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Higher blood pressure prior to pregnancy is associated with increased risk of placental abruption, hypertension and preeclampsia, preterm delivery and fetal growth restriction. These conditions are jointly termed placental syndromes as they are characterised by impaired placentation and early placental vascularization. Placental syndromes are associated with an increased maternal risk of progression to hypertension and cardiovascular disease (CVD) in later life. Women affected by both a clinical placental syndrome and with evidence of placental maternal vascular malperfusion (MVM) have a particularly high risk of hypertension and CVD. Yet whether placental impairment and clinical syndromes are causes or consequences of higher blood pressure in women remains unclear. In this review, we address the relationship between blood pressure and maternal health in pregnancy. We conclude that there is a pressing need for studies with a range of detailed measures of cardiac and vascular structure and function taken before, during and after pregnancy to solve the ‘chicken and egg’ puzzle of women’s blood pressure and pregnancy health, and to inform effective precision medicine prevention and treatment of both placental syndromes and chronic hypertension in women.

Growing evidence indicates that women with a history of common pregnancy complications, including fetal growth restriction and preterm delivery (often combined as low birth weight), hypertensive disorders of pregnancy, and gestational diabetes, are at increased risk for cardiovascular disease later in life. The purpose of this paper was to review the associations of parity and these 4 pregnancy complications with cardiovascular morbidity and mortality; to review the role of cardiovascular risk factors before, during, and after pregnancy complications in explaining these associations; and to explore the implications of this emerging science for new research and policy. We systematically searched for relevant cohort and case-control studies in Medline through December 2012 and used citation searches for already published reviews to identify new studies. The findings of this review suggest consistent and often strong associations of pregnancy complications with latent and future cardiovascular disease. Many pregnancy complications appear to be preceded by subclinical vascular and metabolic dysfunction, suggesting that the complications may be useful markers of latent high-risk cardiovascular trajectories. With further replication research, these findings would support the utility of these prevalent pregnancy complications in identifying high-risk women for screening, prevention, and treatment of cardiovascular disease, the leading cause of morbidity and mortality among women.

Purpose of ReviewTo review the postpartum management of hypertensive disorders of pregnancy.Recent FindingsHypertensive disorders are associated with an increased risk of future cardiovascular disease; however, there is a poor understanding of the underlying mechanisms and few recommendations to guide care in the postpartum period. Recent studies have shown high rates of masked hypertension and home blood pressure monitoring in the first year postpartum may be a promising opportunity to monitor health given evidence of high maternal adherence to this approach. In longer term, women with a history of a hypertensive disorder of pregnancy have higher blood pressures, increased risk of metabolic syndrome, and perhaps excess diastolic dysfunction. Triaging risk and improving handoff from the obstetrician to the primary care provider or subspecialist should be a priority in this population.SummaryHypertensive disorders of pregnancy remain an untapped opportunity to identify excess cardiovascular risk in affected women at a time when mitigating that risk during the reproductive years has the potential to improve future pregnancy health as well as improve women’s long-term cardiometabolic health.

Despite numerous studies of air pollution and adverse birth outcomes, few studies have investigated preeclampsia and gestational hypertension, two pregnancy disorders with serious consequences for both mother and infant. Relying on hospital birth records, we conducted a cohort study identifying 34,705 singleton births delivered at Magee-Women’s Hospital in Pittsburgh, PA between 1997 and 2002. Particle (<10 μm-PM 10 ; <2.5 μm-PM 2.5 ) and ozone (O 3 ) exposure concentrations in the first trimester of pregnancy were estimated using the space–time ordinary Kriging interpolation method. We employed multiple logistic regression estimate associations between first trimester exposures and preeclampsia, gestational hypertension, preterm delivery, and small for gestational age (SGA) infants. PM 2.5 and O 3 exposures were associated with preeclampsia (adjusted OR = 1.15, 95 % CI = 0.96–1.39 per 4.0 μg/m 3 increase in PM 2.5 ; adjusted OR = 1.12, 95 % CI = 0.89–1.42 per 16.8 ppb increase in O 3 ), gestational hypertension (for PM 2.5 OR = 1.11, 95 % CI = 1.00–1.23; for O 3 OR = 1.12, 95 % CI = 0.97–1.29), and preterm delivery (for PM 2.5 ORs = 1.10, 95 % CI = 1.01–1.20; for O 3 ORs = 1.23, 95 % CI = 1.01–1.50). Smaller 5–8 % increases in risk were also observed for PM 10 with gestational hypertension and SGA, but not preeclampsia. Our data suggest that first trimester exposure to particles, mostly PM 2.5 , and ozone, may increase the risk of developing preeclampsia and gestational hypertension, as well as preterm delivery and SGA.

Background: We sought to determine the association between maternal vitamin D status at ≤26 weeks' gestation and the risk of preeclampsia by clinical subtype. Methods: We conducted a case–cohort study among women enrolled at 12 US sites from 1959 to 1966 in the Collaborative Perinatal Project. In serum collected at ≤26 weeks' gestation (median 20.9 weeks) from 717 women who later developed preeclampsia (560 mild and 157 severe cases) and from 2986 mothers without preeclampsia, we measured serum 25-hydroxyvitamin D, over 40 years later, using liquid chromatography–tandem mass spectrometry. Results: Half of women in the subcohort had 25-hydroxyvitamin D (25(OH)D) >50 nmol/L. Maternal 25(OH)D 50 to 74.9 nmol/L was associated with a reduction in the absolute and relative risk of preeclampsia and mild preeclampsia compared with 25(OH)D <30 nmol/L in the crude analysis but not after adjustment for confounders, including race, prepregnancy body mass index, and parity. For severe preeclampsia, 25(OH)D ≥50 nmol/L was associated with a reduction in three cases per 1000 pregnancies (adjusted risk difference = −0.003 [95% confidence interval = −0.005 to 0.0002]) and a 40% reduction in risk (0.65 [0.43 to 0.98]) compared with 25(OH) D <50 nmol/L. Conclusions were unchanged (1) after restricting to women with 25(OH)D measured before 22 weeks' gestation or (2) with formal sensitivity analyses for unmeasured confounding. Conclusions: Maternal vitamin D deficiency may be a risk factor for severe preeclampsia but not for its mild subtypes. Contemporary cohorts with large numbers of severe preeclampsia cases would be needed to confirm or refute these findings.

Per- and polyfluoroalkyl substances (PFAS) have been found to be associated with gestational diabetes mellitus (GDM) development, a maternal health disorder in pregnancy with negative effects that can extend beyond pregnancy. Studies that report on this association are difficult to summarize due to weak associations and wide confidence intervals. One way to advance this field is to sharpen the biologic theory on a causal pathway behind this association, and to measure it directly by way of molecular biomarkers. The aim of this review is to summarize the literature that supports a novel pathway between PFAS exposure and GDM development. Epidemiological studies demonstrate a clear association of biomarkers of thyroid hormones and glucose metabolism with GDM development. We report biologic plausibility and epidemiologic evidence that PFAS dysregulation of maternal thyroid hormones and thyrotropin (TSH) may disrupt glucose homeostasis, increasing the risk of GDM. Overall, epidemiological studies demonstrate that PFAS were positively associated with TSH and negatively with triiodothyronine (T3) and thyroxine (T4). PFAS were generally positively associated with glucose and insulin levels in pregnancy. We propose dysregulation of thyroid function and glucose metabolism may be a critical and missing component in the accurate estimation of PFAS on the risk of GDM.

Background Evidence of placental maternal vascular malperfusion is associated with significant perinatal outcomes such as preeclampsia, intrauterine growth restriction and preterm birth. Elevations in pre-pregnancy blood pressure increase the risk for poor perinatal outcomes; however, the evidence linking pre-pregnancy blood pressure and placental malperfusion is sparse. Materials and methods We conducted a retrospective case-control study of women with singleton gestations with placental evaluations who delivered at Magee-Womens Hospital in 2012. Charts from 100 deliveries with placental malperfusion lesions (vasculopathy, advanced villous maturation, infarct, or fibrin deposition) and 102 deliveries without placental malperfusion were randomly selected for screening. Blood pressure, demographic, and clinical data were abstracted from pre-pregnancy electronic medical records and compared between women with and without subsequent placental malperfusion lesions. Results Overall, 48% of women had pre-pregnancy records, and these were similarly available for women with and without placental malperfusion. Women with placental malperfusion demonstrated a reduction in their pre- to early pregnancy decrease in diastolic blood pressure (DBP). Adjusted for race, pre-pregnancy BMI, age, pre-conception interval, and gestational age at the first prenatal visit, the difference in pre- to early pregnancy DBP was significantly less in women with placental malperfusion compared to those without this pathologic finding (− 1.35 mmHg drop vs − 5.6mmg, p  < 0.05). Conclusion A blunted early gestation drop in DBP may be a risk factor for placental malperfusion, perhaps related to early pregnancy vascular maladaptation. The ability of the electronic medical record to provide pre-pregnancy data serves as an underutilized approach to study pre-pregnancy health.

Background: Prepregnancy overweight is a risk factor for mild preeclampsia and mild transient hypertension of pregnancy. Its association with severe subtypes of these disorders has received less attention. Methods: To assess the association of prepregnancy body mass index (BMI) with severe and mild preeclampsia and transient hypertension of pregnancy, we used data from a 1958-1964 prospective cohort study of 38,188 pregnant women receiving care at 12 U.S. hospitals. Results: There was a monotonic, dose-response relation between prepregnancy BMI and risk of both severe and mild preeclampsia, as well as the risk of severe and mild transient hypertension of pregnancy. Compared with white women with a BMI of 20, the odds ratios for severe preeclampsia at BMI values of 25 and 30 in white women were 1.7 (95% confidence interval = 1.1-2.5) and 3.4 (2.1-5.6), respectively, and 2.1 (1.4-3.2) and 3.2 (2.1-5.0) in black women. The effect of BMI on risk of severe preeclampsia was similar to its effect on mild disease. Compared with the same referent, odds ratios for severe transient hypertension of pregnancy at BMI values of 25 and 30 in white women were 3.6 (2.0-6.5) and 8.8 (4.4-18), respectively, and 3.0 (1.6-5.8) and 4.9 (2.5-9.6) in black women. Overweight was a stronger risk factor for severe than for mild transient hypertension. Conclusions: Incidence of both mild and severe hypertensive disorders of pregnancy rises with increasing BMI. Escalating obesity rates may increase pregnancy hypertensive disorders and ensuing perinatal morbidity.

Pregnant individuals rarely achieve moderate-to-vigorous intensity physical activity recommendations. Purpose The sedentary behavior reduction in pregnancy intervention (SPRING) pilot and feasibility randomized trial aimed to demonstrate feasibility, acceptability, and initial efficacy of a lower intensity intervention targeting reduced sedentary behavior and increased standing and steps. Methods First trimester pregnant individuals at risk for high sedentary behavior and adverse pregnancy outcomes (APO) were randomized 2:1 to a multi-component sedentary behavior reduction intervention or no-contact control. Intervention components included biweekly remote health coaching, wearable activity monitor, height-adjustable workstation, and a private Facebook group. Evidence-based behavioral targets included sedentary time < 9 h/day, increasing standing by 2–3 h/day, and ≥ 7500 steps/day. Participants completed all-remote assessments (baseline, second trimester, third trimester) of sedentary behavior and activity (thigh-worn activPAL) along with exploratory pregnancy health outcomes abstracted from medical records. Intervention effects vs. control were evaluated using generalized mixed models and an intention-to-treat approach. Intervention participants also provided feedback on perceived benefits and acceptability. Results Participants (34 intervention; 17 control) had mean age 32 years, were 83% White, with mean pre-pregnancy BMI 28 kg/m 2 . Retention was high (90% and 83% at second and third trimester follow-up visits). Intervention participants decreased sedentary time (-0.84 h/day, p  = 0.019) and increased standing (+0.77 h/day, p  = 0.003), but did not increase steps/day (+710, p  = 0.257) compared to controls. Intervention participants reported many perceived benefits and identified the wearable, height-adjustable workstation, and behavioral lessons as most useful. Conclusion For pregnant individuals at risk for high sedentary behavior and APOs, a sedentary behavior reduction intervention is feasible, acceptable, and may offer a viable alternative to more intense physical activity recommendations during pregnancy. Further testing in a fully powered clinical trial is warranted. Trial registration NCT05093842 on clinicaltrials.gov

Background Although leisure-time physical activity (PA) contributes to overall health, including pregnancy health, patterns across pregnancy have not been related to birth outcomes. We hypothesized that women with sustained low leisure-time PA would have excess risk of adverse pregnancy outcomes, and that changing patterns across pregnancy (high to low and low to high) may also be related to risk of adverse pregnancy outcomes. Methods Nulliparous women ( n  = 10,038) were enrolled at 8 centers early in pregnancy (mean gestational age in weeks [SD] = 12.05 [1.51]. Frequency, duration, and intensity (metabolic equivalents) of up to three leisure activities reported in the first, second and third trimesters were analyzed. Growth mixture modeling was used to identify leisure-time PA patterns across pregnancy. Adverse pregnancy outcomes (preterm birth, [PTB, overall and spontaneous], hypertensive disorders of pregnancy [HDP], gestational diabetes [GDM] and small-for-gestational-age births [SGA]) were assessed via chart abstraction. Results Five patterns of leisure-time PA across pregnancy were identified: High (35%), low (18%), late decreasing (24%), early decreasing (10%), and early increasing (13%). Women with sustained low leisure-time PA were younger and more likely to be black or Hispanic, obese, or to have smoked prior to pregnancy. Women with low vs. high leisure-time PA patterns had higher rates of PTB (10.4 vs. 7.5), HDP (13.9 vs. 11.4), and GDM (5.7 vs. 3.1, all p  < 0.05). After adjusting for maternal factors (age, race/ethnicity, BMI and smoking), the risk of GDM (Odds ratio 2.00 [95% CI 1.47, 2.73]) remained higher in women with low compared to high patterns. Early and late decreasing leisure-time PA patterns were also associated with higher rates of GDM. In contrast, women with early increasing patterns had rates of GDM similar to the group with high leisure-time PA (3.8% vs. 3.1%, adjusted OR 1.16 [0.81, 1.68]). Adjusted risk of overall PTB (1.31 [1.05, 1.63]) was higher in the low pattern group, but spontaneous PTB, HDP and SGA were not associated with leisure-time PA patterns. Conclusions Sustained low leisure-time PA across pregnancy is associated with excess risk of GDM and overall PTB compared to high patterns in nulliparous women. Women with increased leisure-time PA early in pregnancy had low rates of GDM that were similar to women with high patterns, raising the possibility that early pregnancy increases in activity may be associated with improved pregnancy health. Trial registration Registration number NCT02231398 .