Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association

The contemporary cardio-obstetrics team: The path to improving maternal outcomes in high-risk patients

The field of Cardio-Obstetrics is focused on mitigating cardiovascular risk among pregnant and post-partum individuals. Due to the complexity of caring for pregnant people with acquired or congenital cardiac disease, patients with these conditions are increasingly managed in multidisciplinary Cardio-Obstetrics teams, which are now considered essential to optimize maternal care in high-risk patients. Cardio-Obstetrics teams are composed of multiple subspecialists and have at least 3 roles: (1) provide preconception counseling and risk stratification to patients with known cardiac disease, (2) organize prenatal and postpartum care for patients who develop or present with cardiac disease during pregnancy, and (3) plan for emergent care for patients whose pregnancy "unmasks" cardiac disease, whether acquired disease or an unknown ACHD. Here we describe our experience at Einstein/Montefiore to aid other institutions in developing their own programs.

Serum Ferritin Levels in Pregnancy and Their Association with Gestational Diabetes Mellitus: A Prospective Longitudinal Study

Objective

Elevated serum ferritin (SF) levels are associated with oxidative stress (OS) and systemic inflammation in various disorders. However, the changes in SF levels during pregnancy and their relationship with gestational diabetes mellitus (GDM) and blood glucose levels are not well understood.

Methods

This prospective longitudinal study included 390 participants (130 GDM cases and 260 controls) during early pregnancy. We measured SF levels in the1st, 2nd, and 3rd trimesters, as well as plasma malondialdehyde (MDA) and C-reactive protein (CRP) in the 1st trimester, blood glucose levels in the oral glucose tolerance test (OGTT), and glycosylated hemoglobin (HbA1c) in the 2nd trimester. We used Spearman's rank correlation to estimate the association between SF, OS, inflammation and glucose levels. Logistic regression analysis was performed to estimate the OR of GDM associated with SF. Multiple stepwise regression models were used to assess the relationship between glucose levels and the risk factors.

Results

SF levels decreased with increasing gestation in the study population. Compared to controls, GDM patients had significantly higher levels of SF (1st and 2nd trimesters), MDA, CRP, and HbA1c. SF was positively correlated with MDA and fasting plasma glucose (FPG). Elevated SF levels during early pregnancy were significantly associated with increased GDM risks (OR = 2.024, 95% CI: 1.076 - 3.807). The explanatory variables that contributed to increased glucose levels were SF, MDA, body mass index (BMI), maternal age, and family history of diabetes.

Conclusion

SF is significantly associated with GDM and may be a potential biomarker for GDM in early pregnancy.

Impact of postpartum physical activity on cardiometabolic health, breastfeeding, injury and infant growth and development: a systematic review and meta-analysis

OBJECTIVE

To examine the relationship between postpartum physical activity and maternal postnatal cardiometabolic health, breastfeeding, injury, and infant growth and development.

DESIGN

Systematic review with random-effects meta-analysis and meta-regression.

DATA SOURCES

Eight online databases were searched up until 12 January 2024.

ELIGIBILITY CRITERIA

Studies of all designs in all languages were eligible (except case studies and reviews) if they contained information on the population (postpartum people), intervention (frequency, intensity, duration, volume, or type of exercise, alone ('exercise-only') or in combination with other intervention components (eg, dietary; 'exercise+co-intervention'), comparator (no or low volumes of physical activity), and outcomes: hypertension, diabetes, cardiometabolic risk factors (systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol, high density lipoproteins, low density lipoproteins, and triglycerides, glycated hemoglobin (HbA1C), glucose and insulin concentration), breastfeeding (breast milk quality and volume), infant growth (length and weight) and development, or postpartum injury.

RESULTS

46 unique studies (n=8766 participants) from 20 countries were included. Moderate certainty of evidence showed exercise+co-interventions reduced the odds of developing diabetes by 28% (7 randomised controlled trials (RCTs), n=2496; OR 0.72 95% CI 0.54, 0.98, I2 12%), reduced SBP (10 RCTs, n=2753; mean difference (MD) -2.15 95% CI -3.89 to -0.40, I2 73%) and DBP (9 RCTs, n=2575; MD -1.38 95% CI -2.60 to -0.15, I2 66%) compared with controls. Infant growth and development, breast milk quality and quantity, and risk of injury were not different between exercise and control groups.

CONCLUSIONS

Physical activity improves cardiometabolic health without adversely impacting breast milk supply or quality, infant growth or maternal injury.

Prospective transitions in hemoglobin A1c following gestational diabetes using multistate Markov models

We characterized the state-to-state transitions in postpartum hemoglobin A1c levels after gestational diabetes, including remaining in a state of normoglycemia or transitions between prediabetes or diabetes states of varying severity. We used data from the APPLE Cohort, a postpartum population-based cohort of individuals with gestational diabetes between 2009 and 2011, and linked A1c data with up to 9 years of follow-up (n = 34 171). We examined maternal sociodemographic and perinatal characteristics as predictors of transitions in A1c progression using Markov multistate models. In the first year postpartum following gestational diabetes, 45.1% of people had no diabetes, 43.1% had prediabetes, 4.6% had controlled diabetes, and 7.2% had uncontrolled diabetes. Roughly two-thirds of individuals remained in the same state in the next year. Black individuals were more likely to transition from prediabetes to uncontrolled diabetes (adjusted hazard ratio [aHR] = 2.32; 95% CI, 1.21-4.47) than White persons. Perinatal risk factors were associated with disease progression and a lower likelihood of improvement. For example, hypertensive disorders of pregnancy were associated with a stronger transition (aHR = 2.06; 95% CI, 1.39-3.05) from prediabetes to uncontrolled diabetes. We illustrate factors associated with adverse transitions in incremental A1c stages and describe patient profiles that may warrant enhanced postpartum monitoring.

Experiences of working as a clinical nurse while pregnant during the coronavirus disease-2019 pandemic: a qualitative study

BACKGROUND

Working as a pregnant clinical nurse might experience a range of challenges, such as significant anatomical and physiological changes as well as emotional and cognitive changes. That might be particularly obvious under the historical background of coronavirus disease-2019 (COVID-19) pandemic. However, a dearth of studies has explored the experiences of working as a pregnant nurse during this special period. This study aimed to explore the experiences of working as a clinical nurse while pregnant during the COVID-19 pandemic.

METHODS

A descriptive qualitative design was selected. Purposive sampling, combined with maximum variation strategy and snowball sampling, were utilized to identify and select participants from tertiary-teaching hospitals, specialized hospitals, and community hospitals in Zhejiang Province, southeastern China. Online semi-structured individual interviews were used to collect data, and conventional content analysis was used to analyze the data.

RESULTS

Eleven Chinese nurses with a mean age of 31.8 years, ranging from 26 to 40 years, participated in this study. Four themes and twelve subthemes emerged: (1) still adhering to work as a clinical nurse despite being pregnant during the pandemic; (2) working during pregnancy under pandemic is still an ordinary nurse; (3) still staying in the special life phase as a pregnant mother; and (4) growth and gains as pregnant mother.

CONCLUSION

The pregnant clinical nurses suffered from various changes and difficulties during the pandemic. Managers, occupational health and other health system leaders, and policymakers should be aware of the importance of establishing a work environment that guarantees safe continued pregnancy. Future studies should focus on the establishment of specific guidelines and manuals regarding how pregnant nurses worked, as well as the development of self-protection interventions during pregnancy. Moreover, research on moral stigma and bullying in nursing during pregnancy deserves further exploration.

CLINICAL TRIAL NUMBER

Not applicable.

Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease

BACKGROUND

Pregnancy is an educable and actionable life stage to address social determinants of health (SDOH) and lifelong cardiovascular disease (CVD) prevention. However, the link between a risk score that combines multiple neighborhood-level social determinants in pregnancy and the risk of long-term CVD remains to be evaluated.

OBJECTIVE

To examine whether neighborhood-level socioeconomic disadvantage measured by the Area Deprivation Index (ADI) in early pregnancy is associated with a higher 30-year predicted risk of CVD postpartum, as measured by the Framingham Risk Score.

STUDY DESIGN

An analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. Participant home addresses during early pregnancy were geocoded at the Census-block level. The exposure was neighborhood-level socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]) measured in the first trimester. Outcomes were the predicted 30-year risks of atherosclerotic cardiovascular disease (ASCVD, composite of fatal and nonfatal coronary heart disease and stroke) and total CVD (composite of ASCVD plus coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure) using the Framingham Risk Score measured 2 to 7 years after delivery. These outcomes were assessed as continuous measures of absolute estimated risk in increments of 1%, and, secondarily, as categorical measures with high-risk defined as an estimated probability of CVD ≥10%. Multivariable linear regression and modified Poisson regression models adjusted for baseline age and individual-level social determinants, including health insurance, educational attainment, and household poverty.

RESULTS

Among 4309 nulliparous individuals at baseline, the median age was 27 years (interquartile range [IQR]: 23-31) and the median ADI was 43 (IQR: 22-74). At 2 to 7 years postpartum (median: 3.1 years, IQR: 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR: 1.5, 3.5) and of total CVD was 5.5% (IQR: 3.7, 7.9); 2.2% and 14.3% of individuals had predicted 30-year risk ≥10%, respectively. Individuals living in the highest ADI tertile had a higher predicted risk of 30-year ASCVD % (adjusted ß: 0.41; 95% confidence interval [CI]: 0.19, 0.63) compared with those in the lowest tertile; and those living in the top 2 ADI tertiles had higher absolute risks of 30-year total CVD % (T2: adj. ß: 0.37; 95% CI: 0.03, 0.72; T3: adj. ß: 0.74; 95% CI: 0.36, 1.13). Similarly, individuals living in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (adjusted risk ratio [aRR]: 2.21; 95% CI: 1.21, 4.02) and total CVD ≥10% (aRR: 1.35; 95% CI: 1.08, 1.69).

CONCLUSION

Neighborhood-level socioeconomic disadvantage in early pregnancy was associated with a higher estimated long-term risk of CVD postpartum. Incorporating aggregated SDOH into existing clinical workflows and future research in pregnancy could reduce disparities in maternal cardiovascular health across the lifespan, and requires further study.

Choline in pregnant women: a systematic review and meta-analysis

Context: Choline is a critical nutrient. Inadequate choline intake during pregnancy increases the risk of adverse maternal and offspring health.

OBJECTIVE

A systematic review and meta-analysis were conducted to examine the current recommendations for choline intake by pregnant women, estimate the overall prevalence of pregnant women with adequate choline intake, and explore associations between maternal choline level and adverse pregnancy outcomes (APOs).

METHODS

Choline recommendations for pregnant women were assessed from eight nutrient guidelines of the United States, United Kingdom, Canada, Australia, Asia, International Federation of Gynecology and Obstetrics, and World Health Organization. Data on the prevalence of pregnant women with adequate choline intake and the association between maternal choline level and APOs were collected from 5 databases up to May 2023. Meta-analyses with random effects and subgroup analyses were performed for the pooled estimate of prevalence and association.

RESULTS

Five recent nutrition guidelines from the United States (United States Department of Agriculture), United States (Food and Drug Administration), Canada, Australia, and the International Federation of Gynecology and Obstetrics have emphasized the importance of adequate choline intake for pregnant women. Of 27 publications, 19 articles explored the prevalence and 8 articles explored the association. Meta-analysis of 12 prevalence studies revealed a concerning 11.24% (95% confidence interval, 6.34-17.26) prevalence of pregnant women with adequate choline intake recommendations. A meta-analysis of 6 studies indicated a significant association between high maternal choline levels and a reduced risk of developing APOs, with an odds ratio of 0.51 (95% confidence interval, 0.40-0.65).

CONCLUSION

The existing guidelines highlight the importance of choline in supporting maternal health and fetal development during pregnancy. Furthermore, a high maternal choline level was likely to be associated with a lower risk of APOs. However, 88.76% of pregnant women do not achieve the optimal choline intake. Therefore, specific policies and actions may be necessary to improve choline intake in pregnant women's care and support the well-being of pregnant women.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CDR42023410561.

Exploring the acceptability of a risk prediction tool for cardiometabolic risk (gestational diabetes and hypertensive disorders of pregnancy) for use in early pregnancy: A qualitative study

PROBLEM/ BACKGROUND

The acceptability of providing women with personalised cardiometabolic risk information using risk prediction tools early in pregnancy is not well understood.

AIM

To explore women's and healthcare professionals' perspectives of the acceptability of a prognostic, composite risk prediction tool for cardiometabolic risk (gestational diabetes and/or hypertensive disorders of pregnancy) for use in early pregnancy.

METHODS

Semi-structured interviews were conducted to explore the acceptability of cardiometabolic risk prediction tools, preferences for risk communication and considerations for implementation into antenatal care. The Theoretical Framework of Acceptability informed interview questions. Transcripts were thematically analysed.

FINDINGS

Women ≤24 weeks' gestation (n = 13) and healthcare professionals (n = 8), including midwives (n = 2), general practitioners (n = 2), obstetricians (n = 2), an endocrinologist (n = 1) and cardiologist (n = 1) participated. Participants indicated that providing personalised risk information is only appropriate when preventative measures can be initiated to mitigate risks. Differentiating the risk for each condition (single risk outputs) was often preferred to composite risk outputs to enable targeted monitoring and management. Defining conditions and risks to mother/baby, visually depicting personalised risk scores, and providing clear, patient-centred clinical management plans were recommended. Supportive clinical policy changes, staff engagement/training, and integration into electronic health records were suggested to facilitate uptake into routine antenatal care.

CONCLUSION

Women and healthcare professionals suggested that early pregnancy cardiometabolic risk prediction tools may be acceptable when preventative interventions are available to reduce risks. Risk prediction tools with integrated patient-centred education materials may promote timely access and engagement with preventative interventions to optimise women's current and future health.

Differences between MINOCA and type 2 myocardial infarction: An ITALIAN observational study

BACKGROUND

Myocardial infarction with non-obstructive coronary arteries (MINOCA) and type 2 myocardial infarction (MI), both presenting as non-ST-elevation MI (NSTEMI), are often grouped together due to overlapping symptoms. The aim of our study is to compare their characteristics and prognosis to distinguish between them.

METHODS

Among 7815 patients with NSTEMI who underwent coronary angiography between 2005 and 2022 we identified 538 patients with diagnosis of MINOCA (n = 301; 3,9 %) and type 2 MI (n = 237; 3 %). The outcome was a composite of all-cause mortality, non-fatal MI, hospitalisation for heart failure (HF) and transitory ischemic attack or non-fatal stroke.

RESULTS

The mean age of the entire cohort was 68 (11.5) years, with women being the most frequently represented group (65 %). Comparing the sub-cohorts, MINOCA patients were younger (66.3 (11.7) Vs. 70.6 (11) years, p < 0.01), and less likely to have typical cardiovascular risk than type 2 MI patients. At multivariable analysis different clinical (age, heart rate, typical chest pain, palpitations, postmenopausal status), and instrumental (cardiac rhythm, ST-segment changes, diastolic dysfunction, hypo/akinesia with non-coronary distribution) variables were independent predictors of MINOCA with AUC of 0.83 [95 % CI, 0.78-0.88], p < 0.01 at ROC analysis. At a median follow-up of 61 (IQR 34-100) months, MINOCA patients had significantly lower rate of the composite endpoint compared to type 2 MI (20 % Vs. 32 %, p < 0.01).

CONCLUSIONS

MINOCA cohort was associated with different characteristics compared to type 2 MI and had a better prognosis despite the number of events was not negligible.

Adherence to Healthy Prepregnancy Lifestyle and Risk of Adverse Pregnancy Outcomes: A Prospective Cohort Study

OBJECTIVE

To quantify the association between a combination of modifiable prepregnancy lifestyle factors and the risk of adverse pregnancy outcomes (APOs).

DESIGN

Prospective cohort study.

SETTING

The Japan Environment and Children's Study.

POPULATION

A total of 79 703 pregnant Japanese women without chronic disease.

METHODS

Maternal lifestyle before pregnancy was assessed using a self-administered questionnaire. A healthy lifestyle score (HLS, 0-5 points) was calculated based on adherence to five prepregnancy healthy lifestyle factors: healthy weight, high-quality diet, regular physical activity, not smoking, and not drinking alcohol. Relative risks (RRs) and 95% credible intervals (CrIs) were estimated using a Bayesian log-binomial regression model.

MAIN OUTCOME MEASURES

Composite APOs, defined as the development of any APO, including gestational diabetes, hypertensive disorders of pregnancy, preterm birth, low birth weight, and small-for-gestational-age, transcribed from medical records.

RESULTS

A total of 13 894 women (17.4%) experienced one or more APOs. HLS was inversely associated with the risk of APOs in a dose-response manner. Women with an HLS of 5 points had a 33% (RR 0.67; 95% CrI, 0.61-0.74) lower risk of APOs than those with the lowest HLS (0-1 points). The population attributable fraction of five healthy lifestyle factors was 10.3%. A 1-point increase of HLS could have reduced APO cases by 6.6%.

CONCLUSIONS

A higher HLS was associated with a lower risk of APOs, suggesting that adopting a healthy lifestyle before pregnancy may reduce the risk of APOs, which can increase the risk of future chronic diseases in both mother and child.

Hypertensive Disorders of Pregnancy and Brain Health in Midlife: The CARDIA Study

BACKGROUND

To understand the role of hypertensive disorders of pregnancy (HDP), including preeclampsia and gestational hypertension (GH), in brain health earlier in life, we investigated the association of HDP with midlife cognition and brain health.

METHODS

We studied a prospective cohort of women, baseline age 18 to 30 years, who were assessed at study years 25 and 30 with a cognitive battery and a subset with brain magnetic resonance imaging. A history of HDP was defined based on self-report. We conducted linear regression to assess the association of a history of preeclampsia, GH, or no HDP with cognition and brain magnetic resonance imaging white matter hyperintensities.

RESULTS

Among 1441 women (mean age, 55.2±3.6 years), 202 reported preeclampsia and 112 reported GH. GH was associated with worse cognitive performance: global cognition (mean score, 23.2 versus 24.0; P=0.018), processing speed (67.5 versus 71.3; P=0.01), verbal fluency (29.5 versus 31.1; P=0.033), and a trend for executive function (24.3 versus 22.6; P=0.09), after multivariable adjustment. GH was associated with a greater 5-year decline in processing speed (mean change, -4.9 versus -2.7; P=0.049) and executive function (-1.7 versus 0.3; P=0.047); preeclampsia was associated with a greater 5-year decline on delayed verbal memory (-0.3 versus 0.1; P=0.041). GH and preeclampsia were associated with greater white matter hyperintensities in the parietal and frontal lobes, respectively.

CONCLUSIONS

GH and preeclampsia are associated with cognition and white matter hyperintensities during midlife, with differences in cognitive domains and brain lobes. Women with HDP may need to be closely monitored for adverse brain outcomes starting in midlife.

Early-onset atherosclerotic cardiovascular disease

Recent trends indicate a concerning increase in early-onset atherosclerotic cardiovascular disease (ASCVD) among younger individuals (men aged <55 years women aged <65 years). These findings highlight the pathobiology of ASCVD as a disease process that begins early in life and underscores the need for more tailored screening methods and preventive strategies. Increasing attention has been placed on the growing burden of traditional cardiometabolic risk factors in young individuals while also recognizing unique factors that mediate risk of pre-mature atherosclerosis in this demographic such as substance use, socioeconomic disparities, adverse pregnancy outcomes, and chronic inflammatory states that contribute to the increasing incidence of early ASCVD. Additionally, mounting evidence has pointed out significant disparities in the diagnosis and management of early ASCVD and cardiovascular outcomes based on sex and race. Moving towards a more personalized approach, emerging data and technological developments using diverse tools such as polygenic risk scores and coronary artery calcium scans have shown potential in earlier detection of ASCVD risk. Thus, we review current evidence on causal risk factors that drive the increase in early ASCVD and highlight emerging tools to improve ASCVD risk assessment in young individuals.

The Impact of Dietary Fiber on Cardiovascular Diseases: A Scoping Review

Background/Objectives: Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality globally, placing an ever-increasing burden on healthcare systems. Dietary factors play a crucial role in the development and progression of CVD. Among them, dietary fiber has emerged as a potential modifiable factor with the potential to impact CVD risk. However, the specific and independent effects of dietary fiber on CVD are still not fully understood, making this area of research both challenging and of great significance. Methods: The publications of human studies involving the impact of dietary fiber on CVD were retrieved from databases including PubMed, Embase, Web of Science, Scopus, Cochrane Library, CBM, and China National Knowledge Infrastructure (CNKI). A search was conducted within these databases for studies published between 2014 and 20 March 2024. The included literature was screened and summarized. Results: A total of seven articles were included, and the related studies encompassed various types of dietary fiber, including soluble and insoluble dietary fiber, as well as research from different countries and regions. The outcome indicators involved an important measure known as the hazard ratio (HR). Conclusions: Increasing the intake of dietary fiber could reduce the risk of cardiovascular diseases through various mechanisms. To increase the consumption of dietary fiber from multiple sources, it would be beneficial to develop and promote healthcare interventions to enhance people's awareness of the health benefits of dietary fiber, promote the consumption of fiber-rich foods, and advocate for a healthier diet.

Primary and secondary cardiovascular prevention through life cycles in women. Consensus document of the SEC-GT CVD in Women, ACP-SEC, SEGO, AEEM, SEEN, semFYC, SEMERGEN, AEP, and AEM

This consensus document on cardiovascular disease in women summarizes the views of a panel of experts organized by the Working Group on Women and Cardiovascular Disease of the Spanish Society of Cardiology (SEC-GT CVD in Women), and the Association of Preventive Cardiology of the SEC (ACP-SEC). The document was developed in collaboration with experts from various Spanish societies and associations: the Spanish Society of Gynecology and Obstetrics (SEGO), the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Association for the Study of Menopause (AEEM), the Spanish Association of Pediatrics (AEP), the Spanish Society of Primary Care Physicians (SEMERGEN), the Spanish Society of Family and Community Medicine (semFYC), and the Spanish Association of Midwives (AEM). The document received formal approval from the SEC. This consensus serves as a guide for the clinical community on the diagnostic approach and management of cardiovascular health during the stages or life cycles of women: adolescence, the menopausal transition, postpartum disorders, and other gynecologic conditions. It is based on current evidence and best available practices.

The association between periodontal disease and adverse pregnancy outcomes: a bibliometric analysis from 2000 to 2023

Background

Periodontal disease (PD) refers to a chronic inflammatory disorder affecting the supporting tissues of the teeth triggered by bacterial infection and is recognized to promote systemic inflammation, leading to dysfunction in specific organs. Adverse pregnancy outcomes (APOs), including preterm birth, small for gestational age infants, gestational diabetes and preeclampsia, are linked to pregnancy complications. Recently, the correlation between periodontal disease and adverse pregnancy outcomes has garnered global attention. However, bibliometric studies in this area remain limited. This study aimed to visualize knowledge framework and research trends concerning the relationship between periodontal disease and adverse pregnancy outcomes from 2000 to 2023 through bibliometric approaches.

Methods

On September 22, 2024, articles and reviews on the connection between periodontal disease and adverse pregnancy outcomes were retrieved from the Web of Science Core Collection (WOSCC). CiteSpace [6.3.R1 (64-bit) Advanced] was used to perform knowledge mapping and bibliometric studies.

Results

Over the past 23 years, 932 articles from 73 countries were collected, with the U.S. contributing over one-third (355), followed by Brazil (85) and India (59). The literature in this field has experienced multiple growth phases since 2000, with particularly rapid growth observed after 2019. The University of North Carolina (n = 34, 3.65%) is the leading institution in terms of publication output, primarily representing the U.S. Notably, the Journal of Periodontology and the American Journal of Obstetrics and Gynecology are the most frequently cited journals in the fields of periodontology and obstetrics, respectively. These publications are authored by 94 researchers, with Steven Offenbacher being both the most productive and most highly cited author, making significant contributions to the field. A visual analysis of keywords identifies "oral microbiota," "oral health," "adverse pregnancy outcomes," and "global burden" as emerging research hotspots in exploring the correlation between periodontal disease and adverse pregnancy outcomes.

Conclusions

This first bibliometric and visual analysis of periodontal disease and adverse pregnancy outcomes offers a concise overview of the field and suggests future research should focus on risk factors, high-risk populations, oral microbiota, mechanisms, interventions, and international collaboration.

Pregnancy Complications and Long-Term Atherosclerotic Cardiovascular Disease Risk

PURPOSE OF REVIEW

Discuss the relationship between pregnancy complications and long-term atherosclerotic cardiovascular disease (ASCVD) risk.

RECENT FINDINGS

A large body of research confirms an association between pregnancy complications and increased short and long-term ASCVD risk and seeks to understand mechanisms for these associations. Social determinants of health continue to have a critical impact on the prevalence of adverse pregnancy outcomes (APOs) and long term ASCVD risk. Of the APOs, hypertensive disorders of pregnancy (HDP) are associated with the highest ASCVD risk. Additionally, recent research shows an association between APOs and microvascular coronary heart disease. APOs are associated with increased risk of ASCVD, however there is conflicting evidence on whether there is a causal relationship between APOs and ASCVD or if APOs are simply a marker of ASCVD risk. Current ASCVD risk models do not incorporate a history of APOs, therefore it is imperative that healthcare providers take a reproductive health history and account for pregnancy complications when counseling patients on long-term cardiovascular risk. Non-invasive modalities such as coronary artery calcium scoring can be considered as an adjunct, but further research is warranted to determine which patients would benefit most.

Hypertensive disorders of pregnancy and gestational diabetes mellitus and predicted risk of maternal cardiovascular disease 10-14 years after delivery: A prospective cohort

AIMS

Studies evaluating the relationship between adverse pregnancy outcomes (APOs), namely hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM), with the estimated risk of atherosclerotic cardiovascular disease (ASCVD) remains limited and could inform patient-centred decision-making in the postpartum period. We examined whether HDP or GDM were associated with a higher 10- and 30-year predicted risk of ASCVD measured 10-14 years after delivery.

METHODS

A secondary analysis from the international prospective Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (2013-2016) cohort. The exposures were HDP or GDM (untreated according to the International Association of the Diabetes and Pregnancy Study Groups criteria). Outcomes were 10- and 30-year predicted risk of ASCVD (composite of fatal and non-fatal coronary heart disease and stroke) as quantified by the validated Framingham Risk Score as a continuous measure, and secondarily, at thresholds used for clinical decision-making of ≥7.5% for 10-year predicted risk and ≥20% for 30-year predicted risk.

RESULTS

Of 4432 individuals at a median age of 30.5 years and a median gestational age of 27.9 weeks at pregnancy enrollment, 10.7% developed HDP and 13.7% developed GDM. At 10-14 years after delivery, individuals with HDP had a higher 10-year predicted risk of ASCVD (least squares mean: 2.9% vs. 2.2%; adj. β: 0.59; 95% CI: 0.41-0.77) and a higher 30-year predicted risk of ASCVD (7.7% vs. 6.1%; adj. β: 1.27; 95% CI: 0.81-1.72) compared with those without HDP. Similarly, individuals with GDM had a higher predicted risk of ASCVD (10-year: 3.2% vs. 2.1%; adj. β: 0.51; 95% CI: 0.34-0.67 and 30-year: 8.8% vs. 5.8%; adj. β: 1.56; 95% CI: 1.11-2.01) compared with those without GDM. These results were similar when predicted ASCVD risk was assessed at thresholds of ≥7.5% at 10 years and ≥20% at 30 years.

CONCLUSION

Individuals who experienced HDP or GDM had a higher predicted 10- and 30-year risk of ASCVD measured 10-14 years after delivery compared with individuals who did not experience these APOs.

Postpartum Remote Health Coaching Intervention for Individuals With a Hypertensive Disorder of Pregnancy: Proof-of-Concept Study

Background

Cardiovascular disease (CVD) is the leading cause of death among women in America. Hypertensive disorders of pregnancy (HDP) negatively impact acute and long-term cardiovascular health, with approximately 16% of all pregnancies affected. With CVD 2-4 times more likely after HDP compared to normotensive pregnancies, effective interventions to promote cardiovascular health are imperative.

Objective

With postpartum physical activity (PA) interventions after HDP as an underexplored preventative strategy, we aimed in this study to assess (1) the feasibility and acceptability of a remotely delivered PA intervention for individuals with HDP 3-6 months postpartum and (2) changes in average steps per day, skills related to PA behavior, and postpartum blood pressure (BP).

Methods

A remotely delivered 14-week health coaching intervention was designed based on prior formative work. The health coaching intervention called the Hypertensive Disorders of Pregnancy Postpartum Exercise (HyPE) intervention was tested for feasibility and acceptability with a single-arm proof-of-concept study design. A total of 19 women who were 3-6 months postpartum HDP; currently inactive; 18 years of age or older; resided in Iowa; and without diabetes, kidney disease, and CVD were enrolled. Feasibility was assessed by the number of sessions attended and acceptability by self-reported satisfaction with the program. Changes in steps achieved per day were measured with an activPAL4 micro, PA behavior skills via validated surveys online, and BP was assessed remotely with a research-grade Omron Series 5 (Omron Corporation) BP monitor.

Results

Participants at enrollment were on average 30.3 years of age, 4.1 months postpartum, self-identified as non-Hispanic White (14/17, 82%), in a committed relationship (16/17, 94%), and had a bachelor's degree (9/17, 53%). A total of 140 of 152 possible health coaching sessions were attended by those who started the intervention (n=19, 92%). Intervention completers (n=17) indicated they were satisfied with the program (n=17, 100%) and would recommend it to others (n=17, 100%). No significant changes in activPAL measured steps were observed from pre- to posttesting (mean 138.40, SD 129.40 steps/day; P=.75). Significant improvements were observed in PA behavior skills including planning (mean 5.35, SD 4.97 vs mean 15.06, SD 3.09; P<.001) and monitoring of PA levels (mean 7.29, SD 3.44 vs mean 13.00, SD 2.45; P<.001). No significant decreases were observed for systolic (mean -1.28, SD 3.59 mm Hg; Hedges g=-0.26; P=.16) and diastolic BP (mean -1.80, SD 5.03 mm Hg; Hedges g=-0.44; P=.12).

Conclusions

While PA behaviors did not change, the intervention was found to be feasible and acceptable among this sample of at-risk women. After additional refinement, the intervention should be retested among a larger, more diverse, and less physically active sample.

Severe Maternal Morbidity Associated With Chronic Hypertension, Preeclampsia, and Gestational Hypertension

Importance

Chronic hypertension and preeclampsia are leading risk enhancers for maternal-neonatal morbidity and mortality. Severe maternal morbidity (SMM) indicators include heart, kidney, and liver disease, but studies have not excluded patients with preexisting diseases that define SMM. Thus, SMM risks for uncomplicated chronic hypertension specific to preeclampsia remain unclear.

Objective

To determine SMM rates and estimate relative risks associated with hypertensive disorders of pregnancy among patients with and without chronic hypertension unencumbered by preexisting vascular or end organ diseases.

Design, Setting, and Participants

This retrospective cohort study used longitudinal health data from electronic health records from patients within a community-based, integrated health care system in northern California. The study cohort selected 263 518 pregnant patients without pregestational heart, kidney, or liver disease entering prenatal care at 14 weeks' gestation or earlier and delivering a singleton stillbirth or live birth in 2009 to 2019. The data were analyzed between February 2022 and March 2024.

Exposures

Five joint subgroups combining chronic hypertension status and the hypertensive disorders developing during pregnancy, defined as follows: (1) chronic hypertension with superimposed preeclampsia, (2) chronic hypertension and no preeclampsia, (3) no chronic hypertension with preeclampsia, (4) gestational hypertension, and (5) no chronic hypertension and no preeclampsia or gestational hypertension (reference group).

Main Outcomes and Measures

The main outcome was SMM rates at delivery hospitalization (cases per 10 000 births) using the Centers for Disease Control and Prevention criteria (≥1 of 21 indicators to define SMM) obtained from electronic health records. Modified Poisson regression models estimated crude and adjusted relative risks (aRRs) and 95% CIs of SMM associated with the chronic hypertension and developing hypertensive disorders of pregnancy groups vs the reference group (no chronic hypertension and no preeclampsia or gestational hypertension) adjusted for clinical, sociodemographic, social, and behavioral covariates.

Results

The analysis included a total of 263 518 pregnant patients (mean [SD] age at delivery, 31.0 [5.3] years), including 249 892 patients without chronic hypertension (4.7% developed preeclampsia) and 13 626 patients with chronic hypertension (31.5% developed superimposed preeclampsia). The highest SMM rates occurred in the no chronic hypertension with preeclampsia (934.3 [95% CI, 882.3-988.3] cases per 10 000 births) and the chronic hypertension with superimposed preeclampsia (898.3 [95% CI, 814.5-987.8] cases per 10,000 births) groups. Lower SMM rates occurred in the chronic hypertension and no preeclampsia (195.1 [95% CI, 168.0-225.2] cases per 10,000 births), gestational hypertension (312.7 [95% CI, 281.6-346.1] cases per 10,000 births), and no chronic hypertension and no preeclampsia or gestational hypertension (165.8 [95% CI, 160.6-171.2] cases per 10,000 births) groups (P < .001). Compared with the no chronic hypertension and no preeclampsia or gestational hypertension group, risks of SMM were significantly higher for the chronic hypertension with superimposed preeclampsia group (aRR, 4.97 [95% CI, 4.46-5.54]), no chronic hypertension with preeclampsia group (aRR, 5.12 [95% CI, 4.79-5.48]), chronic hypertension and no preeclampsia group (aRR, 1.17 [95% CI, 1.003-1.36]; P = .046), and the gestational hypertension group (aRR, 1.78 [95% CI 1.60-1.99]).

Conclusions and Relevance

This cohort study found that the highest SMM rates at delivery hospitalization occurred for preeclampsia superimposed on chronic hypertension and preeclampsia without chronic hypertension, while gestational hypertension had intermediate rates of SMM. The patients with chronic hypertension who did not develop preeclampsia had SMM rates that were nearly the same as the lowest-risk patients without chronic hypertension who did not develop preeclampsia or gestational hypertension. These findings provide evidence that prevention of preeclampsia among patients with uncomplicated chronic hypertension is paramount to mitigating maternal morbidity.

History of Pregnancy Loss and Risk for Higher Midlife Blood Pressure in Parous Females

Introduction: Pregnancy loss has been associated with later cardiometabolic conditions, potentially due to shared underlying etiology, but associations with midlife blood pressure (BP) remain unclear. Methods: We examined participants enrolled 1999-2002 in prospective Project Viva. At midlife ∼18 years after enrollment, we collected lifetime pregnancy history and measured BP. Exposures included any pregnancy loss or number of pregnancy losses. Outcomes were systolic and diastolic BP (SBP, DBP), and American Heart Association (AHA) BP categories. We performed multivariable regression adjusted for race and ethnicity, education, income, perceived body size at age 10 years, and age at outcome. Results: Of 623 participants, 33.7% reported pregnancy loss, 9.6% had elevated BP, and 34.8% had hypertension. Mean(±standard deviation) age was 50.7 ± 5.0 years, SBP 118.1 ± 15.6 mmHg, and DBP 74.8 ± 11.5 mmHg. In adjusted models, any pregnancy loss was associated with higher SBP (β = 2.25 mmHg, 95% confidence interval [CI]: -0.23, 4.78). Strongest associations with SBP were among those with first pregnancy loss ≥35 years (β = 5.58 mmHg, 95% CI: 1.76, 9.40 versus 0 pregnancy losses and first pregnancy <35 years). All associations with DBP were nonsignificant but similar in direction. For AHA outcomes, pregnancy loss was associated with higher risk for elevated BP (relative-risk ratio [RRR] = 2.93, 95% CI: 1.58, 5.43) but not with hypertension (RRR = 1.45, 95% CI: 0.95, 2.22) versus normotension. In models examining race and ethnicity, SBP was higher among non-Hispanic White and Hispanic individuals with pregnancy loss; non-Hispanic Black individuals had higher BP regardless of pregnancy loss status. Conclusions: History of pregnancy loss was associated with higher SBP and elevated BP category at midlife. These findings highlight reproductive history as an important consideration for cardiopreventive strategies and interventions.

Relationship Between Race, Predelivery Cardiology Care, and Cardiovascular Outcomes in Preeclampsia/Eclampsia Among a Commercially Insured Population

BACKGROUND

It is unknown whether predelivery cardiology care is associated with future risk of major adverse cardiovascular events (MACE) in preeclampsia/eclampsia (PrE/E). We sought to determine the cumulative incidence of MACE by race and whether predelivery cardiology care was associated with the hazard of MACE up to 1 year post-delivery for Black and White patients with PrE/E.

METHODS

Using Optum's de-identified Clinformatics Data Mart Database, we identified Black and White patients with PrE/E who had a delivery between 2008 and 2019. MACE was defined as the composite of heart failure, acute myocardial infarction, stroke, and death. Cumulative incidence functions were used to compare the incidence of MACE by race. Regression models were used to assess the hazard of MACE by cardiology care for each race. Separate hazards were calculated for the first 14 days and the remainder of the year.

RESULTS

Among 29 336 patients (83.4% White patients, 16.6% Black patients, 99.5% commercially insured, mean age: 30.9 years) with PrE/E, 11.2% received cardiology care (10.9% White patients, 13.0% Black patients). Black patients had higher incidence of MACE than White patients at 1 year post-delivery (2.7% versus 1.4%) with the majority within 14 days of delivery (Black patients: 58.7%; White patients: 67.8%). After adjusting for age and comorbidities, receipt of cardiology care was associated with a lower hazard of MACE for White patients within 14 days after delivery (hazard ratio, 0.31 [95% CI, 0.21-0.46]; P<0.001) but not Black patients (hazard ratio, 1.00 [95% CI, 0.60-1.67]; P=0.999). The effect of the interaction between race and cardiology care was significant in the first 14 days (P<0.001) but not the remainder of the year (P=0.56).

CONCLUSIONS

Among a well-insured population of patients with PrE/E, Black patients had a higher cumulative incidence of MACE up to a year post-delivery. Cardiology care was associated with a lower hazard of MACE only for White patients during the first 14 days after delivery.

[Arterial stiffness detection in women with recent history of pre-eclampsia]

INTRODUCTION

Preeclampsia (PE) is a complication of hypertensive disorders of pregnancy, whose pathophysiology involves endothelial dysfunction. Early establishment of subclinical vascular lesions such as arterial stiffness (AS) could explain the development of cardiovascular disease later in life. AS can be assessed non-invasively using carotid-femoral pulse wave velocity (cf-PWV), aortic systolic blood pressure (ao-SBP) and augmentation index (IAx). We aim to determine cf-PWV, ao-SBP and AIx in women who recently underwent PE and compare it with a control group.

MATERIALS AND METHODS

Cross-sectional study, carried out from 2022 to 2023 in Argentina. Group 1: women who developed PE.

EXCLUSION CRITERIA

history of chronic hypertension, diabetes, autoimmune disease, chronic kidney disease, cardiovascular disease, PE in previous pregnancies; treatment with calcium antagonists during pregnancy; treatment with calcium antagonists, angiotensin-converting enzyme inhibitors or diuretics in the postpartum period. Group 2: healthy postpartum periods. PWV-cf, ao-SBP and IAx were measured in the first 72hours postpartum using Aortic.

RESULTS

Seventy-onewomen were included: Group 1 (n=30); Group 2 (n=41). Group 1 presented higher PWV-cf=6.70±0.68 vs. 5.41±0.48 m/s (P<.0001); ao-SBP=118.3±9.6 vs. 101.2±9.8mmHg (P<.0001); and IAu=22.7±10.7 vs. 9.3±11.9% (P<.0001). In Group 1 there were 25 of 30 women who presented AS parameters (OR=8.50; 95% CI=3.32-15.29; P<.0001).

CONCLUSION

Patients with a recent history of PE showed higher cf-PWV, ao-SBP and AIx values, compatible with AS.

Maternal heart exhibits metabolic and redox adaptations post-uncomplicated pregnancy

Pregnancy may be a challenging period for the maternal systems and has been regarded as a stress test, as imperceptible/mild dysfunctions eventually present may be exacerbated during this period. The cardiovascular system is no exception, and several morphological and functional adaptations accompanying pregnancy have been described. However, long-term pregnancy-induced cardiac molecular alterations remain highly unexplored. The postpartum is marked by reverse remodeling of the pregnancy-induced cardiovascular adaptations, representing a possible critical period for assessing future maternal cardiovascular health. The current study explored the molecular and metabolic alterations in the cardiac tissue eight weeks after a physiological uncomplicated pregnancy. Female Sprague-Dawley rats were fed a chow diet through pregnancy, lactation, and weaning and compared to their non-pregnant counterparts. Eight weeks postpartum, increased levels of the phosphorylated form of AMPKα (Thr172) and its ratio to total AMPKα indicated possible alterations in cardiac metabolic flexibility, accompanied by increased Pparα and Hif1α transcripts levels. Additionally, postpartum hearts exhibited higher mitochondrial ATP and NADH levels without major changes in mitochondrial respiratory function. Elevated Nrf2 levels in the cardiac tissue suggested potential implications for cardiac redox balance, further supported by increased levels or activity of proteins directly regulated by Nrf2. The findings herein reported suggest that at eight weeks postpartum, molecular alterations induced by pregnancy, especially regarding redox balance, are still observed in the mothers' heart. These alterations present at late postpartum may open new avenues to understand the different risk for cardiovascular complications development after normal pregnancies.

Cardiovascular Disease Among Women and Birthing Individuals After Delivering a Child With Congenital Heart Disease

Background

Individuals have a higher risk of cardiovascular disease later in life if they give birth to a child with congenital heart disease (CHD). The mechanism of this association has not been well documented.

Objectives

The authors aimed to describe the prevalence of cardiovascular disease and risk factors in women and birthing individuals 18 to 23 years after delivery of a child with CHD compared to normative data.

Methods

A cross-sectional survey was distributed to mothers whose infants with CHD had undergone cardiac surgery in 1998 to 2003 and previously enrolled in a prospective observational study. We compared rates of cardiovascular disease and risk factors to age- and sex-matched parous women and birthing individuals from National Health and Nutrition Examination Survey.

Results

An attempt was made to contact 533 mothers; 222 (42%) completed the survey. The mean age was 52 years, 86% were White, and 69% completed college. Common cardiovascular risk factors were high cholesterol (32%), hypertension (27%), preterm delivery (32%), and hypertensive disorder of pregnancy (13%). Overall, 15.3% reported presence of cardiovascular disease as defined by atherosclerotic cardiovascular disease, heart failure, valvular disease, or arrhythmia. A higher severity of child's CHD was significantly associated with self-reported maternal cardiovascular disease (P = 0.03). Compared to National Health and Nutrition Examination Survey participants, rates of atherosclerotic cardiovascular disease and cardiovascular risk factors were similar.

Conclusions

Women and birthing individuals whose children had CHD had similar rates of cardiovascular risk factors and disease at 18 to 23 years after delivery, compared to age- and sex-matched parous controls. Higher severity of child's CHD was associated with increased risk of maternal cardiovascular disease, an association that should be evaluated in future studies.

Patient awareness of long-term cardiovascular and metabolic disease risks after hypertensive disorders of pregnancy in Japan

AIM

Given the increasing recognition of the importance of postpartum follow-up care for women with a history of hypertensive disorders of pregnancy (HDP) to mitigate their future risk of cardiovascular and metabolic diseases, here we aimed to evaluate the current status of postpartum follow-up care in Japan and explore the challenges to its implementation.

METHODS

A web-based survey was conducted using a smartphone application among postpartum women between March and May 2024 to assess their knowledge of HDP-related future risk and postpartum follow-up care.

RESULTS

A total of 880 valid responses were obtained, 73 (8.3%) of which were from women with a history of HDP. Of them, 56.2% were aware of the heightened risk of cardiovascular disease and even fewer knew about the risks of metabolic syndrome (37.0%) and the preventive use of low-dose aspirin (12.3%); in fact, 31.5% reported receiving no information about their risk or preventive measures from healthcare providers. Furthermore, 43.8% did not consult specialists or attend regular checkups after their 1-month checkup. Among women with a history of HDP, those who received information and guidance were more likely to implement behavioral changes than those who did not.

CONCLUSIONS

Patient awareness level of HDP-related risk was low and the information provided by their healthcare professionals was insufficient, indicating that postpartum follow-up care in Japan is not satisfactory. This study highlights the need for improved educational strategies and systematic follow-up protocols to ensure that women are adequately informed and supported in managing their long-term health risks.

Haplotyping-based preimplantation genetic testing for inherited cardiovascular disease: a multidisciplinary approach

Given the high morbidity, mortality, and hereditary risk of cardiovascular diseases (CVDs), their prevention and control have garnered widespread attention and remain central to clinical research. This study aims to assess the feasibility and necessity of haplotyping-based preimplantation genetic testing for the prevention of inherited CVD. A total of 15 preimplantation genetic testing for monogenic defect (PGT-M) cycles were performed in 12 CVD families from January 2016 to July 2022. All couples were affected by CVDs and carried specific causative genes (including MYH7, MYBPC3, TTN, TPM1, LMNA, KCNQ1, FBN1 and LDLR). Among the 10 couples with adequate genetic pedigree information, we utilized the karyomapping assay to obtain single-nucleotide polymorphisms (SNPs) allele data. For the 2 couples who had no reference in their family, we used single sperm next-generation sequencing (NGS) to realize haplotype construction. Linkage analysis was performed to deduce embryonic genotype, and aneuploidy was screened simultaneously. Prenatal diagnostic testing via amniocentesis at 18-22 weeks of gestation was performed to verify the genetic conditions of transferred embryos. In total, 120 embryos were examined in this study, and the results showed that only 26.7% (32/120) were mutation-free and euploid-confirmed embryos. Additionally, for female CVD patients, we convened a multidisciplinary team (MDT) to advise the couple on their fertility concerns and management measures during pregnancy and delivery. With our cooperation, 10 couples successfully obtained healthy babies not carrying the pathogenic mutations. The results of prenatal diagnostics were consistent with the results of PGT-M. Our study demonstrates that PGT-M based on haplotype analysis is reliable and necessary for the prevention of inherited CVDs. It also highlights the important value of multidisciplinary collaboration for CVD prevention and treatment. Inherited cardiovascular diseases (CVDs) present as a huge challenge for modern medical and health systems. Hundreds of genetic variants have been reported to cause CVD and the number of people with the disease is enormous and still on the rise globally. Here we recruited twelve couples suffering from inherited CVD and provided them with effective pre-implantation genetic testing for monogenic defect (PGT-M) strategy to avoid the occurrence of genetic defects in the offspring. Specifically, after embryo biopsy, we utilized karyomapping assay (for 10 couples with a family history) or next-generation sequencing (NGS) (for 2 couples having no reference in their pedigree) to obtain single-nucleotide polymorphisms (SNPs) allele data and then performed linkage analysis to deduce embryonic genotype. A total of 120 embryos from 15 PGT-M cycles were examined and 12 variants in 8 genes linked to inherited CVD were identified. Thirty-two mutation-free and euploid confirmed embryos were considered suitable for embryo transfer. Besides, for female CVD patients, we called up a multidisciplinary team (MDT) advising the couple on their fertility concerns and management measures of pregnancy and delivery. With our cooperation, 10 couples successfully obtain healthy babies not carrying the pathogenic mutations. Our study further validated the reliability of PGT-M utilizing linkage analysis as a means to prevent the transmission of genetic disorders to future generations, and offered valuable insights for multidisciplinary clinical practices on CVD.

Systematic druggable genome-wide Mendelian randomization identifies therapeutic targets for hyperemesis gravidarum

BACKGROUND

Hyperemesis gravidarum (HG), excessive vomiting in pregnancy, occurs in 0.3-10.8% of pregnancies and is associated with maternal and fetal morbidity. Despite the existence of several off-label treatment options that have shown clinical effectiveness in managing HG symptoms, the variability in treatment response highlights the need for more effective therapies. Our study aims to identify novel therapeutic targets that could lead to the development of additional, more effective treatment options.

METHODS

A two-sample Mendelian randomization (MR) analysis was performed to estimate the causal effects of blood-druggable genes on HG. Summary statistics for HG were obtained from the FinnGen study and UK Biobank. Cis-expression quantitative trait loci (cis-eQTL) for blood druggable genes were obtained from the eQTLGen Consortium and used as genetic instrumental variables. Another MR method, summary level mendelian randomization (SMR), was used to further confirm our results. We also used eQTL data of other vomiting-related tissues, brain regions, and esophagus, to validate our MR results. Finally, the potential side effects of the druggable genes for HG treatment were assessed using a phenome-wide MR.

RESULTS

Overall, 2499 unique druggable genes were gathered. Two blood drug targets (OVGP1 and LGALS1) showed significant MR results in two independent datasets. No significant heterogeneity of instrumental variables or pleiotropy was detected. In addition, SMR analysis further confirmed the significance of these two prior druggable genes in the brain and esophagus tissues. Further phenome-wide MR analysis revealed no association between genetic proxies of OVGP1, and LGALS1 has been detected in increasing the risk of adverse pregnancy outcomes and other common diseases.

CONCLUSIONS

This study provides genetic evidence that targeting two druggable genes for HG has potential therapeutic advantages. This information is of considerable value in guiding and prioritizing the development of more effective therapies for HG.

Associations between Health-Related Social Needs and Postpartum Linkage to Care

INTRODUCTION

Ongoing care after pregnancy is recommended. Health-related social needs are recognized barriers to care, yet their pregnancy-related prevalence and associations with care are unknown. Researchers sought to assess (1) the prevalence of health-related social needs during pregnancy-based care, and (2) their associations with ongoing care after pregnancy.

METHODS

Electronic health record data were analyzed for individuals with prenatal care and delivery (2018-2021) at an urban safety-net hospital, with routine screening for health-related social needs multiple times during pregnancy through 6 weeks postpartum. Health-related social needs were summarized as screened negative, screened positive, or not screened. Linkage to ongoing care was defined as a completed non-urgent visit separate from pregnancy-based care, >6 weeks through 1 year postpartum. Data were collected in 2022 and analyzed in 2023-2024.

RESULTS

Of 4,941 individuals, 53% identified as Black non-Hispanic and 21% as Hispanic, 68% were publicly insured, and 93% completed ≥1 health-related social needs screening. Nearly 1 in 4 screened positive for health-related social needs, and 53% linked to ongoing care. Compared with those who screened negative for health-related social needs (n=3,491), linkage to ongoing care was similar among those who screened positive (n=1,079; adjusted risk ratio, aRR=1.04, 95% CI=0.98, 1.10) and lower among those not screened (n=371; aRR=0.77, 95% CI=0.68, 0.86).

CONCLUSIONS

Researchers identified a 24% prevalence of pregnancy-related health-related social needs and 53% subsequent linkage to ongoing care. Compared with screening negative for health-related social needs, screening positive was not associated with linkage to care, while being not screened was associated with a 20% lower likelihood of linkage to ongoing care.

Dietary Inflammatory Index Is Differentially Associated With Cardiometabolic Health After Pregnancy on the Basis of Adverse Pregnancy Outcome Exposure

BACKGROUND

Inflammatory diets may influence risk of cardiovascular disease. Subsequent cardiovascular disease is also influenced by adverse pregnancy outcomes (APOs) such as preterm birth, small-for-gestational-age birth, gestational diabetes, and hypertensive disorders of pregnancy. However, the associations between inflammatory diet, APOs, and cardiometabolic health remain unclear.

METHODS AND RESULTS

We used data from the nuMoM2b (Nulliparous Pregnancy Outcomes Study Monitoring Mothers-to-Be) HHS (Heart Health Study) to assess the relationship between dietary quality and cardiometabolic health. We calculated Energy-Adjusted Dietary Inflammatory Index scores representing the inflammatory burden in a person's diet. We used linear regression to determine the association between Energy-Adjusted Dietary Inflammatory Index score and cardiometabolic outcomes. We performed stratified analyses for outcomes with a significant interaction between Energy-Adjusted Dietary Inflammatory Index and APO. Data were available from 3249 participants at a median of 3.1 years after delivery. Higher Energy-Adjusted Dietary Inflammatory Index scores were associated with higher body mass index (B=0.29 kg/m2 [95% CI, 0.16-0.42]), waist circumference (0.66 cm [95% CI, 0.39-0.93]), diastolic blood pressure (0.26 mm Hg [95% CI, 0.09-0.44]), mean arterial pressure (0.23 mm Hg [95% CI, 0.06-0.40]), triglycerides (2.11 mg/dL [95% CI, 1.05-3.18]), creatinine (2.78 mg/dL [95% CI, 1.13-4.44]), insulin (exp[B]=1.04 [95% CI, 1.03-1.05]) and C-reactive protein (exp[B]=1.07 [95% CI, 1.04-1.10]), and lower high-density lipoprotein cholesterol (-0.41 mg/dL [95% CI, -0.66 to -0.37]) (all P<0.01). Significant interactions with APO (P<0.05) were identified for body mass index and waist circumference, with stratified analysis revealing stronger associations for individuals with APOs.

CONCLUSIONS

A more proinflammatory diet was associated with worse cardiometabolic health measures, and these relationships differed by a person's APO history. Further investigation should establish how dietary modifications after pregnancy may potentially mitigate cardiovascular disease risk.

Association between adverse birth outcomes and long-term risk of premature cardiovascular disease and mortality in a contemporary population-based cohort of 502,383 pregnant women

BACKGROUND

Relatively few studies have examined the association between the entire spectrum of adverse birth outcomes [stillbirth, preterm birth (PTB), term births that are low birth weight (LBW) or high birth weight (HBW)] and long-term risk of CVD in the mother. Our objective was to examine the association between birth outcomes and risk of premature CVD or death in a contemporary cohort of pregnant women.

METHODS

We conducted a retrospective population-based cohort study of women in Alberta, Canada, between 01/01/2005 and 01/01/2023. The primary endpoint was a composite of CVD-related hospitalization, CVD-related emergency department visit, or death. Cox proportional hazard modelling was used to examine the independent association between birth outcomes and the risk of CVD or death in the mother, after accounting for other socio-demographic, clinical and pregnancy-related complications.

RESULTS

Among 502,383 mothers, 0.51% had stillbirth, 7.11% had PTB, 86.11% had normal birth weight (NBW), 2.11% had LBW, and 4.15% had HBW. During a median follow-up of 3612 days (∼10 years), compared the NBW group, the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for maternal CVD or death associated with stillbirth was 1.63 (1.33, 1.99); 1.45 (1.36, 1.55) for PTB; 1.22 (1.06, 1.41) for LBW, and 1.13 (1.03, 1.23) for HBW. In addition to birth outcomes, pre-existing diabetes (aHR: 1.61, 95% CI: 1.47, 1.76), gestational hypertension (aHR: 1.47, 95% CI: 1.38, 1.57), and pre-existing hypertension (aHR: 3.28, 95% CI: 2.66, 4.04) carried a higher risk for premature CVD and death in the mother.

CONCLUSIONS

Adverse birth outcomes of stillbirth and preterm birth, and to a lesser degree term births that result in LBW or HBW, are markers of increased risk of premature CVD and death in the mother. Coordinated effort between obstetricians, family physicians, and cardiologists are needed to design and implement effective risk reduction programs tailored for these high-risk women.

Promoting Maternal Health in the Postpartum Period to Advance Birth Equity

Black birthing people experience lower rates of postpartum follow-up care. The objective of this study was to examine factors associated with postpartum follow-up care and explore suggestions for improving the quality and experience of care during the postpartum period. A survey was conducted among Black birthing people in the Boston area who had delivered an infant within two years of the study. Our survey comprised the Jackson, Hogue, Phillips Contextualized Stress Measure (JHPCSM), the Power as Knowing Participation in Change Tool (PKPCT), and demographic questions. One hundred and twenty-one self-identified Black birthing people completed the survey. One-third of participants did not attend their postpartum appointment. Those with public insurance, an educational level of less than a college degree, or were working outside the home were significantly less likely to have a postpartum follow-up visit. Participants who attended postpartum visits had higher scores on the JHPCSM (lower stress) and PKPCT. Inability to take time off from work, COVID-19 concerns, and lack of childcare were the most frequently reported barriers to attending appointments. There is a need for better institutional and policy support for Black parents in the postpartum period.

Unique cardiometabolic factors in women that contribute to modified cardiovascular disease risk

Major risk factors of cardiovascular disease (CVD) include hypertension, obesity, diabetes mellitus and metabolic syndrome; all of which are considered inflammatory conditions. Women are disproportionately affected by inflammatory conditions, with sex differences emerging as early as adolescence. Hormonal fluctuations associated with reproductive events such as menarche, pregnancy and menopause, are hypothesized to promote a pro-inflammatory state in women. Moreover, women who have experienced inflammatory-type conditions such as polycystic ovarian syndrome (PCOS), gestational diabetes or pre-eclampsia, have a cardiometabolic phenotype that pre-disposes to increased risk of myocardial infarction, stroke and coronary heart disease. Women with no notable CVD risk factors are often relatively protected from CVD pre-menopause; but overtake men in risk of major cardiovascular events when the cardiovascular protective effects of oestrogen begin to wane. Sex differences and female-specific factors have long been considered challenging to study and this has led to an underrepresentation of females in clinical trials and lack of female-specific data from pre-clinical studies. However, there is now a clear prerogative to include females at all stages of research, despite inherent complexities and potential variability in data. This review explores recent advancements in our understanding of CVD in women. We summarise the underlying factors unique to women that can promote CVD risk factors, ultimately contributing to CVD burden and the emerging therapies aimed to combat this.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Cardio-Obstetrics Practice in Latin America: A Regional Survey of General Cardiologists

Background

Cardiovascular (CV) disease is a leading cause of death in pregnant women globally, especially in low- and middle-income countries including Latin America (LATAM), where there is lack of data on how cardiologists are trained in cardio-obstetrics (CO) and the practice patterns in the care of pregnant patients.

Objectives

The authors aimed to identify CO competency and practice patterns among LATAM general cardiologists.

Methods

An anonymous cross-sectional Google-based electronic survey was sent via email to clinical cardiologists through local American College of Cardiology chapters and CV societies. Demographics, prior CO training, and practice patterns related to pregnant patients with CV disease were assessed.

Results

A total of 464 participants responded: 53% male, 52.5% from Central America and the Caribbean, 36.5% from South America, and 11% from Mexico. Most (67%) had not received didactic education in CO during fellowship; the majority expressed interest in participation in educational activities on this field, and only 18% reported practicing in centers equipped with CO teams or experts. Specific characteristics of CO practices in the region are shown in the figures.

Conclusions

Based on this survey, the CV care and follow-up of pregnant patients in LATAM is suboptimal; most cardiologists report lack of CO formal education during training and feel uncomfortable providing care during pregnancy although expressed interest in enhancing their knowledge in this field.

A Tool to Help Nurses Provide Health Education on Adverse Pregnancy Outcomes and Cardiovascular Health

Adverse pregnancy outcomes are associated with poor short- and long-term cardiovascular health. However, patients and their health care providers may not have knowledge of this risk or of the healthful practices that can reduce this risk. Childbirth care can be a pivotal time in the patient-clinician relationship to build awareness and spur prevention planning. As part of the American Heart Association-supported program entitled Providing an Optimized and Empowered Pregnancy for You (P3OPPY), our team collaborated with a community advisory board to create a teaching handout about adverse pregnancy outcomes for incorporation into hospital-based postpartum care. This handout can be used by pregnancy and maternity care providers, including postpartum nurses, to provide health education on how adverse pregnancy outcomes can influence risk for future cardiovascular disease and what can be done for prevention.

Associations between adverse pregnancy outcomes and cognitive impairment and dementia: a systematic review and meta-analysis

BACKGROUND

Individuals with adverse pregnancy outcomes have an increased risk of cerebrovascular disease, but the association between adverse pregnancy outcomes and cognitive impairment and dementia is less well established. We aimed to synthesise, combine, and assess the growing body of data examining the associations between adverse pregnancy outcomes and mild cognitive impairment and dementia in parous women.

METHODS

In this systematic review and meta-analysis, we searched PubMed (MEDLINE), Web of Science, and Embase from database inception up to July 18, 2024, with no language restrictions, for observational studies or clinical trials that reported mild cognitive impairment or dementia as outcomes and included female individuals or women who had an adverse pregnancy outcome, including hypertensive disorders of pregnancy, gestational diabetes, stillbirth, fetal growth restriction, preterm birth, or placental abruption. We excluded studies of men, nulliparous women, women with pre-pregnancy conditions associated with impaired cognition, and studies examining cognitive impairment within 6 months of pregnancy. Database searches were supplemented by manual review of the reference lists of included studies. If studies met eligibility criteria but did not have sufficient data for meta-analysis (ie, did not report a summary statistic or a hazard ratio [HR] for outcome estimation), they were included in the systematic review and excluded from the meta-analysis. After removing duplicates, two investigators independently screened titles and abstracts using Covidence software, with potentially eligible studies undergoing full-text review by the same reviewers, with further review by a third reviewer and disagreements resolved by discussion and group consensus. Study quality was assessed and summary statistics extracted by two reviewers independently. The primary outcomes of our study were mild cognitive impairment, all-cause dementia, Alzheimer's disease, and vascular dementia. Heterogeneity was measured using the Q test and I2 statistic, and we used random-effects models with inverse-variance weighting to assess the association between adverse pregnancy outcome and primary outcomes with sufficient meta-analysable data via pooled adjusted HRs and 95% CIs. The study protocol was registered with PROSPERO, CRD42023453511.

FINDINGS

Of 11 251 publications identified, 15 studies (including 7 347 202 participants) met inclusion criteria for the systematic review, and 11 studies (6 263 431 participants) had sufficient data for meta-analysis. A history of any adverse pregnancy outcome was associated with higher risk of all-cause dementia (adjusted HR 1·32 [95% CI 1·17-1·49]; I2= 80%), Alzheimer's disease (1·26 [1·04-1·53]; I2=63%), and vascular dementia (1·94 [1·70-2·21]; I2=0%). A history of any hypertensive disorder of pregnancy was significantly associated with all-cause dementia (1·32 [1·11-1·57]; I2=74%) and vascular dementia (1·78 [1·46-2·17]; I2=0%), but not Alzheimer's disease (1·24 [0·98-1·57]; I2=66%). Stillbirth was not significantly associated with higher risk of all-cause dementia (1·26 [95% CI 0·93-1·71]; I2=62%). In individual studies, similar effect directions were observed for preterm birth and fetal growth restriction, but data were insufficient for meta-analysis.

INTERPRETATION

Given their increased risk of dementia, women with a history of adverse pregnancy outcomes should be evaluated for additional dementia risk factors and monitored closely for any signs of cognitive decline. Furthermore, to obtain more reliable findings, future studies should measure both exposures and outcomes prospectively and objectively.

FUNDING

National Institutes of Health, National Institute of Neurological Disorders and Stroke, National Institute on Aging, and National Heart, Lung and Blood Institute.

Assessing the Accuracy of Cardiovascular Disease Prediction Using Female-Specific Risk Factors in Women Aged 45 to 69 Years in the UK Biobank Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in women. We aimed to assess whether adding female-specific risk factors to traditional factors could improve CVD risk prediction.

METHODS

We used a cohort of women from the UK Biobank Study aged 45 to 69 years, free of CVD at baseline (2006-2010) followed until the end of 2019. We developed Cox proportional hazards models using the risk factors included in 3 contemporary CVD risk calculators: Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT. We added each of the following female-specific risk factors, individually and all together, to determine if these improved measures of discrimination and calibration for predicting CVD: early menarche (<11 years), endometriosis, excessive, frequent or irregular menstruation, miscarriage, number of miscarriages, number of stillbirths, infertility, preeclampsia or eclampsia, gestational diabetes (without subsequent type 2 diabetes), premature menopause (<40 years), early menopause (<45 years), and natural or surgical early menopause (menopause <45 years or timing of menopause reported as unknown and oophorectomy reported at age <45).

RESULTS

In the model of 135 142 women (mean age, 57.5 years; SD, 6.8) using risk factors from Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, CVD incidence was 5.3 per 1000 person-years. The c-indices for the Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models were 0.710, 0.713, and 0.718, respectively. Adding each of the female-specific risk factors did not improve the c-index, the net reclassification index, the integrated discrimination index, the slope of the regression line for predicted versus observed events, and the Brier score or plots of calibration. Adding all female-specific risk factors simultaneously increased the c-index for the Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models to 0.712, 0.715, and 0.720, respectively.

CONCLUSIONS

Although several female-specific factors have been shown to be early indicators of CVD risk, these factors should not be used to reclassify risk in women aged 45 to 69 years when considering whether to commence a blood pressure or lipid-lowering medication.

Nonsevere hypertensive disorders of pregnancy and oral antihypertensive medications: an argument in favor of use

Hypertensive disorders of pregnancy are a common complication of pregnancy and a major contributor to both immediate and long-term morbidity and mortality. Recent data support the treatment of chronic hypertension during pregnancy to a blood pressure goal of <140/90 mmHg. Treatment of severe range blood pressures (≥160/110 mmHg) in the setting of gestational hypertension is recommended to prevent severe morbidity and mortality; however, there remains clinical equipoise regarding treatment of gestational hypertension with blood pressures ≥140/90 but <160/110. While there is limited data to support the treatment of gestational hypertension, we believe that treatment of gestational hypertension to a blood pressure of <140/90, similar to the recommendations for chronic hypertension, will lead to a reduction in severe maternal and neonatal morbidity and mortality related to hypertensive disorders of pregnancy. In this expert review, we summarize the available data regarding the treatment of gestational hypertension and offer recommendations for the treatment of gestational hypertension based on our clinical experience.

Sex-Specific Cardiovascular Risk Factors and Treatment in Females With T2DM and CVD: Developments and Knowledge Gaps

PURPOSE

There are large disparities in the impact of diabetes on cardiovascular disease (CVD) risk and outcomes by sex and gender. Achieving health equity requires understanding risks and medication efficacy in female patients, especially now, as novel pharmacologic treatments are transforming the diabetes and CVD treatment landscape. This review examines 2 bodies of research that can inform sex differences in CVD in patients with diabetes: female-specific risk factors for CVD and sex-related limitations of clinical trial research in evaluating novel diabetes and CVD treatments.

METHODS

Two literature searches were performed using Ovid Medline(R) All. The first retrieved manuscripts covering sex and gender differences related to CVD risk and therapies and diabetes. The second focused on randomized controlled trial data on sex/gender differences and GLP-1/SGLT-2/DPP-4 drugs.

RESULTS

Female-specific risk factors for CVD include early menarche, premature or early menopause, irregular cycles and polycystic ovary syndrome; pregnancy; adverse pregnancy outcomes; history of breast cancer; and autoimmune diseases. Clinical trials of novel pharmacological treatments for diabetes and CVD have undersampled female populations, and clinical characteristics of male and female participants have differed significantly. Thus, evidence to evaluate potential sex differences in treatment efficacy and side effects has been lacking.

CONCLUSION

To improve health of female patients with diabetes, sex-specific cardiovascular risk factors should be taken into account in screening and treatment decisions. Further, studies of cardiovascular and diabetes medications must ensure adequate representation by sex and report participant characteristics and outcomes by sex.

Evaluation of outcomes and risk factors for recurrent preeclampsia in a subsequent pregnancy

PURPOSE

The aim was to evaluate the pregnancy outcomes and identify risk factors for recurrent preeclampsia (PE).

METHODS

Retrospective analysis of patients discharged with PE between January 1, 2010, and January 1, 2023, from two tertiary referral hospitals. They were classified into recurrent and non-recurrent groups based on the presence of PE in subsequent pregnancies.

RESULTS

Among 519 women who had a subsequent pregnancy after a history of PE, 153 developed recurrent PE while 366 did not. The recurrent cases included 81 preterm PE, of which 41 were early-onset PE (EOPE). Recurrent PE correlated significantly with prior EOPE, HELLP syndrome, placental abruption, and stillbirth, as well as with current chronic hypertension (CH) and type 2 diabetes. The recurrent group showed a 5.8-fold higher risk of preterm birth (PTB) compared to the non-recurrent group (50.7% vs. 8.7%). Notably, 58.1% of the PTBs in the non-recurrent group were spontaneous. Logistic regression identified previous EOPE (aOR: 4.22 [95% CI: 2.50-7.13]) and current CH (aOR: 1.86 [95% CI: 1.09-3.18]) as independent contributors for recurrent PE. Furthermore, recurrent preterm PE shared the same risk factors: previous EOPE (aOR: 5.27 [95% CI: 2.82-9.85]) and current CH (aOR: 2.99 [95% CI: 1.57-5.71]). The morbidity of CH in subsequent pregnancy peaked at 31.9% when women with a history of EOPE delivered within three years.

CONCLUSION

Previous EOPE and current CH were sequentially crucial risk factors for the development of PE and preterm PE during the next pregnancy. This may clarify risk stratification in prenatal management for women with a history of PE.

The risk factor for adverse pregnancy outcomes and its impact on clinical effect in IgA nephropathy: A retrospective observational study

AIM

IgA nephropathy (IgAN) is the most common primary glomerular disease worldwide. Pregnant IgAN patients are more susceptible to adverse pregnancy outcomes (APO). However, the risk factor for APO and its effects on the long-term renal outcome of pregnant IgAN patients remained unclear.

METHODS

We performed a retrospective observational study covering 2003-2019 that included 44 female IgAN patients with pregnancy history to investigate the risk factor for APO and its impact on clinical outcome in IgAN. Renal function outcome and proteinuria remission were evaluated in pregnant IgAN women with and without APO.

RESULTS

In this retrospective and observational study, we found that patients with APO exhibited higher levels of serum creatinine and IgM, and lower haemoglobin levels while other clinical characteristics, pathological characteristics and therapy protocol had no significant difference. We found that anaemia and a higher level of serum IgM were independent risk factors for APO. IgAN pregnant women without APO experienced a higher proportion of proteinuria remission than those with APO, but there is no difference in the renal function outcome.

CONCLUSION

Pregnant IgAN patients with higher risks, including lower haemoglobin levels and higher IgM levels deserve intensive monitoring, and aggressive therapy to reduce proteinuria should be carried out in pregnant IgAN patients with APO.

Intact NOX2 in T Cells Mediates Pregnancy-Induced Renal Damage in Dahl SS Rats

BACKGROUND

Hypertensive disorders of pregnancy are associated with increased risk for cardiovascular disease, renal disease, and mortality. While the exact mechanisms remain unclear, T cells and reactive oxygen species have been implicated in its pathogenesis. We utilized Dahl salt-sensitive (SS), SSCD247-/- (Dahl SS CD247 knockout rat; lacking T cells), and SSp67phox-/- (Dahl SS p67phox [NOX2 (NADPH [nitcotinamide adenine dinucleotide phosphate] oxidase 2)] knockout rat; lacking NOX2) rats to investigate these mechanisms in primigravida and multigravida states.

METHODS

We assessed blood pressure and renal damage phenotypes in SS, SSCD247-/-, and SSp67phox-/- rats during primigravida and multigravida states. To investigate the contribution of NOX2 in T cells, we performed adoptive transfers of splenocytes or cluster of differentiation (CD)4+ T cells from either SS or SSp67phox-/- donors into SSCD247-/- recipients to determine pregnancy-specific alterations in phenotype.

RESULTS

Multigravida SS rats developed significant pregnancy-induced renal damage and renal functional impairment associated with elevated maternal mortality rates, whereas deletion of T cells or NOX2 garnered protection. During primigravida states, this attenuation in renal damage was observed, with the greatest protection in the SSp67phox-/- rat. To demonstrate that NOX2 in T cells contributes to adverse pregnancy phenotypes, adoptive transfer of SS splenocytes into SSCD247-/- rats resulted in significant pregnancy-induced renal damage, whereas transfer of SSp67phox-/- splenocytes garnered protection. Specifically, the transfer of SS CD4+ T cells resulted in pregnancy-induced proteinuria and increases in uterine artery resistance index, an effect not seen with the transfer of SSp67phox-/- CD4+ T cells.

CONCLUSIONS

T cells and NOX2-derived reactive oxygen species, thus, contribute to end-organ damage in both primigravida and multigravida pregnancies in the SS rat leading to increases in maternal mortality.

Pre-pregnancy substance use and first trimester cardiovascular health among nulliparous pregnant people: The nuMoM2b Study

BACKGROUND

Suboptimal pre-pregnancy health, including substance use and cardiovascular risk factors, is associated with higher risks of maternal-foetal morbidity and mortality.

OBJECTIVE

To determine if pre-pregnancy substance use is associated with early pregnancy cardiovascular health (CVH). It is hypothesised that pre-pregnancy use of substances is associated with worse CVH in the first trimester of pregnancy.

METHODS

This is a secondary analysis from the 2010-2015 United States nuMoM2b cohort (n = 9895). Pre-pregnancy alcohol, tobacco, marijuana, and illicit substance use were assessed through questionnaires. Latent class analysis categorised participants based on their 3-month pre-pregnancy or ever(*) substance use: (1) Illicit substances*, marijuana*, and alcohol use (n = 1234); (2) marijuana* and alcohol use (n = 2066); (3) tobacco and alcohol use (n = 636); and (4) alcohol only use (n = 3194). The referent group reported no pre-pregnancy substance use (n = 2765). First trimester CVH score from 0 (least healthy) to 100 (most healthy) was calculated using a modified American Heart Association Life's Essential 8 framework and included body mass index (BMI), blood pressure, blood glucose, non-HDL cholesterol, diet, sleep, and physical activity. Multiple linear regression evaluated the relationship between pre-pregnancy substance use classes and CVH scores.

RESULTS

CVH score varied by class: No substance use (mean: 65, SD: ±1.3), illicit substances*, marijuana*, and alcohol use (68 ± 1.3), marijuana* and alcohol use (67 ± 1.3), tobacco and alcohol use (62 ± 1.4), and alcohol only use (67 ± 1.3). In adjusted models, those who used tobacco and alcohol compared to the no substance use class had a lower CVH score (-2.82); other classes had scores ranging from 1.81 to 2.44 points higher than the no substance use class. Individual CVH component scores followed similar patterns.

CONCLUSIONS

All groups, but most markedly those who used tobacco and alcohol prior to pregnancy, began pregnancy with only moderate CVH and may benefit from CVH promotion efforts along with substance use treatment.

Comparison Between SGLT2 Inhibitors and Lactation: Implications for Cardiometabolic Health in Parous Women

Sodium-glucose cotransporter-2 (SGLT2) inhibition and lactation result in the excretion of large amounts of glucose in urine or milk and are associated with a lower risk of cardiovascular events. The respective mechanisms behind this association with cardiovascular protection are not clear. This review compares the contribution of noninsulin-mediated glucose transport during pharmacologic inhibition of SGLT2 with noninsulin-mediated glucose transport during lactation in terms of the implications for the cardiometabolic health of parous women. The search topics used to obtain information on SGLT2 inhibitors included mechanisms of action, atherosclerosis, and heart failure. The search topics used to obtain information on lactation included cardiovascular health and milk composition. Subsequent reference searches of retrieved articles were also used. Active treatment with SGLT2 inhibitors affects glucose and sodium transport in the kidneys and predominantly protects against hospitalization for heart failure soon after the onset of therapy. Active lactation stimulates glucose transport into the mammary gland and improves subclinical and clinical atherosclerotic vascular disease years after delivery. Both SGLT2 inhibitors and lactation have effects on a variety of glucose transporters. Several mechanisms have been proposed to explain the cardiometabolic benefits of SGLT2 inhibition and lactation. Learning from the similarities and differences between both processes will advance our understanding of cardiometabolic health for all people.

Adverse pregnancy outcomes and multiple cancers risk in both mother and offspring: an umbrella review of systematic reviews with meta-analyses of observational studies

BACKGROUND

Adverse pregnancy outcomes have reached epidemic proportions in recent years with serious health ramifications, especially for diverse cancers risk. Therefore, we carried out an umbrella review to systematically evaluate the validity and strength of the data and the extent of potential biases of the established association between adverse pregnancy outcomes and cancers risk in both mother and offspring.

METHODS

PubMed, Embase, and Web of Science databases were searched from inception until 18 January 2024. Meta-analyses of observational studies investigating the relationship between adverse pregnancy outcomes and multiple cancers risk in both mother and offspring were included. Evidence certainty was assessed using Grading of Recommendations, Assessment, Development, and Evaluation. The protocol for this umbrella review was prospectively registered in PROSPERO (CRD42023470544).

RESULTS

The search identified 129 meta-analyses of observational studies and 42 types of cancer. Moderate certainty of evidence, exhibiting statistical significance, has been observed linking per kilogram increase in birth weight to a heightened risk of breast cancer (OR = 1.07, 95% CI = 1.02-1.12), prostate cancer (OR = 1.02, 95% CI = 1.00-1.05), leukemia (OR = 1.18, 95% CI = 1.13-1.23), and acute lymphoblastic leukemia in offspring (OR = 1.18, 95% CI = 1.12-1.23); rubella infection during pregnancy to an increased risk of leukemia in offspring (OR = 2.79, 95% CI = 1.16-6.71); and a linear dose-response association between an increase in the proportion of optimal birth weight and an elevated risk of acute lymphoblastic leukemia in offspring (OR = 1.16, 95% CI = 1.09-1.24), respectively.

CONCLUSIONS

Although some adverse pregnancy outcomes have clinically promising associations with risk of several cancers in both mother and offspring, it is essential to conduct additional research to solidify the evidence, evaluate causality, and ascertain clinical utility.

Postpartum Management of Hypertensive Disorders of Pregnancy in Six Large U.S. Hospital Systems: Descriptive Review and Identification of Clinical and Research Gaps

Hypertensive disorders of pregnancy (HDPs) are a key contributor to maternal morbidity and mortality. Several gaps in knowledge remain regarding best practices in the postpartum management of HDPs. In this review, we describe postpartum HDPs management among six large academic U.S. hospital systems: Medical College of Wisconsin, University of Pittsburgh, University of Wisconsin-Madison, Northwestern University, University of Minnesota, and Boston Medical Center. We identified that all six health systems discharge patients with HDPs diagnosed with a blood pressure (BP) cuff and use the same two antihypertensive medications, nifedipine and labetalol, as first- and second-line treatment of HDPs. Northwestern University routinely adds oral furosemide for 5 days for patients with BP that exceeds 150/100 mm Hg. Most hospital systems administer magnesium sulfate routinely when readmission for HDPs occurs. In contrast, there was variation in BP threshold for antihypertensive treatment initiation, use of remote BP monitoring program, use of a transition clinic, delivery or lack of education on long-term cardiovascular disease risk, and BP management through the first 6 weeks postpartum and beyond. Based on the clinical review, we identified clinical gaps and formulated considerations for research priorities in the field of postpartum HDPs management. KEY POINTS: · Several gaps in knowledge remain regarding best practices in postpartum management of HDPs.. · There is a variation in the BP threshold for antihypertensive treatment initiation.. · Data are lacking on the reduction in severe maternal morbidity (SMM) and racial disparities in SMM with remote monitoring..