Pregnancy: An Underutilized Window of Opportunity to Improve Long-term Maternal and Infant Health-An Appeal for Continuous Family Care and Interdisciplinary Communication

Abstract

Physiologic adaptations during pregnancy unmask a woman's predisposition to diseases. Complications are increasingly predicted by first-trimester algorithms, amplify a pre-existing maternal phenotype and accelerate risks for chronic diseases in the offspring up to adulthood (Barker hypothesis). Recent evidence suggests that vice versa, pregnancy diseases also indicate maternal and even grandparent's risks for chronic diseases (reverse Barker hypothesis). Pub-Med and Embase were reviewed for Mesh terms "fetal programming" and "pregnancy complications combined with maternal disease" until January 2017. Studies linking pregnancy complications to future cardiovascular, metabolic, and thrombotic risks for mother and offspring were reviewed. Women with a history of miscarriage, fetal growth restriction, preeclampsia, preterm delivery, obesity, excessive gestational weight gain, gestational diabetes, subfertility, and thrombophilia more frequently demonstrate with echocardiographic abnormalities, higher fasting insulin, deviating lipids or clotting factors and show defective endothelial function. Thrombophilia hints to thrombotic risks in later life. Pregnancy abnormalities correlate with future cardiovascular and metabolic complications and earlier mortality. Conversely, women with a normal pregnancy have lower rates of subsequent diseases than the general female population creating the term: "Pregnancy as a window for future health." Although the placenta works as a gatekeeper, many pregnancy complications may lead to sickness and earlier death in later life when the child becomes an adult. The epigenetic mechanisms and the mismatch between pre- and postnatal life have created the term "fetal origin of adult disease." Up to now, the impact of cardiovascular, metabolic, or thrombotic risk profiles has been investigated separately for mother and child. In this manuscript, we strive to illustrate the consequences for both, fetus and mother within a cohesive perspective and thus try to demonstrate the complex interrelationship of genetics and epigenetics for long-term health of societies and future generations. Maternal-fetal medicine specialists should have a key role in the prevention of non-communicable diseases by implementing a framework for patient consultation and interdisciplinary networks. Health-care providers and policy makers should increasingly invest in a stratified primary prevention and follow-up to reduce the increasing number of manifest cardiovascular and metabolic diseases and to prevent waste of health-care resources.

Keywords: cardiovascular diseases; fetal programming; metabolic diseases; pregnancy as a window for future health; preventive healthcare.

Figure 1

Effect of developmental environment on later maternal phenotype and pregnancy complications. Risks for non-communicable diseases increase throughout a life course due to reduced plasticity. Increased risk factors, suspicious first-trimester screening, and pregnancy complications may be considered as the first “markers” and thus allow earlier intervention strategies compared to first symptoms of manifest chronic disease. Modified according to Sattar and Greer (4), Godfrey and Barker (11), and Godfrey et al. (12), similarly designed for Ref. (13).

Figure 2

Schematic proposal for health-care concepts to intensify interdisciplinary cooperation, pre-conceptional counseling, and postpartum consultation of women with pregnancy complications, according to Carson (112) or Bohrer and Ehrenthal (36). BMI, body mass index; BP, blood pressure; EBM, evidence-based medicine; GDM, gestational diabetes mellitus; MF, maternal fetal; NCD, non-communicable disease.

Figure 3

Representative pictures of male offspring of rats at postnatal day 650. C, control diet; CEx, control diet + maternal exercise intervention; MO, maternal obesity; and MOEx, maternal obesity + maternal exercise intervention, with gratitude, according to Nathanielsz et al. (146).