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

Subsequent high blood pressure and hypertension by hypertensive disorders of pregnancy: the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study

Hypertensive disorders of pregnancy can cause hypertension in the future. Understanding how the blood pressure values of women with and without hypertensive disorders of pregnancy differ will facilitate follow-up blood pressure monitoring in clinical settings. This study investigated the association between hypertensive disorders of pregnancy and subsequent high blood pressure and hypertension. This study used Japanese data from the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study. Follow-up systolic and diastolic blood pressures in normotensive women during pregnancy and those with hypertensive disorders of pregnancy were estimated using analysis of covariance adjusted for women with low birthweight, history of gestational diabetes mellitus, age, body mass index, pulse rate, smoking and drinking at the follow-up assessment, paternal hypertension history, and maternal hypertension or hypertensive disorders of pregnancy history. Finally, we performed a multiple logistic regression analysis. In total, 7343 women were included in the analysis. Women with a history of hypertensive disorders of pregnancy had higher blood pressure approximately three years postpartum compared with normotensive women. Hypertensive disorders of pregnancy in the most recent pregnancy in different subgroups, such as nulliparous women, multiparous women without a history of hypertensive disorders of pregnancy, and multiparous women with a history of hypertensive disorders of pregnancy, were associated with an increased risk of subsequent hypertension. Women's birthweight was also weakly associated with hypertension. Even one experience of hypertensive disorders of pregnancy may contribute to elevated blood pressure and hypertension approximately three years postpartum. In addition, women's birthweights may have a weak relationship with increasing blood pressure.

Metabolic outcomes in women 6 months and 2 years after preeclampsia versus normotensive pregnancy: A P4 study

Preeclampsia is associated with an increased risk of long-term cardiometabolic disease; however, little is known regarding metabolic factors in the early postpartum years potentially contributing to these health disparities. This study aimed to compare body composition, serum biochemical parameters, energy balance and diet 6 months and 2 years after normotensive pregnancy versus preeclampsia. This is the longitudinal metabolic sub-study of the Postpartum Physiology, Psychology and Paediatric cohort study. Women were assessed 6 months and 2 years after normotensive pregnancy (n = 118) and preeclampsia (n = 47). Metabolic measures included anthropometry, body composition via bioelectrical impedance analysis, serum biochemical parameters, diet via a food recall diary, and 24-h energy expenditure using SenseWear Armbands. Two years postpartum, women after preeclampsia continued to have significantly higher weight (median 67.1 kg vs. 63.1 kg, p = .04) compared to normotensive pregnancies, in addition to higher LDL cholesterol levels (2.7 ± 0.8 mmol/L vs. 2.4 ± 0.6 mmol/L, p = .03). These women were also more likely to have an elevated HOMA-IR score ≥2.08 (44% vs. 19%, p = .01). For all women in our study, waist-to-hip ratio, percent fat mass and activity-associated energy expenditure improved overtime. However, HDL cholesterol levels deteriorated, and excess saturated fat and sodium intake persisted from 6 months postpartum. Therefore, two years after preeclampsia, women remain at greater metabolic risk than their normotensive counterparts, with greater weight, LDL cholesterol and markers of insulin resistance, potentially contributing to long-term cardiovascular morbidity and requiring early intervention.

Acceptability of data linkage to identify women at risk of postnatal complication for the development of digital risk prediction tools and interventions to better optimise postnatal care, a qualitative descriptive study design

BACKGROUND

Pregnancy acts as a cardiovascular stress test. Although many complications resolve following birth, women with hypertensive disorder of pregnancy have an increased risk of developing cardiovascular disease (CVD) long-term. Monitoring postnatal health can reduce this risk but requires better methods to identity high-risk women for timely interventions.

METHODS

Employing a qualitative descriptive study design, focus groups and/or interviews were conducted, separately engaging public contributors and clinical professionals. Diverse participants were recruited through social media convenience sampling. Semi-structured, facilitator-led discussions explored perspectives of current postnatal assessment and attitudes towards linking patient electronic healthcare data to develop digital tools for identifying postpartum women at risk of CVD. Participant perspectives were gathered using post-it notes or a facilitator scribe and analysed thematically.

RESULTS

From 27 public and seven clinical contributors, five themes regarding postnatal check expectations versus reality were developed, including 'limited resources', 'low maternal health priority', 'lack of knowledge', 'ineffective systems' and 'new mum syndrome'. Despite some concerns, all supported data linkage to identify women postnatally, targeting intervention to those at greater risk of CVD. Participants outlined potential benefits of digitalisation and risk prediction, highlighting design and communication needs for diverse communities.

CONCLUSIONS

Current health system constraints in England contribute to suboptimal postnatal care. Integrating data linkage and improving education on data and digital tools for maternal healthcare shows promise for enhanced monitoring and improved future health. Recognised for streamlining processes and risk prediction, digital tools may enable more person-centred care plans, addressing the gaps in current postnatal care practice.

Postpartum and interpregnancy care of women with a history of hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are common complications associated with maternal and neonatal morbidity and mortality worldwide. Insights gained from long-term cohort studies have revealed that women with a history of HDP are predisposed to recurrent HDP in subsequent pregnancies and face heightened risks for cardiovascular and metabolic diseases later in life. Pregnancy is a unique condition that overloads maternal cardiac and metabolic functions, and is recognized as a "maternal stress test" for future cardiovascular and metabolic diseases. Pregnancy and postpartum period provide a valuable opportunity for identifying women with underlying and unrecognized cardiovascular and metabolic risk factors. Establishing an effective postpartum healthcare program for women who have experienced HDP is crucial in reducing the future risk of health complications. Postpartum care consists of supportive care for both mothers and children, including not only the assessment of physical and psychological well-being but also long-term postpartum preventive health management. Interpregnancy care is a continuum from postpartum care and includes supportive care to prepare for future pregnancies. Various initiatives across nations have been initiated to establish follow-up programs for women with a history of HDP; however, sufficient evidence of the impact of such programs is not available. Substantial challenges persist in establishing an efficient postpartum follow-up program, including educational strategies, selection of effective lifestyle interventions, and collaboration among various healthcare providers. This review outlines the postpartum and interpregnancy care of women who have experienced HDP as well as the current status and challenges of related healthcare initiatives in Japan.

Research hotspots and emerging trends of mesenchymal stem cells in cardiovascular diseases: a bibliometric-based visual analysis

Background

Mesenchymal stem cells (MSCs) have important research value and broad application prospects in cardiovascular diseases (CVDs). However, few bibliometric analyses on MSCs in cardiovascular diseases are available. This study aims to provide a thorough review of the cooperation and influence of countries, institutions, authors, and journals in the field of MSCs in cardiovascular diseases, with the provision of discoveries in the latest progress, evolution paths, frontier research hotspots, and future research trends in the regarding field.

Methods

The articles related to MSCs in cardiovascular diseases were retrieved from the Web of Science. The bibliometric study was performed by CiteSpace and VOSviewer, and the knowledge map was generated based on data obtained from retrieved articles.

Results

In our study, a total of 4,852 publications launched before August 31, 2023 were accessed through the Web of Science Core Collection (WoSCC) database via our searching strategy. Significant fluctuations in global publications were observed in the field of MSCs in CVDs. China emerged as the nation with the largest number of publications, yet a shortage of high-quality articles was noted. The interplay among countries, institutions, journals and authors is visually represented in the enclosed figures. Importantly, current research trends and hotspots are elucidated. Cluster analysis on references has highlighted the considerable interest in exosomes, extracellular vesicles, and microvesicles. Besides, keywords analysis revealed a strong emphasis on myocardial infarction, therapy, and transplantation. Treatment methods-related keywords were prominent, while keywords associated with extracellular vesicles gathered significant attention from the long-term perspective.

Conclusion

MSCs in CVDs have become a topic of active research interest, showcasing its latent value and potential. By summarizing the latest progress, identifying the research hotspots, and discussing the future trends in the advancement of MSCs in CVDs, we aim to offer valuable insights for considering research prospects.

Hypertensive Disorders of Pregnancy and Long-Term Maternal Cardiovascular and Metabolic Biomarkers

OBJECTIVE

This study aimed to measure the association between hypertensive disorders of pregnancy (HDP) and long-term maternal metabolic and cardiovascular biomarkers.

STUDY DESIGN

Follow-up study of patients who completed glucose tolerance testing 5 to 10 years after enrollment in a mild gestational diabetes mellitus (GDM) treatment trial or concurrent non-GDM cohort. Maternal serum insulin concentrations and cardiovascular markers VCAM-1, VEGF, CD40L, GDF-15, and ST-2 were measured, and insulinogenic index (IGI, pancreatic β-cell function) and 1/ homeostatic model assessment (insulin resistance) were calculated. Biomarkers were compared by presence of HDP (gestational hypertension or preeclampsia) during pregnancy. Multivariable linear regression estimated the association of HDP with biomarkers, adjusting for GDM, baseline body mass index (BMI), and years since pregnancy.

RESULTS

Of 642 patients, 66 (10%) had HDP: 42 with gestational hypertension and 24 with preeclampsia. Patients with HDP had higher baseline and follow-up BMI, higher baseline blood pressure, and more chronic hypertension at follow-up. HDP was not associated with metabolic or cardiovascular biomarkers at follow-up. However, when HDP type was evaluated, patients with preeclampsia had lower GDF-15 levels (oxidative stress/cardiac ischemia), compared with patients without HDP (adjusted mean difference: -0.24, 95% confidence interval: -0.44, -0.03). There were no differences between gestational hypertension and no HDP.

CONCLUSION

In this cohort, metabolic and cardiovascular biomarkers 5 to 10 years after pregnancies did not differ by HDP. Patients with preeclampsia may have less oxidative stress/cardiac ischemia postpartum; however, this may have been observed due to chance alone given multiple comparisons. Longitudinal studies are needed to define the impact of HDP during pregnancy and interventions postpartum.

KEY POINTS

· Hypertensive disorders of pregnancy were not associated with metabolic dysfunction.. · Cardiovascular dysfunction was not consistently seen after pregnancy hypertension.. · Longitudinal studies with postpartum interventions after preeclampsia are needed..

Preeclampsia-Associated Cardiovascular Risk Factors 6 Months and 2 Years After Pregnancy: The P4 Study

BACKGROUND

Increased cardiovascular risk following preeclampsia is well established and there are signs of early cardiovascular aging 6 months postpartum. This study assessed whether blood pressure (BP) and other cardiovascular measures are abnormal 2 years postpartum in the same cohort to determine ongoing risk markers.

METHODS

Six months and 2 years postpartum, BP was measured using sphygmomanometry, 24-hour ambulatory BP monitoring, and noninvasive central BP. Anthropometric measures, blood, and urine biochemistry were performed. Cross-sectional comparisons between preeclampsia and normotensive pregnancy (NP) groups and longitudinal comparisons within each group were made at 6 months and 2 years.

RESULTS

Two years postpartum, 129 NP, and 52 preeclampsia women were studied who also had 6 months measures. At both time points, preeclampsia group had significantly higher BP (office BP 2 years, 112±12/72±8 versus 104±9/67±7 mm Hg NP; [P<0.001]; mean ambulatory BP monitoring 116±9/73±8 versus 106±8/67±6 mm Hg NP; [P<0.001]). No significant BP changes noted 6 months to 2 years within either group. Office BP thresholds of 140 mm Hg systolic and 90 mm Hg diastolic classified 2% preeclampsia and 0% NP at 2 years. American Heart Association 2017 criteria (above normal, >120/80 mm Hg) classified 25% versus 8% (P<0.002), as did our reference range threshold of 122/79 mm Hg. American Heart Association criteria classified 60% post-preeclampsia versus 16% after NP with above-normal ambulatory BP monitoring (P<0.001). Other cardiovascular risk markers more common 2 years post-preeclampsia included higher body mass index (median 26.6 versus 23.1, P=0.003) and insulin resistance.

CONCLUSIONS

After preeclampsia, women have significantly higher BP 6 months and 2 years postpartum, and have higher body mass index and insulin-resistance scores, increasing their future cardiovascular risk. Regular cardiovascular risk screening should be implemented for all who have experienced preeclampsia.

The effect of a neonatal sleep intervention on maternal postpartum hypertension: a randomized trial

BACKGROUND

In nonpregnant adults, poor sleep is associated with higher blood pressure. Poor sleep is common in the postpartum period and is often attributed to infant caretaking needs. However, its effects on cardiovascular health in individuals with a hypertensive disorder of pregnancy are unknown.

OBJECTIVE

This study aimed to determine the effect of a neonatal sleep intervention on maternal postpartum blood pressure in individuals with a hypertensive disorder of pregnancy.

STUDY DESIGN

In this single-institution pilot randomized controlled trial from July 2021 to March 2022, 110 individuals with a hypertensive disorder of pregnancy were randomized to receive a neonatal sleep intervention (SNOO responsive bassinet) plus usual care of safe sleep education (n=54) or usual care alone (n=56). Remote follow-up visits were conducted at 1 week, 6 weeks, and 4 months after delivery and involved blood pressure and weights, sleep and mood questionnaires, and self-reported infant and maternal sleep logs. Based on institutional data, the sample size had 80% power to detect a 4.5-mm Hg difference in the primary outcome of mean arterial pressure at 6 weeks after delivery.

RESULTS

Baseline characteristics were similar between the arms. At 1 week after delivery, the intervention arm had lower mean arterial pressure and less antihypertensive medication use than the control arm (99±10 vs 103±7 mm Hg [P=.04] and 23% vs 35% [P=.15], respectively). At 6 weeks after delivery, mean arterial pressure was similar between arms (93±8 vs 94±8 mm Hg; P=.54), but there was a lower rate of antihypertensive use in the intervention arm (15% vs 26%; P=.19). Scores from maternal sleep and mood questionnaires at 6 weeks after delivery and self-reported infant and maternal sleep duration at 6 weeks and 4 months after delivery were similar between arms (P>.05).

CONCLUSION

The SNOO responsive bassinet as a neonatal sleep intervention did not result in improved mean arterial pressure at 6 weeks after delivery after hypertensive disorders of pregnancy.

Pregnancy-An Ideal Period to Identify Women at Risk for Chronic Hypertension

BACKGROUND

Cardiovascular disease is the leading cause of mortality in women. Pregnancy is an ideal period to implement cardiovascular prevention strategies as women seek medical help. We aimed to develop a predictive model to identify women at increased risk for chronic hypertension (CH) based on information collected in the index pregnancy.

METHODS

Cohort of 26 511 women seen in 2 consecutive pregnancies. Included were women without CH, with information on maternal characteristics and blood pressure at 11 to 13 weeks' gestation, and the development of preeclampsia or gestational hypertension (GH) in the index pregnancy. Logistic regression models were fitted for the prediction of the development of future CH by the 20th week of the subsequent pregnancy. The performance of screening and risk calibration of the model were assessed.

RESULTS

In this study 1560 (5.9%) women developed preeclampsia or GH (index pregnancy), and 215 (0.8%) developed future CH, with a median of 3.0 years later. Predictors of development of future CH were maternal age, weight, and blood pressure; Black and South Asian ethnicity; family history of preeclampsia; parity; and development of preeclampsia or GH. Preeclampsia or GH detected 52.1% (45.2%-58.9%) of future CH. At a screen-positive rate of 10%, a model including maternal characteristics, early pregnancy blood pressure, and development of preeclampsia or GH detected 73.5% (67.1-79.3) of future CH.

CONCLUSIONS

Early pregnancy maternal characteristics, blood pressure, and development of preeclampsia or GH identify three-fourths of women at risk for future CH. Our results offer an important preventative strategy for identifying women at increased risk of future CH, which is applicable worldwide.

Cardiovascular Disease Risk Factor Interventions in Women With Prior Gestational Hypertensive Disorders or Diabetes in North America: A Rapid Review

Women with previous hypertensive disorders of pregnancy (HDP) or gestational diabetes mellitus (GDM) have a 2- to 3-fold increased risk of cardiovascular disease (CVD). The goal of this rapid review was to summarize evidence of the effectiveness of CVD risk factor interventions for postpartum women with a history of HDP or GDM. A comprehensive search strategy was used to search articles published in 5 databases-Ovid MEDLINE, PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Embase). Observational and intervention studies that identified CVD prevention, screening, and/or risk factor management interventions among postpartum women with prior HDP or GDM in Canada and the US were included. The quality of observational and interventional studies, and their risk of bias, were assessed using appropriate critical appraisal checklists. Eight studies, including 4 observational cohorts, 3 randomized controlled trials, and 1 quasi-experimental study, merited inclusion for analysis. A total of 2449 participants were involved in the included studies. The most effective CVD risk factor intervention was comprised of postpartum transition and follow-up, CVD risk factor education, and advice on lifestyle changes. Most of the observational studies led to improvements in CVD risk factors, including improvements in CVD lifetime risk scores. However, none of the RCTs led to improvements in cardiometabolic risk factors. Few studies have investigated CVD risk factor interventions in the postpartum in women with previous HDP or GDM in North America. Further studies of higher quality are needed.

Postpartum Lifestyle Behaviors among Women with Hypertensive Disorders of Pregnancy: Data from the HUNT Study

Hypertensive disorders of pregnancy (HDP) are associated with an increased risk of cardiovascular disease later in life. Clinical guidelines for postpartum follow-up after HDP often recommend lifestyle counseling to reduce this risk. However, knowledge about lifestyle behaviors and perceptions among women with a history of HDP is limited. We linked data from the fourth survey of the population-based Trøndelag Health Study (HUNT4) with data from the Medical Birth Registry of Norway. The associations between HDP and postpartum lifestyle behaviors and perceptions were examined using multivariable logistic regression. In a secondary analysis, HUNT4 participants with a recent history of pre-eclampsia were compared with women with a recent history of pre-eclampsia participating in a postpartum pilot intervention study. Lifestyle behaviors and perceptions were self-reported and included diet (intake frequency of fruits, vegetables, meat, fish, and sugar-sweetened beverages), alcohol intake, physical activity, sleep, smoking, lifestyle satisfaction, and the importance of a healthy lifestyle. Among 7551 parous HUNT4 participants, 610 had a history of HDP. We found no differences in lifestyle behaviors between women with and without a history of HDP. However, women with HDP had higher odds of being unsatisfied with their lifestyle. Women with pre-eclampsia participating in a postpartum lifestyle intervention study tended to have a healthier lifestyle at baseline than women participating in HUNT4. Future studies should explore how lifestyle intervention programs could be adapted to the needs of women who have experienced HDP or other pregnancy complications that are associated with an increased risk of CVD.

The long-term risk of cardiovascular disease among women with a history of hypertensive disorders of pregnancy: a systematic review of clinical practice guidelines

BACKGROUND

The lifelong risks of cardiovascular disease following preeclampsia and gestational hypertension are well-established. However, it is unclear whether this evidence has been translated into clinical practice guidelines. Thus, this review aimed to assess the quality and content of Australian clinical practice guidelines regarding the risk of cardiovascular disease following gestational hypertension and preeclampsia.

METHODS

We conducted a systematic search of MEDLINE (Ovid), EMBASE (Ovid), and CINAHL databases, as well as hospital, obstetric society, and medical college websites. Publications were included if: they were a clinical practice guideline; were published in the previous ten years; and included recommendations for the management of future cardiovascular disease risk following hypertensive disorders of pregnancy. Quality assessment was performed using Appraisal of Guidelines for Research and Evaluation Instrument Version Two (AGREE-II) and AGREE Recommendations Excellence Instrument (AGREE-REX).

RESULTS

Eighteen guidelines were identified, and of these, less than half (n = 8) included recommendations for managing future cardiovascular risk following hypertensive disorders of pregnancy. Across these eight, four main counselling recommendations were found regarding (1) risk of future cardiovascular disease; (2) risk factor screening; (3) lifestyle interventions; and (4) prenatal counselling for future pregnancies. The quality and content of these recommendations varied significantly, and the majority of guidelines (87.5%) were assessed as low to moderate quality.

CONCLUSIONS

There are limited Australian clinical practice guidelines providing appropriate advice regarding future risk of cardiovascular disease following hypertensive disorders of pregnancy. The quality and content of these guidelines varied significantly. These findings highlight the need for improved translation from evidence-based research to enhance clinical care and guidance.

Prevention of Cardiovascular Disease in Women With Pregnancy-Related Risk Factors: A Prospective Women's Heart Clinic Study

Background Hypertensive disorders of pregnancy, gestational diabetes, and having a small-for-gestational-age baby are known to substantially increase a woman's risk of cardiovascular disease. Despite this, evidence for models of care that mitigate cardiovascular disease risk in women with these pregnancy-related conditions is lacking. Methods and Results A 6-month prospective cohort study assessed the effectiveness of a multidisciplinary Women's Heart Clinic on blood pressure and lipid control in women aged 30 to 55 years with a past pregnancy diagnosis of hypertensive disorders of pregnancy, gestational diabetes, or a small-for-gestational age baby in Melbourne, Australia. The co-primary end points were (1) blood pressure <140/90 mm Hg or <130/80 mm Hg if diabetes and (2) total cholesterol to high-density lipoprotein cholesterol ratio <4.5. The study recruited 156 women with a mean age of 41.0±4.2 years, 3.9±2.9 years from last delivery, 68.6% White, 20.5% South/East Asian, and 80.5% university-educated. The proportion meeting blood pressure target increased (69.2% to 80.5%, P=0.004), with no significant change in lipid targets (80.6% to 83.7%, P=0.182). Systolic blood pressure (-6.9 mm Hg [95% CI, -9.1 to -4.7], P<0.001), body mass index (-0.6 kg/m2 [95% CI, -0.8 to -0.3], P<0.001), low-density lipoprotein cholesterol (-4.2 mg/dL [95% CI, -8.2 to -0.2], P=0.042), and total cholesterol (-4.6 mg/dL [95% CI, -9.1 to -0.2] P=0.042) reduced. Heart-healthy lifestyle significantly improved with increased fish/olive oil (36.5% to 51.0%, P=0.012), decreased fast food consumption (33.8% to 11.0%, P<0.001), and increased physical activity (84.0% to 92.9%, P=0.025). Conclusions Women at high risk for cardiovascular disease due to past pregnancy-related conditions experienced significant improvements in multiple cardiovascular risk factors after attending a Women's Heart Clinic, potentially improving long-term cardiovascular disease outcomes. Registration URL: https://www.anzctr.org.au; Unique identifier: ACTRN12622000646741.

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.

Hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.

Cardiovascular and renal health: Preeclampsia as a risk marker

BACKGROUND

Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies.

MATERIALS AND METHODS

Review of PE and its association with future development of CVD and CKD.

RESULTS

Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage.

CONCLUSIONS

The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.

A retrospective cohort study of hypertension, cardiovascular disease, and metabolic syndrome risk in women with history of preterm and term preeclampsia five years after delivery

OBJECTIVES

To evaluate maternal hypertension, risk of cardiovascular disease (CVD), and metabolic syndrome five years after delivery in preterm preeclampsia (P-PE), term preeclampsia (T-PE), and normal pregnancy.

STUDY DESIGN

This was a retrospective cohort study of women who delivered at Dr. Soetomo Academic Hospital (Indonesia) in 2013 with a diagnosis of PE and were compared with women with normal pregnancies.

MAIN OUTCOMES MEASURES

Blood pressure, National Cholesterol Education Program Adult Treatment Panel III criteria for metabolic syndrome (NCE-ATP III), and Framingham Risk Score (FRS).

RESULTS

In this study, 92 women participated. They were divided into the P-PE (27), T-PE (35), and control groups (30). Women with a history of PE, P-PE, or T-PE had higher blood pressure five years after delivery than those in the control group (p < 0.05). Systolic blood pressure (SBP) >140 mmHg was seen in 66.7% of P-PE and 25.7% of T-PE, while 55.6% of P-PE and 34.3% of T-PE had diastolic blood pressure (DBP) >90 mmHg (p < 0.05). Women with P-PE had the highest risk of developing hypertension (Relative risk (RR): 20; 95% Confidence interval [CI]: 2.85-139.92). Women with history of P-PE (RR: 1.85; 95% CI: 0.77-4.41), T-PE (RR: 1.28; 95% CI: 0.51-3.19), and total PE (RR: 1.53; 95% CI: 0.68-3.43) had an increased risk of positive NECP-ATP III five years after delivery. Women with history of P-PE (RR: 5.17; 95% CI: 0.26-103.22; p = 0.282) and T-PE (RR: 6.03; 95% CI: 0.32-112.22; p = 0.228) are at a greater risk of having an FRS >10% compared to the control group (p = 0.04).

CONCLUSIONS

History of PE, P-PE, and T-PE increased the risk of hypertension and CVD five years after delivery. The results also showed a tendency toward an increased risk of metabolic syndrome in women with a previous history of PE and P-PE.

Aspirin for the Prevention of Early and Severe Pre-Eclampsia Recurrence: A Real-World Population-Based Study

BACKGROUND

Many clinical trials have reported that low-dose aspirin decreases the risk of pre-eclampsia in women with prior pre-eclampsia. However, its impact in a real-world population has not been fully assessed.

OBJECTIVES

To assess the rates of low-dose aspirin initiation during pregnancy in women with a history of pre-eclampsia, and to evaluate the impact of low-dose aspirin in prevention of pre-eclampsia recurrence in a real-world population.

STUDY DESIGN

CONCEPTION is a French nationwide cohort study which uses data from the country's National Health Data System database. We included all women in France who gave birth at least twice between 2010-2018, and who had pre-eclampsia during their first pregnancy. Every dispensing of low-dose aspirin (75-300 mg) between the beginning of their second pregnancy and 36 weeks of gestation (WG) was identified. We used Poisson regression models to estimate the adjusted incidence rate ratios (aIRRs) of receiving aspirin at least once during their second pregnancy. In women who had early and/or severe pre-eclampsia during their first pregnancy, we estimated the IRRs of pre-eclampsia recurrence during their second pregnancy according to the aspirin therapy.

RESULTS

In 28,467 women who were included in the study, the aspirin initiation rate during the second pregnancy ranged from 27.8% for women in whose first pregnancy the pre-eclampsia was mild and late, to 79.9% for those women whose pre-eclampsia was severe and early. Just over half (54.3%) of those treated with aspirin-initiated treatment before 16 WG and adhered to treatment. Compared with women with mild and late pre-eclampsia, the aIRRs (95% CI) for receiving aspirin at least once during the second pregnancy were 1.94 (1.86-2.03) for women with severe and late pre-eclampsia, 2.34 (2.17-2.52) for those with early and mild pre-eclampsia, and 2.87 [2.74-3.01] for those with early and severe pre-eclampsia E. Social deprivation was associated with a lower initiation of aspirin (IRR = 0.74 [0.70-0.78]). Aspirin was not associated with a lower risk of mild and late pre-eclampsia, severe and late pre-eclampsia, or mild and early pre-eclampsia during the second pregnancy. The aIRRs for severe and early pre-eclampsia during the second pregnancy were 0.77 (0.62-0.95) for women who received prescribed aspirin at least once, 0.71 (0.5-0.89) for those who initiated aspirin therapy before 16 WG, and 0.60 (0.47-0.77) for those who adhered to aspirin treatment throughout their second pregnancy. The risk of severe and early pre-eclampsia was lower only when the prescribed mean daily dose was ≥ 100 mg/day.

CONCLUSION

In women with a history of pre-eclampsia, aspirin initiation during a second pregnancy and adherence to the prescribed dosage were largely insufficient, especially for women experiencing social deprivation. Aspirin initiated before 16 WG at a dose ≥ 100 mg/day was associated with a lower risk of severe and early pre-eclampsia.

Patients' understanding of long-term cardiovascular risks and associated health-seeking behaviours after pre-eclampsia

OBJECTIVE

The lifelong risks of cardiovascular disease following hypertensive disorders of pregnancy are well described. Awareness of these risks and associated health-seeking behaviours among affected individuals remains unclear. We aimed to assess participants' knowledge of their cardiovascular disease risk and relevant health-seeking behaviours following a pregnancy affected by preeclampsia or gestational hypertension.

METHODS

We undertook a single-site, cross-sectional cohort study. The target population included individuals who birthed at a large tertiary referral centre in Melbourne, Australia, between 2016 and 2020, and were diagnosed with gestational hypertension or pre-eclampsia. Participants completed a survey assessing pregnancy details, medical comorbidities, knowledge of future risks and health-seeking behaviours post-pregnancy.

RESULTS

1526 individuals met inclusion criteria and 438 (28.6%) completed the survey. Of these, 62.6% (n=237) were unaware of their increased risk of cardiovascular disease following a hypertensive disorder of pregnancy. Participants who reported awareness of their increased risk were more likely to have annual blood pressure monitoring (54.6% vs 38.1%, p<0.01), and at least one assessment of blood cholesterol (p<0.01), blood glucose (p=0.03) and renal function (p=0.01). Participants who were aware were more likely to be taking antihypertensive medication (24.5% vs 6.6%, p<0.01) since pregnancy, compared with those who were unaware. There were no differences between groups in diet, exercise or smoking habits.

CONCLUSION

Among our study cohort, risk awareness was associated with increased health-seeking behaviours. Participants who were aware of their increased risk of cardiovascular disease were more likely to have regular cardiovascular risk factor assessments. They were also more likely to be taking antihypertensive medication.

The L-NAME mouse model of preeclampsia and impact to long-term maternal cardiovascular health

Preeclampsia affects ∼2–8% of pregnancies worldwide. It is associated with increased long-term maternal cardiovascular disease risk. This study assesses the effect of the vasoconstrictor N(ω)-nitro-L-arginine methyl ester (L-NAME) in modelling preeclampsia in mice, and its long-term effects on maternal cardiovascular health. In this study, we found that L-NAME administration mimicked key characteristics of preeclampsia, including elevated blood pressure, impaired fetal and placental growth, and increased circulating endothelin-1 (vasoconstrictor), soluble fms-like tyrosine kinase-1 (anti-angiogenic factor), and C-reactive protein (inflammatory marker). Post-delivery, mice that received L-NAME in pregnancy recovered, with no discernible changes in measured cardiovascular indices at 1-, 2-, and 4-wk post-delivery, compared with matched controls. At 10-wk post-delivery, arteries collected from the L-NAME mice constricted significantly more to phenylephrine than controls. In addition, these mice had increased kidney Mmp9:Timp1 and heart Tnf mRNA expression, indicating increased inflammation. These findings suggest that though administration of L-NAME in mice certainly models key characteristics of preeclampsia during pregnancy, it does not appear to model the adverse increase in cardiovascular disease risk seen in individuals after preeclampsia.

Economic Evaluation of Prenatal and Postpartum Care in Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review

OBJECTIVES

This study aimed to summarize evidence on the economic outcomes of prenatal and postpartum interventions for the management of gestational diabetes mellitus and hypertensive disorders of pregnancy (HDP), assess the quality of each study, and identify research gaps that may inform future research.

METHODS

Electronic databases including PubMed/MEDLINE, Embase, the Cochrane Library, and Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to October 1, 2021. Selected studies were included in narrative synthesis and extracted data were presented in narrative and tabular forms. The quality of each study was assessed using the Consolidated Health Economic Evaluation Reporting Standards and Consensus on Health Economic Criteria list.

RESULTS

Among the 22 studies identified through the systematic review, 19 reported favorable cost-effectiveness of the intervention. For prenatal management of HDP, home blood pressure monitoring was found to be cost-effective compared with in-person visits in improving maternal and neonatal outcomes. For postpartum care, regular screening for hypertension or metabolic syndrome followed by subsequent treatment was found to be cost-effective compared with no screening in women with a history of gestational diabetes mellitus or HDP.

CONCLUSIONS

Existing economic evaluation studies showed that prenatal home blood pressure monitoring and postpartum screening for hypertension or metabolic syndrome were cost-effective. Nevertheless, limitations in the approach of the current economic evaluations may dampen the quality of the evidence and warrant further investigation.

Skipping breakfast during pregnancy and hypertensive disorders of pregnancy in Japanese women: the Tohoku medical megabank project birth and three-generation cohort study

BACKGROUND

Hypertensive disorders of pregnancy (HDP) adversely affect the prognosis of mother and child, and the prognosis depends on the subtype of HDP. Skipping breakfast may be associated with increased blood pressure due to disruption of the circadian clock, but the association with the development of HDP has not been studied. The purpose of this study was to examine the association between skipping breakfast and the development of HDP and HDP subtypes in Japanese pregnant women.

METHODS

Of the pregnant women who participated in the Tohoku Medical Megabank Project Three-Generation Cohort Study, 18,839 who answered the required questions were included in the analysis. This study had a cross-sectional design. The breakfast intake frequency from pre-pregnancy to early pregnancy was classified into four groups: daily, 5-6 times per week, 3-4 times per week, and 0-2 times per week. HDP was classified into gestational hypertension (GH), chronic hypertension (CH), preeclampsia (PE), and severe preeclampsia (SuPE). Multiple logistic regression analysis and multinomial logistic analysis were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for breakfast intake frequency and development of HDP or HDP subtypes. We performed a stratified analysis based on energy intake.

RESULTS

Of the participants, 74.3% consumed breakfast daily, and 11.1% developed HDP. Women who consumed breakfast 0-2 times per week had a higher risk of HDP (OR: 1.33, 95% CI: 1.14-1.56), CH (OR: 1.63, 95% CI: 1.21-2.19), and PE (OR: 1.68, 95% CI: 1.27-2.21) than those who consumed breakfast daily. No association was found between skipping breakfast and the risk of developing GH (OR: 1.26, 95% CI: 0.99-1.61) and SuPE (OR: 0.91, 95% CI: 0.55-1.49). Stratified analysis showed that the risk of developing HDP due to skipping breakfast was highest in the group with the highest daily energy intake.

CONCLUSIONS

Skipping breakfast during pre-to early pregnancy is associated with the development of HDP. Further longitudinal studies are required to clarify the causal association between skipping breakfast and HDP.

Pregnancy complications and cardiovascular disease risk perception: A qualitative study

OBJECTIVES

We aimed to assess women's perceptions on the long-term risks for cardiovascular disease (CVD) after major pregnancy complications.

METHODS

Women who experienced major pregnancy complications and those who experienced uncomplicated pregnancies were invited to participate in a qualitative study. Focus group discussions (FGDs) and self-administered questionnaires were used to explore: The knowledge of long-term sequelae after experiencing a major pregnancy complication; Importance of education on heart health; The practicality of referral to a clinic after pregnancy complications; Willingness for regular postpartum clinic visits after pregnancy complications. A thematic qualitative analysis was undertaken.

RESULTS

26 women participated in four FGDs. The majority of women did not know of the association between major pregnancy complications and CVD. The main views expressed were: Women who experience pregnancy complications should receive education on improving heart health; An appointment for the first CVD risk screening visit needs to be made prior to discharge from the delivery suite; Women will benefit by having the option to select between a hospital and a general-practitioner based model of follow up.

CONCLUSIONS

These views are important in developing postpartum strategies to reduce CVD risk among women who experience pregnancy complications.

Optimising mothers' health behaviour after hypertensive disorders of pregnancy: a qualitative study of a postnatal intervention

Background

Hypertensive disorders of pregnancy have longer-term implications, increasing women’s lifetime cardiovascular disease risk. The Blood Pressure Postpartum study is a multi-centre randomised three-arm trial of interventions, ranging in intensity and including education and lifestyle coaching, to support women to maintain or adopt healthy eating and physical activity during the first postpartum year. This qualitative sub-study nested within the main trial aimed to investigate whether and how women adopted healthy behaviours after a pregnancy complicated by a hypertensive disorder.

Methods

Semi-structured telephone interviews were recorded, transcribed and analysed thematically, following Braun and Clarke principles. They explored behaviour change among new mothers following their hypertensive pregnancy, and the intervention’s effect on their capacity and motivation to pursue healthy lifestyles.

Results

Thirty-four women from all three trial arms participated at 10–12 months postpartum. The three main themes were 1) Awareness of cardiovascular risk: some did not acknowledge the health risks, whereas others embraced this information. 2) Sources of motivation: while the majority were motivated to make a concerted effort to adapt their health behaviour, motivation often centred on their baby and family rather than their own needs. 3) Sustaining behaviour change with a new baby: women in the more intensive intervention arm demonstrated increased recognition of the importance of reducing cardiovascular health risks, with greater motivation and guidance to change their health behaviour. There was minimal evidence of crossover amongst groups, with women largely accepting their randomised level of intervention and not seeking additional help when randomised to minimal intervention.

Conclusions

Among women participating in an early post-hypertensive disorders of pregnancy randomised controlled trial aimed at improving their cardiovascular disease risk profile, the majority recognised the future health risks and appeared motivated to improve their lifestyle, particularly women in the highest-intensity intervention group. This highlights the importance of structured support to assist women embrace healthy lifestyles especially during the challenges of new parenthood.

Trial registration

The Blood Pressure Postpartum study was prospectively registered as a clinical trial with the Australian New Zealand Clinical Trials Registry (anzctr.org.au) on 13 December 2018 (registration number: ACTRN12618002004246).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13590-2.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

The P4 Study: Postpartum Maternal and Infant Faecal Microbiome 6 Months After Hypertensive Versus Normotensive Pregnancy

Objective/Hypothesis

To explore potential differences in faecal microbiome between women, and their infants, who had normotensive pregnancies (NP) and those who had a hypertensive pregnancy (HP), either gestational hypertension (GH) or preeclampsia (PE).

Methods

This is a sub study of P4 (Postpartum Physiology, Psychology, and Paediatrics Study) and includes 18 mother-infant pairs: 10 NP and 8 HP (HP as defined by blood pressure > 140/90mmHg; of which 6 had PE, and 2 GH), six months postpartum. The participating mothers collected stool samples from themselves and their infants. 16S rRNA V3-V4 amplicons were used to study the faecal microbiome.

Results

The sample of women and their infants were mostly primiparous (n =16) with vaginal birth (n = 14). At the time of faecal sampling 8 women were using hormonal contraception, and one HP woman remained on an antihypertensive. All women had blood pressure < 130/80mmHg, and 10 had high BMI (> 30). All infants had started solids, 8 were exclusively breastfed, 1 exclusively formula fed and 9 both. Three infants had been exposed to a course of antibiotics. Six months postpartum, there were no significant differences in alpha or beta diversity between the gut microbiota of HP and NP women (P > 0.05). However, a statistically significant difference was detected in alpha diversity between infants following HP and NP, with lower diversity levels in HP infants (P < 0.05). It was also found that at a genus and species level, the gut microbiota of HP women was enriched with Bifidobacterium and Bifidobacterium sp. and depleted in Barnesiella and Barnesiella intestinihominis when compared to NP women (P < 0.05). Similarly, the gut microbiota of infants born from HP was enriched in Streptococcus infantis and depleted in Sutterella, Sutterella sp., Bacteroides sp. and Clostridium aldenense compared to infants born from NP (P < 0.05).

Discussion

While our findings are at best preliminary, due to the very small sample size, they do suggest that the presence of hypertension in pregnancy may adversely affect the maternal microbiota postpartum, and that of their infants. Further analysis of postpartum microbiome data from future studies will be important to validate these early findings and provide further evidence about the changes in the microbiota in the offspring of women following hypertensive disorders of pregnancy (HDP), including possible links to the causes of long-term cardiovascular disease, the prevalence of which is increased in women who have experienced HDP.

Focus on today's evidence while keeping an eye on the future: lessons derived from hypertension in women

While evidence-based medicine has contributed enormously to the uniformity and rationale of patient care, it is necessary that we anticipate changes in order to implement their rapid translation to practice. The purpose of this review is to expose three issues regarding cardiovascular health in women, including milestones to reflect the pace at which these are incorporated into public policies. Two of these matters, as changes in the thresholds of normal blood pressure in gestation and in nonpregnant women, need further evidence and deserve to be retrospectively analyzed in high-quality databases. The third subject derives from the association of remote cardiovascular complications of hypertensive pregnancies, an example of the unnecessary delay of more than two decades to install a wide prevention strategy when the health system is not on the watch.

Maternal Cardiovascular Disease After Pre-Eclampsia and Gestational Hypertension: A Narrative Review

Previous literature has highlighted that women who have a pregnancy affected by gestational hypertension or preeclampsia are at higher risk of cardiovascular disease (CVD) in later life. However, CVD is a composite of multiple outcomes, including coronary heart disease, heart failure, and stroke, and the risk of both CVD and hypertensive disorders of pregnancy varies by the population studied. We conducted a narrative review of the risk of cardiovascular outcomes for women with prior gestational hypertension and pre-eclampsia. Previous literature is summarized by country and ethnicity, with a higher risk of CVD and coronary heart disease observed after gestational hypertension and a higher risk of CVD, coronary heart disease and heart failure observed after pre-eclampsia in most of the populations studied. Only one study was identified in a low- or middle-income country, and the majority of studies were conducted in white or mixed ethnicity populations. We discuss potential interventions to mitigate cardiovascular risk for these women in different settings and highlight the need for a greater understanding of the epidemiology of CVD risk after gestational hypertension and pre-eclampsia outside of high-income, white populations.

The P4 study: Subsequent pregnancy maternal physiology after hypertensive and normotensive pregnancies

OBJECTIVES

Hypertensive disorders of pregnancy are associated with subsequent increased risk of cardiometabolic disease. Adverse cardiometabolic measures are noted soon after hypertensive versus normotensive pregnancy (NP); to what degree these persist into a subsequent pregnancy (SP) is unknown. This study aimed to assess women's physiology early in SP after hypertensive pregnancy (HP: preeclampsia or gestational hypertension) or NP and compare SP to 6 months postpartum findings from the index pregnancy.

STUDY DESIGN

Prospective sub-study of the P4 (Postpartum, Physiology, Psychology and Paediatric) observational cohort. Measurements six months after NP versus HP, and the SP at 11-13 weeks gestation.

MAIN OUTCOME MEASURES

Blood pressure (BP), blood and urine tests (urine ACR, HOMA-IR, LDL cholesterol), body composition, and contribution of maternal characteristics and inter-pregnancy factors to BP and body fat (FM%) in SP.

RESULTS

49 women (34 NP, 15 HP). In the SP, post-HP women had higher BP (112/70 mmHg HP vs 102/64 mmHg NP; p < .001), with no significant drop from six months postpartum to early SP. On regression analysis, systolic and diastolic BP at 6-months were the major predictors for SP systolic (p < 0.001) and diastolic (p = 0.009) BP respectively in the SP. Longer interpregnancy interval and increased FM% 6-months postpartum were associated with higher SP FM% (p < 0.001).

CONCLUSIONS

BP and body fat six months postpartum were similar early in the SP for HP group, and postpartum BP and FM% were major predictors of their corresponding SP measurements. Postpartum/inter-pregnancy intervention programs to improve these cardiometabolic risk markers might help improve women's long-term health and require investigation.

Pre-eclampsia and long-term health outcomes for mother and infant: an umbrella review

BACKGROUND

Pre-eclampsia is a pregnancy-associated condition with complex disease mechanisms and a risk factor for various long-term health outcomes for the mother and infant.

OBJECTIVE

To summarise evidence on the association of pre-eclampsia with long-term health outcomes arising in women and/or infants.

SEARCH STRATEGY

PubMed, EMBASE, Scopus and ISI Web of Science were searched from inception to July 2020.

SELECTION CRITERIA

Systematic reviews and meta-analyses examining associations between pre-eclampsia and long-term health outcomes in women and their infants.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. We re-estimated the summary effect size by random-effects and fixed-effects models, the 95% confidence interval, the 95% prediction interval, the between-study heterogeneity, any evidence of small-study effects and excess significance bias.

RESULTS

Twenty-one articles were included (90 associations). Seventy-nine associations had nominally statistically significant findings (P < 0.05). Sixty-five associations had large or very large heterogeneity. Evidence for small-study effects and excess significance bias was found in seven and two associations, respectively. Nine associations: cerebrovascular disease (cohort studies), cerebrovascular disease (overall), cardiac disease (cohort studies), dyslipidaemia (all studies), risk of death (late-onset pre-eclampsia), fatal and non-fatal ischaemic heart disease, cardiovascular mortality (cohort studies), any diabetes or use of diabetic medication (unadjusted), and attention deficit/hyperactivity disorder (ADHD) (adjusted) were supported with robust evidence.

CONCLUSION

Many of the meta-analyses in this research field have caveats casting doubts on their validity. Current evidence suggests an increased risk for women to develop cardiovascular-related diseases, diabetes and dyslipidaemia after pre-eclampsia, while offspring exposed to pre-eclampsia are at higher risk for ADHD.

TWEETABLE ABSTRACT

Cardiovascular and cerebrovascular diseases were supported with convincing evidence for long-term health outcomes after pre-eclampsia.

The long-term cardiovascular impact of hypertension in pregnancy - A missed opportunity

Women who have had hypertension in pregnancy, both pre-eclampsia and gestational hypertension, have a two- to three-fold increased risk of cardiovascular disease later in life. It is unclear whether this is an unmasking of latent risk, the result of damage to the vascular tree during pregnancy, or both. Irrespective of the underlying pathophysiology, these women are uniquely identified sufficiently early in their lives for lifestyle interventions, if adopted, to improve their long-term health. Currently, follow-up of these women is inadequate and implementation of a coordinated follow-up program, and further research into how best to provide it, is urgently needed.

Early Pregnancy Atherogenic Profile in a First Pregnancy and Hypertension Risk 2 to 7 Years After Delivery

Background Cardiovascular risk in young adulthood is an important determinant of lifetime cardiovascular disease risk. Women with adverse pregnancy outcomes (APOs) have increased cardiovascular risk, but the relationship of other factors is unknown. Methods and Results Among 4471 primiparous women, we related first-trimester atherogenic markers to risk of APO (hypertensive disorders of pregnancy, preterm birth, small for gestational age), gestational diabetes mellitus (GDM) and hypertension (130/80 mm Hg or antihypertensive use) 2 to 7 years after delivery. Women with an APO/GDM (n=1102) had more atherogenic characteristics (obesity [34.2 versus 19.5%], higher blood pressure [systolic blood pressure 112.2 versus 108.4, diastolic blood pressure 69.2 versus 66.6 mm Hg], glucose [5.0 versus 4.8 mmol/L], insulin [77.6 versus 60.1 pmol/L], triglycerides [1.4 versus 1.3 mmol/L], and high-sensitivity C-reactive protein [5.6 versus 4.0 nmol/L], and lower high-density lipoprotein cholesterol [1.8 versus 1.9 mmol/L]; P<0.05) than women without an APO/GDM. They were also more likely to develop hypertension after delivery (32.8% versus 18.1%, P<0.05). Accounting for confounders and factors routinely assessed antepartum, higher glucose (relative risk [RR] 1.03 [95% CI, 1.00-1.06] per 0.6 mmol/L), high-sensitivity C-reactive protein (RR, 1.06 [95% CI, 1.02-1.11] per 2-fold higher), and triglycerides (RR, 1.27 [95% CI, 1.14-1.41] per 2-fold higher) were associated with later hypertension. Higher physical activity was protective (RR, 0.93 [95% CI, 0.87-0.99] per 3 h/week). When evaluated as latent profiles, the nonobese group with higher lipids, high-sensitivity C-reactive protein, and insulin values (6.9% of the cohort) had increased risk of an APO/GDM and later hypertension. Among these factors, 7% to 15% of excess RR was related to APO/GDM. Conclusions Individual and combined first-trimester atherogenic characteristics are associated with APO/GDM occurrence and hypertension 2 to 7 years later. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02231398.

A review of maternal overweight and obesity and its impact on cardiometabolic outcomes during pregnancy and postpartum

The rates of maternal overweight and obesity, but also excess gestational weight gain, are increasing. Pregnancy complications, including gestational diabetes mellitus, gestational hypertension, pre-eclampsia and delivery of a preterm or growth restricted baby, are higher for both women with overweight and obesity and women who gain excess weight during their pregnancy. Other conditions such as polycystic ovary syndrome are also strongly linked to overweight and obesity and worsened pregnancy complications. All of these conditions place women at increased risk for future cardiometabolic diseases. If overweight and obesity, but also excess gestational weight gain, can be reduced in women of reproductive age, then multiple comorbidities associated with pregnancy complications may also be reduced in the years after childbirth. This narrative review highlights the association between maternal overweight and obesity and gestational weight gain, with gestational diabetes, pre-eclampsia, polycystic ovary syndrome and delivery of a preterm or growth restricted baby. This review also addresses how these adverse conditions are linked to cardiometabolic diseases after birth. We report that while the independent associations between obesity and gestational weight gain are evident across many of the adverse conditions assessed, whether body mass index or gestational weight gain is a stronger driving factor for many of these is currently unclear. Mechanisms linking gestational diabetes mellitus, gestational hypertension, pre-eclampsia, preterm delivery and polycystic ovary syndrome to heightened risk for cardiometabolic diseases are multifactorial but relate to cardiovascular and inflammatory pathways that are also found in overweight and obesity. The need for post-partum cardiovascular risk assessment and follow-up care remains overlooked. Such early detection and intervention for women with pregnancy-related complications will significantly attenuate risk for cardiovascular disease.

Secondary hyperparathyroidism is associated with postpartum blood pressure in preeclamptic women and normal pregnancies

BACKGROUND

Preeclampsia has been associated with features of secondary hyperparathyroidism. In this study, we examine the relationships of calcium metabolism with blood pressure (BP) in preeclamptic women and in a control group of normal (NORM) pregnancies in the postpartum.

METHODS

Sixty-three consecutive preeclamptic women (age 35 ± 6 years) were studied 4 weeks after delivery. We collected clinical and lab information on pregnancy and neonates and measured plasma and urinary calcium and phosphate, plasma parathyroid hormone (PTH) and 25-hydroxy vitamin D [25(OH)D], and performed 24-h ambulatory BP monitoring. BP and calcium metabolism of 51 preeclamptic were compared with 17 NORM pregnant women that matched for age, race, and postpartum BMI.

RESULTS

25(OH)D deficiency (<10 ng/ml) was found in 3% of preeclamptic women, insufficiency (10-30 ng/ml) in 67%, and NORM values (31-100 ng/ml) in the remaining 30%. Elevated plasma PTH (≥79 pg/ml) was found in 24% of preeclamptic women who had 25(OH)D plasma levels of 21.4 ± 8.3 ng/ml. In these women, PTH levels was independently associated with 24-h SBP and DBP and daytime and night-time DBP. Prevalence of nondippers and reverse dippers was elevated (75% and 33%, respectively). No associations between calcium metabolism and neonates' characteristics of preeclamptic women were observed. Prevalence of vitamin D deficiency and insufficiency and of elevated plasma PTH levels were comparable in matched groups. Considering preeclamptic women and matched controls as a whole group, office SBP and DBP levels were associated with PTH independently of preeclampsia and other confounders.

CONCLUSION

Features of secondary hyperparathyroidism are common in the postpartum. Preeclampsia and increased PTH levels were both independent factors associated with increased BP after delivery, and both might affect the future cardiovascular risk of these women.

Be Healthe for Your Heart: A Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women with a History of Preeclampsia

This pilot randomized controlled trial (RCT) aimed to determine the acceptability and preliminary efficacy of a web-based cardiovascular disease (CVD) prevention intervention for women following preeclampsia. Australian women with a recent history (≤4 years post diagnosis) of preeclampsia were randomized into two study arms: (1) Be Healthe for your Heart, a web-based behavioral intervention or; (2) Control, access to the National Heart Foundation website. Assessments were conducted at baseline, and after three months. Intervention acceptability and impact on absolute CVD 30-year risk score, CVD risk markers and health behaviors were assessed. Twenty-four of 31 (77.4%) women completed the three-month assessment. Eleven out of 13 intervention participants (84.6%) agreed/strongly agreed they were satisfied with the program, with a mean score of 4.2 ± 0.9 (maximum of five). There were no significant between or within group differences in absolute CVD risk, CVD risk markers or health behaviors from baseline to three months. Women with a history of preeclampsia were successfully recruited and retained and they reported high levels of acceptability with the Be Healthe for your Heart program. Further research is therefore needed from powered trials to determine the impact of web-based lifestyle interventions on CVD risk in this at-risk group.

Emerging Therapeutic Potential of Mesenchymal Stem/Stromal Cells in Preeclampsia

PURPOSE OF REVIEW

Preeclampsia is a dangerous pregnancy condition affecting both the mother and offspring. It is a multifactorial disease with poorly understood pathogenesis, lacking effective treatments. Maternal immune response, inflammation and oxidative stress leading to endothelial dysfunction are the most prominent pathogenic processes implicated in preeclampsia development. Here, we give a detailed overview of the therapeutic applications and mechanisms of mesenchymal stem/stromal cells (MSCs) as a potential new treatment for preeclampsia.

RECENT FINDINGS

MSCs have gained growing attention due to low immunogenicity, easy cultivation and expansion in vitro. Accumulating evidence now suggests that MSCs act primarily through their secretomes facilitating paracrine signalling that leads to potent immunomodulatory, pro-angiogenic and regenerative therapeutic effects. MSCs have been studied in different animal models of preeclampsia demonstrating promising result, which support further investigations into the therapeutic effects and mechanisms of MSC-based therapies in preeclampsia, steering these therapies into clinical trials.