Maternal Cardiovascular Disease 3 Decades After Preterm Birth: Longitudinal Cohort Study of Pregnancy Vascular Disorders

Maternal-fetal dyad beyond the phenomenology of pregnancy: from primordial cardiovascular prevention on out, do not miss this boat!

Pregnancy represents a stress test for every woman's cardiovascular (CV) system, and a pre-existing maternal unfavorable cardio-metabolic phenotype can uncover both adverse pregnancy outcomes and the subsequent development of cardiovascular disease (CVD) risk factors during and after pregnancy. Moreover, the maternal cardiac and extracardiac environment can affect offspring's cardiovascular health through a complex mechanism called developmental programming, in which fetal growth can be influenced by maternal conditions. This interaction continues later in life, as adverse developmental programming, along with lifestyle risk factors and genetic predisposition, can exacerbate and accelerate the development of CV risk factors and CVD in childhood and adolescence. The aim of this narrative review is to summarize the latest evidences regarding maternal-fetal dyad and its role on primordial, primary and secondary CV prevention.

Live Births in Women over 40 Years of Age Correlate with Obesity Rates

AIMS

This cross-sectional study aimed to analyze the relationship between live birth and the prevalence of obesity in Chinese women over 40 years of age.

METHODS

From April to November 2011, the Endocrinology Branch of the Chinese Medical Association conducted the REACTION project, a national, multicenter, cross-sectional study of Chinese adults aged 40 years and older. Demographic and medical data were collected through validated questionnaires and equipment. Anthropometric indicators, blood pressure, and biochemical data were measured by professional medical personnel. Data were analyzed using descriptive statistics and logistic analysis. Multivariate regression models were used to analyze obesity-related risk factors.

RESULTS

The prevalence of obesity among women increased gradually from 3.8% to 6.0% with an increasing number of live births. Women with two live births had the highest prevalence of overweight at 34.3%. Overall, the obesity and overweight rates were slightly higher in premenopausal women than in postmenopausal women. Univariate regression analysis showed that the risk of obesity in women increased with an increasing number of live births. In addition, multivariate regression analysis showed that the risk of obesity increased with an increasing number of live births in women with systolic blood pressure (SBP) < 121 mmHg or current smoking (P < 0.05).

CONCLUSION

The risk of obesity increases with the number of live births in Chinese women over 40 years of age with SBP < 121 mmHg or current smoking. Our findings may facilitate the development of interventions to prevent obesity in this population.

Cardiovascular diseases in women - Consensus document of the Sociedade Portuguesa de Cardiologia, Sociedade Portuguesa de Ginecologia, Sociedade Portuguesa de Obstetrícia e Medicina Materno-Fetal, Sociedade Portuguesa de Contraceção e Associação Portuguesa de Medicina Geral e Familiar

The main objective of this consensus statement from the Portuguese Society of Cardiology, the Portuguese Society of Gynecology, the Portuguese Society of Obstetrics and Maternal-Fetal Medicine, Portuguese Society of Contraception, Portuguese Association of General Practice and Family Medicine is to improve cardiovascular care for women. It includes a brief review of the state-of-the-art of cardiovascular diseases in women and of the links to other fields such as Gynaecology, Obstetrics and Endocrinology. It also provides final recommendations to help clinicians working in care of women's health.

Interrogating Components of 2 Diet Quality Indices in Pregnancy using a Supervised Statistical Mixtures Approach

BACKGROUND

The Healthy Eating Index (HEI)-2015 and Alternative Healthy Eating Index (AHEI)-2010 evaluate diet holistically in pregnancy. However, it remains unclear how individual index components interact to contribute to health.

OBJECTIVES

To evaluate associations of HEI-2015 and AHEI-2010 components with gestational length using traditional and novel statistical methods in a prospective cohort.

METHODS

Pregnant women completed a 3-mo food-frequency questionnaire (FFQ) at median 13 wk gestation to calculate the HEI-2015 or AHEI-2010. Covariate-adjusted linear regression models evaluated associations of HEI-2015 and AHEI-2010 total scores and individual components (one at a time and simultaneously adjusted) with gestational length. Covariate-adjusted weighted quantile sum regression models evaluated 1) associations of HEI-2015 or AHEI-2010 components as mixtures with gestational length and 2) contributions of components to these associations.

RESULTS

Each 10-point increase in HEI-2015 and AHEI-2010 total score was associated with 0.11 (95% CI: -0.05, 0.27) and 0.14 (95% CI: 0.00, 0.28) wk longer gestation, respectively. In individual or simultaneously adjusted HEI-2015 models, higher intakes of seafood/plant proteins, total protein foods, greens/beans, and saturated fats but lower intakes of added sugars and refined grains were associated with longer gestational length. For the AHEI-2010, higher intake of nuts/legumes and lower intake of sugar-sweetened beverages (SSBs)/fruit juice were associated with longer gestational length. Jointly, 10% increases in HEI-2015 or AHEI-2010 mixtures were associated with 0.17 (95% CI: 0.001, 0.34) and 0.18 (95% CI: 0.05, 0.30) wk longer gestational length, respectively. Seafood/plant protein, total protein foods, dairy, greens/beans, and added sugars were the largest contributors to the HEI-2015 mixture. Nuts/legumes, SSBs/fruit juice, sodium, and DHA/EPA were the largest contributors to the AHEI-2010 mixture. Associations were less precise but consistent in women with spontaneous labors.

CONCLUSIONS

Compared to traditional methods, associations of diet index mixtures with gestational length were more robust and identified unique contributors. Additional studies could consider interrogating these statistical approaches using other dietary indices and health outcomes.

Primary postpartum haemorrhage and longer-term physical, psychological, and psychosocial health outcomes for women and their partners in high income countries: A mixed-methods systematic review

OBJECTIVES

Most research about outcomes following postpartum haemorrhage (PPH) has focused on immediate outcomes. There are fewer studies investigating longer-term maternal morbidity following PPH, resulting in a significant knowledge gap. This review aimed to synthesize the evidence about the longer-term physical and psychological consequences of primary PPH for women and their partners from high income settings.

METHODS

The review was registered with PROSPERO and five electronic databases were searched. Studies were independently screened against the eligibility criteria by two reviewers and data were extracted from both quantitative and qualitative studies that reported non-immediate health outcomes of primary PPH.

RESULTS

Data were included from 24 studies, of which 16 were quantitative, five were qualitative and three used mixed-methods. The included studies were of mixed methodological quality. Of the nine studies reporting outcomes beyond five years after birth, only two quantitative studies and one qualitative study had a follow-up period longer than ten years. Seven studies reported outcomes or experiences for partners. The evidence indicated that women with PPH were more likely to have persistent physical and psychological health problems after birth compared with women who did not have a PPH. These problems, including PTSD symptoms and cardiovascular disease, may be severe and extend for many years after birth and were more pronounced after a severe PPH, as indicated by a blood transfusion or hysterectomy. There was limited evidence about outcomes for partners after PPH, but conflicting evidence of association between PTSD and PPH among partners who witnessed PPH.

CONCLUSION

This review explored existing evidence about longer-term physical and psychological health outcomes among women who had a primary PPH in high income countries, and their partners. While the evidence about health outcomes beyond five years after PPH is limited, our findings indicate that women can experience long lasting negative impacts after primary PPH, including PTSD symptoms and cardiovascular disease, extending for many years after birth.

PROSPERO REGISTRATION

PROSPERO registration number: CRD42020161144.

Coronary artery restenosis and target lesion revascularisation in women by pregnancy history

BACKGROUND

Women's pregnancy history is associated with incident risk of coronary artery disease with some evidence also suggesting a relevance for prognosis following treatment.

OBJECTIVES

To study the associations between maternal history of preterm delivery, a history of small for gestational age infant, parity and age at first delivery with clinical restenosis after percutaneous coronary intervention (PCI).

METHODS

In this prospective cohort study, we included 6027 women <65 years undergoing their first PCI 2006-2017, merging clinical register data on PCI procedures in Sweden with comprehensive registry data on deliveries since 1973. We used proportional hazards regression to study the association between aspects of pregnancy history and clinical restenosis in per-segment analyses, and with target lesion revascularisation (TLR) in per-patient analyses. We adjusted models for procedural-related and patient-related predictors of restenosis.

RESULTS

During 15 981 segment-years of follow-up, 343 (3.7%) events of clinical restenosis occurred. We found no strong evidence of associations between the studied aspects of pregnancy history and clinical restenosis following PCI. For example, the restenosis HR for a history of preterm delivery in the fully adjusted model was 1.09 (95% CI 0.77 to 1.55) and the TLR HR was 1.18 (95% CI 0.91 to 1.52).

CONCLUSION

Risk of restenosis following treatment with PCI did not differ by the studied aspects of pregnancy history, including preterm delivery, in young and middle-aged women. Larger studies are needed to obtain more precise estimates.

Pregnancy-Related Complications and Incidence of Atrial Fibrillation: A Systematic Review

Pregnancy-related complications are associated with a higher risk of various incident cardiovascular diseases, but their specific potential relationship with incident atrial fibrillation (AF) is less clear. This systematic review summarises the available evidence from observational studies which have examined associations between pregnancy-related complications and the risk of AF. MEDLINE and EMBASE (Ovid) were searched for studies between 1990 to 10 February 2022. Pregnancy-related complications examined included hypertensive disorders of pregnancy (HDP), gestational diabetes, placental abruption, preterm birth, small-for-gestational-age and stillbirth. Study selection, data extraction and quality assessment were completed independently by two reviewers. Narrative synthesis was used to evaluate the results of the included studies. Nine observational studies were included, with eight eligible for narrative synthesis. Sample sizes ranged from 1839 to 2,359,386. Median follow-up ranged from 2 to 36 years. Six studies reported that pregnancy-related complications were associated with a significantly increased risk of incident AF. Hazard ratios (HRs) (95% confidence intervals) for the four studies that evaluated HDP ranged from 1.1 (0.8-1.6) to 1.9 (1.4-2.7). For the four studies that evaluated pre-eclampsia, HRs ranged from 1.2 (0.9-1.6) to 1.9 (1.7-2.2). Current evidence from observational studies suggests pregnancy-related complications are associated with a significantly higher risk of incident AF. However, only a small number of studies examining each pregnancy-related complication were identified, and considerable statistical heterogeneity was observed. Further large-scale prospective studies are required to confirm the association between pregnancy-related complications and incident AF.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Versorgungsrealität von Frauen nach hypertensiver Schwangerschaftserkrankung – eine monozentrische fragebogenbasierte Analyse

Einleitung Frauen nach einer hypertensiven Schwangerschaftserkrankung wird aufgrund ihres signifikant erhöhten kardiovaskulären Risikos zu Screeninguntersuchungen und primärer Prävention geraten. Diese Studie soll einen Beitrag zur Ermittlung der aktuellen Nachsorgepraxis leisten und aufzeigen, wie viele Frauen an den empfohlenen Nachsorgeuntersuchungen mit Beratung zur Reduktion von Risikofaktoren teilnehmen.

Material und Methoden Monozentrische Patientinnenbefragung von 113 Frauen, welche im Zeitraum von 2014 bis 2019 von einer hypertensiven Schwangerschaftserkrankung betroffen waren. Es erfolgte eine deskriptive statistische Auswertung.

Ergebnisse Eine Nachsorgeuntersuchung erfolgte bei 54% der Frauen. Es wurden 47% der Patientinnen im persönlichen Gespräch über ihre Erkrankung informiert und auf mögliche langfristige gesundheitliche Konsequenzen hingewiesen. Von 67 übergewichtigen Frauen (BMI≥25 kg/m2) erhielten 23% eine Empfehlung zur Steigerung der körperlichen Aktivität und 13% wurde zur Gewichtsreduktion geraten. Es stellten sich signifikant mehr Frauen mit höherer Krankheitslast (BMI, p=0,027; arterieller Hypertonus, p=0,016) und gravierender Ausprägung der Erkrankung (Eklampsie, Aufenthalt auf einer Intensivstation, jeweils p=0,049) zu weiteren Untersuchungen vor.

Schlussfolgerung Die vorliegenden Ergebnisse legen nahe, dass die Maßnahmen zur Prävention und Früherkennung von kardiovaskulären Erkrankungen in unserem Patientinnenkollektiv nicht ausgeschöpft wurden. Unabhängig des Ausprägungsgrades der Erkrankung sollten alle Frauen eine Empfehlung zur Teilnahme an Nachsorgeuntersuchung erhalten.

Association of Maternal History of Preterm Birth With Congenital Anomalies in Offspring

This study examines the prevalence of congenital anomalies in infants born to mothers with preterm birth occurring in a previous pregnancy.

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman's reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.

Preeclampsia and Fetal Congenital Heart Defects

Endothelial dysfunction, impaired implantation and placental insufficiency have been identified as mechanisms behind the development of pre-eclampsia, resulting in angiogenic factors' alteration. Angiogenic imbalance is also associated with congenital heart defects, and this common physiologic pathway may explain the association between them and pre-eclampsia. This review aims to understand the physiology shared by these two entities and whether women with pre-eclampsia have an increased risk of fetal congenital heart defects (or the opposite). The present research has highlighted multiple vasculogenic pathways associated with heart defects and preeclampsia, but also epigenetic and environmental factors, contributing both. It is also known that fetuses with a prenatal diagnosis of congenital heart disease have an increased risk of several comorbidities, including intrauterine growth restriction. Moreover, the impact of pre-eclampsia goes beyond pregnancy as it increases the risk for following pregnancies and for diseases later in life in both offspring and mothers. Given the morbidity and mortality associated with these conditions, it is of foremost importance to understand how they are related and its causative mechanisms. This knowledge may allow earlier diagnosis, an adequate surveillance or even the implementation of preventive strategies.

Awareness of obstetricians for long-term risks in women with a history of preeclampsia or HELLP syndrome

Purpose

Hypertensive disorders of pregnancy are still a leading cause of maternal and neonatal morbidity and mortality worldwide. Women with a history of preeclampsia have an increased risk for future cardiovascular and cerebrovascular disease, renal disease as well as diabetes mellitus. There is little knowledge on postpartum risk management. The aim of this study was to assess follow-up care for patients after pre-eclampsia or HELLP syndrome.

Methods

This questionnaire-based cross-sectional study aimed to evaluate the current recommendations of obstetricians in Austria regarding follow-up care, long-term risk counselling and risk of recurrence in future pregnancies after preeclampsia or HELLP syndrome. Data were collected using a survey, based on recommendations given by three substantial guidelines on hypertensive disorders of pregnancy, which was distributed via e-mail to 69 public obstetric departments in Austria. Each obstetric department was required to answer one questionnaire per local protocol.

Results

Our results revealed that of the 48 participating hospitals most obstetricians are aware of the importance of follow-up care for women after a pregnancy complicated by preeclampsia. Our data show that most physicians counselled patients about the future cardiovascular health risks associated with preeclampsia or HELLP syndrome (79.2%). Most obstetricians recommended lifestyle modification (77.1%) and continued blood pressure measurements (97.9%). All centers stated to counsel about the risk of recurrence (100%). However, counselling regarding follow-up care to exclude kidney damage (37.5%) and underlying diseases like thrombophilia (39.6%) were less prioritized.

Conclusions

We were able to show that counselling concerning the risk of long-term cardiovascular disease and risk of recurrence after a pregnancy complicated by preeclampsia or HELLP syndrome has been established in obstetric departments in public hospitals. Regarding the evaluation of underlying chronic diseases such as thrombophilia or renal disease, as well as counselling on the future risk of renal disease is still improvable according to our data. Further evaluation of follow-up care after hypertensive disorders of pregnancy in the outpatient and private sector and implementation of structured guidelines for follow-up, as well as screening for cardiovascular disease are necessary to ensure adequate risk management and to provide opportunities for prevention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06181-w.

Shedding light on the pathophysiology of preeclampsia-syndrome in the era of Cardio-Obstetrics: Role of inflammation and endothelial dysfunction

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Preeclampsia (PE) is a worldwide pregnancy complication with serious maternal and neonatal consequences. Our understanding of PE pathophysiology has significantly evolved over the last decades by recognizing that endothelial dysfunction and systemic inflammation, with an associated angiogenic imbalance, are key pieces of this still incomplete puzzle. In the present era, where no single treatment to cure or treat this obstetric condition has been developed so far, PE prevention and early prediction poses the most useful clinical approach to reduce the PE burden. Although most PE episodes occur in healthy nulliparous women, the identification of specific clinical conditions that increase dramatically the risk of PE provides a critical opportunity to improve outcomes by acting on potential reversible factors, and also contribute to better understand this pathophysiologic enigma. In this review, we highlight major clinical contributors of PE and shed light about their potential link with endothelial dysfunction and inflammation.

The Fourth Trimester: Pregnancy as a Predictor of Cardiovascular Disease

Pregnancy identifies women who may be at a greater risk of cardiovascular disease (CVD), based on the development of adverse pregnancy outcomes (APOs), and may identify women who may benefit from atherosclerotic CVD (ASCVD) risk reduction efforts. APOs are common and although they are separate diagnoses, all these disorders seem to share an underlying pathogenesis. What is not clear is whether the APO itself initiates a pathway that results in CVD or whether the APO uncovers a woman's predisposition to CVD. Regardless, APOs have immediate risks to maternal and foetal health, in addition to longer-term CVD consequences. CVD risk assessment and stratification in women remains complex and, historically, has underestimated risk, especially in young women. Further research is needed into the role of ASCVD risk assessment and the effect of aggressive ASCVD risk modification on CVD outcomes in women with a history of APOs.

Preeclampsia and long-term coronary artery disease: How to minimize the odds?

Preeclampsia (PE) is a hypertensive disorder of pregnancy that can cause detrimental obstetric outcomes if not managed properly. Current evidence demonstrates higher risk for long-term cardiovascular disease in preeclamptic women. Even in uncomplicated pregnancies, the heart work overload often reveals subtle cardiac defects or abnormalities, which otherwise remain undiagnosed in women without a history of pregnancy. Pathophysiologic patterns occurring in PE patients resemble biochemical responses observed in cases of cardiovascular disease. It has been estimated that women with an obstetric history of PE are more likely to develop coronary artery disease in the long run. Currently, additionally to whether any approach could actually contribute to minimizing mortality and morbidity among these affected populations, there is no consensus regarding management for these patients. In this review we summarized the current scientific evidence regarding the correlation between PE and long-term coronary artery disease. Based on this knowledge, we propose postpartum and lifetime management for these high-risk patients in order to minimize morbidity and mortality within this population.

Postpartum plasma metabolomic profile among women with preeclampsia and preterm delivery: implications for long-term health

BACKGROUND

Preeclampsia and preterm delivery (PTD) are believed to affect women's long-term health including cardiovascular disease (CVD), but the biological underpinnings are largely unknown. We aimed to test whether maternal postpartum metabolomic profiles, especially CVD-related metabolites, varied according to PTD subtypes with and without preeclampsia, in a US urban, low-income multi-ethnic population.

METHODS

This study, from the Boston Birth Cohort, included 980 women with term delivery, 79 with medically indicated PTD (mPTD) and preeclampsia, 52 with mPTD only, and 219 with spontaneous PTD (sPTD). Metabolomic profiling in postpartum plasma was conducted by liquid chromatography-mass spectrometry. Linear regression models were used to assess the associations of each metabolite with mPTD with preeclampsia, mPTD only, and sPTD, respectively, adjusting for pertinent covariates. Weighted gene coexpression network analysis was applied to investigate interconnected metabolites associated with the PTD/preeclampsia subgroups. Bonferroni correction was applied to account for multiple testing.

RESULTS

A total of 380 known metabolites were analyzed. Compared to term controls, women with mPTD and preeclampsia showed a significant increase in 36 metabolites, mainly representing acylcarnitines and multiple classes of lipids (diacylglycerols, triacylglycerols, phosphocholines, and lysophosphocholines), as well as a decrease in 11 metabolites including nucleotides, steroids, and cholesteryl esters (CEs) (P < 1.3 × 10^-4). Alterations of diacylglycerols, triacylglycerols, and CEs in women with mPTD and preeclampsia remained significant when compared to women with mPTD only. In contrast, the metabolite differences between women with mPTD only and term controls were only seen in phosphatidylethanolamine class. Women with sPTD had significantly different levels of 16 metabolites mainly in amino acid, nucleotide, and steroid classes compared to term controls, of which, anthranilic acid, bilirubin, and steroids also had shared associations in women with mPTD and preeclampsia.

CONCLUSION

In this sample of US high-risk women, PTD/preeclampsia subgroups each showed some unique and shared associations with maternal postpartum plasma metabolites, including those known to be predictors of future CVD. These findings, if validated, may provide new insight into metabolomic alterations underlying clinically observed PTD/preeclampsia subgroups and implications for women's future cardiometabolic health.

The Role of Sex-Specific Risk Factors in the Risk Assessment of Atherosclerotic Cardiovascular Disease for Primary Prevention in Women

PURPOSE OF REVIEW

Robust evidence is emerging regarding the contribution of sex-specific risk factors to a woman's unique risk of atherosclerotic cardiovascular disease (ASCVD). This review summarizes the available literature regarding the association of sex-specific risk factors and ASCVD in women.

RECENT FINDINGS

The American College of Cardiology and American Heart Association Guidelines recommend estimation of 10-year risk of a first ASCVD event using the 2013 Pooled Cohort Equations. This can be further personalized by identifying sex-specific risk factors present in a woman's history. There are multiple vulnerable periods across a woman's life course that are associated with increased risk of ASCVD. Risk factors across the reproductive life course that have been shown to correlate with higher risk for future ASCVD include early menarche, adverse pregnancy outcomes (such as pre-eclampsia or preterm birth), and early natural or surgical menopause. In addition, certain conditions that are more common among women, including autoimmune diseases, history of chest irradiation, and certain chemotherapies, also need to be considered. Finally, risk assessment can be refined with subclinical disease imaging (coronary calcium score) if there remains uncertainty about clinical management with lipid-lowering therapies for primary prevention after inclusion of these risk enhancers. Risk assessment for ASCVD in women requires a personalized approach that incorporates sex-specific risk factors to guide primary prevention measures, such as lipid-lowering therapies. Coronary calcium score imaging may also help further refine risk assessment, but no clinical trials conducted to date have addressed this question.