Atherogenic index of plasma and risk of hypertensive disorders of pregnancy in women with gestational diabetes mellitus: a two-center cohort study

Hypertension Research https://doi.org/10.1038/s41440-026-02684-8 ARTICLE Special Issue: Current evidence and perspectives for hypertension management in Asia Atherogenic index of plasma and risk of hypertensive disorders of pregnancy in women with gestational diabetes mellitus: a twocenter cohort study Xueqi Bai1,2 Qingyi Zhu3 Haidong Wang4 Runrun Hao1,2 Shanshan Wang1,2 Sutong Kan1,2 Lina Zhang1,2 Chun Zhao3 Zhonghua Shi1,2 ● ● ● ● ● ● ● ● 1234567890();,: 1234567890();,: Received: 10 March 2026 / Revised: 28 April 2026 / Accepted: 2 May 2026 © The Author(s) 2026. This article is published with open access Abstract Hypertensive disorders of pregnancy (HDPs) are major contributors to maternal and neonatal morbidity and are closely linked to metabolic disturbances. Women with gestational diabetes mellitus (GDM) exhibit significant lipid abnormalities, yet whether atherogenic lipid indices predict hypertensive complications in this population remains unclear. This study evaluated the predictive value of the atherogenic index of plasma (AIP) and cumulative AIP for HDPs and neonatal outcomes in women with GDM. In this two-center retrospective cohort study, a total of 3967 women with GDM were included. AIP was calculated as log10 (TG/HDL-C). Cumulative AIP was estimated as the mean AIP values measured during the second and third trimesters multiplied by the corresponding exposure time. Adverse outcomes were identified using generalized linear models with P for trend <0.05. Associations between AIP indices and outcomes were evaluated using regression models, dose–response analyses, and subgroup analyses. Predictive performance was assessed using receiver operating characteristic analysis. Both AIP and cumulative AIP were significantly associated with HDPs, including preeclampsia and preeclampsia with severe features, as well as neonatal intensive care unit (NICU) admission (all P < 0.05). Incorporating AIP into clinical models improved discrimination for preeclampsia (AUC 0.699 vs. 0.780, P = 0.025), severe preeclampsia (AUC 0.729 vs. 0.874, P = 0.002), and NICU admission (AUC 0.588 vs. 0.643, P = 0.029). Cumulative AIP produced similar improvements. In conclusion, elevated AIP and cumulative AIP are independently associated with increased risks of HDPs and NICU admission in women with GDM and may serve as practical cardiometabolic biomarkers for risk stratification. Keywords Atherogenic index of plasma Dyslipidemia Hypertensive disorders of pregnancy Gestational diabetes mellitus Preeclampsia ● ● ● ● Introduction These authors contributed equally: Xueqi Bai, Qingyi Zhu, Haidong Wang. Supplementary information The online version contains supplementary material available at https://doi.org/10.1038/s41440026-02684-8. Gestational diabetes mellitus (GDM) is a common metabolic disorder during pregnancy and is increasingly recognized as an important contributor to adverse cardiovascular and obstetric outcomes. Women with GDM are at substantially higher risk of developing hypertensive disorders of pregnancy * Chun Zhao 2 * Zhonghua Shi Changzhou Key Laboratory of Maternal and Child Health Medicine, Changzhou, Jiangsu, China 3 Women’s Hospital of Nanjing Medical University, Nanjing Women and Children’s Healthcare Hospital, Nanjing, Jiangsu, China 4 The Affiliated Huai’an No.1 People’s Hospital of Nanjing Medical University, Huai’an, Jiangsu, China 1 Changzhou Maternal and Child Health Care Hospital, Changzhou Medical Center, Nanjing Medical University, Changzhou, Jiangsu, China X. Bai et al. Graphical Abstract Point of view ● ● ● Clinical relevance AIP and cumulative AIP may serve as simple lipid-related markers to identify women with GDM at higher risk of hypertensive complications and NICU admission. Future direction Prospective multicenter studies are needed to validate optimal AIP-based thresholds and to determine whether AIP-guided surveillance or intervention can improve maternal and neonatal outcomes. Consideration for the Asian population AIP may be particularly useful in Asian populations, where metabolic risk can be substantial despite relatively low BMI. (HDPs), including preeclampsia (PE), which remains a leading cause of maternal and neonatal morbidity worldwide [1]. The global prevalence of GDM has risen to approximately 14% over the past decade, largely driven by increasing rates of obesity and metabolic dysfunction among women of reproductive age [2]. Emerging evidence indicates a close and bidirectional relationship between GDM and HDPs. Women with GDM have a 1.24–1.46-fold higher risk of PE, while the vascular and endothelial dysfunction associated with PE may further aggravate insulin resistance and metabolic dysregulation during pregnancy [3, 4]. These interactions highlight the importance of identifying early cardiometabolic markers that may help predict hypertensive complications in this high-risk population. The atherogenic index of plasma (AIP), defined as the logarithmic transformation of the triglyceride-to-high-density lipoprotein cholesterol (TG/HDL-C) ratio, has emerged as a reliable indicator of atherogenic dyslipidemia and cardiovascular risk [5, 6]. AIP reflects the balance between proatherogenic TG-rich lipoproteins and protective HDL particles and is closely associated with insulin resistance, endothelial dysfunction, and metabolic syndrome [7]. Recent studies have shown that elevated AIP in early pregnancy is associated with an increased risk of developing GDM, suggesting that AIP may serve as a simple and cost-effective biomarker for metabolic risk stratification during pregnancy [8]. However, whether AIP Atherogenic index of plasma and risk of hypertensive disorders of pregnancy in women with gestational. . . can further predict HDPs and adverse neonatal outcomes among women already diagnosed with GDM remains unclear. Most previous studies evaluating AIP in pregnancy have relied on single-time-point measurements. Pregnancy is characterized by profound physiological changes in lipid metabolism, with progressive increases in TGs and other lipoproteins across gestation [9]. Therefore, cumulative exposure to AIP may better reflect the overall metabolic burden affecting maternal vascular function during pregnancy. Cumulative AIP, which integrates repeated AIP measurements over time, has shown value in predicting metabolic diseases such as diabetes in the general population [10]. Nevertheless, its clinical relevance in pregnant populations, particularly for predicting HDPs and related neonatal outcomes, has not been investigated. Therefore, using data from two maternal and child health centers, we evaluated the associations of both single-timepoint AIP and cumulative AIP during pregnancy with HDPs and neonatal intensive care unit (NICU) admission among women with GDM. By examining longitudinal lipid exposure during pregnancy, this study aims to clarify the role of AIP in the development of HDPs in GDM and to assess whe (...truncated)