A global view of hypertensive disorders and diabetes mellitus during pregnancy

REVIEWS A global view of hypertensive disorders and diabetes mellitus during pregnancy Li Jiang1,8, Kun Tang1,2,8, Laura A. Magee3, Peter von Dadelszen Xuan Li2, Enyao Zhang2 and Zulfiqar A. Bhutta1,6,7 ✉ , Alec Ekeroma 3 , 4,5 Abstract | Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis. ✉e-mail: zulfiqar.bhutta@ sickkids.ca https://doi.org/10.1038/ s41574-022-00734-y Two of the most common cardiometabolic disorders (CMDs) that occur during pregnancy are hypertensive disorders in pregnancy (HDP) and diabetes mellitus. HDP includes chronic hypertension, gestational hypertension and pre-eclampsia–eclampsia. Diabetes mellitus during pregnancy can be pre-existing type 1 diabetes mellitus or type 2 diabetes mellitus (T2DM), or gestational diabetes mellitus (GDM) that develops during pregnancy. This Review focuses on HDP and GDM. HDP and GDM share many common risk factors and similarities in their pathophysiology, including oxidative stress, inflammation and vascular endothelial dysfunction1; these two maternal conditions result in a large disease burden for both pregnant individuals and their offspring. Despite decreasing prevalence after years of interventions, HDP remain a leading cause of maternal mortality and morbidity globally, especially in low-income and middle-income countries (LMICs)2–4. The prevalence of GDM has increased dramatically over the past two decades by more than 30% in numerous countries5–7. These two maternal CMDs are related to substantial short-term and long-term adverse Nature Reviews | Endocrinology 0123456789();: health outcomes for pregnant individuals and their offspring. Individuals with HDP or impaired glucose meta bolism during pregnancy experience greater maternal mortality and morbidity rates than people with uncomplicated pregnancies. Furthermore, pregnant people with HDP or impaired glucose metabolism have an increased risk of future CMDs and premature death later in life8–10. Negative influences of HDP and hyperglycaemia during pregnancy on fetuses and neonates include, but are not limited to, intrauterine growth restriction (IUGR) and macrosomia, preterm birth, low birthweight and adverse outcomes later in life11. Notably, the burden of premature deaths from complications of CMDs in pregnancy and associated cardiovascular disease (CVD) later in life falls disproportionately upon LMICs. Several socioenvironmental factors, including poverty, air pollution, educational and sociocultural barriers, and limitations in health-care access and infrastructure12, are responsible for such inequities in disease burden. This Review discusses the global disease burden and risk factors for HDP and GDM, highlighting the Reviews Key points • Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are common cardiometabolic complications of pregnancy. • HDP and GDM show an unevenly distributed disease burden (in terms of prevalence, disability-adjusted life years and/or maternal deaths) in low-income and middleincome countries and/or regions with low sociodemographic and human development indexes. • In addition to common clinical, demographic and behavioural risk factors, the development and clinical consequences of HDP and GDM are substantially influenced by the socioeconomic determinants of health. • Besides prevention and treatment at the individual level, strategies should also be made at different levels and in conjunction with multisector partnerships to improve societal and community conditions to prevent and/or manage HDP and GDM. differences between high-income countries (HICs) and LMICs. In addition, we provide policy recommendations regarding public health interventions that can be contextualized and implemented either worldwide or regionally to help reduce the mortality and morbidity related to these maternal CMDs in an efficient and cost-effective manner. We note that, unless otherwise specified, the terms women and men refer to ciswomen and cismen. Diagnostic criteria HDP. Comprising chronic hypertension, gestational hypertension and pre-eclampsia–eclampsia, the precise definition and classification of HDP is evolving over time, especially for pre-eclampsia. Pre-eclampsia is not a single disorder but a variety of pathophysiological pathways that converge on a common syndromic end point, of high blood pressure occurring with proteinuria after 20 weeks of pregnancy13. In the past 10 years, the definition of pre-eclampsia has been extended to include individuals without proteinuria but with evidence of maternal end-organ or uteroplacental dysfunction14. Two of the broad definitions adopted by most clinical practice guidelines and authorities are those of the International Society for the Study of Hypertension in Pregnancy15 and the American College of Obstetricians and Gynecologists16 (Supplementary Table 1). The application of these broad definitions of pre-eclampsia means patients once diagnosed with gestational hypertension or chronic hypertension were recategorized as pre- eclampsia or chronic hypertension with superimposed pre-eclampsia, respectively17–21. This diagnostic shift will influence clinical management (for example, increased hospital admission and induction of labour)17. Although Author addresses Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada. Vanke School of Public Health, Tsinghua University, Beijing, China. 3 Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, U (...truncated)