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Tretter M. Mitigating Health-Related Uncertainties During Pregnancy: The Role of Smart Health Monitoring Technologies. J Med Internet Res 2024; 26:e48493. [PMID: 38526554 PMCID: PMC11002737 DOI: 10.2196/48493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 01/26/2024] [Accepted: 02/23/2024] [Indexed: 03/26/2024] Open
Abstract
Pregnancy is a time filled with uncertainties, which can be challenging and lead to fear or anxiety for expectant parents. Health monitoring technologies that allow monitoring of the vital signs of both the mother and fetus offer a way to address health-related uncertainties. But are smart health monitoring technologies (SHMTs) actually an effective means to reduce uncertainties during pregnancy, or do they have the opposite effect? Using conceptual reasoning and phenomenological approaches grounded in existing literature, this Viewpoint explores the effects of SHMTs on health-related uncertainties during pregnancy. The argument posits that while SHMTs can alleviate some health-related uncertainties, they may also create new ones. This is particularly the case when the abundance of vital data overwhelms pregnant persons, leads to false-positive diagnoses, or raises concerns about the accuracy and analysis of data. Consequently, it is concluded that the use of SHMTs is not a cure-all for overcoming health-related uncertainties during pregnancy. Since the use of such monitoring technologies can introduce new uncertainties, it is important to carefully consider where and for what purpose they are used, use them sparingly, and promote a pragmatic approach to uncertainties.Using conceptual reasoning and phenomenological approaches grounded in existing literature, the effects of SHMTs on health-related uncertainties during pregnancy are explored. The argument posits that while SHMTs can alleviate some health-related uncertainties, they may also create new ones. This is particularly the case when the abundance of vital data overwhelms pregnant persons, leads to false-positive diagnoses, or raises concerns about the accuracy and analysis of data. Consequently, it is concluded that the use of SHMTs is not a cure-all for overcoming health-related uncertainties during pregnancy. Since the use of such monitoring technologies can introduce new uncertainties, it is important to carefully consider where and for what purpose they are used, use them sparingly, and promote a pragmatic approach to uncertainties.
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Affiliation(s)
- Max Tretter
- Chair of Systematic Theology (Ethics), Seminar for Systematic Theology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Carey C, Mulcahy E, McCarthy FP, Jennings E, Kublickiene K, Khashan A, Barrett P. Hypertensive disorders of pregnancy and the risk of maternal dementia: a systematic review and meta-analysis. Am J Obstet Gynecol 2024:S0002-9378(24)00043-7. [PMID: 38278201 DOI: 10.1016/j.ajog.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/05/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy, including preeclampsia, are associated with an increased risk for maternal cardiovascular disease, stroke, and chronic kidney disease. However, their association with subsequent maternal dementia or cognitive impairment is less well understood. This study aimed to review and synthesize the published literature on hypertensive disorders of pregnancy and the subsequent risk for maternal dementia or cognitive impairment. DATA SOURCES PubMed, Web of Science, Pyschinfo, and CINAHL were searched from database inception until July 31, 2022, for observational studies of hypertensive disorders of pregnancy and maternal dementia or cognitive impairment. STUDY ELIGIBILITY CRITERIA Selected studies included the following: a population of pregnant women, exposure to a hypertensive disorder of pregnancy of interest, and at least 1 primary outcome (dementia) or secondary outcome (cognitive impairment). Two reviewers were involved in study selection. METHODS We followed the Meta-analyses of Observational Studies in Epidemiology guidelines throughout. Random-effects meta-analyses were used to calculate the overall pooled estimates. Bias was assessed using an adapted version of the validated Newcastle-Ottawa Quality Assessment tool. RESULTS A total of 25 eligible studies were identified and included 2,501,673 women. Preeclampsia was associated with a significantly increased risk for vascular dementia (adjusted hazard ratio, 1.89; 95% confidence interval, 1.47-2.43), whereas no clear association was noted between preeclampsia and Alzheimer's disease (adjusted hazard ratio, 1.27; 95% confidence interval, 0.95-1.70), nor between preeclampsia and any (undifferentiated) dementia (adjusted hazard ratio, 1.18; 95% confidence interval, 0.95-1.47). However, in an analysis restricted to women aged 65 years and older, preeclampsia was associated with an increased risk for Alzheimer's disease (adjusted hazard ratio, 1.92; 95% confidence interval, 1.35-2.73) and any dementia (adjusted hazard ratio, 1.87; 95% confidence interval, 1.21-2.91). CONCLUSION Women whose pregnancies were complicated by preeclampsia seem to be at a substantially increased future risk for vascular dementia. The longer-term risks among these women with regards to Alzheimer's disease and other forms of dementia are less clear.
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Affiliation(s)
- Cian Carey
- School of Public Health, University College Cork, Cork, Ireland
| | - Emily Mulcahy
- School of Public Health, University College Cork, Cork, Ireland
| | - Fergus P McCarthy
- Irish Centre for Maternal and Child Health Research, Cork University Maternity Hospital, University College Cork, Cork, Ireland; Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland (Dr McCarthy)
| | - Emma Jennings
- School of Medicine, University College Cork, Cork, Ireland; Department of Geriatric Medicine, Cork University and Mallow General Hospital, Cork, Ireland
| | - Karolina Kublickiene
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology (CLINTEC), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ali Khashan
- School of Public Health, University College Cork, Cork, Ireland; Irish Centre for Maternal and Child Health Research, Cork University Maternity Hospital, University College Cork, Cork, Ireland
| | - Peter Barrett
- School of Public Health, University College Cork, Cork, Ireland; Department of Public Health Area D (Cork & Kerry), St. Finbarr's Hospital, Cork, Ireland.
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Rajkumar T, Freyne J, Varnfield M, Lawson K, Butten K, Shanmugalingam R, Hennessy A, Makris A. Remote blood pressure monitoring in high risk pregnancy - study protocol for a randomised controlled trial (REMOTE CONTROL trial). Trials 2023; 24:334. [PMID: 37198630 DOI: 10.1186/s13063-023-07321-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 04/20/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Pregnant women at high risk for developing a hypertensive disorder of pregnancy require frequent antenatal assessments, especially of their blood pressure. This expends significant resources for both the patient and healthcare system. An alternative to in-clinic assessments is a remote blood pressure monitoring strategy, in which patients self-record their blood pressure at home using a validated blood pressure machine. This has the potential to be cost-effective, increase patient satisfaction, and reduce outpatient visits, and has had widespread uptake recently given the increased need for remote care during the ongoing COVID-19 pandemic. However robust evidence supporting this approach over a traditional face-to-face approach is lacking, and the impact on maternal and foetal outcomes has not yet been reported. Thus, there is an urgent need to assess the efficacy of remote monitoring in pregnant women at high risk of developing a hypertensive disorder of pregnancy. METHODS The REMOTE CONTROL trial is a pragmatic, unblinded, randomised controlled trial, which aims to compare remote blood pressure monitoring in high-risk pregnant women with conventional face-to-face clinic monitoring, in a 1:1 allocation ratio. The study will recruit patients across 3 metropolitan Australian teaching hospitals and will evaluate the safety, cost-effectiveness, impact on healthcare utilisation and end-user satisfaction of remote blood pressure monitoring. DISCUSSION Remote blood pressure monitoring is garnering interest worldwide and has been increasingly implemented following the COVID-19 pandemic. However, robust data regarding its safety for maternofoetal outcomes is lacking. The REMOTE CONTROL trial is amongst the first randomised controlled trials currently underway, powered to evaluate maternal and foetal outcomes. If proven to be as safe as conventional clinic monitoring, major potential benefits include reducing clinic visits, waiting times, travel costs, and improving delivery of care to vulnerable populations in rural and remote communities. TRIAL REGISTRATION The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12620001049965p, on October 11th, 2020).
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Affiliation(s)
- Theepika Rajkumar
- School of Medicine, Western Sydney University, Penrith, NSW, Australia.
- Department of Medicine, Campbelltown Hospital, South Western Sydney Local Health District, Campbelltown, NSW, Australia.
| | - Jill Freyne
- Australian E-Health Research Centre, Health and Biosecurity, CSIRO, Brisbane, QLD, Australia
| | - Marlien Varnfield
- Australian E-Health Research Centre, Health and Biosecurity, CSIRO, Brisbane, QLD, Australia
| | - Kenny Lawson
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Kaley Butten
- Australian E-Health Research Centre, Health and Biosecurity, CSIRO, Brisbane, QLD, Australia
| | - Renuka Shanmugalingam
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
- Department of Renal Medicine, Liverpool Hospital, Liverpool, NSW, Australia
- University of New South Wales, Kensington, NSW, Australia
| | - Annemarie Hennessy
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
- Department of Medicine, Campbelltown Hospital, South Western Sydney Local Health District, Campbelltown, NSW, Australia
| | - Angela Makris
- Department of Renal Medicine, Liverpool Hospital, Liverpool, NSW, Australia
- University of New South Wales, Kensington, NSW, Australia
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Helgeson ES, Palzer EF, Vock DM, Porrett P, Sawinski D, Matas AJ. Pre-kidney Donation Pregnancy Complications and Long-term Outcomes. Transplantation 2022; 106:2052-2062. [PMID: 35404873 PMCID: PMC9529757 DOI: 10.1097/tp.0000000000004146] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hypertension and diabetes are contraindications for living kidney donation in young candidates. However, little is known about the long-term outcomes of women who had these pregnancy-related complications and subsequently became donors. In the general population, gestational hypertension (GHtn), preeclampsia/eclampsia, and gestational diabetes (GDM) are associated with long-term risks. METHODS Donors with the specified predonation complication were matched to contemporary control donors with pregnancies without the complication using nearest neighbor propensity score matching. Propensity scores were estimated using logistic regression with covariates for gravidity, blood pressure, glucose, body mass index, age, and creatinine at donation, donation year, race, relationship with recipient, and family history of disease. Long-term incidence of hypertension, diabetes, cardiovascular disease, and reduced renal function (estimated glomerular filtration rate [eGFR] <30, eGFR <45 mL/min/1.73 m 2 ) were compared between groups using proportional hazards models. RESULTS Of 1862 donors with predonation pregnancies, 48 had preeclampsia/eclampsia, 49 had GHtn without preeclampsia, and 43 had GDM. Donors had a long interval between first pregnancy and donation (median, 18.5 y; interquartile range, 10.6-27.5) and a long postdonation follow-up time (median, 18.0; interquartile range, 9.2-27.7 y). GHtn was associated with the development of hypertension (hazard ratio, 1.89; 95% confidence interval, 1.26-2.83); GDM was associated with diabetes (hazard ratio, 3.04; 95% confidence interval, 1.33-6.99). Pregnancy complications were not associated with eGFR <30 or eGFR <45 mL/min/1.73 m 2 . CONCLUSIONS Our data suggest that women with predonation pregnancy-related complications have long-term risks even with a normal donor evaluation. Donor candidates with a history of pregnancy-related complications should be counseled about these risks.
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Affiliation(s)
- Erika S. Helgeson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Elise F. Palzer
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David M. Vock
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Paige Porrett
- Division of Transplantation, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Deirdre Sawinski
- Division of Renal Electrolyte and Hypertension, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arthur J. Matas
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN
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Hutchesson M, Campbell L, Leonard A, Vincze L, Shrewsbury V, Collins C, Taylor R. Do modifiable risk factors for cardiovascular disease post-pregnancy influence the association between hypertensive disorders of pregnancy and cardiovascular health outcomes? A systematic review of observational studies. Pregnancy Hypertens 2022; 27:138-147. [DOI: 10.1016/j.preghy.2021.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/31/2021] [Indexed: 12/31/2022]
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Garovic VD, Dechend R, Easterling T, Karumanchi SA, McMurtry Baird S, Magee LA, Rana S, Vermunt JV, August P. Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e21-e41. [PMID: 34905954 PMCID: PMC9031058 DOI: 10.1161/hyp.0000000000000208] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.
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Pregnancy and Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00274-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Grieger JA, Hutchesson MJ, Cooray SD, Bahri Khomami M, Zaman S, Segan L, Teede H, Moran LJ. A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum. Ther Adv Reprod Health 2021; 15:2633494120986544. [PMID: 33615227 PMCID: PMC7871058 DOI: 10.1177/2633494120986544] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022] Open
Abstract
The rates of maternal overweight and obesity, but also excess gestational weight gain, are increasing. Pregnancy complications, including gestational diabetes mellitus, gestational hypertension, pre-eclampsia and delivery of a preterm or growth restricted baby, are higher for both women with overweight and obesity and women who gain excess weight during their pregnancy. Other conditions such as polycystic ovary syndrome are also strongly linked to overweight and obesity and worsened pregnancy complications. All of these conditions place women at increased risk for future cardiometabolic diseases. If overweight and obesity, but also excess gestational weight gain, can be reduced in women of reproductive age, then multiple comorbidities associated with pregnancy complications may also be reduced in the years after childbirth. This narrative review highlights the association between maternal overweight and obesity and gestational weight gain, with gestational diabetes, pre-eclampsia, polycystic ovary syndrome and delivery of a preterm or growth restricted baby. This review also addresses how these adverse conditions are linked to cardiometabolic diseases after birth. We report that while the independent associations between obesity and gestational weight gain are evident across many of the adverse conditions assessed, whether body mass index or gestational weight gain is a stronger driving factor for many of these is currently unclear. Mechanisms linking gestational diabetes mellitus, gestational hypertension, pre-eclampsia, preterm delivery and polycystic ovary syndrome to heightened risk for cardiometabolic diseases are multifactorial but relate to cardiovascular and inflammatory pathways that are also found in overweight and obesity. The need for post-partum cardiovascular risk assessment and follow-up care remains overlooked. Such early detection and intervention for women with pregnancy-related complications will significantly attenuate risk for cardiovascular disease.
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Affiliation(s)
- Jessica A. Grieger
- Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Melinda J. Hutchesson
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Shamil D. Cooray
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Diabetes Unit, Monash Health, Melbourne, VIC, Australia
| | - Mahnaz Bahri Khomami
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Sarah Zaman
- Westmead Applied Research Centre, University of Sydney, Sydney, NSW, AustraliaSchool of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Louise Segan
- Department of Cardiology, Alfred Health, Melbourne, VIC, Australia
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Helena Teede
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Diabetes Unit, Monash Health, Melbourne, VIC, Australia
| | - Lisa J. Moran
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3800, Australia. Robinson Research Institute, The University of Adelaide, Adelaide 5000, SA, Australia
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Hutchesson MJ, Taylor R, Shrewsbury VA, Vincze L, Campbell LE, Callister R, Park F, Schumacher TL, Collins CE. Be Health e for Your Heart: A Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women with a History of Preeclampsia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165779. [PMID: 32785044 PMCID: PMC7459885 DOI: 10.3390/ijerph17165779] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 01/07/2023]
Abstract
This pilot randomized controlled trial (RCT) aimed to determine the acceptability and preliminary efficacy of a web-based cardiovascular disease (CVD) prevention intervention for women following preeclampsia. Australian women with a recent history (≤4 years post diagnosis) of preeclampsia were randomized into two study arms: (1) Be Healthe for your Heart, a web-based behavioral intervention or; (2) Control, access to the National Heart Foundation website. Assessments were conducted at baseline, and after three months. Intervention acceptability and impact on absolute CVD 30-year risk score, CVD risk markers and health behaviors were assessed. Twenty-four of 31 (77.4%) women completed the three-month assessment. Eleven out of 13 intervention participants (84.6%) agreed/strongly agreed they were satisfied with the program, with a mean score of 4.2 ± 0.9 (maximum of five). There were no significant between or within group differences in absolute CVD risk, CVD risk markers or health behaviors from baseline to three months. Women with a history of preeclampsia were successfully recruited and retained and they reported high levels of acceptability with the Be Healthe for your Heart program. Further research is therefore needed from powered trials to determine the impact of web-based lifestyle interventions on CVD risk in this at-risk group.
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Affiliation(s)
- Melinda J. Hutchesson
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
- Correspondence:
| | - Rachael Taylor
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
| | - Vanessa A. Shrewsbury
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
| | - Lisa Vincze
- School of Allied Health Sciences & Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD 4222, Australia;
| | - Linda E. Campbell
- School of Psychology, Faculty of Science, The University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Robin Callister
- Priority Research Centre for Physical Activity and Nutrition, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Felicity Park
- Department of Maternal Foetal Medicine, John Hunter Hospital, Newcastle, NSW 2305, Australia;
| | - Tracy L. Schumacher
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
- Priority Research Centre for Health Behaviours, Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia
| | - Clare E. Collins
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
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Barrett PM, McCarthy FP, Evans M, Kublickas M, Perry IJ, Stenvinkel P, Khashan AS, Kublickiene K. Hypertensive disorders of pregnancy and the risk of chronic kidney disease: A Swedish registry-based cohort study. PLoS Med 2020; 17:e1003255. [PMID: 32797043 PMCID: PMC7428061 DOI: 10.1371/journal.pmed.1003255] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/15/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) (preeclampsia, gestational hypertension) are associated with an increased risk of end-stage kidney disease (ESKD). Evidence for associations between HDP and chronic kidney disease (CKD) is more limited and inconsistent. The underlying causes of CKD are wide-ranging, and HDP may have differential associations with various aetiologies of CKD. We aimed to measure associations between HDP and maternal CKD in women who have had at least one live birth and to identify whether the risk differs by CKD aetiology. METHODS AND FINDINGS Using data from the Swedish Medical Birth Register (MBR), singleton live births from 1973 to 2012 were identified and linked to data from the Swedish Renal Register (SRR) and National Patient Register (NPR; up to 2013). Preeclampsia was the main exposure of interest and was treated as a time-dependent variable. Gestational hypertension was also investigated as a secondary exposure. The primary outcome was maternal CKD, and this was classified into 5 subtypes: hypertensive, diabetic, glomerular/proteinuric, tubulointerstitial, and other/nonspecific CKD. Cox proportional hazard regression models were used, adjusting for maternal age, country of origin, education level, antenatal BMI, smoking during pregnancy, gestational diabetes, and parity. Women with pre-pregnancy comorbidities were excluded. The final sample consisted of 1,924,409 women who had 3,726,554 singleton live births. The mean (±SD) age of women at first delivery was 27.0 (±5.1) years. Median follow-up was 20.7 (interquartile range [IQR] 9.9-30.0) years. A total of 90,917 women (4.7%) were diagnosed with preeclampsia, 43,964 (2.3%) had gestational hypertension, and 18,477 (0.9%) developed CKD. Preeclampsia was associated with a higher risk of developing CKD during follow-up (adjusted hazard ratio [aHR] 1.92, 95% CI 1.83-2.03, p < 0.001). This risk differed by CKD subtype and was higher for hypertensive CKD (aHR 3.72, 95% CI 3.05-4.53, p < 0.001), diabetic CKD (aHR 3.94, 95% CI 3.38-4.60, p < 0.001), and glomerular/proteinuric CKD (aHR 2.06, 95% CI 1.88-2.26, p < 0.001). More modest associations were observed between preeclampsia and tubulointerstitial CKD (aHR 1.44, 95% CI 1.24-1.68, p < 0.001) or other/nonspecific CKD (aHR 1.51, 95% CI 1.38-1.65, p < 0.001). The risk of CKD was increased after preterm preeclampsia, recurrent preeclampsia, or preeclampsia complicated by pre-pregnancy obesity. Women who had gestational hypertension also had increased risk of developing CKD (aHR 1.49, 95% CI 1.38-1.61, p < 0.001). This association was strongest for hypertensive CKD (aHR 3.13, 95% CI 2.47-3.97, p < 0.001). Limitations of the study are the possibility that cases of CKD were underdiagnosed in the national registers, and some women may have been too young to have developed symptomatic CKD despite the long follow-up time. Underreporting of postpartum hypertension is also possible. CONCLUSIONS In this study, we found that HDP are associated with increased risk of maternal CKD, particularly hypertensive or diabetic forms of CKD. The risk is higher after preterm preeclampsia, recurrent preeclampsia, or preeclampsia complicated by pre-pregnancy obesity. Women who experience HDP may benefit from future systematic renal monitoring.
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Affiliation(s)
- Peter M. Barrett
- School of Public Health, University College Cork, Cork, Ireland
- Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland
| | - Fergus P. McCarthy
- Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland
- Department of Obstetrics & Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Marie Evans
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Marius Kublickas
- Department of Obstetrics & Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - Ivan J. Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ali S. Khashan
- School of Public Health, University College Cork, Cork, Ireland
- Irish Centre for Maternal and Child Health Research, University College Cork, Cork, Ireland
| | - Karolina Kublickiene
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Women and Cardiovascular Disease: Pregnancy, the Forgotten Risk Factor. Heart Lung Circ 2020; 29:662-667. [DOI: 10.1016/j.hlc.2019.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/25/2019] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
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Barrett PM, McCarthy FP, Kublickiene K, Cormican S, Judge C, Evans M, Kublickas M, Perry IJ, Stenvinkel P, Khashan AS. Adverse Pregnancy Outcomes and Long-term Maternal Kidney Disease: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e1920964. [PMID: 32049292 DOI: 10.1001/jamanetworkopen.2019.20964] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Adverse pregnancy outcomes, such as hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery, are associated with increased risk of maternal cardiovascular disease. Little is known about whether adverse pregnancy outcomes are associated with increased risk of maternal chronic kidney disease (CKD) and end-stage kidney disease (ESKD). OBJECTIVE To review and synthesize the published literature on adverse pregnancy outcomes (hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery) and subsequent maternal CKD and ESKD. DATA SOURCES PubMed, Embase, and Web of Science were searched from inception to July 31, 2019, for cohort and case-control studies of adverse pregnancy outcomes and maternal CKD and ESKD. STUDY SELECTION Selected studies included the following: a population of pregnant women, exposure to an adverse pregnancy outcome of interest, and at least 1 primary outcome (CKD or ESKD) or secondary outcome (hospitalization or death due to kidney disease). Adverse pregnancy outcomes included exposure to hypertensive disorders of pregnancy (preeclampsia, gestational hypertension, or chronic hypertension), preterm delivery (<37 weeks), and gestational diabetes. Three reviewers were involved in study selection. Of 5656 studies retrieved, 23 were eligible for inclusion. DATA EXTRACTION AND SYNTHESIS The Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed throughout. Three reviewers extracted data and appraised study quality. Random-effects meta-analyses were used to calculate overall pooled estimates using the generic inverse variance method. MAIN OUTCOMES AND MEASURES Primary outcomes included CKD and ESKD diagnosis, defined using established clinical criteria (estimated glomerular filtration rate or albuminuria values) or hospital records. The protocol for this systematic review was registered on PROSPERO (CRD42018110891). RESULTS Of 23 studies included (5 769 891 participants), 5 studies reported effect estimates for more than 1 adverse pregnancy outcome. Preeclampsia was associated with significantly increased risk of CKD (pooled adjusted risk ratio [aRR], 2.11; 95% CI, 1.72-2.59), ESKD (aRR, 4.90; 95% CI, 3.56-6.74), and kidney-related hospitalization (aRR, 2.65; 95% CI, 1.03-6.77). Gestational hypertension was associated with increased risk of CKD (aRR, 1.49; 95% CI, 1.11-2.01) and ESKD (aRR, 3.64; 95% CI, 2.34-5.66). Preterm preeclampsia was associated with increased risk of ESKD (aRR, 5.66; 95% CI, 3.06-10.48); this association with ESKD persisted for women who had preterm deliveries without preeclampsia (aRR, 2.09; 95% CI, 1.64-2.66). Gestational diabetes was associated with increased risk of CKD among black women (aRR, 1.78; 95% CI, 1.18-2.70), but not white women (aRR, 0.81; 95% CI, 0.58-1.13). CONCLUSIONS AND RELEVANCE In this meta-analysis, exposure to adverse pregnancy outcomes, including hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery, was associated with higher risk of long-term kidney disease. The risk of ESKD was highest among women who experienced preeclampsia. A systematic approach may be warranted to identify women at increased risk of kidney disease, particularly after hypertensive disorders of pregnancy, and to optimize their long-term follow-up.
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Affiliation(s)
- Peter M Barrett
- School of Public Health, University College Cork, Cork, Ireland
- Irish Centre for Maternal & Child Health, University College Cork, Cork, Ireland
| | - Fergus P McCarthy
- Irish Centre for Maternal & Child Health, University College Cork, Cork, Ireland
- Department of Obstetrics & Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Karolina Kublickiene
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Sarah Cormican
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - Conor Judge
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - Marie Evans
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marius Kublickas
- Department of Obstetrics & Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - Ivan J Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ali S Khashan
- School of Public Health, University College Cork, Cork, Ireland
- Irish Centre for Maternal & Child Health, University College Cork, Cork, Ireland
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13
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Melchiorre K, Thilaganathan B, Giorgione V, Ridder A, Memmo A, Khalil A. Hypertensive Disorders of Pregnancy and Future Cardiovascular Health. Front Cardiovasc Med 2020; 7:59. [PMID: 32351977 PMCID: PMC7174679 DOI: 10.3389/fcvm.2020.00059] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/24/2020] [Indexed: 12/24/2022] Open
Abstract
Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations. These women are known to have higher cardiovascular morbidity and mortality later in life in comparison with parous controls who had normotensive pregnancies. Several studies have demonstrated that women with preeclampsia present in a state of segmental impaired myocardial function, biventricular chamber dysfunction, adverse biventricular remodeling, and hypertrophy, a compromised hemodynamic state and indirect echocardiographic signs of localized myocardial ischemia and fibrosis. These cardiac functional and geometric changes are known to have strong predictive value for cardiovascular disease in non-pregnant subjects. A "dose effect" response seems to regulate this relationship with severe HDP, early-onset HDP, coexistence of fetal growth disorders, and recurrence of HDP resulting in poorer cardiovascular measures. The mechanism underlying the relationship between HDP in younger women and cardiovascular disease later in life is unclear but could be explained by sharing of pre-pregnancy cardiovascular risk factors or due to a direct impact of HDP on the maternal cardiovascular system conferring a state of increased susceptibility to future metabolic or hemodynamic insults. If so, the prevention of HDP itself would become all the more urgent. Shortly after delivery, women who experienced HDP express an increased risk of classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile, and diabetes with higher frequency than controls. Within one or two decades after delivery, this group of women are more likely to experience premature cardiovascular events, such as symptomatic heart failure, myocardial ischemia, and cerebral vascular disease. Although there is general agreement that women who suffered from HDP should undertake early screening for cardiovascular risk factors in order to allow for appropriate prevention, the exact timing and modality of screening has not been standardized yet. Our findings suggest that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, stop smoking, healthy diet, and daily exercise which are well-established and cost-effective prevention strategies.
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Affiliation(s)
- Karen Melchiorre
- Department of Obstetrics and Gynecology, Spirito Santo Hospital of Pescara, Pescara, Italy
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Veronica Giorgione
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Anna Ridder
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Alessia Memmo
- Department of Obstetrics and Gynecology, Spirito Santo Hospital of Pescara, Pescara, Italy
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
- *Correspondence: Asma Khalil
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14
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Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, Smith GN, Gore GC, Ray JG, Nerenberg K, Platt RW. Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications. Circulation 2019; 139:1069-1079. [PMID: 30779636 DOI: 10.1161/circulationaha.118.036748] [Citation(s) in RCA: 317] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD. METHODS We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI). RESULTS Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage. CONCLUSIONS Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.
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Affiliation(s)
- Sonia M Grandi
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Kristian B Filion
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Department of Medicine, McGill University, Montreal, QC, Canada (K.F.)
| | - Sarah Yoon
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Henok T Ayele
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Carla M Doyle
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Canada (J.H.)
| | - Graeme N Smith
- Department of Obstetrics and Gynaecology, School of Medicine, Queen's University, Kingston, ON, Canada (G.S.)
| | - Genevieve C Gore
- Schulich Library of Science and Engineering, McGill University, Montreal, QC, Canada (G.G.)
| | - Joel G Ray
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada (J.R.)
| | - Kara Nerenberg
- University of Calgary, Department of Medicine, Cumming School of Medicine, AB, Canada (K.N.)
| | - Robert W Platt
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,McGill University Health Center Research Institute and Department of Pediatrics, McGill University, Montreal, QC, Canada (R.P.)
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15
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Acuna S, Zaffar N, Dong S, Ross H, D'Souza R. Pregnancy outcomes in women with cardiothoracic transplants: A Systematic review and meta-analysis. J Heart Lung Transplant 2019; 39:93-102. [PMID: 31839511 DOI: 10.1016/j.healun.2019.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/07/2019] [Accepted: 11/25/2019] [Indexed: 12/23/2022] Open
Abstract
Increasing numbers of women with thoracic transplants are planning and continuing pregnancies. However, pregnancy outcomes and risks to the mother and baby have not been systematically assessed. MEDLINE, EMBASE, and Cochrane Central were searched from their inception to January 2018, to identify studies reporting outcomes on 3 or more pregnancies following thoracic transplants. Pooled incidences were calculated using a random-effect meta-analysis. Risk-of-bias was assessed using the Joanna Briggs Checklist for case series. Subgroup analysis was conducted based on the organ transplanted. Of the 3,658 records identified, 12 studies were included that reported on 385 pregnancies in 272 thoracic transplant recipients. Maternal complications included mortality (pooled incidence 0.5% [95% confidence intervals 0, 1.1%] during pregnancy and 15.4% [10.4, 20.3%] during follow-up, which ranged between 3 and 7 years), graft rejection (7.4% [4.2, 10.5%]), hypertensive disorders of pregnancy [26.6% [13.7, 39.6%]), and cesarean deliveries (41.4% [33.4, 48.7%]). Maternal mortality was more common in recipients of lung vs heart transplants (41.4% [23.4, 59.3] vs 10.8% [5.9, 15.8]), respectively. Although 78.4% (69.8, 86.9%) of the pregnancies resulted in live births, 51.2% (31, 71.3%) were born preterm and neonatal deaths occurred in 3.4% (1.3, 5.6%). Congenital anomalies affected 4.3% (1.8, 6.8%) of the newborns. Although few maternal deaths occurred during pregnancy, in keeping with median survival data, delayed mortality for thoracic transplant recipients remains high. Despite the high numbers of live births, these pregnancies continue to be at risk for hypertensive disorders, graft rejection, preterm birth, and neonatal mortality. Prospectively gathered data from international registries should supplement these findings to better inform clinical counseling and practice.
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Affiliation(s)
- Sergio Acuna
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Nusrat Zaffar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Susan Dong
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
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16
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Yeung KR, Sunderland N, Lind JM, Heffernan S, Pears S, Xu B, Hennessy A, Makris A. Increased salt sensitivity in offspring of pregnancies complicated by experimental preeclampsia. Clin Exp Pharmacol Physiol 2018; 45:1302-1308. [PMID: 29992611 DOI: 10.1111/1440-1681.13008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/25/2018] [Accepted: 06/26/2018] [Indexed: 01/28/2023]
Abstract
Preeclampsia is a hypertensive disorder of pregnancy known to increase the risk of cardiovascular disease in mothers and offspring. Offspring exposed to a suboptimal intrauterine environment may experience altered fetal programming and subsequent long-term cardiovascular changes. This study investigated changes in the vascular response in offspring from experimental preeclampsia (EPE) induced by uterine artery ligation, in the absence of fetal growth restriction, compared to normal baboon pregnancies (controls), following a high salt diet challenge. After 1 week of standard diet (containing <1% salt), animals were fed a high salt diet (6%) for 2 weeks. Systolic and diastolic blood pressure (SBP, DBP), aldosterone, renin and creatinine clearance were evaluated in EPE (n = 6, 50% male) and control (n = 6, 50% male) offspring. A repeated measures analysis was performed, and P < 0.05 was considered significant. At baseline, there were no differences between the groups in any parameter (EPE, mean age and weight 3.2 ± 1.2 years, 6.8 ± 1.0 kg, respectively; Control, 2.9 ± 0.8 years, 7.1 ± 1.5 kg). After salt loading the EPE group had significantly higher SBP (92 ± 5 mm Hg) compared to the control group (83 ± 4 mm Hg, P = 0.03). Aldosterone concentration was higher in the EPE group despite the same salt excretion and no difference in renal function. Salt sensitivity may differ in offspring from hypertensive pregnancies due to fetal programming. This could have long-term consequences for cardiovascular health of EPE offspring and further research is required to determine the exact pathological mechanisms.
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Affiliation(s)
- Kristen R Yeung
- Western Sydney University, Sydney, NSW, Australia.,Heart Research Institute, Sydney, NSW, Australia
| | | | | | | | - Suzanne Pears
- Heart Research Institute, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Bei Xu
- Western Sydney University, Sydney, NSW, Australia.,Heart Research Institute, Sydney, NSW, Australia
| | - Annemarie Hennessy
- Western Sydney University, Sydney, NSW, Australia.,Heart Research Institute, Sydney, NSW, Australia
| | - Angela Makris
- Western Sydney University, Sydney, NSW, Australia.,Heart Research Institute, Sydney, NSW, Australia.,Nephrology Department, Liverpool Hospital, Liverpool, NSW, Australia
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17
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Groenhof TKJ, van Rijn BB, Franx A, Roeters van Lennep JE, Bots ML, Lely AT. Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when. Eur J Prev Cardiol 2017; 24:1735-1745. [PMID: 28895439 PMCID: PMC5669282 DOI: 10.1177/2047487317730472] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Women with a history of a hypertensive disorder during pregnancy (HDP) have an increased risk of cardiovascular events. Guidelines recommend assessment of cardiovascular risk factors in these women later in life, but provide limited advice on how this follow-up should be organized. Design Systematic review and meta-regression analysis. Methods The aim of our study was to provide an overview of existing knowledge on the changes over time in three major modifiable components of cardiovascular risk assessment after HDP: blood pressure, glucose homeostasis and lipid levels. Data from 44 studies and up to 6904 women with a history of a HDP were compared with risk factor levels reported for women of corresponding age in the National Health And Nutrition Examination Survey, Estudio Epidemiólogico de la Insuficiencia Renal en España and Hong Kong cohorts (N = 27,803). Results Compared with the reference cohort, women with a HDP presented with higher mean blood pressure. Hypertension was present in a higher rate among women with a previous HDP from 15 years postpartum onwards. At 15 years postpartum (±age 45), one in five women with a history of a HDP suffer from hypertension. No differences in glucose homeostasis parameters or lipid levels were observed. Conclusions Based on our analysis, it is not possible to point out a time point to commence screening for cardiovascular risk factors in women after a HDP. We recommend redirection of future research towards the development of a stepwise approach identifying the women with the highest cardiovascular risk.
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Affiliation(s)
- T Katrien J Groenhof
- 1 Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, The Netherlands
| | - Bas B van Rijn
- 1 Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, The Netherlands.,2 Academic Unit of Human Development and Health, Institute for Life Sciences, University of Southampton, UK
| | - Arie Franx
- 1 Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, The Netherlands
| | | | - Michiel L Bots
- 4 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - A Titia Lely
- 1 Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, The Netherlands
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18
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Rosato E, Perrone G, Capri O, Galoppi P, Candelieri M, Marcoccia E, Schiavi MC, Zannini I, Brunelli R. Hypertension and early menopause after the use of assisted reproductive technologies in women aged 43 years or older: Long-term follow-up study. J Obstet Gynaecol Res 2016; 42:1782-1788. [PMID: 27718320 DOI: 10.1111/jog.13141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 07/16/2016] [Indexed: 01/23/2023]
Abstract
AIM The aim of this study was to investigate the long-term consequences to women's health and the onset of menopause in healthy women of advanced reproductive age who conceived by assisted reproductive technologies (ART). METHODS Healthy women who conceived by ART (72) and controls (80) were selected among 320 women ≥ 43 years, who delivered between January 2010 and December 2011 in the Department of Gynecological and Obstetrical Sciences and Urological Sciences of "Sapienza" University of Rome. Body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and presence of hypertension and diabetes were analyzed at three days, six months, and three years after delivery. The onset of menopause was analyzed after three years. RESULTS In the ART group, SBP, DBP and hypertension were higher at three days, six months, and three years after delivery. Menopausal age was significantly lower. CONCLUSION The impact of ART in healthy women of advanced reproductive age in the years after delivery is not limited to the possible development of cardiovascular risk factors, such as hypertension, but can also influence the age of onset of menopause.
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Affiliation(s)
- Elena Rosato
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Giuseppina Perrone
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Oriana Capri
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Paola Galoppi
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Miriam Candelieri
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Eleonora Marcoccia
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Michele Carlo Schiavi
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Ilaria Zannini
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
| | - Roberto Brunelli
- Department of Gynecological and Obstetrical Sciences and Urological Sciences, "Sapienza" University of Rome, Rome, Italy
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19
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Savitri AI, Zuithoff P, Browne JL, Amelia D, Baharuddin M, Grobbee DE, Uiterwaal CSPM. Does pre-pregnancy BMI determine blood pressure during pregnancy? A prospective cohort study. BMJ Open 2016; 6:e011626. [PMID: 27515754 PMCID: PMC4985806 DOI: 10.1136/bmjopen-2016-011626] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To evaluate if pre-pregnancy body mass index (BMI) determines blood pressure throughout pregnancy and to explore the role of gestational weight gain in this association. In addition, the effects of pre-pregnancy BMI and gestational weight gain on the occurrence of gestational hypertension and pre-eclampsia were investigated. DESIGN Prospective cohort study. SETTING Maternal and child health primary care referral centre, Jakarta, Indonesia. POPULATION AND MEASUREMENTS 2252 pregnant women visiting Budi Kemuliaan Hospital and its branch for regular antenatal care visits from July 2012 to April 2015. Pre-pregnancy BMI (kg/m(2)) was based on self-reported pre-pregnancy weight and measured height at first visit. Gestational weight gain was calculated as weight at the day of delivery minus the pre-pregnancy weight. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured during pregnancy at every visit. Linear mixed models were used to analyse this relation with repeated blood pressure measures as the outcome and pre-pregnancy BMI as the predictor. When looking at gestational hypertension and pre-eclampsia as outcomes, (multiple) logistic regression was used in the analysis. RESULTS Independent of pre-pregnancy BMI, SBP and DBP increased by 0.99 mm Hg/month and 0.46 mm Hg/month, respectively. Higher pre-pregnancy BMI was associated with higher pregnancy SBP (0.25 mm Hg/kg/m(2); 95% CI 0.17 to 0.34; p<0.01) and DBP (0.18 mm Hg/kg/m(2); 0.13 to 0.24; p<0.01) in adjusted analysis. Every 1 kg/m(2) higher pre-pregnancy BMI was associated with 6% and 9% higher odds for gestational hypertension (adjusted OR (aOR) 1.06; 95% CI 1.03 to 1.09; p<0.01) and pre-eclampsia (aOR 1.09; 1.04 to 1.14; p<0.01). Accounting for gestational weight gain did not attenuate these associations. CONCLUSIONS Pre-pregnancy BMI determines the level, but not the change, of blood pressure in pregnancy and is linked to higher odds for gestational hypertension and pre-eclampsia, independent of gestational weight gain.
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Affiliation(s)
- Ary I Savitri
- Julius Center for Health Sciences and Primary Care, Julius Global Health, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter Zuithoff
- Julius Center for Health Sciences and Primary Care, Julius Global Health, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joyce L Browne
- Julius Center for Health Sciences and Primary Care, Julius Global Health, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | | | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, Julius Global Health, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Cuno S P M Uiterwaal
- Julius Center for Health Sciences and Primary Care, Julius Global Health, University Medical Center Utrecht, Utrecht, The Netherlands
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20
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Christensen M, Kronborg CS, Eldrup N, Rossen NB, Knudsen UB. Preeclampsia and cardiovascular disease risk assessment - Do arterial stiffness and atherosclerosis uncover increased risk ten years after delivery? Pregnancy Hypertens 2016; 6:110-4. [PMID: 27155337 DOI: 10.1016/j.preghy.2016.04.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/06/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Epidemiological studies associate preeclampsia with increased risk of premature cardiovascular disease (CVD) later in life. This study aims to make a comprehensive CVD risk assessment comparing women with previous preeclamptic pregnancies to women with previous normotensive pregnancies 10years after index pregnancy. STUDY DESIGN A nested, matched, observational cohort study. MAIN OUTCOME MEASURES Markers of arterial stiffness, aortic pulse wave velocity (aPWV) and augmentation index (AIx-75), and markers of atherosclerosis, carotid intima-media thickness (cIMT) and carotid plaque presence. Traditional CVD risk factors and 10-year and 30-year Framingham CVD risk scores were also assessed. RESULTS Women were included from April 2014 to October 2014 at a tertiary referral hospital in Denmark. Twenty-one exposed women with a history of preeclampsia and 21 unexposed with a history of normotensive pregnancies were included. Ten years after delivery, significantly more exposed women suffered from hypertension and received antihypertensive treatment and significantly more fulfilled the hypertension-definition at screening. Previously preeclamptic women also tended to have more unfavorable CVD risk estimates. The Framingham risk scores seemed to extend the unfavorable CVD risk. The exposed women tended to have a higher aPWV compared to unexposed women, (P=0.057). No differences were shown in the other examined arteriosclerotic or atherosclerotic variables. CONCLUSIONS Ten years after delivery, we found increased risk of hypertension and trend toward unfavorable CVD risk profile in 40-year-old previously preeclamptic women. However, arterial stiffness and atherosclerosis did not uncover any additional CVD risk information at this time point.
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Affiliation(s)
- Martin Christensen
- Clinical Research Unit, Randers Regional Hospital, Skovlyvej 1, 8930 Randers NO, Denmark; Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus N, Denmark.
| | | | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Niklas Blach Rossen
- Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1-3, 8600 Silkeborg, Denmark; Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Noerrebrogade 44, 8000 Aarhus C, Denmark.
| | - Ulla Breth Knudsen
- Department of Gynecology and Obstetrics, Horsens Regional Hospital, Sundsvej 30, 8700 Horsens, Denmark.
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Usselman CW, Skow RJ, Matenchuk BA, Chari RS, Julian CG, Stickland MK, Davenport MH, Steinback CD. Sympathetic baroreflex gain in normotensive pregnant women. J Appl Physiol (1985) 2015; 119:468-74. [PMID: 26139215 DOI: 10.1152/japplphysiol.00131.2015] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/30/2015] [Indexed: 12/11/2022] Open
Abstract
Muscle sympathetic nerve activity is increased during normotensive pregnancy while mean arterial pressure is maintained or reduced, suggesting baroreflex resetting. We hypothesized spontaneous sympathetic baroreflex gain would be reduced in normotensive pregnant women relative to nonpregnant matched controls. Integrated muscle sympathetic burst incidence and total sympathetic activity (microneurography), blood pressure (Finometer), and R-R interval (ECG) were assessed at rest in 11 pregnant women (33 ± 1 wk gestation, 31 ± 1 yr, prepregnancy BMI: 23.5 ± 0.9 kg/m(2)) and 11 nonpregnant controls (29 ± 1 yr; BMI: 25.2 ± 1.7 kg/m(2)). Pregnant women had elevated baseline sympathetic burst incidence (43 ± 2 vs. 33 ± 2 bursts/100 heart beats, P = 0.01) and total sympathetic activity (1,811 ± 148 vs. 1,140 ± 55 au, P < 0.01) relative to controls. Both mean (88 ± 3 vs. 91 ± 2 mmHg, P = 0.4) and diastolic (DBP) (72 ± 3 vs. 73 ± 2 mmHg, P = 0.7) pressures were similar between pregnant and nonpregnant women, respectively, indicating an upward resetting of the baroreflex set point with pregnancy. Baroreflex gain, calculated as the linear relationship between sympathetic burst incidence and DBP, was reduced in pregnant women relative to controls (-3.7 ± 0.5 vs. -5.4 ± 0.5 bursts·100 heart beats(-1)·mmHg(-1), P = 0.03), as was baroreflex gain calculated with total sympathetic activity (-294 ± 24 vs. -210 ± 24 au·100 heart beats(-1)·mmHg(-1); P = 0.03). Cardiovagal baroreflex gain (sequence method) was not different between nonpregnant controls and pregnant women (49 ± 8 vs. 36 ± 8 ms/mmHg; P = 0.2). However, sympathetic (burst incidence) and cardiovagal gains were negatively correlated in pregnant women (R = -0.7; P = 0.02). Together, these data indicate that the influence of the sympathetic nervous system over arterial blood pressure is reduced in normotensive pregnancy, in terms of both long-term and beat-to-beat regulation of arterial pressure, likely through a baroreceptor-dependent mechanism.
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Affiliation(s)
- Charlotte W Usselman
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada; Alberta Diabetes Institute, Women and Children's Health Research Institute, and
| | - Rachel J Skow
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada; Alberta Diabetes Institute, Women and Children's Health Research Institute, and
| | - Brittany A Matenchuk
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada; Alberta Diabetes Institute, Women and Children's Health Research Institute, and
| | - Radha S Chari
- Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Colleen G Julian
- Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado; and
| | - Michael K Stickland
- Division of Pulmonary Medicine, Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Margie H Davenport
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada; Alberta Diabetes Institute, Women and Children's Health Research Institute, and
| | - Craig D Steinback
- Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory, Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada; Alberta Diabetes Institute, Women and Children's Health Research Institute, and
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22
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Cardiovascular disease in women: the significance of hypertension and gestational diabetes during pregnancy. Curr Opin Cardiol 2015; 29:447-53. [PMID: 25003394 DOI: 10.1097/hco.0000000000000094] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) remains the major killer of women around the globe. Complications during pregnancy, including hypertensive disorders of pregnancy and gestational diabetes mellitus, are now recognized as risk factors for future CVD. RECENT FINDINGS Studies of diverse populations demonstrate the links between these complications of pregnancy and a woman's future risk of CVD including atherosclerosis, hypertension, stroke, coronary artery disease, and heart failure. Markers that persist in these women following pregnancy continue to be identified and include microalbuminuria, proteinuria, elevated homocysteine levels, C-reactive protein, and salt sensitivity. Efforts are now being placed on establishing specialized clinics to monitor women beyond pregnancy to help reduce the burden of future disease. SUMMARY Pregnancy offers a unique window through which women at risk of future CVD may be identified. Clinicians have an opportunity to implement health monitoring, lifestyle modifications, and other interventions during this period, and beyond, that will help reduce the burden of CVD. Research should continue to focus on identifying and understanding the mechanisms that lead to future CVD in these women; deciphering whether pregnancy unmasks an existing predisposition to disease, compounds the risk of future disease, or is the direct cause of future disease.
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Abstract
The aim of this article is to determine whether the age of a woman at first birth is associated with treatment for high blood pressure (HBP) later in life.Baseline data for 62,914 women were sourced from the "45 and Up Study," an observational cohort study of healthy aging in Australia. These women had given first birth between the ages of 18 and 45 years. Odds ratios and 95% confidence intervals for the association between age that a woman gave first birth and treatment for HBP were estimated using logistic regression. Data were stratified by current age (<60 and ≥60 years) and adjusted for demographic and lifestyle factors.There was a significant association between age at first birth and present day HBP. Older age at first birth was associated with a lower likelihood of HBP in women aged 25 to <35 years and 35 to 45 years at first birth (in women currently <60 years) and 35 to 45 years at first birth (in women currently ≥60 years of age), compared with women aged 18 to <25 years at first birth, adjusting for demographic and lifestyle factors.Women who were older when they gave first birth had lower odds of treatment for HBP compared with women who were younger when they gave birth to their first child. The contribution of a woman's pregnancy history, including her age at first birth, should be discussed with a patient when assessing her risk of HBP.
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Affiliation(s)
- Joanne M Lind
- From the University of Western Sydney, School of Medicine, Sydney, New South Wales, Australia
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Lupton SJ, Chiu CL, Hodgson LAB, Tooher J, Ogle R, Wong TY, Hennessy A, Lind JM. Changes in retinal microvascular caliber precede the clinical onset of preeclampsia. Hypertension 2013; 62:899-904. [PMID: 24019405 DOI: 10.1161/hypertensionaha.113.01890] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preeclampsia is a leading cause of maternal morbidity and mortality. The degree of maternal cardiovascular dysfunction that precedes the onset of preeclampsia is largely unknown. This prospective cohort study aimed to characterize differences in vivo in retinal microvascular caliber and blood pressure throughout pregnancy in relation to preeclampsia development. Women were recruited from Royal Prince Alfred Hospital, Sydney, Australia, of which 92 women were included in the study. Retinal images and blood pressures were collected at 13, 19, 29, and 38 weeks of gestation. Retinal vessels were analyzed as the central retinal arteriolar equivalent corrected for mean arterial blood pressure and the central retinal venular equivalent corrected for mean arterial blood pressure, using generalized linear models adjusted for age and body mass index. The preeclampsia group were significantly older (P=0.002) and had a significantly higher mean body mass index (P=0.005). The central retinal arteriolar equivalent corrected for mean arterial blood pressure was significantly reduced at 13 (P=0.03), 19 (P=0.007), and 38 (P=0.03) weeks of gestation in the preeclampsia group. The central retinal venular equivalent corrected for mean arterial blood pressure was also significantly lower at 13 (P=0.04) and 19 (P=0.001) weeks of gestation in the women who progressed to preeclampsia. This study directly documents increased peripheral resistance in vivo, observed as the combination of constricted retinal arterioles or venules and elevated blood pressure, in women who later developed preeclampsia. This difference preceded the clinical signs of preeclampsia.
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Affiliation(s)
- Samantha J Lupton
- University of Western Sydney, School of Medicine, Locked Bag 1797, Penrith, NSW 2751, Australia.
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