Perceptions of diabetes distress during pregnancy in women with type 1 and type 2 diabetes: a qualitative interpretive description study.

BACKGROUND: Diabetes distress is commonly seen in adults with pre-existing diabetes and is associated with worsened glycemic management and self-management practices. While a majority of women report increased stress during pregnancy, it is unknown how women with type 1 or type 2 diabetes experience diabetes distress during this unique and transitional time. PURPOSE: This study aimed to understand the experiences and perceptions of diabetes distress in women with pre-existing diabetes during pregnancy. METHODS: A qualitative study using an interpretive description approach was conducted. In-depth, one to one interviewing was used to capture rich descriptions of the pregnancy experience. Nested, stratified, and theoretical sampling was used to recruit 18 participants with type 1 and type 2 diabetes from the quantitative strand of this mixed methods study. Constant comparative analysis was used to inductively analyze the data and develop themes. FINDINGS: Four themes, each with several subthemes, emerged under the main finding of "Diabetes Distress": 1) Worry for Baby's Health - "What's this going to do to the baby?"' 2) Feeling Overwhelmed with Diabetes Management-"It just seemed unattainable"; 3) Living with Diabetes - "There's no way out" and 4) Cycle of Diabetes Distress. CONCLUSIONS: The findings from this study identify the sources and experiences of diabetes distress during pregnancy in women with pre-existing diabetes. Diabetes distress often presents as cyclical and multifaceted during pregnancy, with elements of fear for the unborn baby, difficulties with diabetes management, and having negative lived experiences of diabetes. Further work is needed to develop appropriate screening tools for pregnancy and interventions to mitigate diabetes distress. Diabetes educators are well-positioned provide emotional support and person-centred self-management education to individuals with diabetes.

Maternal Health Outcomes After Pregnancy-Associated Stroke: A Population-Based Study With 19 Years of Follow-Up.

BACKGROUND: Pregnancy-associated stroke carries high short-term morbidity and mortality, but data on subsequent maternal outcomes are limited. We evaluated long-term maternal health outcomes after pregnancy-associated stroke. METHODS: In this retrospective cohort study, we used administrative data to identify pregnant adults aged ≤49 years with stroke between 2002-2020 in Ontario, Canada and 2 comparison groups: (1) non-pregnant female patients with stroke and (2) pregnant patients without stroke. Patients who survived the index admission were followed until 2021. After propensity score matching, we used Cox regression with a robust variance estimator to compare pregnant patients with stroke and the 2 comparison groups for the composite outcome of death and all-cause non-pregnancy readmission. Where proportional hazard assumption was not met, we reported time-varying hazard ratios (HR) with 95% CIs by modeling the log-hazard ratio as a function of time using restricted cubic splines. RESULTS: We identified 217 pregnant patients with stroke, 7604 non-pregnant patients with stroke, and 1 496 256 pregnant patients without stroke. Of the 202 pregnant patients with stroke who survived the index stroke admission, 41.6% (6.8 per 100 person-years) subsequently died or were readmitted during follow-up. Median follow-up times were 5 years (pregnancy-associated stroke), 3 years (non-pregnant stroke), and 8 years (pregnant without stroke). Pregnant patients with stroke had a lower hazard of death and all-cause readmission compared with non-pregnant patients with stroke at 1-year follow-up (HR, 0.64 [95% CI, 0.44-0.94]), but this association did not persist during longer-term follow-up. Conversely, pregnant patients with stroke had higher hazard of death and readmission compared with pregnant patients without stroke at 1-year follow-up (HR, 5.70 [95% CI, 3.04-10.66]), and this association persisted for a decade. CONCLUSIONS: Stroke during pregnancy is associated with long-term health consequences. It is essential to transition care postpartum to primary or specialty care to optimize vascular health.

Symptoms of postural orthostatic tachycardia syndrome in pregnancy: a cross-sectional, community-based survey.

OBJECTIVE: To evaluate the relationship between postural orthostatic tachycardia syndrome (POTS) and pregnancy. DESIGN: Cross-sectional survey. SETTING: International. SAMPLE: A total of 8941 female patients with a diagnosis of POTS. METHODS: Data from the survey were analysed using descriptive measures and stratified for comparisons. MAIN OUTCOME MEASURES: Symptom course of POTS during pregnancy. Secondary outcomes included pregnancy loss, POTS onset during pregnancy and the impacts of a comorbid diagnosis of Ehlers-Danlos syndrome or an autoimmune disorder on symptoms during pregnancy. RESULTS: Overall, 40.8% (n = 3652) of participants reported one or more pregnancies. Most participants experienced worsening of symptoms in the first (62.6%) and third (58.9%) trimesters and 3 months after pregnancy (58.7%), and 81.1% experienced worsening symptoms at any point in their pregnancy. Most participants with worsening symptoms in the first trimester also experienced worsening symptoms in the second (61.6%) and third (68.1%) trimesters, but if they improved in the first trimester then this improvement persisted in the second and third trimesters. Of participants who reported that POTS was triggered by a specific event (41.3%), 8.1% reported pregnancy as the trigger for the onset. CONCLUSIONS: Postural orthostatic tachycardia syndrome symptoms in the first trimester of pregnancy may help predict symptom course throughout the duration of pregnancy. Some individuals may experience an initial onset of POTS during pregnancy. This novel information may guide clinicians in counselling patients with POTS who are planning pregnancy.

Understanding the self-management experiences and support needs during pregnancy among women with pre-existing diabetes: a qualitative descriptive study.

BACKGROUND: With the increasing prevalence of pre-existing type 1 and type 2 diabetes in pregnancy and their associated perinatal risks, there is a need to focus on interventions to achieve optimal maternal glycemia to improve pregnancy outcomes. One strategy focuses on improving diabetes self-management education and support for expectant mothers with diabetes. This study's objective is to describe the experience of managing diabetes during pregnancy and identify the diabetes self-management education and support needs during pregnancy among women with type 1 and type 2 diabetes. METHODS: Using a qualitative descriptive study design, we conducted semi-structured interviews with 12 women with pre-existing type 1 or 2 diabetes in pregnancy (type 1 diabetes, n = 6; type 2 diabetes, n = 6). We employed conventional content analyses to derive codes and categories directly from the data. RESULTS: Four themes were identified that related to the experiences of managing pre-existing diabetes in pregnancy; four others were related to the self-management support needs in this population. Women with diabetes described their experiences of pregnancy as terrifying, isolating, mentally exhausting and accompanied by a loss of control. Self-management support needs reported included healthcare that is individualized, inclusive of mental health support and support from peers and the healthcare team. CONCLUSIONS: Women with diabetes in pregnancy experience feelings of fear, isolation and a loss of control, which may be improved through personalized management protocols that avoid "painting everybody with the same brush" as well as peer support. Further examination of these simple interventions may yield important impacts on women's experience and sense of connection.

Thyroid function testing and management during and after pregnancy among women without thyroid disease before pregnancy.

BACKGROUND: Screening in pregnancy for subclinical hypothyroidism, often defined as thyroid-stimulating hormone (TSH) greater than 2.5 mIU/L or greater than 4.0 mIU/L, is controversial. We determined the frequency and distribution of TSH testing by gestational age, as well as TSH values associated with treatment during pregnancy and the frequency of postpartum continuation of thyroid hormone therapy. METHODS: We performed a retrospective cohort study of pregnancies in Alberta, Canada. We included women without thyroid disease who delivered between October 2014 and September 2017. We used delivery records, physician billings, and pharmacy and laboratory administrative data. Our key outcomes were characteristics of TSH testing and the initiation and continuation of thyroid hormone therapy. We calculated the proportion of pregnancies with thyroid testing and the frequency of each specific thyroid test. RESULTS: Of the 188 490 pregnancies included, 111 522 (59.2%) had at least 1 TSH measurement. The most common time for testing was at gestational week 5 to 6. Thyroid hormone therapy was initiated at a median gestational age of 7 (interquartile range 5-12) weeks. Among women with first TSH measurements of 4.01 to 9.99 mIU/L who were not immediately treated, the repeat TSH measurement was 4.00 mIU/L or below in 67.9% of pregnancies. Thyroid hormone was continued post partum for 44.6% of the women who started therapy during their pregnancy. INTERPRETATION: The findings of our study suggest that current practice patterns may contribute to overdiagnosis of hypothyroidism and overtreatment during pregnancy and post partum.

Cardiovascular Risk Assessment and Follow-Up of Women After Hypertensive Disorders of Pregnancy:A Prospective Cohort Study.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) comprise an independent, sex-specific risk factor for cardiovascular disease (CVD) in women. This study examined the utility of CVD risk models proposed in the 2016 Canadian Cardiovascular Society (CCS) lipid guidelines to identify women requiring further screening or lipid treatment following HDP. METHODS: Using data collected from the postpartum Maternal Health Clinic (MHC) at Kingston General Hospital in Kingston, Ontario and the Preeclampsia New Emerging Team (PE-NET) cohort study, the study investigators used the models recommended by the CCS guidelines and the cardiometabolic model of life expectancy in each cohort to estimate CVD risk in women after HDP. (Canadian Task Force Classification II-2). RESULTS: Using the 10-Year Modified Framingham Risk Score, all women were classified by the 2016 CCS Guidelines as low risk, requiring no follow-up. The 30-Year and Lifetime Risk Scores resulted in significant reclassification of women at risk in the PE-NET control and HDP groups (P < 0.001 and P < 0.0001, respectively); 49.2% of women with HDP were classified as high risk, requiring follow-up, compared with 14.3% of control subjects. Using the cardiometabolic model, median life expectancy was significantly lower and expected onset of CVD was earlier in the HDP group compared with the control group (P < 0.0001). CONCLUSION: The 2016 CCS lipid guidelines' risk classification recommendations significantly underestimated lifelong CVD risk in the HDP group compared with the control group. Women with HDP also had a significant decrease in cardiometabolic life expectancy and an earlier predicted age at onset of CVD. Early primary prevention in this at-risk population may improve CVD outcomes and reduce the future burden on the health care system.

The Effectiveness of eHealth Technologies on Weight Management in Pregnant and Postpartum Women: Systematic Review and Meta-Analysis.

BACKGROUND: The emergence and utilization of electronic health (eHealth) technologies has increased in a variety of health interventions. Exploiting the real-time advantages offered by mobile technologies during and after pregnancy has the potential to empower women and encourage behaviors that may improve maternal and child health. OBJECTIVE: The objective of this study was to assess the effectiveness of eHealth technologies for weight management during pregnancy and the postpartum period and to review the efficacy of eHealth technologies on health behaviors, specifically nutrition and physical activity. METHODS: A systematic search was conducted of the following databases: MEDLINE, EMBASE, Cochrane database of systematic reviews (CDSR), Cochrane central register of controlled trials (CENTRAL), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO. The search included studies published from 1990 to July 5, 2016. All relevant primary studies that involved randomized controlled trials (RCTs), non-RCTs, before-and-after studies, historically controlled studies, and pilot studies were included. The study population was adult women of childbearing age either during pregnancy or the postpartum period. eHealth weight management intervention studies targeting physical activity, nutrition, or both, over a minimum 3-month period were included. Titles and abstracts, as well as full-text screening were conducted. Study quality was assessed using Cochrane's risk of bias tool. Data extraction was completed by a single reviewer, which was then verified by a second independent reviewer. Results were meta-analyzed to calculate pooled estimates of the effect, wherever possible. RESULTS: Overall, 1787 and 176 citations were reviewed at the abstract and full-text screening stages, respectively. A total of 10 studies met the inclusion criteria ranging from high to low risk of bias. Pooled estimates from studies of the effect for postpartum women resulted in a significant reduction in weight (-2.55 kg, 95% CI -3.81 to -1.28) after 3 to 12 months and six studies found a nonsignificant reduction in weight gain for pregnant women (-1.62 kg, 95% CI -3.57 to 0.33) at approximately 40 weeks. CONCLUSIONS: This review found evidence for benefits of eHealth technologies on weight management in postpartum women only. Further research is still needed regarding the use of these technologies during and after pregnancy.

Cardiovascular risk reduction and weight management at a hospital-based postpartum preeclampsia clinic.

OBJECTIVE: Women who develop preeclampsia during pregnancy are at high risk of developing future chronic diseases, including premature cardiovascular disease. We have established an interdisciplinary clinic that aims to prevent cardiovascular disease through educational counselling focused on lifestyle modifications in the early postpartum period. The objective of this study was to evaluate changes in weight and cardiovascular risk factors in participating women after six months of attendance at the clinic. METHODS: We conducted a retrospective chart review of women who had a pregnancy complicated by preeclampsia, and who subsequently attended the Postpartum Preeclampsia Clinic. Study subjects had baseline assessments of lifestyle, physical, and laboratory parameters. Individualized goals for cardiovascular risk reduction and lifestyle were established, centering on physical activity and dietary modifications. The primary outcome was change in weight. RESULTS: Over the study period, 21 women were seen for a minimum of six months of follow-up. At an average (± SD) of 4.4 ± 1.4 months postpartum, subjects showed a non-significant improvement in weight (mean weight loss of 0.4 ± 4.5 kg) and BMI (mean decrease in BMI 0.1 ± 1.7 kg/m2). Physical activity improved significantly, from 14% of subjects participating in physical activity before pregnancy to 76% at a mean of 4.4 months postpartum. CONCLUSION: This study has demonstrated the early benefits of a longitudinal interdisciplinary intervention with counselling about lifestyle modifications for prevention of cardiovascular disease in women with recent preeclampsia. A study with a larger sample size and longer duration of follow-up is planned to confirm these findings.

Objectif : Les femmes qui en viennent à connaître une prééclampsie pendant la grossesse sont exposées à un risque élevé d'en venir par la suite à présenter des maladies chroniques, dont la maladie cardiovasculaire prématurée. Nous avons mis sur pied une clinique interdisciplinaire qui vise à prévenir la maladie cardiovasculaire par l'offre de services de counseling pédagogique axés sur les modifications à apporter au mode de vie aux débuts de la période postpartum. Cette étude avait pour objectif d'évaluer les modifications du poids et des facteurs de risque cardiovasculaire chez les participantes, après six mois de consultations à la clinique. Méthodes : Nous avons mené une analyse rétrospective des dossiers des femmes dont la grossesse avait été compliquée par la prééclampsie et qui avaient par la suite fréquenté la Postpartum Preeclampsia Clinic. Pour déterminer les paramètres de départ, les participantes à l'étude ont été soumises à des évaluations du mode de vie, à des examens physiques et à des analyses de laboratoire. Des objectifs personnalisés en matière de réduction du risque cardiovasculaire et de modification du mode de vie ont été établis, le tout étant axé sur l'activité physique et les modifications du régime alimentaire. La modification du poids constituait le critère d'évaluation principal. Résultats : Au cours de la période d'étude, 21 femmes ont fait l'objet d'un suivi d'une durée minimale de six mois. À 4,4 ± 1,4 mois postpartum en moyenne (± σ), les participantes présentaient une amélioration non significative en matière de poids (perte pondérale moyenne de 0,4 ± 4,5 kg) et d'IMC (diminution moyenne de l'IMC de 0,1 ± 1,7 kg/m2). Le niveau d'activité physique a connu une amélioration significative, passant de 14 % des participantes pratiquant des activités physiques avant la grossesse à 76 % après 4,4 mois postpartum en moyenne. Conclusion : Cette étude a démontré les avantages précoces d'une intervention interdisciplinaire longitudinale, s'accompagnant de services de counseling sur les modifications à apporter au mode de vie, pour assurer la prévention des maladies cardiovasculaires chez des femmes ayant récemment connu une prééclampsie. Nous prévoyons mener une étude comptant un échantillon plus large et un suivi de plus longue durée, en vue de confirmer ces constatations.

Lower achievement of guideline recommended care in Canadian adults with early-onset diabetes: A population-based cohort study.

AIMS: Adults with early-onset diabetes (age < 40 years) have an increased risk of complications, and it is unclear whether they are receiving guideline recommended care. We compared the frequency and results of haemoglobin A1c (HbA1c) testing in adults with early-onset and usual-onset diabetes and assessed factors related to guideline concordance. METHODS: Population-level databases from Alberta, Canada (∼4.5 million) were used to identify adults with incident diabetes. The cohort was stratified by age at diagnosis (< 40 vs. ≥ 40 years) and then followed for 365 days for HbA1c testing. Adjusted multivariable analyses were used to identify clinical and sociodemographic factors associated with guideline concordance. RESULTS: Among 23,643 adults with incident diabetes (mean age 54.1 ± 15.4 years; 42.1 % female), 18.9 % had early-onset diabetes. Early-onset diabetes was associated with lower frequency of testing (adjusted odds ratio (aOR), 0.80; 95 % CI 0.70-0.90) and above target glycaemic levels compared to usual-onset diabetes (aOR, 1.45; 95 % CI 1.29-1.64). Factors associated with guideline concordant frequency of HbA1c testing were rural residence and insulin use. CONCLUSIONS: In our universal care setting with premium-free health care, early-onset diabetes was associated with lower rates of HbA1c testing and sub-optimal glycaemic control compared to those with usual-onset diabetes.

The Examination and Exploration of Diabetes Distress in Pre-existing Diabetes in Pregnancy: A Mixed-methods Study.

OBJECTIVES: Diabetes distress (DD) has been understudied in the pregnancy population. Pregnancy is known to be a complex, highly stressful time for women with diabetes because of medical risks and the high burden of diabetes management. Our aim in this study was to explain and understand DD in women with pre-existing diabetes in pregnancy. METHODS: An explanatory, sequential mixed-methods study was undertaken. The first strand consisted of a cross-sectional study of 76 women with type 1 and type 2 diabetes. A nested sampling approach was used to re-recruit 18 women back into the second strand for qualitative interviews using an interpretive description approach. RESULTS: DD was measured by the validated Problem Area in Diabetes (PAID) scale. A PAID score of ≥40 was positive for distress. DD prevalence was 22.4% in the cross-sectional cohort and the average PAID score was 27.75 (standard deviation 16.08). In the qualitative strand, women with a range of PAID scores (10.0 to 60.0) were sampled for interviews. The majority of these participants described themes of DD in their interviews. Of the 15 women who described DD thematically, only 6 had positive PAID scores. CONCLUSIONS: Integration of the mixed-methods data underscores important meta-inferences about DD in pregnancy, namely that DD was present to a greater degree than the PAID tool is sensitive to. DD was present qualitatively in most of the qualitative sample, despite interviewing women with a range of PAID scores. Future research on a pregnancy-specific DD scale is needed.

Understanding Patient Perspectives on Specialized, Longitudinal, Postpartum, Cardiovascular Risk-Reduction Clinics.

Background: Females who experience hypertensive disorders of pregnancy (HDP) have an increased lifelong risk of cardiovascular disease. Thus, Canadian clinical practice guidelines recommend cardiovascular risk reduction follow-up after a patient has HDP. This study examined the experiences of patients with HDP who attended a specialized, longitudinal general internal medicine postpartum cardiovascular risk reduction clinic called PreVASC. PreVASC focuses on comprehensive cardiovascular risk reduction through cardiovascular risk factor screening and management tailored specifically for female patients after they have HDP. Methods: This multimethod study examined the experiences of female patients with HDP via the following: (i) a quantitative survey (summarized with descriptive statistics); (ii) semistructured qualitative patient phone interviews (results grouped thematically); and (iii) triangulation of qualitative themes with quantitative survey results. Results: Overall, 37% of eligible clinic patients (42 of 115) participated; 79% of participants (n = 33) reported being "very satisfied" with the PreVASC clinic's specialized longitudinal model of care, and 95% (n = 40) reported making at least one preventive health behaviour change after receiving individualized counselling on cardiovascular risk reduction. Qualitative results found improvements in patient-reported cardiovascular health knowledge, health behaviours, and health-related anxiety. A preference for in-person vs phone clinic visits was reported by participants. Conclusions: An in-person, general internal medicine specialist-led, longitudinal model of cardiovascular disease preventive care focused specifically on cardiovascular risk reduction after HDP had positive impacts on patient experience, health knowledge, and preventive health behaviours. This novel knowledge on patient preferences for a longitudinal, specialized model of care advances cardiovascular risk reduction tailored specifically for high-risk people after HDP.

Contexte: Les femmes qui sont atteintes de troubles hypertensifs de la grossesse (THG) présentent un risque accru de maladie cardiovasculaire durant leur vie. Par conséquent, les lignes directrices canadiennes de pratique clinique recommandent un suivi pour la réduction du risque cardiovasculaire après la survenue d'un THG. Cette étude visait à examiner l'expérience des patientes qui ont été atteintes de THG et qui ont fréquenté l'une des cliniques de médecine interne spécialisées dans la réduction du risque cardiovasculaire post-partum et offrant une prise en charge longitudinale (PreVASC). Les cliniques PreVASC se concentrent sur la réduction des risques cardiovasculaires globaux par la détection des facteurs de risque cardiovasculaire et une prise en charge spécialement adaptée pour les femmes qui ont subi un THG. Méthodologie: Cette étude visait à examiner l'expérience des femmes atteintes d'un THG en faisant appel à diverses méthodes : i) sondage quantitatif (résumé par des statistiques descriptives); ii) entrevues téléphoniques semi-structurées de nature qualitative avec des patientes (résultats regroupés par thèmes); et iii) triangulation des thèmes qualitatifs et des résultats du sondage quantitatif. Résultats: Globalement, 37 % des patientes admissibles (42 sur 115) ont participé à l'étude; 79 % des participantes (n = 33) ont déclaré être « très satisfaites ¼ du modèle de soins longitudinal spécialisé des cliniques PreVASC, et 95 % (n = 40) ont déclaré avoir adopté au moins un comportement préventif pour leur santé après avoir reçu des conseils personnalisés sur la réduction du risque cardiovasculaire. Les résultats qualitatifs obtenus auprès des patientes font état d'une amélioration des connaissances sur la santé cardiovasculaire, les comportements sains et l'anxiété liée à la santé. Les participantes ont dit préférer les visites cliniques en personne aux consultations par téléphone. Conclusions: L'adoption d'un modèle longitudinal de médecine interne comprenant des rencontres avec des spécialistes pour prévenir les maladies cardiovasculaires, en particulier réduire le risque cardiovasculaire après un THG a eu des effets positifs chez les patientes en ce qui concerne l'expérience, les connaissances en matière de santé et les comportements à adopter pour prévenir les problèmes de santé. Ces nouvelles connaissances sur les préférences des patientes à l'égard de soins longitudinaux spécialisés représentent un pas en avant dans la mise en place d'une approche personnalisée de réduction du risque cardiovasculaire pour les personnes présentant un risque élevé après un THG.

Nutrition Interventions for Lowering Cardiovascular Risk After Hypertensive Disorders of Pregnancy: A Systematic Review.

Background: Hypertension is one of the most common medical problems during pregnancy. Hypertensive disorders of pregnancy (HDP) increase the risk of premature cardiovascular disease (CVD) 2- to 4-fold within 10 years after delivery. Early health behaviour modifications may prevent or manage several cardiovascular risk factors. Importantly, compared with women without HDP, fewer women with HDP achieve national dietary guidelines to prevent CVD. This highlights an opportunity for programs tailored for women post-HDP to support their nutritional behaviours as a key component of postpartum CVD preventive care. This systematic review investigated the impacts of nutrition modifications on lowering measures of CVD risk after HDP. Methods: Four electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) were searched in October 2022 with a search strategy focused on nutrition programs/interventions and women post-HDP. Additional inclusion criteria were original research and reported outcome of CVD risk or cardiovascular risk factors. Results: Six studies were included: 4 experimental trials and 2 prospective cohort studies. Of the nutrition interventions, 4 were embedded within comprehensive health behaviour intervention programs. Outcome measures varied, but all studies reported blood pressure. A narrative synthesis found that the range of changes in blood pressure varied from no change to clinically meaningful change. Conclusions: This review found statistically nonsignificant yet clinically important improvements in measures of cardiovascular risk across a range of nutritional interventions in women after HDP. Further high-quality evidence is needed to inform the design and implementation of nutritional preventive cardiovascular care targeting this high CVD-risk population.

Contexte: L'hypertension est l'un des problèmes médicaux les plus fréquents durant la grossesse. Les troubles hypertensifs de la grossesse (THG) font augmenter le risque de maladies cardiovasculaires (MCV) prématurées de 2 à 4 fois dans les 10 années après l'accouchement. Des modifications précoces des comportements liés à la santé peuvent permettre de prévenir ou de prendre en charge plusieurs facteurs de risque cardiovasculaire. Notamment, par rapport aux femmes sans THG, moins de femmes atteintes de THG se conforment aux lignes directrices nationales en matière d'alimentation pour prévenir les MCV. D'où la possibilité qui s'offre aux programmes adaptés aux femmes post-THG d'encourager l'adoption de leurs comportements nutritionnels, une composante essentielle des soins de prévention des MCV dans la période du post-partum. La présente revue systématique visait à examiner les répercussions des modifications nutritionnelles sur la réduction des mesures du risque de MCV après les THG. Méthodes: En octobre 2022, nous avons effectué des recherches dans 4 bases de données électroniques (MEDLINE, Embase, CINAHL, Cochrane Library) au moyen d'une stratégie de recherche axée sur les interventions/programmes nutritionnels et les femmes post-THG. Les critères d'inclusion supplémentaires étaient la recherche initiale et les résultats signalés du risque de MCV ou des facteurs de risque cardiovasculaire. Résultats: Nous avons tenu compte de 6 études : 4 essais expérimentaux et 2 études de cohorte prospectives. Parmi les interventions nutritionnelles, 4 étaient intégrées aux programmes exhaustifs d'interventions sur les comportements liés à la santé. Les critères de jugement variaient, mais la pression artérielle était signalée dans toutes les études. Une synthèse narrative a permis de constater que l'étendue des changements dans la pression artérielle allait d'une absence de changement à des changements significatifs sur le plan clinique. Conclusions: Cette revue a permis de constater des améliorations non significatives sur le plan statistique, mais importantes sur le plan clinique des mesures du risque cardiovasculaire de différentes interventions nutritionnelles chez les femmes après les THG. D'autres données probantes de grande qualité sont nécessaires pour faciliter l'élaboration et la mise en œuvre de soins de prévention nutritionnelle des maladies cardiovasculaires visant cette population exposée à un risque élevé de MCV.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 9: Summary of Current Status, Challenges, Opportunities, and Recommendations.

This final chapter of the Canadian Women's Heart Health Alliance "ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women" presents ATLAS highlights from the perspective of current status, challenges, and opportunities in cardiovascular care for women. We conclude with 12 specific recommendations for actionable next steps to further the existing progress that has been made in addressing these knowledge gaps by tackling the remaining outstanding disparities in women's cardiovascular care, with the goal to improve outcomes for women in Canada.

Dans ce chapitre final de l'ATLAS sur l'épidémiologie, le diagnostic et la prise en charge de la maladie cardiovasculaire chez les femmes de l'Alliance canadienne de santé cardiaque pour les femmes, nous présentons les points saillants de l'ATLAS au sujet de l'état actuel des soins cardiovasculaires offerts aux femmes, ainsi que des défis et des occasions dans ce domaine. Nous concluons par 12 recommandations concrètes sur les prochaines étapes à entreprendre pour donner suite aux progrès déjà réalisés afin de combler les lacunes dans les connaissances, en s'attaquant aux disparités qui subsistent dans les soins cardiovasculaires prodigués aux femmes, dans le but d'améliorer les résultats de santé des femmes au Canada.

Risks of gestational diabetes and preeclampsia over the last decade in a cohort of Alberta women.

OBJECTIVES: The incidence of gestational diabetes mellitus (GDM) is increasing. However, less is known about the incidence of preeclampsia (PE) and whether it is affected by the presence of GDM. We sought to document the population-level incidence of GDM and PE during the last decade and examine the association between GDM and PE after accounting for established risk factors. METHODS: We selected a population-based cohort retrospectively using data from the Alberta Perinatal Health Program registry. Logistic regression was used to examine the association between GDM and PE after adjusting for baseline characteristics. RESULTS: Of 426 296 deliveries between 2000 and 2009, 422 672 were in women without pre-existing diabetes. Among these women, the incidence of GDM increased from 3.1% in 2000 to 4.6% in 2009 (P < 0.01), while the incidence of PE remained stable at approximately 1.3% per year. The incidence of PE was significantly higher in women with GDM than in those without GDM (2.6% vs. 1.2%; P < 0.01). After adjustment, women with GDM had a 90% higher risk of PE than those without GDM (OR 1.9; 95% CI 1.7 to 2.1). Other significant risk factors for PE were age, obesity, nulliparity, multifetal gestation, pre-existing hypertension, and chronic kidney disease. CONCLUSION: In this contemporary population-based study spanning 10 years, there was a significant increase in the incidence of GDM over time. The higher incidence of PE in women with GDM than in normoglycemic women suggests a need for heightened surveillance and monitoring of women with GDM for the development of PE.

Objectifs : L'incidence du diabète sucré gestationnel (DSG) est en hausse. Toutefois, nous en savons moins pour ce qui est de l'incidence de la prééclampsie (PE) et de la question de savoir si cette dernière est affectée par la présence d'un DSG. Nous avons cherché à documenter l'incidence populationnelle du DSG et de la PE au cours de la dernière décennie, ainsi qu'à examiner l'association entre le DSG et la PE à la suite de la neutralisation de l'effet des facteurs de risque établis. Méthodes : Nous avons, de façon rétrospective, sélectionné une cohorte en population générale au moyen de données issues du registre du Alberta Perinatal Health Program. Une régression logistique a été utilisée pour examiner l'association entre le DSG et la PE, à la suite de la neutralisation de l'effet des caractéristiques de base. Résultats : Des 426 296 accouchements s'étant déroulés entre 2000 et 2009, 422 672 ont été constatés chez des femmes ne présentant pas un diabète préexistant. Chez ces femmes, l'incidence du DSG est passée de 3,1 % en 2000 à 4,6 % en 2009 (P < 0,01), tandis que l'incidence de la PE est demeurée stable à environ 1,3 % par année. L'incidence de la PE était considérablement plus élevée chez les femmes présentant un DSG que chez les femmes qui n'en présentaient pas un (2,6 % vs 1,2 %; P < 0,01). À la suite de la neutralisation, les femmes présentant un DSG connaissaient une hausse du risque de PE de l'ordre de 90 %, par comparaison avec les femmes ne présentant pas un DSG (RC 1,9; IC à 95 %, 1,7 - 2,1). Parmi les autres facteurs de risque significatifs en matière de PE, on trouvait l'âge, l'obésité, la nulliparité, la gestation multifœtale, l'hypertension préexistante et la maladie rénale chronique. Conclusion : Dans le cadre de cette étude contemporaine en population générale couvrant une période de 10 ans, nous avons constaté une hausse considérable de l'incidence du DSG avec le temps. L'incidence accrue de la PE chez les femmes présentant un DSG, par comparaison avec les femmes normoglycémiques, semble indiquer la nécessité d'intensifier la surveillance et le monitorage de l'apparition d'une PE chez les femmes qui présentent un DSG.

Patient Perspectives on a Pilot Virtual Follow-up Program After Hypertensive Disorders of Pregnancy: A Qualitative Study.

Background: Hypertensive disorders of pregnancy (HDPs) are a risk factor for future cardiovascular disease; therefore, follow-up and implementation of early interventions is recommended. We performed a qualitative study to assess the feasibility and user response to a mobile-health tool and virtual consultation aimed at educating people with an HDP on future cardiovascular risk, and at better understanding patients' priorities for postpartum care. Methods: Participants with a history of an HDP in the past 5 years had access to an online educational tool and participated in a virtual consultation to discuss their cardiovascular risks after experiencing an HDP. Participants were invited to a focus group to obtain feedback on their postpartum experience and the Her-HEART program. Results: A total of 20 female participants were enrolled in the study between January 2020 and February 2021. Of these, 16 participants took part in 1 of 5 focus groups. Participants reported a lack of awareness of future cardiovascular disease risks prior to participating in the program, and identified barriers to counselling, including traumatic birth experiences, inappropriate timing, and competing priorities. Participants reported that the virtual Her-HEART program was an effective avenue to provide counselling on long-term cardiovascular risks. They highlighted the importance of coordinated care pathways and mental health support in postpartum follow-up programs. Conclusion: We have shown the feasibility of providing an educational website and virtual consultation to facilitate counselling in people affected by HDPs. Our results shed light on patient-reported priorities related to the content and delivery of postpartum counselling after an HDP.

Contexte: Les troubles hypertensifs de la grossesse (THG) représentent un facteur de risque de maladies cardiovasculaires. Il est donc recommandé d'assurer un suivi et d'intervenir de façon précoce. Nous avons réalisé une étude qualitative pour évaluer la faisabilité et la réaction des utilisatrices à un outil de santé mobile et à une consultation virtuelle visant à informer les personnes atteintes d'un THG à propos de leur risque cardiovasculaire et à mieux comprendre leurs priorités en matière de soins post-partum. Méthodologie: Les participantes ayant présenté un THG au cours des cinq dernières années ont eu accès à un outil éducatif en ligne et ont participé à une consultation virtuelle pour discuter de leur risque cardiovasculaire. Elles ont été invitées à un groupe de discussion afin d'obtenir des commentaires sur leur expérience post-partum et sur le programme Her-HEART. Résultats: Au total, 20 participantes ont été sélectionnées entre janvier 2020 et février 2021. Parmi elles, 16 ont pris part à l'un des cinq groupes de discussion. Les participantes ont déclaré qu'elles connaissaient mal leur risque de maladies cardiovasculaires avant de participer au programme et ont fait état d'obstacles les faisant hésiter à consulter, notamment des expériences traumatisantes à l'accouchement, le manque de temps et des priorités conflictuelles. Les participants ont déclaré que le programme virtuel Her-HEART était un moyen efficace de fournir des conseils sur les risques cardiovasculaires à long terme. Elles ont souligné l'importance d'une trajectoire de soins coordonnée et d'un soutien psychologique dans les programmes de suivi post-partum. Conclusion: Nous avons démontré la pertinence d'un site Web éducatif et d'une consultation virtuelle pour faciliter l'accompagnement des patientes atteintes d'un THG. Les résultats mettent également en lumière les priorités des patientes ayant présenté un tel trouble en ce qui concerne les modalités d'un accompagnement post-partum.

Association Between the Route of Administration and Formulation of Estrogen Therapy and Hypertension Risk in Postmenopausal Women: A Prospective Population-Based Study.

BACKGROUND: Hypertension is the leading global cause of cardiovascular disease and premature mortality in women. The effects of postmenopausal hormone therapy (HT) on blood pressure are uncertain but may be related to route of estrogen administration and formulation of estrogen. We sought to determine the association between route of administration and formulation of estrogen HT and hypertension risk in postmenopausal women. METHODS: Population-based cohort study with women aged ≥45 years who filled ≥2 consecutive prescriptions for estrogen-only HT, identified from linked provincial health administrative data from Alberta, Canada, between 2008 and 2019. The primary outcome, incident hypertension, was identified using standardized International Classification of Diseases, Ninth and Tenth Revision. Cox proportional hazard models were used to calculate hazard ratios (HRs) for hypertension in women using oral HT compared with nonoral HT (transdermal, vaginal, or intramuscular). RESULTS: In total, 112 240 women used an estrogen-only form of HT. Oral estrogen was associated with a higher risk of hypertension compared with both transdermal (HR, 1.14 [95% CI, 1.08-1.20]) and vaginal (HR, 1.19 [95% CI, 1.13-1.25]) estrogens. Conjugated equine estrogen was associated with an increased risk of hypertension compared with estradiol (HR, 1.08 [95% CI, 1.04-1.14]) but not estrone (HR, 1.00 [95% CI, 0.93-1.10]). Duration of estrogen exposure and cumulative dose of estrogen was positively associated with risk of hypertension. CONCLUSIONS: Oral estrogen-only HT use was associated with an increased risk of hypertension in women. In women using estrogen-only HT, nonoral estradiol at the lowest dose and for the shortest time-period is associated with the lowest risk of hypertension.

The Implementation of Preeclampsia Screening and Prevention (IMPRESS) Study.

BACKGROUND: Preeclampsia affects between 2% and 5% of pregnancies and is one of the leading causes of perinatal morbidity and mortality worldwide. Despite strong evidence that the combination of systematic preeclampsia screening based on the Fetal Medicine Foundation preeclampsia risk calculation algorithm with treatment of high-risk patients with low-dose aspirin reduces the incidence of preterm preeclampsia more than currently used risk-factor-based screening, real-world implementation studies have not yet been done in Canada. OBJECTIVE: This study aimed to assess the operational feasibility of implementing first-trimester screening and prevention of preterm preeclampsia (<37 weeks) alongside a publicly funded first-trimester combined screening program for aneuploidies. STUDY DESIGN: This was a prospective implementation study. Consecutive pregnant patients referred for first-trimester combined screening (11-13+6 weeks) were offered screening for preeclampsia based on the Fetal Medicine Foundation algorithm concomitantly with their aneuploidy screen. Consenting participants were screened using maternal risk factors, mean arterial pressure, uterine artery Doppler pulsatility index, pregnancy-associated plasma protein-A, and placental growth factor. Risk for preterm preeclampsia (<37 weeks) was calculated using the Fetal Medicine Foundation algorithm, and individuals with a risk score ≥1 per 100 were recommended to use aspirin (162 mg once daily at bedtime, <16-36 weeks). Implementation metrics assessed included: acceptability, operational impact, proportion of aspirin initiation, quality and safety measures, and screen performance. RESULTS: Between December 1, 2020 and April 23, 2021, 1124 patients consented to preeclampsia screening (98.3% uptake), and 92 (8.2%) screened positive. Appointments for patients receiving first-trimester combined screening aneuploidy and preeclampsia screening averaged 6 minutes longer than first-trimester combined screening alone, and adding uterine artery Doppler pulsatility index averaged 2 minutes. Of the 92 patients who screened as high-risk for preeclampsia, 72 (78.3%) were successfully contacted before 16 weeks' gestation. Of these, 62 (86.1%) initiated aspirin, and 10 (13.9%) did not. Performance audit identified a consistent negative bias with mean arterial pressure measurements (median multiple of the median <1 in 10%); other variables were satisfactory. There were 7 cases of preterm preeclampsia (0.69%): 5 and 2 in the high- and low-risk groups, respectively. Screening detected 5 of 7 (71.4 %) preterm preeclampsia cases, with improved performance after adjustment for aspirin treatment effect. CONCLUSION: This study confirms the operational feasibility of implementing an evidence-based preeclampsia screening and prevention program in a publicly funded Canadian setting. This will facilitate implementation into clinical service and the scaling up of this program at a regional and provincial level.

Glucose control during labour in diabetic women.

OBJECTIVES: Glucose control during labour is important for mother and neonate, with high rates of neonatal hypoglycemia reported in offspring of women with pre-existing or gestational diabetes (48% and 19%, respectively). How glucose control can be achieved is rarely specified. We conducted a chart review of a standardized approach using an iterative intravenous insulin-glucose infusion. METHODS: We performed a retrospective review of the records of 274 diabetic women during labour. Fifty-five women had type 1 diabetes, 55 had type 2 diabetes, and 164 had gestational diabetes (GDM). The protocol used hourly capillary blood glucose determinations, each prompting changes in insulin-glucose infusion rates as required. Outcomes included maternal blood glucose levels three hours before delivery and neonatal hypoglycemia (blood glucose < 2 mmol/L). RESULTS: The insulin-glucose infusion was used in 47% of women with type 1, type 2, and gestational diabetes requiring ≥ 0.5 units/kg/day of insulin during pregnancy and in 8% of women with GDM treated by diet or < 0.5 units/kg/day of insulin. The overall rate of maternal hypoglycemia was low (6.6% with blood glucose ≤ 3.5 mmol/L and 1.5% ≤ 3.0 mmol/L) pre-delivery; 13.9% of women had a blood glucose level ≥ 7.0 mmol/L. The neonatal hypoglycemia rate was 7.3% (4.9% in the offspring of women with GDM and 10.9% in the offspring of women with pre-existing diabetes). In women with type 1 and type 2 diabetes and high-dose insulin-requiring GDM, the rate of blood glucose values outside the range of 3.6 to 6.9 mmol/L was lower in those using the intravenous protocol (16.7%) than in those not using it (34.8%), but this reduction was not statistically significant. CONCLUSION: Standardized management for diabetic women in labour using an intravenous insulin-glucose protocol was effective in achieving stable maternal blood glucose levels with low rates of neonatal hypoglycemia.

The effect of non-oral hormonal contraceptives on hypertension and blood pressure: A systematic review and meta-analysis.

Oral contraceptives (OC) are associated with increased risk of hypertension and elevated blood pressure (BP). Whether non-oral hormonal contraceptives have similar associations is unknown. We sought to investigate the effect of non-oral hormonal contraceptive (NOHC) use on the risk of hypertension and changes in BP, compared to non-hormonal contraceptive and OC use. We searched bibliographic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) until August 2020. Studies reporting risk of hypertension or changes in systolic and diastolic BP with NOHC use compared with either non-hormonal contraceptive or OC use. Abstract screening, full-text review, data extraction, and quality assessment were completed in duplicate. For studies reporting dichotomous outcomes, we reported results as relative risk with 95% confidence intervals (CI). A random-effects model was used to estimate pooled weighted mean difference and 95% CI of change in BP. Twenty-five studies were included. A lower incidence of hypertension was observed with injectable contraceptive use compared to non-hormonal contraceptive and OC use, although it was unclear if this was statistically significant. Compared to non-hormonal contraceptive use, injectable contraceptive use was associated with increased BP (SBP: 3.24 mmHg, 95%CI 2.49 to 3.98 mmHg; DBP: 3.15 mmHg, 95%CI 0.09 to 6.20 mmHg), the hormonal intra-uterine device use was associated with reduced BP (SBP: -4.50 mmHg, 95%CI -8.44 to -0.57 mmHg; DBP: -7.48 mmHg, 95% -14.90 to -0.05 mmHg), and the vaginal ring was associated with reduced diastolic BP (-3.90 mmHg, 95%CI -6.67 to -1.13 mmHg). Compared to OC use, the injectable contraceptive use was associated with increased diastolic BP (2.38 mmHg, 95%CI 0.39 to 4.38 mmHg). NOHC use is associated with changes in BP which differ by type and route of administration. Given the strong association between incremental increases in BP and cardiovascular risk, prospective studies are required.