Pregnancy and Long-Term Maternal Cardiovascular Health: Progress Through Harmonization of Research Cohorts and Biobanks

Retinal oximetry and microvascular assessment after hypertensive pregnancy complications

PURPOSE

Women with hypertensive disorders of pregnancy (HDP) are at increased risk of developing premature cardiovascular disease (CVD). The mechanisms behind this are not fully understood, but microvascular alterations have been documented in retinal arterioles and venules. The aim of this study was to use non-invasive retinal imaging to investigate the structural and functional properties of arterioles, venules and capillaries in this patient group.

METHODS

We examined 27 women with previous HDP and 23 controls at 3 years postpartum. The retinal microvasculature was assessed by vessel calibre measurements, retinal oximetry and optical coherence tomography angiography. Differences were analysed using non-parametric tests and multiple regression analyses, adjusted for age and body mass index.

RESULTS

Median arteriolar oxygen saturation (SaO2; 94.2% vs. 93.0%), venular oxygen saturation (SvO2; 60.1% vs. 62.4%) and arteriovenous saturation difference (AV-difference; 32.8% vs. 32.3%) were similar across groups. Capillary vessel density (VD; 46.2% vs. 46.3%), skeletonised VD (VSD; 21.3 vs. 21.1 mm/mm2) and vessel diameter index (21.65 vs. 21.86) were also comparable. In the HDP group, mean arterial pressure (MAP) was positively correlated with AV-difference (R2 = 0.209) and negatively correlated with arteriolar diameter (CRAE; r2 = 0.382).

CONCLUSIONS

Structural microvascular alterations appear not to be key biomarkers for CVD risk after HDP as early as 3 years postpartum in otherwise healthy women. Further studies are needed to evaluate whether such changes occur later in life. MAP was associated with AV-difference only in the HDP group, suggesting specific mechanisms affecting functional microvascular properties in these women.

Hypertensive disorders of pregnancy and long-term maternal cardiovascular risk: Bridging epidemiological knowledge into personalized postpartum care and follow-up

Cardiovascular disease (CVD) is globally the leading cause of death and disability. Sex-specific causes of female CVD are under-investigated. Pregnancy remains an underinvestigated sex-specific stress test for future CVD and a hitherto missed opportunity to initiate prevention of CVD at a young age. Population-based studies show a strong association between female CVD and hypertensive disorders of pregnancy. This association is also present after other pregnancy complications that are associated with placental dysfunction, including fetal growth restriction, preterm delivery and gestational diabetes mellitus. Few women are, however, offered systematic cardio-preventive follow-up after such pregnancy complications. These women typically seek help from the health system at first clinical symptom of CVD, which may be decades later. By this time, morbidity is established and years of preventive opportunities have been missed out. Early identification of modifiable risk factors starting postpartum followed by systematic preventive measures could improve maternal cardiovascular health trajectories, promoting healthier societies. In this non-systematic review we briefly summarize the epidemiological associations and pathophysiological hypotheses for the associations. We summarize current clinical follow-up strategies, including some proposed by international and national guidelines as well as user support groups. We address modifiable factors that may be underexploited in the postpartum period, including breastfeeding and blood pressure management. We suggest a way forward and discuss the remaining knowledge gaps and barriers for securing the best evidence-based follow-up, relative to available resources after a hypertensive pregnancy complication in order to prevent or delay onset of premature CVD.

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.

Possible Role of Fibrinaloid Microclots in Postural Orthostatic Tachycardia Syndrome (POTS): Focus on Long COVID

Postural orthostatic tachycardia syndrome (POTS) is a common accompaniment of a variety of chronic, inflammatory diseases, including long COVID, as are small, insoluble, 'fibrinaloid' microclots. We here develop the argument, with accompanying evidence, that fibrinaloid microclots, through their ability to block the flow of blood through microcapillaries and thus cause tissue hypoxia, are not simply correlated with but in fact, by preceding it, may be a chief intermediary cause of POTS, in which tachycardia is simply the body's exaggerated 'physiological' response to hypoxia. Similar reasoning accounts for the symptoms bundled under the term 'fatigue'. Amyloids are known to be membrane disruptors, and when their targets are nerve membranes, this can explain neurotoxicity and hence the autonomic nervous system dysfunction that contributes to POTS. Taken together as a system view, we indicate that fibrinaloid microclots can serve to link POTS and fatigue in long COVID in a manner that is at once both mechanistic and explanatory. This has clear implications for the treatment of such diseases.

The effect of adverse pregnancy outcomes on vascular aging in young women: the Kailuan study

Adverse pregnancy outcomes (APOs) are at increased future cardiovascular risk and require effective risk mitigation. However, data regarding appropriate postpartum screening for young women with APOs are lacking. We aimed to investigate the association between APOs and vascular aging by the determination of high pulse wave velocity (PWV) in young women. Women who gave birth from 1990 to 2020 and underwent brachial-ankle pulse wave velocity (baPWV) assessments in the postpartum period were recruited. We excluded women with age ≥50 years at the baPWV assessment or missing postpartum health examinations. The history of APOs including hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and low birth weight were assessed by medical records. High PWV was defined as baPWV above the 90th percentile for different age group. Multivariable Logistic regression was used to evaluate the association of APOs and high PWV. 3193 participants were included in the analysis, including 912 (28.6%) individuals with APOs. The prevalence of high PWV in the non-APO group and the APOs group were 7.19% (164) and 13.9% (127), respectively (P < 0.05). Compared with non-APO group, the OR (95% CI) of APOs group was 1.67 (1.29-2.16). The risks in the 20-29, 30-39, and 40-49 age groups were 2.51 (1.13-5.59), 1.83 (1.30-2.59), and 1.35 (0.82-2.21) (P for trend <0.05). We conclude that APOs are risk factors of vascular aging for young women and the risk decreased with increasing age. BaPWV should be an important indicator for preventive cardiovascular risk management in young women with APOs. Clinical trial registration: Registration number ChiCTR-TNRC-11001489, http://www.chictr.org.cn/showproj.aspx?proj=8050 .

Gestational diabetes mellitus, follow-up of future maternal risk of cardiovascular disease and the use of eHealth technologies-a scoping review

BACKGROUND

Globally, gestational diabetes mellitus complicates 1 in 6 pregnancies and increases future risk of type 2 diabetes and cardiovascular disease in the affected women. There is a lack of consensus on the optimal follow-up of these women. eHealth is emerging as a health care tool, but its practical utility and advantages over standard care in the follow-up after pregnancy complications remains to be determined. Our aim was to systematically review the existing literature on cardiovascular follow-up after gestational diabetes, the utility of eHealth technology for this purpose, and to identify research gaps.

METHODS

We performed a systematic scoping review following a published protocol and the Joanna Briggs methodology for studies up until May 2022. Four databases were searched: Ovid MEDLINE, Embase, Maternity and Infant Care, and Cochrane Database of Systematic Reviews. Primary research articles and systematic reviews were included in the final analyses. Two reviewers independently screened abstracts and performed full text assessment. Data was extracted using a data charting form. In all stages of the process, if consensus was not reached, a third reviewer was consulted. The findings from the data charting process provided the basis for summarizing the findings from the included studies.

RESULTS

The search of the databases generated 2772 hits. After removing duplicates and manually adding a total of 19 studies, reviews, and guidelines, a total of 2769 titles and abstracts were screened, and 97 papers underwent full-text review. In the final analyses, 15 articles and 12 systematic reviews were included, whereas guidelines are presented as supplementary material. No studies were identified that examined follow-up regarding long-term overall cardiovascular risk after gestational diabetes. Various lifestyle interventions were tested for individual cardiovascular risk factors, with diverging effects. eHealth technologies were found acceptable by participants but had no consistent, statistically significant effect on relevant health outcomes.

CONCLUSIONS

This scoping review of the existing literature revealed neither an established systematic cardiovascular follow-up strategy for women after gestational diabetes nor evidence that eHealth technologies are superior to conventional follow-up. Further research into the utility of eHealth in cardiovascular follow-up after complicated pregnancies should include longer-term follow-up and core cardiovascular outcomes.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this scoping review was published at Open Science Framework (osf.io/p5hw6).

Unraveling the mysteries of spiral artery remodeling

Spiral artery remodeling is the process by which the uterine vessels become large bore low resistance conduits, allowing delivery of high volumes of maternal blood to the placenta to nourish the developing fetus. Failure of this process is associated with the pathophysiology of most of the major obstetric complications, including late miscarriage, fetal growth restriction and pre-eclampsia. However, the point at which remodeling 'fails' in these pathological pregnancies is not yet clear. Spiral artery remodeling has predominantly been described in terms of its morphological features, however we are starting to understand more about the cellular and molecular triggers of the different aspects of this process. This review will discuss the current state of knowledge of spiral artery remodeling, in particular the processes involved in loss of the vascular smooth muscle cells, and consider where in the process defects would lead to a pathological pregnancy.

Fetal microchimerism and the two-stage model of preeclampsia

Fetal cells cross the placenta during pregnancy and some have the ability to persist in maternal organs and circulation long-term, a phenomenon termed fetal microchimerism. These cells often belong to stem cell or immune cell lineages. The long-term effects of fetal microchimerism are likely mixed, potentially depending on the amount of fetal cells transferred, fetal-maternal histocompatibility and fetal cell-specific properties. Both human and animal data indicate that fetal-origin cells partake in tissue repair and may benefit maternal health overall. On the other hand, these cells have been implicated in inflammatory diseases by studies showing increased fetal microchimerism in women with autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. During pregnancy, preeclampsia is associated with increased cell-transfer between the mother and fetus, and an increase in immune cell subsets. In the current review, we discuss potential mechanisms of transplacental transfer, including passive leakage across the compromised diffusion barrier and active recruitment of cells residing in the placenta or fetal circulation. Within the conceptual framework of the two-stage model of preeclampsia, where syncytiotrophoblast stress is a common pathophysiological pathway to maternal and fetal clinical features of preeclampsia, we argue that microchimerism may represent a mechanistic link between stage 1 placental dysfunction and stage 2 maternal cardiovascular inflammation and endothelial dysfunction. Finally, we postulate that fetal microchimerism may contribute to the known association between placental syndromes and increased long-term maternal cardiovascular disease risk. Fetal microchimerism research represents an exciting opportunity for developing new disease biomarkers and targeted prophylaxis against maternal diseases.

The Placenta: A Maternofetal Interface

The placenta is the gatekeeper between the mother and the fetus. Over the first trimester of pregnancy, the fetus is nourished by uterine gland secretions in a process known as histiotrophic nutrition. During the second trimester of pregnancy, placentation has evolved to the point at which nutrients are delivered to the placenta via maternal blood (hemotrophic nutrition). Over gestation, the placenta must adapt to these variable nutrient supplies, to alterations in maternal physiology and blood flow, and to dynamic changes in fetal growth rates. Numerous questions remain about the mechanisms used to transport nutrients to the fetus and the maternal and fetal determinants of this process. Growing data highlight the ability of the placenta to regulate this process. As new technologies and omics approaches are utilized to study this maternofetal interface, greater insight into this unique organ and its impact on fetal development and long-term health has been obtained.

Cardiovascular health metrics in low and middle-income countries: A scoping review

BACKGROUND

In 2010 the American Heart Association defined the concept of ideal cardiovascular health to renew the focus on primordial prevention for cardiovascular disease. Evidence primarily from high-income countries suggests ideal CVH prevalence is low and decreases with age, with vulnerable populations differentially affected. We aimed to identify and characterize the evidence relevant to CVH metrics in low- and middle-income countries (LMICs).

METHODS

We followed the Joanna Briggs Institute guideline for the conduct of this scoping review. We searched MEDLINE, Embase, LILACS and study registers from inception to 14 March 2022. We included cross-sectional and cohort studies in populations representing a geographically-defined unit (urban or rural) in LMICs, and with data on CVH metrics i.e. all health or clinical factors (cholesterol, blood pressure, glycemia and body mass index) and at least one health behavior (smoking, diet or physical activity). We report findings following the PRISMA-Scr extension for scoping reviews.

RESULTS

We included 251 studies; 85% were cross-sectional. Most studies (70.9%) came from just ten countries. Only 6.8% included children younger than 12 years old. Only 34.7% reported seven metrics; 25.1%, six. Health behaviors were mostly self-reported; 45.0% of studies assessed diet, 58.6% physical activity, and 90.0% smoking status.

CONCLUSIONS

We identified a substantial and heterogeneous body of research presenting CVH metrics in LMICs. Few studies assessed all components of CVH, especially in children and in low-income settings. This review will facilitate the design of future studies to bridge the evidence gap. This scoping review protocol was previously registered on OSF: https://osf.io/sajnh.

Impact of Adverse Gestational Milieu on Maternal Cardiovascular Health

Cardiovascular disease affects 1% to 4% of the nearly 4 million pregnancies in the United States each year and is the primary cause of pregnancy-related mortality. Adverse pregnancy outcomes are associated with cardiovascular complications during pregnancy persisting into the postpartum period. Recently, investigations have identified an altered sex hormone milieu, such as in the case of hyperandrogenism, as a causative factor in the development of gestational cardiovascular dysfunction. The mechanisms involved in the development of cardiovascular disease in postpartum women are largely unknown. Animal studies have attempted to recapitulate adverse pregnancy outcomes to investigate causal relationships and molecular underpinnings of adverse gestational cardiac events and progression to the development of cardiovascular disease postpartum. This review will focus on summarizing clinical and animal studies detailing the impact of adverse pregnancy outcomes, including preeclampsia, gestational diabetes mellitus, and maternal obesity, on gestational cardiometabolic dysfunction and postpartum cardiovascular disease. Specifically, we will highlight the adverse impact of gestational hyperandrogenism and its potential to serve as a biomarker for maternal gestational and postpartum cardiovascular dysfunctions.

Parity and hypertension risk in couples: does number of parity matter: findings from Tehran Lipid and Glucose Study

BACKGROUND AND AIMS

As reported, hypertension (HTN) plays a leading role in explaining mortality worldwide, but it still has many confounding factors. This study explored whether the number of parity and age matters for HTN among couples from the Tehran Lipid and Glucose Study (TLGS).

METHODS

This study was conducted on 2851 couples from TLGS. All the variables were collected based on the standard protocol. The participants were categorized into four and five categories according to the number of parity (childless, one, two, three, or more parities) and age (18-30y, 30-40y, 40-50y, 50-60y, and 60-70y), respectively. Spline regression models via log link function for the binary outcome and linear link function for continuous outcomes were applied to evaluate the effect of interaction term age and parity categories on the desired outcome.

RESULTS

Among the total of 2851 pairs, 2.3% had no child, 9.5% had 1 child, 38.4% had 2 children, and 49.8% had ≥ 3 children. The adjusted risk (95% CI) of HTN in females aged 40-50y with 1 child, 2 and ≥ 3 children compared to no child were 1.14(1.04, 1.26), 1.05(1.01, 1.10), 1.12(1.07, 1.17), respectively (p < 0.05). Moreover, in those aged 50-60y with 2 and ≥ 3 children, the risk of HTN significantly increased by 4%. In females aged 60-70y with ≥ 3 children compared to those without children, the risk of HTN increased by 2%. For males aged 30-40y with 2 children compared to the no child group, the adjusted risk of HTN increased by 17%, while for those with ≥ 3 children in the same age group, this risk significantly decreased by 13%. Moreover, in males aged 30-40y with 2 children, risk ratio of HTN increased by 17%, but in males with ≥ 3 children, it decreased by 13% and in those in the same groups but aged 40-50y the risk increased by 6% and 11%, respectively.

CONCLUSION

Our findings suggest that gender, childlessness, having one child, and multi-parity had different impacts on HTN. Further research is needed to confirm our findings.

Circulating angiotensin II type I receptor - autoantibodies in diabetic pregnancies

Pregnant women with either pre-existing or gestational diabetes mellitus are at increased risk of preeclampsia as well as future cardiovascular disease. The renin-angiotensin system is dysregulated in both diabetes mellitus and preeclampsia. In preeclampsia, maternal levels of circulating agonistic autoantibodies against the angiotensin II Type I receptor (AT₁-AAs) are increased. Circulating AT₁-AAs are thought to contribute to both the pathophysiology of preeclampsia and the increased risk of future cardiovascular disease. Studies exploring AT₁-AA in diabetes outside pregnancy suggest their potential for both metabolic and cardiovascular pathogenicity. No studies have investigated AT₁-AAs in diabetic pregnancies. We hypothesized elevated maternal circulating AT₁-AA levels in pregnancies complicated by any type of diabetes mellitus. Third-trimester maternal serum from 39 women (controls: n = 10; type 1 diabetes: n = 9; type 2 diabetes: n = 10; gestational diabetes=10) were analyzed for AT₁-AA using an established bioassay method. Circulating AT₁-AAs were present in 70% (7/10) of the controls and 83% (24/29) of the diabetes group (P = 0.399). Presence of AT₁-AA was correlated to hsCRP levels (P = 0.036), but neither with maternal circulating angiogenic factors (soluble fms-like tyrosine kinase-1 and placental growth factor), nor with maternal or fetal characteristics indicative of metabolic disease or placental dysfunction. Our study is the first to demonstrate presence of circulating AT₁-AAs in pregnant women with any type of diabetes. Our findings suggest AT₁-AAs presence in pregnancy independently of placental dysfunction, nuancing the current view on their pathogenicity. Whether AT₁-AAs per se contribute to increased risk of adverse pregnancy outcomes and future cardiovascular disease remains currently unanswered.

Peripartum and Long-Term Maternal Cardiovascular Health After Preeclampsia

There is widespread acceptance of the increased prevalence of cardiovascular diseases occurring within 1 to 2 decades in women following a preeclamptic pregnancy. More recent evidence suggests that the deranged biochemical and echocardiographic findings in women do not resolve in the majority of preeclamptic women following giving birth. Many women continue to be hypertensive in the immediate postnatal period with some exhibiting occult signs of cardiac dysfunction. There is now promising evidence that with close monitoring and effective control of blood pressure control in the immediate postnatal period, women may have persistently lower blood pressures many years after stopping their medication. This review highlights the evidence that delivering effective medical care in the fourth trimester of pregnancy can improve the long-term cardiovascular health after a preeclamptic birth.

Setting a stage: Inflammation during preeclampsia and postpartum

Preeclampsia (PE) is a leading cause of maternal and fetal mortality worldwide. The immune system plays a critical role in normal pregnancy progression; however, inappropriate inflammatory responses have been consistently linked with PE pathophysiology. This inflammatory phenotype consists of activation of the innate immune system, adaptive immune system, and increased inflammatory mediators in circulation. Moreover, recent studies have shown that the inflammatory profile seen in PE persists into the postpartum period. This manuscript aims to highlight recent advances in research relating to inflammation in PE as well as the inflammation that persists postpartum in women after a PE pregnancy. With the advent of the COVID-19 pandemic, there has been an increase in obstetric disorders associated with COVID-19 infection during pregnancy. This manuscript also aims to shed light on the relationship between COVID-19 infection during pregnancy and the increased incidence of PE in these women.

Long-term effects of preeclampsia on maternal cardiovascular health and postpartum utilization of primary care: an observational claims data study

PURPOSE

Preeclampsia occurs in up to 15% of pregnancies and constitutes a major risk factor for cardiovascular disease. This observational cohort study aimed to examine the association between preeclamptic pregnancies and cardiovascular outcomes as well as primary and specialized care utilization after delivery.

METHODS

Using statutory claims data we identified women with singleton live births between 2010 and 2017. Main outcomes included the occurrence of either hypertension or cardiovascular disease after one or more preeclamptic pregnancies, number of contacts to a general practitioner or cardiologist after delivery and prescribed antihypertensive medication. Data were analyzed using Cox proportional hazard regression models adjusted for maternal age, diabetes, dyslipidemia, and obesity.

RESULTS

The study cohort consisted of 181,574 women with 240,698 births. Women who experienced preeclampsia once had an increased risk for cardiovascular (hazard ratio, HR = 1.29) or hypertensive (HR = 4.13) events. In women affected by recurrent preeclampsia, risks were even higher to develop cardiovascular disease (HR = 1.53) or hypertension (HR = 6.01). In the following years after delivery, general practitioners were seen frequently, whereas cardiologists were consulted rarely (0.3 and 2.4%).

CONCLUSION

Women affected by preeclampsia experience an increased risk of developing chronic hypertension and cardiovascular disease, especially those with recurrent preeclampsia. Future medical guidelines should take this potential risk into account.

Serum amyloid A1 and pregnancy zone protein in pregnancy complications and correlation with markers of placental dysfunction

BACKGROUND

Hypertensive disorders of pregnancy (preeclampsia, gestational hypertension, and chronic hypertension), diabetes mellitus, and placental dysfunction confer an increased risk of long-term maternal cardiovascular disease. Preeclampsia is also associated with acute atherosis that involves lesions of uteroplacental spiral arteries, resembling early stages of atherosclerosis. Serum amyloid A1 is involved in hypercoagulability and atherosclerosis and may aggregate into amyloid-aggregations of misfolded proteins. Pregnancy zone protein may inhibit amyloid aggregation. Amyloid is involved in Alzheimer's disease and cardiovascular disease; it has been identified in preeclampsia, but its role in preeclampsia pathophysiology is unclear.

OBJECTIVE

We hypothesized that serum amyloid A1 would be increased and pregnancy zone protein decreased in hypertensive disorders of pregnancy and diabetic pregnancies and that serum amyloid A1 and pregnancy zone protein would correlate with placental dysfunction markers (fetal growth restriction and dysregulated angiogenic biomarkers) and acute atherosis.

STUDY DESIGN

Serum amyloid A1 is measurable in both the serum and plasma. In our study, plasma from 549 pregnancies (normotensive, euglycemic controls: 258; early-onset preeclampsia: 71; late-onset preeclampsia: 98; gestational hypertension: 30; chronic hypertension: 9; diabetes mellitus: 83) was assayed for serum amyloid A1 and pregnancy zone protein. The serum levels of angiogenic biomarkers soluble fms-like tyrosine kinase-1 and placental growth factor were available for 547 pregnancies, and the results of acute atherosis evaluation were available for 313 pregnancies. The clinical characteristics and circulating biomarkers were compared between the pregnancy groups using the Mann-Whitney U, chi-squared, or Fisher exact test as appropriate. Spearman's rho was calculated for assessing correlations.

RESULTS

In early-onset preeclampsia, serum amyloid A1 was increased compared with controls (17.1 vs 5.1 µg/mL, P<.001), whereas pregnancy zone protein was decreased (590 vs 892 µg/mL, P=.002). Pregnancy zone protein was also decreased in diabetes compared with controls (683 vs 892 µg/mL, P=.01). Serum amyloid A1 was associated with placental dysfunction (fetal growth restriction, elevated soluble fms-like tyrosine kinase-1 to placental growth factor ratio). Pregnancy zone protein correlated negatively with soluble fms-like tyrosine kinase-1 to placental growth factor ratio in all study groups. Acute atherosis was not associated with serum amyloid A1 or pregnancy zone protein.

CONCLUSION

Proteins involved in atherosclerosis, hypercoagulability, and protein misfolding are dysregulated in early-onset preeclampsia and placental dysfunction, which links them and potentially contributes to future maternal cardiovascular disease.

Circulating cardiovascular biomarkers during and after preeclampsia: Crosstalk with placental function?

Cardiovascular disease (CVD) is the leading cause of death in women, yet sex-specific risk factors remain understudied. Preeclampsia and other adverse pregnancy outcomes imply an increased maternal cardiovascular risk. We hypothesized that cardiac troponin T (cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) are increased in such pregnancies and correlate with markers of placental dysfunction. We also investigated these cardiovascular biomarkers 1 or 3 years postpartum. Prior to delivery, we included serum from 417 pregnant women: 55 early-onset preeclampsia (EO-PE), 63 late-onset preeclampsia (LO-PE), 30 gestational hypertension (GH) and 269 healthy controls. Postpartum, we included 341 women 1 or 3 years after delivery: 26 EO-PE, 107 LO-PE, 61 GH, and 147 healthy pregnancies. Prior to delivery, median cTnT and NT-proBNP concentrations were higher in women with EO-PE, LO-PE, or GH than in controls. Median GDF-15 was higher in EO-PE and LO-PE compared to controls. Postpartum, GDF-15 was elevated in women with previous EO-PE. Markers of placental dysfunction correlated with CVD biomarkers in pregnancy, but not postpartum. Our findings underscore the cardiovascular burden of hypertensive disorders of pregnancy and the crosstalk with placental function. The upregulation of circulating GDF-15 following early-onset preeclampsia is in line with the epidemiological excessive risk of premature CVD in this group of women. GDF-15 may be explored for targeting postpartum women with most to gain from intensified preventive follow-up for CVD.

Cardiovascular biomarkers in pregnancy with diabetes and associations to glucose control

AIM

Cardiovascular disease (CVD) is a leading cause of death in both men and women. Type 1 and 2 diabetes mellitus (DM1 and DM2) are well-known risk factors for CVD. In addition, gestational diabetes mellitus (GDM) is a female sex-specific risk factor for CVD. Here, we measure circulating concentrations of cardiac troponin T (cTNT), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) during pregnancy-a window of time often referred to as a cardiovascular stress test for women.

METHODS

This study utilized data from 384 pregnant women: 64 with DM1, 16 with DM2, 35 with GDM and 269 euglycemic controls. Blood was predominantly sampled within a week before delivery. Cardiovascular biomarker concentrations were measured in serum using electrochemiluminescence immunoassay.

RESULT

Circulating cTnT levels were higher in women with DM1, DM2 and GDM as compared to controls, whereas NT-proBNP and GDF-15 levels were only increased in women with DM1. Glucose dysregulation, assessed by third trimester HbA1c levels, positively correlated with all three CVD biomarker levels, whereas pregestational body mass index correlated negatively with GDF-15.

CONCLUSIONS

Our results support the presence of myocardial affection in women with diabetic disorders during pregnancy. Although pregestational DM1 in this study was associated with the most adverse CVD biomarker profile, women with GDM displayed an adverse cTnT profile similar to what we found in women with pregestational DM2. This supports that women with GDM should be offered long-term intensified cardiovascular follow-up and lifestyle advice following delivery, similarly to the well-established CV follow-up of women with pregestational DM.

Risk of future cardiovascular diseases in different years postpartum after hypertensive disorders of pregnancy: A systematic review and meta-analysis

OBJECTIVE

There are limited data on the optimal timing and frequency of postpartum follow-up visits after hypertensive disorders of pregnancy (HDP) for primary prevention and early detection of cardiovascular diseases (CVDs) in high-risk women. We aimed to evaluate the risk of cardiovascular outcomes later in life in women with prior HDP in different years postpartum and in preeclamptic women with severe features, or early onset of preeclampsia.

METHODS

We searched MEDLINE, Cochrane Library, Web of Science, and Scopus without language restriction for relevant articles published from inception to March 16, 2022. We included prospective and retrospective cohort studies assessing hypertension, ischemic heart disease, heart failure, venous thromboembolism, peripheral vascular disease, stroke, dementia, composite cardiovascular and/or cerebrovascular diseases, and mortality after 6 weeks postpartum, in women with prior HDP compared with controls. Two authors independently selected and appraised the studies. Article quality was independently assessed using the Newcastle-Ottawa Scale (NOS). Random-effect models were used for meta-analysis. Stratified analyses based on years postpartum, severity, and onset of preeclampsia were performed.

RESULTS

We included 59 studies for qualitative review, of which 56 were included in quantitative meta-analysis, involving 1,262,726 women with prior HDP and 14,711,054 controls. Women with prior HDP had increased risks of hypertension (relative risk [RR] 3.46, 95% confidence interval [CI]: 2.67-4.49), ischemic heart disease (RR 2.06, 95% CI: 1.38-3.08), and heart failure (RR 2.53, 95% CI: 1.28-5.00) later in life, compared with those with normotensive pregnancies. The risk of hypertension was highest during 5 years postpartum (RR 5.34, 95% CI: 2.74-10.39). Compared with normotensive pregnancies, the risk of future CVDs significantly increased in preeclamptic women.

DISCUSSION

A history of HDP is associated with approximately 2- to 4-fold increase in the risk of CVDs. Screening for CVDs and their risk factors in women with prior HDP since delivery, especially the first 5 years after delivery is suggested for early detection and appropriate management. Evidence on the risks of CVDs in preeclampsia with severe features and early onset of preeclampsia is limited due to having few studies and high heterogeneity.

FUNDING

The Royal Golden Jubilee PhD Program-RGJ (PHD/0183/2561); Thailand Science Research and Innovation (TSRI) Research Career Development Grant-RSA (RSA6180009); Targeted Research Grants Program of the Faculty of Medicine, Prince of Songkla University, Thailand.

REGISTRATION

CRD42020191550.

Impairment of mitochondrial respiration in platelets and placentas: a pilot study in preeclamptic pregnancies

Preeclampsia (PE) is a major complication of pregnancy with partially elucidated pathophysiology. Placental mitochondrial dysfunction has been increasingly studied as major pathomechanism in both early- and late-onset PE. Impairment of mitochondrial respiration in platelets has recently emerged as a peripheral biomarker that may mirror organ mitochondrial dysfunction in several acute and chronic pathologies. The present study was purported to assess mitochondrial respiratory dys/function in both platelets and placental mitochondria in PE pregnancies. To this aim, a high-resolution respirometry SUIT (Substrate-Uncoupler-Inhibitor-Titration) protocol was adapted to assess complex I (glutamate + malate)- and complex II (succinate)-supported respiration. A decrease in all respiratory parameters (basal, coupled, and maximal uncoupled respiration) in peripheral platelets was found in preeclamptic as compared to healthy pregnancies. At variance, placental mitochondria showed a dichotomous behavior in preeclampsia in relation to the fetal birth weight. PE pregnancies with fetal growth restriction were associated with decreased in coupled respiration (oxidative phosphorylation/OXPHOS capacity) and maximal uncoupled respiration (electron transfer/ET capacity). At variance, these respiratory parameters were increased for both complex I- and II-supported respiration in PE pregnancies with normal weight fetuses. Large randomized controlled clinical studies are needed in order to advance our understanding of mitochondrial adaptive vs. pathological changes in preeclampsia.

Levels of blood pressure, cardiovascular biomarkers and their correlations in women with previous pre-eclamptic pregnancy within 7 years postpartum: a cross-sectional study in Thailand

OBJECTIVE

To assess the levels of blood pressure, cardiovascular biomarkers and their correlations measured within 7 years postpartum in women with previous pre-eclamptic pregnancies compared with women with previous normotensive pregnancies.

DESIGN

Cross-sectional study.

SETTING

Two tertiary hospitals in the southern region of Thailand.

PARTICIPANTS

Women with pre-eclamptic and normotensive pregnancies in the past 7 years were enrolled from 1 October 2019 to 30 April 2021. Eligible women were interviewed, examined for body mass index (BMI) and blood pressure, and donated morning spot urine and blood samples.

PRIMARY OUTCOME MEASURES

Serum high-sensitivity C reactive protein, creatinine, fasting blood glucose (FBS), glycated haemoglobin (HbA1c), low-density lipoprotein (LDL) cholesterol, urine microalbumin to creatinine ratio (UACR) and sodium were measured. Group differences in biomarkers were tested using unpaired t-test, Wilcoxon rank-sum test or χ² test. The levels of blood pressure and biomarkers between the two study groups at <2 years, 2-4 years and >4 years were also compared. The correlations between blood pressure and biomarkers were analysed using Pearson's correlation and partial correlation methods.

RESULTS

From 206 women included in the analysis, 88 had pre-eclamptic pregnancies and 118 had normotensive pregnancies. Compared with women with previous normotensive pregnancies, women with previous pre-eclamptic pregnancies had significantly increased rates of hypertension (31.8% vs 7.6%, p<0.001) and obesity (55.7% vs 40.7%, p=0.038), as well as higher serum levels of FBS (p<0.001), HbA1c (p<0.001), LDL cholesterol (p=0.03), creatinine (p<0.001) and UACR (p<0.001). Correlation coefficients of BMI, serum creatinine and UACR with blood pressure ranged from 0.27 to 0.31.

CONCLUSION

The risk of hypertension after a pre-eclamptic pregnancy increased. Blood pressure measurement combined with BMI, serum creatinine and UACR screening at least once during 7 years postpartum is suggested for early detection of cardiovascular risk.

Substantial decrease in preeclampsia prevalence and risk over two decades: A population-based study of 1,153,227 deliveries in Norway

OBJECTIVES

Analyze secular trends of preeclampsia in Norway based on risk factors.

STUDY DESIGN

Population-based cohort study of 1,153,227 women using data from Medical Birth Registry of Norway from 1999 to 2018. Aggregated data from Norwegian Prescription Database from 2004 to 2018 were used. Main exposure variable was time period. Descriptive statistics identified the prevalence of preeclampsia, labor induction and aspirin use. Multiple logistic regression analysis was performed to estimate the risk of preeclampsia during the time periods.

MAIN OUTCOME MEASURES

Preeclampsia.

RESULTS

Overall preeclampsia prevalence decreased from 4.3% in 1999-2002 to 2.7% in 2015-2018. A reduction was observed in all subgroups of women with known risk factors (age, nulliparity, diabetes, chronic hypertension, assisted reproduction, twin pregnancy). Adjusted risk of preeclampsia was reduced by 44% from 1999-2002 to 2015-2018 (aOR = 0.56, 95%CI 0.54, 0.58), while the net prevalence of gestational hypertension remained stable over the study period. Labor induction increased 104%. Aspirin prescriptions increased among fertile women in the general Norwegian population.

CONCLUSIONS

Preeclampsia prevalence and risk were reduced regardless of risk factors and despite an increased proportion of high-risk parturients (advanced age, lower parity, use of assisted reproduction). A corresponding increase in aspirin prescriptions among fertile women and an overall increase in labor inductions were also observed, suggesting that clinical interventions may partly explain the observed reduction in preeclampsia prevalence. Lower average blood pressure and improved health in the population may also explain some of the reduction.

Severe Maternal Morbidity and Long-Term Risk of Cardiovascular Hospitalization

BACKGROUND

Severe maternal morbidity is rising, yet the association with cardiovascular disease is not clear. We examined the risk of cardiovascular hospitalization up to 3 decades after having a pregnancy complicated by severe maternal morbidity.

METHODS

We analyzed a longitudinal cohort of 1 336 846 women who were pregnant between 1989 and 2019 in Quebec, Canada. The main exposure measure was severe maternal morbidity in any pregnancy, including severe preeclampsia, acute renal failure, sepsis, and other life-threatening conditions. Using time-varying Cox regression models, we compared the adjusted risk of hospitalization for cardiovascular disease up to 3 decades after pregnancy for women with severe maternal morbidity relative to women without severe morbidity.

RESULTS

Five percent of women had severe maternal morbidity. Overall, there were 68 287 cardiovascular hospitalizations during 21 725 672 person-years of follow-up in the cohort. Compared with no morbidity, women with any severe morbidity had a greater risk of cardiovascular hospitalization (hazard ratio [HR], 1.77 [95% CI, 1.72-1.82]). The association was the greatest within the first year of delivery (HR, 4.42 [95% CI, 3.77-5.19]) but persisted beyond 15 years (HR, 1.44 [95% CI, 1.37-1.51]). Having a cardiac complication (HR, 5.37 [95% CI, 4.65-6.20]), cerebrovascular accident (HR, 3.82 [95% CI, 2.94-4.96]), or acute renal failure (HR, 2.60 [95% CI, 2.15-3.14]) during pregnancy was strongly associated with future cardiovascular hospitalization.

CONCLUSIONS

Women with severe maternal morbidity have a greater risk of cardiovascular disease after pregnancy, both in the short and long term. These women may benefit from active surveillance for cardiovascular disease.

The prediction of preeclampsia: the way forward

Despite intensive investigation, we still cannot adequately predict, treat, or prevent preeclampsia. We have gained awareness that preeclampsia is a syndrome not a disease and is heterogeneous in its presentation and pathophysiology, which may indicate differing underlying phenotypes, and that the impact extends beyond pregnancy per se. Effects on the fetus and mother extend many years after pregnancy, as evidenced by fetal programming of adult disease and increased risk of the development of maternal cardiovascular disease. The increased occurrence of preeclampsia in women with preexisting risk factors suggests that the stress of pregnancy may expose subclinical vascular disease as opposed to preeclampsia damaging the vasculature. The heterogeneity of preeclampsia has blighted efforts to predict preeclampsia early in gestation and has thwarted success in attempts at therapy with treatments, such as low-dose aspirin or global antioxidants. There is a critical need to identify the phenotypes to enable their specific prediction and treatment. Such studies require considerably larger collections of patients than employed in past and current studies. This does not necessarily imply much larger patient numbers in single studies but can be facilitated by the ability to easily combine many smaller studies. This can be accomplished by agreeing on a priori standardized and harmonized clinical data and biospecimen collection across new studies. Such standards are being established by international groups of investigators. Leadership by international organizations, perhaps adopting a carrot and stick approach, to overcome investigator, institutional and funder reticence toward data sharing is required to ensure adoption of such standards. Future studies should include women in both low- and high-resource settings and employ social media and novel methods for data collection and analysis, including machine learning and artificial intelligence. The goal is to identify the pathophysiology underlying differing preeclampsia phenotypes, their successful prediction with the design, and the implementation of phenotype-specific therapies.

Failure of physiological transformation and spiral artery atherosis: their roles in preeclampsia

Physiological transformation with remodeling of the uteroplacental spiral arteries is key to a successful placentation and normal placental function. It is an intricate process that involves, but is not restricted to, complex interactions between maternal decidual immune cells and invasive trophoblasts in the uterine wall. In normal pregnancy, the smooth muscle cells of the arterial tunica media of uteroplacental spiral arteries are replaced by invading trophoblasts and fibrinoid, and the arterial diameter increases 5- to 10-fold. Poor remodeling of the uteroplacental spiral arteries is linked to early-onset preeclampsia and several other major obstetrical syndromes, including fetal growth restriction, placental abruption, and spontaneous preterm premature rupture of membranes. Extravillous endoglandular and endovenous trophoblast invasions have recently been put forth as potential contributors to these syndromes as well. The well-acknowledged disturbed extravillous invasion of maternal spiral arteries in preeclampsia is summarized, as are briefly novel concepts of disturbed extravillous endoglandular and endovenous trophoblast invasions. Acute atherosis is a foam cell lesion of the uteroplacental spiral arteries associated with poor remodeling. It shares some morphologic features with early stages of atherosclerosis, but several molecular differences between these lesions have also recently been revealed. Acute atherosis is most prevalent at the maternal-fetal interface, at the tip of the spiral arteries. The localization of acute atherosis downstream of poorly remodeled arteries suggests that alterations in blood flow may trigger inflammation and foam cell development. Acute atherosis within the decidua basalis is not, however, confined to unremodeled areas of spiral arteries or to hypertensive disorders of pregnancy and may even be present in some clinically uneventful pregnancies. Given that foam cells of atherosclerotic lesions are known to arise from smooth muscle cells or macrophages activated by multiple types of inflammatory stimulation, we have proposed that multiple forms of decidual vascular inflammation may cause acute atherosis, with or without poor remodeling and/or preeclampsia. Furthermore, we propose that acute atherosis may develop at different gestational ages, depending on the type and degree of the inflammatory insult. This review summarizes the current knowledge of spiral artery remodeling defects and acute atherosis in preeclampsia. Some controversies will be presented, including endovascular and interstitial trophoblast invasion depths, the concept of 2-stage trophoblast invasion, and whether the replacement of maternal spiral artery endothelium by fetal endovascular trophoblasts is permanent. We will discuss the role of acute atherosis in the pathophysiology of preeclampsia and short- and long-term health correlates. Finally, we suggest future opportunities for research on this intriguing uteroplacental interface between the mother and fetus.

Usage of Digital Health Tools and Perception of mHealth Intervention for Physical Activity and Sleep in Black Women

Black women of reproductive age are disproportionately affected by chronic health conditions and related disease risk factors such as physical inactivity and obesity. Health promotion studies need to focus on this population since optimizing preconception health will lead to improvement of both birth outcomes and the woman’s long-term health. mHealth interventions that utilize wearable sensors to provide personalized and timely feedback can be used to promote physical activity (PA). This study aimed to examine Black women’s wearable sensor usage and their perceptions about future mHealth interventions that target PA and sleep. Our analysis included 497 Black women (aged 18–47 years) who completed a cross-sectional online survey. Ninety-two percent of participants did not meet the recommended level of PA, and 32.3% reported poor sleep quality. More participants indicated interest in a remote PA program (77%) than an in-person one (73%). More than half of participants indicated interest in receiving personalized feedback messages based on wearable trackers about PA (58.1%) and sleep (63.5%). This perceived acceptability of remote intervention and wearable-based feedback messages did not differ by socioeconomic status. Remotely delivered mHealth interventions that utilize wearables can be a viable behavioral change strategy to promote PA and sleep quality in Black women.

Does Adding Adverse Pregnancy Outcomes Improve the Framingham Cardiovascular Risk Score in Women? Data from the Tehran Lipid and Glucose Study

Background

Limited and conflicting evidence is available regarding the predictive value of adding adverse pregnancy outcomes (APOs) to established cardiovascular disease (CVD) risk factors. Hence, the objective of this study was to determine whether adding APOs to the Framingham risk score improves the prediction of CVD events in women.

Methods and Results

Out of 5413 women who participated in the Tehran Lipid and Glucose Study, 4013 women met the eligibility criteria included for the present study. The exposure and the outcome variables were collected based on the standard protocol. Cox proportional hazard model was used to evaluate the association of APOs and CVDs. The variant of C‐statistic for survivals and reclassification of subjects into Framingham risk score categories after adding APOs was reported. Out of the 4013 eligible subjects, a total of 1484 (36.98%) women reported 1 APO, while 395 (9.84%) of the cases reported multiple APOs. Univariate proportional hazard Cox models showed the significant relations between CVD events and APOs. The enhanced model had a higher C‐statistic indicating more acceptable discrimination as well as a slight improvement in discrimination (C‐statistic differences: 0.0053). Moreover, we observed a greater risk of experiencing a CVD event in women with a history of multiple APOs compared with cases with only 1 APO (1 APO: hazard ratio [HR] = 1.22; 2 APOs: HR; 1.94; ≥3 APOs: HR = 2.48).

Conclusions

Beyond the established risk factors, re‐estimated CVDs risk by adding APOs to the Framingham risk score may improve the accurate risk estimation of CVD. Further observational studies are needed to confirm our findings.

Cellular immune responses in the pathophysiology of preeclampsia

Preeclampsia, defined as new-onset hypertension accompanied by proteinuria occurring at 20 weeks of gestation or later, is a leading cause of perinatal morbidity and mortality worldwide. The pathophysiology of this major multi-systemic syndrome includes defective deep placentation, oxidative stress, endothelial dysfunction, the presence of an anti-angiogenic state, and intravascular inflammation, among others. In this review, we provide a comprehensive overview of the cellular immune responses involved in the pathogenesis of preeclampsia. Specifically, we summarize the role of innate and adaptive immune cells in the maternal circulation, reproductive tissues, and at the maternal-fetal interface of women affected by this pregnancy complication. The major cellular subsets involved in the pathogenesis of preeclampsia are regulatory T cells, effector T cells, NK cells, monocytes, macrophages, and neutrophils. We also summarize the literature on those immune cells that have been less characterized in this clinical condition, such as γδ T cells, invariant natural killer T cells, dendritic cells, mast cells, and B cells. Moreover, we discuss in vivo studies utilizing a variety of animal models of preeclampsia to further support the role of immune cells in this disease. Finally, we highlight the existing gaps in knowledge of the immunobiology of preeclampsia that require further investigation. The goal of this review is to promote translational research leading to clinically relevant strategies that can improve adverse perinatal outcomes resulting from the obstetrical syndrome of preeclampsia.

Acute Atherosis Lesions at the Fetal-Maternal Border: Current Knowledge and Implications for Maternal Cardiovascular Health

Decidua basalis, the endometrium of pregnancy, is an important interface between maternal and fetal tissues, made up of both maternal and fetal cells. Acute atherosis is a uteroplacental spiral artery lesion. These patchy arterial wall lesions containing foam cells are predominantly found in the decidua basalis, at the tips of the maternal arteries, where they feed into the placental intervillous space. Acute atherosis is prevalent in preeclampsia and other obstetric syndromes such as fetal growth restriction. Causal factors and effects of acute atherosis remain uncertain. This is in part because decidua basalis is challenging to sample systematically and in large amounts following delivery. We summarize our decidua basalis vacuum suction method, which facilitates tissue-based studies of acute atherosis. We also describe our evidence-based research definition of acute atherosis. Here, we comprehensively review the existing literature on acute atherosis, its underlying mechanisms and possible short- and long-term effects. We propose that multiple pathways leading to decidual vascular inflammation may promote acute atherosis formation, with or without poor spiral artery remodeling and/or preeclampsia. These include maternal alloreactivity, ischemia-reperfusion injury, preexisting systemic inflammation, and microbial infection. The concept of acute atherosis as an inflammatory lesion is not novel. The lesions themselves have an inflammatory phenotype and resemble other arterial lesions of more extensively studied etiology. We discuss findings of concurrently dysregulated proteins involved in immune regulation and cardiovascular function in women with acute atherosis. We also propose a novel hypothesis linking cellular fetal microchimerism, which is prevalent in women with preeclampsia, with acute atherosis in pregnancy and future cardiovascular and neurovascular disease. Finally, women with a history of preeclampsia have an increased risk of premature cardiovascular disease. We review whether presence of acute atherosis may identify women at especially high risk for premature cardiovascular disease.

Maternal Cardiovascular and Cerebrovascular Health After Placental Abruption: A Systematic Review and Meta-Analysis (CHAP-SR)

Placental abruption and cardiovascular disease (CVD) have common etiological underpinnings, and there is accumulating evidence that abruption may be associated with future CVD. We estimated associations between abruption and coronary heart disease (CHD) and stroke. The meta-analysis was based on the random-effects risk ratio (RR) and 95% confidence interval (CI) as the effect measure. We conducted a bias analysis to account for abruption misclassification, selection bias, and unmeasured confounding. We included 11 cohort studies comprising 6,325,152 pregnancies, 69,759 abruptions, and 49,265 CHD and stroke cases (1967-2016). Risks of combined CVD morbidity-mortality among abruption and nonabruption groups were 16.7 and 9.3 per 1,000 births, respectively (RR = 1.76, 95% CI: 1.24, 2.50; I2 = 94%; τ2 = 0.22). Women who suffered abruption were at 2.65-fold (95% CI: 1.55, 4.54; I2 = 85%; τ2 = 0.36) higher risk of death related to CHD/stroke than nonfatal CHD/stroke complications (RR = 1.32, 95% CI: 0.91, 1.92; I2 = 93%; τ2 = 0.15). Abruption was associated with higher mortality from CHD (RR = 2.64, 95% CI: 1.57, 4.44; I2 = 76%; τ2 = 0.31) than stroke (RR = 1.70, 95% CI: 1.19, 2.42; I2 = 40%; τ2 = 0.05). Corrections for the aforementioned biases increased these estimates. Women with pregnancies complicated by placental abruption may benefit from postpartum screening or therapeutic interventions to help mitigate CVD risks.

Circulating extracellular vesicles during pregnancy in women with type 1 diabetes: a secondary analysis of the CONCEPTT trial

BACKGROUND

Extracellular vesicles are membrane vesicles that are released into the extracellular environment and accumulate in the circulation in vascular disease. We aimed to quantify circulating extracellular vesicles in pregnant women with type 1 diabetes and to examine associations between extracellular vesicle levels, continuous glucose measures, and pregnancy outcomes.

METHODS

We used plasma samples from the Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Trial study and quantified circulating extracellular vesicles by flow cytometry (n = 163). Relationships with clinical variables were assessed by repeated measures correlation. Logistic regression was used to assess associations between elevated extracellular vesicle levels and pregnancy outcomes.

RESULTS

Platelet extracellular vesicle levels were inversely associated with glucose time above range and glycaemic variability measures (P < 0.05). A weak positive association was observed between endothelial extracellular vesicles and mean amplitude of glycemic excursion (P < 0.05). In a univariate logistic regression model, high baseline endothelial extracellular vesicles was associated with increased risk of neonatal intensive care unit (NICU) admission (OR: 2.06, 1.03-4.10), and respiratory distress requiring ventilation (OR: 4.98, 1.04-23.92). After adjusting for HbA1c and blood pressure the relationship for NICU admission persisted and an association with hyperbilirubinemia was seen (OR: 2.56, 1.10-5.94). Elevated platelet extracellular vesicles were associated with an increased risk of NICU admission (OR: 2.18, 1.04-4.57), and hyperbilirubinemia (OR: 2.61, 1.11-6.12) after adjusting for HbA1c and blood pressure.

CONCLUSIONS

High levels of extracellular vesicles in early pregnancy were associated with adverse neonatal outcomes. Assessment of extracellular vesicles may represent a novel approach to personalized care in type 1 diabetes pregnancy.

Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension

Patients with a history of hypertensive disorders of pregnancy (HDP) suffer higher rates of long-term cardiovascular events including heart failure, coronary artery disease, and stroke. Cardiovascular changes during pregnancy can act as a natural stress test, subsequently unmasking latent cardiovascular disease in the form of HDP. Because HDP now affect 10% of pregnancies in the United States, the American Heart Association has called for physicians who provide peripartum care to promote early identification and cardiovascular risk reduction. In this review, we discuss the epidemiology, pathophysiology, and outcomes of HDP-associated cardiovascular disease. In addition, we propose a multi-pronged approach to support cardiovascular risk reduction for women with a history of HDP. Additional research is warranted to define appropriate blood pressure targets in the postpartum period, optimize the use of pregnancy history in risk stratification tools, and clarify the effectiveness of preventive interventions. The highest rates of HDP are in populations with poor access to resources and quality health care, making it a major risk for inequity of care. Interventions to decrease long-term cardiovascular disease risk in women following HDP must also target disparity reduction.

Optimizing women's cardiovascular health after hypertensive disorders of pregnancy: a translational approach to cardiovascular disease prevention

Women who experience a hypertensive disorder of pregnancy (HDP) are amongst those at the highest risk of premature cardiovascular diseases (CVD). In Canada, effective CVD prevention interventions tailored specifically for this high-risk population are urgently needed. The objective of this review is to summarize a broad range of mechanistic and clinical studies examining the association of HDP with future CVD to inform postpartum clinical follow-up strategies focused on improving women's cardiovascular health. The current state of the science (animal model, observational and intervention studies) largely support two main hypotheses explaining the epidemiological link between HDP and long-term risk of CVD. First, that the complicated pregnancy "unmasks" women who were predisposed to CVD prior to pregnancy (i.e., women with subclinical atherosclerosis or pre-pregnancy CVD risk factors). Second, that HDP causes vascular dysfunction and/or worsens preexisting, subclinical CVD risk factors. Despite this strong evidence, several knowledge gaps remain in the understanding of specific mechanisms linking these two theories and the impacts of other important contributors (e.g., intersectional factors). From a clinical perspective, given the consistent data demonstrating a high prevalence of CVD risk factors after HDP, routine care after pregnancy at minimum should include: 1) standardized assessment of pregnancy-associated CV risks (P-CVRs); 2) early and regular screening of traditional CVD risk factors; 3) education and support for health behaviours as first line therapy (including breastfeeding); 4) individualized pharmacotherapy (i.e., statins, antihypertensives or antiglycemic agents as clinically indicated); and 5) consideration of a woman's health goals, reproductive plans and social context.

A Lifecourse Perspective on Female Sex-Specific Risk Factors for Later Life Cognition

PURPOSE OF REVIEW

The prevalence of Alzheimer's disease and related dementias is greater in women compared to men. We provide a review of female sex-specific risk factors across the lifecourse for cognition in older adulthood, highlighting areas that need further study.

RECENT FINDINGS

Pregnancy may affect late-life cognition, with adverse pregnancy outcomes associated with an increased risk of cognitive decline but parity providing a protective effect. Cumulative estrogen exposure, influenced by age of menarche, menopause, and exogenous estrogen use, may modify a woman's risk for dementia. Menopause transition-associated symptoms may impact cognitive health at the time of the symptoms, but long-term effects remain unknown. As compared to natural menopause, surgical menopause seems to increase the risk for cognitive impairment. Studies that have assessed the association between women's reproductive health and cognition have produced conflicting results. Future studies that address these inconsistencies among diverse populations are needed to better care for women throughout their lives.

Deficiency in CD4 T Cells Leads to Enhanced Postpartum Internal Carotid Artery Vasoconstriction in Mice: The Role of Nitric Oxide

The risk of postpartum (PP) stroke is increased in complicated pregnancies. Deficiency in CD4 T cell subsets is associated with preeclampsia and may contribute to PP vascular disease, including internal carotid artery (ICA) stenosis and stroke. We hypothesized that CD4 T cell deficiency in pregnancy would result in ICA dysregulation, including enhanced ICA vasoconstriction. We characterized the function, mechanical behavior, and structure of ICAs from C57BL/6 (WT) and CD4 deficient (CD4KO) mice, and assessed the role of NO in the control of ICA function at pre-conception and PP. WT and CD4KO mice were housed under pathogen-free conditions, mated to same-strain males, and allowed to litter or left virgin. At 3 days or 4 weeks PP, mice were euthanized. The responses to phenylephrine (PE), high K⁺ and acetylcholine (ACh) were assessed in pressurized ICAs before and after NOS inhibition. Passive lumen diameters were measured at 3–140 mmHg. eNOS and iNOS expression as well as the presence of T cells were evaluated by immunohistochemistry. Constriction of WT ICAs to PE was not modified PP. In contrast, responses to PE were significantly increased in ICAs from PP as compared to virgin CD4KO mice. Constriction to high K⁺ was not enhanced PP. ICAs from WT and CD4KO mice were equally sensitive to ACh with a significant rightward shift of dose-response curves after L-NNA treatment. NOS inhibition enhanced PE constriction of ICAs from WT virgin and PP mice. Although a similar effect was detected in ICAs of virgin CD4KO mice, no such changes were observed in vessels from PP CD4KO mice. Passive arterial distensibility at physiological levels of pressure was not modified at PP. ICA diameters were significantly increased in PP with no change in vascular wall thickness. Comparison of eNOS expression in virgin, 3 days and 4 weeks PP revealed a reduced expression in ICA from CD4 KO vs. WT PP vessels which reached significance at 4 weeks PP. iNos expression was similar and decreased over the PP period in vessels from WT and CD4KO mice. Dysregulation of the CD4 T cell population in pregnancy may make ICA vulnerable to vasospasm due to decreased NO-dependent control of ICA constriction. This may lead to cerebral hypoperfusion and increase the risk of maternal PP stroke.

Low physical activity levels 1 year after pregnancy complications

OBJECTIVES

Women with previous preeclampsia (PE), gestational hypertension (GH), or gestational diabetes mellitus (GDM) have increased cardiovascular disease (CVD) risk. Physical activity (PA) is an important CVD risk modifier. We aimed to assess PA levels, using a validated objective method, and other modifiable CVD risk factors in women with these previous pregnancy complications.

STUDY DESIGN

One year postpartum we assessed PA levels for 1 week in women with previous PE (n = 68), GH (n = 26), GDM (n = 23), and normotensive pregnancies (n = 65), using the ActiGraph-wGT3X-BT™ accelerometer.

OUTCOME MEASURES

We assessed adherence to American PA guidelines (≥150 min/week of moderate or ≥75 min/week of vigorous intensity PA), and time spent in moderate and vigorous PA. We also assessed steps/day, blood pressure and anthropometric indices.

RESULTS

Recommended PA levels were achieved in only 50%, 39%, and 35% following PE, GH, and GDM, respectively, not significantly different from controls (52%). Differences in moderate and vigorous PA levels and steps/day between the groups were non-significant, except from lower vigorous PA in women with previous GDM. Elevated blood pressure (systolic BP ≥ 120 mmHg and/or diastolic BP ≥ 80 mmHg) was more common after PE and GH. Overweight rates were significantly higher in PE, GH, and GDM groups compared to controls.

CONCLUSIONS

Less than half of women achieved recommended PA levels 1 year postpartum. This did not differ significantly between women with previous PE, GH, or GDM compared to controls. Measures to increase PA in postpartum women are warranted, especially in women with pregnancy complications associated with high risk of premature CVD.

Cardiovascular disease and cancer in women with accreta and retained placenta: a longitudinal cohort study

PURPOSE

The association between placental detachment disorders and risk of chronic disease is unclear. We determined the association of placenta accreta and retained placenta with risk of future maternal cardiovascular disease and cancer.

METHODS

We tracked a longitudinal cohort of 541,051 pregnant women over a period of 13 years (2006-2019) in Quebec, Canada. The main exposure measures were placenta accreta and retained placenta in any pregnancy. Outcomes included future hospitalizations for cardiovascular disease and cancer. Using Cox regression models adjusted for maternal characteristics, we estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of accreta and retained placenta with cardiovascular disease and cancer at 13 years.

RESULTS

The incidence of cardiovascular hospitalization was 21.2 per 10,000 person-years for accreta and 23.4 per 10,000 for retained placenta with postpartum hemorrhage, compared with 20.3 per 10,000 for neither placental disorder. Cancer incidence followed a similar pattern, with rates highest for retained placenta with hemorrhage. Retained placenta with hemorrhage was associated with 1.19 times the risk of cardiovascular disease (95% CI 1.03-1.38) and 1.27 times the risk of cancer (95% CI 1.06-1.53). Retained placenta with hemorrhage was associated with heart failure (HR 1.84, 95% CI 1.04-3.27), cardiomyopathy (HR 1.88, 95% CI 1.03-3.43), and cervical cancer (HR 2.03, 95% CI 1.17-3.52). Accreta and retained placenta without hemorrhage were not associated with these outcomes.

CONCLUSION

Retained placenta with hemorrhage may be a risk marker for cardiovascular disease and certain cancers later in life.

Risk of type 2 diabetes mellitus in women with prior hypertensive disorders of pregnancy: a systematic review and meta-analysis

AIMS/HYPOTHESIS

The association between a history of hypertensive disorders of pregnancy (HDP) and subsequent type 2 diabetes (referred to throughout as diabetes) remains inconclusive. We reviewed the most recent evidence to quantify the association of previous HDP with incident diabetes.

METHODS

A systematic search of MEDLINE, Embase and CINAHL was performed up to 17 February 2020 to identify observational studies of the association between HDP (pre-eclampsia or gestational hypertension) and incident diabetes. Studies of women with pre-pregnancy diabetes were excluded. Two independent reviewers screened citations and abstracted results. Study quality was assessed in duplicate using the Newcastle-Ottawa Scale. Random-effects models were used to pool effect estimates. Heterogeneity was assessed using the I² statistic.

RESULTS

After screening 4617 citations, 16 cohort studies with a total of 3,095,457 participants were included (unspecified HDP n = 5, pre-eclampsia only n = 4, gestational hypertension and pre-eclampsia n = 7). Risks of subsequent diabetes were significantly higher in women with a history of any HDP (HDP: adjusted hazard ratio [aHR] 2.24, 95% CI 1.95, 2.58; gestational hypertension: aHR 2.19 [95% CI 1.69, 2.84]; pre-eclampsia: aHR 2.56 [95% CI 2.02, 3.24]; preterm pre-eclampsia: aHR 3.05 [95% CI 2.05, 4.56]). The association between HDP and diabetes persisted in studies that adjusted for gestational diabetes mellitus (aHR 2.01 [95% CI 1.77, 2.28]).

CONCLUSIONS/INTERPRETATION

HDP are independently associated with a higher risk of diabetes. Further study is needed to determine how HDP contribute to diabetes risk prediction to develop evidence-based screening and prevention strategies. Graphical abstract.

Cardiac Remodeling During Pregnancy With Metabolic Syndrome: Prologue of Pathological Remodeling

BACKGROUND

The heart undergoes physiological hypertrophy during pregnancy in healthy individuals. Metabolic syndrome (MetS) is now prevalent in women of child-bearing age and might add risks of adverse cardiovascular events during pregnancy. The present study asks if cardiac remodeling during pregnancy in obese individuals with MetS is abnormal and whether this predisposes them to a higher risk for cardiovascular disorders.

METHODS

The idea that MetS induces pathological cardiac remodeling during pregnancy was studied in a long-term (15 weeks) Western diet-feeding animal model that recapitulated features of human MetS. Pregnant female mice with Western diet (45% kcal fat)-induced MetS were compared with pregnant and nonpregnant females fed a control diet (10% kcal fat).

RESULTS

Pregnant mice fed a Western diet had increased heart mass and exhibited key features of pathological hypertrophy, including fibrosis and upregulation of fetal genes associated with pathological hypertrophy. Hearts from pregnant animals with WD-induced MetS had a distinct gene expression profile that could underlie their pathological remodeling. Concurrently, pregnant female mice with MetS showed more severe cardiac hypertrophy and exacerbated cardiac dysfunction when challenged with angiotensin II/phenylephrine infusion after delivery.

CONCLUSIONS

These results suggest that preexisting MetS could disrupt physiological hypertrophy during pregnancy to produce pathological cardiac remodeling that could predispose the heart to chronic disorders.

Associations of gestational cardiovascular health with pregnancy outcomes: the Hyperglycemia and Adverse Pregnancy Outcome study

BACKGROUND

The American Heart Association's formal characterization of cardiovascular health combines several metrics in a health-oriented, rather than disease-oriented, framework. Although cardiovascular health assessment during pregnancy has been recommended, its significance for pregnancy outcomes is unknown.

OBJECTIVE

The purpose of this study was to examine the association of gestational cardiovascular health-formally characterized by a combination of 5 metrics-with adverse maternal and newborn outcomes.

STUDY DESIGN

We analyzed data from the Hyperglycemia and Adverse Pregnancy Outcome study, including 2304 mother-newborn dyads from 6 countries. Maternal cardiovascular health was defined by the combination of the following 5 metrics measured at a mean of 28 (24-32) weeks' gestation: body mass index, blood pressure, lipids, glucose, and smoking. Levels of each metric were categorized using pregnancy guidelines, and the total cardiovascular health was scored (0-10 points, where 10 was the most favorable). Cord blood was collected at delivery, newborn anthropometrics were measured within 72 hours, and medical records were abstracted for obstetrical outcomes. Modified Poisson and multinomial logistic regression were used to test the associations of gestational cardiovascular health with pregnancy outcomes, adjusted for center and maternal and newborn characteristics.

RESULTS

The average age of women at study exam was 29.6 years old, and they delivered at a mean gestational age of 39.8 weeks. The mean total gestational cardiovascular health score was 8.6 (of 10); 36.3% had all ideal metrics and 7.5% had 2+ poor metrics. In fully adjusted models, each 1 point higher (more favorable) cardiovascular health score was associated with lower risks for preeclampsia (relative risk, 0.67 [95% confidence interval, 0.61-0.73]), unplanned primary cesarean delivery (0.88 [0.82-0.95]), newborn birthweight >90th percentile (0.81 [0.75-0.87]), sum of skinfolds >90th percentile (0.84 [0.77-0.92]), and insulin sensitivity <10th percentile (0.83 [0.77-0.90]). Cardiovascular health categories demonstrated graded associations with outcomes; for example, relative risks (95% confidence intervals) for preeclampsia were 3.13 (1.39-7.06), 5.34 (2.44-11.70), and 9.30 (3.95-21.86) for women with ≥1 intermediate, 1 poor, or ≥2 poor (vs all ideal) metrics, respectively.

CONCLUSION

More favorable cardiovascular health at 24 to 32 weeks' gestation was associated with lower risks for several adverse pregnancy outcomes in a multinational cohort.

Kinetics of Postpartum Mesenteric Artery Structure and Function Relative to Pregnancy and Lactation in Mice

Epidemiological evidence suggests that normal pregnancy in women is associated with decreased cardiovascular risk in later life. Clinical studies have provided evidence that alterations in vascular function and structure are detectable long after delivery. To understand these findings, we examined mesenteric artery reactivity at both early (3 days and 2–4 weeks) and late (12 weeks) postpartum (PP) time points in relation to late pregnancy (LP) and lactation. Vessels from virgin controls, LP, PP, and nursing and non-nursing mothers were tested for responses to phenylephrine (PE), high potassium solutions (high K⁺), and acetylcholine (ACh). Passive arterial distensibility, vessel dimensions, and collagen and elastin content were evaluated for the studied groups. We observed that (1) there was a significant inhibition of vascular reactivity to PE in LP, 3 days and 2 weeks PP vessels that returned to pre-pregnancy levels at 4 and 12 weeks PP; (2) inhibition of NO production in PP vessels restored PE-induced constriction to pre-pregnancy levels; (3) vasodilator responses to ACh were similar at all PP periods; (4) LP and early PP was associated with a persistent increase in arterial distensibility that correlates with a PP-induced reduction in wall collagen, and regressed to pre-conception levels at 12 weeks PP; (5) vessels from non-nursing PP mice demonstrated an increased PE reactivity, diminished responses to ACh, and reduced distensibility compared to breastfeeding mice. These studies provide a timeframe for mesenteric artery adaptations that occur during pregnancy and extend to the PP period, but which may be modified by PP events.

Pregnancy and postpartum levels of circulating maternal sHLA-G in preeclampsia

Preeclampsia is a leading cause of maternal and offspring mortality and morbidity, and predicts increased future cardiovascular disease risk. Placental dysfunction and immune system dysregulation are likely key pathophysiological factors. Soluble human leukocyte antigen G (sHLA-G) may dampen the specific immune response towards placental trophoblasts. Previous studies have shown low sHLA-G levels in preeclampsia, but postpartum, levels are unknown. Furthermore, the relationship between sHLA-G and sFlt-1 and PlGF, placental function markers, is unknown. We hypothesized that low maternal sHLA-G during pregnancy would be associated with placental dysfunction, including preeclampsia, gestational hypertension, and dysregulated sFlt-1 and PlGF, and that sHLA-G would remain decreased following preeclampsia. We included 316 pregnant women: 58 with early-onset preeclampsia (<34 weeks' gestation), 81 with late-onset preeclampsia (≥34 weeks' gestation), 25 with gestational hypertension, and 152 normotensive controls. Postpartum (1 or 3 years), we included 321 women: 29 with early-onset preeclampsia, 98 with late-onset preeclampsia, 57 with gestational hypertension, and 137 who were normotensive during their index pregnancies. In pregnancy, plasma sHLA-G was significantly lower both in the early- and late-onset preeclampsia groups compared to controls. In women with preeclampsia or gestational hypertension, sHLA-G was inversely correlated with serum sFlt-1. Postpartum, plasma sHLA-G levels were significantly higher in women who had had early-onset preeclampsia compared to controls. Our results support that sHLA-G may be important for placental function. Unexpectedly, sHLA-G was elevated up to 3 years after early-onset preeclampsia, suggesting an excessively activated immune system following this severe preeclampsia form, potentially contributing to future cardiovascular disease risk.

Bioinformatics-based identification of miRNA-, lncRNA-, and mRNA-associated ceRNA networks and potential biomarkers for preeclampsia

This study aimed to identify significantly altered long non-coding RNAs (lncRNAs), microRNAs (miRNAs), mRNAs, pathways in preeclampsia (PE), and to investigate their targeted relationships and biological functions.GSE96985 from Gene Expression Omnibus database was extracted, involving 3 PE and 4 normal tissues. After the differential expression analysis of miRNAs, lncRNAs, and mRNAs using the limma package, protein-protein interaction (PPI) network and module analyses were performed for differentially expressed mRNAs (dif-mRNAs). Combined with the miRanda and miRWalk tools, a regulatory relationship between dif-miRNAs and dif-mRNAs/lncRNAs (dif-mRNAs/dif-lncRNAs) was predicted. Finally, mRNA-miRNA-lncRNA regulatory network construction was performed using Cytoscape software.A total of 511 dif-mRNAs were screened in PE. The top 5 nodes in the PPI networks included up-regulated complement component 3 (C3), C-X-C motif chemokine ligand 8 (CXCL8), and fibronectin 1 (FN1). Three significant network modules were identified for dif-mRNAs. C3 and CXCL8 were identified in module A, and FN1 was identified in module C. A disintegrin and metalloproteinase with thrombospondin motifs 6 (ADAMTS6) was down-regulated by the miR-210-3p. Therefore, lnc-CTD-2383M3.1 functions as a competing endogenous RNA in ADAMTS6 expression regulation by competitively binding to miR-210-3p during the regulation process of PE.C3, CXCL8, FN1, and ADAMTS6 might be involved in the development of PE. The lnc-CTD-2383M3.1-miR-210-3p-ADAMTS6 axis might be a potential regulatory mechanism in PE.

Influence of maternal and perinatal characteristics on risk of postpartum chronic hypertension after pre-eclampsia

OBJECTIVE

To assess the prevalence of new-onset postpartum chronic hypertension (PPCH) after pre-eclampsia and to determine the factors are associated with it.

METHODS

This study was conducted in a tertiary center in south India, between June 2018 and February 2019, consisting of pre-eclamptic women who were recruited as part of an ongoing cohort and had completed at least 3 months of postpartum follow-up. Demographic, medical, and laboratory details were collected. Primary outcome was a diagnosis of new-onset PPCH at 3 months.

RESULTS

PPCH at 3 months was noted in 32 (18.1%) women. During postnatal follow-up, 2 (1.1%) women experienced hemiplegia from stroke and 19 (10.7%) had elevated serum creatinine levels (>1.1 mg/dL). On multivariate analysis, advancing maternal age (adjusted odds ratio [aOR] 1.10, 95% confidence interval [CI] 1.01-1.21), multiparity (aOR 2.79, 95% CI 1.07-7.24), and eclampsia (aOR 3.07, 95% CI 1.03-9.13) increased the risk of PPCH at 3 months postpartum.

CONCLUSION

One in five women present with a diagnosis of new-onset PPCH within 3 months postpartum in a cohort of predominantly preterm and/or severe pre-eclampsia. A significant but weak association of PPCH with peripartum clinical characteristics was noted. The role of biochemical, hemodynamic, and echocardiographic biomarkers should be evaluated for prediction of PPCH after pre-eclampsia in future studies.