Importance:Metformin and glyburide monotherapy are used as alternatives to insulin in managing gestational diabetes. Whether a sequential strategy of these oral agents results in noninferior perinatal outcomes compared with insulin alone is unknown. Objective:To test whether a treatment strategy of oral glucose-lowering agents is noninferior to insulin for prevention of large-for-gestational-age infants. Design, Setting, and Participants:Randomized, open-label noninferiority trial conducted at 25 Dutch centers from June 2016 to November 2022 with follow-up completed in May 2023. The study enrolled 820 individuals with gestational diabetes and singleton pregnancies between 16 and 34 weeks of gestation who had insufficient glycemic control after 2 weeks of dietary changes (defined as fasting glucose >95 mg/dL [>5.3 mmol/L], 1-hour postprandial glucose >140 mg/dL [>7.8 mmol/L], or 2-hour postprandial glucose >120 mg/dL [>6.7 mmol/L], measured by capillary glucose self-testing). Interventions:Participants were randomly assigned to receive metformin (initiated at a dose of 500 mg once daily and increased every 3 days to 1000 mg twice daily or highest level tolerated; n = 409) or insulin (prescribed according to local practice; n = 411). Glyburide was added to metformin, and then insulin substituted for glyburide, if needed, to achieve glucose targets. Main Outcomes and Measures:The primary outcome was the between-group difference in the percentage of infants born large for gestational age (birth weight >90th percentile based on gestational age and sex). Secondary outcomes included maternal hypoglycemia, cesarean delivery, pregnancy-induced hypertension, preeclampsia, maternal weight gain, preterm delivery, birth injury, neonatal hypoglycemia, neonatal hyperbilirubinemia, and neonatal intensive care unit admission. Results:Among 820 participants, the mean age was 33.2 (SD, 4.7) years). In participants randomized to oral agents, 79% (n = 320) maintained glycemic control without insulin. With oral agents, 23.9% of infants (n = 97) were large for gestational age vs 19.9% (n = 79) with insulin (absolute risk difference, 4.0%; 95% CI, -1.7% to 9.8%; P = .09 for noninferiority), with the confidence interval of the risk difference exceeding the absolute noninferiority margin of 8%. Maternal hypoglycemia was reported in 20.9% with oral glucose-lowering agents and 10.9% with insulin (absolute risk difference, 10.0%; 95% CI, 3.7%-21.2%). All other secondary outcomes did not differ between groups. Conclusions and Relevance:Treatment of gestational diabetes with metformin and additional glyburide, if needed, did not meet criteria for noninferiority compared with insulin with respect to the proportion of infants born large for gestational age. Trial Registration:Netherlands Trial Registry Identifier: NTR6134.

IMPORTANCE Metformin and glyburide monotherapy are used as alternatives to insulin in managing gestational diabetes. Whether a sequential strategy of these oral agents results in noninferior perinatal outcomes compared with insulin alone is unknown. OBJECTIVE To test whether a treatment strategy of oral glucose-lowering agents is noninferior to insulin for prevention of large-for-gestational-age infants. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label noninferiority trial conducted at 25 Dutch centers from June 2016 to November 2022 with follow-up completed in May 2023. The study enrolled 820 individuals with gestational diabetes and singleton pregnancies between 16 and 34 weeks of gestation who had insufficient glycemic control after 2 weeks of dietary changes (defined as fasting glucose >95 mg/dL [>5.3 mmol/L], 1-hour postprandial glucose >140 mg/dL [>7.8 mmol/L], or 2-hour postprandial glucose >120 mg/dL [>6.7 mmol/L], measured by capillary glucose self-testing). INTERVENTIONS Participants were randomly assigned to receive metformin (initiated at a dose of 500 mg once daily and increased every 3 days to 1000 mg twice daily or highest level tolerated; n = 409) or insulin (prescribed according to local practice; n = 411). Glyburide was added to metformin, and then insulin substituted for glyburide, if needed, to achieve glucose targets. MAIN OUTCOMES AND MEASURES The primary outcome was the between-group difference in the percentage of infants born large for gestational age (birth weight >90th percentile based on gestational age and sex). Secondary outcomes included maternal hypoglycemia, cesarean delivery, pregnancy-induced hypertension, preeclampsia, maternal weight gain, preterm delivery, birth injury, neonatal hypoglycemia, neonatal hyperbilirubinemia, and neonatal intensive care unit admission. RESULTS Among 820 participants, the mean age was 33.2 (SD, 4.7) years). In participants randomized to oral agents, 79% (n = 320) maintained glycemic control without insulin. With oral agents, 23.9% of infants (n = 97) were large for gestational age vs 19.9% (n = 79) with insulin (absolute risk difference, 4.0%; 95% CI, -1.7% to 9.8%; P = .09 for noninferiority), with the confidence interval of the risk difference exceeding the absolute noninferiority margin of 8%. Maternal hypoglycemia was reported in 20.9% with oral glucose-lowering agents and 10.9% with insulin (absolute risk difference, 10.0%; 95% CI, 3.7%-21.2%). All other secondary outcomes did not differ between groups. CONCLUSIONS AND RELEVANCE Treatment of gestational diabetes with metformin and additional glyburide, if needed, did not meet criteria for noninferiority compared with insulin with respect to the proportion of infants born large for gestational age.

Objectives: Blood pressure control in severe hypertension of pregnancy is crucial for mother and neonate. In absence of evidence, guidelines recommend either intravenous labetalol or nicardipine. We compared the effectiveness and safety of these two drugs in women with severe hypertension in pregnancy. Study design: We performed an open label randomized controlled trial. Women with a singleton pregnancy complicated by severe hypertension (systolic >= 160 mmHg and/or diastolic >= 110 mmHg) requiring intravenous antihypertensive treatment were randomized to intravenous labetalol or intravenous nicardipine. The primary outcome was a composite adverse neonatal outcome defined as severe Respiratory Distress Syndrome (RDS), Broncho Pulmonary Dysplasia (BPD), Intraventricular Hemorrhage (IVH) IIB or worse, Necrotizing Enterocolitis (NEC), or perinatal death defined as fetal death or neonatal death before discharge from the neonatal intensive care unit (NICU). Based on a power analysis, we estimated that 472 women (236 per group) needed to be included to detect a difference of 15% in the primary outcome with 90% power. The study was halted prematurely at 30 inclusions because of slow recruitment and trial fatigue. Results: Between August 2018 and April 2022, we randomized 30 women of which 16 were allocated to intravenous nicardipine and 14 to intravenous labetalol. The composite adverse neonatal outcome was not significantly different between the two groups (25 % versus 43 % OR 0.28 (95 % CI 0.05-1.43), p = 0.12)). Respiratory distress syndrome occurred more often in the labetalol group than in the nicardipine group (42.9 % versus 12.5 %). Neonatal hypoglycemia occurred more often in the nicardipine group than in the labetalol group (31 % versus 7 %). Time until blood pressure control was faster in women treated with nicardipine than in women treated with labetalol (45 (15-150 min vs. 120 (60-127,5) min). Conclusion: In our prematurely halted small RCT, we were unable to provide evidence for the optimal choice of treatment for severe hypertension to improve neonatal outcome and/or to obtain faster blood pressure control. Differences in Respiratory distress syndrome and neonatal hypoglycemia between the groups might be the result of coincidental finding due to the small groups included in the study. A larger randomized trial would be needed to determine the safest and most efficacious (intravenous) therapy for severe hypertension in pregnancy. This study emphasizes the challenges of conducting a RCT for the optimal treatment for these women.

Abstract Tuberculosis (TB) is a disease with a high burden, with most patients in low and middle income countries (LMIC). In Western countries however, this disease is rare, but with the increasing number of migrants it becomes more relevant. Especially in women with fertility issues, TB is not the most likely diagnosis and therefore difficult to discover and treat. If TB is not detected at an early stage, it can have major consequences for fertility and pregnancy outcomes. Screening should be suggested in women originated from high endemic countries with unexplained fertility loss, or during first trimester screening. QuantiFERON testing and PCR sampling for TB should be the golden standard. This case report describes fertility issues and an immature delivery in a young woman caused by extrapulmonary TB in the genital tract. With this case report, we hope to draw attention to this disease so that early detection can take place and serious outcome can be prevented.

Background Hypertensive disorders of pregnancy are associated with cardiovascular disease later in life. Given that hypertensive disorders of pregnancy often occur at a relatively young age, there might be an opportunity to use preventive measures to reduce the risk of early cardiovascular disease and mortality. The aim of this study was to assess the risk of cardiovascular mortality in women after a hypertensive disorder of pregnancy.Methods In this population-based cohort study, the Netherlands Perinatal Registry (PRN) and the national death registry at the Dutch Central Bureau for Statistics were linked. We analysed women in the Netherlands with a first birth during 1995-2015 to determine the association between cardiovascular mortality and hypertensive disorders of pregnancy (based on recorded diastolic blood pressure or proteinuria, or both). We analysed the association between the highest diastolic blood pressure measured in pregnancy and cardiovascular mortality and constructed survival curves to assess cardiovascular mortality after hypertensive disorders of pregnancy, specifically pre-eclampsia and gestational hypertension. To differentiate between the severity of hypertensive disorders of pregnancy, cardiovascular mortality was assessed in women with a combination of hypertensive disorders of pregnancy with preterm birth (gestational age < 37 weeks) and growth restriction (birthweight in the 10th percentile or less). All hazard ratios (HRs) were adjusted for maternal age.Findings Between Jan 1, 1995, and Dec 31, 2015, the PRN contained 2 462 931 deliveries and 1 625 246 women. In 1 243 890 women data on their first pregnancy were available and were included in this analysis after linkage, with a median follow-up time of 11(.)2 years (IQR 6(.)1-16(.)3). 259 177 (20(.)8%) women had hypertensive disorders of pregnancy, and of these 45 482 (3(.)7%) women had pre-eclampsia and 213 695 (17(.)2%) women had gestational hypertension; 984 713 (79(.)2%) women did not develop hypertension in their first pregnancy. Compared with women without hypertensive disorders of pregnancy, the risk of death from any cause was higher in women who had hypertensive disorders (HR 1middot30 [95% CI 1(.)23-1(.)37], p < 0(.)001), pre-eclampsia (1(.)65 [1(.)48-1(.)83]; p < 0(.)0001), and gestational hypertension (1(.)23 [1(.)16-1.30]; p < 0(.)0001). Those women with pre-eclampsia had a higher risk of cardiovascular mortality compared with those without any hypertensive disorders of pregnancy (adjusted HR 3middot39 [95% CI 2(.)67-4(.)29]), as did those with gestational hypertension (2(.)22 [1(.)91-2(.)57]). For women with a history of hypertensive disorders of pregnancy combined with preterm birth (gestational age < 37 weeks) and birthweight in the 10th percentile or less, the adjusted HR for cardiovascular mortality was 6middot43 (95% CI 4(.)36-9(.)47), compared with women without a hypertensive disorder of pregnancy. The highest diastolic blood pressure measured during pregnancy was the strongest risk factor for cardiovascular mortality (for 80-89 mm Hg: adjusted HR 1(.)47 [95% CI 1(.)00-2(.)17]; for 130 mm Hg and higher: 14(.)70 [7.31-29.52]). Interpretation Women with a history of hypertensive disorders of pregnancy have a risk of cardiovascular mortality that is 2-3 times higher than that of women with normal blood pressure during pregnancy. The highest measured diastolic blood pressure during pregnancy is an important predictor for cardiovascular mortality later in life; therefore, women who have hypertensive disorders of pregnancy should be given personalised cardiovascular follow-up plans to reduce their risk of cardiovascular mortality.Funding None.Copyright (c) 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

BACKGROUND:Preterm birth is the leading cause of neonatal morbidity and mortality. The recurrence rate of spontaneous preterm birth is high, and additional preventive measures are required. Our objective was to assess the effectiveness of low-dose aspirin compared to placebo in the prevention of preterm birth in women with a previous spontaneous preterm birth. METHODS AND FINDINGS:We performed a parallel multicentre, randomised, double-blinded, placebo-controlled trial (the APRIL study). The study was performed in 8 tertiary and 26 secondary care hospitals in the Netherlands. We included women with a singleton pregnancy and a history of spontaneous preterm birth of a singleton between 22 and 37 weeks. Participants were randomly assigned to aspirin 80 mg daily or placebo initiated between 8 and 16 weeks of gestation and continued until 36 weeks or delivery. Randomisation was computer generated, with allocation concealment by using sequentially numbered medication containers. Participants, their healthcare providers, and researchers were blinded for treatment allocation. The primary outcome was preterm birth <37 weeks of gestation. Secondary outcomes included a composite of poor neonatal outcome (bronchopulmonary dysplasia, periventricular leukomalacia > grade 1, intraventricular hemorrhage > grade 2, necrotising enterocolitis > stage 1, retinopathy of prematurity, culture proven sepsis, or perinatal death). Analyses were performed by intention to treat. From May 31, 2016 to June 13, 2019, 406 women were randomised to aspirin (n = 204) or placebo (n = 202). A total of 387 women (81.1% of white ethnic origin, mean age 32.5 ± SD 3.8) were included in the final analysis: 194 women were allocated to aspirin and 193 to placebo. Preterm birth <37 weeks occurred in 41 (21.2%) women in the aspirin group and 49 (25.4%) in the placebo group (relative risk (RR) 0.83, 95% confidence interval (CI) 0.58 to 1.20, p = 0.32). In women with ≥80% medication adherence, preterm birth occurred in 24 (19.2%) versus 30 (24.8%) women (RR 0.77, 95% CI 0.48 to 1.25, p = 0.29). The rate of the composite of poor neonatal outcome was 4.6% (n = 9) versus 2.6% (n = 5) (RR 1.79, 95% CI 0.61 to 5.25, p = 0.29). Among all randomised women, serious adverse events occurred in 11 out of 204 (5.4%) women allocated to aspirin and 11 out of 202 (5.4%) women allocated to placebo. None of these serious adverse events was considered to be associated with treatment allocation. The main study limitation is the underpowered sample size due to the lower than expected preterm birth rates. CONCLUSIONS:In this study, we observed that low-dose aspirin did not significantly reduce the preterm birth rate in women with a previous spontaneous preterm birth. However, a modest reduction of preterm birth with aspirin cannot be ruled out. Further research is required to determine a possible beneficial effect of low-dose aspirin for women with a previous spontaneous preterm birth. TRIAL REGISTRATION:Dutch Trial Register (NL5553, NTR5675) https://www.trialregister.nl/trial/5553.

To evaluate the effectiveness of aspirin compared to placebo for the prevention of preterm birth (PTB) when initiated in early pregnancy in women with a previous spontaneous preterm birth (SPTB). We performed a multicenter, double-blind, randomized controlled trial (APRIL, NTR 5675). We recruited women with a singleton pregnancy and a history of SPTB (singleton pregnancy 22+0 - 37+0 weeks) following either preterm prelabor rupture of membranes or spontaneous contractions. After informed consent, participants were randomly assigned to daily aspirin (80 mg) or placebo started between 8+0 and 16+0 weeks gestation. Treatment was continued until 36+0 weeks gestation or delivery. Primary outcome was PTB before 37+0 weeks gestation. Secondary outcomes included a composite of poor neonatal outcome (bronchopulmonary dysplasia, periventricular leukomalacia >grade 1, intraventricular hemorrhage >grade 2, necrotizing enterocolitis >stage 1, retinopathy of prematurity, culture proven sepsis or perinatal death). A sample of 384 women was required to detect a PTB reduction from 36 to 23% (α-error 0.05, β-error 0.2). Analyses were performed by intention to treat. Between May 2016 and June 2019, we randomly allocated 194 women to aspirin and 193 to placebo. The PTB rate was 21.2% in the aspirin group versus 25.4% in the placebo group (RR 0.83; 95% CI 0.58-1.2). SPTB occurred in 20.1% versus 23.8% of women (RR 0.84; 95% CI 0.58-1.2). For women who were ≥80% compliant with study medication, PTB rates were 18.5% versus 24.8% (RR 0.75; 95% CI 0.46-1.2). The poor neonatal outcome rate was 4.6% versus 2.6% (RR 1.79; 95% CI 0.61 to 5.3). There were no significant differences in maternal morbidities such as hypertensive disorders and postpartum hemorrhage. Our data did not demonstrate a reduction of PTB in women with a previous SPTB who used aspirin 80 mg. The RR for PTB is comparable to larger studies on aspirin in other groups of women. A small reduction of PTB from aspirin in women with a previous SPTB cannot be excluded with the current sample size.

IntroductionIn women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM.MethodsThe SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle.Ethics and disseminationThe study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals.Trial registration numberNTR6134; Pre-results.

Hypertensive pregnancy disorders (HPD) are associated with cardiovascular disease (CVD) later in life. Since hypertension in pregnancy occurs at a relatively young age this may signal an opportunity for preventive measure for CVD at a relative early age. This study investigated the relationship between HPD and cardiovascular mortality in a large national cohort. Women who gave birth during 1995–2015 (registered in the Dutch National Birth Registry) were linked with the National Death Registry. The risk of cardiovascular mortality (CVM) after HPD was analyzed prospectively in two different cohorts: Women with a history of HDP in one or more pregnancies and HDP in the first pregnancy of the women. Cox-regression models with survival curves were executed. Of 1,625,246 parous women 21.9% had a history of HDP. Both gestational hypertension (GH; 18.1%) and preeclampsia (PE; 3.8%) were associated with a 2–3 times higher CVM risk compared to women without a history of HPD. Similar results were found in the cohort of 1,243,890 women whose first nulliparous pregnancy was analyzed. Women with HDP, delivery <37 weeks and IUGR had a 5–6-fold higher CVM-risk and women with HDP with a diastolic blood pressure >110 mmHg had a 4.5-fold higher CVM-risk. Women were followed for a mean time of 10.4 years and died at a mean age of 40 years old. Women with a history of HDP have a 2–3-fold times higher CVM risk. Cardiovascular mortality risk is present at a relatively young age (<50 years). This accentuates the need of development of a cardiovascular management program which is designed to follow-up women directly after the index pregnancy and trace and treat women with cardiovascular disease.

IntroductionCardiovascular disease is the leading cause of death in women. Observational studies suggest that women with a history of recurrent miscarriage have an increased risk of cardiovascular disease. Material and methodsWomen who visited the recurrent miscarriage clinic at Leiden University Medical Center between 2000 and 2010 and who had their third consecutive miscarriage before the age of 31years, were invited to participate in this follow-up study (between 2012 and 2014). The reference group consisted of women with at least one uncomplicated pregnancy and no miscarriage, matched by zip code, age, and date of pregnancy. All women were invited for risk factor screening, including physical examination and blood collection. Main outcome measures were the (extrapolated) 10- and 30-year cardiovascular risk scores using the Framingham risk score. A subanalysis was performed for women with idiopathic recurrent miscarriage. ResultsThirty-six women were included in both groups. Mean follow up was 7.5years. Women with recurrent miscarriage had a significantly higher extrapolated 10-year cardiovascular risk score (mean 6.24%, SD 5.44) compared with women with no miscarriage (mean 3.56%, SD 1.82, P=.007) and a significantly higher 30-year cardiovascular risk score (mean 9.86%, SD 9.10) compared with women with no miscarriage (mean 6.39%, SD 4.20, P=.04). Similar results were found in women with idiopathic recurrent miscarriage (n=28). ConclusionsWomen with a history of recurrent miscarriage differ in cardiovascular risk profile at a young age compared with women with no miscarriage. The findings support an opportunity to identify women at risk of cardiovascular disease later in life and a possible moment for intervention.

Cardiovascular disease is the leading cause of death in women. Observational studies suggest that women with a history of recurrent miscarriage have an increased risk of cardiovascular disease. Women who visited the recurrent miscarriage clinic at Leiden University Medical Center between 2000 and 2010 and who had their third consecutive miscarriage before the age of 31 years, were invited to participate in this follow-up study (between 2012 and 2014). The reference group consisted of women with at least one uncomplicated pregnancy and no miscarriage, matched by zip code, age, and date of pregnancy. All women were invited for risk factor screening, including physical examination and blood collection. Main outcome measures were the (extrapolated) 10- and 30-year cardiovascular risk scores using the Framingham risk score. A subanalysis was performed for women with idiopathic recurrent miscarriage. Thirty-six women were included in both groups. Mean follow up was 7.5 years. Women with recurrent miscarriage had a significantly higher extrapolated 10-year cardiovascular risk score (mean 6.24%, SD 5.44) compared with women with no miscarriage (mean 3.56%, SD 1.82, P  = .007) and a significantly higher 30-year cardiovascular risk score (mean 9.86%, SD 9.10) compared with women with no miscarriage (mean 6.39%, SD 4.20, P  = .04). Similar results were found in women with idiopathic recurrent miscarriage (n = 28). Women with a history of recurrent miscarriage differ in cardiovascular risk profile at a young age compared with women with no miscarriage. The findings support an opportunity to identify women at risk of cardiovascular disease later in life and a possible moment for intervention.

OBJECTIVE:Women with a history of preeclampsia have an increased risk of cardiovascular disease. Gynaecologists have an important role in the counselling and management of cardiovascular risk factors after preeclampsia. We aimed to assess the role of gynaecologists in informing women on interventions and risk factor follow-up after early and late preeclampsia. METHODS:In 2011 and 2014, all gynaecologists in the Netherlands were invited for a questionnaire. Results were analysed and compared over time. RESULTS:In 2011, the questionnaire was answered by 244 and in 2014 by 167 gynaecologists. After early preeclampsia, in 2011, 53% advised yearly blood pressure measurements; this increased to 65% in 2014. Over the years there was an increase in respondents advising an increased physical activity of 35% in 2011 to 56% in 2014. After late preeclampsia, in 2011, 36% advised yearly blood pressure measurements; this increased to 46% in 2014. There was an increase in gynaecologists advising increased activity (32% in 2011 to 56% in 2014). In both early and late preeclampsia, smoking cessation and weigh loss were advised often (70-80%); glucose and lipid screening were advised rarely (6-20%). CONCLUSION:Although there is still a considerable scope for improvement, an increasing number of gynaecologists advise women after preeclampsia on preventive interventions to decrease risks of cardiovascular disease.

OBJECTIVE:To reduce cardiovascular risk after preeclampsia, we investigated the effect of framing, the perceived probability and its interaction, on the willingness to modify behavior.METHODS:Participants scored their willingness to modify behavior on two cases with different probabilities of developing cardiovascular disease. Both cases were either presented as "chance of health" or "risk of disease".RESULTS:165 questionnaires were analyzed. ANOVA revealed a significant effect of probability, non-significant effect of framing and a non-significant interaction between probability and framing.CONCLUSION:Perceived probability influences willingness to modify behavior to reduce cardiovascular risk after preeclampsia; framing and the interaction was not of influence.

OBJECTIVE:To analyse preventive interventions of women with cardiovascular risk factors postpartum. METHODS:3.5 years postpartum, women with history of hypertension in pregnancy were invited for a questionnaire, 1 year after a cardiovascular risk assessment. RESULTS:Two hundred and fifty-seven women completed the questionnaire. At risk factor analyses, 35% had hypertension, 37% abnormal lipid- or glucose levels, 63% BMI ≥ 25 and 19% smoked. One year later, 36% of women with hypertension used anti-hypertensives, 0% of women with abnormal laboratory findings used anti-cholesterol and 1% anti-diabetes medication, 31% of the obese women achieved BMI reduction (≥ 5%), 42% of the women who smoked, quit. CONCLUSION:A minority improved their risk profile.

Observational studies have consistently described that women with a history of hypertension in pregnancy have a markedly increased risk of cardiovascular disease (CVD) later in life. Pregnancy is suggested as a “stress test” that identifies women who are at risk for developing clinical cardiovascular disease in later life. This opens up the opportunity for preventive measures at a relatively young age. Helping women to address their cardiovascular risk by modifying lifestyle has proven difficult. Motivation to change behaviour is crucial for effective interventions. Research on promoting healthy lifestyle has demonstrated that even subtle differences in message framing can affect (intentions to improve) health-related behavior. So, framing risk information could be effective in motivating these women too. Perceived probability of developing a disease appears to be another important factor influencing people’s motivation to modify behavior. Investigating the impact of framing information as a health score versus a risk score and the impact of high versus low probability of developing CVD on the willingness to modify behavior after preeclampsia. Obstetric nurses (n = 165) were invited to participate in a questionnaire containing two hypothetical scenarios, a case with mild preeclampsia and a case with severe preeclampsia. Scores of their willingness to modify behaviour were analysed on a Likert scale by ANOVA. We found no significant effect of framing F(3,287) = 1.932, p 0.166. A significant main effect was found of the severity of the case (F(3,287) = 11.12, p 0.001) and a non-significant interaction between severity and framing on the willingness to modify behavior (F(3,287) = 0.592, p 0.442). Framing information in health or risk score and its interaction with probability is not of influence in motivating women to modify their lifestyle to decrease cardiovascular risk after preeclampsia. Framing in health or risk score does not seem to be contributing in clinical practice. Those who are presented with a higher risk are more motivated to change their lifestyle.

Observational studies have shown an increased lifetime risk of cardiovascular disease (CVD) in women who experienced a hypertensive disorder in pregnancy. This risk is related to the severity of the pregnancy-related hypertensive disease and gestational age at onset. However, it has not been investigated whether these differences in CVD risk factors are already present at postpartum cardiovascular screening. We evaluated postpartum differences in CVD risk factors in 3 subgroups of patients with a history of hypertensive pregnancy. We compared the prevalence of common CVD risk factors postpartum among 448 women with previous early-onset preeclampsia, 76 women with previous late-onset preeclampsia, and 224 women with previous pregnancy-induced hypertension. Women with previous early-onset preeclampsia were compared with women with late-onset preeclampsia and pregnancy-induced hypertension and had significantly higher fasting blood glucose (5.29 versus 4.80 and 4.83 mmol/L), insulin (9.12 versus 6.31 and 6.7 uIU/L), triglycerides (1.32 versus 1.02 and 0.97 mmol/L), and total cholesterol (5.14 versus 4.73 and 4.73 mmol/L). Almost half of the early-onset preeclampsia women had developed hypertension, as opposed to 39% and 25% of women in the pregnancy-induced hypertension and late-onset preeclampsia groups, respectively. Our data show differences in the prevalence of common modifiable CVD risk factors postpartum and suggest that prevention strategies should be stratified according to severity and gestational age of onset for the hypertensive disorders of pregnancy.

BACKGROUNDResults from a number of long-term follow-up studies have suggested that hypertensive disorders in pregnancy are associated with increased risk of cardiovascular disease later in life. More recently, this putative relationship has been substantiated with findings of elevated cardiovascular risk factors, such as lipid profiles and glucose, in women with a history of hypertensive pregnancy disorders. Homocysteine is a sensitive indicator of increased risk but data on homocysteine levels in women with a history of hypertensive pregnancy disorders are inconsistent.DESIGNThis cohort study included 279 women with a history of hypertensive pregnancy disorders at term and 85 women with a history of uncomplicated pregnancies who participated in the Hypitat Risk Assessment Study (HyRAS).METHODSBlood samples for total homocysteine determination were taken 2.5 years postpartum. Homocysteine levels were determined in plasma using an immunoassay.RESULTSWomen with a history of hypertensive pregnancy disorders had significant higher median homocysteine levels (10.66 μmol/L) 2.5 years postpartum compared with women with a history uncomplicated pregnancies (9.82 μmol/L; p=0.002). Women with a history of hypertensive pregnancy disorders had a higher risk of having a homocysteine level in the highest quartile (odds ratio 3.4, 95% confidence interval 1.5-7.6).CONCLUSIONAt 2.5 years postpartum, women with a history hypertensive pregnancy disorders had higher homocysteine levels than women who had uncomplicated pregnancies. Although higher homocysteine levels might be a potential link between a history of hypertensive pregnancy disorders and increased cardiovascular disease risk later in life, the clinical implications remain an area for future research.

Depression is among the leading causes of disability adjusted life years. For women in their fertile ages the occurrence of depression is of great impact for their selves and families. We analyzed the association between term hypertensive pregnancy disorders and depression scores. Two to six years after pregnancy, women with a history of term preeclampsia or gestational hypertension were included in the hypertensive pregnancy cohort (HTP cohort) (n = 257). Controls were women who had an uncomplicated pregnancy (n = 83) (NTP cohort).The Edinburgh Postnatal Depression Scale (EPDS score) (Cox et al., 1987) was used to determine individual depression scores. Depression was defined as an EPDS score >12 or the use of antidepressants. Potential differences between groups were compared using the Student’s T test, the Chi-squared test (X2 test), or the Mann–Whitney U test when appropriate. We used logistic regression analyses to adjust for potential confounders. Women in the HTP cohort had higher depression scores than women in the NTP cohort (Table 1) and were more often depressed (OR 5.8 (1.4–24.6)). After correction for parity (adjusted OR 1.3 (0.8–2.0), BMI (adjusted OR 1.2 (1.1–1.2) and antihypertensive medication use (adjusted OR 1.1 (0.3–3.8), no significant differences were found in depression rates with an adjusted OR 4.2 (0.9–18.8). More than three years postpartum women with a history of term hypertensive pregnancy disorders are more often depressed compared to women with a history of a normotensive pregnancy.Download : Download full-size image