventional CVD risk factors, further research may identify additional pathways.

Cardiovascular Disease in Relation to Placental Abruption: A Population-Based Cohort Study from Denmark

BACKGROUND

Cardiovascular (CVD) complications stemming from vascular dysfunction have been widely explored in the setting of preeclampsia. However, the impact of abruption, a strong indicator of microvascular disturbance, on the risk of CVD mortality and morbidity remains poorly characterised.

METHODS

We designed a cohort analysis of 828 289 women who delivered singletons in Denmark between 1978 and 2010. We linked the National Patient Registry and the Registry of Causes of Death to the Danish Birth Registry to ascertain CVD events. We estimated CVD risks in relation to abruption from Cox proportional hazards regression following adjustments for confounders.

RESULTS

With 13 231 562 person-years of follow-up of women with at least one delivery, 11 829 pregnancies were complicated by abruption. The median (interquartile range) follow-up in the non-abruption and abruption groups was 16 (8, 24) and 18 (10, 25) years, respectively. CVD mortality rates in women with and without abruption were 0.9 and 0.3 per 10 000 person-years, respectively (adjusted hazard ratio (HR) 2.7, 95% confidence interval (CI) 1.5, 5.0). The corresponding CVD morbidity complication rates were 16.7 and 10.0 per 10 000 person-years, respectively (HR 1.5, 95% CI 1.4, 1.8). The increased risks were evident for ischaemic heart disease, acute myocardial infarction, hypertensive heart disease, non-rheumatic valvular disease, and congestive heart failure.

CONCLUSIONS

This study shows increased hazards of CVD morbidity and mortality in relation to abruption. A better understanding of the pathogenesis of distorted placental microvasculature is needed as this appears to be a harbinger of CVD later in life.

Neonatal outcomes following preterm birth classified according to placental features

BACKGROUND

Preterm birth has staggering health implications, and yet the causes of most cases are still unknown. Placental features have been understudied as an etiology for preterm birth, and the association between placental pathologic lesions and neonatal outcomes are incompletely understood.

OBJECTIVE

We sought to characterize births according to placental pathology and relate these to adverse neonatal outcomes.

STUDY DESIGN

We studied 20,091 births (15,710 term and 4381 preterm) with placental evaluations. Births were classified according to the presence or absence of placental lesions consistent with malperfusion (vasculopathy, infarct, advanced villous maturation, perivillous fibrin, fibrin deposition) and intrauterine inflammation/infection (chorioamnionitis, funisitis, vasculitis). Outcomes were gestational week of delivery, birthweight z-score, neonatal respiratory distress syndrome, and intraventricular hemorrhage.

RESULTS

Among all preterm births, evidence of placental malperfusion was identified more often than inflammation/infection (50.6% vs 27.3%, P < .0001). Placental malperfusion was associated with reduced fetal growth (adjusted birthweight z-score, -0.83, P < .0001) and lesions of inflammation/infection were associated with earlier delivery (adjusted difference -2.08 weeks, P < .0001) than those with no lesions. When both placental lesions were present, earlier delivery (adjusted difference -2.28 weeks, P < .0001) and reduced fetal growth (adjusted birthweight z-score difference, -0.24, P = .001) were observed more often than when neither lesion was present. Findings were similar when restricted to cases of spontaneous preterm birth. Intraventricular hemorrhage was higher in preterm births with malperfusion lesions than cases with no lesions (7.6% vs 3.4%; odds ratio, 1.98; confidence interval, 1.18-3.32), accounting for gestational age and other covariates.

CONCLUSION

Placental pathology provides important insight into subtypes of preterm birth with adverse neonatal outcomes. Co-occurrence of malperfusion and inflammation/infection, especially among spontaneous preterm births, may be a novel pattern of placental injury linked to severe adverse outcomes.

The Impact of Kidney Development on the Life Course: A Consensus Document for Action

Hypertension and chronic kidney disease (CKD) have a significant impact on global morbidity and mortality. The Low Birth Weight and Nephron Number Working Group has prepared a consensus document aimed to address the relatively neglected issue for the developmental programming of hypertension and CKD. It emerged from a workshop held on April 2, 2016, including eminent internationally recognized experts in the field of obstetrics, neonatology, and nephrology. Through multidisciplinary engagement, the goal of the workshop was to highlight the association between fetal and childhood development and an increased risk of adult diseases, focusing on hypertension and CKD, and to suggest possible practical solutions for the future. The recommendations for action of the consensus workshop are the results of combined clinical experience, shared research expertise, and a review of the literature. They highlight the need to act early to prevent CKD and other related noncommunicable diseases later in life by reducing low birth weight, small for gestational age, prematurity, and low nephron numbers at birth through coordinated interventions. Meeting the current unmet needs would help to define the most cost-effective strategies and to optimize interventions to limit or interrupt the developmental programming cycle of CKD later in life, especially in the poorest part of the world.

Non-communicable diseases during pregnancy in low and middle income countries

Apart from the risks of obstetric complications like haemorrhage and eclampsia, a large number of medical conditions affect pregnancy and result in adverse outcomes for both the mother and offspring. Non-communicable diseases in pregnancy are becoming increasingly important in contributing to death and poor health. Changes in the patterns and distribution of these conditions mean that we need new perspectives and ways of dealing with these challenges for the future. This article reviews the burden of ill-health due to non-communicable diseases during pregnancy in low and middle income countries and presents some paradigms relevant to public health and health system needs of the future.

Guidelines for the Reduction of Cardiovascular Disease in Women

Since 1984, more women than men have died each year from cardiovascular disease. Various organizations, such as the American Heart Association and the American College of Cardiology, have published prevention guidelines for heart disease and stroke that may improve care for women. In this article, we review these guidelines, the results of new studies on emerging risk factors, and new approaches for reducing cardiovascular disease in women.

Insights into genetic susceptibility in the etiology of spontaneous preterm birth

Preterm birth (PTB; <37 weeks of gestation) is a complex disorder, whose etiology is influenced by a variety of factors. A greater understanding of the biological mechanisms that contribute to PTB will facilitate identification of those at increased risk and may inform new treatments. To accomplish this, it is vital to elucidate the heritability patterns of this condition as well as the environment and lifestyle factors that increase risk for PTB. Identifying individual genes that contribute to the etiology of PTB presents particular challenges, and there has been little agreement among candidate gene and genome-wide studies performed to date. In this review we will evaluate recent genetic studies of spontaneous PTB, discuss common themes among their findings, and suggest approaches for future studies of PTB.

Duration of pregnancy, even at term, predicts long-term risk of coronary heart disease and stroke mortality in women: a population-based study

OBJECTIVE

Preterm delivery may predict an increased risk of cardiovascular disease in mothers, providing opportunities for prevention. No study had examined whether gestation length within the term period predicts future CVD, and there are few data segregating spontaneous from medically indicated deliveries.

STUDY DESIGN

We used proportional hazards models to predict CVD death by gestation length, adjusted for age, education, and delivery year among 688,662 women with births from 1967 through 1998 in the Medical Birth Registry of Norway. Mothers were traced in the National Cause of Death Registry through 2009; there were 2324 CVD deaths.

RESULTS

Compared with women who delivered spontaneously at 39-41 weeks' gestation, women who spontaneously delivered earlier had higher risks of CVD death. Hazard ratios were 1.9 at 22-31 weeks, 2.2 at 32-34 weeks, 1.6 at 35-36 weeks, and 1.4 at 37-38 weeks. Risks were higher among women with medically indicated deliveries (hazard ratio, 4.8 at 22-31 weeks, 2.7 at 32-34 weeks, 4.3 at 35-36 weeks, and 1.6 at 37-38 weeks compared with spontaneous deliveries at 39-41 weeks). Neither spontaneous nor indicated delivery after 41 weeks was associated with CVD mortality. Risks were highest with recurrent preterm pregnancies, and for women who delivered only one child, especially if that delivery was preterm.

CONCLUSION

Women who deliver spontaneously before 37 weeks had a 2-fold increased risk of CVD mortality compared with women who had delivered after 38 weeks. Even women with spontaneous deliveries at early term (37-38 weeks) had a 41% elevated risk of CVD death compared with women delivering at 39-41 weeks.

Pregnancy complications and cardiovascular disease death: 50-year follow-up of the Child Health and Development Studies pregnancy cohort

BACKGROUND

Few studies have investigated the combination of pregnancy complications that predict risk for cardiovascular disease (CVD) death and how risk changes with age. This report presents a comprehensive investigation of the relation of the occurrence of multiple pregnancy complications to CVD death over 5 decades in a large pregnancy cohort.

METHODS AND RESULTS

We examined pregnancy events (1959-1967) and CVD death through 2011 in 14 062 women from the Child Health and Development Studies. CVD death was determined by linkage to California Vital Statistics and National Death Index. Women were a median age of 26 years at enrollment and 66 years in 2011. Preexisting hypertension (hazard ratio, 3.5; 95% confidence interval, 2.4-5.1); glycosuria (hazard ratio, 4.2; confidence interval, 1.3-13.1); late-onset preeclampsia (after week 34, hazard ratio, 2.0; confidence interval, 1.2-3.5); and hemoglobin decline over the second and third trimesters (hazard ratio, 1.7; confidence interval, 1.2-2.7) predicted CVD death. Delivery of a small-for-gestation or preterm infant and early-onset preeclampsia (by week 34) significantly predicted premature CVD death (P<0.05 for age dependence). Preterm birth combined with hemorrhage, gestational hypertension, or preexisting hypertension identified women with a 4- to 7-fold increased risk of CVD death. Preeclampsia in combination with preexisting hypertension conferred a significant nearly 6-fold risk in comparison with a 4-fold risk for preexisting hypertension alone.

CONCLUSIONS

We observed combinations of pregnancy complications that predict high risk of death and 2 new risk markers, glycosuria and hemoglobin decline. Obstetricians serve as primary care physicians for many young women and can readily use these complications to identify high-risk women to implement early prevention.

Adverse Pregnancy Conditions, Infertility, and Future Cardiovascular Risk: Implications for Mother and Child

Adverse pregnancy conditions in women are common and have been associated with adverse cardiovascular and metabolic outcomes such as myocardial infarction and stroke. As risk stratification in women is often suboptimal, recognition of non-traditional risk factors such as hypertensive disorders of pregnancy and premature delivery has become increasingly important. Additionally, such conditions may also increase the risk of cardiovascular disease in the children of afflicted women. In this review, we aim to highlight these conditions, along with infertility, and the association between such conditions and various cardiovascular outcomes and related maternal risk along with potential translation of risk to offspring. We will also discuss proposed mechanisms driving these associations as well as potential opportunities for screening and risk modification.

Preterm birth and future risk of maternal cardiovascular disease - is the association independent of smoking during pregnancy?

BACKGROUND

While the association of preterm birth and the risk of maternal cardiovascular disease (CVD) has been well-documented, most studies were limited by the inability to account for smoking during pregnancy - an important risk factor for both preterm birth and CVD. This study aimed to determine whether the increased future risk of maternal cardiovascular disease (CVD) associated with preterm birth is independent of maternal smoking during pregnancy.

METHODS

A population-based record linkage study of 797,056 women who delivered a singleton infant between 1994 and 2011 in New South Wales, Australia was conducted. Birth records were linked to the mothers' subsequent hospitaliation or death from CVD. Preterm births were categorised as late (35-36 weeks), moderate (33-34 weeks), or extreme (≤32 weeks); and as spontaneous or indicated. Cox proportional hazard regression was used to estimate adjusted hazard ratios (AHR) [95 % CI].

RESULTS

During the study period, 59,563 women (7.5 %) had at least one preterm birth. After adjustment for CVD risk factors other than smoking, AHR [95 % CI] of CVD among women who ever had a preterm birth was 1.78 [1.61-1.96]. Associations were greater for extreme (AHR = 1.98 [1.63-2.42]) and moderate (AHR = 2.06 [1.69-2.51]) than late preterm birth (AHR = 1.63 [1.44-1.85]), for indicated (AHR = 2.04 [1.75-2.38]) than spontaneous preterm birth (AHR = 1.65 [1.47-1.86]), and for having ≥ two (AHR = 2.29[1.75-2.99]) than having one preterm birth (AHR = 1.73[1.57-1.92]). A further adjustment for maternal smoking attenuated, but did not eliminate, the associations. Smoking during pregnancy was also independently associated with maternal CVD risks, with associations being stronger for mothers who smoked during last pregnancy (AHR = 2.07 [1.93-2.23]) than mothers who smoked during a prior pregnancy (AHR = 1.64 [1.41-1.90]).

CONCLUSIONS

Associations of preterm birth and maternal CVD risk are independent of maternal smoking during pregnancy. This underscores the importance of smoking cessation in reducing CVD and suggests that a history of preterm delivery (especially if severe, indicated or recurrent) identifies women who could be targeted for CVD screening and preventative therapies.

DNA methylation provides insight into intergenerational risk for preterm birth in African Americans

African Americans are at increased risk for spontaneous preterm birth (PTB). Though PTB is heritable, genetic studies have not identified variants that account for its intergenerational risk, prompting the hypothesis that epigenetic factors may also contribute. The objective of this study was to evaluate DNA methylation from maternal leukocytes to identify patterns specific to PTB and its intergenerational risk. DNA from peripheral leukocytes from African American women that delivered preterm (24-34 weeks; N = 16) or at term (39-41 weeks; N = 24) was assessed for DNA methylation using the HumanMethylation450 BeadChip. In maternal samples, 17,829 CpG sites associated with PTB, but no CpG site remained associated after correction for multiple comparisons. Examination of paired maternal-fetal samples identified 5,171 CpG sites in which methylation of maternal samples correlated with methylation of her respective fetus (FDR < 0.05). These correlated sites were enriched for association with PTB in maternal leukocytes. The majority of correlated CpG sites could be attributed to one or more genetic variants. They were also significantly more likely to be in genes involved in metabolic, cardiovascular, and immune pathways, suggesting a role for genetic and environmental contributions to PTB risk and chronic disease. The results of this study may provide insight into the factors underlying intergenerational risk for PTB and its consequences.

Other adverse pregnancy outcomes and future chronic disease

Cardiovascular disease is the leading cause of morbidity and mortality in females worldwide. Pregnancy is associated with significant physiologic changes that may function as a natural stress test to detect women at future risk. It is established that women who have had a pregnancy complicated by gestational diabetes or a hypertensive disorder of pregnancy are at increased risk of cardiovascular disease later in life, and there is growing evidence that women who deliver infants preterm or growth-restricted infants have an elevated risk as well. Consideration should be given to including these outcomes as indicators of cardiovascular risk. Pregnancy represents a teachable moment when it would be ideal to identify women at risk. Improved integration of women's primary health care and an enhanced knowledge base on the part of clinicians will be necessary to fully incorporate these findings into the clinical care of women.

Cardiovascular disease risk in women with a history of spontaneous preterm delivery: A systematic review and meta-analysis

BACKGROUND

Increasing evidence suggests a relation between having had spontaneous preterm delivery and cardiovascular disease in the future. We performed a systematic review and meta-analysis to assess the relation between a history of spontaneous preterm delivery and risk of ischaemic heart disease (IHD), stroke or overall cardiovascular disease (CVD).

METHODS

We carried out a systematic search in Medline (from 1966 to 17 July 2014) and Embase (from 1980 to 17 July 2014). We included studies with a cohort design assessing the relation between spontaneous preterm delivery and fatal or nonfatal IHD, stroke, or overall CVD. IHD, stroke and CVD were assessed through linkage with national registries. Hazard ratios (HRs) were pooled using a random-effects model.

RESULTS

Of the 10 cohort studies included; sample sizes ranged from 3706 to 923,686 women and follow-up ranged from 12-35 years. Spontaneous preterm delivery was related to an increased risk of developing or dying from IHD (HR 1.38, 95% confidence interval (CI) 1.22-1.57), stroke (HR 1.71, 95% CI 1.53-1.91) and overall CVD (relative risk (HR) 2.01, 95% CI 1.52-2.65). All studies found a positive effect, although substantial between-study heterogeneity was found for IHD and CVD.

CONCLUSION

Spontaneous preterm delivery is an independent risk factor for the development of IHD, stroke and overall CVD.

Preterm birth and long-term maternal cardiovascular health

PURPOSE

To investigate whether preterm birth (PTB) is associated with greater cardiovascular disease (CVD) risk in a longitudinal cohort.

METHODS

We examined differences in systolic blood pressure (SBP), diastolic blood pressure, insulin resistance (Homeostatic model assessment of insulin resistance), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein, triglycerides, C-reactive protein, and interleukin 6 at 3 years postpartum between women who delivered preterm (gestation <37 weeks; n = 54) versus term (≥37 weeks; n = 751) using multivariable linear regression. We also assessed relations with body mass index, weight change from prepregnancy, and waist circumference at 3 and 7 years postpartum.

RESULTS

Median age at enrollment was 33.9 years (range: 16.4-44.9). After adjusting for age, race, prepregnancy body mass index, parity, marital status, education, and SBP during early pregnancy, women with PTB had 3.99 mm Hg (95% confidence interval, 0.82-7.16) higher SBP and 7.01 mg/dL (1.54-12.50) lower HDL than those who delivered at term. The association with SBP was attenuated after accounting for hypertension before or during pregnancy (2.78 mm Hg [-0.30 to 5.87]). PTB was not related to other postpartum outcomes.

CONCLUSIONS

PTB is related to greater CVD risk by 3 years postpartum as indicated by higher SBP and lower HDL. Although these associations may be due to preexisting conditions exacerbated during pregnancy, PTB may flag high-risk women for more vigilant CVD monitoring and lifestyle interventions.

The mother--the long-term implications on metabolic and cardiovascular complications

There is cumulating evidence linking the occurrence of pregnancy complications, including miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm birth, and fetal growth restriction, with increased future risk of type 2 diabetes mellitus, and hospitalization and death due to cardiovascular and cerebrovascular diseases. Such association is largely related to genetic predisposition and shared pathophysiological mechanisms and changes, which may precede the index pregnancy. Awareness of this association would allow identification of the at-risk women for implementation of preventive measures to reduce the recurrence risk of these complications and mitigate the future development of metabolic and cardiovascular diseases worldwide.

Concentrations of endothelial nitric oxide synthase, angiotensin-converting enzyme, vascular endothelial growth factor and placental growth factor in maternal blood and maternal metabolic status in pregnancy complicated by hypertensive disorders

Hypertensive disorders of pregnancy (HDPs) are associated with altered maternal metabolism, impaired perinatal outcome and increased risk for remote maternal complications. The aim of our study was to analyse associations between circulating levels of angiogenic factors and markers of oxidative stress and metabolic status in women with HDP. Forty-six women in singleton pregnancies complicated by HDP and 30 healthy controls were enrolled in a prospective observational study. Serum concentrations of endothelial nitric oxide synthase (eNOS), angiotensin-converting enzyme, vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) were measured in the third trimester and correlated with maternal anthropometrics and metabolic status. We found significantly lower eNOS levels in patients with severe hypertension vs controls, a strong association between eNOS and PlGF in the study group, a significant association between maternal prepregnancy body mass index (BMI) and VEGF levels and an inverse correlation between VEGF and PlGF. Maternal prepregnancy BMI was the only independent predictor for VEGF concentrations. We noted reduced levels of PlGF and eNOS and increased VEGF levels in women with severe hypertension/preeclampsia. First, different forms of HDP are associated with different alteration patterns in concentrations of angiogenic factors and markers of oxidative stress. Second, maternal prepregnancy BMI, but not body weight, is a significant predictor for VEGF levels in late pregnancy.

Concentrations of eNOS, VEGF, ACE and PlGF in maternal blood as predictors of impaired fetal growth in pregnancy complicated by gestational hypertension/preeclampsia

OBJECTIVES

To investigate into an association between circulating levels of vascular factors (VF: ACE, eNOS, PlGF and VEGF) and impaired fetal growth measured as a small for gestational age newborn (SGA) in women with gestational hypertension/preeclampsia.

METHODS

A prospective observational trial in 46 patients in singleton pregnancies. Concentrations of VF were compared between participants who delivered SGA versus non-SGA newborns.

RESULTS

only low levels of ACE were associated with significantly increased risk for SGA (for a cut-off value, LR: 1.4-3.6).

CONCLUSIONS

Circulating levels of VF are not sufficient predictors of SGA in pregnancies complicated by gestational hypertension/preeclampsia.

History of preterm birth and subsequent cardiovascular disease: a systematic review

A history of preterm birth (PTB) may be an important lifetime risk factor for cardiovascular disease (CVD) in women. We identified all peer-reviewed journal articles that met study criteria (English language, human studies, female, and adults ≥19 years old), that were found in the PubMed/MEDLINE databases, and that were published between Jan. 1, 1995, and Sept. 17, 2012. We summarized 10 studies that assessed the association between having a history of PTB and subsequent CVD morbidity or death. Compared with women who had term deliveries, women with any history of PTB had increased risk of CVD morbidity (variously defined; adjusted hazard ratio [aHR] ranged from 1.2-2.9; 2 studies), ischemic heart disease (aHR, 1.3-2.1; 3 studies), stroke (aHR, 1.7; 1 study), and atherosclerosis (aHR, 4.1; 1 study). Four of 5 studies that examined death showed that women with a history of PTB have twice the risk of CVD death compared with women who had term births. Two studies reported statistically significant higher risk of CVD-related morbidity and death outcomes (variously defined) among women with ≥2 pregnancies that ended in PTBs compared with women who had at least 2 births but which ended in only 1 PTB. Future research is needed to understand the potential impact of enhanced monitoring of CVD risk factors in women with a history of PTB on risk of future CVD risk.

Importance of engaging obstetrician/gynecologists in cardiovascular disease prevention

PURPOSE OF REVIEW

To review recent evidence regarding traditional and sex-specific factors identified among women during their reproductive years and their importance in lifetime risk for cardiovascular disease (CVD).

RECENT FINDINGS

Longitudinal studies demonstrated a woman's burden of risk during her reproductive years is associated with future risk of CVD. Similarly, women with a healthy lifestyle are relatively protected and have the lowest lifetime risk. Some primary prevention strategies, when implemented during this age window, were cost-effective. The link between pregnancy outcome and future CVD risk is now better understood, and evidence now relates pregnancy-associated hypertension and diabetes, as well as a preterm delivery or a low birth weight delivery, to excess risk. Gaps in preventive healthcare for women in this age group included low rates of treatment initiation for hypertension and failure to follow guidelines for diabetes surveillance among women with a history of gestational diabetes. Knowledge gaps for standard CVD prevention, as well as the link between pregnancy complications and future CVD risk, were identified among both primary care providers and obstetrician/gynecologists.

SUMMARY

Traditional and sex-specific risk factors for CVD present during women's reproductive years. Engaging the obstetrician/gynecologist provides a strategy to enhance prevention.