Cardiometabolic Health in First Time Pregnancy (POPPY)

Preconception to pOst-partum Study of Cardiometabolic Health in Primigravid PregnancY

Women who experience placental complications (syndromes) during pregnancy, such as pre-eclampsia (high blood pressure and kidney problems), gestational hypertension (high blood pressure during pregnancy) and fetal growth restriction (baby being small) have twice the risk of developing heart disease and diabetes later in life, compared to women who have a healthy pregnancy.

This study aims to assess risk factors for heart disease and diabetes in women who are actively trying to conceive, before and during their pregnancy, and 9-12 months after delivery of their baby, to see whether placental syndromes make a difference to their heart health. This will allow us to understand, if, and how, placental syndromes increase the risk of heart disease and diabetes, and, therefore, how best to reduce this risk and potentially prevent placental syndromes in the future. The investigators will also recruit women who are NOT planning pregnancy, as a control group.

Study Overview

• Status: Recruiting
• Conditions: Heart Diseases; Diabetes; Pregnancy Related; Cardiometabolic Health; Placental; Syndrome, Dysfunction

Detailed Description

Pre-eclampsia (PE), gestational hypertension (GH) and fetal growth restriction (FGR) share a common aetiology in that they arise from complex interactions between defective placentation, trophoblast dysfunction and the maternal cardiovascular and other systems. These placental syndromes affect approximately one in five nulliparous women and are a leading cause of maternal and child morbidity. Although usually considered self-limiting, and cured by delivery, placental syndromes are associated with an increased risk of maternal hypertension, diabetes and cardiovascular disease (CVD) in later life. Indeed, as summarised by NICE, PE is associated with a 4-fold increased risk of hypertension, and 2-fold excess risk of ischaemic heart disease and stroke. Similarly, Danish National Registry data show that women with GH have a 6-fold risk of subsequent hypertension, a 3-fold risk of diabetes and a 2-fold risk of CVD; similar to that reported for PE.

Whilst these risks have most impact in later life, they are evident almost immediately - women who develop hypertension in pregnancy have a 12 to 25-fold risk of developing permanent hypertension in the year after giving birth, compared to women with a normotensive pregnancy. Approximately one third of women in their 40s who had a hypertensive pregnancy, develop hypertension over the subsequent decade, compared with only 11% who had a normotensive pregnancy. Precursors of CVD (i.e. pre-clinical phenotypes) are also apparent in the early post-partum period in women who experience a placental syndrome. Increased aortic stiffness, elevated carotid intima-media thickness (cIMT) and left ventricular dysfunction have all been reported in women with previous PE/GH and FGR.

Whether placental syndromes simply "unmask" women with pre-existing (pre-conception) poor cardiometabolic health, or cause later maternal diabetes and CVD, remains unknown. If the former is correct, then improving cardiometabolic health in young women prior to conception could be key to reducing the incidence of placental syndromes. Conversely, if placental syndromes lead to CVD and diabetes independently of established cardiometabolic risk factors (e.g. by causing end organ damage), a focus on CVD/diabetes prevention in this high-risk group of women is likely to reduce the burden of these diseases. To date, studies with pre-conception measures of cardiometabolic risk factors are few, modest in patient number and detail, and have yielded conflicting results.

The study will test definitively, the hypothesis that placental syndromes adversely affect cardiometabolic health post-partum, independently of women's pre-conception cardiometabolic health. To do this, an observational, prospective study of healthy, nulliparous women, recruited pre-pregnancy will be undertaken.

Recruitment of the study population will utilise local advertisements and networks, social media and charitable organisations involved in pregnancy research. The study focus is nulliparous women to maximize the occurrence of placental syndromes (risk is highest in first pregnancies), and to remove any confounding effect of previous pregnancies.

The study does not involve randomisation of participants; participant study arm will be determined by individuals and their intention to conceive during the determined study period, or not, in line with the inclusion/exclusion criteria.

A sufficient number of women will be recruited to the Pregnancy arm of the study to yield 1500 viable pregnancies (~3000 women, based on our feasibility data). Of these, the investigators anticipate that 135 women will experience a placental syndrome, taking into account attrition. A Non-Pregnancy study arm, women voluntarily planning not to conceive during their involvement in the study; n~500 will also be recruited, to act as a control arm.

Individual participant study duration will last between approximately 12 and 33 months dependent on study arm and timings around pregnancy and follow-up. For those in the Non-Pregnancy arm study duration will last approximately 18 months, ending after the second follow up visit. Study duration for those in the Pregnancy arm will vary, between 12 months and 33 months, dependent on time from recruitment to pregnancy occurrence and/or occurrence of placental syndrome; those (Pregnancy arm) participants who do not become pregnant will experience a shorter study duration (12 months) and only a proportion of those experiencing a healthy pregnancy will attend a final follow-up visit 18 months after delivery.

The output of this study will primarily aim to determine to what extent the association between placental syndromes and maternal cardio-metabolic health post-pregnancy is explained by pre-pregnancy subclinical cardiometabolic health. As secondary aims the study also aims to determine which aspects of pre-pregnancy cardiometabolic health impact on women's cardiovascular adaptation to pregnancy; whether haemodynamic maladaptation is an early pregnancy biomarker for the later clinical manifestations of placental dysfunction; and whether an uncomplicated pregnancy results in improved maternal cardiometabolic health post-partum. Finally, the investigators will determine whether pre-pregnancy cardiovascular risk factors affect the rate of early fetal loss (miscarriage), which will answer an important clinical question, as recurrent miscarriage is associated with increased cardiovascular risk.

• Study Type: Observational
• Enrollment (Estimated): 3500

Contacts and Locations

• Study Contact: Name: Heike Templin; Phone Number: 0044 1223 250874; Email: cuh.poppycctu@nhs.net

Study Locations

• United Kingdom
  • Cambridge, United Kingdom, CB2 0QQ
    • Recruiting
    • Cambridge University Hospitals NHS Foundation Trust
    • Contact: Site PI: Carmel McEniery
  • Glasgow, United Kingdom
    • Recruiting
    • NHS Greater Glasgow and Clyde
    • Contact: Site PI: Christian Delles
  • London, United Kingdom, W2 1NY
    • Recruiting
    • Imperial College Healthcare NHS Trust
    • Contact: Site PI: Christoph Lees
  • London, United Kingdom, SE5 9RS
    • Not yet recruiting
    • King's College Hospital NHS Foundation Trust
    • Contact: Site PI: Lucilla Poston
  • London, United Kingdom, NW1 2BU
    • Not yet recruiting
    • University College London Hospitals Nhs Foundation Trust
    • Contact: Site PI: David Williams
  • London, United Kingdom, SW17 0QT
    • Not yet recruiting
    • St George's University Hospitals NHS Foundation Trust
    • Contact: Site PI: Asma Khalil
  • Manchester, United Kingdom, M13 9WL
    • Not yet recruiting
    • Manchester University NHS Foundation Trust
    • Contact: Laura Ormesher

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

Nulliparous women to maximise the occurrence of placental syndrome.

Description

Pregnancy Arm Inclusion Criteria:

To be included in the trial the participant must:

• Nulliparous (no previous pregnancy beyond 20 weeks' gestation)
• Actively considering pregnancy within approximately 12 months
• Aged between 18 and 45 years
• Ability to consent and willing to participate

Pregnancy Arm Exclusion Criteria:

The presence of any of the following will preclude participant inclusion:

• Currently pregnant
• Established infertility
• Planning or actively using fertility treatments (e.g. IVF, ICSI, FET, IUI)
• Assigned male sex at birth
• Autoimmune disease (e.g. rheumatoid arthritis, lupus)
• Thrombophilia
• Type 1 diabetes
• Known advanced chronic kidney disease (stages 4-5)
• Malignant hypertension
• Clinically manifest CVD (e.g. previous myocardial infarction, stroke)
• Active cancer/being treated for cancer currently (other than skin cancer)
• Any other condition preventing full participation in the study

Non-Pregnancy Arm Inclusion criteria

To be included in the trial the participant must:

• Nulliparous (no previous pregnancy beyond 20 weeks' gestation)
• Not planning to conceive during next 18 months
• Aged between 18 and 45 years
• Ability to consent and willing to participate

Non-Pregnancy Exclusion Criteria

The presence of any of the following will preclude participant inclusion:

• Currently pregnant
• Planning or actively using fertility treatments (e.g. IVF, ICSI, FET, IUI)
• Assigned male sex at birth
• Autoimmune disease (e.g. rheumatoid arthritis, lupus)
• Thrombophilia
• Type 1 diabetes
• Known advanced chronic kidney disease (stages 4-5)
• Malignant hypertension
• Clinically manifest CVD (e.g. previous myocardial infarction, stroke)
• Active cancer/being treated for cancer currently (other than skin cancer)
• Any other condition preventing full participation in the study

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Pregnancy ~3000 participants; Actively planning to conceive within approximately 12 months of study registration. No previous pregnancies.
Non-Pregnancy ~500 participants; Not planning to conceive within 18 months of study registration. No previous pregnancies.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
QRISK3	Predicted lifetime CVD risk	Risk difference between women who experienced a healthy pregnancy and those who experienced a pregnancy complication at 9-12 months postpartum

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Blood Pressure Systolic, Blood Pressure Diastolic Pulse Wave Analysis: Supine Systolic BP, Supine diastolic BP, Central Systolic BP, Central diastolic BP, Supine MAP	BP (mmHg)	Assessed at 9-12 months postpartum
Height	m	Assessed at 9-12 months postpartum
BMI	kg/m2	Assessed at 9-12 months postpartum
BMR	KJ	Assessed at 9-12 months postpartum
Waist:Hip ratio	Waist measurement (cm), Hip measurement (cm), Waist/Hip measurement	Assessed at 9-12 months postpartum
Body fat (%), Tanita (%)	(Tanita scales)	Assessed at 9-12 months postpartum
Weight, Fat mass, Fat free mass, Total body water	kg	Assessed at 9-12 months postpartum
Sodium, Potassium, Urea, Total Cholesterol, Triglyceride, HDL-Cholesterol, LDL-cholesterol, Non-HDL cholesterol	Lipids (mmol/L)	Assessed at 9-12 months postpartum
Creatinine	Lipids (µmol/L)	Assessed at 9-12 months postpartum
HbA1c	Lipids (mmol/mol)	Assessed at 9-12 months postpartum
White blood count (WBC), Platelet count, Neutrophil count, Lymphocyte count, Monocyte count, Eosinophil count, Basophil count	Lipids (10*9/L)	Assessed at 9-12 months postpartum
Red blood cell (RBC)	Lipids (10*12/L)	Assessed at 9-12 months postpartum
Haemoglobin (Hb) Haemoglobin (Hb) Haemoglobin (Hb)	Lipids (g/L)	Assessed at 9-12 months postpartum
Haematocrit	Lipids (L/L)	Assessed at 9-12 months postpartum
Mean cell volume (MCV)	Lipids (fL)	Assessed at 9-12 months postpartum
Mean cell haemoglobin (MCH)	Lipids (pg)	Assessed at 9-12 months postpartum
Red cell distribution width (RDW)	Lipids (%)	Assessed at 9-12 months postpartum
Urine	Protein, Blood, Glucose, Leukocytes, Nitrites	Assessed at 9-12 months postpartum
APWV: Aortic Pulse Wave Velocity, Carotid Intima-media thickness	Suprasternal notch to distal (Femoral artery) (mm), Suprasternal notch to proximal (carotid artery) (mm), Carotid IMT (mm)	Assessed at 9-12 months postpartum
Oral glucose tolerance test (OGGT)	mmol	Assessed at 24-28 weeks pregnancy
Diabetes Risk	QDiabetes 2018	Risk difference between women who experienced a healthy pregnancy and those who experienced a pregnancy complication at 9-12 months postpartum

Collaborators and Investigators

• Sponsor: Cambridge University Hospitals NHS Foundation Trust
• Collaborators: King's College London; Imperial College London; University College, London; Wellcome Trust; University of Bristol; University of Cambridge; St George's, University of London; University of Glasgow
• Investigators: Principal Investigator: Ian Wilkinson, MD, Cambridge University Hospitals NHS Foundation Trust

Study record dates

Study Major Dates

• Study Start (Actual): May 24, 2023
• Primary Completion (Estimated): December 1, 2027
• Study Completion (Estimated): December 1, 2052

Study Registration Dates

• First Submitted: April 17, 2023
• First Submitted That Met QC Criteria: May 3, 2023
• First Posted (Actual): May 12, 2023

Study Record Updates

• Last Update Posted (Actual): April 9, 2024
• Last Update Submitted That Met QC Criteria: April 5, 2024
• Last Verified: April 1, 2024

More Information

Terms related to this study

• Keywords: diabetes; pregnancy; CVD risk; cardiovascular; heart disease; childbirth; cardiometabolic; nulliparous; placental syndrome
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Heart Diseases
• Other Study ID Numbers: POPPY

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Data will only be available to request after the investigator has finished with the data and will not included patient identifiable data.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No