AHA: Complications of pregnancy may increase CVD risk; improved postpartum care needed
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Certain pregnancy-related complications may represent “red flags” for future CVD in pregnant and postpartum women with a history of complications of pregnancy, researchers wrote.
According to a scientific statement published in Circulation, improved diet and exercise before pregnancy and better patient education and postpartum care may help to mitigate risk factors for CVD later in life.
“Pregnancy leads to many vascular, metabolic and physiological adaptations in the mother, including increased insulin resistance, adipose deposition, hypercoagulability, cardiac remodeling and decreased vascular resistance,” Nisha I. Parikh, MD, MPH, cardiovascular epidemiologist and population scientist at the University of California, San Francisco, and chair of the statement writing committee, and colleagues wrote. “These changes support fetal growth and development and prepare the mother for the increased energy and nutritional demands of lactation to support the newborn’s postnatal growth. The physiological stress of pregnancy may unmask adverse maternal and fetal pregnancy outcomes.”
For the scientific statement, the committee reviewed epidemiological evidence associated with individual adverse pregnancy outcomes and CVD risk among women with a history of prior complications of pregnancy.
‘Red flags’ and risk factor reduction
According to a press release form the American Heart Association, the scientific statement highlighted six pregnancy complications considered red flags for CVD later in life:
- Gestational hypertension, defined as BP during pregnancy above 140/90 mm Hg after 20 weeks, increases a woman’s risk for CVD by 67% and increases the odds of a stroke by 83%.
- Preeclampsia is associated with a 2.7 times greater risk for CVD in later life.
- Gestational diabetes is associated with increased risk for CVD by 68% and 10-fold increased risk for developing diabetes after pregnancy.
- Preterm delivery, defined as childbirth before 37 weeks, is associated with twofold increased risk for CVD and stroke in later life.
- Placental abruption is associated with 82% increased risk for CVD.
- Stillbirth is associated with a nearly twofold increased risk for CVD in later life.
“Adverse pregnancy outcomes are linked to women having hypertension, diabetes, abnormal cholesterol and cardiovascular disease events, including heart attack and stroke, long after their pregnancies,” Parikh said in the release. “Preventing or treating risk factors early can prevent cardiovascular disease; therefore, adverse pregnancy outcomes can be a powerful window into cardiovascular disease prevention if women and their health care professionals harness the knowledge and use it for health improvement.”
Lifestyle modification such as optimizing dietary patterns among reproductive age and pregnant women, especially those with gestational diabetes or preeclampsia, may help to prevent CVD later in life. Prior research suggests healthy dietary patterns characterized by high intake of fruits, vegetables, legumes, nuts and fish and low intake of red and processed meats in the 3 years before pregnancy were associated with lower risk for adverse outcomes of pregnancy, according to the scientific statement. In addition, the Dietary Approaches to Stop Hypertension (DASH) diet was associated with lower BP during pregnancy and better outcomes among women with gestational diabetes.
The committee also stated that improved physical activity to mitigate maternal obesity may also reduce adverse outcomes of pregnancy and risk for CVD. According to the statement, maternal obesity conferred short-term difficulties with lactation, but in the long term was associated with postpartum weight retention, diabetes and increased risks for subsequent hypertensive disorders of pregnancy.
“The American College of Obstetricians and Gynecologists has recently called this period the fourth trimester to expand the focus beyond the traditional single postpartum visit,” the committee wrote. “Longer coverage for postpartum care such that the obstetrician/gynecologist or other health care providers can screen for the development of CVD risk factors and provide adequate CVD risk prevention counseling, rather than simply offering a single postpartum visit, would improve long-term risk reduction for patients with adverse pregnancy outcomes.”
Other initiatives that could improve care mentioned in the statement included improved patient education; improved communication between obstetrics providers and primary care physicians; the addition of female-specific risk factors to existing CVD risk assessment tools; and better follow-up for women with pregnancy complications.
The ‘golden year’
In a related commentary, Eliza C. Miller, MD, MS, assistant professor of neurology in the division of stroke and cerebrovascular disease at Columbia University, discussed missed opportunities for better care of women who experience adverse pregnancy outcomes and the “golden year” concept.
“The so-called ‘Golden Hour’ for conditions such as sepsis and acute stroke refers to a critical time window for early recognition and treatment, when we can change a patient’s clinical trajectory and prevent severe morbidity and mortality,” Miller wrote. “[The] pregnancy and the postpartum period can be considered a ‘Golden Year’ in a woman’s life, offering a rare opportunity for clinicians to identify young women at risk and work with them to improve their cardiovascular health trajectories.
“The AHA/American Stroke Association has already called for closer monitoring and intensive risk factor modification in the postpartum period for women with adverse pregnancy outcomes,” Miller wrote. “This ‘fourth trimester’ model of care should be implemented as a key strategy for cardiovascular risk reduction after adverse pregnancy outcomes. Telehealth visits and home blood pressure monitoring are powerful tools that could be employed for this purpose. Smooth transitions from obstetric care to general primary cardiovascular care, or specialty care if needed, should be established. Rigorous qualitative research is needed to understand how we can better support women who experience adverse pregnancy outcomes both during and after the event.”
Reference:
- Pregnancy is the “Golden Year” for Cardiovascular Disease Prevention in Women. https://professional.heart.org/en/science-news/adverse-pregnancy-outcomes-and-cardiovascular-disease-risk/Commentary. Accessed March 29, 2021.
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