Complications during pregnancy may be a wake-up call pointing to a higher risk for cardiovascular (CVD) and other diseases later in life. Therefore, the postpartum and interpregnancy periods are opportune windows for reducing CVD susceptibility and providing preventive care, especially for mothers with a history of adverse pregnancy outcomes (APOs). To that end, the American Heart Association recently released a scientific statement in Circulation outlining pregnancy-related CVD risks and reviewing evidence for preventive lifestyle strategies based on the AHA’s Life’s Essential 8 recommendations.
The Life’s Essential 8 encompass healthy eating, sleeping, and activity patterns; controlling weight, blood pressure, cholesterol, and blood sugar; and avoiding tobacco use.
“The motivation behind this statement was that complications in pregnancy are becoming more common and we now have more understanding that these serve as important risk factors for heart disease later in life,” said Jennifer Lewey, MD, MPH, director of the Penn Women’s Cardiovascular Health Program and an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine in Philadelphia.
Perelman School of Medicine
Dr. Jennifer Lewey
“These risk factors are underrecognized and underappreciated. Clinicians don’t feel comfortable counseling their patients about how to reduce their cardiovascular disease risk,” Dr. Lewey, chair of the AHA writing group, said in an interview.
“So we thought this was the perfect time to highlight what we know and don’t know about how to care for this population,” she said.
APOs predispose mothers to heart disease and other long-term complications, including heart failure, stroke, chronic kidney disease, and vascular dementia. “Pregnancy is a significant stress on the body, and APOs such as preeclampsia can lead to vascular changes in the blood vessels and structural changes to the heart that can persist long term,” Dr. Lewey explained. Reduced maternal physical activity and unshed weight can compound the problem.
Varying by race and ethnicity, the proportion of mothers experiencing pregnancy complications, such as high blood pressure, gestational diabetes, and/or preterm birth is estimated at 10%-20%, the statement authors noted. These complications may serve as a wake-up call to young mothers.
The AHA panel believes that identifying at-risk women at younger ages will enable prevention through lifestyle changes and timely treatment. Little is known, however about what specific care may best reduce long-term CVD risk in women who had pregnancy complications, Dr. Lewey said. While randomized clinical trials have yet to evaluate the effects of postpartum interventions on CVD outcomes, the need for strategies supported by rigorous evidence is clear. “In particular, the fourth trimester, defined as the 12 weeks after delivery, is an optimal time to engage postpartum individuals in care to reduce maternal morbidity and improve care transitions,” the AHA group wrote.
An earlier AHA statement in 2021 recommended frequent cardiac risk factor screening in the first year postpartum at 6 and 12 weeks and again at 6 and 12 months, with appropriate transition from postpartum to longitudinal primary care around the 8- to 12-week mark.
Among the current statement’s findings: High blood pressure is the most prevalent cardiovascular condition during pregnancy, and the last two decades have seen a 25% increase in preeclampsia.
Hypertension during pregnancy carries a two- to fourfold higher risk of chronic hypertension within 2-7 years.
Women with one or more APOs experience heart attack and stroke at younger ages. Commenting on the statement but not involved in it, internist Natalie A. Cameron, MD, a primary and preventive care physician at Northwestern Medicine in Chicago, said, “This statement will be very helpful for physicians from a primary care perspective, especially since in internal medicine we don’t standardly receive education in cardiovascular health in the context of pregnancy and the first year postpartum.”
Northwestern Medicine
Dr. Natalie A. Cameron
Dr. Cameron also noted that new research suggests the mother’s cardiovascular health during pregnancy can affect the child’s health through adolescence. “There’s a potential intergenerational effect and there may even be some programming and changes to the offspring in utero related to maternal lifestyle factors.”
While the postpartum period would seem like an opportune time to piggyback postpartum visits with infant wellness checkups, “the fact is that, in the U.S., many mothers are lost to care after delivery,” Dr. Lewey said. “But it’s essential to ensure transition to postpartum care.”
According to Dr. Cameron, physicians should be aware of the risk factor data and educate their pregnant and postpartum patients about reducing risk factors. “As I like to say, ‘If you’re going to take care of others, you need to take care of yourself first.’ ” While this statement may be a good starting point, future trials are needed to improve screening for subclinical CVD in individuals with APOs before symptom onset, the statement authors wrote.
This scientific statement was prepared on behalf of the American Heart Association. Dr. Lewey and several coauthors reported research funding from various agencies within the National Institutes of Health. Dr. Brown reported research funding from a cy-près court settlement with Wyeth. Dr. Cameron had no competing interests relevant to her comments.