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BACKGROUND: Hypertensive disorders of pregnancy (HDP) are associated with increased risk of cardiovascular disease (CVD) 20–30 years later; however, cardiovascular (CV) risk in the decade after HDP is less studied. OBJECTIVES: The purpose of this study was to evaluate differences in CV risk factors as well as subclinical CVD among a well-characterized group of racially diverse patients with and without a history of HDP 10 years earlier. METHODS: This is a prospective study of patients with and without a diagnosis of HDP ≥10 years earlier (2005–2007) who underwent in-person visits with echocardiography, arterial tonometry, and flow-mediated dilation of the brachial artery. RESULTS: A total of 135 patients completed assessments (84 with and 51 without a history of HDP); 85% self-identified as Black. Patients with a history of HDP had a 2.4-fold increased risk of new hypertension compared with those without HDP (56.0% vs. 23.5%; adjusted relative risk: 2.4; 95% CI: 1.39–4.14) with no differences in measures of left ventricular structure, global longitudinal strain, diastolic function, arterial stiffness, or endothelial function. Patients who developed hypertension, regardless of HDP history, had greater left ventricular remodeling, including greater relative wall thickness; worse diastolic function, including lower septal and lateral e’ and E/A ratio; more abnormal longitudinal strain; and higher effective arterial elastance than patients without hypertension. CONCLUSIONS: We found a 2.4-fold increased risk of hypertension 10 years after HDP. Differences in noninvasive measures of CV risk were driven mostly by the hypertension diagnosis, regardless of HDP history, suggesting that the known long-term risk of CVD after HDP may primarily be a consequence of hypertension development.

Background: Rising rates of postpartum obesity increase risk for cardiovascular (CV) disease, especially among individuals with adverse pregnancy outcomes. Engagement in weight loss programs (WLP) have not been well studied in the postpartum period. Our objective was to understand barriers to engagement in an online behavioral WLP among a racially diverse postpartum population with CV risk factors. Methods: We conducted a qualitative study of participants enrolled in a clinical trial. We identified individuals who were 3-12 months postpartum, had a body mass index ≥ 27 kg/m2, and had ≥1 of the following: chronic hypertension, hypertensive disorder of pregnancy, gestational or pre-gestational diabetes. We randomized 60 subjects 1:2 to usual care or online WLP based on the Diabetes Prevention Program. We conducted semi-structured virtual interviews with participants in the WLP who completed final assessments to understand barriers to and facilitators of program engagement. Interviews were recorded and transcribed, a codebook was developed iteratively with concurrent interrater reliability assessment, and themes were identified using content analysis. Results: Of 26 eligible participants, 20 completed interviews (77%). Mean age was 35 years and 45% were Black. Common barriers to program engagement were a lack of time due to competing life priorities and stressors, coupled with insufficient program personalization and peer support (see Table). In terms of facilitators, participants discussed intentionality, creating a routine to complete program requirements (e.g., daily morning weights) and specific aspects of the program structure (e.g., weekly feedback) as playing important roles in maximizing program engagement. Conclusion: Participants identified several opportunities to improve program engagement and weight loss success among postpartum individuals in future studies. These strategies will be critical to the implementation of future lifestyle interventions using remote technology in this population.

Acute stress during pregnancy can have adverse effects on maternal health and increase the risk for postpartum depression and impaired mother-infant bonding. The COVID-19 pandemic represents an acute environmental stressor during which it is possible to explore risk and resilience factors that contribute to postpartum outcomes. To investigate prenatal risk and resilience factors as predictors of postpartum depression and impaired mother-infant bonding, this study recruited a diverse cohort of 833 pregnant women from an urban medical center in Philadelphia, Pennsylvania, and assessed them once during pregnancy in the early phase of the COVID-19 pandemic (April-July 2020) and again at approximately twelve weeks postpartum. Adverse childhood experiences, prenatal depression and anxiety, and COVID-19-related distress predicted a greater likelihood of postpartum depression. Prenatal depression was the only unique predictor of impaired maternal-infant bonding after postpartum depression was controlled for. Women reporting greater emotion regulation, self-reliance, and nonhostile relationships had healthier postpartum outcomes. Policies to increase the number of nonspecialty providers providing perinatal mental health services as well as reimbursement for integrated care and access to mental health screening and care are needed to improve lifelong outcomes for women and their children.

Objective To determine whether perceived stress is associated with preterm birth (PTB) and to investigate racial differences in stress and PTB. Study design A secondary analysis of a prospective cohort study of 1911 women with singleton pregnancies examined responses to psychosocial stress questionnaires at 16-20 weeks of gestation. Results High perceived stress (19%) and PTB (10.8%) were prevalent in our sample (62% non-Hispanic Black). Women with PTB were more likely to be Black, have chronic hypertension (cHTN), pregestational diabetes, and higher BMI. Women with high perceived stress had more PTBs than those with lower stress (15.2% vs. 9.8%), and stress was associated with higher odds of PTB (aOR: 1.55, 95% CI: 1.09-2.19). Conclusion The significant association between high perceived stress and PTB suggests that prenatal interventions to reduce maternal stress could improve the mental health of pregnant women and may result in reduced rates of PTB.

Background: Increasing rates of obesity are a major contributor to CV disease among women of reproductive age, especially Black women. Enrollment of racially diverse populations in behavioral weight loss trials is suboptimal and may be impacted by recruitment approaches. Our objectives are to evaluate the effectiveness of recruitment strategies informed by principles of behavioral economics on the enrollment of women into a weight loss trial and to understand the impact of race and insurance. Methods: We tested 4 strategies to enroll postpartum women with CV risk factors into a behavioral weight loss trial. 1,047 individuals who met inclusion criteria in the electronic health record were randomized to receive one of two personalized emails. Email 1 stated that “we reserved a spot” in the study for the patient. Email 2 asked the patient to “commit to health.” Patients who did not respond or have an email address were then randomized to receive a mailer or mailer plus baby bib (gift). All groups were asked to sign up for a virtual information session. We compared response rates between the 2 email and 2 mail strategies. We identified participant characteristics associated with signing up using multivariate logistic regression. Results: Mean age was 31.3 years, 65% were Black and 52% had Medicaid. 1000 patients were randomized to email 1 (n=497) and email 2 (n=503). Response rates were similar in the email groups (17.7% vs. 20.3%, p=0.299). 849 patients were randomized to the mailer (n=424) or mailer plus gift (n=425). Response rates were low but did not differ by strategy (2.6% vs. 3.8%, p=0.331), and largely did not vary by race or insurance (Table). In multivariable analysis, Medicaid insurance was associated with lower odds of signing up for an info session, but race was not. Conclusion: A tailored email is a low-cost and time effective strategy to recruit racially diverse women in a behavioral weight loss trial, though women with Medicaid insurance may require additional outreach.

IMPORTANCE: Hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease, yet few interventions have targeted this population to decrease long-term risk. OBJECTIVE: To determine whether a digital health intervention improves physical activity in postpartum individuals with hypertensive disorders of pregnancy. DESIGN, SETTING, AND PARTICIPANTS: This 12-week randomized clinical trial enrolled postpartum individuals who delivered at the University of Pennsylvania and had a hypertensive disorder of pregnancy between October 2019 and June 2020. Analysis was intention to treat. INTERVENTIONS: All participants received a wearable activity tracker, established a baseline step count, selected a step goal greater than baseline, and were randomly assigned to control or intervention. Participants in the control arm received daily feedback on goal attainment. Participants in the intervention arm were placed on virtual teams and enrolled in a game with points and levels for daily step goal achievement and informed by principles of behavioral economics. MAIN OUTCOMES AND MEASURES: The primary outcome was change in mean daily step count from baseline to 12-week follow-up. Secondary outcome was proportion of participant-days that step goal was achieved. RESULTS: A total of 127 participants were randomized (64 in the control group and 63 in the intervention group) and were enrolled a mean of 7.9 weeks post partum. Participants had a mean (SD) age of 32.3 (5.6) years, 70 (55.1%) were Black, and 52 (41.9%) had Medicaid insurance. The mean (SD) baseline step count was similar in the control and intervention arms (6042 [2270] vs 6175 [1920] steps, respectively). After adjustment for baseline steps and calendar month, participants in the intervention arm had a significantly greater increase in mean daily step steps from baseline compared with the control arm (647 steps; 95% CI, 169-1124 steps; P = .009). Compared with the control arm, participants in the intervention arm achieved their steps goals on a greater proportion of participant-days during the intervention period (0.47 vs 0.38; adjusted difference 0.11; 95% CI, 0.04-0.19; P = .003). CONCLUSIONS AND RELEVANCE: In this study, a digital health intervention using remote monitoring, gamification, and social incentives among postpartum individuals at elevated cardiovascular risk significantly increased physical activity throughout 12 weeks. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03311230

Childbirth trauma is common and increases risk for postpartum depression (PPD). However, we lack brief measures to reliably identify individuals who experience childbirth trauma and who may be at greater prospective risk for PPD. To address this gap, we used data from a racially diverse prospective cohort (n=1082). We collected survey data during pregnancy and at 12 weeks postpartum, as well as clinician-reported data from medical records. A new three-item measure of patient-reported childbirth trauma was a robust and independent risk factor for PPD, above and beyond other known risk factors for PPD, including prenatal anxiety and depression. Cesarean birth, greater blood loss, and preterm birth were each associated with greater patient-reported childbirth trauma. Finally, there were prospective indirect pathways whereby cesarean birth and higher blood loss were related to higher patient-reported childbirth trauma, in turn predicting greater risk for PPD. Early universal postpartum screening for childbirth trauma, targeted attention to individuals with childbirth complications, and continued screening for depression and anxiety can identify individuals at risk for PPD. Such efforts can inform targeted interventions to improve maternal mental health, which plays a vital role in infant development.

Acute stress during pregnancy can have adverse effects on maternal health and increase the risk for postpartum depression and impaired mother-infant bonding. The COVID-19 pandemic represents an acute environmental stressor during which it is possible to explore risk and resilience factors that contribute to postpartum outcomes. To investigate prenatal risk and resilience factors as predictors of postpartum depression and impaired mother-infant bonding, this study recruited a diverse cohort of 833 pregnant women from an urban medical center in Philadelphia, Pennsylvania, and assessed them once during pregnancy in the early phase of the COVID-19 pandemic (April–July 2020) and again at approximately twelve weeks postpartum. Adverse childhood experiences, prenatal depression and anxiety, and COVID-19-related distress predicted a greater likelihood of postpartum depression. Prenatal depression was the only unique predictor of impaired maternal-infant bonding after postpartum depression was controlled for. Women reporting greater emotion regulation, self-reliance, and nonhostile relationships had healthier postpartum outcomes. Policies to increase the number of nonspecialty providers providing perinatal mental health services as well as reimbursement for integrated care and access to mental health screening and care are needed to improve lifelong outcomes for women and their children.

Failure to predict and understand the causes of preterm birth, the leading cause of neonatal morbidity and mortality, have limited effective interventions and therapeutics. From a cohort of 2000 pregnant women, we performed a nested case control study on 107 well-phenotyped cases of spontaneous preterm birth (sPTB) and 432 women delivering at term. Using innovative Bayesian modeling of cervicovaginal microbiota, seven bacterial taxa were significantly associated with increased risk of sPTB, with a stronger effect in African American women. However, higher vaginal levels of β-defensin-2 lowered the risk of sPTB associated with cervicovaginal microbiota in an ethnicity-dependent manner. Surprisingly, even in Lactobacillus spp. dominated cervicovaginal microbiota, low β-defensin-2 was associated with increased risk of sPTB. These findings hold promise for diagnostics to accurately identify women at risk for sPTB early in pregnancy. Therapeutic strategies could include immune modulators and microbiome-based therapeutics to reduce this significant health burden., Here, Elovitz et al. investigate associations between cervicovaginal microbiota (CVM) and spontaneous preterm birth (sPTB) in a large cohort of African American and non-African American women, and find that CVM and local immune response early in pregnancy are associated with sPTB in an ethnicity-dependent manner.

Background: Peripartum cardiomyopathy (PPCM) occurs in ≈1:2000 deliveries in the United States and worldwide. The genetic underpinnings of PPCM remain poorly defined. Approximately 10% of women with PPCM harbor truncating variants in TTN (TTNtvs). Whether mutations in other genes can predispose to PPCM is not known. It is also not known if the presence of TTNtvs predicts clinical presentation or outcomes. Nor is it known if the prevalence of TTNtvs differs in women with PPCM and preeclampsia, the strongest risk factor for PPCM. Methods: Women with PPCM were retrospectively identified from several US and international academic centers, and clinical information and DNA samples were acquired. Next-generation sequencing was performed on 67 genes, including TTN , and evaluated for burden of truncating and missense variants. The impact of TTNtvs on the severity of clinical presentation, and on clinical outcomes, was evaluated. Results: Four hundred sixty-nine women met inclusion criteria. Of the women with PPCM, 10.4% bore TTNtvs (odds ratio=9.4 compared with 1.2% in the reference population; Bonferroni-corrected P [ P *]=1.2×10 –46 ). We additionally identified overrepresentation of truncating variants in FLNC (odds ratio=24.8, P *=7.0×10 –8 ), DSP (odds ratio=14.9, P *=1.0×10 –8 ), and BAG3 (odds ratio=53.1, P *=0.02), genes not previously associated with PPCM. This profile is highly similar to that found in nonischemic dilated cardiomyopathy. Women with TTNtvs had lower left ventricular ejection fraction on presentation than did women without TTNtvs (23.5% versus 29%, P =2.5×10 –4 ), but did not differ significantly in timing of presentation after delivery, in prevalence of preeclampsia, or in rates of clinical recovery. Conclusions: This study provides the first extensive genetic and phenotypic landscape of PPCM and demonstrates that predisposition to heart failure is an important risk factor for PPCM. The work reveals a degree of genetic similarity between PPCM and dilated cardiomyopathy, suggesting that gene-specific therapeutic approaches being developed for dilated cardiomyopathy may also apply to PPCM, and that approaches to genetic testing in PPCM should mirror those taken in dilated cardiomyopathy. Last, the clarification of genotype/phenotype associations has important implications for genetic counseling.

The COVID-19 pandemic has disproportionately impacted the well-being of vulnerable populations in the US, including Black people. The impact on pregnant women is of special concern for the intrauterine and post-natal development of their offspring. We evaluated in an online survey a sample of 913 pregnant women, 216 Black, 571 White, 126 Other, during a 2-week stay-at-home mandate in the Philadelphia region. We applied logistic regression models and analysis of covariance to examine general and pregnancy-specific worries and negative consequences arising from the COVID-19 pandemic, symptoms of anxiety and depression, and resilience. Black pregnant women reported greater likelihood of having their employment negatively impacted, more concerns about a lasting economic burden, and more worries about their prenatal care, birth experience, and post-natal needs. In the full sample, 11.1% of women met screening criteria for anxiety and 9.9% met criteria for depression. Black women were more likely to meet criteria for depression than White women, but this difference was not significant accounting for covariates. Resilience factors including self-reliance and emotion regulation were higher in Black women. Racial disparities related to COVID-19 in pregnant women can advance the understanding of pregnancy related stressors and improve early identification of mental health needs.

Safe Start is a community health worker program representing a partnership between a high-volume, inner-city, hospital-based prenatal clinic; a community-based organization; a large Medicaid insurer; and a community behavioral health organization to improve perinatal outcomes among publicly insured pregnant women with chronic health conditions in Philadelphia, Pennsylvania. As of June 2019, 291 women participated in the program. Relative to a comparison group (n = 300), Safe Start participants demonstrate improved engagement in care, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays.

OBJECTIVE The primary purpose of this study was to examine associations of objectively measured sleep duration with weight changes in black and Hispanic mothers over the first postpartum year. METHODS Data were from 159 mothers (69% black, 32% Hispanic). Nocturnal sleep duration was assessed using wrist actigraphy at 6 weeks and 5 months post partum, examined as a continuous variable and in categories (

BACKGROUND: Spontaneous preterm birth (sPTB) is a major contributor to infant mortality and its etiology remains poorly understood. Host immunity and maternal stress may play a role in the pathogenesis of sPTB but mechanisms are poorly delineated. Antimicrobial proteins in the cervicovaginal space, such as beta defensins, modulate immune responses to bacteria and have been shown to modulate the risk of sPTB from non-optimal microbiota. While stress is known to induce immunological changes, no study has examined the interplay between maternal stress and the immune response in association with sPTB. OBJECTIVES: Our objectives were to determine whether psychosocial stress was associated with a mediator of the immune system in the cervicovaginal space, beta defensin-2, and to examine the combined impact of high stress and low cervicovaginal beta defensin-2 levels on the odds of sPTB. STUDY DESIGN: From the Motherhood & Microbiome cohort study (n=2000), we performed a secondary, nested case-control study, frequency matched by race/ethnicity, of 519 pregnant women (110 sPTB and 409 term). Stress and cervicovaginal beta defensin-2 levels were measured at 16–20 weeks of gestation. Stress was dichotomized at a score of 30 on Cohen’s Perceived Stress Scale (PSS-14). We measured cervicovaginal beta defensin-2 levels with ELISA and dichotomized at the median. We modeled associations of high stress and low cervicovaginal beta defensin-2 levels using multivariable logistic regression. We also compared the proportion of women with high stress and low cervicovaginal beta defensin-2 levels among women with spontaneous preterm and term births using Chi-Square tests. We modeled adjusted associations of stress and cervicovaginal beta defensin-2 levels with odds of sPTB using logistic regression. RESULTS: The majority of the study population was non-Hispanic black (72.8%), insured by Medicaid (51.1%), and had a PSS-14 score < 30 (80.2%). High stress was associated with reduced adjusted odds of low beta defensin-2 levels (aOR 0.63, 95% CI: 0.38 −0.99). In a model adjusted for race and smoking, both high stress (aOR 1.72, 95% CI: 1.03–2.90) and low beta defensin-2 (aOR 1.58, 95% CI: 1.004–2.49) were associated with increased odds of sPTB. We then built a model of the four possible combinations of low and high stress and low and high beta defensin-2 levels with the odds of sPTB. Women with either high stress (aOR 1.37, 95% CI: 0.68 – 2.78) or low beta defensin-2 (aOR 1.40, 95% CI: 0.83–2.34), had slightly elevated but not significantly increased odds of sPTB compared to women with neither exposure. However, women with both high stress and low beta defensin-2 had significantly elevated odds of sPTB compared to women with neither exposure (aOR 3.16, 95 % CI: 1.46 – 6.84). CONCLUSION: High perceived stress and low cervicovaginal beta defensin-2 levels are associated with higher odds of sPTB, and when present concurrently, they result in the highest odds of sPTB in a largely non-Hispanic black cohort. Our findings warrant further work to examine social determinants of health and the host cervicovaginal immune responses that may modulate the pathogenesis of sPTB.

Peripartum cardiomyopathy (PPCM) disproportionately affects women of African ancestry, but well-powered studies to explore differences in severity of disease and clinical outcomes are lacking.To compare the clinical characteristics, presentation, and outcomes of PPCM between African American and non-African American women.This retrospective cohort study using data from January 1, 1986, through December 31, 2016, performed at the University of Pennsylvania Health System, a tertiary referral center serving a population with a high proportion of African American individuals, included 220 women with PPCM.Demographic and clinical characteristics and echocardiographic findings at presentation, as well as clinical outcomes including cardiac recovery, time to recovery, cardiac transplant, persistent dysfunction, and death, were compared between African American and non-African American women with PPCM.A total of 220 women were studied (mean [SD] age at diagnosis, 29.5 [6.6] years). African American women were diagnosed with PPCM at a younger age (27.6 vs 31.7 years, P .001), were diagnosed with PPCM later in the postpartum period, and were more likely to present with a left ventricular ejection fraction less than 30% compared with non-African American women (48 [56.5%] vs 30 [39.5%], P = .03). African American women were also more likely to worsen after initial diagnosis (30 [35.3%] vs 14 [18.4%], P = .02), were twice as likely to fail to recover (52 [43.0%] vs 24 [24.2%], P = .004), and, when they did recover, recovery took at least twice as long (median, 265 vs 125.5 days; P = .02) despite apparent adequate treatment.In a large cohort of women with well-phenotyped PPCM, this study demonstrates a different profile of disease in African American vs non-African American women. Further work is needed to understand to what extent these differences stem from genetic or socioeconomic differences and how treatment of African American patients might be tailored to improve health outcomes.