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Published:December 19, 2016DOI:https://doi.org/10.1016/j.ajog.2016.12.011
      The authors thank Quinn for comments regarding our article titled “Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.”
      • Cain M.A.
      • Salemi J.L.
      • Tanner J.P.
      • Kirby R.S.
      • Salihu H.M.
      • Louis J.M.
      Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.
      The article presented the short-term risk of cardiovascular disease among nulliparous women experiencing placental syndromes. We then further evaluated this risk when the women experienced placental syndromes in conjunction with a preterm delivery or delivery of a small-for-gestational-age (SGA) infant. A statewide, multiyear maternal-infant database in the state of Florida provided data for our study. Due to the nature of the study database and the reliance primarily on administrative diagnostic coding, we were unable to identify the root cause of subsequent cardiovascular disease among these women. Although the placental syndromes may be the unmasking of underlying disease, the syndrome itself may also cause damage that increases a woman’s lifetime, and even shorter term, risk of cardiovascular disease. Dr Quinn’s letter to the editor adds to the possible etiologies for subsequent cardiovascular disease; specifically discussing the potential stretching of intrauterine nerves leading to uterorenal nerve activation and preeclampsia. These vascular changes may then cause resistant renal hypertension and ultimately cardiovascular disease. Prior studies note vascular dysfunction may be caused by preeclampsia.
      • Grand'Maison S.
      • Pilote L.
      • Okano M.
      • Landry T.
      • Dayan N.
      Markers of vascular dysfunction after hypertensive disorders of pregnancy: a systematic review and meta-analysis.
      • Tomimatsu T.
      • Mimura K.
      • Endo M.
      • Kumasawa K.
      • Kimura T.
      Pathophysiology of preeclampsia: an angiogenic imbalance and long-lasting systemic vascular dysfunction.
      Certainly, further investigation into the pathophysiology of placental syndromes and their impact on vascular disease is warranted.
      Dr Quinn also notes a trade of sensitivity for specificity in our decision to not include intrauterine growth restriction and preterm labor in our definition of placental syndromes. In an effort to evaluate the additional impact of poor fetal growth and preterm deliveries, we included SGA and preterm birth in addition to placental syndromes. Women who experienced a placental syndrome as well as either SGA or preterm birth were at greater risk of cardiovascular disease than those with a placental syndrome without SGA or preterm birth (Table 2).
      • Cain M.A.
      • Salemi J.L.
      • Tanner J.P.
      • Kirby R.S.
      • Salihu H.M.
      • Louis J.M.
      Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.
      We agree that, if we were to have omitted consideration of SGA and preterm birth from the study entirely, our definition of placental syndromes would have had suboptimal sensitivity. We instead chose to highlight this increase in risk conferred by SGA and/or preterm birth by evaluating these outcomes both with and without a more specific definition of placental syndromes.

      References

        • Cain M.A.
        • Salemi J.L.
        • Tanner J.P.
        • Kirby R.S.
        • Salihu H.M.
        • Louis J.M.
        Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.
        Am J Obstet Gynecol. 2016; 215: 484.e1-484.e14
        • Grand'Maison S.
        • Pilote L.
        • Okano M.
        • Landry T.
        • Dayan N.
        Markers of vascular dysfunction after hypertensive disorders of pregnancy: a systematic review and meta-analysis.
        Hypertension. 2016; 68: 1447-1458
        • Tomimatsu T.
        • Mimura K.
        • Endo M.
        • Kumasawa K.
        • Kimura T.
        Pathophysiology of preeclampsia: an angiogenic imbalance and long-lasting systemic vascular dysfunction.
        Hypertens Res. 2016 Nov 10; (Epub ahead of print)

      Linked Article

      • Progressive uterorenal denervation may contribute to both placental and cardiovascular syndromes?
        American Journal of Obstetrics & GynecologyVol. 216Issue 4
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          Cain et al1 find that women experiencing “placental syndromes” are at increased risk of serious cardiovascular disease within 5 years. We believe they have a common source of injury, namely, progressive autonomic denervation. Both uterus and kidneys receive sympathetic nerves from the same thoracic segments (T10-12). Persistent physical efforts during defecation are a common source of progressive autonomic injury in Western populations where they complicate 20-30% of Western bowel movements.2 With the introduction of Western fast foods and removal of squat toilets over the past 25 years, it is becoming a major source of recent, cardiovascular morbidity in China.
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