Gali Pariente

An association between gestational diabetes mellitus and long-term maternal cardiovascular morbidity

Objective To investigate whether a diagnosis of gestational diabetes mellitus (GDM) is a risk factor for subsequent long-term cardiovascular morbidity. Design A population-based study. Setting Soroka University Medical Center, a tertiary centre in the southern region of Israel. Patients A cohort of women with and without a diagnosis of GDM who delivered during the years 1988–1999 with a follow-up period until 2010. Interventions A comparison of the incidence of cardiovascular morbidity. Results Of 47 909 deliveries that met the inclusion criteria, 4928 (10.3%) occurred in patients who were diagnosed with GDM. During a follow-up period of more than 10 years, compared with women who gave birth at the same time period, after adjustment for age and ethnicity, patients with GDM had higher rates of cardiovascular morbidity including non-invasive cardiac diagnostic procedures (OR=1.8; 95% CI 1.4 to 2.2), simple cardiovascular events (OR=2.7; 95% CI 2.4 to 3.1) and total cardiovascular hospitalisations (OR=2.3; 95% CI 2.0 to 2.5). In a Cox proportional hazards model, adjusted for comorbidities such as pre-eclampsia and obesity, GDM was independently associated with cardiovascular hospitalisations (adjusted HR 2.6, 95% CI 2.3 to 3). Conclusions GDM is an independent risk factor for long-term cardiovascular morbidity in a follow-up period of more than a decade.

Placental abruption: critical analysis of risk factors and perinatal outcomes

Objective. To investigate risk factors and pregnancy outcome of patients with placental abruption. Methods. A population-based study comparing all pregnancies of women with and without placental abruption was conducted. Stratified analysis using multiple logistic regression models was performed to control for confounders. Results. During the study period there were 185,476 deliveries, of which 0.7% (1365) occurred in patients with placental abruption. The incidence of placental abruption increased between the years 1998 to 2006 from 0.6 to 0.8%. Placental abruption was more common at earlier gestational age. The following conditions were significantly associated with placental abruption, using a multivariable analysis with backward elimination: hypertensive disorders, prior cesarean section, maternal age, and gestational age. Placental abruption was significantly associated with adverse perinatal outcomes such as Apgar scores <7 at 1 and 5 min and perinatal mortality. Patients with placental abruption were more likely to have cesarean deliveries, as well as cesarean hysterectomy.Using another multivariate analysis, with perinatal mortality as the outcome variable, controlling for gestational age, hypertensive disorders, etc., placental abruption was noted as an independent risk factor for perinatal mortality. Conclusions. Placental abruption is an independent risk factor for perinatal mortality. Since the incidence of placental abruption has increased during the last decade, risk factors should be carefully evaluated in an attempt to improve surveillance and outcome.

Long-term maternal atherosclerotic morbidity in women with pre-eclampsia

Objective To investigate whether severe and recurrent pre-eclampsia increase the risk for long-term maternal atherosclerotic disease. Study design A population-based study compared the incidence of long-term atherosclerotic morbidity in a cohort of women who delivered in the years 1988–2012. The exposure variable was pre-eclampsia. Mean follow-up duration was 11.2 years. Kaplan–Meier survival curves were used to estimate cumulative incidence of simple, complex (ie, angina pectoris and congestive heart failure, respectively) cardiovascular-related and renal-related hospitalisations. Cox proportional hazards models were used to estimate the adjusted HRs for cardiovascular and renal morbidity. Results During the study, 96 370 patients met the inclusion criteria; 7824 (8.1%) in patients who were diagnosed at least once with pre-eclampsia. Patients with pre-eclampsia had higher rates of cardiovascular morbidity including cardiac non-invasive (OR 1.4; 95% CI 1.1 to 1.7; p=0.005) and invasive diagnostic procedures (OR 1.7; 95% CI 1.2 to 2.3; p=0.001), simple (OR 1.5; 95% CI 1.2 to 1.8; p=0.001), as well as complex cardiovascular events (OR 2.4; 95% CI 2.2 to 2.8; p=0.001) and renal (OR 3.7; 95% CI 2.2 to 6.0; p=0.001) hospitalisations. A significant linear association was noted between the severity of pre-eclampsia (no pre-eclampsia, mild pre-eclampsia, severe pre-eclampsia and eclampsia) and cardiovascular (2.7% vs 4.5% vs 5.2% vs 5.7%, respectively; p=0.001), as well as renal disease (0.1% vs 0.2% vs 0.5% vs 1.1%, respectively; p=0.001). Likewise, a linear association was found between the number of previous pregnancies with pre-eclampsia (no pre-eclampsia, one event and ≥2 events of pre-eclampsia) and risk for future simple cardiovascular disease (1.2% vs 1.6% vs 2.2%, respectively; p=0.001), complex cardiovascular disease (1.3% vs 2.7% vs 4.6%, respectively; p=0.001) and total cardiovascular hospitalisations (2.7% vs 4.4% vs 6.0%, respectively; p=0.001). Using a Kaplan–Meier survival curve, patients with pre-eclampsia had significantly higher cumulative incidence of atherosclerotic-related hospitalisations. In a Cox proportional hazards model, adjusted for confounders such as maternal age, parity, diabetes mellitus and obesity, pre-eclampsia remained independently associated with atherosclerotic hospitalisations. Conclusions Previous pregnancy with pre-eclampsia is an independent risk factor for long-term maternal atherosclerotic morbidity. The risk is more substantial for patients with severe and recurrent episodes of pre-eclampsia.

Placental abruption as a significant risk factor for long-term cardiovascular mortality in a follow-up period of more than a decade.

BACKGROUND To investigate the risk for subsequent cardiovascular events in women having placental abruption during a follow-up period of more than 10 years. METHODS A population-based study of the incidence of cardiovascular events in women who had placental abruption with women without placental abruption during 1988-99 and with follow-up until 2010. Associations between placental abruption and maternal long-term cardiovascular morbidity and mortality were investigated. Kaplan-Meier survival curves and multivariable Cox regression were used to estimate cumulative incidence of cardiovascular mortality. RESULTS During the study period, there were 47 585 deliveries meeting the inclusion criteria; of these, 653 occurred in patients with placental abruption. No significant association was noted between placental abruption and subsequent long-term hospitalisations because of cardiovascular causes. However, placental abruption was associated with long-term cardiovascular mortality [odds ratio (OR) = 6.6; 95% confidence interval (CI) 2.3, 18.3]. The cardiovascular case fatality rate for the placental abruption group was 13.0% vs. 2.5% in the comparison group (P < 0.001). Patients with a history of placental abruption had a significantly higher risk for cardiovascular mortality during the follow-up period (Log-rank test P = 0.017). Using Cox multivariable regression models, placental abruption remained an independent risk factor for long-term maternal cardiovascular mortality [adjusted hazard ratio (HR) = 4.3; 95% CI 1.1, 18.6). CONCLUSION Placental abruption is a significant risk factor for long-term cardiovascular mortality in a follow-up period of more than a decade.

Prenatal Diagnosis of Congenital Lobar Emphysema: Case Report and Review of the Literature

Congenital lobar emphysema (CLE) is a rare developmental anomaly of the lower respiratory tract, which is characterized by hyperinflation of 1 or more of the pulmonary lobes. The routine use of prenatal sonography has resulted in early identification and serial evaluation of congenital lung lesions. 1 Prenatal diagnosis of CLE is rarely reported in the literature. 2 Here we report a case of a fetus with an echogenic lung presenting in the second trimester suspected of CLE. A discussion of the causes and natural course of CLE is presented.

Association between delivery of a small-for-gestational-age neonate and long-term maternal cardiovascular morbidity

To investigate whether delivering a small‐for‐gestational‐age (SGA) newborn is a risk factor for subsequent long‐term maternal cardiovascular morbidity.

Recurrent pregnancy loss: a risk factor for long-term maternal atherosclerotic morbidity?

OBJECTIVE We sought to investigate whether patients with a history of recurrent pregnancy loss (RPL) have an increased risk for future maternal atherosclerotic morbidity. STUDY DESIGN A population-based study compared the incidence of long-term atherosclerotic morbidity (renal and cardiovascular) in a cohort of women with and without a diagnosis of RPL. Patients had a mean follow-up duration of more than a decade. Women with known atherosclerotic disease were excluded from the study. Cardiovascular morbidity was divided into 4 categories according to severity and type including simple and complex cardiovascular events and invasive and noninvasive cardiac procedures. Kaplan-Meier survival curves were used to estimate cumulative incidence of cardiovascular and renal hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazard ratios for cardiovascular and renal morbidity. RESULTS During the study period 99,285 patients were included; of these 6.7% (n = 6690) had a history of RPL. Patients with RPL had higher rates of renal and cardiovascular morbidity including cardiac invasive and noninvasive diagnostic procedures, simple as well as complex cardiovascular events, and hospitalizations due to cardiovascular causes. Using Kaplan-Meier survival curves, patients with a previous diagnosis of RPL had a significantly higher cumulative incidence of cardiovascular but not renal hospitalizations. Using a Cox proportional hazards model, adjusted for confounders such as preeclampsia, diabetes mellitus, obesity, and smoking, a history of RPL remained independently associated with cardiovascular hospitalizations (adjusted hazard ratio, 1.6; 95% confidence interval, 1.4-1.8; P = .001). CONCLUSION RPL is an independent risk factor for long-term maternal cardiovascular complications.

Gestational Diabetes Mellitus Is a Significant Risk Factor for Long-Term Maternal Renal Disease

CONTEXT Gestational diabetes mellitus (GDM) was found to be an independent risk factor for recurrent long-term type 2 diabetes mellitus, cardiovascular morbidity, and vascular endothelial dysfunction. However, data on the link between GDM and future risk for long-term maternal renal disease are limited. OBJECTIVE The purpose of this study was to investigate whether GDM poses a risk for subsequent long-term maternal renal morbidity. DESIGN A population-based noninterventional study compared the incidence of future renal morbidity in a cohort of women with and without previous GDM. Deliveries occurred during a 25-year period, with a mean follow-up duration of 11.2 years. SETTING The study was conducted at the Soroka University Medical Center. PARTICIPANTS The study population was composed of all singleton pregnancies in women who delivered between January 1988 and December 2013. MAIN OUTCOME MEASURE The main outcome was diagnosis of renal morbidities. RESULTS Of 97,968 women who met the inclusion criteria, 9542 (9.7%) had at least 1 previous pregnancy with GDM. Using a Kaplan-Meier survival curve, we show that women with GDM had higher rates of total renal morbidity (0.1% vs 0.2%, for no GDM and with GDM, respectively; odds ratio, 2.3, 95% confidence interval, 1.4-3.7; P < .001). In addition, we found a significant dose-response association (using the χ(2) test for trends) between the number of pregnancies with GDM and future risk for renal morbidity (0.1%, 0.2%, and 0.4% for no GDM, 1 episode of GDM, and 2 episodes of GDM, respectively; P < .001). In a Cox proportional hazards model, adjusted for confounders, GDM was independently associated with future renal morbidity. CONCLUSION GDM is a significant risk factor for future maternal renal morbidity. The risk is more substantial for patients with recurrent episodes of GDM.

Is stillbirth associated with long-term atherosclerotic morbidity?

OBJECTIVE The purpose of this study was to investigate whether women who experienced at least 1 stillbirth are at increased risk for subsequent maternal long-term atherosclerotic morbidity. STUDY DESIGN We conducted a population-based study that compared the incidence of long-term atherosclerotic morbidity in a cohort of women with and without previous stillbirth. Deliveries occurred during a 25-year period. Patients with known cardiovascular or renal disease before the index pregnancy were excluded from the study. Kaplan-Meier survival curves were used to estimate the cumulative incidence of cardiovascular- and renal-related hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazards ratio for cardiovascular- and renal-related hospitalizations. RESULTS Of 99,280 deliveries that met the inclusion criteria, 1879 deliveries (1.9%) occurred in patients who had had at least 1 stillbirth. After stillbirth, patients had a significantly higher cumulative incidence of cardiovascular and renal morbidity (Kaplan-Meier survival curve). During the follow-up period, patients with at least 1 stillbirth had higher rates of total cardiovascular and renal hospitalizations and had higher rates of simple and complex cardiovascular events. A significant stepwise increase was found between the number of stillbirths and future risk for cardiovascular morbidity. In a Cox proportional hazards model that was adjusted for confounders, previous stillbirth was associated independently with atherosclerotic morbidity. CONCLUSION Stillbirth is an independent risk factor for long-term maternal atherosclerotic morbidity. The risk is higher for patients with recurrent episodes of stillbirth.

Obesity in pregnancy: what's next? Long-term cardiovascular morbidity in a follow-up period of more than a decade.

Abstract Objective: To investigate whether obesity during pregnancy poses a risk for subsequent maternal long-term cardiovascular morbidity, after controlling for diabetes and hypertensive disorders. Study design: Data were analyzed from consecutive pregnant women who delivered between 1988 and 1999, and were followed-up until 2010. Long-term cardiovascular morbidity was compared among women with and without obesity in pregnancy (maternal pre-pregnancy body mass index (BMI) of 30 kg/m2 or more). Kaplan–Meier survival curves were used to compare cumulative incidence of cardiovascular hospitalizations. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for long-term cardiovascular hospitalizations. Results: During the study period 46 688 women met the inclusion criteria, 1221 (2.6%) had a BMI ≥30 kg/m2. During a follow-up period of more than 10 years, patients with obesity had higher rates of simple cardiovascular events and total number of cardiovascular hospitalizations. These complications tended to occur at a shorter interval (mean 4871 days ± 950 versus 5060 days ± 1140; p = 0.001). In a Cox proportional hazards model that adjusted for diabetes mellitus, preeclampsia and maternal age, obesity was independently associated with cardiovascular hospitalizations (adjusted HR 2.6, 95% CI 2.0–3.4). Conclusion: Obesity during pregnancy is an independent risk factor for long-term cardiovascular morbidity, and these complications tend to occur earlier. Pregnancy should be considered as a window of opportunity to predict future health problems and as an opportunity to promote womens health. Obese parturients might benefit from cardiovascular risk screening that could lead to early detection and secondary prevention of cardiovascular morbidity.