Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when

Association between pregnancy-related complications and development of type 2 diabetes and hypertension in women: an umbrella review

BACKGROUND

Despite many systematic reviews and meta-analyses examining the associations of pregnancy complications with risk of type 2 diabetes mellitus (T2DM) and hypertension, previous umbrella reviews have only examined a single pregnancy complication. Here we have synthesised evidence from systematic reviews and meta-analyses on the associations of a wide range of pregnancy-related complications with risk of developing T2DM and hypertension.

METHODS

Medline, Embase and Cochrane Database of Systematic Reviews were searched from inception until 26 September 2022 for systematic reviews and meta-analysis examining the association between pregnancy complications and risk of T2DM and hypertension. Screening of articles, data extraction and quality appraisal (AMSTAR2) were conducted independently by two reviewers using Covidence software. Data were extracted for studies that examined the risk of T2DM and hypertension in pregnant women with the pregnancy complication compared to pregnant women without the pregnancy complication. Summary estimates of each review were presented using tables, forest plots and narrative synthesis and reported following Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines.

RESULTS

Ten systematic reviews were included. Two pregnancy complications were identified. Gestational diabetes mellitus (GDM): One review showed GDM was associated with a 10-fold higher risk of T2DM at least 1 year after pregnancy (relative risk (RR) 9.51 (95% confidence interval (CI) 7.14 to 12.67) and although the association differed by ethnicity (white: RR 16.28 (95% CI 15.01 to 17.66), non-white: RR 10.38 (95% CI 4.61 to 23.39), mixed: RR 8.31 (95% CI 5.44 to 12.69)), the between subgroups difference were not statistically significant at 5% significance level. Another review showed GDM was associated with higher mean blood pressure at least 3 months postpartum (mean difference in systolic blood pressure: 2.57 (95% CI 1.74 to 3.40) mmHg and mean difference in diastolic blood pressure: 1.89 (95% CI 1.32 to 2.46) mmHg). Hypertensive disorders of pregnancy (HDP): Three reviews showed women with a history of HDP were 3 to 6 times more likely to develop hypertension at least 6 weeks after pregnancy compared to women without HDP (meta-analysis with largest number of studies: odds ratio (OR) 4.33 (3.51 to 5.33)) and one review reported a higher rate of T2DM after HDP (hazard ratio (HR) 2.24 (1.95 to 2.58)) at least a year after pregnancy. One of the three reviews and five other reviews reported women with a history of preeclampsia were 3 to 7 times more likely to develop hypertension at least 6 weeks postpartum (meta-analysis with the largest number of studies: OR 3.90 (3.16 to 4.82) with one of these reviews reporting the association was greatest in women from Asia (Asia: OR 7.54 (95% CI 2.49 to 22.81), Europe: OR 2.19 (95% CI 0.30 to 16.02), North and South America: OR 3.32 (95% CI 1.26 to 8.74)).

CONCLUSIONS

GDM and HDP are associated with a greater risk of developing T2DM and hypertension. Common confounders adjusted for across the included studies in the reviews were maternal age, body mass index (BMI), socioeconomic status, smoking status, pre-pregnancy and current BMI, parity, family history of T2DM or cardiovascular disease, ethnicity, and time of delivery. Further research is needed to evaluate the value of embedding these pregnancy complications as part of assessment for future risk of T2DM and chronic hypertension.

Deciphering the immunological interactions: targeting preeclampsia with Hydroxychloroquine's biological mechanisms

Preeclampsia (PE) is a complex pregnancy-related disorder characterized by hypertension, followed by organ dysfunction and uteroplacental abnormalities. It remains a major cause of maternal and neonatal morbidity and mortality worldwide. Although the pathophysiology of PE has not been fully elucidated, a two-stage model has been proposed. In this model, a poorly perfused placenta releases various factors into the maternal circulation during the first stage, including pro-inflammatory cytokines, anti-angiogenic factors, and damage-associated molecular patterns into the maternal circulation. In the second stage, these factors lead to a systemic vascular dysfunction with consecutive clinical maternal and/or fetal manifestations. Despite advances in feto-maternal management, effective prophylactic and therapeutic options for PE are still lacking. Since termination of pregnancy is the only curative therapy, regardless of gestational age, new treatment/prophylactic options are urgently needed. Hydroxychloroquine (HCQ) is mainly used to treat malaria as well as certain autoimmune conditions such as systemic lupus and rheumatoid arthritis. The exact mechanism of action of HCQ is not fully understood, but several mechanisms of action have been proposed based on its pharmacological properties. Interestingly, many of them might counteract the proposed processes involved in the development of PE. Therefore, based on a literature review, we aimed to investigate the interrelated biological processes of HCQ and PE and to identify potential molecular targets in these processes.

Knowledge and care regarding long-term cardiovascular risk after hypertensive disorders of pregnancy and gestational diabetes

BACKGROUND

Adverse pregnancy outcomes (APO), such as preeclampsia (PE) and gestational diabetes (GDM) are substantial risk factors for cardiovascular disease (CVD) later in life. Identifying these high-risk female individuals during pregnancy offers the possibility of preventing long-term CVD and chronic kidney disease via a structured therapeutic and surveillance plan. We aimed to evaluate the current practice of postpartum care in women after APO and the impact on the women's awareness about their future risk for CVD.

METHODS

Women diagnosed with PE and GDM at the University Hospital of St. Poelten/Lilienfeld between 2015-2020 were identified and participated in a structured telephone interview about postpartum medical care and knowledge about the impact of APOs on long-term cardiovascular health.

RESULTS

Of 161 out of the 750 women contacted, 29% (n = 46) were diagnosed with PE and 71% (n = 115) with GDM. One third of all women and up to 44% of women diagnosed with PE, were unaware that APOs are related to CVD. Women diagnosed with PE were less likely to receive postpartum care information than those with GDM (30.4% vs. 49.6%, p = 0.027), and only one third of all women after APOs were counselled by a physician or healthcare professional. Of the women 50% received recommendations regarding lifestyle changes after delivery; significantly more women with GDM than women with PE (54% vs. 37%, p = 0.05). Only 14% had at least one long-term follow-up.

CONCLUSION

This study identified a significant deficit of structured postpartum care and a lack of awareness among women after APO and their healthcare providers about the increased risk of long-term CVD.

The Association between Nutrition, Physical Activity, and Cardiometabolic Health at 6 Months following a Hypertensive Pregnancy: A BP2 Sub-Study

Hypertensive disorders of pregnancy (HDP) complicate 5-10% of pregnancies, with resultant lifelong increased risks of cardiovascular disease (CVD). We aimed to describe lifestyle behaviours at 6 months post-HDP in four HDP subgroups, and their association with markers of cardiometabolic health. Subgroups were chronic hypertension (CH), gestational hypertension (GH), preeclampsia, and preeclampsia superimposed on chronic hypertension (CH + PE). The BP2 study is a multi-site, three-arm, randomised controlled trial. At 6 months postpartum, the NSW Population Health Survey and BP2 surveys collected lifestyle behaviours and demographic data. Body mass index (BMI), waist circumference, and blood pressure (BP) were also assessed. Descriptive statistics, ANOVA and Spearman's correlation coefficients were used. Of 484 women (16% CH, 23% GH, 55% preeclampsia, and 6% CH + PE), 62% were overweight or obese. Only 6% met the recommended five vegetable and two fruit serves per day, and 43% did not meet the recommended 150 min of moderate-vigorous physical activity in five sessions per week. Adherence to both diet and physical activity recommendations was correlated with more favourable cardiometabolic outcomes, including lower BMI, waist circumference, and systolic and diastolic BP. Lifestyle interventions that improve diet and physical activity post-HDP are needed to reduce BP, BMI, and long-term CVD in this high-risk population.

Prevention and Screening for Cardiometabolic Disease Following Hypertensive Disorders in Pregnancy in Low-Resource Settings: A Systematic Review and Delphi Study

Hypertensive disorders in pregnancy (HDP) and cardiometabolic and kidney diseases are rising in low- and middle-income countries (LMICs). While HDP are risk factors for cardiometabolic and kidney diseases, cost-effective, scalable strategies for screening and prevention in women with a history of HDP are lacking. Existing guidelines and recommendations require adaptation to LMIC settings. This article aims to generate consensus-based recommendations for the prevention and screening of cardiometabolic and kidney diseases tailored for implementation in LMICs. We conducted a systematic review of guidelines and recommendations for prevention and screening strategies for cardiometabolic and chronic kidney diseases following HDP. We searched PubMed/Medline, Embase and Cochrane Library for relevant articles and guidelines published from 2010 to 2021 from both high-income countries (HICs) and LMICs. No other filters were applied. References of included articles were also assessed for eligibility. Findings were synthesized narratively. The summary of guiding recommendations was subjected to two rounds of Delphi consensus surveys with experts experienced in LMIC settings. Fifty-four articles and 9 guidelines were identified, of which 25 were included. Thirty-five clinical recommendations were synthesized from these and classified into six domains: identification of women with HDP (4 recommendations), timing of first counseling and provision of health education (2 recommendations), structure and care setting (12 recommendations), information and communication needs (5 recommendations), cardiometabolic biomarkers (8 recommendations) and biomarkers thresholds (4 recommendations). The Delphi panel reached consensus on 33 final recommendations. These recommendations for health workers in LMICs provide practical and scalable approaches for effective screening and prevention of cardiometabolic disease following HDP. Monitoring and evaluation of implementation of these recommendations provide opportunities for reducing the escalating burden of noncommunicable diseases in LMICs.

Long-Term Consequences of Placental Vascular Pathology on the Maternal and Offspring Cardiovascular Systems

Over the last thirty years, evidence has been accumulating that Hypertensive Disorders of Pregnancy (HDP) and, specifically, Preeclampsia (PE) produce not only long-term effects on the pregnant woman, but have also lasting consequences for the fetus. At the core of these consequences is the phenomenon known as defective deep placentation, being present in virtually every major obstetrical syndrome. The profound placental vascular lesions characteristic of this pathology can induce long-term adverse consequences for the pregnant woman’s entire arterial system. In addition, placental growth restriction and function can, in turn, cause a decreased blood supply to the fetus, with long-lasting effects. Women with a history of HDP have an increased risk of Cardiovascular Diseases (CVD) compared with women with normal pregnancies. Specifically, these subjects are at a future higher risk of: Hypertension; Coronary artery disease; Heart failure; Peripheral vascular disease; Cerebrovascular accidents (Stroke); CVD-related mortality. Vascular pathology in pregnancy and CVD may share a common etiology and may have common risk factors, which are unmasked by the “stress” of pregnancy. It is also possible that the future occurrence of a CVD may be the consequence of endothelial dysfunction generated by pregnancy-induced hypertension that persists after delivery. Although biochemical and biophysical markers of PE abound, information on markers for a comparative evaluation in the various groups is still lacking. Long-term consequences for the fetus are an integral part of the theory of a fetal origin of a number of adult diseases, known as the Barker hypothesis. Indeed, intrauterine malnutrition and fetal growth restriction represent significant risk factors for the development of chronic hypertension, diabetes, stroke and death from coronary artery disease in adults. Other factors will also influence the development later in life of hypertension, coronary and myocardial disease; they include parental genetic disposition, epigenetic modifications, endothelial dysfunction, concurrent intrauterine exposures, and the lifestyle of the affected individual.

Health-Related Lifestyle Profiles in Healthy Adults: Associations with Sociodemographic Indicators, Dispositional Optimism, and Sense of Coherence

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Promoting healthy behaviors throughout life is an essential prevention tool. This study investigated the associations among lifestyle profiles (including diet, alcohol consumption, physical activity, cigarette smoking, and cardiovascular screening), sociodemographic factors (gender, age, education, and family history of CVDs), and psychological factors (sense of coherence and dispositional optimism). In total, 676 healthy adults (mean age = 35 years; range = 19-57; 46% male) participated in an online survey. Lifestyle profiles were identified through cluster analysis, and a multinomial logistic regression was then performed to explore their association with sociodemographic and psychological variables. Results show that men were more likely than women to belong to the lifestyle profile with the highest amount of physical activity (OR = 2.40; p < 0.001) and the greatest attention to cardiovascular screening (OR = 2.09; p < 0.01). Lower dispositional optimism was associated with the profile paying the greatest attention to cardiovascular screening (OR = 0.67; p < 0.05). Sense of coherence, in terms of lower comprehensibility (OR = 0.67; p < 0.05) and higher manageability (OR = 1.43; p < 0.05), was associated with the lifestyle profile characterized by an unhealthy diet, sedentary lifestyle, and nonsmoking. This study shed light on factors associated with different co-occurring health-related behaviors that should be considered in planning effective communication strategies promoting adherence to health claims.

Metabolic syndrome following hypertensive disorders in pregnancy in a low-resource setting: A cohort study

OBJECTIVES

Hypertensive disorders in pregnancy (HDPs) are associated with risk of future metabolic syndrome. Despite the huge burden of HDPs in sub-Saharan Africa, this association has not been adequately studied in this population.

STUDY DESIGN

This was a prospective cohort study on pregnant women recruited between August 2017 - April 2018 and followed up to one year after their deliveries and evaluated for presence of metabolic syndrome at delivery, nine weeks, six months and one year.

MAIN OUTCOME MEASURES

Prevalence of metabolic syndrome RESULTS: A total of 488 pregnant women were included: 410 and 78 with HDPs and normotensive, respectively. None of the normotensive had metabolic syndrome until one year (1.7% = 1 out of 59 observations), while among those with HDPs were 17.4% (71 of 407), 8.7% (23 of 263), 4.7% (11 of 232) and 6.1% (17 of 278), at delivery, nine weeks, six months and one year postpartum, respectively. High BMI and blood pressure were the drivers of metabolic syndrome in this population. The incidence rate in HDPs versus normotensive at one year were, respectively, 57.5/1000 persons' year (95%CI; 35.8 - 92.6) and 16.9/1000 persons' years (95%CI; 2.4-118.3), with incidence rate ratio of 3.4/1000 person's years. Only parity significantly predicted the presence of metabolic syndrome at one year [(aOR= 3.26/delivery (95%CI; 1.21-8.79)].

CONCLUSION

HDPs were associated with a higher incidence of metabolic syndrome up to one year postpartum. Women with HDPs should be routinely screened for metabolic syndrome within the first year postpartum to reduce cardiometabolic risks.

Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Cardiovascular Prevention Guidelines

We present the adaptation for Spain of the updated European Cardiovascular Prevention Guidelines. In this update, greater stress is laid on the population approach, and especially on the promotion of physical activity and healthy diet through dietary, leisure and active transport policies in Spain. To estimate vascular risk, note should be made of the importance of recalibrating the tables used, by adapting them to population shifts in the prevalence of risk factors and incidence of vascular diseases, with particular attention to the role of chronic kidney disease. At an individual level, the key element is personalised support for changes in behaviour, adherence to medication in high-risk individuals and patients with vascular disease, the fostering of physical activity, and cessation of smoking habit. Furthermore, recent clinical trials with PCSK9 inhibitors are reviewed, along with the need to simplify pharmacological treatment of arterial hypertension to improve control and adherence to treatment. In the case of patients with type 2 diabetes mellitus and vascular disease or high vascular disease risk, when lifestyle changes and metformin are inadequate, the use of drugs with proven vascular benefit should be prioritised. Lastly, guidelines on peripheral arterial disease and other specific diseases are included, as is a recommendation against prescribing antiaggregants in primary prevention.

[Statement of the Spanish Interdisciplinary Vascular Prevention Committee on the updated European Cardiovascular Prevention Guidelines]

We present the adaptation for Spain of the updated European Cardiovascular Prevention Guidelines. In this update, greater stress is laid on the population approach, and especially on the promotion of physical activity and healthy diet through dietary, leisure and active transport policies in Spain. To estimate vascular risk, note should be made of the importance of recalibrating the tables used, by adapting them to population shifts in the prevalence of risk factors and incidence of vascular diseases, with particular attention to the role of chronic kidney disease. At an individual level, the key element is personalised support for changes in behaviour, adherence to medication in high-risk individuals and patients with vascular disease, the fostering of physical activity, and cessation of smoking habit. Furthermore, recent clinical trials with PCSK9 inhibitors are reviewed, along with the need to simplify pharmacological treatment of arterial hypertension to improve control and adherence to treatment. In the case of patients with type 2 diabetes mellitus and vascular disease or high vascular disease risk, when lifestyle changes and metformin are inadequate, the use of drugs with proven vascular benefit should be prioritised. Lastly, guidelines on peripheral arterial disease and other specific diseases are included, as is a recommendation against prescribing antiaggregants in primary prevention.

Maternal risk of hypertension 7-15 years after pregnancy: clues from the placenta

OBJECTIVE

To assess whether pre-eclampsia (PE)-related placental/extraplacental membrane findings are linked to moderately elevated blood pressure (BP) in pregnancy and later-life hypertension.

DESIGN

Prospective cohort.

SETTING

52 prenatal clinics, 5 Michigan communities.

SAMPLE

The POUCH Study recruited women at 16-27 weeks' gestation (1998-2004) and studied a sub-cohort in depth. This sample (n = 490) includes sub-cohort women with detailed placental assessments and cardiovascular health evaluations 7-15 years later in the POUCHmoms follow-up study.

METHODS

PE-related placental/extraplacental membrane findings (i.e. mural hyperplasia, unaltered/abnormal vessels or atherosis in decidua; infarcts) were evaluated in relation to pregnancy BP and odds of Stage 2 hypertension at follow up using weighted polytomous regression. Follow-up hypertension odds also were compared in three pregnancy BP groups: normotensives (referent) and moderately elevated BP with or without PE-related placental/extraplacental membrane findings.

MAIN OUTCOME MEASURES

Stage 2 hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg, or using antihypertensive medications) at follow up.

RESULTS

After excluding women with pregnancy hypertension (i.e. chronic, PE, gestational), mural hyperplasia and unaltered/abnormal decidual vessels were each associated with Stage 2 hypertension at follow up: adjusted odds ratio (aOR) = 2.7, 95% CI 1.1-6.6, and aOR = 1.7 (95% CI 0.8-3.4), respectively. Women with moderately elevated BP in pregnancy and evidence of mural hyperplasia or unaltered/abnormal decidual vessels had greater odds of Stage 2 hypertension at follow up: aOR = 4.5 (95% CI 1.6-12.5 and aOR = 2.6, 95% CI 1.1-5.9, respectively.

CONCLUSIONS

PE-related placental/extraplacental membrane findings help risk-stratify women with moderately elevated BP in pregnancy for later development of hypertension.

TWEETABLE ABSTRACT

Placental findings associated with mother's risk of later-life hypertension.

Investigating the current knowledge and needs concerning a follow-up for long-term cardiovascular risks in Dutch women with a preeclampsia history: a qualitative study

BACKGROUND

There is increasing evidence that a history of preeclampsia is an important risk factor for future cardiovascular events. Awareness of this risk could provide opportunities for identification of women at risk, with opportunities for prevention and / or early intervention. A standardized follow-up has not yet been implemented in the north of the Netherlands. The objective of this qualitative study was to explore the opinions and wishes among women and physicians about the follow-up for women with a history of preeclampsia.

METHODS

Semi-structured interviews with 15 women and 14 physicians (5 obstetricians, 4 general practitioners, 3 vascular medicine specialists and 2 cardiologists) were performed and addressed topics about knowledge on CVR, current - and future follow-up. Women were approached through the HELLP foundation and their physicians. Physicians were approached by email. The interviews were recorded, typed and coded using ATLAS.ti software. A theoretical-driven thematic analysis was performed.

RESULTS

Women had some knowledge about the association between preeclampsia and the increased CVR, but missed information from their health care providers. Specialists were aware of the association, but the information and advice they provided to their patients was minimal and inconsistent according to themselves. Whereas some general practitioners regarded their own knowledge as limited. There was a clear desire among women for a more extensive follow-up with specific attention to both emotional and physical consequences of preeclampsia. Physicians indicated that they preferred to see a follow up program concerning the CVR at the general practitioner as part of the already existent cardiovascular risk management (CVRM) program.

CONCLUSION

Women and medical specialists consider it important to improve aftercare for women after a pregnancy complicated by preeclampsia. Introducing these women into the CVRM program at the general practitioner is regarded as a preferred first step. Further research is warranted to establish an evidence-based guideline for the follow-up of these women.

Assessing Knowledge Gaps of Women and Healthcare Providers Concerning Cardiovascular Risk After Hypertensive Disorders of Pregnancy-A Scoping Review

Background: A history of a Hypertensive Disorder of Pregnancy (HDP) at least doubles a woman's risk of cardiovascular disease (CVD). The risk increases within 10 years after HDP and continues for life, making long-term health after HDP of major public health importance. Understanding knowledge gaps in health care professionals and women regarding cardiovascular health after HDP is an important component in addressing these risks.

Objectives: The primary aim was to examine what women and healthcare providers (HCP) know about cardiovascular risks after HDP. The secondary aims were to identify enablers and barriers to knowledge and action on knowledge.

Methods: A scoping review was conducted. This was a narrative synthesis, using PRISMA-ScR guidelines, of English-language full text articles that included assessment of knowledge of women, and/or HCP, on long term cardiovascular risk after HDP. The databases Embase, Medline, Scopus, ProQuest, Cochrane, and PsycInfo were searched from 01 January 2005 to 31 May 2019.

Results: Twelve studies were included, six addressing women's knowledge, five addressing HCP knowledge, and one addressing both. The studies included 402 women and 1,215 HCP from seven countries. Regarding women's knowledge, six of seven studies found women had limited or no knowledge about the link between HDP and CVD. Where women were aware of the link, the majority had sourced their own information, rather than obtaining it through their HCP. In five of six studies, HCP also mostly had limited knowledge about HDP-CVD links. Primary enablers for HCP acquisition of knowledge and counseling were the availability and knowledge of guidelines. Where comparisons between HCP groups were made, obstetricians had greater knowledge than family physicians, internal medical specialists, or midwives.

Conclusion: There was a low level of knowledge amongst HCP and women about increased CVD risk after HDP. Where women had higher levels of knowledge, the information was often obtained informally rather than from HCP. There were variations in knowledge of HCP, with obstetricians generally more aware than other professions. Further country and context-specific research on current status of women's and HCP's knowledge is therefore necessary when creating educational strategies to address knowledge gaps after HDP.

Postpartum Interventions to Reduce Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: A Systematic Review

Introduction: Hypertensive disorders (HDP) affect ~7% of pregnancies. Epidemiological evidence strongly suggests HDP independently increases that individual's risk of later cardiovascular disease (CVD). Focus on reduction or mitigation of this risk has been limited. This review seeks to identify trialed interventions to reduce cardiovascular risk after HDP.

Methods: Online medical databases were searched to identify full-text published results of randomized controlled trials (RCT) in women <10 years postpartum after HDP that trialed interventions to reduce cardiovascular risk. Outcomes sought included cardiovascular disease events, chronic hypertension, and other measures of cardiovascular risk such as obesity, smoking status, diet, and physical activity. Publications from January 2008 to July 2019 were included.

Results: Two RCTs were identified. One, a trial of calcium vs. placebo in 201 women with calcium commenced from the first follow-up visit outside of pregnancy and continued until 20 weeks' gestation if another pregnancy occurred. A non-significant trend toward decreased blood pressure was noted. The second RCT of 151 women tested an online education programme (vs. general information to control group) to increase awareness of risk factors and personalized phone-based lifestyle coaching in women who had a preeclampsia affected pregnancy in the 5 years preceding enrolment. Significant findings included increase in knowledge of CVD risk factors, reported healthy eating and decreased physical inactivity, however adoption of a promoted heart healthy diet and physical activity levels did not differ significantly between groups. Several observational studies after HDP, and one meta-analysis of studies of lifestyle interventions not performed specifically after HDP but used to extrapolate likely benefits of lifestyle interventions, were identified which supported the use of lifestyle interventions. Several ongoing RCTs were also noted.

Discussion: There is a paucity of intervention trials in the early years after HDP to guide evidence-based cardiovascular risk reduction in affected women. Limited evidence suggests lifestyle intervention may be effective, however degree of any risk reduction remains uncertain.

Conclusion: Sufficiently powered randomized controlled trials of appropriate interventions (e.g., lifestyle behavior change, pharmacological) are required to assess the best method of reducing the risk of cardiovascular disease in this at-risk population of women.

Risk prediction of maternal cardiovascular disease one year after hypertensive pregnancy complications or gestational diabetes mellitus

BACKGROUND

Previous preeclampsia, gestational hypertension and gestational diabetes mellitus show a firm epidemiological association to maternal cardiovascular disease risk. Cardiovascular disease risk assessment is recommended in women after these pregnancy complications, but not offered in most countries. We therefore wanted to evaluate the applicability of currently recommended cardiovascular disease risk scores for women one-year postpartum of such pregnancy complications.

DESIGN AND METHODS

We tested applicability of three scoring systems, the Atherosclerotic Cardiovascular Disease (ASCVD) score, the Joint British Societies for the Prevention of Cardiovascular Disease (JBS3) score and Framingham 30 year Risk Score-Cardiovascular Disease (FRS-CVD) in 235 women one-year postpartum (controls: 94, gestational hypertension: 35, preeclampsia: 81, gestational diabetes mellitus: 25). Statistical analysis was performed with Mann-Whitney U test for continuous and Fisher's mid-corrected p and Pearson's r for dichotomous variables. A value of p < 0.050 was considered significant.

RESULTS

Most women (87.7%) were below 40 years of age, rendering 10-year risk estimations recommended by American and European societies inapplicable. FRS-CVD could be assessed in all women. Significantly fewer could be assessed by the ASCVD (81.5%) and JBS3 (91.6%). All scoring systems showed small, but significant increases in risk scores for one or more of the pregnancy complication groups, but none at the risk magnitude for cardiovascular disease shown in epidemiological studies.

CONCLUSION

We demonstrate that ASCVD, JBS3 and FRS-CVD are inadequate in assessing cardiovascular disease risk one-year postpartum. We suggest that pregnancy complications need to be considered separately when evaluating maternal cardiovascular disease risk and need for postpartum follow-up.

Referral to Cardiology Following Postpartum Cardiovascular Risk Screening at the Maternal Health Clinic in Kingston, Ontario

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally among women, and certain pregnancy complications can be the earliest indicators of increased CVD risk. Nonetheless, there is no recommendation for follow-up of cardiovascular risk factors identified through postpartum screening programs. This study describes current referral practices and clinical course from the Maternal Health Clinic in Kingston, Ontario, for women deemed at high cardiovascular risk postpartum.

METHODS

We investigated the cohort of women referred from the postpartum Maternal Health Clinic to cardiology for further assessment and management, specifically examining timing and recommended interventions to reduce CVD risk.

RESULTS

Women referred to cardiology differed significantly from those not referred in history of hypertensive disorders of pregnancy (P < 0.05) and demonstrated a significantly worse CVD risk profile at 6 months postpartum (P < 0.0001). Life expectancy by the cardiometabolic model for women referred was 5 years shorter (P < 0.0001). Only half of the women referred to cardiology scheduled a visit; the median time to the scheduled appointment was 12 months. Of women seen by cardiology, 60% were deemed eligible for cardiac rehabilitation.

CONCLUSIONS

Although women at highest risk for CVD are being identified and referred to cardiology, the existing system is not designed for this demographic. Too many women are missing their appointments or being seen beyond 1 year postpartum. To initiate lifestyle changes and/or therapeutic interventions, we suggest that CVD prevention programming begins within 1 year of delivery. Future studies should investigate the viability of traditional cardiac rehabilitation programs among this unique population.

Hypertensive disorders of pregnancy and cardiometabolic outcomes in childhood: A systematic review

Background

Hypertensive disorders of pregnancy (HDPs) are among the leading causes of maternal and perinatal morbidity and mortality worldwide and have been suggested to increase long-term cardiovascular disease risk in the offspring.

Objective

The objective of this study was to investigate whether HDPs are associated with cardiometabolic markers in childhood.

Search strategy

PubMed, The Cochrane Library and reference lists of included studies up to January 2019.

Selection criteria

Studies comparing cardiometabolic markers in 2–18-year-old children of mothers with HDP in utero, to children of mothers without HDP.

Data collection and analysis

Sixteen studies reported in 25 publications were included in this systematic review, of which three were considered as having high risk of bias. Thus 13 studies were included in the evidence synthesis: respectively two and eight reported pregnancy induced hypertension and preeclampsia, and three studies reported on both HDPs.

Main results

Most studies (n = 4/5) found a higher blood pressure in children exposed to pregnancy induced hypertension. Most studies (n = 7/10) found no statistically significantly higher blood pressure in children exposed to preeclampsia. No association was found between exposure to HDP and levels of cholesterol, triglycerides or glucose (n = 5/5). No studies investigated an association with (carotid) intima-media thickness, glycated haemoglobin or diabetes mellitus type 2.

Conclusions

Most studies showed that exposure to pregnancy induced hypertension is associated with a higher offspring blood pressure. There is no convincing evidence for an association between exposure to preeclampsia and blood pressure in childhood. Based on current evidence, exposure to HDP is not associated with blood levels of cholesterol, triglycerides and glucose in childhood.

lncRNA HIF1A Antisense RNA 2 Modulates Trophoblast Cell Invasion and Proliferation through Upregulating PHLDA1 Expression

Long noncoding RNAs (lncRNAs) have been reported to be involved in various human diseases, and increasing studies have revealed that lncRNAs can play a vital role in preeclampsia (PE). In our study, lncRNA hypoxia-inducible factor 1 alpha (HIF1A) antisense RNA 2 (HIF1A-AS2) was found to be significantly downregulated in placenta tissues of PE patients by quantitative real-time PCR analysis. Moreover, Cell Counting Kit-8 (CCK-8) assays showed that downregulation of HIF1A-AS2 can impede cell proliferation of HTR-8/SVneo and JAR trophoblasts cells. Ectopic overexpression of HIF1A-AS2 can increase the function of trophoblasts cell migration and invasion in vitro. RNA-sequencing (RNA-seq), RNA immunoprecipitation (RIP), and chromatin immunoprecipitation (ChIP) experiments showed that HIF1A-AS2 can recruit lysine-specific demethylase 1 (LSD1) and epigenetically repress pleckstrin homology-like domain, family A, member 1 (PHLDA1) transcription in human trophoblasts cells. In summary, our findings suggest that downregulated HIF1A-AS2 may play a role in the pathogenesis and progression of PE, and has potential as a novel prognostic marker in PE.

Pre-eclampsia through the eyes of the obstetrician and anesthesiologist

Due to the high risk of morbidity and mortality from unrecognized and untreated pre-eclampsia, clinicians should have a high index of suspicion to evaluate, treat and monitor patients presenting with signs concerning for pre-eclampsia. Early blood pressure management and seizure prophylaxis during labor are critical for maternal safety. Intrapartum, special anesthetic considerations should be employed to ensure the safety of the parturient and fetus. Patients who have pre-eclampsia should be aware that they are at high risk for the future development of cardiovascular disease.

Decreased heart rate recovery in women with a history of pre-eclampsia

BACKGROUND

A growing body of literature has reported that a history of pre-eclampsia (PE) increases a woman's long-term risk of cardiovascular diseases (CVD). Autonomic nervous system dysfunction was found to be significant in this specific population, but most studies observed the role of sympathetic over-activation. The aim of this study was to assess whether parasympathetic impairment was involved in women 1 year after PE, and heart rate recovery (HRR) was used to represent parasympathetic tone.

STUDY DESIGN

47 women with previous PE (PE group) and 58 women with a healthy pregnancy (control group) were examined. Blood pressure levels, lipid profiles, homeostasis model assessment of insulin resistance (HOMA-IR), inflammatory biomarkers and HRR were compared between the two groups, and the association between the biochemical parameters and HRR in the PE group was evaluated.

RESULTS

Compared with the Control group, body mass index, 24-h mean diastolic blood pressure, low-density lipoprotein cholesterol and Ln(HOMA-IR) were higher, and HRR was slower in the PE group. Furthermore, body mass index, total cholesterol, and Ln(HOMA-IR) were independent determinants of HRR in the PE group according to multiple regression analysis.

CONCLUSIONS

Our findings suggest that parasympathetic impairment is involved in this specific female population, and its close association with body mass index, total cholesterol and insulin resistance might contribute to an increased risk of CVD development in women with PE history.

Recurrence of pre-eclampsia and the risk of future hypertension and cardiovascular disease: a systematic review and meta-analysis

Background

Women with a history of hypertensive disorders, including pre‐eclampsia, during pregnancy have a two‐ to‐five‐fold increased risk of cardiovascular disease (CVD). In 15% of women, pre‐eclampsia recurs in the following pregnancy.

Objectives

To evaluate all evidence on the future risk of developing hypertension and CVD after multiple pregnancies complicated by pre‐eclampsia compared with pre‐eclampsia in a single pregnancy followed by normal subsequent pregnancy.

Search strategy

Embase and Medline were searched until June 2017.

Selection criteria

All relevant studies on the risk of developing hypertension, atherosclerosis, ischaemic heart disease, cerebrovascular accident (CVA), thromboembolism, heart failure or overall hospitalisation and mortality due to CVD after having had recurrent pre‐eclampsia.

Data collection and analysis

Twenty‐two studies were included in the review. When possible, we calculated pooled risk ratios (RR) with 95% CI through random‐effect analysis.

Main results

Recurrent pre‐eclampsia was consistently associated with an increased pooled risk ratio of hypertension (RR 2.3; 95% CI 1.9–2.9), ischaemic heart disease (RR 2.4; 95% CI 2.2–2.7), heart failure (RR 2.9; 95% CI 2.3–3.7), CVA (RR 1.7; 95% CI 1.2–2.6) and hospitalisation due to CVD (RR 1.6; 95% CI 1.3–1.9) when compared with women with subsequent uncomplicated pregnancies. Other studies on thromboembolism, atherosclerosis and cardiovascular mortality found a positive effect, but data could not be pooled.

Conclusions

This systematic review and meta‐analysis support consistent higher risk for future development of hypertension and CVD in women with recurring pre‐eclampsia as opposed to women with a single episode of pre‐eclampsia.

Tweetable abstract

The risk of future cardiovascular disease increases when women have recurrence of pre‐eclampsia compared with a single episode.

The risk of future cardiovascular disease increases when women have recurrence of pre‐eclampsia compared to a single episode.

This paper includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights15394

Postpartum Sequelae of the Hypertensive Diseases of Pregnancy: A Pilot Study

Background

Hypertensive disorders are one of the most common medical conditions that may complicate pregnancy. Postpartum blood pressure (BP) pattern is, however, less clear in affected women and decision to discharge them is usually decided arbitrarily.

Materials and Methods

A cohort study conducted at Lagos University Teaching Hospital, Lagos, Nigeria, aimed at determining the proportion of pregnant women with pregnancy-induced hypertension (PIH) and preeclampsia (PE) whose BP remains elevated 6 weeks postdelivery and factors associated with the persistent rise. Fifteen women each with PIH and PE were studied in different phases of pregnancy and followed up until 6 weeks postdelivery. Fifteen normotensive pregnant women served as controls. BP patterns were monitored and fasting lipid levels, serum creatinine, fasting glucose profile (FGP), and FGP/insulin ratio were assayed. Data were analyzed with IBM SPSS version 20.

Results

Proportion of women with PIH or PE who had persistent hypertension at 6 weeks postpartum was 3/29 (10.3%), risk ratio of 1.1. No statistically significant association was found between mean arterial BP at 6 weeks postpartum and age, parity, gestational age at delivery, body mass index, and family history of hypertension. Serum creatinine level showed moderate correlation with persistent hypertension at 6 weeks postpartum (r = 0.441,P = 0.006), with sensitivity of 100% and specificity of 81.8% at cutoff value of 1.2 mg/dL in detecting pregnant women with hypertensive disorders who will likely remain hypertensive at 6 weeks postpartum.

Conclusion

There is a need for long-term follow-up of women with PIH/PE beyond puerperium.