Adverse pregnancy outcomes ‘unmask’ CVD risk in women
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RANCHO PALOS VERDES, Calif. — The prepregnancy period offers a critical opportunity for physicians to optimize CV health early rather than intervening when cardiometabolic disease develops during or after pregnancy, according to a speaker.
The relationship between adverse pregnancy outcomes and CVD identifies these pregnancy complications as important markers for CVD prevention, Sadiya S. Khan, MD, MSc, FACC, FAHA, assistant professor of medicine and preventive medicine, associate program director of the cardiovascular disease fellowship and director of research in the section of heart failure at Northwestern University Feinberg School of Medicine, said during a presentation at the Cardiometabolic Health Congress Women’s Cardiometabolic Health and Wellness Masterclass. A reproductive life course framework can prioritize the peripartum period when risk for CVD is unmasked, along with a shift from addressing maternal morbidity to equitably promoting maternal health and optimize generational health, Khan said.
“This is why it is so important to understand these cardiovascular and cardiometabolic complications of pregnancy as the first clinical manifestation where we have a unique window and opportunity for risk mitigation,” Khan said.
CV health is declining overall in the U.S., particularly among young women, Khan said. Rates of obesity, severe obesity, hypertension and prediabetes and type 2 diabetes are rising, each increasing the burden of maternal morbidity and mortality.
“This is really setting up that perfect storm,” Khan said. “If we have worse health coming into pregnancy, for pregnant individuals, there is higher pregnancy-related risk for seeing this increased burden of morbidity and mortality.”
A cross-sectional study of National Center for Health Statistics Natality Data, representing all live births in the U.S. from 2011 to 2019, show less than half of pregnant women had optimal prepregnancy CV health. Optimal prepregnancy CV health declined in each race/ethnicity, age, insurance and WIC subgroup, with persistent disparities by race and ethnicity and socioeconomic status, Khan said.
Pregnancy an ‘opportunity to intervene’
The reproductive life course — the period between menarche and menopause, often including pregnancy — may be the most important period for CV risk in women, Khan said. Complications that arise during pregnancy, such as hypertensive disorders of pregnancy, eclampsia and gestational diabetes, are associated with long-term morbidity and mortality and should be considered “red flags” for cardiometabolic health optimization.
“If we can intervene earlier, during these first manifestations, we may be able to prevent those downstream sequelae,” said Khan, calling pregnancy “nature’s stress test."
Many physiological changes that occur with pregnancy are normal for the growth of the fetus; however, changes such as a consistently elevated BP and diagnosed insulin resistance are signals the pregnancy itself is “unmasking” risk that already existed, Khan said.
“This could potentially set someone on this pathway for subclinical disease, which includes endothelial dysfunction, abnormal cardiac mechanics and development of CV risk factors and overt CVD,” Khan said. “This affords us an opportunity to intervene earlier in the disease course.”
Maternal death ‘tip of the iceberg’
The U.S. leads all other high-income countries in the rate of maternal mortality; CVD is one of the leading causes, Khan said. About half of deaths occur during the postpartum period, as far out as 1 year after delivery.
“Black women are three times more likely to die during pregnancy or of pregnancy-related circumstances than non-Hispanic white women,” Khan said. “There are significant disparities and health inequities related to these outcomes related to pregnancy.”
Yet, maternal deaths are just the “tip of the iceberg,” Khan said; data also show a growing burden of gestational hypertension, eclampsia and admission to the ICU during and after delivery. Many of these complications occur in young women aged 20 to 29 years.
“While age is an important relative risk factor, it is not the driving factor of why we are seeing these increases,” Khan said. “In fact, we need to have a high level of suspicion and awareness even among young adults.”
Emerging opportunities to target CV health
People who experience adverse pregnancy outcomes should be monitored and assessed more closely after delivery to ensure they receive optimal education and counseling, screenings, risk assessments and medications, if needed. Continuity of care is also crucial, Khan said.
“Often, there are these gaps between obstetrics care and primary care or specialty care with preventive cardiology,” Khan said. “We also know that postpartum care can be a prepregnancy intervention. If an individual goes on to another pregnancy, that interpregnancy period, we are optimizing health after an adverse pregnancy outcome, which can be beneficial for them and their future children.”
Reference:
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Khan SS. Adverse cardiovascular and cardiometabolic complications associated with pregnancy. Presented at: CMHC Women’s Cardiometabolic Health and Wellness Masterclass; Sept. 9-11, 2022; Rancho Palos Verdes, California.
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