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For women with pre-existing and gestational diabetes, pregnancy involves specialized and intensive medical care to optimize maternal and infant outcomes. Medical management for patients with diabetes in pregnancy typically occurs via frequent face-to-face outpatient appointments. COVID-19-induced barriers to face-to-face care have identified the need for high-quality, patient-centred virtual health-care modalities, such as mobile health (mHealth) technologies. Our aim in this review was to identify the patient-reported benefits and limitations of mHealth technologies among women with diabetes in pregnancy. We also aimed to determine how the women's experiences aligned with the best practice standards for patient-centred communication.The framework presented by Arksey and O'Malley for conducting scoping reviews, with refinements by Levac et al, was used to guide this review. Relevant studies were identified through comprehensive database searches of MEDLINE, Embase, Emcare and PsycINFO. Thomas and Harden's methods for the thematic synthesis of qualitative research in systematic reviews guided the synthesis of patient-reported benefits and limitations of mHealth technology.Overall, 19 studies describing the use of 16 unique mobile health technologies among 742 women were included in the final review. Patient-reported benefits of mobile health included convenience, support of psychosocial well-being and facilitation of diabetes self-management. Patient-reported limitations included lack of important technological features, perceived burdensome aspects of mHealth and lack of trust in virtual health care.Women with diabetes report some benefits from mHealth use during pregnancy. Codesigning future technologies with end-users may help address the perceived limitations and effectiveness of mHealth technologies.

Background Because much of diabetes management during pregnancy occurs at home, self-management factors such as self-efficacy, self-care activities, and care satisfaction may affect glycemia. Our objective was to explore trends in glycemic control during pregnancy in women with type 1 or type 2 diabetes; assess self-efficacy, self-care, and care satisfaction; and examine these factors as predictors of glycemic control. Methods We conducted a cohort study from April 2014 to November 2019 at a tertiary center in Ontario, Canada. Self-efficacy, self-care, care satisfaction, and A1C were measured three times during pregnancy (T1, T2, and T3). Linear mixed-effects modeling explored trends in A1C and examined self-efficacy, self-care, and care satisfaction as predictors of A1C. Results We recruited 111 women (55 with type 1 diabetes and 56 with type 2 diabetes). Mean A1C significantly decreased by 1.09% (95% CI −1.38 to −0.79) from T1 to T2 and by 1.14% (95% CI −1.43 to −0.86) from T1 to T3. Self-efficacy significantly predicted glycemic control for women with type 2 diabetes and was associated with a mean change in A1C of −0.22% (95% CI −0.42 to −0.02) per unit increase in scale. The exercise subscore of self-care significantly predicted glycemic control for women with type 1 diabetes and was associated with a mean change in A1C of −0.11% (95% CI −0.22 to −0.01) per unit increase in scale. Conclusion Self-efficacy significantly predicted A1C during pregnancy in a cohort of women with preexisting diabetes in Ontario, Canada. Future research will continue to explore the self-management needs and challenges in women with preexisting diabetes in pregnancy.

African, Caribbean, and Black (ACB) women globally experience health inequities that impact on their cardiovascular health outcomes during the perinatal period, and for years after. Aside from being at a high risk of having and dying from hypertensive disorders of pregnancy, ACB women who survive face a lifelong risk of cardiovascular disease years after the diagnosis. Racism as a determinant of health intersects with gender, societal structures, and immigration status to contribute to cardiovascular health and access to quality health care services for ACB women. Equitable policies and culturally appropriate programs are needed to improve the cardiovascular health of ACB women.

Background: Women with hypothyroidism before pregnancy often require an increase in their levothyroxine dosage to maintain a euthyroid state during pregnancy. The objectives of this study were to investigate: (i) the frequency and distribution of thyrotropin (TSH) testing and levothyroxine dosage adjustment by gestational age, (ii) the magnitude of levothyroxine increase by the underlying etiology of hypothyroidism, and (iii) the relationship of overtreatment or undertreatment during pregnancy with adverse pregnancy outcomes among women using thyroid replacement before pregnancy. Methods: A retrospective cohort study of pregnancies in women on thyroid replacement before pregnancy in Alberta, Canada, was performed. Women using thyroid replacement anytime during the two years before pregnancy who delivered between October 2014 and September 2017 were included. Delivery records, physician billing, and laboratory and pharmacy administrative data were linked. Outcomes included characteristics of TSH testing, levothyroxine dosing, and pregnancy outcomes. The frequency and gestational timing of TSH testing and levothyroxine adjustments were calculated. Multiple logistic regression was used to test whether pregnancies with TSH

Background: Cardiovascular disease (CVD) is the leading cause of death in women globally. In recent years, attention has turned to infertility and pregnancy-related events as potential markers for early mortality and future CVD. Methods: The Study of Women’s Health Across the Nation (SWAN) is an ongoing longitudinal cohort study of women’s health. Women aged 42-52 years with a uterus and ≤ 1 intact ovary, a menstrual period, and no hormone medications within 3 months before enrollment were eligible. Infertility was self-reported and defined as the inability to achieve pregnancy after 12 months of trying to conceive, or use of fertility medications for > 1 month. Outcomes included development of metabolic syndrome over a 7-year follow-up, and any atherosclerotic CVD event (ie, stroke, angina, myocardial infarction) over a 10-year follow-up. Cox proportional hazards models were used to calculate hazard ratios (HRs) for metabolic syndrome and CVD events in participants with infertility, with adjustment for relevant covariates. Participants without infertility were used as the comparison group. Results: We included 2370 participants in the analysis of metabolic syndrome risk, and 2809 participants were included in the analysis of CVD event risk. Participants with self-reported infertility did not have a higher risk of developing metabolic syndrome (HR, 0.91; 95% confidence interval, 0.71-1.15) or experiencing CVD events (HR, 0.79; 95% confidence interval, 0.52-1.21) after adjusting for relevant covariates. Conclusions: Infertility was not associated with development of metabolic syndrome or CVD events in women; further research is required to investigate the effects of specific causes of infertility and fertility treatments on CVD outcomes. Résumé: Introduction: Les maladies cardiovasculaires (MCV) sont la principale cause de décès chez les femmes dans le monde. Au cours de dernières années, l’infertilité et les complications de la grossesse ont retenu l’attention, à savoir qu’ils constituent des marqueurs potentiels de la mortalité précoce et des MCV futures. Méthodes: La Study of Women’s Health Across the Nation (l’étude SWAN) qui constitue une étude de cohorte longitudinale sur la santé des femmes est en cours. Les femmes âgées de 42 à 52 ans qui ont un utérus et ≤ 1 ovaire intact, une période menstruelle et qui ne prenaient aucun médicament hormonal 3 mois avant le recrutement étaient admissibles. L’infertilité était autodéclarée et définie comme l’incapacité à être enceinte après 12 mois de tentatives de conception ou l’utilisation de médicaments pour traiter l’infertilité durant > 1 mois. L’issue était la suivante : la survenue du syndrome métabolique au cours du suivi de 7 ans ou de tout événement lié à la MCV athérosclérotique (c.-à-d. l’accident vasculaire cérébral, l’angine, l’infarctus du myocarde) au cours du suivi de 10 ans. Nous avons utilisé les modèles de risques proportionnels de Cox pour calculer les rapports de risque (RR) du syndrome métabolique et des événements liés aux MCV chez les participantes infertiles par l’ajustement des covariables pertinentes. Les participantes fertiles constituaient le groupe témoin. Résultats: Nous avons recruté 2 370 participantes pour l’analyse du risque de syndrome métabolique, et 2 809 participantes pour l’analyse du risque d’événements liés aux MCV. Les participantes qui avaient autodéclaré leur infertilité n’avaient pas de risque plus élevé de souffrir du syndrome métabolique (RR, 0,91 ; intervalle de confiance à 95 %, 0,71-1,15) ou de subir des événements liés aux MCV (RR, 0,79 ; intervalle de confiance à 95 %, 0,52-1,21) après l’ajustement des covariables pertinentes. Conclusions: L’infertilité n’était pas associée à la survenue du syndrome métabolique ou des événements liés aux MCV chez les femmes. D’autres recherches qui porteront sur les effets des causes particulières de l’infertilité et des traitements favorisant la fertilité sur l’évolution des MCV sont nécessaires.

There is a lack of cost-effective and readily available access to evidence-based information to manage healthy behaviours for pregnant individuals. Mobile health (mHealth) tools offer a cost-effective, interactive, personalized option that can be delivered anywhere at a time most convenient for the user. This study protocol was primarily developed to i) assess the feasibility of the SmartMoms Canada intervention in supporting participants to achieve gestational weight gain (GWG) guidelines. The secondary objectives are to: ii) assess user experience with the app, measured by adherence to the program via app software metrics and frequency of use; iii) determine the impact of SmartMoms Canada app usage on the adoption of healthful behaviours related to nutrition, physical activity and sleep habits, improvements in health-related quality of life, pregnancy-related complications, and symptoms of depression, and iv) investigate the potential extended effects of the app on postpartum health-related outcomes.This is a feasibility trial. Pregnant individuals aged 18-40 years with pre-gravid body mass index between 18.5 and 39.9 kg/mSmartMoms Canada is the first bilingual Canadian-centric app designed for pregnant people. This mHealth intervention, with its ability to supply frequent interactions, provides pregnancy- related health knowledge to users, potentially leading to an improvement in pregnancy-related outcomes and behaviours, and, ultimately a reduction in the present economic burden related to in-person interventions.ISRCTN, ISRCTN16254958. Registered 20 December 2019, http://www.isrctn.com/ ISRCTN16254958.

POINTS CLES L’obesite est une maladie chronique complexe dans laquelle la graisse corporelle anormale ou excessive (adiposite) nuit a la sante, augmente le risque de complications medicales a long terme et reduit la duree de vie[1][1]. Les etudes epidemiologiques definissent l’obe

BackgroundPsychosocial factors have been implicated as both a cause and consequence of hypertension in the general population but are less understood in relation to hypertensive disorders of pregnancy (HDP). The aims of this review were to (1) synthesize the existing literature examining associations between depression and/or anxiety in pregnancy and HDP and (2) assess if depression and/or anxiety in early pregnancy was a risk factor for HDP.MethodsA comprehensive search of Medline, Embase, CINAHL, and PsycINFO was conducted from inception to March 2020 using terms related to ‘pregnancy’, ‘anxiety’, ‘depression’, and ‘hypertensive disorders’. English-language cohort and case-control studies were included if they reported: (a) the presence or absence of clinically significant symptoms of depression/anxiety, or a medical record diagnosis of depression or an anxiety disorder in pregnancy; (b) diagnosis of HDP; and/or (c) data comparing the depressed/anxious group to the non-depressed/anxious group on HDP. Data related to depression/anxiety, HDP, study characteristics, and aspects related to study quality were extracted independently by two reviewers. Random-effects meta-analyses of estimated pooled relative risks (RRs) were conducted for depression/anxiety in pregnancy and HDP.ResultsIn total, 6291 citations were retrieved, and 44 studies were included across 61.2 million pregnancies. Depression and/or anxiety were associated with HDP [RR = 1.39; 95% confidence interval (CI) 1.25–1.54].ConclusionsWhen measurement of anxiety or depression preceded diagnosis of hypertension, the association remained (RR = 1.27; 95% CI 1.07–1.50). Women experiencing depression or anxiety in pregnancy have an increased prevalence of HDP compared to their non-depressed or non-anxious counterparts.

KEY POINTS Obesity is a complex chronic disease in which abnormal or excess body fat (adiposity) impairs health, increases the risk of long-term medical complications and reduces lifespan.[1][1] Epidemiologic studies define obesity using the body mass index (BMI; weight/height2), which can stratify

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.

Hypertension Canada's 2020 guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children provide comprehensive, evidence-based guidance for health care professionals and patients. Hypertension Canada develops the guidelines using rigourous methodology, carefully mitigating the risk of bias in our process. All draft recommendations undergo critical review by expert methodologists without conflict to ensure quality. Our guideline panel is diverse, including multiple health professional groups (nurses, pharmacy, academics, and physicians), and worked in concert with experts in primary care and implementation to ensure optimal usability. The 2020 guidelines include new guidance on the management of resistant hypertension and the management of hypertension in women planning pregnancy.

Despite a global understanding that indicators and outcomes of cardiovascular disease (CVD) are known to differ between men and women, uptake of the recognition of sex and gender influences on the clinical care of women has been slow or absent. The Canadian Women’s Heart Health Alliance (CWHHA) was established as a network of experts and advocates to develop and disseminate evidence-informed strategies to transform clinical practice and augment collaborative action on women’s cardiovascular health in Canada. As an initial project, the CWHHA membership undertook an environmental scan of CVD in women in Canada from which a scientific statement could be developed to summarize critical sex- and gender-specific issues in CVD. This comprehensive review of the evidence focused on the sex- and gender-specific differences in comorbidity, risk factors, disease awareness, presentation, diagnosis, and treatment across the entire spectrum of CVD. In the process of creating the review, it was recognized that the team of CWHHA experts had also assembled an expansive collection of original research articles that were synthesized into detailed chapters reporting on the present state of the evidence unique to each cardiovascular condition in women. This work comprises an “ATLAS” on the epidemiology, diagnosis, and management of CVD in women. The overall goal of the ATLAS is to create a living document that will help clinicians and the public recognize the unique aspects of women’s heart health care and provide policy makers with information they need to ensure equitable care for women with CVD. Résumé: Bien que l’on sache généralement que les indicateurs et les résultats des maladies cardiovasculaires (MCV) ne sont pas les mêmes chez les hommes et les femmes, la reconnaissance des différences entre les genres et les sexes dans la pratique clinique se fait lentement, voire pas du tout. L’Alliance nationale de la santé cardiaque des femmes (l’Alliance) est un réseau formé d’experts et d’intervenants ayant pour mission de formuler et de diffuser des stratégies fondées sur des faits afin de transformer la pratique clinique et de stimuler l’action concertée en matière de santé cardiovasculaire des femmes au Canada. Le premier projet des membres de l’Alliance a été de réaliser une analyse de la situation des femmes sur le plan des MCV au Canada, à partir de laquelle un énoncé scientifique pourrait être formulé pour résumer les différences entre les genres et les sexes en ce qui a trait aux MCV. Cette revue exhaustive des données probantes était axée sur les disparités entre les genres et les sexes sur les plans de la comorbidité, des facteurs de risque, des connaissances, des symptômes, du diagnostic et du traitement à l’égard de l’ensemble du spectre des MCV. Au cours des travaux nécessaires à cette revue, il est apparu que l’équipe des experts de l’Alliance avait aussi réuni une vaste collection d’articles sur la recherche de pointe, qui ont été synthétisés dans des chapitres détaillés faisant état des données actuelles sur la façon particulière dont chacune des maladies cardiovasculaires peut toucher les femmes. Un « atlas » de l’épidémiologie, du diagnostic et de la prise en charge des MCV chez les femmes a donc été ainsi créé. L’objectif global était de concevoir un document évolutif pour aider les cliniciens et le grand public à reconnaître les aspects particuliers des soins de santé cardiaque des femmes et fournir aux décideurs les renseignements dont ils ont besoin afin d’assurer que les femmes atteintes d’une MCV reçoivent des soins équitables.

Hypertensive disorders of pregnancy (HDP) commonly occur postpartum and are associated with preventable maternal morbidity and mortality. HDP is the most common reason for presentation to the Emergency Department (ED) after delivery. However, given the broad range of non-specific symptoms, recognition and management of postpartum HDP may be delayed leading to serious adverse clinical outcomes. Objectives To describe: (1) the clinical presentation; (2) ED physician’s diagnosis; and (3) current ED management of women with HDP in Calgary ED’s. Methods A retrospective review of postpartum women (within 42 days of delivery) attending three Calgary EDs between 2011 and 2012 was performed. Administrative data was used to randomly select 119 women; 44 with diagnostic codes for any HDP (labeled “HDP”) and 75 with diagnostic codes for related diagnoses (e.g., abdominal pain, headache) (labeled “non-HDP”). Charts were reviewed for: maternal demographics; obstetrical history; and ED clinical findings, investigations and management. Results Maternal characteristics were similar between groups. There was considerable overlap in clinical presentation between groups, with no significant difference for any presenting symptom. Only 52.3% (CI 40.0–64.3%) of women in the “HDP” group had HDP investigations (bloodwork and urinalysis) vs. 30.4% (CI 18.7–58.5%) of “non-HDP” (p = 0.072). HDP was diagnosed by the ED team in 42.9% (CI 31.1–55.5%) of the HDP group of whom only 40.3% (CI 28.7–53.1) received antihypertensive therapy. Conclusions Postpartum HDP is commonly under-recognized and under-treated in the ED, highlighting opportunities for interventions to improve the recognition and management of postpartum HDP.

Women with preeclampsia are at increased short-term risk of adverse cardiovascular outcomes during pregnancy and the early postpartum period. We aimed to develop and internally validate a risk assessment tool to predict acute cardiovascular morbidity in preeclampsia.The study was conducted at an academic obstetrics hospital. Participants with preeclampsia at delivery from 2007 to 2017 were included. A model to predict acute cardiovascular morbidity at delivery and within 6 weeks after delivery was developed and evaluated. The primary composite outcome included pulmonary edema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm, and difficult-to-control severe hypertension. We assessed model discrimination and calibration. We used bootstrapping for internal validation.A total of 4171 participants with preeclampsia were included. The final model comprised 8 variables. Predictors positively associated with acute cardiovascular morbidity (presented as odds ratio with 95% confidence interval) were: gestational age at delivery (20-36 weeks: 5.36 [3.67-7.82]; 37-38 weeks: 1.75 [1.16-2.64]), maternal age (≥ 40 years: 1.65 [1.00-2.72]; 35-39 years: 1.49 [1.07-2.09]), and previous caesarean delivery (1.47 [1.01-2.13]). The model had an area under the receiver operating characteristic curve of 0.72 (95% CI 0.69-0.74). Moreover, it was adequately calibrated and performed well on internal validation.This risk prediction tool identified women with preeclampsia at highest risk of acute cardiovascular morbidity. If externally validated, this tool may facilitate early interventions aimed at preventing adverse cardiovascular outcomes in pregnancy and postpartum.

The objective of the study is to characterize the antenatal care utilization and obstetric and newborn outcomes among refugee women at a specialized refugee clinic and determine whether these outcomes varied between refugees (government-assisted or privately-sponsored) and asylum seekers. This retrospective cohort study included women receiving antenatal care at a specialized refugee clinic between 2011 and 2016. Time from arrival to first clinic visit, Adequacy of Prenatal Care Utilization Index, and obstetric and newborn outcomes were examined, stratified by refugee category. Amongst 179 women, median time from arrival to first clinic visit was longer for asylum seekers (2.8 months, IQR 12.9) compared to government-assisted and privately-sponsored refugees (0.4 months, IQR 0.7, and 1.6 months, IQR 3.2, respectively; p

Backgroud An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. Data Sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods of Study Selection: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm to 11:00 am] or longer working hours [h] [>40 h per week]);comparator (fixed day shift [typical working period between 8:00 am- 6:00 pm] or standard working hours [≤40 h per week]); and outcomes (preterm delivery, low birth weight [birth weight Tabulation, Integration, and Results From 3305 unique citations, 62 observational studies (196,989 women) were included. “Low” to “very low” certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (OR=1.13, 95% CI: 1.00 to 1.28, I 2 =31%), having a small for gestational age baby (OR=1.18, 95% CI: 1.01 to 1.38, I 2 =0%), preeclampsia (OR=1.75, 95% CI: 1.01 to 3.01, I 2 =75%) and gestational hypertension (OR=1.19, 95% CI: 1.10 to 1.29, I 2 =0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (OR=1.21, 95% CI: 1.03 to 1.42, I 2 =36%) and miscarriage (OR=1.23, 95% CI: 1.03 to 1.47, I 2 =37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (OR=1.38, 95% CI: 1.08 to 1.77, I 2 =73%), preterm delivery (OR=1.21, 95% CI: 1.11 to 1.33, I 2 =30%), an infant of low birth weight (OR=1.43, 95% CI: 1.11 to 1.84, I 2 =0%), or an infant of small for gestational age (OR=1.16, 95% CI: 1.00 to 1.36, I 2 =57%). Dose-response analysis showed women working more than 55.5 hours per week (versus 40) had a 10% increase in the odds of having a preterm delivery. Conclusion Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Sex influences the cardiovascular risk associated with body mass index (BMI) in older adults. Whether this risk differs by sex in younger adults is unknown. We aimed to evaluate the association between measures of adiposity and arterial stiffness and reninangiotensin-aldosterone system (RAAS) activity in younger adults, stratified by sex.Body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR) and fat mass% (FM%) were measured in healthy participants in a fasting, high-salt state. Arterial stiffness [pulse wave velocity (PWV) and aortic augmentation index (AIx)] were measured at baseline and in response to angiotensin II challenge, a validated marker of RAAS activity. Associations were evaluated using linear regression analysis and stratified by sex.Ninety-five healthy, normotensive, non-diabetic females (n = 67, 37 ± 2 y, BMI 25 ± 1 kg/mThe associations between adiposity measures and cardiovascular risk differ by sex in a young population. These factors should be considered when managing cardiovascular risk.

IntroductionFor women with pre-existing type 1 and type 2 diabetes, glycaemic targets are narrow during the preconception and prenatal periods to optimise pregnancy outcomes. Women aim to achieve glycaemic targets during pregnancy through the daily tasks of diabetes self-management. Diabetes self-management during pregnancy involves frequent self-monitoring of blood glucose and titration of insulin based on glucose measures and carbohydrate intake. Our objective is to explore how self-management and support experiences help explain glycaemic control among women with pre-existing diabetes in pregnancy.Methods and analysisWe will conduct a four-phased mixed-methods sequential comparative case study. Phase I will analyse the data from a prospective cohort study to determine the predictors of glycaemic control during pregnancy related to diabetes self-management among women with pre-existing diabetes. In phase II, we will use the results of the cohort analysis to develop data collection tools for phase III. Phase III will be a qualitative description study to understand women’s diabetes education and support needs during pregnancy. In phase IV, we will integrate the results of phases I and III to generate unique cases representing the ways in which self-management and support experiences explain glycaemic control in pregnancy.Ethics and disseminationThe phase I cohort study received approval from our local ethics review board, the Hamilton Integrated Ethics Review Board. We will seek ethics approval for the phase III qualitative study prior to its commencement. Participants will provide informed consent before study enrolment. We plan to publish our results in peer-reviewed journals and present our findings to stakeholders at relevant conferences/symposia.

Women who experience a hypertensive disorder of pregnancy (HDP) are amongst those at the highest risk of premature cardiovascular diseases (CVD). In Canada, effective CVD prevention interventions tailored specifically for this high-risk population are urgently needed. The objective of this review is to summarize a broad range of mechanistic and clinical studies examining the association of HDP with future CVD to inform postpartum clinical follow-up strategies focused on improving women's cardiovascular health. The current state of the science (animal model, observational and intervention studies) largely support two main hypotheses explaining the epidemiological link between HDP and long-term risk of CVD. First, that the complicated pregnancy “unmasks” women who were predisposed to CVD prior to pregnancy (i.e., women with subclinical atherosclerosis or pre-pregnancy CVD risk factors). Second, that HDP causes vascular dysfunction and/or worsens preexisting, subclinical CVD risk factors. Despite this strong evidence, several knowledge gaps remain in the understanding of specific mechanisms linking these two theories and the impacts of other important contributors (e.g., intersectional factors). From a clinical perspective, given the consistent data demonstrating a high prevalence of CVD risk factors after HDP, routine care after pregnancy at minimum should include: 1) standardized assessment of pregnancy-associated CV risks (P-CVRs); 2) early and regular screening of traditional CVD risk factors; 3) education and support for health behaviours as first line therapy (including breastfeeding); 4) individualized pharmacotherapy (i.e., statins, antihypertensives or antiglycemic agents as clinically indicated); and 5) consideration of a woman's health goals, reproductive plans and social context.

Background: Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD. Methods: We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI). Results: Our systematic review included 83 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3–2.2), preeclampsia (OR 2.7; 95% ICI, 2.5–3.0), placental abruption (OR 1.8; 95% ICI, 1.4–2.3), preterm birth (OR 1.6; 95% ICI, 1.4–1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1–2.5), and stillbirth (OR 1.5; 95% ICI, 1.1–2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage. Conclusions: Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.

Women have unique sex- and gender-related risk factors for cardiovascular disease (CVD) that can present or evolve over their lifespan. Pregnancy-associated conditions, polycystic ovarian syndrome, and menopause can increase a woman’s risk of CVD. Women are at greater risk for autoimmune rheumatic disorders, which play a role in the predisposition and pathogenesis of CVD. The influence of traditional CVD risk factors (eg, smoking, hypertension, diabetes, obesity, physical inactivity, depression, anxiety, and family history) is greater in women than men. Finally, there are sex differences in the response to treatments for CVD risk and comorbid disease processes. In this Atlas chapter we review sex- and gender-unique CVD risk factors that can occur across a woman’s lifespan, with the aim to reduce knowledge gaps and guide the development of optimal strategies for awareness and treatment. Résumé: Les femmes présentent des facteurs de risque de maladies cardiovasculaires (MCV) uniques, liés au sexe et au genre, qui peuvent se manifester ou évoluer tout au long de leur vie. Les troubles médicaux associés à la grossesse, le syndrome des ovaires polykystiques et la ménopause peuvent augmenter le risque de MCV chez une femme. Les femmes sont plus exposées aux troubles rhumatologiques auto-immuns, qui jouent un rôle dans la prédisposition et dans la pathogenèse des MCV. L’influence des facteurs de risque traditionnels pour les MCV (par exemple, le tabagisme, l’hypertension, le diabète, l’obésité, la sédentarité, la dépression, l’anxiété et les antécédents familiaux) est plus importante chez les femmes que chez les hommes. Enfin, il existe des différences entre les sexes dans la réponse aux traitements du risque de MCV et des processus pathologiques comorbides. Dans ce chapitre de l’Atlas, nous passons en revue les facteurs de risque de MCV propres au sexe et au genre qui peuvent survenir tout au long de la vie d’une femme, dans le but de réduire les lacunes dans les connaissances et d’orienter l’élaboration de stratégies optimales de sensibilisation et de traitement.

Background The average age at first birth is steadily increasing in developed countries; however, demographic shifts in maternal age at childbearing have not occurred in isolation. While temporal increases in adverse pregnancy outcomes are typically attributed to increases in maternal age, little is known about how maternal health status has changed across maternal age, period of delivery, and birth cohort. Methods Natality files were used to identify primiparous women delivering liveborn, singleton infants in the USA in 1989, 1994, 1999, 2004, 2009, and 2014 (n = 6,857,185). Age-period-cohort models using the intrinsic estimator adjusted for temporal trends in smoking and gestational weight gain were used to quantify temporal changes in the rates of pre-existing (chronic hypertension, pre-existing diabetes) and pregnancy-associated (pregnancy-associated hypertension, gestational diabetes, eclampsia) diseases. Log-linear models were used to model the impact of temporal changes on preterm birth, small, and large for gestational age (SGA/LGA) births. Results Significant period effects resulted in temporal increases in the rate of chronic hypertension, pregnancy-associated hypertension, and gestational diabetes, and a significant decrease in the rate of eclampsia. These observed period effects were associated with a 10.6% increase in the rate of SGA and a 7.1% decrease in LGA. Had the rate of pre-existing and pregnancy-associated diseases remained static over this time period, the rate of preterm birth would have increased by 5.9%, but instead only increased by 4.4%. Conclusions Independent of changes in the incidence of pre-existing and pregnancy-associated diseases as women age, the obstetric population is becoming less healthy over time. This is important, as these changes have a direct negative impact on short-term obstetric outcomes and women’s long-term health.

We present Hypertension Canada's inaugural evidence-based Canadian recommendations for the management of hypertension in pregnancy. Hypertension in pregnancy is common, affecting approximately 7% of pregnancies in Canada, and requires effective management in order to reduce maternal, fetal and newborn complications. Given this importance, these guidelines were developed in partnership with the Society of Obstetricians and Gynaecologists of Canada with the main common objective of improving the management of women with hypertension in pregnancy. Guidelines for the diagnosis, assessment, prevention and treatment of hypertension in adults and children are published separately. In this first Hypertension Canada Guidelines for hypertension in pregnancy, seven recommendations for the management of non-severe and severe hypertension in pregnancy are presented. For non-severe hypertension in pregnancy (systolic blood pressure 140-159 mm Hg and/or diastolic blood pressure 80-109 mm Hg), we provide guidance for the threshold for initiation of antihypertensive therapy, blood pressure targets, as well as first- and second-line antihypertensive medications. Severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg) requires urgent antihypertensive therapy to reduce maternal, fetal and newborn adverse outcomes. The specific evidence and rationale underlying each of these guidelines are discussed.

Hypertension Canada provides annually-updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines were introduced, and one existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke was revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.

Backgroud An increasing number of original studies suggest that exposure to shift work and long working hours during pregnancy could be associated with the risk of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influences of shift work and longer working hours during pregnancy on maternal and fetal health outcomes. Data Sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods of Study Selection: Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy); exposure (rotating shift work [shifts change according to a set schedule], fixed night shift [typical working period is between 11:00 pm to 11:00 am] or longer working hours [h] [>40 h per week]);comparator (fixed day shift [typical working period between 8:00 am- 6:00 pm] or standard working hours [≤40 h per week]); and outcomes (preterm delivery, low birth weight [birth weight Tabulation, Integration, and Results From 3305 unique citations, 62 observational studies (196,989 women) were included. “Low” to “very low” certainty evidence from these studies revealed that working rotating shifts was associated with an increased odds of preterm delivery (OR=1.13, 95% CI: 1.00 to 1.28, I 2 =31%), having a small for gestational age baby (OR=1.18, 95% CI: 1.01 to 1.38, I 2 =0%), preeclampsia (OR=1.75, 95% CI: 1.01 to 3.01, I 2 =75%) and gestational hypertension (OR=1.19, 95% CI: 1.10 to 1.29, I 2 =0%), compared to those who worked a fixed day shift. Working fixed night shifts was associated with an increased odds of preterm delivery (OR=1.21, 95% CI: 1.03 to 1.42, I 2 =36%) and miscarriage (OR=1.23, 95% CI: 1.03 to 1.47, I 2 =37%). Compared with standard hours, working longer hours was associated with an increased odds of miscarriage (OR=1.38, 95% CI: 1.08 to 1.77, I 2 =73%), preterm delivery (OR=1.21, 95% CI: 1.11 to 1.33, I 2 =30%), an infant of low birth weight (OR=1.43, 95% CI: 1.11 to 1.84, I 2 =0%), or an infant of small for gestational age (OR=1.16, 95% CI: 1.00 to 1.36, I 2 =57%). Dose-response analysis showed women working more than 55.5 hours per week (versus 40) had a 10% increase in the odds of having a preterm delivery. Conclusion Pregnant women who work rotating shifts, fixed night shifts, or longer hours have an increased risk of adverse pregnancy outcomes.

Backgroud An increasing number of studies suggest that exposure to physically demanding work during pregnancy could be associated with increased risks of adverse pregnancy outcomes, but the results remain conflicted and inconclusive. Objective To examine the influence of occupational activities during pregnancy on maternal and fetal health outcomes. Data sources Five electronic databases and three gray literature sources were searched up to March 15, 2019. Methods Of Study Selection Studies of all designs (except case studies and reviews) were included, which contained information on the relevant population (women who engaged in paid work during pregnancy), occupational exposures (heavy lifting, prolonged standing, prolonged walking, prolonged bending, and heavy physical workload), comparator (no exposure to the listed physical work demands), and outcomes (preterm birth, low birth weight, small for gestational age, miscarriage, gestational hypertension, pre-eclampsia, gestational diabetes mellitus, stillbirth, and intrauterine growth restriction). Tabulation, Integration, And Results Eighty observational studies (N=853,149) were included. ‘Low’ to ‘very low’ certainty evidence revealed that lifting objects ≥ 11 kilograms (kg) was associated with an increased odds ratio (OR) of miscarriage (OR: 1.31, 95% CI: 1.08 to 1.58, I2=79%), and pre-eclampsia (OR: 1.35, 95% CI: 1.07 to 1.71, I2=0%). Lifting objects for a combined weight of > 100kg per day was associated with an increased odds of preterm delivery (OR: 1.31, 95% CI: 1.11 to 1.56, I2=0%) and having a low-birth-weight neonate (OR: 2.08, 95% CI: 1.06 to 4.11, I2=73%). Prolonged standing was associated with increased odds of preterm delivery (OR: 1.11, 95% CI: 1.02 to 1.22, I2=30%), and having a small-for-gestational-age neonate (OR: 1.17, 95% CI: 1.01 to 1.35, I2=41%. A heavy physical workload was associated with increased odds of preterm delivery (OR: 1.23, 95% CI: 1.07 to 1.41, I2=32%), and having a low-birth-weight neonate (OR: 1.79, 95% CI: 1.11 to 2.87, I2=87%). All other associations were not statistically significant. Dose-response analysis showed women standing more than 2.5 hours per day (versus no standing) had a 10% increase in the odds of having a preterm delivery. Conclusion Physically demanding work during pregnancy is associated with an increased risk of adverse pregnancy outcomes.

Background: Combined oral contraceptives (COCs) are associated with increased blood pressure (BP) and hypertension. Whether non-oral forms of hormonal contraceptive (NOHC) have similar associations is unknown. Methods: We conducted a systematic review investigating the association between NOHC use and blood pressure compared to women using COC and non-hormonal contraception (NHC). Three databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) were searched for articles published from database inception through October 2018. Primary studies examining women using NOHC [transdermal, hormonal intrauterine device (IUD), implant, vaginal ring or injectables] compared with women using COC or NHC were included. Two independent investigators screened identified abstracts. Data on study population, hormonal exposure, outcomes, study quality and risk of bias were independently extracted from each eligible study. Primary outcomes were change in BP or prevalence of hypertension. Quality of case control and cohort studies was assessed using the Newcastle-Ottawa scale. Quality of randomized control trials was assessed using the Cochrane risk of bias tool. Results: Of 3981 studies reviewed, 22 met inclusion criteria (12 studies on injectables, 6 on implants, 4 on hormonal IUDs, 3 on the vaginal ring). Some studies examining the effect of IUD use showed a significantly lower BP compared to COC use, and no difference compared to NHC users. No differences in BP were reported with vaginal ring use compared to COC or NHC use. Conflicting results were presented with implant use compared to NHC use, but no change in BP compared to COC. Five studies reported increased BP with injectable use compared to COC and NHC, while seven studies showed no change in BP. All women remained in the normotensive range in all included studies. Conclusion: Non-oral hormonal contraceptive use is associated with increases in blood pressure, though the effects differ by route of administration. These results may inform contraceptive choices in women with or at risk of hypertension.

Background: Oral contraceptive use is associated with increased CV risk. Whether non-oral hormonal contraceptive use poses a similar risk is unclear. Objectives: To evaluate the association between oral and non-oral hormonal and arterial stiffness and renin-angiotensin system (RAS) activity in premenopausal women. Methods: Healthy premenopausal women using non-oral hormonal contraception (NOHC), oral hormonal contraception (OC) (minimum duration of 3 months) and controls were studied in a fasting, high-salt state. Aortic augmentation index (AIx) and pulse wave velocity (PWV) were measured at baseline and in response to Angiotensin II (AngII) challenge, a validated marker of arterial RAS activity. Results from the 3 groups were compared using ANOVA and presented as mean and standard error. Results: Fifty-six women (6 OC, 8 NOHC, 42 controls) were studied. Women were similar in age (OC 29±7yvs NOHC 28±4yvs controls 32±2y, p=0.52)and BMI (OC 26.7±1vsNOHC 22.3±2vs controls25.3±4, p=0.12). No differences were observed amongst the groups with regards to baseline arterial stiffness measures (AIx: OC 4.08±1%; NOHC -2.75±2%; controls 9.01±3%; p =0.10; PWV: OC 6.94±3 m/s; NOHC 6.4±2 m/s; controls 8.04±5m/s; p=0.49). In response to AngII challenge, NOHC users had a greater change in AIx compared to OC after adjustment for age and blood pressure (NOHC 17.06±3%; controls 9.76±1%; p=0.048). No significant changes in PWV were observed among NOHC or OC and controls. Conclusions: Arterial RAS is lower in non-oral hormonal contraceptive users, suggesting this may be a safer contraception option in women at high risk of CVD.

The hypertensive disorders of pregnancy (HDP), including preeclampsia (PE) and gestational hypertension (GHTN), are independent risk factors for future maternal cardiovascular disease. Epidemiologic evidence has demonstrated that women with HDP have abnormal cardiovascular risk factors in the early postpartum period, but this has not been fully characterized.This study aimed to assess the lipid profiles among women with PE, GHTN, and normal blood pressure in the first 4 years postpartum.Discharge Abstract Database was used to identify women hospitalized for a delivery in Calgary, Alberta, Canada, between January 2010 and December 2012 (N = 27,300). This was linked with Calgary Laboratory Services (for lipid levels) and the Pharmaceutical Information Network database (for lipid medication prescriptions) over the first 4 years postpartum (2010-2016). Logistic regression analysis was used to compare the frequency of lipid tests among HDP subtypes, adjusted for maternal age, gestational age at delivery, and parity.Only about half of the women with HDP had a lipid test in the first 4 years postpartum: 50.8% (PE) and 48.8% (GHTN) vs 41.5% in normotensive women (P .001). Low-density lipoprotein cholesterol levels were significantly higher in women with HDP: 106.3 ± 35.2 mg/dL (2.75 ± 0.91 mmol/L) in PE, 102.5 ± 30.5 mg/dL (2.65 ± 0.79 mmol/L) in GHTN, and 96.7 ± 29.0 mg/dL (2.50 ± 0.75 mmol/L) in normotensive women (P .001).Postpartum lipid screening helps identify women at risk of cardiovascular disease; however, only 50% of women with HDP were tested in the first years postpartum. As such, an early opportunity for primary CVD prevention strategies in young women may be lost.

Women with the hypertensive disorders of pregnancy (HDP) (preeclampsia [PE] and gestational hypertension [GHTN]) have increased risks of future diabetes. Postpartum glycemic testing offers early identification and treatment of dysglycemia, but evidence-based recommendations for this high-risk population are lacking. The objective of this study was to describe the risks of developing dysglycemia in women with normotensive and hypertensive pregnancies over the first 4 years postpartum.The Discharge Abstract Database was used to identify women who delivered singleton live-born infants in Calgary, Alberta, Canada, between January 2010 and December 2012 (N=27,300). This was linked with Calgary Laboratory Services (for glycemic tests) and the Pharmaceutical Information Network databases (for antidiabetes medication prescriptions) over the first 4 years postpartum. Logistic regression analyses compared glycemic testing and results were adjusted for maternal age, gestational age, parity and the Pampalon deprivation index.Women with HDP had more glycemic testing (GHTN 67.8% and PE 69.9% vs normotensive 60.9%; p0.001) and significantly higher results for fasting plasma glucose (GHTN 4.82±0.51 mmol/L and PE 4.84±0.54 mmol/L vs normotensive 4.73±0.49 mmol/L; p0.001), random plasma glucose (GHTN 5.20±0.96 mmol/L and PE 5.39±1.71 mmol/L vs normotensive 5.00±0.87 mmol/L; p0.001) and glycated hemoglobin levels (PE 5.62±0.53% vs normotensive 5.49±0.32%; p0.001). Women with HDP had a higher adjusted odds (95% confidence interval) of developing type 2 diabetes compared with normotensive women (GHTN: 2.26, 1.50 to 13.4; PE: 2.02, 0.91 to 4.46).The high prevalence of early dysglycemia highlights the importance of targeted postpartum glycemic testing in women after HDP. Further research on optimal glycemic testing (specific tests and timing) in these high-risk women is needed.