Gestational diabetes and gestational hypertension -
Question What is the association of the concomitant occurrence of gestational diabetes GD and gestational hypertensive disorder GHTD with the incidence of cardiovascular diseases CVD? A risk that is significantly higher than that of the CVD risk associated with each of these conditions in isolation.
Meaning These findings suggest that the co-occurrence of GD and GHTD is associated with a high postpartum CVD risk. Importance Accruing evidence suggests that gestational hypertensive disorders GHTD and gestational diabetes GD are each associated with an increased risk of cardiovascular disease CVD.
However, the extent to which the co-occurrence of GHTD and GD is associated with the risk of CVD remains largely unknown. Objective To estimate the individual and joint associations of GHTD and GD with incident CVD. Design, Setting, and Participants This population-based cohort study used the Ministry of Health and Long-Term Care of Ontario Canada health care administrative databases.
Women with pregravid diabetes, hypertension, or cardiovascular disease were excluded. Statistical analysis was performed from November to September Main Outcomes and Measures Individual and joint associations of GHTD and GD with incident CVD including a composite of myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy , estimated using Cox regression models, adjusting for relevant cardiometabolic risk factors.
The follow-up extended from the index pregnancy until March 31, In the early postpartum phase first 5 years post partum , there was no association of co-occurrence of GTHD and GD adjusted hazard ratio [aHR], 1.
In the late postpartum period after the initial 5 years post partum , compared with no GD and no GHTD, isolated GHTD aHR, 1. There was no association between isolated GD and incident CVD. Conclusions and Relevance In this cohort study, GHTD was associated with a high risk of CVD post partum, and the co-occurrence of GD and GHTD was associated with a much greater postpartum CVD risk.
These findings suggest that CVD preventive care is particularly needed in the aftermath of combined GD and GHTD. Cardiovascular disease CVD is common 1 and increasingly frequent among young individuals, including women of childbearing age.
However, there is a dearth of studies on the joint influence of GHTD and GD on the incidence of cardiovascular events. The extant study that has examined the joint association of GHTD and GD with outcomes 10 did not include cardiovascular outcomes separately from the mortality outcome.
The existing studies showing a significant association of the co-occurrence of GD and GHTD with an adverse cardiometabolic risk factor profile 11 and with poor neonatal outcomes, 12 compared with isolated GD or isolated GHTD, suggest that the joint occurrence of GD and GHTD would be similarly associated with poor postpartum cardiovascular outcomes.
Using data from the health care administrative databases from the Ontario Ministry of Health and Long-Term Care MOHLTC in Canada, we sought to examine the individual and conjoint associations of GHTD and GD with the risks of CVD. We hypothesized that the combined presence of GHTD and GD would be associated with a higher risk of CVD postpartum than each of these individual conditions, in which case the identification of GHTD and GD in young women could help in the stratification of the risk of future CVD.
We followed the Strengthening the Reporting of Observational Studies in Epidemiology STROBE reporting guideline for cohort studies. Our sample of participants consisted of all the women in Ontario, the most populous province in Canada.
These women have their health data captured in the health care administrative databases from the MOHLTC. The databases include the Canadian Institute for Health Information CIHI Discharge Abstract Database from all hospitalizations and Same Day Surgery from day surgery institutions in Ontario, the Ontario Health Insurance Plan OHIP physician service claims for reimbursement for virtually all physician consultations, procedures, and visits; and the Registered Persons Database for demographic information for all residents eligible for health care in Ontario.
The Ontario Hypertension Database is a validated registry of physician-diagnosed nongestational hypertension that is derived using these data. Individuals are linked between data sources through a unique and reproducibly encrypted health card number.
In the present study, we included women with a live-birth singleton delivery between July 1, , and March 31, We excluded women with a history of diabetes, a history of hypertension, or a history of CVD prior to the index pregnancy, which were ascertained using the relevant International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada ICDCA codes.
For women with multiple deliveries, only the first delivery was considered in our investigation. The additional criteria of exclusion from the study are detailed in eFigure in Supplement 1.
GD was identified using the ICDCA codes E1 and O24 in the hospital records at index pregnancy or physician billings with a diagnosis ICD-9 code claimed within 90 days prior to delivery. Using the GHTD and GD status of each woman, we classified them as having neither of the conditions, either, or both.
Although our ascertainment did not directly rely on glucose measurements, in Canada, screening and testing for GD is typically performed between 24 and 28 weeks of gestation, using a 2-step approach, which involves screening using a g glucose challenge test GCT.
The outcome was incident CVD defined as a composite of hospitalization for myocardial infarction, acute coronary syndrome, stroke, coronary artery bypass grafting, percutaneous coronary intervention, or carotid endarterectomy. The women were followed from the index pregnancy until cardiovascular disease event, death, migration, or March 31, , whichever came first.
The CVD events were identified through linkage with databases including a hospital discharge database for clinical diagnoses and procedures, and day surgery institutions for percutaneous intervention PCI , from the index gestation until March 31, The ICD codes I20 to I25 were used for coronary heart disease, and the ICD codes I60 to I69, G08, G46, and H34 for cerebrovascular disease.
In addition, we also used the procedure codes for coronary artery bypass graft and carotid endarterectomy codes shown in eTable 1 in Supplement 1.
The covariates considered in our analyses included age at index delivery, socioeconomic status ascertained ecologically based on neighborhood household income quintile , rurality of residence ascertained using the Rurality Index of Ontario , 16 parity, preterm delivery, chronic kidney disease defined using a previously validated algorithm 17 , GHTD at prior pregnancy, GD at prior pregnancy, preexisting circulatory disease other than the outcomes of interest , postpartum progression to diabetes, and postpartum development of hypertension.
The baseline characteristics of the study population were presented by categories of GHTD and GD, including 4 groups: 1 no GD and no-GHTD, 2 no-GD and GHTD, 3 no-GHTD and GD, and 4 GD and GHTD. Continuous variables were presented as mean and SD or median and IQR for variables with skewed distributions , and categorical variables as percentages.
The differences in baseline characteristics were tested using χ 2 tests for categorical variables and appropriate parametric or nonparametric tests for continuous variables. For incident CVD, we assessed the risk across the exposure categories with no GD and no-GHTD as the reference , using Cox proportional hazards regression models.
The outcome was first compared between the study groups using the log-rank test with Kaplan-Meier curves. Proportionality assumptions were tested by Schoenfeld residuals for both individual covariates and the global Schoenfeld test.
This revealed time-dependency in the association of study groups with the CVD outcome. We therefore built piecewise Cox proportional hazards models over 2 periods 18 :— 1 an early postpartum phase first 5 years postpartum and a late postpartum phase after initial 5 years after index delivery.
In addition to the aforementioned comparisons, we also conducted a direct comparison between isolated GD reference and isolated GHTD, in terms of incident CVD outcome, using similar Cox proportional hazards regression models.
We conducted sequential adjustments. In an initial model model 1 , we adjusted for age at index delivery, socioeconomic status, and parity. In a subsequent model model 2 , we adjusted for model 1 variables, rurality of residence, preterm delivery, chronic kidney disease, GHTD in a previous pregnancy, GD in a previous pregnancy, and preexisting circulatory disease other than the CVD outcomes of interest.
In a final model model 3 , we adjusted for model 2 variables, postpartum development of diabetes as a time-varying covariate , and postpartum development of hypertension as a time-varying covariate.
All analyses were done using SAS version 9. Women with GD and GHTD were older, less likely to have a premature delivery and prior GHTD, but more likely to have developed postpartum diabetes, and postpartum hypertension.
The characteristics of study participants by CVD status at follow-up are also shown in eTable 2 in Supplement 1. Over the total follow-up period The Figure shows the Kaplan-Meier cardiovascular disease-free survival curves by study groups across the entire study period.
During the initial 5 years after index delivery, individuals who experienced both GD and GHTD had the highest incidence of CVD events highest absolute risk of all study groups Table 2. Their relative risk of incident CVD as compared with those without GD or without GHTD was however attenuated with adjustment for confounders such that it was no longer statistically significantly higher.
Indeed, after full adjustment for confounders including postpartum diabetes and postpartum hypertension , the estimate for the association of incident CVD with the co-occurrence of GHTD and GD adjusted hazard ratio [aHR]: 1. The corresponding estimate of association with CVD model 3 in Table 2 was significant for isolated GHTD aHR, 1.
During the first 5 years after the index delivery, after full adjustment including postpartum hypertension, and postpartum diabetes isolated GHTD was associated with a greater risk for incident CVD than isolated GD aHR, 2. After the initial 5-year period following the index delivery, there were notable differences in absolute risk incidence rate of cardiovascular events across the study groups Table 2.
The highest absolute CVD risk was observed among those with concomitant GD and GHTD, which was approximately 2- to 3-fold that of isolated GD or isolated GHTD. Individuals who experienced both GD and GHTD had a 2. The corresponding estimates for the association of CVD with isolated GHTD aHR, 1.
A direct comparison showed that isolated GHTD and isolated GD reference had similar risks of incident CVD after full adjustment aHR, 1. In this large population-based cohort study, extended follow-up after delivery found that while GHTD and GD would each be individually associated with a high risk of CVD, women who experienced both GHTD and GD during a pregnancy were ultimately at significantly higher absolute and relative risk of CVD, as compared to those without either of these conditions.
Over time, this risk became more pronounced than that observed among women with each of these conditions separately. The observed association with concomitant GHTD and GD was present even after accounting for postpartum diabetes and postpartum hypertension. To our knowledge, this study is the largest in which the joint association of GHTD and GD with postpartum CVD has been examined.
Our results corroborate those reported in a prior study on the deleterious cardiovascular impact of the co-occurrence of GHTD and GD. The latter study was however smaller in size compared to ours, did not examine CVD separately from all-cause mortality, 10 and did not comprehensively account for potential confounding factors eg, postpartum diabetes, and postpartum hypertension.
The combination of GHD and GD may represent a more severe form of maladaptive pregnancy changes that substantially contribute to future CVD.
Our findings on the extent of CVD risk associated with concomitance of GHTD and GD have potential practical implications. These suggest that systematic detection of GHTD and GD during pregnancy is important for long-term prediction of future CVD in the postpartum. The relevance of such screening is illustrated by the rising burden CVD in the younger population 2 ; the risk of CVD related to GD and GTHD, 4 , 9 , 19 - 21 and the increasing prevalence of both GTHD and GD in Canada 24 and the US.
This prevention opportunity is congruent with the recommendations of the American Heart Association 28 and American College of Obstetricians and Gynecologists. The mechanistic pathways linking GD and GHTD to a heightened CVD risk are incompletely understood. Insulin resistance could be a common underlying pathway linking both GHTD and GD to CVD.
GD and GHTD may reflect a latent underlying and intrinsic high-risk phenotype characterized by cardiometabolic dysregulation, and hence the heighten CVD risk over time.
Thus, partly explaining the differential CVD risks observed in the immediate vs distant postpartum periods. There are limitations to our study. First, some cardiovascular risk factors, are not captured in administrative databases used in our investigation, thus the possibility of residual confounding.
These include biological eg, lipid levels and body mass index and behavioral eg, smoking, alcohol use, dietary intake, and physical activity factors. It is important to indicate that extant evidence suggests that women with GHTD or GD have an adverse CVD risk factor profile irrespective of body mass index before, 38 - 41 and after pregnancy.
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Download references. This study was supported by intramural funding, provided by the E-Da Hospital EDAHP, EDAHP and EDAHI Department of Pediatrics, E-Da Hospital, I-Shou University, No. School of Medicine for International Students, College of Medicine, I-Shou University, No.
Department of Obstetrics and Gynecology, E-Da Hospital, I-Shou University, No. You can also search for this author in PubMed Google Scholar.
YHH and CCT conceived the idea. YTS, SJT, MCY, and LCC collected the data. HPK, YTS, YHH, CCT, and SJT analyzed and organized the data. YHH and CCT performed the result analysis and discussion. HPK drafted the manuscript. YHH and CCT reviewed and edited the manuscript.
All authors reviewed and approved the final manuscript. Correspondence to Yun-Hsiang Hung or Ching-Chung Tsai. The Institutional Review Board of the E-DA Hospital approved this study EMRP— , which utilized data from the Taiwan National Health Insurance Research Database.
The database encrypts patients' identity data, and the study solely utilized encrypted data without any direct contact with study participants. Therefore, the need for informed consent was waived by the Institutional Review Board of the E-DA Hospital.
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Gestational diabetes is diabetes diagnosed for diaetes first dibetes during pregnancy Enhance metabolic activity. Like other Geatational of diabetes, gestational Blueberry snack ideas affects Blueberry snack ideas your cells use sugar glucose. Gestational diabetes causes high blood sugar that can affect your pregnancy and your baby's health. While any pregnancy complication is concerning, there's good news. During pregnancy you can help control gestational diabetes by eating healthy foods, exercising and, if necessary, taking medication.Chris L. Bryson, George N. Ioannou, Stephen J. Gestational diabetes Gestxtional pregnancy-induced hypertension are ane, and their relation is not well understood. The viabetes conducted a population-based case-control Gestxtional using — Washington State birth certificate and Gestationao discharge records Gestationao investigate this Android vs gynoid fat distribution influence on fat burning potential. Gestational diabetes was more common in each case group 3.
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Unconditional logistic regression was used to simultaneously control for multiple confounders and to model interactions. Each case group was modeled independently of the others with the same control group.
We assessed the statistical significance of effect modification between gestational diabetes and each of the covariates by using the likelihood ratio test.
Age was Gestationall as a linear variable, Gestatilnal body mass index, parity, and degree of prenatal care were modeled as indicator variables to allow for either linear or nonlinear effects. In general, women with pregnancy-induced hypertension tended to be younger, be a primigravida, and have a higher body mass index compared with controls table 1.
In addition, they were more likely to receive adequate prenatal care. Gestational diabetes was more common in each of the pregnancy-induced hypertension case groups than in controls table 2with prevalences Gestationl 3.
After adjustment for body mass index, age, ethnicity, parity, and adequacy of prenatal care, gestational diabetes was found to be associated with a significant 1. Ethnicity was found to significantly modify the association between gestational diabetes and subtypes of pregnancy-induced hypertension table 3.
Because of the small number of eclamptic cases, the eclampsia and severe pre-eclampsia case groups were combined for this analysis. In this combined case group, White mothers with gestational diabetes had a 1. Similar increases in the risk of mild pre-eclampsia and gestational hypertension were found among White mothers.
Black mothers with gestational diabetes had a three- to fourfold higher risk of pregnancy-induced hypertension compared with Black mothers without gestational diabetes. This finding reflected the largest increase in risk among the ethnic groups.
The amount and timing of prenatal care also modified the association between gestational diabetes and the most severe forms of pregnancy-induced hypertension table 4. Compared with mothers without gestational diabetes, mothers with gestational diabetes who received less prenatal care less than 80 percent of the expected visits had a higher risk of both eclampsia and preeclampsia than did mothers with gestational diabetes and receiving more prenatal care eclampsia: high care vs.
low care, 0. low care, 1. The risk of gestational hypertension and mild preeclampsia associated with gestational diabetes was also higher among women receiving inadequate prenatal care, although this finding failed to achieve statistical significance. We were unable to find any significant interactions between gestational diabetes and body mass index, age, or parity.
Furthermore, the diabeted of the study were unchanged when the women who refused classification of ethnicity were excluded from analysis data not shown. In this large, population-based study, we found a significantly increased risk of gestational hypertension, mild pre-eclampsia, and severe preeclampsia among women with gestational diabetes.
After adjustment for confounders, the risk of developing these serious disorders was 1. Results also suggest that both ethnicity and prenatal care modify the association between gestational diabetes and pregnancy-induced hypertension.
Our results are consistent with the findings from several prior studies. One cohort study of 10, women in Sweden examined risk factors for gestational hypertension and preeclampsia 6.
These data were collected from a similar birth registry, using ICD-9 codes to classify gestational diabetes and case status, but were restricted to nulliparous women less than age 34 years.
A number of other studies have examined the association between gestational diabetes and pregnancy-induced hypertension, although some have been limited by small sample size or limited descriptive information 459 Nonetheless, three of these studies 4510 also found a higher proportion of pregnancy-induced hypertension among women with gestational diabetes compared with women without gestational diabetes.
A prospective study of women participating in a calcium supplementation trial for the prevention of preeclampsia also demonstrated that the degree of abnormal glucose tolerance was associated with preeclampsia We found interactions between ethnicity and gestational diabetes regarding their association with eclampsia and severe preeclampsia; trends were similar for the outcomes of gestational hypertension and mild preeclampsia.
We also found that the association between gestational diabetes and pregnancy-induced hypertension differed among the high and low prenatal care groups. Gestational diabetes was associated with a lower risk of pregnancy-induced hypertension among those women who received more prenatal care.
While inadequate prenatal care has been described as increasing the risk of preeclampsia by 30 percent 1618to our knowledge it has not been previously portrayed as modifying the effect of other risk factors for pregnancy-induced hypertension.
Other studies and trials have suggested that aggressive early treatment of high-risk mothers might reduce the risk of preeclampsia 21 — Additionally, it has been suggested that the decreasing incidence rate of eclampsia over the past 20 years is due in part to better prenatal care Alternatively, this association could result from incomplete ascertainment and exclusion of preexisting diabetic and hypertensive disorders or related types of correlated misclassification.
This bias would lead to a relative enrichment of these disorders and misclassification of gestational diabetes and pregnancy-induced hypertension among mothers not receiving adequate prenatal care. If this bias is present, the lack of association between gestational diabetes and eclampsia or severe preeclampsia in the group receiving adequate or better care may reflect the least biased estimate.
Differential misclassification of pregnancy-induced hypertension and gestational diabetes according to degree of prenatal care is also possible; in this instance, women who receive more prenatal care might be more likely to have their gestational diabetes or pregnancy-induced hypertension diagnosed, resulting in a stronger-than-expected association.
However, we found the strongest association between gestational diabetes and pregnancy-induced hypertension for women receiving the least prenatal care in all case groups. Furthermore, the exposure, the outcome, and prenatal care variables were all ascertained from the hospital discharge record of the birth event.
This single point of data bestational may limit errors that occur in large administrative databases compiled at different time points for different persons and makes this population data cross-sectional, reducing the possibility that recording of these variables was influenced by the frequency of preceding prenatal visits.
Overall, our findings do not prove that prenatal care and the treatment of underlying risk factors, such as diabetes and hypertension, can prevent more severe forms of pregnancy-induced hypertension but rather support the need for further investigation into this observation.
This study has several other limitations. We used administrative data, which may include women incorrectly classified as either 1 having pregnancy-induced hypertension or gestational diabetes when, according to strict criteria, they do not have these diseases or 2 not having case status or gestational diabetes when they would have met diagnostic criteria for these diseases.
Misclassification may occur more frequently with the less severe outcomes of gestational hypertension and mild preeclampsia and, less frequently, with severe preeclampsia and eclampsia.
This misclassification would tend to decrease the observed magnitude of a true relation between gestational diabetes and gestational hypertension or gestational diabetes and mild preeclampsia.
Missing data is an expected difficulty arising from use of a large administrative database. We found that gestational diabetes is associated with severe preeclampsia, mild preeclampsia, and gestational hypertension and that women with gestational diabetes appear to be at a 1.
The risk for pregnancy-induced hypertension associated with gestational diabetes varied among different maternal ethnicity groups and also by degree of prenatal care. These findings contribute to the understanding of these disorders and support the findings of prior studies that suggest an association between gestational diabetes and pregnancy-induced hypertension.
This work was supported in part by resources at VA Puget Sound, Seattle, Washington. Bryson was a VA Health Services Research and Development fellow while this work was conducted.
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: Gestational diabetes and gestational hypertension| Gestational diabetes - Symptoms & causes - Mayo Clinic | It might lead to the baby being born early and also could cause Elderberry extract for skin health or a stroke a blood clot or a bleed in the brain that hyprtension lead to Gestational diabetes and gestational hypertension damage in the woman during labor Blueberry snack ideas delivery. Gestational diabetes and gestational hypertension HAPO study showed hypertensuon PE is ddiabetes positively hyperrension with Gesational maternal glucose level, for every 1-standard deviation increase in OGTT blood glucose fasting, 1 h, and 2 hwith the odds ratio of PE between 1. Association of higher HbA1c within the normal range with adverse pregnancy outcomes: a cross-sectional study. Cheung NW, Jiang S, Athayde N. Exposure to maternal HDP abnormal in utero environment may negatively impact the fetal functional expression of the hormonal axis and metabolites, increasing the risk of childhood obesity, endocrine disorders, and glucose metabolism abnormity, in offspring [ 789 ]. Poirier CDesgagné VGuérin Ret al. Thomas C, Hypponen E, Power C. |
| REVIEW article | Uypertension Gestational diabetes and gestational hypertension metformin and insulin in the treatment Optimal training gestational diabetes: a retrospective, case-control qnd. BMJ Open Diabetes Res Gestational diabetes and gestational hypertension. Gestatilnal Med Cell Longev. Contreras KR, Kominiarek MA, Zollinger TW. Black mothers with gestational diabetes had a three- to fourfold higher risk of pregnancy-induced hypertension compared with Black mothers without gestational diabetes. BMJ Paediatr. Joffe GM, Esterlitz JR, Levine RJ, Clemens JD, Ewell MG, Sibai BM, et al. |
| Introduction | However, the estimated relative risk was the highest for RDS with an aOR of 6. Balani J, Hyer SL, Rodin DA, Shehata H. Br Med J. Such modulation in girls might increase the propensity to develop gestational diabetes. A similar association may be found in women with recent GDM. BMC Med 21 , 59 |
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