Preterm and small for gestational Pregnancy: a stress test age - - PowerPoint PPT Presentation

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Mar 08, 2023 285 likes •348 views

Why hypertension in midlife women? Impact of Prior Preterm or Term Small for Gestational Age Birth Extent of awareness, treatment, and control of high BP Cardiovascular disease among women 40 years in the U.S (%) on Maternal Blood

SLIDE 1

Impact of Prior Preterm or Term Small for Gestational Age Birth

n Maternal Blood Pressure

During the Menopausal Transition: Study of Women’s Health Across the Nation

Ya Yamn mnia I.

I. Corté

tés, , Ph PhD, , MPH MPH, , FNP-BC BC

Assistant Professor School of Nursing University of North Carolina at Chapel Hill

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING 2

Why hypertension in midlife women?

87 90 85 80 82 82 77 71 59 54 55 50 NH WHITE NH BLACK HISPANIC NH ASIAN Awareness Treatment Control

Cardiovascular disease

(CVD) is leading cause of death in women.

High blood pressure (BP)

is a major risk factor for CVD and stroke.

Elimination could reduce

CVD mortality by 38%.

Synchronous effect of

chronologic and reproductive aging

Extent of awareness, treatment, and control of high BP among women ≥ 40 years in the U.S (%)

References: Chobanian et al., Hypertension 2003; Patel et al., Ann Intern Med 2015; Zhang and Moran et al., Hypertension 2014

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Pregnancy: a “stress test”

Sattar and Greer, BMJ 2002; 325; Catov et al., J Women’s Health 2015.

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Preterm and small for gestational age (SGA) delivery

Preterm delivery associated with more rapid

increases in BP even with normotensive pregnancy.

§ Higher BP à coronary artery calcification.

Preterm and SGA delivery associated with

hypertension at age ≤ 45 years.

Preterm birth à BP at late midlife
Whether preterm or SGA delivery is associated with

increases in BP across the menopausal transition is unknown.

References: Catov et al., Hypertension 2013; Catov et al., Hypertension 2018; Xu et al., PLos One 2014.

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Study purpose

To characterize the relationship between history of

preterm and term SGA birth with longitudinal measures of BP during the menopausal transition.

To examine whether self-reported history of preterm

and term SGA birth is associated with prevalent and incident hypertension.

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Detroit, , MI Boston,M ,MA Newark, , NJ Pittsburgh,P ,PA Chicago, , IL Lo Los s Angeles, s, CA Oa Oakland, CA

Mu Multi ti-si site, e, mul ulti-et ethnic, c, longitudinal st study

Study of Women’s Health Across the Nation (SWAN)

= Black = Hispanic = Chinese = Japanese

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Detroit, , MI Boston,M ,MA Newark, , NJ Pittsburgh,P ,PA Chicago, , IL Lo Los s Angeles, s, CA Oa Oakland, CA

Wo Women enrolled 1996-1997 1997

Study of Women’s Health Across the Nation (SWAN)

= Black = Hispanic = Chinese = Japanese

THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Detroit, , MI Boston,M ,MA Newark, , NJ Pittsburgh,P ,PA Chicago, , IL Lo Los s Angeles, s, CA Oa Oakland, CA

Study of Women’s Health Across the Nation (SWAN)

= Black = Hispanic = Chinese = Japanese

Age 42-52 years Pre or early perimenopausal Intact uterus and at least one ovary Menstrual bleeding in past 3 months No hormone therapy in past 3 months

SLIDE 3

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SWAN procedures

Analysis includes baseline and up to 13 follow-up

visits over approx. 16 years

At each visit:

§ Socio-demographics and lifestyle factors § Medical/medication history § Menopause status, hormone therapy § Physical measures (e.g., waist, BMI, BP) § Blood draw (e.g. sex hormones, lipids)

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Research Design and Variables

Pregnancy histo tory (Vi Visit t 13):

§ Preterm birth (delivery <37 weeks gestation) § Term SGA (birth weight ≤10th percentile for gestational age) § Term appropriate for gestational age was referent

Outcome (baseline thru Visit 13):

§ Systolic BP, diastolic BP § Prevalent hypertension (normal, elevated, stage 1, stage 2) § Incident hypertension (systolic BP ≥140 or diastolic BP ≥90 or med)

References: World Health Organization, Weight Percentile Calculator; Flack et al., Am J Hypertens. 2018

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Statistical Analyses

Participant characteristics

§ ANOVA or Kruskal-Wallis and Chi-Square or Fisher’s Exact

Change in BP over time – linear mixed models

§ years since baseline, years since final menstrual period

Prevalence of hypertension - generalized estimating equation
Incident hypertension - cox regression
Sensitivity analyses – excluding history of hypertensive pregnancy
Interactions with race/ethnicity

Model 1 Demographics

(age, site, race/ethnicity)

Model 2 CVD risk factors

(smoking, BMI, physical activity, medications)

Model 3 Reproductive factors

(parity, age at 1st birth, hypertensive/diabetes pregnancy)

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Table 1. Participant characteristics at baseline (n=1772)

Me Mean ± SD SD, Me Media ian [IQR], n (% (%) No A No Adv dver erse e Pr Pregnancy (n (n= 1411) PT PTB (n (n= 197) Te Term-SG SGA (n (n=164) ) P Age, Mean ± SD 46.5 ± 2.7 46.1 ± 2.7 46.8 ± 2.6 0. 0.03 03 Race/Ethnicity White Black Hispanic Chinese 668 (47.4) 361 (25.6) 82 (5.8) 297 (21.1) 93 (47.2) 57 (28.9) 20 (10.2) 27 (13.7) 35 (21.3) 91 (55.5) 10 (6.1) 28 (17.1) <0 <0.0001 College degree 606 (43.5) 75 (38.1) 63 (38.9) 0.39 Hard to pay for basics 344 (26.0) 62 (33.0) 62 (42.2) <0 <0.0001 Age at first birth, Mean ± SD 25.9 ± 6.0 24.9 ± 6.0 23.4 ± 6.0 <0 <0.0001 Parity ≥4 175 (12.4) 47 (23.9) 41 (25.0) <0 <0.0001 Gestational diabetes 64 (4.5) 14 (7.3) 16 (9.8) <0 <0.0001 Hypertensive pregnancy 115 (8.2) 32 (16.7) 23 (14.1) <0 <0.0001 Current smoker 192 (13.7) 32 (16.3) 32 (19.5) 0.11 Physical activity 7.8 ± 1.8 7.6 ± 1.6 7.3 ± 1.7† 0. 0.04 04 BMI (kg/m2) 27.9 ± 7.1 28.2 ± 7.5 28.8 ± 7.3 0.31 Total cholesterol 193.3 ± 33.1 198.2 ± 37.6 194.0 ± 33.9 0.17 Diabetes 34 (2.4) 17 (8.6) 12 (7.3) 0. 0.0006 0006 Systolic BP (mm/Hg) 115.8 ± 16.0 119.6 ± 15.9‡ 121.6 ± 16.8ψ <0 <0.0001 Diastolic BP (mm/Hg) 74.6 ± 10.1 76.3 ± 10.5† 77.5 ± 10.1‡ 0. 0.0004 0004 Antihypertensive treatment 119 (8.4) 23 (11.7) 23 (14.0) 0. 0.03 03

Note: BP= blood pressure; PTB = preterm birth; SGA= small for gestational age

SLIDE 4

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A B C D

Blood Pressure from Baseline to Visit 13 According to Pregnancy History

*A *Adjusted : Term SGA: 1.77, p= 0.03 Term SGA*Time: -0.03, p= 0.87 *A *Adjusted : Term SGA: -1.13, p= 0.52 Term SGA*Time: -0.56, p= 0.06 *A *Adjusted : Term SGA: -1.85, p= 0.12 Term SGA*Time:-0.41, p= 0.06 FMP FMP *A *Adjusted: Term SGA: 2.20, p= 0.08 Term SGA*Time: -0.64, p= 0.03

Un Unadjusted Systolic Blood Pressure (Y (Years rs S Sin ince B Baselin line) Un Unadjusted Systolic Blood Pressure (Y (Years rs S Sin ince FM FMP) Un Unadjusted Di Diastolic Blood Pressure (Y (Years rs S Sin ince B Baselin line) Un Unadjusted Di Diastolic Blood Pressure (Y (Years rs S Sin ince FM FMP)

Te Term SGA Pr Preterm No No Adverse

*a *adjusted for time since baseline, baseline age, site, race/ethnicity, financial strain, smoking, physical activity, BM BMI, medic icatio tions (B (BP, di diabet abetes es, , lip lipid id-lo lowerin ing). THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Od Odds s of eleva vated blood pressu ssure or hyp ypertensi sion ac accor

ding ng to

pregnanc egnancy hi histor

ry (bas

basel eline ne to

Visit 13)

13)

PT PTB Te Term rm-SG SGA OR OR (95% CI) P OR OR (95% CI) P Crude 1.60 (1.26, 2.03) 0.0001 1.68 (1.31, 2.15) <0.0001 Model 1 1.50 (1.17, 1.92) 0.001 1.14 (0.85, 1.53) 0.38 Model 2 1.52 (1.14, 2.02) 0.004 1.26 (0.90, 1.76) 0.19 Model 3 1.41 (1.03, 1.94) 0.03 1.42 (0.98, 2.06) 0.06

*Reference group = term and appropriate for gestational age *Elevated BP or hypertension = systolic ≥ 120, diastolic ≥ 80, or anti-hypertensives (ACC/AHA 2017)

Note. AGA= appropriate for gestational age, PTB =preterm birth, SGA= small for gestational age.

Model 1, adjusted for time since baseline, baseline age, study site, race/ethnicity, financial strain Model 2, Model 1 + smoking, physical activity, menopause status, and BMI, medications (diabetes, lipid-lowering). Model 3, Model 2 + parity, age at first birth, excluding gestational hypertension/preeclampsia and gestational diabetes.

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Cox Cox regr egres ession

n for
r inc

ncidenc dence e of

f hy

hyper pertens ension

(b (baseline t to V Visit 1 13) )

PT PTB Te Term rm-SG SGA HR ( (95% 95% C CI) I) P HR ( (95% 95% C CI) I) P Crude 1.42 (1.29, 1.56) <0.0001 1.32 (1.19, 1.46) <0.0001 Model 1 1.44 (1.31, 1.58) <0.0001 1.24 (1.11, 1.39) <0.0001 Model 2 1.28 (1.11, 1.47) 0.001 1.15 (0.98, 1.35) 0.08 Model 3 1.36 (0.96, 1.94) 0.09 1.12 (0.76, 1.66) 0.56

*Reference group = term and appropriate for gestational age *Excluded women with systolic BP ≥140 or diastolic BP ≥90 or reported use of anti-hypertensive at baseline

Note. AGA= appropriate for gestational age, PTB =preterm birth, SGA= small for gestational age.

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Summary

At baseline, women with prior preterm and term SGA

delivery had higher BP.

Association between pregnancy history and BP measures

was similar by chronologic vs. reproductive aging.

History of preterm and term SGA delivery associated with

hypertension, but more pronounced with preterm birth and perhaps independent of hypertensive pregnancy.

No interactions with race/ethnicity.

SLIDE 5

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Limitations and Strengths

Li Limitat ations

ns:
Could not assess pre-pregnancy risk factors
Retrospective recall of pregnancy history

Str Strength ths:

Established multi-site, multi-ethnic cohort
Repeated measures of BP up to 16 years
Assessed chronological and reproductive aging

17 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Conclusions

Association between preterm and term SGA delivery

and elevated BP persists in the menopausal transition, but more pronounced with preterm birth.

Additional analyses are necessary to examine if rate
f change differs across stages of reproductive aging.
These findings are important as elevations in blood

pressure in these groups of women may be linked to future cardiovascular disease.

18 THE UNIVERSITY of NORTH CAROLINA at CHAPEL HILL SCHOOL of NURSING

Acknowledgments

Study of Women's Health Across the Nation (SWAN) has grant support from:

National Institute on Aging (NIA): U01AG012505, U01AG012535, U01AG012531, U01AG012539, U01AG012546, U01AG012553, U01AG012554, U01AG012495 National Institute of Nursing Research (NINR, U01NR004061) and NIH Office of Research on Women's Health (ORWH)

Cardiovascular Epidemiology Training Program (T32HL083825) Co-authors:

Emma Barinas-Mitchell Maria Brooks Janet M. Catov Karen A. Matthews

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SLIDE 6

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References

Catov JM. Pregnancy as a Window to Cardiovascular Disease Risk: How Will We Know? J Women’s Health (Larchmt). 2015;24(9):691-692. Catov JM, Snyder GG, Fraser A, et al. Blood Pressure Patterns and Subsequent Coronary Artery Calcification in Women Who Delivered Preterm Births. Hypertension. 2018;72(1):159- 166. Catov JM, Lewis CE, Lee M, Wellons MF, Gunderson EP. Preterm birth and future maternal blood pressure, inflammation, and intimal-medial thickness: the CARDIA study. Hypertension. 2013;61(3):641-646. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206–1252. doi: 10.1161/01.HYP.0000107251.49515.c2. Cortes YI, Catov JM, Brooks M, et al. History of Adverse Pregnancy Outcomes, Blood Pressure, and Subclinical Vascular Measures in Late Midlife: SWAN (Study of Women's Health Across the Nation). J Am Heart Assoc. 2017;7(1).

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References

Flack JM, Calhoun D, Schiffrin EL. The New ACC/AHA Hypertension Guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Am J

Hypertens. 2018;31(2):133-135.

Matthews KA, Crawford SL, Chae CU, Everson-Rose SA, Sowers MF, Sternfeld B, Sutton- Tyrrell K. Are changes in cardiovascular disease risk factors in midlife women due to chronological aging or to the menopausal transition? J Am Coll Cardiol. 2009;54:2366–2373 Patel SA, Winkel M, Ali MK, Narayan KM, Mehta NK. Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data. Ann Intern Med. 2015;163:245– 253. doi: 10.7326/M14-1753. Sattar and Greer, BMJ 2002; 325. World Health Organization.www.who.int/reproductivehealth/.../weight_percentiles_calculator.xls. Accessed October 9, 2015. Xu J, Barinas-Mitchell E, Kuller LH, Youk AO, Catov JM. Maternal hypertension after a low-birth- weight delivery differs by race/ethnicity: evidence from the National Health and Nutrition Examination Survey (NHANES) 1999-2006. PLoS One. 2014;9(8):e104149.