complications of pregnancy and lifetime risk to … · complications of pregnancy and lifetime ......

Complications of

Pregnancy and Lifetime

Risk to Health Brian McCulloch MD

Advocate Lutheran General Hospital

September 26, 2015

Pregnancy as a window to future health

In 2005 the CDC stated that almost 1 in every 2 adults had at least one

chronic illness

There are three time periods where a women has to enters into health care

on a regular basis : as an infant, for pregnancy and when she develops a

chronic disease.

Health education and prevention of these chronic diseases will be the task as

we move forward.

But first we have to identify those at risk

With pregnancy you have a trapped

population

To not seek prenatal care would be not acceptable by our society

How to use that time to educate, identify problems and direct the patient

and introduce the offspring to the health care system is extremely important

On average there are about 10 prenatal visits routinely covered for global

care

There are usually monthly visits up till 28 weeks and biweekly to 36 weeks

and then weekly till delivery.

Women’s health care

What we’ll be talking about

Definition of gestational diabetes

Screening after gestational diabetes

Long term maternal outcome after gestational diabetes

Fetal / childhood/ adult outcome after gestational diabetes

Gestational hypertension, Chronic hypertension and Preeclampsia Definitions

Long term outcome after preeclampsia

Weight gain and obesity in pregnancy

Maternal long term outcome

I want to start back in the recent past :

1964 with glucose testing

John O’Sullivan published on 752 pregnant women who had 100 gram glucose

screening in 1964

Initially he established the screening guidelines that everyone could agree on

and became our diabetic screening in pregnancy

They did this to improve perinatal outcome and lower the rate of macrosomia

(large fetus) and thereby improve perinatal morbidity and mortality.

He had a stable population in his area in Boston and he did long term follow

up

This started as far back as 1964 with

glucose testing

He later showed that in ten years there was the asymptote (the statistical

peak at which diabetes will show up in the population)

Using his criteria he predicted there would be about a 50 % risk of diabetes

postpartum and it peaked at 10 years

Gestational diabetes

ACOG 2013 practice bulletin

All women should get screened

Usually a two step process

A one hour screen with glucose level less than 130 - 140 mg/dl

If elevated than a 3 hour testing should be done with:

Fasting < 95

One hour <180

Two hour <155

Three hour<140

Gestational Diabetes is estimated to complicate about 6-7 % of pregnancies

ACOG 2103: practice bulletin

Should be seen and consulted by a register Dietician

Started on a diet:

33 -40 % CHO

20 % protein

40 % fat

Blood sugars should be checked fasting and 2 hours after eating

With ideal: fasting < 90

2 hour <120

One step screening

Fasting serum blood sugar then 75 gram load

And if one value elevated then label it diabetes

Cut off values : Fasting< 92

One hour <180

Two hour <153

Very high failure rate 18 %

So not universally accepted

Post partum follow up

Screening should be at 6-12 weeks

Fasting blood sugar (easier to perform)

or 75 gram glucose with 2 hour (higher sensitivity)

Up to one third of GDM’s will have impaired glucose metabolism

15 to 50% will develop type 2 diabetes later in life

ADA recommends screening every 3 years

90% of women with a history of

Gestational diabetes recognize it

as a risk factor for type 2

diabetes, but only 16% felt they

themselves were at risk

Swedish study

18 year old males

Registration data for the military

Had info on brothers

Association of maternal diabetes mellitus in

pregnancy with offspring adiposity into early

adulthood Circulation 2011 Results :

Maternal early pregnancy BMI was weakly positively associated with birth

weight and moderately associated with offspring BMI at age 18.

Maternal early pregnancy BMI was positively associate with odds of Diabetes

mellitus in pregnancy.

There is evidence that greater amniotic fluid and cord blood insulin levels are

related to later offspring adiposity.

The does appear to be an inutero mechanism to explain elevated BMI beyond

the familial cofounding mechanism.

There has been many more medical

relationships identified in pregnancy

over the next 40+ years

There was a big interest with the 2011 update Guidelines from the

American heart association published in the journal Circulation.

Effectiveness-Based Guidelines

for the Prevention of

Cardiovascular Disease in

Women—2011 Update

A Guideline From the American

Heart Association

Published OnLine Feb 16, 2011

Cardiovascular disease

Cardiovascular disease has been identified as a women's disease also not just

a man’s disease.

There was a downward trend in female cardiovascular disease till 2008 but

now that is rising again paralleling the obesity epidemic

Obesity

Facts from the WHO (updated March 2013)

Obesity has almost doubled since 1980 worldwide

2008: 1.4 billion adults were overweight (35%), 500 million were obese (11%) (age 20 and over)

300 million women were obese

More than 40 million children under the age of five were overweight in 2011

Care Implications in the Setting of

Obesity in Pregnancy

Copyright © 2009 Wolters Kluwer. 5

FIGURE 2.

DIABETES BEGETS DIABETES

How Does Ob Care Contribute to Obesity

Crisis?

Yet a normal fetus/placenta/AF only accounts for 10-15# of weight

Implications of IOM Recommendations

Decreases incidence of SGA infants

Does not look at excessive LGA rates

Does not look at weight retention by mothers

Recommend increased weight gain for teens and Blacks

due to risk of SGA – BUT these groups at increase risk of

significant obesity

Obesity in the reproductive age

From 1980 to 1999 – increases in:

Mean maternal weight increased by 20% (144 to 172lbs)

Saw increases in:

Percentage of women ≥200lb (7.3 24.4%)



Percentage with a BMI >29 (16.3 36.4%)

Lu GC et al, Gray Journal (American Journal of Obstetrics and Gynecology), 2001, in

Birmingham, Alabama

Definition of obesity based on BMI

(kg/m2)

<18.5 Underweight

18.5 – 24.9 Normal Weight

25 – 29.9 Overweight

≥ 30 Obese

–30 – 34.9 Class I

–35 – 39.9 Class II

–≥ 40 Class III

Correlates well with fat mass

Healthcare professionals who meet women for the first time later in their lives

should take a careful and detailed history of pregnancy complications with

focused questions about a history of gestational diabetes mellitus,

preeclampsia, preterm birth, or birth of an infant small for gestational age

Appropriate referral postpartum by the obstetrician to a primary care physician

or cardiologist should occur so that in the years after pregnancy risk factors can

be carefully monitored and controlled

Nutrition is important for both

short- and long-term health

Barker hypothesis – fetal origins (Twenty years ago, he showed for the first time- that people who had low birth weight are at greater risk of developing coronary heart disease.)

“thrifty phenotype” The thrifty phenotype hypothesis

suggests that early-life metabolic adaptations help in survival of the organism by selecting an appropriate trajectory of growth in response to environmental cues. Recently, some scientists have proposed that the thrifty phenotype prepares the organism for its likely adult environment in long term.

Healthcare professionals who meet women for the first time later in their lives

should take a careful and detailed history of pregnancy complications with

focused questions about a history of gestational diabetes mellitus, preeclampsia,

preterm birth, or birth of an infant small for gestational age

Appropriate referral postpartum by the obstetrician to a primary care physician or

cardiologist should occur so that in the years after pregnancy risk factors can be

carefully monitored and controlled

What is preeclampsia ?

In 2013 ACOG put out a booklet about 40 pages and cited 124

reference articles : Hypertension in pregnancy

They defined preeclampsia as a pregnancy –specific hypertensive

disease with multisystem involvement

Most often at term

Can be superimposed on another hypertensive disorder like CHTN

Preeclampsia

New onset hypertension

New onset of proteinuria

However There can be multisystem organ involvement

Defined as platelet count less than 100,000

Elevated LFT’s ( 2 times the normal )

Renal insufficiency serum creatinine of >1.1

Pulmonary edema

Headache with visual disturbances

Preeclampsia:

Hypertension definitions

Hypertension is defined as greater than 140 systolic and or

a diastolic blood pressure of greater than 90.

Proteinuria is defined as 300 mg/dl protein in a 24 hour

collection or a protein to creatinine ratio on a urine

specimen exceeding 3.0 mg/dl

Hypertension in pregnancy taskforce

2013 terminology recommendations

Use the term preeclampsia without severe features or

Preeclampsia with severe features

We should not use the terms mild preeclampsia or severe

preeclampsia

Hypertension in pregnancy taskforce

2013 recommendations

Chronic hypertension elevated BP’s before pregnancy or before 20 weeks

gestation

Chronic hypertension with superimposed preeclampsia

(preeclampsia occurs 4-5 times higher in this patient group )

Gestational hypertension – new onset BP elevation after 20 weeks

Postpartum hypertension

Preeclampsia and risk of cardiovascular

disease and cancer in later life Bellamy,L BMJ 2007

Increased risk of HTN ………………

Ischemic heart disease…………….

Increased stroke risk ………………..

Increased DVT risk …………………..

RR 3.70 at 14.1 years




What Is Relative Risk

The probability of an event occurring

RELATIVE RISK

RISK DISEASE PRESENT DISEASE ABSENT

SMOKER A B

NON-SMOKER C D

RELATIVE RISK = A/A+B

C/C+D

A RELATIVE RISK GREATER THAN 1 MEANS

THE DISEASE IS MORE LIKELY TO OCCUR IN

THE EXPERIMENTAL GROUP THAN THE

CONTROL

PREECLAMPSIA AND CANCER RISK

Overall there was no increased risk of

cancer including breast cancer

17 years after preeclampsia.

METABOLIC SYNDROME

Metabolic syndrome (aka Syndrome X - dyslipidemia, hypertension,

hyperglycemia commonly cluster together.

This clustering he called Syndrome X)

*ATP III1 identified 6 components of the metabolic syndrome that relate to

CVD:

Abdominal obesity

Atherogenic dyslipidemia

Raised blood pressure

Insulin resistance ± glucose intolerance

Proinflammatory state

Prothrombotic state

*The National Cholesterol Education Program’s Adult Treatment Panel III

report (ATP III)

METABOLIC SYNDROME

35% of woman

Native Americans highest risk at 60% of woman between

45-49

Less than 10% in France, until 60 years of age when risk

hits 18%

Those with the syndrome have the highest risk of heart

disease

Effectiveness-Based Guidelines

for the Prevention of

Cardiovascular Disease in

Women—2011 Update

A Guideline From the American

Heart Association

Published OnLine Feb 16, 2011

Pregnancy loss and later risk of

atherosclerotic disease circulation 2013

Population based cohort study with long term follow up in Denmark

1997 to 2008 greater than 1 million women studied

> 1 Stillborn then IRR was 2.69 for MI,

1.74 for cerebral infarct ,and

2.42 for renovascular hypertension

> 1 Miscarriage then IRR was 1.13 for MI

1.16 cerebral infarcts

1.20renovascular hypertension

IRR( incidence rate ratios)

Brisbane England 1981 - 1984

8456 Mothers Interviewed 4 times: first prenatal visit

3-5 days after birth

6 months after birth

5 years after birth

Physical exam of the child at 5 years of age

47 % loss to follow up

Results :Smoking ,paternal weight /BMI ,shorter breast fed children all had

higher blood pressure but only 0.92 mmHg

Women's Health

Cardiovascular sequelae of

preeclampsia/eclampsia:

A systematic review and meta-analyses Sarah D. McDonald, MD,

Women's Health



A systematic review and meta-analyses Sarah D. McDonald, MD, MSc,a Ann Malinowski, MSc, MD,b Qi Zhou, PhD,c Salim Yusuf, MD, PhD,d,e

and Philip J. Devereaux, MD, PhDc,d Hamilton, Ontario, Canada am Heart J 2008

Five case-control and 10 cohort studies met eligibility criteria, with

a total of 116,175 women with and

2,259,576 women without preeclampsia/eclampsia.



A systematic review and meta-analyses

Sarah D. McDonald, MD, Hamilton, Ontario

Am Heart J.2008 Relative to women with uncomplicated pregnancies, women with a history of

preeclampsia/eclampsia had an increased risk of:

cardiac disease in both the case-control studies (odds ratio 2.47, 95% CI 1.22-5.01)

and the cohort studies (relative risk [RR]2.33, 1.95-2.78)

increased risk of cerebrovascular disease (RR 2.03, 1.54-2.67)

peripheral arterial disease(RR 1.87, 0.94-3.73),

cardiovascular mortality (RR 2.29, 1.73-3.04).

Meta-regression revealed a graded relationship

between the severity of preeclampsia/eclampsia and the

risk of cardiac disease

mild: RR 2.00, 1.83-2.19,

moderate: RR2.99, 2.51-3.58,

severe: RR 5.36, 3.96-7.27, P <.0001

RISK OF SUBSEQUENT

CARDIOVASCULAR DISEASE

Mild

2.0

Moderate

2.99

Severe

5.36



A systematic review and meta-analyses

Sarah D. McDonald, MD, Hamilton, Ontario

Am Heart J.2008

Conclusions

Women with a history of preeclampsia/eclampsia

have approximately double the risk of early cardiac,

cerebrovascular, and peripheral arterial disease, and

cardiovascular mortality. (Am Heart J 2008;156:918-30.)

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