Long-term blood pressure changes measured from before to after pregnancy relative to nonparous women

Childhood maltreatment and trajectories of cardiometabolic health across the reproductive life span among individuals with a first birth during the Coronary Artery Risk Development in Young Adults Study

OBJECTIVE

Childhood adversity is associated with poor cardiometabolic health in adulthood; little is known about how this relationship evolves through childbearing years for parous individuals. The goal was to estimate differences in cardiometabolic health indicators before, during and after childbearing years by report of childhood maltreatment in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study.

METHODS

Including 743 individuals nulliparous at baseline (1985-1986) with one or more pregnancies >20 weeks during follow-up (1986-2022), we fit segmented linear regression models to estimate mean differences between individuals reporting or not reporting childhood maltreatment (physical or emotional) in waist circumference, triglycerides, high-density lipoprotein cholesterol, systolic and diastolic blood pressure, fasting glucose, and body mass index (BMI) prior to, during, and following childbearing years using generalized estimating equations, allowing for interaction between maltreatment and time within each segment, and adjusting for total parity, parental education, and race (Black or white, self-reported).

RESULTS

Individuals reporting maltreatment (19%; 141) had a greater waist circumference (post-childbearing: +2.9 cm, 95% CI (0.7, 5.0), higher triglycerides [post-childbearing: +8.1 mg/dL, 95% CI (0.7, 15.6)], and lower HDL cholesterol [post-childbearing: -2.1 mg/dL, 95% CI (-4.7, 0.5)] during all stages compared to those not reporting maltreatment. There were not meaningful differences in blood pressure, fasting glucose, or BMI. Individuals who reported maltreatment did not report faster changes over time.

CONCLUSION

Differences in some aspects of cardiometabolic health between individuals reporting versus not reporting childhood maltreatment were sustained across reproductive life stages, suggesting potentially persistent impacts of childhood adversity.

Normotensive placental extracellular vesicles provide long-term protection against hypertension and cardiovascular disease

BACKGROUND

Women with normotensive pregnancy are at a reduced risk of developing cardiovascular disease postpartum compared with those who experience hypertensive conditions during pregnancy. However, the underlying mechanisms remain poorly understood. During normotensive pregnancy, vast numbers of placental extracellular vesicles are released into the maternal circulation, which protect endothelial cells from activation and alter maternal vascular tone. We hypothesized that placental extracellular vesicles play a mechanistic role in lowering the risk of cardiovascular disease following normotensive pregnancy.

OBJECTIVE

This study aimed to investigate the long-term effects of placental extracellular vesicles derived from normotensive term placentae on the cardiovascular system and explore the mechanisms underlying their biological effects.

STUDY DESIGN

Spontaneously hypertensive rats were injected with placental extracellular vesicles from normotensive term pregnancies (2 mg/kg each time, n=8) or vehicle control (n=9) at 3 months of age. Blood pressure and cardiac function were regularly monitored from 3 months to 15 months of age. The response of mesenteric resistance arteries to vasoactive substances was investigated to evaluate vascular function. Cardiac remodeling, small artery remodeling, and renal function were investigated to comprehensively assess the impact of placental extracellular vesicles on cardiovascular and renal health.

RESULTS

Compared with vehicle-treated control animals, rats treated with normotensive placental extracellular vesicles exhibited a significantly lower increase in blood pressure and improved cardiac function. Furthermore, the vasodilator response to the endothelium-dependent agonist acetylcholine was significantly enhanced in the normotensive placental extracellular vesicle-treated spontaneously hypertensive rats compared with the control. Moreover, treatment with placental extracellular vesicles reduced wall thickening of small renal vessels and attenuated renal fibrosis.

CONCLUSION

Placental extracellular vesicles from normotensive term pregnancies have long-lasting protective effects reducing hypertension and mitigating cardiovascular damage in vivo.

Large-Scale Data Harmonization Across Prospective Studies

The Preconception Period Analysis of Risks and Exposures Influencing Health and Development (PrePARED) Consortium creates a novel resource for addressing preconception health by merging data from numerous cohort studies. In this paper, we describe our data harmonization methods and results. Individual-level data from 12 prospective studies were pooled. The crosswalk-cataloging-harmonization procedure was used. The index pregnancy was defined as the first postbaseline pregnancy lasting more than 20 weeks. We assessed heterogeneity across studies by comparing preconception characteristics in different types of studies. The pooled data set included 114,762 women, and 25,531 (22%) reported at least 1 pregnancy of more than 20 weeks' gestation during the study period. Babies from the index pregnancies were delivered between 1976 and 2021 (median, 2008), at a mean maternal age of 29.7 (standard deviation, 4.6) years. Before the index pregnancy, 60% of women were nulligravid, 58% had a college degree or more, and 37% were overweight or obese. Other harmonized variables included race/ethnicity, household income, substance use, chronic conditions, and perinatal outcomes. Participants from pregnancy-planning studies had more education and were healthier. The prevalence of preexisting medical conditions did not vary substantially based on whether studies relied on self-reported data. Use of harmonized data presents opportunities to study uncommon preconception risk factors and pregnancy-related events. This harmonization effort laid the groundwork for future analyses and additional data harmonization.

Placental syndromes and maternal cardiovascular health

The placental syndromes gestational hypertension, preeclampsia and intrauterine growth restriction are associated with an increased cardiovascular risk to the mother later in life. In this review, we argue that a woman's pre-conception cardiovascular health drives both the development of placental syndromes and long-term cardiovascular risk but acknowledge that placental syndromes can also contribute to future cardiovascular risk independent of pre-conception health. We describe how preclinical studies in models of preeclampsia inform our understanding of the links with later cardiovascular disease, and how current pre-pregnancy studies may explain relative contributions of both pre-conception factors and the occurrence of placental syndromes to long-term cardiovascular disease.

Placental syndromes and long-term risk of hypertension

Higher blood pressure prior to pregnancy is associated with increased risk of placental abruption, hypertension and preeclampsia, preterm delivery and fetal growth restriction. These conditions are jointly termed placental syndromes as they are characterised by impaired placentation and early placental vascularization. Placental syndromes are associated with an increased maternal risk of progression to hypertension and cardiovascular disease (CVD) in later life. Women affected by both a clinical placental syndrome and with evidence of placental maternal vascular malperfusion (MVM) have a particularly high risk of hypertension and CVD. Yet whether placental impairment and clinical syndromes are causes or consequences of higher blood pressure in women remains unclear. In this review, we address the relationship between blood pressure and maternal health in pregnancy. We conclude that there is a pressing need for studies with a range of detailed measures of cardiac and vascular structure and function taken before, during and after pregnancy to solve the 'chicken and egg' puzzle of women's blood pressure and pregnancy health, and to inform effective precision medicine prevention and treatment of both placental syndromes and chronic hypertension in women.

Number of children and disability pension due to mental and musculoskeletal disorders: A longitudinal register-based study in Norway

Earlier research has documented a relationship between parity and all-cause mortality, as well as parity and cause-specific mortality (e.g. cancer and cardiovascular disease mortality). Less is known about the relationship between parity and two very common (but less deadly) types of disorder: mental and musculoskeletal. We examine the association between parity and risk of disability pensioning from all causes and due to mental or musculoskeletal disorders, using Norwegian register data. In addition to controlling for adult socio-demographic characteristics, we control for unobserved confounding from family background by estimating sibling fixed-effects models. We find a higher risk of disability pensioning among the childless and those with one child than for parents with two children, both for all causes combined and for mental disorders. Childless men and fathers with one child also experience excess risk of being pensioned due to musculoskeletal disorders. For mental disorders, we find a positive association with high parity, particularly for men.

Women's Reproductive Milestones and Cardiovascular Disease Risk: A Review of Reports and Opportunities From the CARDIA Study

In 1985 to 1986, the CARDIA (Coronary Artery Risk Development in Young Adults) study enrolled 5115 Black or White participants, including 2788 women, aged 18 to 30 years. Over the following 35 years, the CARDIA study amassed extensive longitudinal data on women's reproductive milestones, spanning menarche to menopause. Although not initially conceived as a study of women's health, >75 CARDIA study publications address relationships between reproductive factors and events with cardiovascular and metabolic risk factors, subclinical and clinical cardiovascular disease, and social determinants of health. The CARDIA study was one of the earliest population-based reports to note Black-White differences in age at menarche and associations with cardiovascular risk factors. Adverse pregnancy outcomes, particularly gestational diabetes and preterm birth, have been assessed along with postpartum behaviors, such as lactation. Existing studies have examined risk factors for adverse pregnancy outcomes and lactation, as well as their relationship to future cardiovascular and metabolic risk factors, diagnoses, and subclinical atherosclerosis. Ancillary studies examining components of polycystic ovary syndrome and ovarian biomarkers, such as anti-Müllerian hormone, have facilitated examination of reproductive health in a population-based cohort of young adult women. As the cohort transitioned through menopause, examination of the importance of premenopausal cardiovascular risk factors along with menopause has improved our understanding of shared mechanisms. The cohort is now aged in the 50s to mid-60s, and women will begin to experience a greater number of cardiovascular events as well as other conditions, such as cognitive impairment. Thus, in the next decade, the CARDIA study will provide a unique resource for understanding how the women's reproductive life course epidemiology informs cardiovascular risk, as well as reproductive and chronological aging.

The role of angiotensin II and relaxin in vascular adaptation to pregnancy

In brief

There is a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular function and can be maintained postpartum. This review outlines the cardiovascular changes that occur in a healthy human and rodent pregnancy, as well as different pathways that are activated by angiotensin II and relaxin that result in blood vessel dilation.

Abstract

During pregnancy, systemic and uteroplacental blood flow increase to ensure an adequate blood supply that carries oxygen and nutrients from the mother to the fetus. This results in changes to the function of the maternal cardiovascular system. There is also a pregnancy-induced vasodilation of blood vessels, which is known to have a protective effect on cardiovascular health/function. Additionally, there is evidence that the effects of maternal vascular vasodilation are maintained post-partum, which may reduce the risk of developing high blood pressure in the next pregnancy and reduce cardiovascular risk later in life. At both non-pregnant and pregnant stages, vascular endothelial cells produce a number of vasodilators and vasoconstrictors, which transduce signals to the contractile vascular smooth muscle cells to control the dilation and constriction of blood vessels. These vascular cells are also targets of other vasoactive factors, including angiotensin II (Ang II) and relaxin. The binding of Ang II to its receptors activates different pathways to regulate the blood vessel vasoconstriction/vasodilation, and relaxin can interact with some of these pathways to induce vasodilation. Based on the available literature, this review outlines the cardiovascular changes that occur in a healthy human pregnancy, supplemented by studies in rodents. A specific focus is placed on vasodilation of blood vessels during pregnancy; the role of endothelial cells and endothelium-derived vasodilators will also be discussed. Additionally, different pathways that are activated by Ang II and relaxin that result in blood vessel dilation will also be reviewed.

Alcohol Use and Blood Pressure Among Adults with Hypertension: the Mediating Roles of Health Behaviors

BACKGROUND

Alcohol use is associated with increased blood pressure among adults with hypertension, but it is unknown whether some of the observed relationship is explained by mediating behaviors related to alcohol use.

OBJECTIVE

We assess the potential indirect role of smoking, physical inactivity, unhealthy diet, and poor medication adherence on the association between alcohol use and blood pressure among Black and White men and women with hypertension.

DESIGN

Adjusted repeated-measures analyses using generalized estimating equations and mediation analyses using inverse odds ratio weighting.

PARTICIPANTS

1835 participants with hypertension based on ACC/AHA 2017 guidelines in three most recent follow-up exams of the longitudinal Coronary Artery Risk Development in Young Adults cohort study (2005-2016).

MAIN MEASURES

Alcohol use was assessed using both self-reported average ethanol intake (drinks/day) and engagement in heavy episodic drinking (HED) in the past 30 days. Systolic and diastolic blood pressure (SBP, DBP) were measured by trained technicians (mmHg). Smoking, physical inactivity, and diet were self-reported and categorized according to American Heart Association criteria, and medication adherence was assessed using self-reported typical adherence to antihypertensive medications.

KEY RESULTS

At baseline (2005-2006), 57.9% of participants were Black and 51.4% were women. Mean age (standard deviation) was 45.5 (3.6) years, mean SBP was 128.7 (15.5) mmHg, and mean DBP was 83.2 (10.1) mmHg. Each additional drink per day was significantly associated with higher SBP (β = 0.713 mmHg, 95% confidence interval (CI): 0.398, 1.028) and DBP (β = 0.398 mmHg, 95% CI: 0.160, 0.555), but there was no evidence of mediation by any of the behaviors. HED was not associated with blood pressure independent of average consumption.

CONCLUSIONS

These findings support the direct nature of the association of alcohol use with blood pressure and the utility of advising patients with hypertension to limit consumption in addition to other behavioral and pharmacological interventions.

Reproductive history, as measured by parity, age at first birth and sex of offspring, and cancer-specific survival after a haematological malignancy

BACKGROUND

Overall, women have better cancer-specific survival than men following haematological malignancies. The effect of reproductive factors on prognosis in women remains unknown and population-based studies are needed.

MATERIAL AND METHODS

A nationwide cohort of 21,237 Swedish women with a recorded haematological malignancy at ages 18-69 years was identified in the Swedish Cancer Register 1970-2018. Pre-diagnosis childbirths for each woman were linked to the Swedish Multigeneration Register. Net survival and excess hazard ratios for parity, age at first birth, time since the latest birth, and sex of offspring were estimated using flexible parametric models adjusted for age, year, and educational level.

RESULTS

In unadjusted analyses, parity (p = 0.0012) and high age at first birth (p < 0.0001) were associated with better survival. After co-adjustments for reproductive factors and confounders, the associations were attenuated. The adjusted association with parity was mainly observed among women aged above 40 years at diagnosis (p = 0.0033). The associations with reproductive factors were non-significant across subtypes of haematological malignancy. There was a tendency of higher excess mortality for an increasing number of boys compared to girls, although only significant for women with three or more children (p = 0.0126).

CONCLUSION

Reproductive factors were in part associated with survival following diagnosis of a haematological malignancy. However, the effect sizes were small with inconsistent association patterns, and thus reproductive factors may only partly contribute to the survival advantage of women over men.

The association of reproductive history with hypertension and obesity according to menopausal status: the J-MICC Study

Previous studies have reported that the number of pregnancies and childbirths affected the risk of cardiovascular diseases (CVDs). However, the influence of reproductive history on hypertension and obesity, which are important risk factors for CVDs, is still unclear. Moreover, this association may vary depending on menopausal status. We evaluated the association of reproductive history with hypertension and obesity using a large cross-sectional dataset from the Japan Multi-Institutional Collaborative Cohort Study (J-MICC Study). At the baseline survey, physical data, blood samples, and self-reported health questionnaires were collected. Participants with insufficient data were excluded, and 24,558 women from eight study regions were included in this study. Logistic regression analysis was conducted to evaluate the association of reproductive history with hypertension and obesity using multivariable-adjusted odds ratios. In premenopausal women, childbirth showed a generally protective effect on hypertension but not on obesity. In postmenopausal women, childbirth was positively associated with obesity and hypertension but not with hypertension after adjusting for BMI. In conclusion, reproductive history was associated with hypertension and obesity in a large Japanese population, and this association differed between premenopausal and postmenopausal women.

Prevalence of Hypertension and Adherence to Dietary Approaches to Stop Hypertension Diet Score in Childbearing Age Tunisian Women: A Cross-Sectional Study

Background and Aims

The prevalence, awareness, and treatment of hypertension, along with their sociodemographic, anthropometric, and lifestyle associations, were evaluated in a cross-sectional survey of childbearing age Tunisian women. Adherence to the Dietary Approaches to Stop Hypertension diet score was also assessed for hypertensive versus nonhypertensive women.

Methods and Results

A total of 1689 nonpregnant women, aged 20-49 years, were randomly sampled a regional (Greater Tunis), two-stage, stratified, cross-sectional cluster survey from March 2009 to January 2010. Data on medical history and sociodemographic characteristics were collected using a questionnaire. The average daily intake of energy and nutrients was computed using a specific Tunisian food composition database. The Dietary Approaches to Stop Hypertension diet score (0 to 10) was assessed by adding the individual scores (0 to 1) of ten nutrient components according to dietary guidelines. The overall prevalence of hypertension was 21.4%. Age, obesity, abdominal fat, parity, and family history were significantly associated with hypertension. The mean Dietary Approaches to Stop Hypertension accordance score was 4.93 for hypertensive women and 4.86 for nonhypertensive women (P = 0.0556). After adjustment for age, energy intake, and all nutritional covariates, no associations were observed between hypertension and Dietary Approaches to Stop Hypertension diet components.

Conclusion

Though no clear-cut associations between hypertension and environmental or behavioral factors were identified in the study, the association with abdominal obesity and multiparity suggests that interventions aimed at lifestyle modifications to reduce these risk factors could be also useful in the prevention of hypertension.

Live birth/parity number and the risk of incident hypertension among parous women during over 13 years of follow-up

The effect of live birth/parity number on incident hypertension was investigated among Iranian parous women aged 30–70 years. The study population included 2188 normotensive women who were enrolled in 1999–2001. They were followed for incident hypertension (based on JNC 7 report) by 3‐year intervals up to April 2018. Multivariable Cox proportional hazard models, adjusted for a wide set of potential hypertension risk factors, reproductive factors, and pregnancy complications, were applied to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of the number of parity/live birth(s) for incident hypertension. Additionally, as a sensitivity analysis, age‐scale Cox regression was also done. During a median follow‐up of 13.5 years, 935 incident hypertension have occurred. Compared to those with two live births, the participants who had 3 and ≥4 live births were at higher risk of hypertension development by the HRs of 1.25 [95% CI: 1.02–1.55] and 1.39 [1.12–1.72], respectively, in the full‐adjusted model. Moreover, each additional live birth increased the risk of hypertension by a HR of 1.06 [95%CI: 1.02–1.11]. Results of parity number were also similar. Considering age as time scale also did not change the results generally. The authors found a significant interaction between live birth/parity number and age groups; the adverse effect of higher live birth/parity numbers on hypertension development was mainly found among those aged < 50 years. To sum up, compared to the live birth/parity number of two, Iranian women with ≥3 live birth/parity had a higher risk of incident hypertension; the issue was more prominent among younger mothers.

The effect of bearing and rearing a child on blood pressure: a nationally representative instrumental variable analysis of 444611 mothers in India

BACKGROUND

At the individual level, it is well known that pregnancies have a short-term effect on a woman's cardiovascular system and blood pressure. The long-term effect of having children on maternal blood pressure, however, is unknown. We thus estimated the causal effect of having children on blood pressure among mothers in India, a country with a history of high fertility rates.

METHODS

We used nationally representative cross-sectional data from the 2015-16 India National Family and Health Survey (NFHS-4). The study population comprised 444 611 mothers aged 15-49 years. We used the sex of the first-born child as an instrumental variable (IV) for the total number of a woman's children. We estimated the effect of an additional child on systolic and diastolic blood pressure in IV (two-stage least squares) regressions. In additional analyses, we stratified the IV regressions by time since a mother last gave birth. Furthermore, we repeated our analyses using mothers' husbands and partners as the regression sample.

RESULTS

On average, mothers had 2.7 children [standard deviation (SD): 1.5], a systolic blood pressure of 116.4 mmHg (SD: 14.4) and diastolic blood pressure of 78.5 mmHg (SD: 9.4). One in seven mothers was hypertensive. In conventional ordinary least squares regression, each child was associated with 0.42 mmHg lower systolic [95% confidence interval (CI): -0.46 to -0.39, P < 0.001] and 0.13 mmHg lower diastolic (95% CI: -0.15 to -0.11, P < 0.001) blood pressure. In the IV regressions, each child decreased a mother's systolic blood pressure by an average of 1.00 mmHg (95% CI: -1.26 to -0.74, P < 0.001) and diastolic blood pressure by an average of 0.35 mmHg (95% CI: -0.52 to -0.17, P < 0.001). These decreases were sustained over more than a decade after childbirth, with effect sizes slightly declining as the time since last birth increased. Having children did not influence blood pressure in men.

CONCLUSIONS

Bearing and rearing a child decreases blood pressure among mothers in India.

Prenatal Exercise and Cardiovascular Health (PEACH) Study: Impact on the Vascular System

PURPOSE

Healthy pregnancy is typically associated with favorable vascular adaptations to both structure and function of the peripheral arteries. Exercise is independently associated with improvements in peripheral vascular health; however, the impact of exercise on prenatal adaptations is unclear. Therefore, we hypothesized that a structured aerobic exercise intervention between the second and third trimester (TM2 and TM3, respectively) of pregnancy would augment the already-positive changes in vascular outcomes.

METHODS

We recruited 59 inactive pregnant women (<20 weeks gestation) and randomized them into control (standard care; n = 28) or exercise (moderate intensity aerobic exercise, 3-4 days/week, 25-40 minutes, 14 ± 1 weeks; n = 31) conditions. Before and after the intervention all women completed comprehensive peripheral vascular assessment, which included blood markers of vascular health, carotid distensibility metrics, measures of arterial stiffness (pulse wave velocity; PWV), and [superficial] femoral artery reactivity during cold pressor test (CPT).

RESULTS

Carotid artery diameter increased from 6.5 mm to 6.9 mm (p < 0.001) strain (%)decreased from 9.9% to 8.4% (p < 0.001). Carotid artery blood flow, compliance and distensibility coefficients, stiffness (β), distensibility (1/β), and Elastic modulus were not different across gestation. PWV was not different across gestation. Superficial femoral artery diameter was increased from 5.4 mm to 5.6 mm (p = 0.004) while blood flow, conductance, and resistance at rest and during CPT were not different across gestation. None of our measures of vascular health were impacted by exercise.

CONCLUSION

We did not observe an impact of aerobic exercise on altering the changes across pregnancy in blood vessel health. However, the present study was conducted in women who were overall at low risk for developing gestational hypertension and should be interpreted with caution. Future work in high-risk women is needed.

The association between parity, CVD mortality and CVD risk factors among Norwegian women and men

BACKGROUND

Several studies have shown that women and men with two children have lower mortality than the childless, but there is less certainty about mortality, including CVD mortality, at higher parities and meagre knowledge about factors underlying the parity-mortality relationship.

METHODS

The association between parity and CVD mortality was analyzed by estimating discrete-time hazard models for women and men aged 40-80 in 1975-2015. Register data covering the entire Norwegian population were used, and the models included a larger number of relevant sociodemographic control variables than in many previous studies. To analyze the relationship between parity and seven CVD risk factors, logistic models including the same variables as the mortality models were estimated from the CONOR collection of health surveys, linked to the register data.

RESULTS

Men (but not women) who had four or more children had higher mortality from CVD than those with two, although this excess mortality was not observed for the heart disease sub-group. Overweight, possibly in part a result of less physical activity, seems to play a role in this. All CVD risk factors except smoking and alcohol may contribute to the relatively high CVD mortality among childless.

CONCLUSIONS

Childbearing is related to a number of well-known CVD risk factors, and becoming a parent or having an additional child is, on the whole, associated with lower-or at least not higher-CVD mortality in Norway. However, for men family sizes beyond three children are associated with increased CVD mortality, with risks of overweight one possible pathway.

Twenty-Five-Year Changes in Office and Ambulatory Blood Pressure: Results From the Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Blood pressure (BP) measured in the office setting increases from early through later adulthood. However, it is unknown to what extent out-of-office BP derived via ambulatory BP monitoring (ABPM) increases over time, and which participant characteristics and risk factors might contribute to these increases.

METHODS

We assessed 25-year change in office- and ABPM-derived BP across sex, race, diabetes mellitus (DM), and body mass index (BMI) subgroups in the Coronary Artery Risk Development in Young Adults study using multivariable-adjusted linear mixed effects models.

RESULTS

We included 288 participants who underwent ABPM at the Year 5 Exam (mean [SD] age, 25.1 [3.7]; 45.8% men) and 455 participants who underwent ABPM at the Year 30 Exam (mean [SD] age, 49.5 [3.7]; 42.0% men). Office, daytime, and nighttime systolic BP (SBP) increased 12.8 (95% confidence interval [CI], 7.6-17.9), 14.7 (95% CI, 9.7-19.8), and 16.6 (95% CI, 11.4-21.8) mm Hg, respectively, over 25 years. Office SBP increased 6.5 (95% CI, 2.3-10.6) mm Hg more among black compared with white participants. Daytime SBP increased 6.3 (95% CI, 0.2-12.4) mm Hg more among participants with a BMI ≥25 vs. <25 kg/m2. Nighttime SBP increased 4.7 (95% CI, 0.5-8.9) mm Hg more among black compared with white participants, and 17.3 (95% CI, 7.2-27.4) mm Hg more among participants with vs. without DM.

CONCLUSIONS

Office- and ABPM-derived BP increased more from early through middle adulthood among black adults and participants with DM and BMI ≥25 kg/m2.

The Association of Lactation Duration with Visceral and Pericardial Fat Volumes in Parous Women: The CARDIA Study

BACKGROUND

Lactation is associated with lower risks for cardiovascular disease in women. Organ-related adiposity, which plays significant roles in the development of cardiometabolic diseases, could help explain this observation. We evaluated the association of lactation duration with visceral (VAT) and pericardial (PAT) fat volumes in women.

METHODS

Data were obtained from 910 women enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study (1985-1986) without diabetes prior to pregnancy who had ≥1 birth during 25 years of follow-up and had VAT and PAT measured from computed tomographic scans in 2010-2011. Cumulative lactation duration across all births since baseline was calculated from self-reports collected at periodic exams.

RESULTS

At baseline, the average age of women (48% black, 52% white) was 24 ± 3.7 years. After controlling for baseline age, race, smoking status, body mass index, fasting glucose, family history of diabetes, fat intake, total cholesterol, physical activity, and follow-up covariates (parity, gestational diabetes), the mean fat volumes across categories of lactation [none (n = 221), 1-5 months (n = 306), 6-11 months (n = 210), and ≥12 months (n = 173)] were 122.0, 113.7 105.0, and 110.1 cm3 for VAT and 52.2, 46.7, 44.5, and 43.4 cm3 for PAT, respectively. Changes in body weight from the first post-baseline birth to the end of follow-up mediated 21% and 18% of the associations of lactation with VAT and PAT, respectively.

CONCLUSIONS

In this prospective study, longer cumulative lactation duration was associated with lower VAT and PAT volumes, with weight gain partially mediating these associations.

Impact of prior preterm or term small for gestational age birth on maternal blood pressure during the menopause transition in the Study of Women's Health Across the Nation

OBJECTIVE

To examine whether blood pressure (BP) accelerates more rapidly during the menopause transition for women with a history of preterm or term small for gestational age (SGA) delivery compared to women with all term and appropriate for gestational age (AGA) births.

METHODS

A longitudinal analysis was conducted with 1,008 parous women who had BP data at ≥2 study visits. We used generalized linear modeling to examine BP before the final menstrual period, at the final mentrual period, and up to 10 years after the final menstrual period, according to pregnancy group. We assessed maternal changes in BP over time in relation to years near the final menstrual period using a piece-wise linear model, consistent with menopause-induced changes. Models were adjusted for socio-demographics, body mass index, smoking, physical activity, medications, parity, age at first birth, gestational diabetes, and gestational hypertension/preeclampsia.

RESULTS

At baseline, women were on average 46 years old, 101 (10%) reported a prior preterm birth, and 102 (10.1%) reported a term SGA birth. Compared to women with all term AGA births, women with a term SGA birth had higher BP before the final menstrual period, at the final menstrual period, and up to 10 years after the final menstrual period; women with a preterm birth had higher BP in the postmenopausal years. Annual rate of change in BP during the menopause transition did not differ between pregnancy groups.

CONCLUSIONS

Women with a history preterm and term SGA delivery have higher BP than women with all term AGA births during the menopause transition, but rate of change in BP does not differ in these groups relative to final menstrual period.

Reproduction, DNA methylation and biological age

STUDY QUESTION

Are reproductive characteristics associated with genome-wide DNA methylation and epigenetic age?

SUMMARY ANSWER

Our data suggest that increasing parity is associated with differences in blood DNA methylation and small increases in epigenetic age.

WHAT IS KNOWN ALREADY

A study of 397 young Filipino women (ages 20-22) observed increasing epigenetic age with an increasing number of pregnancies.

STUDY DESIGN, SIZE, DURATION

We used data from 2356 non-Hispanic white women (ages 35-74) enrolled in the Sister Study cohort.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data on reproductive history were ascertained via questionnaire. Of the 2356 women, 1897 (81%) reported at least one live birth. Among parous women, 487 (26%) women reported ever experiencing a pregnancy complication. Three epigenetic clocks (i.e. Hannum, Horvath and Levine) and genome-wide methylation were measured in DNA from whole blood using Illumina's HumanMethylation450 BeadChip. We estimated association β-values and 95% CIs using linear regression.

MAIN RESULTS AND THE ROLE OF CHANCE

All three epigenetic clocks showed weak associations between number of births and epigenetic age (per live birth; Hannum: β = 0.16, 95% CI = 0.02, 0.29, P = 0.03; Horvath: β = 0.12, 95% CI = -0.04, 0.27, P = 0.14; Levine: β = 0.27, 95% CI = 0.08, 0.45, P = 0.01); however, additional adjustment for current BMI attenuated the associations. Among parous women, a history of abnormal glucose tolerance during pregnancy was associated with increased epigenetic age by the Hannum clock (β = 0.96; 95% CI = 0.10, 1.81; P = 0.03) and Levine clocks (β = 1.69; 95% CI = 0.54, 2.84; P < 0.01). In epigenome-wide analysis, increasing parity was associated with methylation differences at 17 CpG sites (Bonferroni corrected P≤ 1.0 × 10-7).

LIMITATIONS, REASONS FOR CAUTION

We relied on retrospective recall to ascertain reproductive history and pregnancy complications.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings suggest that parity is associated with small increases in epigenetic age and with DNA methylation at multiple sites in the genome.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the Intramural Research program of the NIH, National Institute of Environmental Health Sciences (Z01-ES049033, Z01-ES049032 and Z01-ES044055). None of the authors have a conflict of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Gravidity, parity, blood pressure and mortality among women in Bangladesh from the HEALS cohort

OBJECTIVES

Despite a hypothesised connection of reproductive history with hypertension and mortality, the nature of this association is poorly characterised. We evaluated the association of parity and gravidity with blood pressure, hypertension and all-cause mortality.

DESIGN

Prospective cohort study.

SETTING

Health Effects of Arsenic Longitudinal Study cohort in rural Bangladesh.

PARTICIPANTS

There were 21 634 Bangladeshi women recruited in 2000-2002, 2006-2008 and 2010-2014 included in the present analysis.

METHODS

Reproductive history was ascertained through an interviewer-administered questionnaire at the baseline visit. Blood pressure was measured by a trained study physician following a standard protocol at the baseline visit. Vital status was ascertained at the biennial follow-up of study participants through June 2017. Linear and logistic regression models estimated the relationship between parity and gravidity with blood pressure and hypertension, respectively. Cox proportional hazards models estimated the relationship with all-cause mortality only among women aged >45 years.

RESULTS

Diastolic blood pressure was lowest in women with parity one (reference) and elevated in nulliparous women (adjusted % change=3.12; 95% CI 1.93 to 4.33) and women with parity >2 (adjusted % change=1.71; 95% CI 1.12 to 2.31). The associations with nulliparity were stronger for women aged >45 years. Similar association patterns were observed with hypertension. Further, in nulliparous women aged >45 years, 265 deaths (6.6%) were ascertained during the follow-up period (median follow-up time=8 years), and we observed suggestive elevated risks of all-cause mortality (adjusted HR 3.83; 95% CI 0.74 to 19.78). The relationships between reproductive history, blood pressure, hypertension and mortality were similar when modelling reproductive history as gravidity rather than parity.

CONCLUSIONS

For women in rural Bangladesh, nulliparity and nulligravidity appear to be associated with higher blood pressure and subsequent elevated risk of mortality.

Life Course Changes in Cardiometabolic Risk Factors Associated With Preterm Delivery: The 30-Year CARDIA Study

Background

Women who deliver preterm infants (<37 weeks) have excess cardiovascular risk; however, it is unclear whether the unfavorable changes in the cardiometabolic profile associated with preterm delivery initiate before, during, or after childbearing.

Methods and Results

We identified 1306 women (51% Black) with births between baseline (1985–1986) and year 30 in the CARDIA (Coronary Artery Risk Development in Young Adults) study. We compared life course changes in blood pressure, body mass index, waist circumference, and lipids in women with preterm deliveries (n=318) with those with all term deliveries (n=988), using piecewise linear mixed‐effects models. Specifically, we evaluated group differences in rates of change before and after the childbearing period and change in level across the childbearing period. After adjusting for the covariates, women with preterm deliveries had a higher change in diastolic blood pressure across the childbearing period than those with all term deliveries (1.59 versus −0.73 mm Hg, P<0.01); the rates of change did not differ by group, both prechildbearing and postchildbearing. Women with preterm deliveries had a larger body mass index increase across the childbearing period (1.66 versus 1.22 kg/m², P=0.03) compared with those with all term deliveries, followed by a steeper increase after the childbearing period (0.22 versus 0.17 kg/m² per year, P=0.02).

Conclusions

Preterm delivery was associated with unfavorable patterns of change in diastolic blood pressure and adiposity that originate during the childbearing years and persist or exacerbate later in life. These adverse changes may contribute to the elevated cardiovascular risk among women with preterm delivery.

Life-Course Reproductive History and Cardiovascular Risk Profile in Late Mid-Life: The CARDIA Study

Background

Reproductive events, that is, a preterm birth (PTB), small‐for‐gestational‐age infant (SGA), and vasomotor symptoms of menopause, are associated with subclinical atherosclerotic cardiovascular disease (ASCVD). We evaluated whether women with a past PTB and/or SGA (henceforth PTB/SGA) were more likely to have severe vasomotor symptoms of menopause and whether the estimated 10‐year ASCVD risk was higher in women with PTB/SGA and vasomotor exposures.

Methods and Results

We assigned 1866 women (mean age=55±1 years) in the CARDIA (Coronary Artery Risk Development in Young Adults) study to the following categories of reproductive exposures: none, PTB/SGA only, vasomotor symptoms only, or both PTB/SGA and vasomotor symptoms. We used Kruskal‐Wallis tests to evaluate the differences in pooled cohort equation ASCVD risk scores by category and linear regression to evaluate the associations of categories with ASCVD risk scores adjusted for study center, body mass index, education, current hormone replacement therapy use, parity, and hysterectomy. Women with PTB/SGA were more likely to have severe vasomotor symptoms, 36% versus 30%, P<0.02. ASCVD risk score was higher in women with both PTB/SGA and vasomotor symptoms (4.6%; 95% CI, 4.1%–5.1%) versus women with no exposures (3.3%; 95% CI, 2.9%–3.7%) or vasomotor symptoms only (3.8%; 95% CI, 3.5%–4.0%). ASCVD risk score was higher in women PTB/SGA (4.8%; 95% CI, 3.6%–5.9%) versus no exposures. PTB/SGA and vasomotor symptoms was associated with ASCVD risk score in white women versus no exposures (β=0.40; 95% CI, 0.02–0.78).

Conclusions

Women with prior PTB/SGA were more likely to have severe vasomotor symptoms of menopause. Reproductive exposures were associated with an estimated 10‐year ASCVD risk in white women.

Effect of Parity on Pregnancy-Associated Hypertension Among Asian American Women in the United States

OBJECTIVES

Pregnancy-associated hypertension (PAH) includes gestational hypertension, preeclampsia and eclampsia. Although a protective effect of multi-parity on PAH has been reported in previous studies, the association has not been examined among Asian American women in the U.S.

METHODS

Using data from 2014 U.S. National Vital Statistics System, we examined the prevalence of PAH among Asian American women who had singleton live births (N = 235,303), and its association with parity (number of previous pregnancies including live births and fetal deaths) controlling for potential confounders. We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CI) using multivariable logistic regression analysis.

RESULTS

Overall, 2.72% (95% CI 2.66%, 2.79%) of Asian American women were recorded to have PAH during pregnancy. Parity was inversely associated with PAH in our study, where Asian American women who had 1-2 and 3 or more previous pregnancies had significantly lower odds of PAH (aOR 0.61, 95% CI 0.58, 0.65; and aOR 0.62, 95% CI 0.57, 0.68, respectively) compared to nulliparous women, after controlling for potential confounders.

CONCLUSIONS

Recent U.S. vital statistics data revealed that nulliparity is significantly associated with PAH among Asian American women. Future studies should identify specific factors that are associated with PAH and factors contributing to disparities in PAH risk among Asian American women.

Predictors of incident hypertension in healthy non-diabetic postmenopausal women with normal renal function

Introduction: We aimed to investigate the incidence of hypertension and to identify potential risk factors in healthy, non-diabetic recently postmenopausal Greek women with normal renal function.Patients and methods: This retrospective cohort study evaluated 141 recently postmenopausal women at baseline and annually thereafter (follow-up time: 1 to 8 years). Blood samples were obtained, and ultrasound evaluations were performed at baseline. A detailed medical history, anthropometric parameters, blood pressure and cardiovascular risk factors were recorded for every woman at each visit. Incident hypertension was defined as the first occurrence of office systolic or diastolic blood pressure, measured at 2 different visits within 2 months or history of initiation of antihypertensive medication.Results: Incident hypertension was diagnosed in 30 out of 141 women (21.3%). The median time to incident hypertension was 3.5 years. Adiposity, elevated cholesterol and triglyceride levels, insulin resistance and parity were positively associated with incident hypertension. In multivariate analysis, however, obesity and insulin resistance were the only statistically significant variables associated with more than 3-fold and 2-fold respectively increased risk of incident hypertension (HOMA-IR, O.R = 1.988, p-value =.043; obesity, O.R = 3.746, p-value =.019).Conclusion: A significant proportion of women entering the menopause present incident hypertension and this is mostly associated with obesity and insulin resistance.

Association of Adverse Pregnancy Outcomes With Hypertension 2 to 7 Years Postpartum

Background Identifying pregnancy-associated risk factors before the development of major cardiovascular disease events could provide opportunities for prevention. The objective of this study was to determine the association between outcomes in first pregnancies and subsequent cardiovascular health. Methods and Results The Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-be Heart Health Study is a prospective observational cohort that followed 4484 women 2 to 7 years (mean 3.2 years) after their first pregnancy. Adverse pregnancy outcomes (defined as hypertensive disorders of pregnancy, small-for-gestational-age birth, preterm birth, and stillbirth) were identified prospectively in 1017 of the women (22.7%) during this pregnancy. The primary outcome was incident hypertension (HTN). Women without adverse pregnancy outcomes served as controls. Risk ratios (RR) and 95% CIs were adjusted for age, smoking, body mass index, insurance type, and race/ethnicity at enrollment during pregnancy. The overall incidence of HTN was 5.4% (95% CI 4.7% to 6.1%). Women with adverse pregnancy outcomes had higher adjusted risk of HTN at follow-up compared with controls (RR 2.4, 95% CI 1.8-3.1). The association held for individual adverse pregnancy outcomes: any hypertensive disorders of pregnancy (RR 2.7, 95% CI 2.0-3.6), preeclampsia (RR 2.8, 95% CI 2.0-4.0), and preterm birth (RR 2.7, 95% CI 1.9-3.8). Women who had an indicated preterm birth and hypertensive disorders of pregnancy had the highest risk of HTN (RR 4.3, 95% CI 2.7-6.7). Conclusions Several pregnancy complications in the first pregnancy are associated with development of HTN 2 to 7 years later. Preventive care for women should include a detailed pregnancy history to aid in counseling about HTN risk. Clinical Trial Registration URL: http://www.clinicaltrials.gov Unique identifier: NCT02231398.

Pre-pregnancy kidney function and subsequent adverse pregnancy outcomes

BACKGROUND

Renal insufficiency is associated with pregnancy complications including fetal growth restriction, preterm birth (PTB), and pre-eclampsia.

OBJECTIVE

To determine the effect of preconception kidney function within the normal range on pregnancy outcome.

METHOD

1043 (50% black, 50% white) women who participated in the CARDIA study who had kidney function and biochemical analyses measured before at least one pregnancy delivered during the 20 years post-baseline period were included in analysis. Kidney function estimated as glomerular filtration rate (eGFR) via modified CKD-EPI equations, serum creatinine, and urinary albumin/creatinine ratio were evaluated as predictors of infant birthweight, gestational age, birthweight-for-gestational-age, and hypertensive disorders of pregnancy via self-report, using multiple regression with adjustment for confounders (age, race, smoking, BMI, center, parity, systolic blood pressure at baseline). Serum uric acid was also examined at both baseline and year 10.

RESULTS

Unadjusted pre-pregnancy eGFR (baseline) was associated with lower average birthweight-for-gestational-age, but this disappeared after adjustment for confounders. A decline in GFR from baseline to year 10 was associated with lower birthweight (adjusted estimate -195 g, p = 0.03 overall), especially among whites. After adjustment for confounders, no association was found with gestational age or hypertensive disorders.

CONCLUSIONS

No strong evidence for an association between preconception kidney function in the normal range and birthweight or gestational age was found. Possible racial differences in these relationships warrant further examination.

Parity and risk of maternal cardiovascular disease: A dose-response meta-analysis of cohort studies

BACKGROUND

Parity has been reported to play an important role in the development of cardiovascular disease; however, the results are still controversial. We aimed to conduct a meta-analysis of cohort studies to assess quantitatively the association between parity and cardiovascular disease risk.

METHODS

PubMed and Web of Science databases were searched to 1 June 2018, supplemented by manual searches of the bibliographies of retrieved articles. And multivariate-adjusted relative risks were pooled by using random-effects models. Restricted cubic spline analysis with four knots was used to explore the relationship of parity and the risk of cardiovascular disease.

RESULTS

Ten cohort studies involving 150,512 incident cases of cardiovascular disease among 3,089,929 participants were included in the meta-analysis. A significant association between parity and cardiovascular disease risk was observed while comparing parity with nulliparity, with a summarised relative risk of 1.14 (95% confidence interval (CI) 1.09-1.18; I² = 62.0%, P = 0.002). In the dose-response analysis, we observed a potential non-linear J-shaped dose-response relationship between the number of parity and cardiovascular disease risk, the summary risk estimates for an increase of one live birth was 1.04 (95% CI 1.02-1.05), with significant heterogeneity ( I² = 89.6%). In addition, the similar J-shaped associations between parturition number and cardiovascular disease, ischaemic heart disease or stroke risk were also observed.

CONCLUSIONS

Our findings suggest that ever parity is related to cardiovascular disease risk and there is an association between the number of pregnancies and the risk of cardiovascular disease. Since the number of included studies was limited, further studies are warranted to confirm our findings.

Cardiovascular Health of Mothers in the United States: National Health and Nutrition Examination Survey 2007-2014

Background: Pregnancy and childrearing can impact women's health and alter chronic disease trajectories in later life, including cardiovascular disease. The purpose of this study was to assess measures of women's cardiovascular health by time since last live birth. Materials and Methods: Data were from 4,021 nonpregnant U.S. women, 20-44 years of age, participating in the 2007-2014 National Health and Nutrition Examination Survey (NHANES). Cardiovascular health was assessed using physical measures, laboratory measures, self-reported behaviors, medical conditions, and selected psychosocial factors by time since last live birth. Results: Women reported their last live birth within the past 12 months ("mothers of infants"; 7.4%), >12 months, but <3 years ago ("mothers of toddlers"; 10.0%), or ≥3 years ago ("mothers of older children"; 45.2%); 37.3% were nulliparous. Compared with nulliparous women, mothers of older children had a higher prevalence of selected cardiovascular risk factors, including unhealthy diet (75.6% vs. 68.8%) and smoking (28.1% vs. 21.9%), after adjustment for sociodemographics (including age). Mothers of toddlers had a higher prevalence of unhealthy diet (78.0% vs. 68.8%). Mothers also had poorer metabolic health as indicated by a higher prevalence of low HDL cholesterol among mothers of toddlers and older children (44.2% and 40.4%, respectively, vs. 33.6%), and a higher prevalence of high waist circumference among mothers of infants (65.6% vs. 53.8%). Some mothers also had a higher prevalence of other cardiovascular risk factors, including low physical activity and poor sleep. Conclusion: Prior pregnancy and childrearing may be associated with selected cardiovascular risk factors among nonpregnant reproductive-aged U.S. women.

Cardiorespiratory fitness, exercise haemodynamics and birth outcomes: the Coronary Artery Risk Development in Young Adults Study

OBJECTIVE

Determine associations of cardiorespiratory fitness, exercise systolic blood pressure (SBP) and heart rate recovery (HRR) following a maximal exercise test performed years preceding pregnancy with odds of preterm birth (PTB; <37 weeks' gestation) and small for gestational age (SGA; birthweight <10th percentile) delivery.

DESIGN

Prospective, longitudinal.

SETTING

Multi-site, observational cohort study initially consisting of 2787 black and white women aged 18-30 at baseline (1985-86) and followed for 25 years (Y25; 2010-2011).

POPULATION

768 nulliparous women at baseline who reported ≥1 live birth by the Y25 exam.

METHODS

We used Poisson regression to determine associations of exposures with PTB/SGA.

MAIN OUTCOME MEASURES

PTB and/or SGA births.

RESULTS

Women with PTB (n = 143) and/or SGA (n = 88) were younger, had completed fewer years of education and were more likely to be black versus women without PTB/SGA (n = 546). Women with PTB/SGA had lower fitness (501 ± 9 versus 535 ± 6 seconds, P < 0.002) and higher submaximal SBP than women without PTB/SGA (144 ± 1 versus 142 ± 1 mmHg, P < 0.04). After adjustment, no exercise test variables were associated with PTB/SGA, though the association with HRR and submaximal SBP approached significance in the subset of women who completed the exercise test <5 years before the index birth.

CONCLUSIONS

Neither fitness nor haemodynamic responses to exercise a median of 5 years preceding pregnancy, were associated with PTB/SGA. These findings indicate excess likelihood of PTB/SGA is not detectable by low fitness or exercise haemodynamic responses 5 years preceding pregnancy, but exercise testing, especially HRR and submaximal SBP, may be more useful when conducted closer to the onset of pregnancy.

TWEETABLE ABSTRACT

Exercise testing conducted >5 years before pregnancy may not detect women likely to have PTB/SGA.

Cumulative Incidence of Hypertension by 55 Years of Age in Blacks and Whites: The CARDIA Study

BACKGROUND

Blacks have higher blood pressure levels compared with whites beginning in childhood. Few data are available on racial differences in the incidence of hypertension from young adulthood through middle age.

METHODS AND RESULTS

We calculated the cumulative incidence of hypertension from age 18 to 55 years among participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study. Incident hypertension was defined by the first visit with mean systolic blood pressure ≥130 mm Hg, mean diastolic blood pressure ≥80 mm Hg, or self-reported use of antihypertensive medication. Among 3890 participants without hypertension at baseline (aged 18-30 years), cumulative incidence of hypertension by age 55 years was 75.5%, 75.7%, 54.5%, and 40.0% in black men, black women, white men, and white women, respectively. Among participants with systolic blood pressure/diastolic blood pressure <110 and 70, 110 to 119/70 to 74, and 120 to 129/75 to 79 mm Hg at baseline, blacks were more likely than whites to develop hypertension: multivariable-adjusted hazard ratios 1.97 (95% confidence interval, 1.65, 2.35), 1.80 (95% confidence interval, 1.52, 2.14), and 1.59 (95% confidence interval, 1.31, 1.93), respectively. Parental history of hypertension and higher body mass index, serum uric acid, and systolic blood pressure/diastolic blood pressure categories were associated with a higher risk for hypertension among blacks and whites. A higher Dietary Approaches to Stop Hypertension diet adherence score was associated with a lower risk for hypertension in blacks and whites.

CONCLUSIONS

Regardless of blood pressure level in young adulthood, blacks have a substantially higher risk for hypertension compared with whites through 55 years of age.

Blood Pressure Patterns and Subsequent Coronary Artery Calcification in Women Who Delivered Preterm Births

Women who delivered preterm infants have excess cardiovascular disease, but vascular pathways linking these conditions are not understood. We considered that higher blood pressure over 25 years among women with preterm delivery may be associated with coronary artery calcification (CAC). The CARDIA study (Coronary Artery Risk Development in Young Adults) enrolled 1049 black and white women with births between 1985 and 2010 (n=272 ever preterm [<37 weeks]; n=777 all term births [≥37 weeks]). Latent mixture modeling identified blood pressure trajectories across 20 years, and these were related to CAC at years 20 and 25. Three systolic blood pressure (SBP) patterns were identified: low stable (n=563; 53%), moderate (n=416; 40%), and moderate increasing (n=70; 7%). Women with moderate-increasing SBP were more likely to have delivered preterm compared with those in the low-stable group (40% versus 21%; P<0.0001), and they were more likely to have CAC (38.5% versus 12.2%). The SBP and CAC association varied by preterm birth (P interaction=0.04). Women with preterm delivery and a moderate-increasing SBP had a 2.17-fold higher hazards of CAC (95% confidence interval, 1.14-4.12) compared with women with term births and a lower SBP pattern, adjusted for cardiovascular disease risk factors and other pregnancy features. There was no excess CAC in women with moderate-increasing SBP and term births (adjusted hazard ratio, 1.02; 95% confidence interval, 0.49-2.14). Associations were stronger in women with hypertensive disorders of pregnancy but also detected in those with normotensive preterm deliveries. Women who deliver preterm infants are more likely to follow a high-risk blood pressure pattern throughout the childbearing years that is associated with CAC at midlife.

Lactation Duration and Progression to Diabetes in Women Across the Childbearing Years: The 30-Year CARDIA Study

Importance

Lactation duration has shown weak protective associations with incident diabetes (3%-15% lower incidence per year of lactation) in older women based solely on self-report of diabetes, studies initiated beyond the reproductive period are vulnerable to unmeasured confounding or reverse causation from antecedent biochemical risk status, perinatal outcomes, and behaviors across the childbearing years.

Objective

To evaluate the association between lactation and progression to diabetes using biochemical testing both before and after pregnancy and accounting for prepregnancy cardiometabolic measures, gestational diabetes (GD), and lifestyle behaviors.

Design, Setting, and Participants

For this US multicenter, community-based 30-year prospective cohort study, there were 1238 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study of young black and white women ages 18 to 30 years without diabetes at baseline (1985-1986) who had 1 or more live births after baseline, reported lactation duration, and were screened for diabetes up to 7 times during 30 years after baseline (1986-2016).

Exposures

Time-dependent lactation duration categories (none, >0 to 6 months, >6 to <12 months, and ≥12 months) across all births since baseline through 30 years.

Main Outcomes and Measures

Diabetes incidence rates per 1000 person-years and adjusted relative hazards (RH) with corresponding 95% CIs, as well as proportional hazards regression models adjusted for biochemical, sociodemographic, and reproductive risk factors, as well as family history of diabetes, lifestyle, and weight change during follow-up.

Results

Overall 1238 women were included in this analysis (mean [SD] age, 24.2 [3.7] years; 615 black women). There were 182 incident diabetes cases during 27 598 person-years for an overall incidence rate of 6.6 cases per 1000 person-years (95% CI, 5.6-7.6); and rates for women with GD and without GD were 18.0 (95% CI, 13.3-22.8) and 5.1 (95% CI, 4.2-6.0), respectively (P for difference < .001). Lactation duration showed a strong, graded inverse association with diabetes incidence: adjusted RH for more than 0 to 6 months, 0.75 (95% CI, 0.51-1.09); more than 6 months to less than 12 months, 0.52 (95% CI, 0.31-0.87), and 12 months or more 0.53 (0.29-0.98) vs none (0 days) (P for trend = .01). There was no evidence of effect modification by race, GD, or parity.

Conclusions and Relevance

This study provides longitudinal biochemical evidence that lactation duration is independently associated with lower incidence of diabetes. Further investigation is required to elucidate mechanisms that may explain this relationship.

The impact of parity on life course blood pressure trajectories: the HUNT study in Norway

The drop in blood pressure during pregnancy may persist postpartum, but the impact of pregnancy on blood pressure across the life course is not known. In this study we examined blood pressure trajectories for women in the years preceding and following pregnancy and compared life course trajectories of blood pressure for parous and nulliparous women. We linked information on all women who participated in the population-based, longitudinal HUNT Study, Norway with pregnancy information from the Medical Birth Registry of Norway. A total of 23,438 women were included with up to 3 blood pressure measurements per woman. Blood pressure trajectories were compared using a mixed effects linear spline model. Before first pregnancy, women who later gave birth had similar mean blood pressure to women who never gave birth. Women who delivered experienced a drop after their first birth of − 3.32 mmHg (95% CI, − 3.93, − 2.71) and − 1.98 mmHg (95% CI, − 2.43, − 1.53) in systolic and diastolic blood pressure, respectively. Subsequent pregnancies were associated with smaller reductions. These pregnancy-related reductions in blood pressure led to persistent differences in mean blood pressure, and at age 50, parous women still had lower systolic (− 1.93 mmHg; 95% CI, − 3.33, − 0.53) and diastolic (− 1.36 mmHg; 95% CI, − 2.26, − 0.46) blood pressure compared to nulliparous women. The findings suggest that the first pregnancy and, to a lesser extent, successive pregnancies are associated with lasting and clinically relevant reductions in systolic and diastolic blood pressure.

Association Between Gestational Diabetes and Incident Maternal CKD: The Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with increased risk for diabetes mellitus, metabolic syndrome, and cardiovascular disease. We evaluated whether GDM is associated with incident chronic kidney disease (CKD), controlling for prepregnancy risk factors for both conditions.

STUDY DESIGN

Prospective cohort.

SETTING & PARTICIPANTS

Of 2,747 women (aged 18-30 years) enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study in 1985 to 86, we studied 820 who were nulliparous at enrollment, delivered at least 1 pregnancy longer than 20 weeks' gestation, and had kidney function measurements during 25 years of follow-up.

PREDICTOR

GDM was self-reported by women for each pregnancy.

OUTCOMES

CKD was defined as the development of estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2 or urine albumin-creatinine ratio ≥ 25mg/g at any one CARDIA examination in years 10, 15, 20, or 25.

MEASUREMENTS

HRs for developing CKD were estimated for women who developed GDM versus women without GDM using complementary log-log models, adjusting for prepregnancy age, systolic blood pressure, dyslipidemia, body mass index, smoking, education, eGFR, fasting glucose concentration, physical activity level (all measured at the CARDIA examination before the first pregnancy), race, and family history of diabetes. We explored for an interaction between race and GDM.

RESULTS

During a mean follow-up of 20.8 years, 105 of 820 (12.8%) women developed CKD, predominantly increased urine albumin excretion (98 albuminuria only, 4 decreased eGFR only, and 3 both). There was evidence of a GDM-race interaction on CKD risk (P=0.06). Among black women, the adjusted HR for CKD was 1.96 (95% CI, 1.04-3.67) in GDM compared with those without GDM. Among white women, the HR was 0.65 (95% CI, 0.23-1.83).

LIMITATIONS

Albuminuria was assessed by single untimed measurements of urine albumin and creatinine.

CONCLUSIONS

GDM is associated with the subsequent development of albuminuria among black women in CARDIA.

Association of Pregnancy Complications and Characteristics With Future Risk of Elevated Blood Pressure: The Västerbotten Intervention Program

Pregnancy characteristics are associated with risk of cardiovascular diseases, but their independent associations with hypertension or blood pressure (BP) levels remain uncertain. We linked the Swedish Medical Birth Register with Västerbotten Intervention Program data (Northern Sweden). Using linear and logistic regression, we related pregnancy factors in any prior pregnancy with BP and hypertension at 40 years of age in 15 896 parous women free of prepregnancy hypertension. Pregnancy factors included parity, age at first delivery, preeclampsia, gestational diabetes mellitus, placental abruption, shortest gestational age small for gestational age baby (<third percentile for birth weight) or stillbirth. We defined hypertension as systolic BP ≥140 mm Hg and diastolic BP ≥90 mm Hg or antihypertensive use. Multivariable models were adjusted for all pregnancy factors and potential lifestyle and sociodemographic confounders. At 40 years of age, 1535 women (9.6%) had hypertension. In multivariable models, lower parity, younger age at first birth, preeclampsia, small for gestational age, and placental abruption were independently associated with higher systolic and diastolic BP levels at 40 years of age. Younger age at first birth, preeclampsia, gestational age <32 versus ≥37 weeks, and small for gestational age were independently associated with hypertension. Our findings raise the possibility that earlier and more frequent BP screening may be desirable in women with these pregnancy characteristics.

Intake of fish and long-chain omega-3 polyunsaturated fatty acids and incidence of metabolic syndrome among American young adults: a 25-year follow-up study

PURPOSE

Studies suggest that long-chain ω-3 polyunsaturated fatty acid (LCω3PUFA) intake and its primary food source-fish-may have beneficial effects on the individual components of metabolic syndrome (MetS). We examined the longitudinal association between fish or LCω3PUFA intake and MetS incidence.

METHODS

We prospectively followed 4356 American young adults, free from MetS and diabetes at baseline, for incident MetS and its components in relation to fish and LCω3PUFA intake. MetS was defined by the National Cholesterol Education Program/Adult Treatment Panel III criteria. Cox proportional hazards model was used for analyses, controlling for socio-demographic, behavioral, and dietary factors.

RESULTS

During the 25-year follow-up, a total of 1069 incident cases of MetS were identified. LCω3PUFA intake was inversely associated with the incidence of MetS in a dose-response manner. The multivariable adjusted hazards ratio (HR) [95 % confidence interval (CI)] of incident MetS was 0.54 (95 % CI 0.44, 0.67; P for linear trend < 0.01) as compared the highest to the lowest quintile of LCω3PUFA intake. A threshold inverse association was found between non-fried fish consumption and the incidence of MetS. The multivariable adjusted HRs (95 % CIs) from the lowest to the highest quintile were 1.00, 0.70 (0.51, 0.95), 0.68 (0.52, 0.91), 0.67 (0.53, 0.86), and 0.71 (0.56, 0.89) (P for linear trend = 0.49). The observed inverse associations were independent of the status of baseline individual components of MetS.

CONCLUSIONS

Our findings suggest that intakes of LCω3PUFAs and non-fried fish in young adulthood are inversely associated with the incidence of MetS later in life.

Preterm Delivery and Metabolic Syndrome in Women Followed From Prepregnancy Through 25 Years Later

OBJECTIVE

To investigate whether women who deliver preterm have excess risk for metabolic dysregulation independent of prepregnancy factors.

METHODS

We conducted a multicenter, longitudinal, observational study of 1,205 women (50% black) in the Coronary Artery Risk Development in Young Adults study with at least one birth between baseline (1985-1986) and year 25 and no metabolic syndrome or diabetes before pregnancy. Cardiometabolic factors were measured prepregnancy and at up to five subsequent examinations. We estimated the relative hazards of incident metabolic syndrome in women with one or more preterm births (less than 37 weeks of gestation, n=295) compared with only term births (37 weeks of gestation or greater, n=910). Self-reported gestational diabetes mellitus, hypertension during pregnancy, and time-dependent weight gain were also considered as covariates.

RESULTS

Of 315 cases of metabolic syndrome in 17,717 person-years of follow-up, the incidence rate was higher among women with preterm compared with term births (22.0 compared with 16.4 per 1,000 person-years; relative hazard 2.91 [95% confidence interval (CI) 2.75-3.09]). After adjustment for prepregnancy cardiometabolic factors and covariates, the relative hazard (95% CI) for metabolic syndrome was 1.52 (1.22-1.88) for women with preterm compared with term births. Gestational diabetes mellitus, hypertension during pregnancy, and weight gain only modestly attenuated this association. Elevated blood pressure (36.3% compared with 26.7%, P=.002) and central adiposity (51.5% compared with 44.0%, P=.02) were the individual metabolic syndrome components that were different in women with preterm compared with term births.

CONCLUSION

Women with a history of preterm birth have increased risk of incident metabolic syndrome compared with those with term births, independent of the prepregnancy metabolic status and pregnancy complications.

Gestational Weight Gain and Health Outcomes 18 Years Later in Urban Black Women

OBJECTIVES

Excessive gestational weight gain (GWG) is associated with higher body mass index (BMI) later in life. Increased BMI is associated with health problems, but there is limited evidence linking GWG directly to later health in black women. We examined the association between GWG and health conditions 18 years after a first birth.

METHODS

This study was a secondary data analysis of 467 urban black women, enrolled during pregnancy (1990-1991). GWG was the difference between self-reported pre-pregnancy weight and measured weight at delivery. Hypertension, diabetes, obesity, and self-reported health were assessed with self-report and measurements of blood pressure, height, and weight, approximately 18 years after first childbirth.

RESULTS

Higher pre-pregnancy BMI was associated with increased probability of each health condition. Higher GWG was associated with hypertension for women with a pre-pregnancy BMI under 21.3 kg/m(2) (P < .05) and obesity for women with a pre-pregnancy BMI under 25.9 kg/m(2) (P < .05). Diabetes and poor health were not associated with GWG.

CONCLUSIONS

GWG may impact a mother's hypertension and obesity status 18 years after childbirth for underweight and normal weight women.

Association between Parity and Blood Pressure in Korean Women: Korean National Health and Nutrition Examination Survey, 2010-2012

Background

Pregnancy considerably alters cardiovascular dynamics, and thereby affects the transition of blood pressure after delivery in women. We aimed to analyze the association between parity and blood pressure in Korean adult women.

Methods

We included 8,890 women who participated in Korean National Health and Nutrition Examination Survey between 2010 and 2012. We divided the population according to the menopause status and analyzed the association between parity and blood pressure by using multiple regression analysis, and on hypertension, by using logistic regression analysis.

Results

Systolic and diastolic blood pressures were significantly associated with parity in premenopausal women (β=-0.091 [P<0.001] and β=-0.069 [P<0.001], respectively). In the analysis that excluded women receiving antihypertensive medication, the systolic and diastolic blood pressure of postmenopausal women were significantly associated with parity (β=-0.059 [P=0.022] and β=-0.054 [P=0.044], respectively). Parity was found to prevent hypertension after adjustment for confounders in postmenopausal women (odds ratio, 0.55; 95% confidence interval, 0.310-0.985).

Conclusion

We found that parity prevented hypertension in Korean women.

Chromium exposure and incidence of metabolic syndrome among American young adults over a 23-year follow-up: the CARDIA Trace Element Study

Studies suggest that chromium deficiency is associated with elevated levels of fasting blood glucose, circulating insulin, cholesterol and triglycerides, and decreased proportion of lean body mass. However, data directly relating chromium levels to metabolic syndrome (MetS) risk are lacking. A total of 3,648 American adults from the Coronary Artery Risk Development in Young Adults (CARDIA) study, aged 20-32 years, were prospectively examined for the incidence of MetS and its five components from 1987-88 to 2010-11. Baseline toenail chromium levels were measured with instrumental neutron-activation analysis. Incident MetS was defined by the NCEP-ATP III criteria. During the 23-year follow-up, 878 incident MetS cases were identified. Baseline toenail chromium was inversely associated with incidence of MetS as well as its blood lipid components. The multivariable-adjusted hazard ratio (HR) (95% confidence interval [CI]) of MetS comparing the highest to the lowest quartiles of toenail chromium levels was 0.80 (0.66-0.98; Plinear trend = 0.006). The adjusted HRs were 0.82 (0.68-0.98; Ptrend = 0.045) for having abnormal triglycerides levels and 0.75 (0.64-0.88; Ptrend  = 0.030) for having abnormal HDL cholesterol levels. Toenail chromium levels were inversely and longitudinally associated with incidence of MetS in American young adults. This inverse association was mainly explained by its relation to blood lipids.

Nulliparity is associated with less healthy markers of subclinical cardiovascular disease in young women with overweight and obesity

OBJECTIVE

Higher parity is associated with increased subclinical cardiovascular disease (CVD) in mid-life and older women and with increased CVD risk overall. The relationship between parity, subclinical CVD, and infertility in young women with overweight and obesity has been infrequently evaluated.

METHODS

Reproductive histories were obtained in 191 (66%) young women with overweight and obesity (BMI 25-39.9 kg/m(2) ) participating in a weight loss trial. Baseline carotid intima-media thickness (IMT) and inter-adventitial diameter (IAD) were assessed via B-mode ultrasound. Linear regression was used to estimate the relationship between parity and carotid measures, adjusted for demographic, cardiovascular, and reproductive risk factors.

RESULTS

Nulliparous women (n = 70, age 34.9 ± 7.1) had increased common carotid IAD (0.230 mm, SE 0.08, P = 0.003) and mean common carotid artery (CCA) IMT (0.031 mm, SE 0.01, P = 0.007) compared with parous women (n = 102, age 39.5 ± 4.9), persisting after adjustment for age, race, and CVD risk factors. No other reproductive factors were statistically significantly associated.

CONCLUSIONS

Nulliparity is associated with markers of less healthy carotid arteries in a sample of disease-free 25- to 45-year-old women with overweight or obesity. This may represent a beneficial effect of pregnancy or indicate overall better health in women with overweight/obesity who are capable of childbearing.

Parity as predictor of early hypertension during menopausal transition

OBJECTIVES

Studies regarding the effects of parity on blood pressure in later life produced conflicting results. The aim of our study is to analyse whether parity influences the prevalence of hypertension in perimenopausal and postmenopausal women.

METHODS

One thousand perimenopausal and postmenopausal women (mean age 55.2 ± 5.4 years) were enrolled with a median follow-up of 63.0 months. The study sample consisted of patients who self-referred, in 1998-2009, to the BenEssere Donna Clinic, dedicated to menopause-related disorders.

RESULTS

One hundred and twenty-two (12.2%) women were nulliparous and 878 (87.8%) had at least one child. Thirty-four (27.9%) women among nulliparous and 326 (37.1%) among parous were hypertensive at baseline (P = 0.046) and 812 women (81.2%) were in their postmenopausal period. Univariate analysis showed that women with one or more children were at higher risk of being hypertensive [odds ratio (OR): 1.529; 95% confidence interval (CI): 1.006-2.324; P = 0.047]. Likewise, multivariate analysis revealed that parity (OR: 2.907; 95% CI: 1.290-6.547; P = 0.010), BMI (OR: 1.097; 95% CI: 1.048-1.149; P < 0.001) and family history of hypertension (OR: 3.623; 95% CI: 2.231-5.883; P < 0.001) were independently related to hypertension at baseline. In a subanalysis of 640 initially normotensive women, 109 (17.0%) patients developed hypertension after follow-up, without a statistically significant association with parity (13.6% in nulliparous versus 17.6% in parous; P = 0.362). Consistently, parity showed no relationship with the incidence of hypertension during follow-up (OR: 1.350; 95% CI: 0.707-2.579; P = 0.363).

CONCLUSION

For the first time in a population of White perimenopausal and postmenopausal women, parity was demonstrated to be independently associated with early hypertension during menopausal transition. Conversely, postmenopausal hypertension was not related with parity.

Preterm birth and future maternal blood pressure, inflammation, and intimal-medial thickness: the CARDIA study

Preterm birth (PTB, <37 weeks) may be a marker of endothelial dysfunction and a proinflammatory phenotype; both are risk factors for cardiovascular disease. We studied 916 women (46% black) with 1181 live births between enrollment in the Coronary Artery Risk Development in Young Adults study (age 18-30 years) and 20 years later. C-reactive protein was measured at years 7, 15, and 20. Interleukin-6 and carotid intima-media thickness, which incorporated the common carotid arteries, bifurcations, and internal carotid arteries, were measured at year 20. Blood pressure, lipids, anthropometrics, and pregnancy events were assessed at all visits. Change in risk factors and differences in inflammatory markers and intima-media thickness according to PTB were evaluated. Women with PTBs (n=226) had higher mean systolic blood pressures before pregnancy (106 versus 105 mm Hg, respectively; P=0.03). Systolic and diastolic blood pressure increased more rapidly over 20 years compared with women with term births (P<0.01 time interaction), even after removing women with self-reported hypertension in pregnancy. Women with PTB versus term births had similar mean intima-media thickness adjusted for age, body mass index, race, lifestyle, and cardiovascular risk factors. C-reactive protein and interleukin-6 did not differ according to PTB. Women with PTB, regardless of hypertension during pregnancy, had higher blood pressure after pregnancy compared with women with term births. In the United States, where rates of PTB are high and race disparities persist, PTB may identify women with higher blood pressure in the years after pregnancy.