Associations Among Lactation, Maternal Carbohydrate Metabolism, and Cardiovascular Health

Maternal metabolic conditions as predictors of breastfeeding outcomes: Insights from an Australian cohort study

INTRODUCTION

Breastfeeding represents an important opportunity to optimize health outcomes for both mother and infant, particularly in the context of maternal metabolic conditions such as diabetes and polycystic ovary syndrome. However, evidence suggests that women affected by these conditions breastfeed at reduced rates and durations. Our aim was to use the large, prospective, community-based Australian Longitudinal Study on Women's Health (ALSWH) to conduct an in-depth exploratory analysis of breastfeeding outcomes in Australian women affected by key maternal metabolic conditions.

MATERIAL AND METHODS

Data from 12 920 pregnancies to 5605 women from the 1973-1978 birth cohort of the ALSWH were examined. Univariable and multivariable regression using generalized estimating equation models were applied to assess breastfeeding initiation and duration (outcome measures) in relation to key self-reported maternal metabolic diagnoses (pre-gestational type 1 and type 2 diabetes, gestational diabetes, and polycystic ovary syndrome; main explanatory variables). Key sociodemographic and clinical covariates were also considered.

RESULTS

Results showed no significant association between specific maternal metabolic diagnoses (pre-gestational or gestational diabetes, or polycystic ovary syndrome) and breastfeeding outcomes. However, maternal body mass index emerged as a key predictor of suboptimal breastfeeding outcomes. Pregnancies affected by maternal obesity were associated with a 2.1-fold increase in the odds of not initiating breastfeeding, after adjusting for other key variables (95% CI 1.67 to 2.60, p < 0.01). Maternal overweight and obesity were, respectively, associated with an adjusted 1.4-fold (95% CI 1.20 to 1.55, p < 0.01) and 1.8-fold increase (95% CI 1.60 to 2.10, p < 0.01) in the odds of a breastfeeding duration less than 6 months.

CONCLUSIONS

Maternal obesity, rather than any specific maternal metabolic condition, appears to be a key predictor of breastfeeding outcomes in Australian women.

The relationship between pregnancy count and duration of breast-feeding with metabolic syndrome (Fasa Persian cohort study)

BACKGROUND

Changes that occur during pregnancy and after that during breastfeeding induce some symptoms similar to metabolic syndrome (MetS) risk factors. This study aims to determine the relationship between pregnancy, as well as the duration of breastfeeding and MetS controlling the effect of other risk factors like hypertension, glucose intolerance, triglyceride, central obesity, and reduction of high-density lipoprotein in women of Fasa Persian Cohort Study.

MATERIALS AND METHODS

In this cross-sectional study, 5015 women aged 35-70 years were investigated in the Sheshdeh region from 2016 to 2021, and the information related to the disease symptoms was collected through questionnaires, examinations, and laboratory tests. MetS was calculated based on two guidelines according to adult treatment panel III (ATP III) and international diabetes federation (IDF) methods. For reporting the data, the odds ratio with its 95% confidence interval was used. In order to eliminate the effect of confounders, logistic regression was used.

RESULTS

Prevalence of MetS showed a descending trend in women with up to two pregnancies and it reached 22.6% and 22.4% using ATPIII and IDF methods respectively, while with an increase in the number of pregnancies of more than two, MetS prevalence was ascending. The prevalence of MetS did not have any specific trend across various breastfeeding duration groups. Multivariate analysis approved that the odds ratio of developing MetS in comparison with women who had two pregnancies was significantly increasing trend when the pregnancy counts increased.

CONCLUSION

The chance of developing MetS based on both IDF and ATP III methods after adjustment for confounding effects would grow with an increase in the number of pregnancies to more than two and breast-feeding of more than seven years. It is recommended that women with more than two pregnancies or the long duration of breast-feeding women undergo a specialized examination to investigate and control MetS problems so that future diseases could be prevented.

Study protocol for the sheMATTERS study (iMproving cArdiovascular healTh in new moThERS): a randomized behavioral trial assessing the effect of a self-efficacy enhancing breastfeeding intervention on postpartum blood pressure and breastfeeding continuation in women with hypertensive disorders of pregnancy

BACKGROUND

Individuals with hypertensive disorders of pregnancy (HDP) have an elevated lifetime risk of chronic hypertension, metabolic syndrome, and premature cardiovascular disease. Because breastfeeding duration and exclusivity have been associated in observational studies with improved cardiovascular health, optimizing breastfeeding in those with HDP might be an unrealized cardio-prevention approach, in particular because individuals with HDP have more breastfeeding challenges. Breastfeeding supportive interventions targeting one's breastfeeding self-efficacy have been shown to improve breastfeeding rates.

METHODS

We designed an open-label, multi-center 1:1 randomized behavioral trial to test whether a previously validated self-efficacy enhancing breastfeeding intervention can improve breastfeeding duration and/or exclusivity, and lower postpartum blood pressure at 12 months. Randomization is computer-generated and stratified by site (four hospitals in Montreal, Quebec and one hospital in Kingston, Ontario; all in Canada). Included are breastfeeding participants with HDP (chronic/gestational hypertension or preeclampsia) who delivered a live singleton infant at > 34 weeks, speak English or French, and have no contraindications to breastfeeding. Informed and written consent is obtained at hospitalization for delivery or a re-admission with hypertension within 1 week of discharge. Participants assigned to the intervention group receive a breastfeeding self-efficacy-based intervention delivered by a trained lactation consultant in hospital, with continued reactive/proactive support by phone or text message for up to 6 months postpartum. Regardless of group assignment, participants are followed for self-reported outcomes, automated office blood pressure, and home blood pressure at several time points with end of follow-up at 12 months.

DISCUSSION

This study will assess whether an intensive nurse-led behavioral intervention can improve breastfeeding rates and, in turn, postpartum blood pressure - an early marker for atherosclerotic cardiovascular disease. If effective, this form of enhanced breastfeeding support, along with closer BP and metabolic surveillance, can be implemented broadly in individuals lactating after HDP.

TRIAL REGISTRATION

ClinicalTrials.gov, # NCT04580927 , registered on Oct 9, 2020.

Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice

Hypertensive disorders of pregnancy (HDP) are the most common causes of maternal and perinatal morbidity and mortality. They are responsible for 16% of maternal deaths in high-income countries and approximately 25% in low- and middle-income countries. The impact of HDP can be lifelong as they are a recognized risk factor for future cardiovascular disease. During pregnancy, the cardiovascular system undergoes significant adaptive changes that ensure adequate uteroplacental blood flow and exchange of oxygen and nutrients to nurture and accommodate the developing fetus. Failure to achieve normal cardiovascular adaptation is associated with the development of HDP. Hemodynamic alterations in women with a history of HDP can persist for years and predispose to long-term cardiovascular morbidity and mortality. Therefore, pregnancy and the postpartum period are an opportunity to identify women with underlying, often unrecognized, cardiovascular risk factors. It is important to develop strategies with lifestyle and therapeutic interventions to reduce the risk of future cardiovascular disease in those who have a history of HDP.

Breastfeeding following bariatric surgery among obese women with and without diabetes mellitus

BACKGROUND

Information on exclusive breastfeeding (BF) and BF initiation following bariatric surgery (BS) among obese women with diabetes mellitus (DM) and without DM (non-DM) is limited.

METHODS

Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). The 65 women in the DM group (40 women with gestational, 19 with Type 2 and 6 with Type 1) was similar to 84 with non-DM in BS type: Roux-en-Y (51 vs 55%), sleeve gastrectomy (32 vs 35%), laparoscopic gastric banding (17 vs 7%) and gastro-duodenal anastomosis (0 vs 4%).

RESULTS

Women with DM were older (35 vs 33y), of advanced age (54 vs 27%), with higher prevalence of grade 3 obesity (66 vs 46%), chronic hypertension (31 vs 10%), delivery of late-preterm infants (23 vs 10%) and neonatal hypoglycemia (25 vs 12%). Although infant feeding intention was similar: BF (66 vs 79%), partial BF (9 vs 7%) or formula (25 vs 14%), at discharge women with DM had lower exclusive BF (29 vs 41%) and BF initiation rates (68 vs 76%) than those with non-DM. Women with grade 3 obesity (52% were DM) differed from those with grades 1-2 (34% were DM) in exclusive BF (27 vs 52%), and BF initiation rates (66 vs 86%).

CONCLUSION

After BS, women with DM, especially those with grade 3 obesity, had higher rates of chronic hypertension and preeclampsia and lower rates of exclusive BF and BF initiation than those who had DM but had less severe obesity.

Impact of excessive gestational weight gain on exclusive breastfeeding among women with Type 1 and Type 2 diabetes and obesity

BACKGROUND

Pregestational diabetes, obesity and gestational weight gain (GWG) are associated with adverse perinatal outcomes, however, the influence of excessive GWG on lactation at discharge is less known. Our aim is to evaluate the impact of excessive GWG using the LifeCycle project guidelines on exclusive breastfeeding (EBF) and any BF rates at discharge among 171 women with Type 1 and 294 Type 2 diabetes and obesity who intended to BF.

METHODS AND FINDINGS

Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). GWG was categorized as adequate, inadequate or excessive according to the 2019 LifeCycle Project guidelines. Women with Type 1 were younger (30 vs 33y), primiparous (51 vs 32%), delivered earlier (37 vs 38w) than women with Type 2 andwere different in grade 1 (40 vs 26%), grade 3 obesity (19 vs 49%) and median GWG (15 vs 11kg). Of all 465 women with Type 1 and Type 2 combined, 365 (78%) who had excessive GWG and 100 (22%) who had non-excessive GWG showed similar EBF (27 vs 25%) and any BF (72 vs 72%) rates. Regression analysis showed that after adjusting for potential confounders excessive GWG was not a predictor of EBF or any BF at discharge.

CONCLUSION

Type 1 and Type 2 diabetes, obesity and excessive GWG are associated with low EBF, however, excessive GWG is not an independent predictor of low EBF or any BF at discharge.

Exclusive breastfeeding among women with type 1 and type 2 diabetes mellitus

Objective

To compare exclusive breastfeeding (BF) and BF initiation among 185 women with Type 1 and 212 women with Type 2 pregestational diabetes who intended exclusive or partial BF and delivered at ≥34 weeks of gestation.

Methods

Retrospective cohort study. At discharge, exclusive BF is direct BF or BF complemented with expressed breast milk. BF initiation is defined by exclusive or partial BF.

Results

Type 1 and Type 2 groups were similar in prior BF experience (69 vs 67%) but were different in intention to BF exclusively (92 vs 78%) and partially (8 vs 22%). Women in the Type 1 group were younger (median age 30 vs 33y), likely to be primiparous (47 vs 25%), have a lower median BMI (32 vs 36 kg/m²) and deliver by primary cesarean (37 vs 26%). Infants born to Type 1 women were more likely to be admitted to the NICU (44 vs 18%) and to have hypoglycemia (59 vs 41%). At discharge, exclusive BF among Type 1 was higher (34 vs 23%), partial BF was similar (47 vs 46%) while FF (formula feeding) was lower (19 vs 31%) than in the Type 2 group. BF initiation occurred in 81% of Type 1 and 69% of Type 2 women.

Conclusion

Intention to BF exclusively was higher in Type 1 women compared to Type 2. At discharge, exclusive BF and BF initiation were lower and FF higher in the Type 2 group highlighting the need for different strategies if lactation in this special population is to be improved.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus

OBJECTIVE

To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF.

METHODS

Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation.

RESULTS

CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM.

CONCLUSION

Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

Metabolic Conditions Including Obesity, Diabetes, and Polycystic Ovary Syndrome: Implications for Breastfeeding and Breastmilk Composition

Breastfeeding is internationally recognized as the recommended standard for infant nutrition, informed by evidence of its multiple benefits for both mother and baby. In the context of common metabolic conditions such as polycystic ovary syndrome, diabetes (type 1, type 2, and gestational), and obesity, breastfeeding may be particularly beneficial for both mother and infant. However, there is evidence of delayed lactogenesis and reduced breastfeeding rates and duration in women with these conditions, and the effects of altered maternal metabolic environments on breastmilk composition (and potentially infant outcomes) are incompletely understood. In this review, we explore the relationships between maternal metabolic conditions, lactogenesis, breastfeeding, and breastmilk composition. We examine relevant potential mechanisms, including the central role of insulin both in lactogenesis and as a milk-borne hormone. We also describe the bioactive and hormonal components of breastmilk and how these may link maternal and infant health.

Association of lactation with maternal risk of type 2 diabetes: A systematic review and meta-analysis of observational studies

AIM

To investigate the association between lactation and maternal risk of type 2 diabetes, including a potential graded association according to lactation duration.

METHODS

A systematic review and meta-analysis of observational studies that investigated the reported association between lactation (irrespective of duration, intensity or mode) and maternal risk of type 2 diabetes was conducted.

RESULTS

A total of 22 studies (17 cohort studies and five cross-sectional studies) were included in this systematic review, and 16 contributed to the meta-analysis. Studies that investigated the association of lactation with risk of type 2 diabetes in the first months after birth in women with gestational diabetes reported conflicting results. Studies with a longer follow-up showed a graded protective association for lactation and the risk of type 2 diabetes, with a potentially larger risk reduction in women with gestational diabetes than in those without gestational diabetes. Overall, ever versus never lactation was associated with a 27% lower risk of type 2 diabetes (RR 0.73, 95% CI [0.65, 0.83]). Each additional month of lactation was associated with a 1% lower risk of type 2 diabetes (RR 0.99, 95% CI [0.98, 0.99]). However, the overall quality of the studies was modest.

CONCLUSIONS

Lactation is associated with a significantly reduced risk of maternal type 2 diabetes over the life course, particularly in women with gestational diabetes. The protective effect seems to increase with longer duration of lactation. Further research is warranted to understand whether this association is modified by exposure to other risk factors.

Long-term cardio-metabolic effects after gestational diabetes: a review

Women with GDM are at high risk of metabolic syndrome and type 2 diabetes (T2DM). A relationship with GDM and future development of cardiovascular disease (CVD) has been also recognized. Pregnancy and postpartum period in women with GDM give us the opportunity to identify the underlying, often unrecognized, CVD risk factors. Ideally, the postpartum follow-up of this women should be done by a multidisciplinary team to evaluate their cardio-metabolic risk and to counseling regarding lifestyle modification (healthy diet and regular physical activity) and breastfeeding that can reduce their risk. Longer follow-up of these women should be individualized, focusing attention on women at medium-high cardio-metabolic risk. The link between GDM and T2DM-CVD offers us a great opportunity for the diseases prevention.

Lactation Patterns in Women with Hypertensive Disorders of Pregnancy: An Analysis of Illinois 2012-2015 Pregnancy Risk Assessment Monitoring System (PRAMS) Data

BACKGROUND

Hypertensive disorders of pregnancy have lifelong implications on maternal cardiovascular health. Breastfeeding has a variety of maternal benefits, including improved lifelong maternal cardiovascular outcomes, with longer periods of lactation resulting in further improvement. Women with hypertensive disorders of pregnancy encounter many barriers to breastfeeding. Little is known about lactation initiation and duration rates in women with hypertensive disorders of pregnancy. The purpose of this study is to describe lactation patterns in women with HDP, hypertensive disorders of pregnancy, compared to normotensive controls using data from the phase 7 Illinois Pregnancy Risk Assessment Monitoring System (PRAMS).

SUBJECTS AND METHODS

Illinois PRAMS 2012-2015 (Phase 7) data was used to assess lactation patterns as well as rationale for not initiating breastfeeding or earlier cessation. Women who delivered during this time period were eligible to participate in the PRAMS survey, 5285 were included the analysis.

RESULTS

Overall, 17.6% of all women in the study reported their healthcare provider did not speak with them prenatally about breastfeeding. Women who reported they had HDP, were significantly less likely (p ≤ 0.001) to ever breastfeed or pump breast milk to feed their baby, even for a short period, than those women without an HDP. At the time the PRAMS survey was completed, more women without an HDP were still breastfeeding or providing their baby with pumped milk (54.9 v. 48%; p = 0.002). More women with HDP reported stopping breastfeeding because they got sick or had to stop for medical reasons (p = 0.002) and/or because their baby was jaundiced (p = 0.007).

CONCLUSION

Cardiovascular disease remains the leading cause of death among women and women with a history of HDP are at increased risk for cardiovascular related morbidity and mortality. Obstetrical providers and nurses caring for this high-risk population should ensure they educate women about the increased cardiovascular risk associated with HDP and the maternal cardiovascular benefits associated with lactation in order to promote and support lactation in this population of women.

Body composition helps: Differences in energy expenditure between pregnant and nonpregnant females

OBJECTIVES

Human pregnancy is associated with important physiological changes that usually increase energetic requirements. However, great variability exists in the costs and mechanisms required to bear pregnancy. Since body mass (BM) and composition are modified during gestation, it is of great interest to compare the influence of BM on energy expenditure (EE) in pregnant and nonpregnant females.

METHODS

BM, body composition, and EE of 77 volunteers (35 pregnant and 42 nonpregnant females) were measured. The pregnant volunteers completed two measurement rounds at 28 and 32 gestation weeks. Differences on the measured parameters were sought, and comparison of regression lines was computed to test how BM affected the EE of the volunteers.

RESULTS

BM and body composition parameters are significantly higher in pregnant females, but EE is not statistically different. Pregnant females have a larger percentage of fat mass, but lower percentage of fat-free mass (FFM). The EE per kg of FFM is similar in both groups. Comparison of regression lines shows that pregnancy does not change the relationship between BM and EE, but for similar BM pregnant females expend less energy than nonpregnant females.

CONCLUSIONS

We propose that their larger percentage of passive body tissues is the reason why pregnant females expend less energy than nonpregnant females of similar BM, without changing the scaling of EE on BM. Thus, pregnancy could not be as energetically constraining as usually assumed, with important consequences for human reproductive ecology.

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.

Pregnancy and the Postpartum Period as an Opportunity for Cardiovascular Risk Identification and Management

Cardiovascular disease (CVD) is the leading cause of death in women. Because women generally present with more atypical symptoms of CVD than do men and because underlying CVD risk factors are often present for years before the onset of CVD, it is important to use innovative ways to identify women who should undergo CVD risk screening at a younger age. Pregnancy and the postpartum period afford us that opportunity, given that the development of certain pregnancy complications (hypertensive disorders of pregnancy, gestational diabetes, preterm birth, delivery of a neonate with fetal growth restriction, and significant placental abruption) can reliably identify women with underlying, often unrecognized, CVD risk factors. Women with one or more of these pregnancy complications should be identified at the time of delivery and referred for regular follow-up. This would ideally take the form of a multidisciplinary clinic including clinicians and allied health specialists to carry out physical and biochemical screening and counseling regarding lifestyle modification and possible therapeutic interventions. Longer-term follow-up and recommendations should be individualized based on findings and risks. There is also an opportunity for future pregnancy counseling and discussion about the importance of weight loss between pregnancies, initiation of a routine involving physical activity, use of preconception folic acid, and the potential initiation of low-dose aspirin for those women at risk for future preeclampsia and fetal growth restriction or the use of progesterone for women at risk for preterm labor. The link between pregnancy complications and future CVD affords us with the earliest opportunity for CVD risk assessment for health preservation and disease prevention.

Indicateurs du risque cardiovasculaire liés à la grossesse

Objectif

Définir les indicateurs de risque cardiovasculaire liés à la grossesse et leur lien avec une maladie cardiovasculaire (MCV) subséquente, et offrir des conseils sur la façon dont les fournisseurs de soins de première ligne peuvent contribuer à réduire le risque de future MCV par l’entremise du dépistage et de l’intervention précoces.

Sources d’information

Sources primaires de recherche, revues systématiques et méta-analyses, et revues de synthèse clinique.

Message principal

La maladie cardiovasculaire est la principale cause de décès chez les femmes. Puisque les facteurs de risque sous-jacents de MCV sont souvent présents plusieurs années avant que la MCV se déclare, il importe de recourir à des moyens novateurs pour identifier les femmes qui devraient se soumettre à un dépistage du risque de MCV à un plus jeune âge. La grossesse et le post-partum en donnent l’occasion, puisque certaines complications liées à la grossesse (troubles hypertensifs, diabète gestationnel, naissance prématurée idiopathique, accouchement d’un bébé accusant un retard de croissance intra-utérine ou abruptio placentae) identifient avec fiabilité les femmes qui présentent des facteurs de risque sous-jacents et souvent non reconnus de MCV.

Conclusion

Les femmes aux prises avec au moins 1 de ces complications liées à la grossesse doivent être identifiées dès l’accouchement et recevoir un suivi formel après avoir accouché, y compris : anamnèse détaillée, examen physique, dépistage biochimique, counseling sur les modifications du mode de vie et, possiblement, interventions thérapeutiques. Le lien entre les complications de la grossesse et une future MCV est la première occasion d’évaluer le risque de MCV dans le but de préserver la santé et de prévenir la maladie.

Pregnancy-related cardiovascular risk indicators: Primary care approach to postpartum management and prevention of future disease

OBJECTIVE

To define pregnancy-related cardiovascular risk indicators and their association with developing future cardiovascular disease (CVD), and to provide guidance on how primary care providers can help lower future CVD risk through early identification and intervention.

SOURCES OF INFORMATION

Primary research sources, systematic reviews and meta-analyses, and clinical review articles.

MAIN MESSAGE

Cardiovascular disease is the leading cause of death in women. As underlying CVD risk factors are often present for years before the onset of CVD, it is important to use innovative ways to identify women who should undergo CVD risk screening at a younger age. Pregnancy and the postpartum period afford that opportunity, given that the development of certain pregnancy complications (hypertensive disorders of pregnancy, gestational diabetes mellitus, idiopathic preterm birth, delivery of a baby with intrauterine growth restriction, or placental abruption) can reliably identify women with underlying, often unrecognized, CVD risk factors.

CONCLUSION

Women with 1 or more of these pregnancy complications should be identified at the time of delivery and have formalized postpartum follow-up, including a thorough history, a physical examination, biochemical screening, counseling around lifestyle modification, and possible therapeutic intervention. The link between pregnancy complications and future CVD affords the earliest opportunity for CVD risk assessment for health preservation and disease prevention.

Pregnancy-related events associated with subclinical cardiovascular disease burden in late midlife: SWAN

BACKGROUND AND AIMS

Reproductive factors are associated with later life CVD in women (e.g., age at first birth, preeclampsia, gestational diabetes), but studies have focused largely on premenopausal women. We examined the relationship of reproductive factors with subclinical CVD burden in late midlife women.

METHODS

We included 964 parous women from the Study of Women's Health Across the Nation (SWAN), who completed a reproductive history questionnaire at the 13th SWAN visit (2011-2012), and a carotid ultrasound and brachial-ankle pulse wave velocity (baPWV) assessment. The primary outcomes were carotid intima-media thickness, plaque, and baPWV; our secondary outcome was a composite subclinical CVD index created using these measures. Linear and logistic regression was performed to examine associations with individual subclinical CVD measures, and multinomial logistic regression was used in analyses of the composite index. Models adjusted for socio-demographics and cardiovascular risk factors.

RESULTS

Mean age at subclinical CVD assessment was 60.2 years (SD ± 2.7). History of gestational hypertension/preeclampsia was associated with greater carotid IMT (β: 0.038, p = 0.004). Earlier age at first birth was associated with subclinical CVD, but not when accounting for CVD risk factors. History of gestational diabetes was associated with greater baPWV, but not related to our composite index.

CONCLUSIONS

Pregnancy history is an important marker of subclinical CVD in late midlife and may impact the vasculature through distinct pathways. Future studies are necessary to evaluate racial/ethnic differences in the observed associations and to assess the benefit of a composite subclinical CVD index for earlier CVD risk modification in midlife women.

Association of breastfeeding, maternal anthropometry and body composition in women at 30 years of age

This study aimed at assessing the association of breastfeeding with maternal body mass index (BMI), waist circumference, fat mass index, fat free mass index, android/gynoid fat ratio and bone mineral density. In 1982, the maternity hospitals in Pelotas, Rio Grande do Sul State, Brazil, were daily visited and all live births were identified and examined. These subjects underwent follow-up for several times. At 30 years of age, the participants were interviewed and examined. Parous women provided information on parity and duration of breastfeeding. Multiple linear regression was used in the multivariate analysis, controlling for genomic ancestry, family income, schooling and smoking at 2004-2005. After controlling for confounding factors, breastfeeding was inversely associated with BMI and fat mass index, whereas breastfeeding per live birth was negatively associated with BMI, waist circumference and fat mass index. Women who had had a child in the last 5 years and had breastfed, showed lower BMI (β = -2.12, 95%CI: -4.2; -0.1), waist circumference (β = -4.46, 95%CI: -8.3; -0.6) and fat mass index (β = -1.79, 95%CI: -3.3; -0.3), whereas no association was observed among those whose last childbirth was > 5 years, but the p-value for the tests of interaction were > 0.05. Our findings suggest that breastfeeding is associated with lower BMI and other adiposity measures, mostly in the first years after delivery. Besides that, it has no negative impact on bone mineral density.

Relationship of Postpartum Levels of Cystatin and High-Sensitivity C-Reactive Protein and Duration of Lactation in Mothers with Previous Gestational Hypertension or Preeclampsia

Background: Women with hypertensive disorders of pregnancy are at increased risk of cardiovascular disease in later life. We sought to determine the association between lactation and markers of maternal cardiovascular health among postpartum women with and without hypertensive disorders of pregnancy via measures of inflammation (high-sensitivity C-reactive protein [hsCRP]) and renal function (cystatin C). Materials and Methods: This prospective cohort study enrolled primarily overweight and obese women during early pregnancy. At a postpartum study visit occurring 6-24 months after delivery, we collected data on lactation duration and measured hsCRP and cystatin C. We assessed associations between lactation duration and levels of hsCRP and cystatin C among normotensive women and women with preeclampsia or gestational hypertension using analysis of variance and chi-squared tests. Linear regression models adjusted for age, race, education, prepregnancy body mass index, current smoking, and time since delivery. Results: Of 425 women, 37 (9%) had preeclampsia and 48 (11%) had gestational hypertension during enrollment pregnancy. The postpartum visit occurred at a mean of 8.6 ± 4.4 months after delivery. Women with a history of preeclampsia had significantly higher levels of cystatin C (mean 0.86 versus 0.78 mg/L; p = 0.03) compared with normotensive women, but nonsignificant elevation in hsCRP (mean 8.39 versus 6.04 mg/L; p = 0.08). Women with gestational hypertension had no differences in mean hsCRP or cystatin C compared with normotensive women. Among the 237 women with any lactation, 78 (18%) lactated for at least 6 months. Lactation duration both in the overall sample and among women with gestational hypertension or preeclampsia was not associated with levels of hsCRP or cystatin C. Conclusions: Preeclampsia history was associated with elevated postpartum levels of cystatin C; however, duration of lactation was not associated with postpartum hsCRP or cystatin C, regardless of history of gestational hypertension or preeclampsia. Further research is needed on mechanisms through which lactation may affect maternal risk of cardiovascular disease.

Pregestational Diabetes in Pregnancy

Diabetes is a common chronic condition in women of reproductive age. Preconception care is crucial to reducing the risk of adverse maternal and fetal outcomes, such as hypertensive disorders, abnormal fetal growth, traumatic delivery and stillbirth, associated with poor glycemic control. Insulin is the preferred medication to optimize glucose control in women with pregestational diabetes. Frequent dose adjustments are needed during pregnancy to achieve glycemic goals, and team-based multidisciplinary care may help. Postpartum care should include lactation support, counseling on contraceptive options, and transition to primary care.

Breastfeeding and later maternal risk of hypertension and cardiovascular disease - The role of overall and abdominal obesity

In this study, we examined how any, full, and partial breastfeeding durations were associated with maternal risk of hypertension and cardiovascular disease (CVD), and how prepregnancy body mass index (BMI) and waist circumference 7 years postpartum influenced these associations. A total of 63,260 women with live-born singleton infants in the Danish National Birth Cohort (1996-2002) were included. Interviews during pregnancy and 6 and 18 months postpartum provided information on prepregnancy weight, height, and the duration of full and partial breastfeeding. Waist circumference was self-reported 7 years postpartum. Cox regression models were used to estimate hazard ratios of incident hypertension and CVD, registered in the National Patient Register from either 18 months or 7 years postpartum through 15 years postpartum. Any breastfeeding ≥4 months was associated with 20-30% lower risks of hypertension and CVD compared to <4 months in both normal/underweight and overweight/obese women. At follow-up starting 7 years postpartum, similar risk reductions were observed after accounting for waist circumference adjusted for BMI. Partial breastfeeding >2 months compared to ≤2 months, following up to 6 months of full breastfeeding, was associated with 10-25% lower risk of hypertension and CVD. Compared with short breastfeeding duration, additional partial breastfeeding was as important as additional full breastfeeding in reducing risk of hypertension and CVD. Altogether, longer duration of breastfeeding was associated with lower maternal risk of hypertension and CVD irrespective of prepregnancy BMI and abdominal adiposity 7 years after delivery. Both full and partial breastfeeding contributed to an improved cardiovascular health in mothers.

Breastfeeding and the Risk of Maternal Cardiovascular Disease: A Prospective Study of 300 000 Chinese Women

BACKGROUND

Breastfeeding confers substantial benefits to child health and has also been associated with lower risk of maternal cardiovascular diseases (CVDs) in later life. However, the evidence on the effects of CVD is still inconsistent, especially in East Asians, in whom the frequency and duration of breastfeeding significantly differ from those in the West.

METHODS AND RESULTS

In 2004-2008, the nationwide China Kadoorie Biobank recruited 0.5 million individuals aged 30 to 79 years from 10 diverse regions across China. During 8 years of follow-up, 16 671 incident cases of coronary heart disease and 23 983 cases of stroke were recorded among 289 573 women without prior CVD at baseline. Cox regression yielded adjusted hazard ratios (HRs) and 95% CIs for incident CVD by breastfeeding. Overall, ≈99% of women had given birth, among whom 97% reported a history of breastfeeding, with a median duration of 12 months per child. Compared with parous women who had never breastfed, ever breastfeeding was associated with a significantly lower risk of CVD, with adjusted HRs of 0.91 (95% CI, 0.84-0.99) for coronary heart disease and 0.92 (95% CI, 0.85-0.99) for stroke. Women who had breastfed for ≥24 months had an 18% (HR, 0.82; 0.77-0.87) lower risk of coronary heart disease and a 17% (HR, 0.83; 0.79-0.87) lower risk of stroke compared with women who had never breastfed. Among women who ever breastfed, each additional 6 months of breastfeeding per child was associated with an adjusted HR of 0.96 (95% CI, 0.94-0.98) for coronary heart disease and 0.97 (95% CI, 0.96-0.98) for stroke.

CONCLUSIONS

Among Chinese women, a history of breastfeeding was associated with an ≈10% lower risk of CVD in later life and the magnitude of the inverse association was stronger among those with a longer duration of breastfeeding.

Maternal metabolic adaptations to pregnancy among young women in Cebu, Philippines

OBJECTIVES

Evidence that fetal development has long-term impacts on health has increased interest in maternal-fetal nutrient exchange. Although maternal metabolism is known to change during gestation to accommodate fetal nutrient demands, little is known about these modifications outside of a Western, clinical context. This study characterizes maternal metabolic adaptations to pregnancy, and their associations with offspring birth weight (BW), among women living in the Philippines.

METHODS

Fasting glucose, triglycerides, insulin, leptin, and adiponectin were assessed in 808 participants in the Cebu Longitudinal Health and Nutrition Survey (Metropolitan Cebu, Philippines). Cross-sectional relationships between metabolites and hormones and gestational and lactational status were evaluated. Among the subset of currently pregnant women, associations between maternal glucose and triglycerides and offspring BW were also examined.

RESULTS

Women in their second and third trimesters had significantly lower fasting glucose and adiponectin compared to nulliparous women, and leptin levels and triglyceride levels were notably higher late in pregnancy (all P < .05). Among pregnant women, fasting glucose was a positive predictor of offspring BW, but only in males (P = .012, R²  = .28). Hormones and metabolites in post-partum women trend back toward levels found in nulliparous women, with some differences by breastfeeding status.

CONCLUSIONS

We find evidence for marked changes in maternal lipid and carbohydrate metabolism during pregnancy, consistent with known adaptations to support fetal growth. The finding of sex-specific relationships between maternal glucose and offspring BW adds to evidence for greater impacts of the maternal-gestational environment on biology and health in male offspring.