Midgestation cardiovascular phenotype in women who develop gestational diabetes and hypertensive disorders of pregnancy: comparative study

Abstract

Objective Women with gestational diabetes mellitus (GDM) and/or hypertensive disorders of pregnancy (HDP) are at increased long‐term cardiovascular risk. Mild cardiac functional alterations have been detected in women with GDM or HDP in midgestation, prior to clinical onset of the disease, but these functional alterations have not been found to be useful as screening tools. In contrast, increased impedance to peripheral blood flow, measured by echocardiography or ophthalmic artery Doppler, has been shown to provide incremental value to maternal characteristics for the prediction of pre‐eclampsia. However, it is unknown whether similar changes can be detected in women at risk of GDM. In this study, we performed detailed cardiovascular phenotyping in a large, unselected population of women in midgestation to identify similarities and differences in cardiovascular adaptation in women who are at risk of GDM and/or HDP. Methods This was a prospective observational study in women attending for a routine hospital visit at 19 + 1 to 23 + 3 weeks' gestation. This visit included assessment of flow velocity waveforms from the maternal ophthalmic arteries, echocardiography for assessment of maternal cardiovascular function and measurement of uterine artery pulsatility index and serum placental growth factor (PlGF) for assessment of placental perfusion and function. The measured indices were converted to either multiples of the median (MoM) values or deviation from the median (delta) after adjusting for maternal characteristics and elements of medical history. Biomarker delta or MoM values in the GDM and HDP groups were compared with those in the unaffected group using 95% CI and t‐tests. Results The study population of 5214 pregnancies contained 4429 (84.9%) that were unaffected by GDM or HDP, 509 (9.8%) complicated by GDM without HDP, 41 (0.8%) with GDM and HDP, and 235 (4.5%) with HDP without GDM. In HDP cases, with or without GDM, there was evidence of impaired placentation, with a decrease in PlGF, and increased impedance to flow in the peripheral circulation, suggested by an increase in ophthalmic artery peak systolic velocity (PSV) ratio, peripheral vascular resistance assessed on echocardiography and mean arterial pressure. In the GDM group without HDP, there was no evidence of altered placental perfusion or function and ophthalmic artery PSV ratio was not significantly different from that in the unaffected group; peripheral vascular resistance and mean arterial pressure were increased but to a lesser degree than in the HDP group. In the HDP group, there was an increase in global longitudinal systolic strain and slight increase in isovolumic relaxation time, while in the GDM group, there was an increase in mitral valve E/e′, myocardial performance index and global longitudinal systolic strain. Conclusions In midgestation, women who subsequently develop HDP or GDM have a mild subclinical reduction in left ventricular function. In HDP cases, with or without GDM, there is evidence of impaired placentation and al...

Vascular phenotype at 35–37 weeks' gestation in women with gestational diabetes mellitus

“…In this study, we have demonstrated for the first time an increase in ophthalmic artery PSV ratio in women with GDM. In our previous second-trimester study, before diagnosis of GDM, there was no increase in the ophthalmic artery PSV ratio 17 . These findings suggest progressive or more advanced vascular disease with development of GDM.…”

“…In a first‐trimester screening study, we found that, in 105 women who subsequently developed GDM, compared with 6736 who did not develop GDM, there were increased carotid–femoral pulse‐wave velocity and central systolic blood pressure 4 . In a second‐trimester screening study involving 5214 women, we found that, in 509 women who subsequently developed GDM, maternal hemodynamics, including cardiac output, peripheral vascular resistance and ophthalmic artery PSV ratio, were not significantly different from those in the non‐GDM group 17 . In a cross‐sectional third‐trimester study, we used a handheld pressure tonometer in the radial artery and found that, in 34 women with GDM, compared with 34 non‐diabetic controls, aortic stiffness and augmentation index were marginally increased 3 .…”