BJOG Editor's Choice

Rare disastrous complications of pregnancy such as maternal stroke or the birth of a child who develops cerebral palsy as a result of birth asphyxia have obvious serious long-term consequences, but it is becoming increasingly clear that more common complications of pregnancy have important life-long effects on the mother and her offspring. It is well established that gestational diabetes mellitus (GDM) increases the risk of developing type 2 diabetes mellitus, and different studies of the risk suggest that the greater the period of follow up the greater the reported risk, with figures for longer-term follow up of more than 70%. The increased risk may plateau after 10 years (Kim et al. Diabetes Care 2002;25:1862–8). Clearly type 2 diabetes is a strong risk factor for cardiovascular disease (CVD), but does GMD in itself increase the risk of CVD regardless of other risk factors? On page 1530, Fadl et al. examined the association of past GDM in women on the risk of cardiovascular events defined as diagnosis or death related to ischaemic heart disease, ischaemic stroke, atherosclerosis or peripheral vascular disease in a Swedish population-based case-control study of 2639 cases and 13 310 controls. They used logistic regression to examine associations of past GDM with CVD before and after adjustment for conventional risk factors and confounders such as smoking, hypertension and obesity. They report that in the absence of these recognised cardiovascular risk factors GDM was still associated with a raised CVD risk among women with body mass index between 25 and 29 kg/m2, which was comparable in magnitude to the effects of smoking or obesity. The paper is accompanied by a mini commentary on page 1537 that stresses the importance of aggressive smoking cessation efforts, weight loss and control of chronic hypertension in women with a history of GDM to reduce the risk of later CVD. Perhaps the most shocking finding of this study was that the mean time from index pregnancy to cardiovascular event was only around 9 years and the mean age at cardiovascular event diagnosis was just over 40 years. There may be a 10-year window of opportunity to reduce this risk. A paper by Tuovinen et al. on page 1482 examines the effects of maternal hypertension in pregnancy on the mental health of offspring in what is the longest follow-up study of the transgenerational consequences of maternal hypertensive disorders to date. In this paper the mental functioning of 778 participants from the Helsinki Birth Cohort 1934–44 study born after normotensive, pre-eclamptic, or hypertensive pregnancies was examined at a mean age of around 69 years. Previous maternal pre-eclampsia, but not hypertension without proteinuria, was associated with a variety of self-reported adverse scores of adaptive functioning, psychiatric and psychological problems. During most of that epoch, the management of pre-eclampsia was expectant, with limited neonatal care and limited availability of medication, so generalisability from these findings to babies born in current high-resource settings is limited, but this study provides further evidence for the life-time increased risks of an adverse intrauterine environment. On page 1509 we publish data from Canada from what appears to be the largest cohort study of cases of appendicitis in pregnancy so far. Management strategies and maternal morbidity were compared between 35 570 nonpregnant women with appendicitis and 7114 cases of appendicitis among 7 037 386 births during a corresponding time frame. Peritonitis was more common in pregnant women (20% versus 16% adjusted odds ratio 1.3) and there was a two-fold increase in sepsis and septic shock, transfusion, pneumonia, bowel obstruction, postoperative infection and length of stay >3 days in pregnant women with appendicitis. Expectant management was more commonly applied in pregnant than nonpregnant women (6 versus 4%), but in these pregnant women this strategy was associated with a considerably increased risk of increased risk of shock and peritonitis compared with pregnant women who were managed surgically (Figures 1 and 2). The authors of the paper conclude that ‘although effective antibiotics and advances in imaging and surgical technique have contributed to better outcomes’ these outcomes would be improved further ‘if the threshold to operate in pregnant women with suspicious symptoms is reduced’. It is, of course, not possible to say whether increased use of imaging and effective antibiotics has led to an increase in the threshold to operate in pregnant women with suspicious symptoms, which we may wish to avoid.

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