Skip to main content

Advertisement

SpringerLink
Log in

Cardiovascular Health During Pregnancy: Future Health Implications for Mothers

  • Cardiovascular Disease (R Foraker, Section Editor)
  • Published:
Current Epidemiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Healthy pregnancy requires profound maternal vascular, immune, and metabolic adaptations to support placentation and fetal growth. It is now well established that an impaired ability to mount these adaptations contributes to adverse pregnancy outcomes. Pregnancy now can be viewed as a “stress test,” with adverse pregnancy outcomes being a harbinger of excess cardiovascular disease (CVD) risk. Thus, we review the current evidence that links pregnancy features to maternal CVD risk.

Recent Findings

The most recent work demonstrates that cardiovascular risk is detectable within 1 to 5 years after pregnancy. Rates of hypertension as soon as 1 year post-partum are quite high in women with gestational hypertension, and cardiac structure differences can be detected as soon as 5 years post-partum following preeclampsia.

Summary

Pregnancy complications can identify CVD risk during the reproductive years and provide opportunities to improve women’s health. We summarize the next steps needed to leverage pregnancy as a window to improved maternal cardiovascular health.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–e245.

    Article  PubMed  Google Scholar 

  2. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates. J Am Coll Cardiol. 2007;50:2128–32.

    Article  PubMed  Google Scholar 

  3. Gupta A, Wang Y, Spertus JA, et al. Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010. J Am Coll Cardiol. 2014;64:337–45.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Mosca L, Manson J, Sutherland S, Langer R, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Circulation. 1997;96:2468–82.

    Article  CAS  PubMed  Google Scholar 

  5. Bairey Merz CN. Women and ischemic heart disease paradox and pathophysiology. JACC Cardiovascular imaging. 2011;4:74–7.

    Article  PubMed  Google Scholar 

  6. Dreyer RP, Wang Y, Strait KM, et al. Gender differences in the trajectory of recovery in health status among young patients with acute myocardial infarction: results from the variation in recovery: role of gender on outcomes of young AMI patients (VIRGO) study. Circulation. 2015;131:1971–80.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Wilmot KA, O’Flaherty M, Capewell S, Ford ES, Vaccarino V. Coronary heart disease mortality declines in the United States from 1979 through 2011: evidence for stagnation in young adults, especially women. Circulation. 2015;132:997–1002.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Shay CM, Ning H, Allen NB, et al. Status of cardiovascular health in US adults: prevalence estimates from the National Health and Nutrition Examination Surveys (NHANES) 2003-2008. Circulation. 2012;125:45–56.

    Article  PubMed  Google Scholar 

  9. Folsom A, Kaye S, Sellers T, et al. Body fat distribution and 5-year risk of death in older women. JAMA. 1993;269:483–7.

    Article  CAS  PubMed  Google Scholar 

  10. Gordon T, Castelli W, Hjortland M, Kannel W, Dawber T. Diabetes, blood lipids, and the role of obesity in coronary heart disease risk for women. The Framingham study Ann Intern Med. 1977;87:393–7.

    Article  CAS  PubMed  Google Scholar 

  11. Manson J, Colditz G, Stampfer M, et al. A prospective study of obesity and risk of coronary heart disease in women. N Engl J Med. 1990;322:882–9.

    Article  CAS  PubMed  Google Scholar 

  12. Cheng S, Claggett B, Correia AW, et al. Temporal trends in the population attributable risk for cardiovascular disease: the atherosclerosis risk in communities study. Circulation. 2014;130:820–8.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Gierach GL, Johnson BD, Bairey Merz CN, et al. Hypertension, menopause, and coronary artery disease risk in the Women’s Ischemia Syndrome Evaluation (WISE) study. J Am Coll Cardiol. 2006;47:S50–8.

    Article  PubMed  Google Scholar 

  14. Matthews KAP, Kuller LHMDD, Sutton-Tyrrell KD, Chang Y-FP. Changes in cardiovascular risk factors during the perimenopause and postmenopause and carotid artery atherosclerosis in healthy women. Stroke. 2001;32:1104–11.

    Article  CAS  PubMed  Google Scholar 

  15. Sattar I, Greer I. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? BMJ. 2002;325:157–60.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Rich-Edwards JW, McElrath TF, Karumanchi SA, Seely EW. Breathing life into the lifecourse approach. Hypertension. 2010;56:331–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Loria CM, Liu K, Lewis CE, et al. Early adult risk factor levels and subsequent coronary artery calcification: the CARDIA study. J Am Coll Cardiol. 2007;49:2013–20.

    Article  PubMed  Google Scholar 

  18. Berry JD, Dyer A, Cai X, et al. Lifetime risks of cardiovascular disease. NEJM. 2012;366:321–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Johnson HM, Thorpe CT, Bartels CM, et al. Undiagnosed hypertension among young adults with regular primary care use. J Hypertens. 2014;32:65–74.

    Article  CAS  PubMed  Google Scholar 

  20. Pletcher MJ, Bibbins-Domingo K, Lewis CE, et al. Prehypertension during young adulthood and coronary calcium later in life. Ann Intern Med. 2008;149:91–9.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Allen N, Berry JD, Ning H, Van Horn L, Dyer A, Lloyd-Jones DM. Impact of blood pressure and blood pressure change during middle age on the remaining lifetime risk for cardiovascular disease: the cardiovascular lifetime risk pooling project. Circulation. 2012;125:37–44.

    Article  PubMed  Google Scholar 

  22. Liu K, Colangelo LA, Daviglus ML, et al. Can antihypertensive treatment restore the risk of cardiovascular disease to ideal levels?: the coronary artery risk development in young adults (CARDIA) study and the multi-ethnic study of atherosclerosis (MESA). J Am Heart Assoc. 2015;4

  23. Erdogan D, Yildirim I, Ciftci O, et al. Effects of normal blood pressure, prehypertension, and hypertension on coronary microvascular function. Circulation. 2007;115:593–9.

    Article  PubMed  Google Scholar 

  24. Institute of Medicine Committee on Public Health Priorities to R, Control H. A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension. Washington (DC): National Academies Press (US); 2010.

  25. U S Department of Commerce United States Census Bureau. Atlanta, GA. at http://www.census.gov/hhes/fertility/data/cps/historical.html.)

  26. Pew Research Center. Childlessness up among all women; Down among women with advanced degrees. Washington DC: Pew Research Center; June 25, 2010.

  27. Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis. BMJ. 2007;335:974.

    Article  PubMed  PubMed Central  Google Scholar 

  28. •• Veerbeek JH, Hermes W, Breimer AY, et al. Cardiovascular disease risk factors after early-onset preeclampsia, late-onset preeclampsia, and pregnancy-induced hypertension. Hypertension. 2015;65:600–6. Rates of hypertension are extremely high as soon as one year following early onset preeclampsia or gestational hypertension that occurs at any time during pregnancy.

    Article  CAS  PubMed  Google Scholar 

  29. Hermes W, Franx A, van Pampus MG, et al. Cardiovascular risk factors in women who had hypertensive disorders late in pregnancy: a cohort study. Am J Obstet Gynecol.

  30. Hubel CA, Lyall F, Weissfeld L, Gandley RE, Roberts JM. Small low-density lipoproteins and vascular cell adhesion molecule-1 are increased in association with hyperlipidemia in preeclampsia. Metabolism. 1998;47:1281–8.

    Article  CAS  PubMed  Google Scholar 

  31. Hubel CA, Powers R, Snaedal S, et al. C-reactive protein is increased 30 years after eclamptic pregnancy. J Soc Gynecol Invest. 2006;13(2 Suppl):292A.

    Google Scholar 

  32. Magnussen EB, Vatten LJ, Smith GD, Romundstad PR. Hypertensive disorders in pregnancy and subsequently measured cardiovascular risk factors. Obstet Gynecol. 2009;114:961–70.

    Article  PubMed  Google Scholar 

  33. Romundstad PR, Magnussen EB, Smith GD, Vatten LJ. Hypertension in pregnancy and later cardiovascular risk: common antecedents? Circulation. 2010;122:579–84.

    Article  PubMed  Google Scholar 

  34. • Ghossein-Doha C, van Neer J, Wissink B, et al. Pre-eclampsia: an important risk factor for asymptomatic heart failure. Ultrasound Obstet Gynecol. 2017;49:143–9. Cardiac structure differences can be detected as soon as 4 years after preeclampsia.

    Article  CAS  PubMed  Google Scholar 

  35. •• Cain MA, Salemi JL, Tanner JP, Kirby RS, Salihu HM, Louis JM. Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes. Am J Obstet Gynecol. 2016;215:484–e1–e14. As soon as 5 years after delivery, women with pregnancy complications have excess CVD and associated health care costs are high.

    Article  PubMed  Google Scholar 

  36. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123:1243–62.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Bellamy L, Casas JP, Hingorani AD, Williams D. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. Lancet. 2009;373:1773–9.

    Article  CAS  PubMed  Google Scholar 

  38. Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care. 2002;25:1862–8.

    Article  PubMed  Google Scholar 

  39. Sarwar N, Gao P, Seshasai SR, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375:2215–22.

    Article  CAS  PubMed  Google Scholar 

  40. Shah BR, Retnakaran R, Booth GL. Increased risk of cardiovascular disease in young women following gestational diabetes mellitus. Diabetes Care. 2008;31:1668–9.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Carr DB, Utzschneider KM, Hull RL, et al. Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes. Diabetes Care. 2006;29:2078–83.

    Article  PubMed  Google Scholar 

  42. Fadl H, Magnuson A, Ostlund I, Montgomery S, Hanson U, Schwarcz E. Gestational diabetes mellitus and later cardiovascular disease: a Swedish population based case-control study. BJOG. 2014;121:1530–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Retnakaran R, Shah BR. Role of type 2 diabetes in determining retinal, renal, and cardiovascular outcomes in women with previous gestational diabetes mellitus. Diabetes Care. 2017;40:101–8.

    Article  PubMed  Google Scholar 

  44. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000–15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet. 2016;388(10063):3027–35.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Robbins CL, Hutchings Y, Dietz PM, Kuklina EV, Callaghan WM. History of preterm birth and subsequent cardiovascular disease: a systematic review. Am J Obstet Gynecol. 2014;210:285–97.

    Article  PubMed  Google Scholar 

  46. Irgens H, Reisaeter L, Irgens L, Lie R. Long term mortality of mothers and fathers after pre-eclampsia. BMJ. 2001;323:1213–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Catov JM, Wu CS, Olsen J, Sutton-Tyrrell K, Li J, Nohr EA. Early or recurrent preterm birth and maternal cardiovascular disease risk. Ann Epidemiol. 2010;20:604–9.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Heida KY, Velthuis BK, Oudijk MA, et al. Cardiovascular disease risk in women with a history of spontaneous preterm delivery: a systematic review and meta-analysis. Eur J Prev Cardiol. 2016;23:253–63.

    Article  PubMed  Google Scholar 

  49. Rich-Edwards JW, Klungsoyr K, Wilcox AJ, Skjaerven R. Duration of pregnancy, even at term, predicts long-term risk of coronary heart disease and stroke mortality in women: a population-based study. Am J Obstet Gynecol. 2015;213:518–e1–8.

    Article  PubMed  Google Scholar 

  50. Catov J, Althouse A, Lewis C, Harville E, Gunderson EP. Preterm delivery and metabolic syndrome in women followed from prepregnancy through 25 years later. Obstet Gynecol. 2016;127:1127–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Catov JM, Lewis CE, Lee M, Wellons MF, Gunderson EP. Preterm birth and future maternal blood pressure, inflammation, and intimal-medial thickness: the CARDIA study. Hypertension. 2013;

  52. Lykke JA, Paidas MJ, Damm P, Triche EW, Kuczynski E, Langhoff-Roos J. Preterm delivery and risk of subsequent cardiovascular morbidity and type-II diabetes in the mother. BJOG. 2010;117:274–81.

    Article  CAS  PubMed  Google Scholar 

  53. •• Tanz LJ, Stuart JJ, Williams PL, et al. Preterm delivery and maternal cardiovascular disease in young and middle-aged adult women. Circulation. 2017;135:578–89. Preterm birth may identify novel mechanisms linking pregnancy health to long term maternal cardiovascular health.

    Article  PubMed  Google Scholar 

  54. Bonamy A-KE, Parikh NI, Cnattingius S, Ludvigsson JF, Ingelsson E. Birth characteristics and subsequent risks of maternal cardiovascular disease/clinical perspective. Circulation. 2011;124:2839–46.

    Article  PubMed  Google Scholar 

  55. Lykke JA, Langhoff-Roos J, Lockwood CJ, Triche EW, Paidas MJ. Mortality of mothers from cardiovascular and non-cardiovascular causes following pregnancy complications in first delivery. Paediatr Perinat Epidemiol. 2010;24:323–30.

    Article  PubMed  Google Scholar 

  56. Mongraw-Chaffin ML, Cirillo PM, Cohn BA. Preeclampsia and cardiovascular disease death: prospective evidence from the child health and development studies cohort. Hypertension. 2010;56:166–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. • Wikström A-K, Gunnarsdottir J, Nelander M, Simic M, Stephansson O, Cnattingius S. Prehypertension in pregnancy and risks of small for gestational age infant and stillbirth. Hypertension. 2016;67:640–6. Modest elevations in blood pressure during pregnancy that do not cross the threshold for hypertension are linked to small for gestational age births and stillbirths.

    PubMed  Google Scholar 

  58. Green A, Beral V, Moser K. Mortality in women in relation to their childbearing history. BMJ. 1988;297:391–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  59. Ness RB, Harris T, Cobb J, et al. Number of pregnancies and the subsequent risk of cardiovascular disease. N Engl J Med. 1993;328:1528–33.

    Article  CAS  PubMed  Google Scholar 

  60. Steenland K, Lally C, Thun M. Parity and coronary heart disease among women in the American Cancer Society CPS II population. Epidemiology. 1996;7:641–3.

    Article  CAS  PubMed  Google Scholar 

  61. Parikh NI, Cnattingius S, Dickman PW, Mittleman MA, Ludvigsson JF, Ingelsson E. Parity and risk of later-life maternal cardiovascular disease. Am Heart J. 2010;159:215–21. e6

    Article  PubMed  Google Scholar 

  62. Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteristics and women's future cardiovascular health: an underused opportunity to improve women's health? Epidemiol Rev. 2014;36:57–70.

    Article  PubMed  Google Scholar 

  63. Ness RB, Cobb J, Harris T, D'Agostino RB. Does number of children increase the rate of coronary heart disease in men? Epidemiology. 1995;6:442–5.

    Article  CAS  PubMed  Google Scholar 

  64. Lawlor DA, Emberson JR, Ebrahim S, et al. Is the association between parity and coronary heart disease due to biological effects of pregnancy or adverse lifestyle risk factors associated with child-rearing? Findings from the British Women’s Heart and Health Study and the British Regional Heart Study. Circulation. 2003;107:1260–4.

    Article  PubMed  Google Scholar 

  65. Dekker JM, Schouten EG. Number of pregnancies and risk of cardiovascular disease. N Engl J Med. 1993;329:1893–4. author reply 4–5

    Article  CAS  PubMed  Google Scholar 

  66. Skjaerven R, Wilcox AJ, Klungsoyr K, et al. Cardiovascular mortality after pre-eclampsia in one child mothers: prospective, population based cohort study. BMJ. 212:345–e7677.

  67. Retnakaran R, Austin PC, Shah BR. Effect of subsequent pregnancies on the risk of developing diabetes following a first pregnancy complicated by gestational diabetes: a population-based study. Diabetic medicine: a journal of the British Diabetic Association. 2011;28:287–92.

    CAS  Google Scholar 

  68. D'Agostino RB Sr, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation. 2008;117:743–53.

    Article  PubMed  Google Scholar 

  69. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2935–59.

    Article  PubMed  Google Scholar 

  70. Ridker PM, Buring JE, Rifai N, Cook NR. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynolds Risk Score. JAMA. 2007;297:611–9.

    Article  CAS  PubMed  Google Scholar 

  71. Stuart JJ, Bairey Merz CN, Berga SL, et al. Maternal recall of hypertensive disorders in pregnancy: a systematic review. J Women’s Health (Larchmt). 2013;22:37–47.

    Article  Google Scholar 

  72. Carter E, Stuart J, Farland L, et al. Pregnancy complications as markers for subsequent maternal cardiovascular disease: validation of a maternal recall questionnaire. J Women’s Health. 2015;24:702–12.

    Article  Google Scholar 

  73. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507–20.

    Article  CAS  PubMed  Google Scholar 

  74. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122:1122–31.

    Article  Google Scholar 

  75. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S76–99.

    Article  PubMed  Google Scholar 

  76. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society. Circulation. 2014;129:S102–38.

    Article  PubMed  Google Scholar 

  77. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1–45.

    Article  PubMed  Google Scholar 

  78. Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Obstetrics, Gynecology, RS and Epidemiology, University of Pittsburgh School of Medicine, 204 Craft Avenue, Suite A208, Pittsburgh, PA, 15213, USA

    J. M. Catov

  2. Barbra Streisand Women’s Heart Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    N. Bairey-Merz

  3. Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA

    J. Rich-Edwards

Authors
  1. J. M. Catov
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. N. Bairey-Merz
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. Rich-Edwards
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. M. Catov.

Ethics declarations

Conflict of Interest

J. M. Catov and J. Rich-Edwards each declare no potential conflicts of interest. Dr. Bairey Merz reports other from Annenberg Center for Health Science (lecture), other from American Diabetes Association (lecture), other from DCCT/EDIC (investigators meeting), other from Expert Exchange (lectures), other from Japanese Circulation Society (lectures), other from Kaiser (lectures), other from Mayo (lecture), other from Northwestern (young investigators grant review), other from Pacific Medical Center (lecture), other from Practice Point Communications (lectures), other from Pri-Med (lectures), other from Sanofi (consulting), other from University of Colorado (lecture), other from UCSF (lecture) Ð, other from University of Utah (lecture), other from Women’s Health Congress (lecture), other from WomenHeart (lecture), other from ACRWH (NIH advisory council), other from New York University (lecture), other from San Bernardino 18th Cardiology Symposium (lecture), other from UCSD (lecture), other from NIH-CASE (grant review study section), grants from WISE HFpEF, grants from RWISE, grants from Microvascular, grants from Normal Control, grants from FAMRI, from NHLBI Research Triangle Institute (RTI) International (Consultant), outside the submitted work.

Human and Animal Rights and Informed Consent

This article contains no studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Cardiovascular Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Catov, J.M., Bairey-Merz, N. & Rich-Edwards, J. Cardiovascular Health During Pregnancy: Future Health Implications for Mothers. Curr Epidemiol Rep 4, 232–238 (2017). https://doi.org/10.1007/s40471-017-0116-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40471-017-0116-x

Keywords

Search

Navigation