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Ray GW, Zeng Q, Kusi P, Zhang H, Shao T, Yang T, Wei Y, Li M, Che X, Guo R. Genetic and inflammatory factors underlying gestational diabetes mellitus: a review. Front Endocrinol (Lausanne) 2024; 15:1399694. [PMID: 38694942 PMCID: PMC11061502 DOI: 10.3389/fendo.2024.1399694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/28/2024] [Indexed: 05/04/2024] Open
Abstract
Gestational diabetes mellitus (GDM) poses a significant global health concern, impacting both maternal and fetal well-being. Early detection and treatment are imperative to mitigate adverse outcomes during pregnancy. This review delves into the pivotal role of insulin function and the influence of genetic variants, including SLC30A8, CDKAL1, TCF7L2, IRS1, and GCK, in GDM development. These genetic variations affect beta-cell function and insulin activity in crucial tissues, such as muscle, disrupting glucose regulation during pregnancy. We propose a hypothesis that this variation may disrupt zinc transport, consequently impairing insulin production and secretion, thereby contributing to GDM onset. Furthermore, we discussed the involvement of inflammatory pathways, such as TNF-alpha and IL-6, in predisposing individuals to GDM. Genetic modulation of these pathways may exacerbate glucose metabolism dysregulation observed in GDM patients. We also discussed how GDM affects cardiovascular disease (CVD) through a direct correlation between pregnancy and cardiometabolic function, increasing atherosclerosis, decreased vascular function, dyslipidemia, and hypertension in women with GDM history. However, further research is imperative to unravel the intricate interplay between inflammatory pathways, genetics, and GDM. This understanding is pivotal for devising targeted gene therapies and pharmacological interventions to rectify genetic variations in SLC30A8, CDKAL1, TCF7L2, IRS1, GCK, and other pertinent genes. Ultimately, this review offers insights into the pathophysiological mechanisms of GDM, providing a foundation for developing strategies to mitigate its impact.
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Affiliation(s)
- Gyan Watson Ray
- Department of Internal Medicine, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
| | - Qiaoli Zeng
- Department of Internal Medicine, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
| | - Phidelia Kusi
- University of Ghana, Ministry of Fisheries and Aquaculture Development, Fisheries Commission, Accra, Ghana
| | - Hengli Zhang
- Department of Internal Medicine, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
| | - Taotao Shao
- Department of Internal Medicine, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, China
| | - Taili Yang
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
| | - Yue Wei
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
| | - Mianqin Li
- Department of Obstetric, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, Guangdong, China
| | - Xiaoqun Che
- Department of Obstetric, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, Guangdong, China
- Reproductive Medicine Center, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, Guangdong, China
| | - Runmin Guo
- Department of Internal Medicine, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
- Key Laboratory of Research in Maternal and Child Medicine and Birth Defects, Guangdong Medical University, Foshan, China
- Matenal and Child Research Institute, Shunde Women and Children’s Hospital (Maternity and Child Healthcare Hospital of Shunde Foshan), Guangdong Medical University, Foshan, China
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Sonaglioni A, Piergallini E, Naselli A, Nicolosi GL, Ferrulli A, Bianchi S, Lombardo M, Ambrosio G. The effect of gestational diabetes mellitus on carotid artery intima-media thickness in and after pregnancy: a systematic review and meta-analysis. Acta Diabetol 2024; 61:139-149. [PMID: 37936027 DOI: 10.1007/s00592-023-02206-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
AIMS The association between gestational diabetes mellitus (GDM) and common carotid artery (CCA) intima-media thickness (IMT) is still controversial. This systematic review and meta-analysis was performed to assess the correlation between GDM and CCA-IMT in and after pregnancy. METHODS PubMed and EMBASE databases were systematically reviewed on April 2023. Studies measuring CCA-IMT in both pregnant women with GDM and women with previous history of GDM (pGDM) vs. healthy controls were included. The subtotal and overall standardized mean differences (SMDs) of CCA-IMT were calculated using the random-effect model. RESULTS Nineteen studies with a total of 302 GDM and 861 pGDM women were analyzed. The average value of CCA-IMT measured in GDM/pGDM (0.59 ± 0.12 mm) was slightly increased in comparison to the accepted reference limits of IMT according to age classes. Substantial heterogeneity was detected for the studies involving both GDM and pGDM women, with an overall statistic I2 of 86.0% (p < 0.001). Large SMDs were obtained for the studies conducted on both GDM and pGDM women, with an overall SMD of 0.89 (95%CI 0.63-1.15, p < 0.001). Egger's test for a regression intercept gave a p-value of 0.37, indicating no publication bias. On meta-regression analysis, all potential confounders (number of patients, age at pregnancy, body mass index, measuring time, follow-up duration and GDM criteria) were not significantly associated with effect modification. CONCLUSIONS GDM in and after pregnancy is independently associated with subclinical atherosclerosis. The association between GDM and carotid remodeling is potentially mediated by the longstanding underlying risk.
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Affiliation(s)
| | | | | | | | - Anna Ferrulli
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Stefano Bianchi
- Division of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
| | | | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria "S. Maria Della Misericordia", Perugia, Italy
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Martin SL, Zhang L, Callahan ML, Bahorski J, Lewis CE, Hidalgo BA, Durant N, Harper LM, Battarbee AN, Habegger K, Moore BA, Everett A, Aslibekyan S, Sertie R, Yi N, Garvey WT, Chandler‐Laney P. Mother-child cardiometabolic health 4-10 years after pregnancy complicated by obesity with and without gestational diabetes. Obes Sci Pract 2022; 8:627-640. [PMID: 36238222 PMCID: PMC9535673 DOI: 10.1002/osp4.599] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/20/2021] [Accepted: 01/30/2022] [Indexed: 11/25/2022] Open
Abstract
Objective Obesity in pregnancy and gestational diabetes (GDM) increase cardiometabolic disease risk but are difficult to disentangle. This study aimed to test the hypothesis that 4-10 years after a pregnancy complicated by overweight/obesity and GDM (OB-GDM), women and children would have greater adiposity and poorer cardiometabolic health than those with overweight/obesity (OB) or normal weight (NW) and no GDM during the index pregnancy. Methods In this cross-sectional study, mother-child dyads were stratified into three groups based on maternal health status during pregnancy (OB-GDM = 67; OB = 76; NW = 76). Weight, height, waist and hip circumferences, and blood pressure were measured, along with fasting glucose, insulin, HbA1c, lipids, adipokines, and cytokines. Results Women in the OB and OB-GDM groups had greater current adiposity and poorer cardiometabolic health outcomes than those in the NW group (p < 0.05). After adjusting for current adiposity, women in the OB-GDM group had higher HbA1c, glucose, HOMA-IR and triglycerides than NW and OB groups (p < 0.05). Among children, adiposity was greater in the OB-GDM versus NW group (p < 0.05), but other indices of cardiometabolic health did not differ. Conclusions Poor cardiometabolic health in women with prior GDM is independent of current adiposity. Although greater adiposity among children exposed to GDM is evident at 4-10 years, differences in cardiometabolic health may not emerge until later.
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Affiliation(s)
- Samantha L. Martin
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Li Zhang
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Makenzie L. Callahan
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jessica Bahorski
- School of NursingUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Cora E. Lewis
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Bertha A. Hidalgo
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Nefertiti Durant
- Department of PediatricsDivision of Adolescent MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Lorie M. Harper
- Department of Women's HealthDivision of Maternal‐Fetal MedicineDell Medical SchoolThe University of Texas at AustinAustinTexasUSA
| | - Ashley N. Battarbee
- Department of Obstetrics and GynecologyDivision of Maternal Fetal MedicineUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Kirk Habegger
- Department of MedicineDivision of Endocrinology, Diabetes, and MetabolismUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Bethany A. Moore
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Alysha Everett
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Stella Aslibekyan
- Department of EpidemiologyUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Rogerio Sertie
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Nengjun Yi
- Department of BiostatisticsUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - W. Timothy Garvey
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Paula Chandler‐Laney
- Department of Nutrition SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
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Sonaglioni A, Nicolosi GL, Esposito V, Bianchi S, Lombardo M. Prognostic indicators of persistent carotid intima-media thickness increase in postpartum period in a population of normotensive women with gestational diabetes mellitus. Eur J Obstet Gynecol Reprod Biol 2021; 269:47-54. [PMID: 34968874 DOI: 10.1016/j.ejogrb.2021.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/07/2021] [Accepted: 12/11/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The association between gestational diabetes mellitus (GDM) and common carotid artery (CCA)-intima media thickness (IMT) is still controversial. In the present study, we aimed to compare the CCA-IMT measured in GDM women to that obtained in healthy pregnant women in the third trimester of pregnancy. Secondly, we investigated the main independent predictors of persistent CCA-IMT increase (defined as CCA-IMT ≥ 0.6 mm) in postpartum period in GDM women. STUDY DESIGN 30 consecutive GDM women and 30 healthy pregnant women matched for anagraphic age (34.1 ± 4.5 vs 32.8 ± 4.2 yrs, p = 0.25), ethnicity (caucasian 56.7 vs 63.3%, p = 0.59), gestational age (36.2 ± 1.7 vs 36.5 ± 1.6 weeks, p = 0.48) and cardiovascular risk factors were examined in this prospective case-control study. All women underwent obstetric visit, blood tests, conventional transthoracic echocardiography implemented with two-dimensional speckle tracking echocardiography analysis of left ventricular and left atrial myocardial strain parameters and carotid ultrasound examination at two time points: 36-38 weeks' gestation and 6-10 weeks after delivery. RESULTS At 36.2 ± 1.7 weeks of gestation, CCA-IMT was significantly increased in GDM women than controls (0.81 ± 0.11 vs 0.55 ± 0.12, p < 0.001). Twelve GDM women (40% of the total) were found with persistent CCA-IMT increase (0.76 ± 0.14 mm) in postpartum period (8.2 ± 2.2 weeks), whereas the remaining 18 (60% of the total) showed a normalization in CCA-IMT (0.56 ± 0.1 mm). At multivariate logistic regression analysis, third trimester body mass index (BMI) (OR 1.78, 95%CI 1.24-2.54, p = 0.01), glycosylated hemoglobin (HbA1C) (OR 1.51, 95%CI 1.13-1.89, p = 0.03) and neutrophil-to-lymphocyte ratio (NLR) (OR 1.68, 95%CI 1.25-4.65, p = 0.02) resulted to be independently associated with persistent CCA-IMT increase in postpartum period in GDM women. A BMI ≥ 29.2 Kg/m2, an HbA1C ≥ 37.5 mmol/mol and a NLR ≥ 5.5 were the best cut-off values for identifying GDM women with persistent CCA-IMT increase in postpartum period. CONCLUSIONS GDM is associated with increased CCA-IMT during pregnancy. This increase may be persistent in postpartum period in GDM women with obesity, uncontrolled diabetes and increased inflammatory markers.
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Affiliation(s)
| | | | - Valentina Esposito
- Department of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
| | - Stefano Bianchi
- Department of Gynecology and Obstetrics, IRCCS MultiMedica, Milan, Italy
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Lorenzo-Almorós A, Hang T, Peiró C, Soriano-Guillén L, Egido J, Tuñón J, Lorenzo Ó. Predictive and diagnostic biomarkers for gestational diabetes and its associated metabolic and cardiovascular diseases. Cardiovasc Diabetol 2019; 18:140. [PMID: 31666083 PMCID: PMC6820966 DOI: 10.1186/s12933-019-0935-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/21/2019] [Indexed: 12/11/2022] Open
Abstract
Gestational diabetes mellitus (GDM) is defined as the presence of high blood glucose levels with the onset, or detected for the first time during pregnancy, as a result of increased insulin resistance. GDM may be induced by dysregulation of pancreatic β-cell function and/or by alteration of secreted gestational hormones and peptides related with glucose homeostasis. It may affect one out of five pregnancies, leading to perinatal morbidity and adverse neonatal outcomes, and high risk of chronic metabolic and cardiovascular injuries in both mother and offspring. Currently, GDM diagnosis is based on evaluation of glucose homeostasis at late stages of pregnancy, but increased age and body-weight, and familiar or previous occurrence of GDM, may conditionate this criteria. In addition, an earlier and more specific detection of GDM with associated metabolic and cardiovascular risk could improve GDM development and outcomes. In this sense, 1st-2nd trimester-released biomarkers found in maternal plasma including adipose tissue-derived factors such as adiponectin, visfatin, omentin-1, fatty acid-binding protein-4 and retinol binding-protein-4 have shown correlations with GDM development. Moreover, placenta-related factors such as sex hormone-binding globulin, afamin, fetuin-A, fibroblast growth factors-21/23, ficolin-3 and follistatin, or specific micro-RNAs may participate in GDM progression and be useful for its recognition. Finally, urine-excreted metabolites such as those related with serotonin system, non-polar amino-acids and ketone bodies, may complete a predictive or early-diagnostic panel of biomarkers for GDM.
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Affiliation(s)
- A Lorenzo-Almorós
- Renal, Vascular and Diabetes Laboratory, Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Av. Reyes Católicos 2, 28040, Madrid, Spain
| | - T Hang
- Renal, Vascular and Diabetes Laboratory, Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Av. Reyes Católicos 2, 28040, Madrid, Spain
| | - C Peiró
- Department of Pharmacology, School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - L Soriano-Guillén
- Department of Paediatrics, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - J Egido
- Renal, Vascular and Diabetes Laboratory, Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Av. Reyes Católicos 2, 28040, Madrid, Spain
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, Madrid, Spain
| | - J Tuñón
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Spain
| | - Ó Lorenzo
- Renal, Vascular and Diabetes Laboratory, Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Av. Reyes Católicos 2, 28040, Madrid, Spain.
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM) Network, Madrid, Spain.
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Wu P, Mamas MA, Gulati M. Pregnancy As a Predictor of Maternal Cardiovascular Disease: The Era of CardioObstetrics. J Womens Health (Larchmt) 2019; 28:1037-1050. [DOI: 10.1089/jwh.2018.7480] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Pensee Wu
- Keele Cardiovascular Research Group, Center for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- Academic Unit of Obstetrics and Gynecology, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Center for Prognosis Research, Institute of Primary Care and Health Sciences, University of Keele, Stoke-on-Trent, United Kingdom
- Academic Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
| | - Martha Gulati
- Division of Cardiology, University of Arizona, Phoenix, Arizona
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Contreras-Duarte S, Carvajal L, Fuenzalida B, Cantin C, Sobrevia L, Leiva A. Maternal Dyslipidaemia in Pregnancy with Gestational Diabetes Mellitus: Possible Impact on Foetoplacental Vascular Function and Lipoproteins in the Neonatal Circulation. Curr Vasc Pharmacol 2018; 17:52-71. [DOI: 10.2174/1570161115666171116154247] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 10/30/2017] [Accepted: 11/04/2017] [Indexed: 01/06/2023]
Abstract
Dyslipidaemia occurs in pregnancy to secure foetal development. The mother shows a physiological
increase in plasma total cholesterol and Triglycerides (TG) as pregnancy progresses (i.e. maternal
physiological dyslipidaemia in pregnancy). However, in some women pregnancy-associated dyslipidaemia
exceeds this physiological adaptation. The consequences of this condition on the developing
fetus include endothelial dysfunction of the foetoplacental vasculature and development of foetal aortic
atherosclerosis. Gestational Diabetes Mellitus (GDM) associates with abnormal function of the foetoplacental
vasculature due to foetal hyperglycaemia and hyperinsulinaemia, and associates with development
of cardiovascular disease in adulthood. Supraphysiological dyslipidaemia is also detected in
GDM pregnancies. Although there are several studies showing the alteration in the maternal and neonatal
lipid profile in GDM pregnancies, there are no studies addressing the effect of dyslipidaemia in the
maternal and foetal vasculature. The literature reviewed suggests that dyslipidaemia in GDM pregnancy
should be an additional factor contributing to worsen GDM-associated endothelial dysfunction by altering
signalling pathways involving nitric oxide bioavailability and neonatal lipoproteins.
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Affiliation(s)
- Susana Contreras-Duarte
- Cellular and Molecular Physiology Laboratory (CMPL), Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
| | - Lorena Carvajal
- Cellular and Molecular Physiology Laboratory (CMPL), Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
| | - Bárbara Fuenzalida
- Cellular and Molecular Physiology Laboratory (CMPL), Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
| | - Claudette Cantin
- Cellular and Molecular Physiology Laboratory (CMPL), Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
| | - Luis Sobrevia
- Cellular and Molecular Physiology Laboratory (CMPL), Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
| | - Andrea Leiva
- Cellular and Molecular Physiology Laboratory (CMPL), Division of Obstetrics and Gynaecology, School of Medicine, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago 8330024, Chile
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Brazeau AS, Meltzer SJ, Pace R, Garfield N, Godbout A, Meissner L, Rahme E, Da Costa D, Dasgupta K. Health behaviour changes in partners of women with recent gestational diabetes: a phase IIa trial. BMC Public Health 2018; 18:575. [PMID: 29716559 PMCID: PMC5930949 DOI: 10.1186/s12889-018-5490-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 04/20/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND We recently demonstrated that a gestational diabetes history in mothers is associated with higher postpartum incident diabetes not only in mothers but also in fathers. In the present study, we examined changes in health behaviours and cardiometabolic profiles in both mothers and partners who participated in a diabetes prevention program within 5 years of a gestational diabetes pregnancy. METHODS Couples were enrolled into a 13-week program that included 5 half-day group sessions and web/telephone-based support between sessions. It was designed in consultation with patients and previously studied in mothers. We computed mean changes from baseline (95% CI) for physical activity, eating, and sleep measures, and cardiometabolic parameters (fasting and 2-h post glucose load plasma glucose, BMI, blood pressure) in both partners and mothers. RESULTS Among 59 couples enrolled, 45 partners (76%) and 47 mothers (80%) completed final evaluations. Baseline cardiometabolic measures averaged within normal limits. Similar to mothers, partners increased physical activity (+ 1645 steps/day, 95%CI 730, 2561; accelerometer assessed moderate-to-vigorous physical activity + 36.4 min/week, 95% CI 1.4, 71.4) and sleep duration (+ 0.5 h/night, 95% CI 0.1, 0.9) and reduced the sodium-to-potassium ratio of food intake (- 0.09 95% CI -0.19, - 0.001). No conclusive changes were observed in glucose measures or insulin resistance; in analyses combining mothers and partners, systolic blood pressure decreased (- 2.7 mmHg, 95% CI -4.4, - 1.0). CONCLUSIONS Partners and mothers demonstrated improved physical activity, sleep, and dietary quality. Baseline cardiometabolic profiles averaged at normal values and there were no changes in glucose or insulin resistance; some blood pressure impact was observed. While strategies need to be developed to attract participants at higher cardiometabolic risk, this study demonstrates that partners of women within 5 years of a gestational diabetes diagnosis can be recruited and do achieve health behaviour change. TRIAL REGISTRATION ClinicalTrials.gov: NCT02343354 (date of registration: January 22, 2015).
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Affiliation(s)
| | - Sara J Meltzer
- Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Romina Pace
- Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Natasha Garfield
- Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Ariane Godbout
- Division of Endocrinology, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | | | - Elham Rahme
- Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Deborah Da Costa
- Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Kaberi Dasgupta
- Department of Medicine, McGill University, Montréal, Québec, Canada.
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Dehmer EW, Phadnis MA, Gunderson EP, Lewis CE, Bibbins-Domingo K, Engel SM, Jonsson Funk M, Kramer H, Kshirsagar AV, Heiss G. Association Between Gestational Diabetes and Incident Maternal CKD: The Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Kidney Dis 2018; 71:112-122. [PMID: 29128412 PMCID: PMC5742081 DOI: 10.1053/j.ajkd.2017.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 08/07/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is associated with increased risk for diabetes mellitus, metabolic syndrome, and cardiovascular disease. We evaluated whether GDM is associated with incident chronic kidney disease (CKD), controlling for prepregnancy risk factors for both conditions. STUDY DESIGN Prospective cohort. SETTING & PARTICIPANTS Of 2,747 women (aged 18-30 years) enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study in 1985 to 86, we studied 820 who were nulliparous at enrollment, delivered at least 1 pregnancy longer than 20 weeks' gestation, and had kidney function measurements during 25 years of follow-up. PREDICTOR GDM was self-reported by women for each pregnancy. OUTCOMES CKD was defined as the development of estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2 or urine albumin-creatinine ratio ≥ 25mg/g at any one CARDIA examination in years 10, 15, 20, or 25. MEASUREMENTS HRs for developing CKD were estimated for women who developed GDM versus women without GDM using complementary log-log models, adjusting for prepregnancy age, systolic blood pressure, dyslipidemia, body mass index, smoking, education, eGFR, fasting glucose concentration, physical activity level (all measured at the CARDIA examination before the first pregnancy), race, and family history of diabetes. We explored for an interaction between race and GDM. RESULTS During a mean follow-up of 20.8 years, 105 of 820 (12.8%) women developed CKD, predominantly increased urine albumin excretion (98 albuminuria only, 4 decreased eGFR only, and 3 both). There was evidence of a GDM-race interaction on CKD risk (P=0.06). Among black women, the adjusted HR for CKD was 1.96 (95% CI, 1.04-3.67) in GDM compared with those without GDM. Among white women, the HR was 0.65 (95% CI, 0.23-1.83). LIMITATIONS Albuminuria was assessed by single untimed measurements of urine albumin and creatinine. CONCLUSIONS GDM is associated with the subsequent development of albuminuria among black women in CARDIA.
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Affiliation(s)
- Elizabeth W Dehmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Milind A Phadnis
- Department of Biostatistics, University of Kansas School of Medicine, Kansas City, KS
| | - Erica P Gunderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Cora E Lewis
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kirsten Bibbins-Domingo
- Department of Medicine, University of California San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA
| | - Stephanie M Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Holly Kramer
- Division of Nephrology and Hypertension, Department of Public Health Sciences and Medicine, Loyola Medical Center, Maywood, IL
| | - Abhijit V Kshirsagar
- UNC Kidney Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gerardo Heiss
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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10
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Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, Hu FB, Manson JE, Zhang C. Association of History of Gestational Diabetes With Long-term Cardiovascular Disease Risk in a Large Prospective Cohort of US Women. JAMA Intern Med 2017; 177:1735-1742. [PMID: 29049820 PMCID: PMC5820722 DOI: 10.1001/jamainternmed.2017.2790] [Citation(s) in RCA: 171] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Previous studies identify gestational diabetes (GD) as a risk factor for intermediate markers of cardiovascular disease (CVD) risk; however, few are prospective, evaluate hard CVD end points, or account for shared risk factors including body weight and lifestyle. OBJECTIVE To prospectively evaluate history of GD in relation to incident CVD risk. DESIGN, SETTING, AND PARTICIPANTS The Nurses' Health Study II (NHS II) is an observational cohort study of US female nurses established in 1989, with ongoing follow-up. Biennial questionnaires updated behavioral characteristics, health outcomes, and lifestyle factors. Multivariable Cox models estimated the hazard ratio (HR) and 95% CI for CVD risk. We included 89 479 women who reported at least 1 pregnancy and were free of CVD and cancer at baseline. Follow-up through May 31, 2015, was complete for more than 90% of eligible participants. EXPOSURES History of GD was self-reported at baseline (1989) via questionnaire and updated every 2 years. MAIN OUTCOMES AND MEASURES We observed 1161 incident self-reported nonfatal or fatal myocardial infarction or stroke, confirmed via medical records. RESULTS Participants had a mean (SD) age of 34.9 (4.7) years. Adjusting for age, prepregnancy body mass index, and other covariates, GD vs no GD was associated with subsequent CVD (HR, 1.43; 95% CI, 1.12-1.81). Additional adjustment for weight gain since pregnancy and updated lifestyle factors attenuated the association (HR, 1.29; 95% CI, 1.01-1.65). Classifying GD by progression to T2D in relation to CVD risk indicated a positive association for GD with progression to T2D vs no GD or T2D (HR, 4.02; 95% CI, 1.94-8.31), and an attenuated relationship for GD only (HR, 1.30; 95% CI, 0.99-1.71). CONCLUSIONS AND RELEVANCE Gestational diabetes was positively associated with CVD later in life, although the absolute rate of CVD in this younger cohort of predominantly white women was low. This relationship is possibly mediated in part by subsequent weight gain and lack of healthy lifestyle.
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Affiliation(s)
- Deirdre K Tobias
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jennifer J Stuart
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Connors Center for Women's Health and Gender Biology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Shanshan Li
- Boston University School of Medicine, Boston, Massachusetts
| | - Jorge Chavarro
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eric B Rimm
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Janet Rich-Edwards
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Connors Center for Women's Health and Gender Biology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Frank B Hu
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - JoAnn E Manson
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Connors Center for Women's Health and Gender Biology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Cuilin Zhang
- Boston University School of Medicine, Boston, Massachusetts.,Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland
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11
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Is Uric Acid a Missing Link between Previous Gestational Diabetes Mellitus and the Development of Type 2 Diabetes at a Later Time of Life? PLoS One 2016; 11:e0154921. [PMID: 27166795 PMCID: PMC4864200 DOI: 10.1371/journal.pone.0154921] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/21/2016] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION A high level of uric acid (UA) is a strong, independent risk factor for type 2 diabetes mellitus. The relationship between UA levels and the development of type 2 diabetes in women with previous gestational diabetes mellitus (pGDM) remains unclear. The aim of study was to evaluate the UA levels in pGDM women in relation to their current nutritional status and carbohydrate metabolism. MATERIAL AND METHODS 199 women with pGDM diagnoses based on oral glucose tolerance tests (OGTTs) 5-12 years previously and a control group of 50 women without pGDM. The assessment included anthropometric parameters, body composition (Tanita SC-330S), current OGTT, insulin resistance index (HOMA-IR), β-cell function (HOMA-%B), HbA1c, lipids, and uric acid. RESULTS No differences between groups were found in terms of age, time from the index pregnancy, anthropometric parameters, lipids or creatinine levels. The incidences of overweight and obesity were similar. Carbohydrate abnormalities were more frequent in the pGDM group than the control group (43.2% vs 12.0% p<0.001). The women with pGDM had significantly higher fasting glucose, HbA1c, glucose and insulin levels in the OGTTs, but similar HOMA-IR values. Their UA levels were significantly higher (258±58 vs 230±50 μmol/L, p<0.005) and correlated with BMI and the severity of carbohydrate disorders. The normal weight and normoglycemic pGDM women also demonstrated higher UA levels than a similar control subgroup (232±48 vs 208±48 μmol/L, p<0.05). Multivariate analysis revealed significant correlations of UA level with BMI (β = 0.38, 95% CI 0.25-0.51, p<0.0001), creatinine level (β = 0.23, 95% CI 0.11-0.35, p<0.0005), triglycerides (β = 0.20, 95% CI 0.07-0.33, p<0.005) and family history of diabetes (β = 0.13, 95% CI 0.01-0.25, p<0.05). In logistic regression analysis, the association between higher UA level (defined as value ≥297 μmol/L) and presence of any carbohydrate metabolism disorder (IFG, IGT or diabetes) was statistically significant (odds ratio 3.62 [95% CI 1.8-7.3], p<0.001). CONCLUSIONS Higher UA levels may be associated with the development of type 2 diabetes in pGDM women, also in these with normal body weights.
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12
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Chandler-Laney PC, Shepard DN, Schneider CR, Flagg LA, Granger WM, Mancuso MS, Biggio JR, Gower BA. Relatively Low β-Cell Responsiveness Contributes to the Association of BMI with Circulating Glucose Concentrations Measured under Free-Living Conditions among Pregnant African American Women. J Nutr 2016; 146:994-1000. [PMID: 27052534 PMCID: PMC4841920 DOI: 10.3945/jn.115.222877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 02/17/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Body mass index (BMI, in kg/m(2)) is positively associated with plasma glucose in late pregnancy and with risk of adverse obstetric outcomes. Much of the existing research uses single-clinic measures of plasma glucose, which may not accurately reflect circulating glucose under free-living conditions. Furthermore, little is known about circulating glucose concentrations of African American women, who tend to have poorer diet quality and a greater risk of obstetric complications. OBJECTIVE The objective of the study was to test the hypothesis that the positive association of BMI in early pregnancy with third-trimester circulating glucose concentrations measured under free-living conditions among African American women would be at least partially attributable to lower β-cell insulin secretion relative to insulin sensitivity [i.e., lower disposition index (DI)]. METHODS Using a prospective, observational design, 40 pregnant African American women (mean ± SD age: 23.1 ± 4.0 y; mean ± SD BMI: 28.4 ± 7.5) wore continuous glucose monitors and accelerometers for 3 d at 32-35 wk of gestation and concurrently maintained a food diary to report their self-selected meals. The DI was derived from a 75-g oral glucose tolerance test. Linear regression modeling was used to calculate the association of BMI with the 24-h glucose (GLUC24h) and 2-h (GLUC2hPP) postprandial glucose areas under the curve and with the percentage of time the glucose concentrations were >120 mg/dL. RESULTS The positive associations between BMI and GLUC24h (standardized β = 0.36, P = 0.03) and the percentage of time glucose concentrations were >120 mg/dL (standardized β = 0.40, P = 0.02) were independent of total carbohydrate intake and physical activity and were attenuated when DI was added to the model. The positive association of BMI with GLUC2hPP was attenuated when DI was added to the model, and DI itself was independently associated with GLUC2hPP after self-selected breakfast and dinner (standardized β = -0.33 and -0.42, respectively; P = 0.01). CONCLUSIONS The association of BMI with high circulating glucose in free-living pregnant African American women is at least partially attributable to lower β-cell responsiveness.
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Affiliation(s)
| | | | | | | | | | - Melissa S Mancuso
- Obstetrics and Gynecology, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
| | - Joseph R Biggio
- Obstetrics and Gynecology, Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
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13
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Goueslard K, Cottenet J, Mariet AS, Giroud M, Cottin Y, Petit JM, Quantin C. Early cardiovascular events in women with a history of gestational diabetes mellitus. Cardiovasc Diabetol 2016; 15:15. [PMID: 26817691 PMCID: PMC4728938 DOI: 10.1186/s12933-016-0338-0] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/14/2016] [Indexed: 12/25/2022] Open
Abstract
Background The effect of gestational diabetes mellitus (GDM) on cardiovascular diseases (CVD) is not assessed within the first 10 years postpartum, regardless of subsequent diabetes. The aim of this study was to determine the risk of CVD events related to GDM within 7 years of postpartum. Methods This nationwide population-based study of deliveries in 2007 and 2008 with a follow-up of 7 years was based on data from the French medico-administrative database. Two groups were formed: women with a history of GDM and women without GDM or previous diabetes. CVD included angina pectoris, myocardial infarction, stroke, heart bypass surgery, coronary angioplasty, carotid endarterectomy and fibrinolysis. Hypertensive disease was assessed separately. Determinants studied included age, obesity, subsequent diabetes mellitus and hypertensive diseases during pregnancy. Adjusted odds ratios for outcomes were calculated using multiple logistic regressions. Results The hospital database recorded 1,518,990 deliveries in 2007 and 2008. Among these, 62,958 women had a history of GDM. After adjusting for age, DM, obesity and hypertensive disorders in pregnancy, GDM was significantly associated with a higher risk of CVD (adjusted Odds Ratio aOR = 1.25 [1.09–1.43]). Considering each variable in a separate model, GDM was associated with angina pectoris (aOR = 1.68 [1.29–2.20]), myocardial infarction (aOR = 1.92 [1.36–2.71]) and hypertension (aOR = 2.72 [2.58–2.88]) but not with stroke. Conclusions A history of GDM was identified as a risk factor of CVD, especially coronary vascular diseases, within the 7 years postpartum. A lifestyle changes from postpartum onwards can be recommended and supported.
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Affiliation(s)
- Karine Goueslard
- CHRU Dijon, Service de Biostatistique et d'Informatique Médicale (DIM), Université de Bourgogne, 21000, Dijon, France.
| | - Jonathan Cottenet
- CHRU Dijon, Service de Biostatistique et d'Informatique Médicale (DIM), Université de Bourgogne, 21000, Dijon, France.
| | - Anne-Sophie Mariet
- CHRU Dijon, Service de Biostatistique et d'Informatique Médicale (DIM), Université de Bourgogne, 21000, Dijon, France.
| | - Maurice Giroud
- Registre dijonnais des AVC, INSERM, INVS, EA4184, Univ. Bourgogne Franche-Comté, 21000, Dijon, France.
| | - Yves Cottin
- Service de Cardiologie, CHRU Dijon, 21000, Dijon, France.
| | - Jean-Michel Petit
- Centre de Recherche INSERM Unité 866, Univ. Bourgogne Franche-Comté, 21000, Dijon, France. .,Services de diabétologie et endocrinologie, CHRU Dijon, 21000, Dijon, France. .,Centre Hospitalier Universitaire, BP 77908, 21079, Dijon Cedex, France.
| | - Catherine Quantin
- CHRU Dijon, Service de Biostatistique et d'Informatique Médicale (DIM), Université de Bourgogne, 21000, Dijon, France. .,Clinical Investigation Center, clinical epidemiology/clinical trials unit, INSERM CIC 1432, Dijon University Hospital, 21000, Dijon, France. .,INSERM, UMR1181, Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), Univ. Bourgogne Franche-Comté, 21000, Dijon, France.
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14
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Gongora MC, Wenger NK. Cardiovascular Complications of Pregnancy. Int J Mol Sci 2015; 16:23905-28. [PMID: 26473833 PMCID: PMC4632731 DOI: 10.3390/ijms161023905] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023] Open
Abstract
Pregnancy causes significant metabolic and hemodynamic changes in a woman's physiology to allow for fetal growth. The inability to adapt to these changes might result in the development of hypertensive disorders of pregnancy (hypertension, preeclampsia or eclampsia), gestational diabetes and preterm birth. Contrary to previous beliefs these complications are not limited to the pregnancy period and may leave permanent vascular and metabolic damage. There is in addition, a direct association between these disorders and increased risk of future cardiovascular disease (CVD, including hypertension, ischemic heart disease, heart failure and stroke) and diabetes mellitus. Despite abundant evidence of this association, women who present with these complications of pregnancy do not receive adequate postpartum follow up and counseling regarding their increased risk of future CVD. The postpartum period in these women represents a unique opportunity to intervene with lifestyle modifications designed to reduce the development of premature cardiovascular complications. In some cases it allows early diagnosis and treatment of chronic hypertension or diabetes mellitus. The awareness of this relationship is growing in the medical community, especially among obstetricians and primary care physicians, who play a pivotal role in detecting these complications and assuring appropriate follow up.
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Affiliation(s)
- Maria Carolina Gongora
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Nanette K Wenger
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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