Kara Nerenberg, MD, MSc , FRCPC Assistant Professor, University of Alberta
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Pregnancy-related diseases,their long-term health consequences and opportunities for interventions.
Kara Nerenberg, MD, MSc, FRCPC
Assistant Professor, University of Alberta
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Objectives
1. To understand the associations b/t pregnancy related diseases (preeclampsia & GDM) and future chronic diseases (vascular & renal).
2. To outline opportunities for interventions to reduce a woman’s risk of future chronic diseases.
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Life-course model of pregnancy-associated diseases
•CAD•CVD•PAD•CKD
Chronic Diseases
•T2DM•HTN
Postpartum
• Gluc• Lipids• BMI• MA
•GDM•PEC
Pregnancy
• Gluc• Lipids• BMI•HTN•CKD
Pre-pregnancy
Offspring• T2DM• Obesity• Atherosclerosis
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Questions to answer:
1. What chronic diseases do I need to look for? (awareness & screening)
2. Do we both have the same risk? (individualized risk assesment)
3. What can I do to prevent these chronic diseases? (prevention)
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Preeclampsia
•CAD•CVD•PAD•CKD
Long-term Chronic Diseases
•T2DM•HTN
Postpartum
• Gluc• Lipids• BMI• MA
•GDM•PEC
Pregnancy
• Gluc• Lipids• BMI•HTN•CKD
Pre-pregnancy
A hypertensive disorder of pregnancy. BP ≥ 140/90 AND proteinuria ≥ 300 mg/24 hrs. 5-10% of all pregnancies maternal and fetal morbidity & mortality. A disease of maternal vascular endothelial dysfunction.
JOGC. 2008;30: S1-S48.
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Preeclampsia Pathophysiology
Phase I Abnormal Placentation
Phase II Maternal Syndrome
Circulation. 2011;123: 2856-2869.Clin J Am Nephrol. 2007;2:543-549.
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Preeclampsia Pathophysiology – Maternal Vascular Endothelium
Circulation. 2011;123: 2856-2869.
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Endothelial dysfunction Atherosclerosis
1. http://www.robertsfox.com/EndoPAT.htm
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Risk Factors for Preeclampsia
JOGC. 2008;30: S1-S48.
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Resolution of HTN Post-PEC
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Resolution of HTN Post-PEC
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Resolution of Proteinuria Post-PEC
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Resolution of Proteinuria Post-PEC
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Am J Obstet Gynecol. 2009;200:58.e1-58.e8.
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Preeclampsia and Chronic HTN
Am J Obstet Gyncol. 1986;155:1011-6.
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Preeclampsia and Chronic HTN
BMJ. 2007; 974-977.
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T2DM:• PEC – 3.97 / 1000 • No PEC 2.21 / 1000
• HR: 1.82* (1.26, 2.62)
HTN in pregnancy. 2009;28:435-447.
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Am J Kidney Dis. 2010;55:1026-1039.
Microalbuminuria* at 7.1 yrs PP:
PEC Severe PEC
4x 8x
* MA also with CVD
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NEJM. 2008;359:800-809.
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Lancet. 2005; 366;1797-803.
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Lancet. 2005; 366;1797-803.
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CV Outcome Study Risk 95% CI
Cardiac Disease Case-control (n=4)
OR: 2.47 1.22, 5.01
Cohort (n=10) RR: 2.33 1.95, 2.78
Cerebrovascular Cohort (n=6) RR: 2.03 1.54, 2.67
Peripheral Arterial Cohort (n=3) RR: 1.87 0.94, 3.73
CV Mortality Cohort (n=5) RR: 2.29 1.73, 3.04
Am Heart J 2008;145:918-930.
Metaregression Severity of Preeclampsia
Relative Risk 95% CI
Cardiac Disease Mild 2.00 1.83, 2.19
Moderate 2.99 2.51, 3.58
Severe 5.36 3.96, 7.27
P<0.0001.
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1
Preeclampsia & CVD:
Mild: 2.0 (1.8, 2.2)
Mod: 3.0 (2.5, 3.6)
Severe: 5.4 (4.0, 7.3)
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Preeclampsia and CVD Death 14403 women:
481 PEC 244 CVD deaths
RF for CVD (HR): PEC – 2.14 (1.3-3.6) <34 wk – 9.54(4.5-20.3)
Survival at 30 yrs (56y) Early PEC – 85.9% Late PEC – 98.3% No PEC – 99.3%
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Preeclampsia
Pregnancy CNS: Cerebral edema
Eclampsia / PRES CVS: HTN (severe)
CHF / MI Renal: Proteinuria
AKI Liver: Edema: AST/ALT
Hematoma / rupture Heme: HELLP
Thromboembolism
Post-partum
Stroke / CNS deficits ? Seizure disorder
Chronic HTN CAD/PAD cardiomyopathy
Microalbuminuria CKD / Dialysis
? Cirrhosis VTE Metabolic: Obesity,
T2DM, Dyslipidemia
Endo: hypothyroidism
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Gestational Diabetes (GDM)1
•CAD•CVD•PAD•CKD
Long-term Chronic Diseases
•T2DM•HTN
Postpartum
• Gluc• Lipids• BMI•MA
•GDM•PEC
Pregnancy
• Gluc• Lipids• BMI•HTN•CKD
Pre-pregnancy
“Glucose intolerance with onset or first recognition during pregnancy”.
1. CDA. CPG 2008. Cdn J Diabetes. 2008;32:Suppl 1.
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GDM – Risk Factors
Age ≥ 35* Ethnicity*
Aboriginal Hispanic South Asian Asian African
FHx DM
Previous GDM Delivery of
macrosomic infant BMI ≥ 30* PCOS* Acanthosis Nigricans Corticosteroids
* Similar RF to preeclampsia
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1. CDA. CPG 2008. Cdn J Diabetes. 2008;32:Suppl 1.
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CMAJ. 2008;179:229-234.
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Diabetes Care. 2008;31:1668-1669.
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Normoglycemic
Mild: HR 1.19 (1.02-1.39)
GDM: HR 1.66 (1.30-2.13)
CMAJ. 2009; 181: 371-376.
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Gestational Diabetes
Pregnancy GDM
Preeclampsia
Post-partum Type 2 Diabetes
Chronic HTN
CAD / CVD
Obesity
Dyslipidemia Microalbuminuria
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Pregnancy and Future Disease
Circulation. 2011;123: 2856-2869.
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CV Risk Period CVD Risk Score
OR (95% CI) P-value
10-Year ≥ 5% 13.1 (3.4-85.5) <0.001
30-Year ≥ 10% 8.4 (3.5-23.2) <0.001
Lifetime ≥ 39% 3.3 (1.8-6.1) <0.001
(n=99 women with preeclampsia; n= 118 controls)
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Interventions
•CAD•CVD•PAD•CKD
Long-term Chronic Diseases
•T2DM•HTN
Postpartum
• Gluc• Lipids• BMI• MA
•GDM•PEC
Pregnancy
• Gluc• Lipids• BMI•HTN•CKD
Pre-pregnancy
Offspring• T2DM• Obesity• Atherosclerosis
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No clear recommendations Adoption of “heart healthy” lifestyle
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Part 2: Recommendations for Hypertension Treatment
2012 Canadian Hypertension Education Program Recommendations
From CHEP - http://www.hypertension.ca/chep-recommendations
Women with
Preeclampsia and GDM
Not Addresse
d
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Women with
Preeclampsia and GDM
Not Addresse
d
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Women with Preeclampsia
Not
Addressed
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SOGCPost-partum Recommendations
1. JOGC. 2008;30: S1-S48.
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SOGC Recommendations – Modified from CHEP 2008
1. JOGC. 2008;30: S1-S48.
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Preeclampsia FoundationPost-partum Recommendations
Eat a heart healthy diet. Exercise 30 mins, 5 days
a week. Maintain a BMI 19-25. Stop smoking.
1. www.preeclampsia.org. Accessed on-line, Feb 29, 2012.
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Post-partum Preeclampsia Interventions
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Women appreciative of info received Women preferred:
Individualized counseling Ongoing monitoring of lifestyle
Balanced use of computer resources Flexibility in scheduling / Child care
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3 arms:1. Placebo2. Metformin 850 mg bid3. “Lifestyle” goals
- 7% weight loss- 150 mins activity
1. NEJM. 2002;346:393-403.2. Diabetes Care. 2007:30; S242-245.
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P: Pregnant women with GDM at Dx Otherwise healthy
I: “DEBI” lifestyle intervention (DPP) Diet, exercise and breastfeeding intervention Telephone & in person sessions (RD / Lact) Antenatal to 1 year post-partum
C: Usual care / lifestyle information O: 10 meet PP wt goal / 20 BF x 6/12 M: RCT
Diabetes Care. 2011;34: 1519-1525.
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Results
Authors suggested: Earlier implementation of DEBI program To minimize Gestational wt gain (GWG)
Participants suggested: Physical Activity: Website
Support needed from family / social network Tips on exercising with a newborn
Diet: Low-fat recipes Tips on transitioning from diabetic diet.
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Lessons from Lifestyle Programs
Pregnant / Post-partum women are interested and will participate.
Dietary education needs to be more comprehensive.
Specific physical activity advice. Website preferred mode of delivery. Awaiting results of Cochrane review of
Lifestyle interventions post GDM
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Knowledge & Knowledge Translation %
Increased risk of chronic HTN with HDP ~ 50%
Specialist communicate this risk to patients ~ 60%
Specialist arrange for follow-up of BP ~ 60%
GP’s actually informed of C-HTN risk ~ 10%
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Life-course model of pregnancy-associated diseases
•CAD•CVD•PAD•CKD
Chronic Diseases
•T2DM•HTN
Postpartum
• Gluc• Lipids• BMI• MA
•GDM•PEC
Pregnancy
• Gluc• Lipids• BMI•HTN•CKD
Pre-pregnancy
Offspring• T2DM• Obesity• Atherosclerosis
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Summary:
PE and GDM Context of a “life-course model”
Future maternal disease risk Vascular risk in offspring Recurrence in future pregnancies
Vascular RF monitoring & management Frequency unclear – “annual” Optimal targets unclear – “high risk” Lifestyle intervention counseling – first line
Extensive Research Opportunities