Metabolic disorders during pregnancy and postpartum cardiometabolic risk

in Endocrine Connections

Hormonal changes during pregnancy can trigger gestational diabetes (GDM), which is constantly increasing. Its main characteristic is pronounced insulin resistance, but it appears to be a multifactorial process involving several metabolic factors; taken together, the latter leads to silent or clinically evident cardiovascular (CV) events. Insulin resistance and central adiposity are of crucial importance in the development of metabolic syndrome, and they appear to correlate with CV risk factors, including hypertension and atherogenic dyslipidaemia. Hypertensive disease of pregnancy (HDP) is more likely to be an accompanying co-morbidity in pregnancies complicated with GDM. There is still inconsistent evidence as to whether or not co-existent GDM and HDP have a synergistic effects on postpartum risk of cardiometabolic disease; however, this synergism is becoming more accepted since both these conditions may promote endothelial inflammation and early atherosclerosis. Regardless of the presence or absence of the synergism between GDM and HDP, these conditions need to be dealt early enough, in order to reduce CV morbidity and to improve health outcomes for both women and their offspring.

Abstract

Hormonal changes during pregnancy can trigger gestational diabetes (GDM), which is constantly increasing. Its main characteristic is pronounced insulin resistance, but it appears to be a multifactorial process involving several metabolic factors; taken together, the latter leads to silent or clinically evident cardiovascular (CV) events. Insulin resistance and central adiposity are of crucial importance in the development of metabolic syndrome, and they appear to correlate with CV risk factors, including hypertension and atherogenic dyslipidaemia. Hypertensive disease of pregnancy (HDP) is more likely to be an accompanying co-morbidity in pregnancies complicated with GDM. There is still inconsistent evidence as to whether or not co-existent GDM and HDP have a synergistic effects on postpartum risk of cardiometabolic disease; however, this synergism is becoming more accepted since both these conditions may promote endothelial inflammation and early atherosclerosis. Regardless of the presence or absence of the synergism between GDM and HDP, these conditions need to be dealt early enough, in order to reduce CV morbidity and to improve health outcomes for both women and their offspring.

Introduction

There are several pregnancy indices of hormonal changes (such as oestrogens, progesterone, corticotropin-releasing hormone, cortisol, human placental growth hormone and human placental lactogen) that are implicated in the development of gestational diabetes (GDM) cases (1). Epidemiological evidence has consistently shown that among mothers with prior history of GDM, 30–84% of them had GDM recurrence in subsequent pregnancies (2), 20–40% developed metabolic syndrome (MetS) within 2–20 years (3, 4) and 17–63% developed type 2 diabetes mellitus (T2DM) and obesity within 5–16 years (5, 6, 7). Longitudinal studies have shown that women with prior GDM and obesity were at higher risk to develop MetS compared with those without such metabolic history (8), and these women with prior GDM and obesity had relatively higher values of anthropometric parameters (such as BMI and waist circumference), blood pressure, glucose, homeostatic model assessment, insulin, C-peptide and fibrinogen, together with lower HDL-C levels (9).

Insulin resistance and central adiposity are of crucial importance in the development of MetS, and they appear to correlate with cardiovascular (CV) risk factors, including hypertension, atherogenic dyslipidaemia and glucose intolerance. The underlying mechanism of GDM is mainly pronounced insulin resistance (1). However, other factors, such as race, ethnicity, environmental and genetic factors (10), appear to contribute to the development of silent or clinical CV events. Interestingly, hypertensive disease of pregnancy (HDP) is very likely to be an accompanying co-morbidity in pregnancies complicated with GDM (11, 12, 13). Indeed, both these gestational complications share common risk factors such as maternal age, parity and pre-pregnancy BMI. Arguably, they may also share underlying mechanisms predisposing to subsequent recurrence of pregnancy complications and postpartum cardiometabolic disorders (14, 15, 16, 17, 18).

However, it may also be true that HDP and GDM are the result of inherent susceptibility to cardiovascular disease (CVD). Mothers who were obese or had a personal history of chronic hypertension or diabetes before pregnancy are more likely to develop HDP or GDM (19, 20, 21), and family history of CV risk is closely related to future CVD (22, 23).

Is there a synergistic effect of GDM and HDP on postpartum cardiometabolic risk?

It has been reported that there is a significant link between pregnancy complications (GDM and HDP) and CVD later in life (18, 24), since HDP and GDM may promote endothelial inflammation and early atherosclerosis independently of underlying conditions (25, 26, 27, 28, 29, 30). HDP and GDM also negatively impact on inflammatory biomarkers, including higher levels of plasminogen activator inhibitor-1, adiponectin, C-reactive protein, leptin and TNF alpha (1, 14). Importantly, these inflammatory biomarkers play an important role beyond their role in diabetes, insulin resistance, visceral obesity, CVD and hypertension (32, 33). Moreover, GDM and HDP are linked with elevated LDL-C and small dense LDL particles, which are implicated in CVD (31, 34).

Even though GDM and HDP may co-exist in pregnancies of the same mothers and are associated with CV risk, some controversy remains as to whether or not co-existent GDM and HDP have a synergistic effect to the risk of postpartum cardiometabolic disease (13). GDM or HDP is associated with a 15-fold higher risk in postpartum diabetes, with a sixfold greater risk of postpartum hypertension and a 40% risk increase for CVD mortality in the mothers (35). Meta-analyses have demonstrated that GDM is associated with a sevenfold higher risk of T2DM in affected mothers, and HDP is associated with a double risk of postpartum diabetes (5, 26). It has also been shown that a prior GDM can enhance the risk of having not only T2DM but also CVD, independently (36).

Interestingly, the study of Li et al. (37) shows that GMD and HDP contribute independently and not synergistically to the postpartum cardiometabolic risk, and this was somewhat unexpected, given the accumulating evidence (35, 36, 37) that suggest that these conditions interplay in increasing the risk of diabetes, hypertension and CVD later in the mothers’ lives as well as in their offspring (10, 26, 38). There are some potential limitations in the study of Li et al. that need to be briefly discussed (37). First, the small cohort of subjects and the relative brief follow-up period. In addition, GDM cases may be somewhat misclassified because the diabetes diagnosis required fasting and/or the 2-h glucose testing after a 75 g oral glucose intake. Further, the data on GDM and HDP history were based on self-reports only. Finally, as already highlighted by the authors, since some mothers with an episode of GDM and/or HDP did not or were not able to conceive, subsequently, these findings could have underestimated their risks.

It is well known in literature that women with GMD and HDP are more prone to MetS (39, 40, 41), and they appear to transmit an increased risk to the offspring through vertical transmission (8). Thus, it seems that women with GMD and HDP create an adverse metabolic memory (42).

Conclusion

Women who have had GDM and/or HDP are now recognised to carry a high risk of CVD and, regardless of the presence or absence of the synergism between GDM and HDP, they need to be followed very carefully. Indeed, the American Heart Association recommends long-term surveillance and management of CV risk factors in women with these pregnancy-related complications (43, 44). Of note, many women with GDM have later in life an undiagnosed T2DM (45) and, therefore, increased awareness of GDM and HDP is needed. In addition, postpartum screening tools and biomarkers of subsequent risk are very helpful in long-termfollow-up.

Declaration of interest

All authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this editorial. This editorial was written independently. The authors have given talks, attended conferences and participated in advisory boards and trials sponsored by various pharmaceutical companies.

Funding

This work did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

References

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    GundersonEPJacobsDRJrChiangVLewisCEFengJQuesenberryCPJrSidneyS. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: a 20-year prospective study in CARDIA (Coronary Artery Risk Development in Young Adults). Diabetes 2010 59 495504. (https://doi.org/10.2337/db09-1197)

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    RizviAACuadraSNikolicDGiglioRVMontaltoGRizzoM. Gestational diabetes and the metabolic syndrome: can obesity and small, dense low density lipoproteins be key mediators of this association? Current Pharmaceutical Biotechnology 2014 15 3846. (https://doi.org/10.2174/1389201015666140330193653)

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  • 1

    Ben-HaroushAYogevYHodM. Epidemiology of gestational diabetes mellitus and its association with Type 2 diabetes. Diabetic Medicine 2004 21 103113. (https://doi.org/10.1046/j.1464-5491.2003.00985.x)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    KimCBergerDKChamanyS. Recurrence of gestational diabetes mellitus: a systematic review. Diabetes Care 2007 30 13141319. (https://doi.org/10.2337/dbib6-2517)

  • 3

    GundersonEPJacobsDRJrChiangVLewisCEFengJQuesenberryCPJrSidneyS. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: a 20-year prospective study in CARDIA (Coronary Artery Risk Development in Young Adults). Diabetes 2010 59 495504. (https://doi.org/10.2337/db09-1197)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    LauenborgJMathiesenEHansenTGlümerCJørgensenTBorch-JohnsenKHornnesPPedersenODammP. The prevalence of the metabolic syndrome in a Danish population of women with previous gestational diabetes mellitus is three-fold higher than in the general population. Journal of Clinical Endocrinology and Metabolism 2005 90 40044010. (https://doi.org/10.1210/jc.2004-1713)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    BellamyLCasasJPHingoraniADWilliamsD. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet 2009 373 17731779. (https://doi.org/10.1016/S0140-6736(09)60731-5)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    HannaFWPetersJR. Screening for gestational diabetes; past, present and future. Diabetic Medicine 2002 19 351358. (https://doi.org/10.1046/j.1464-5491.2002.00684.x)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    LeeAJHiscockRJWeinPWalkerSPPermezelM. Gestational diabetes mellitus: clinical predictors and long-term risk of developing type 2 diabetes: a retrospective cohort study using survival analysis. Diabetes Care 2007 30 878883. (https://doi.org/10.2337/dbib6-1816)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    MalcolmJ. Through the looking glass: gestational diabetes as a predictor of maternal and offspring long-term health. Diabetes/Metabolism Research and Reviews 2012 28 307311. (https://doi.org/10.1002/dmrr.2275)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    BoSMongeLMacchettaCMenatoGPinachSUbertiBPaganoG. Prior gestational hyperglycemia: a long-term predictor of the metabolic syndrome. Journal of Endocrinological Investigation 2004 27 629635. (https://doi.org/10.1007/BF03347494)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    RizviAACuadraSNikolicDGiglioRVMontaltoGRizzoM. Gestational diabetes and the metabolic syndrome: can obesity and small, dense low density lipoproteins be key mediators of this association? Current Pharmaceutical Biotechnology 2014 15 3846. (https://doi.org/10.2174/1389201015666140330193653)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    DuklerDPorathABashiriAErezOMazorM. Remote prognosis of primiparous women with preeclampsia. European Journal of Obstetrics Gynecology and Reproductive Biology 2001 96 6974. (https://doi.org/10.1016/S0301-2115(00)00392-4)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    XiongXSaundersLDWangFLDemianczukNN. Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes. International Journal of Gynaecology and Obstetrics 2001 75 221228. (https://doi.org/10.1016/S0020-7292(01)00496-9)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 13

    EhrenthalDBMaidenKRogersSBallA. Postpartum healthcare after gestational diabetes and hypertension. Journal of Women’s Health 2014 23 760764. (https://doi.org/10.1089/jwh.2013.4688)

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    SolomonCGSeelyEW. Brief review: hypertension in pregnancy: a manifestation of the insulin resistance syndrome? Hypertension 2001 37 232239. (https://doi.org/10.1161/01.HYP.37.2.232)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    VambergueANuttensMCGoeussePBiausqueSLepeutMFontaineP. Pregnancy induced hypertension in women with gestational carbohydrate intolerance: the diagest study. European Journal of Obstetrics Gynecology and Reproductive Biology 2002 102 3135. (https://doi.org/10.1016/S0301-2115(01)00556-5)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    DammPHoushmand-OeregaardAKelstrupLLauenborgJMathiesenERClausenTD. Gestational diabetes mellitus and long-term consequences for mother and offspring: a view from Denmark. Diabetologia 2016 59 13961399. (https://doi.org/10.1007/s00125-016-3985-5)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    GongoraMCWengerNK. Cardiovascular complications of pregnancy. International Journal of Molecular Sciences 2015 16 2390523928. (https://doi.org/10.3390/ijms161023905)

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    NaderiSTsaiSAKhandelwalA. Hypertensive disorders of pregnancy. Current Atherosclerosis Reports 2017 19 15. (https://doi.org/10.1007/s11883-017-0648-z)

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