From the Editor

Adverse pregnancy outcomes and later cardiovascular disease

OBG Manag. 2021 June;33(6):8, 10, 12-13 | doi: 10.12788/obgm.0106

Such adverse pregnancy outcomes (APOs) as miscarriage, preterm birth, low-birth weight, gestational diabetes, preeclampsia, and placental abruption have been reported to be associated with an increased risk of later cardiovascular morbidity and mortality. Counseling your patients who have experienced an APO about the protective effect of breastfeeding, eating a heart-healthy diet, exercise, and optimizing weight may help them to live a long and healthy life.

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References

Martin JA, Hamilton BE, Osterman MJ, et al. Births: final data for 2019. Natl Vital Stat Rep. 2021;70:1-51.
Deputy NP, Kim SY, Conrey EJ, et al. Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth—United States, 2012-2016. MMWR Morb Mortal Wkly Rep. 2018;67:1201-1207. doi: 10.15585/mmwr.mm6743a2.
Fingar KR, Mabry-Hernandez I, Ngo-Metzger Q, et al. Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014. Statistical brief #222. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Agency for Healthcare Research and Quality: Rockville, MD; April 2017.
Magnus MC, Wilcox AJ, Morken NH, et al. Role of maternal age and pregnancy history in risk of miscarriage: prospective register-based study. BMJ. 2019;364:869.
Parikh NI, Gonzalez JM, Anderson CAM, et al. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women. Circulation. 2021;143:e902-e916. doi: 10.1161 /CIR.0000000000000961.
Brown MC, Best KE, Pearce MS, et al. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28:1-19. doi: 10.1007/s10654-013- 9762-6.
Groenfol TK, Zoet GA, Franx A, et al; on behalf of the PREVENT Group. Trajectory of cardiovascular risk factors after hypertensive disorders of pregnancy. Hypertension. 2019;73:171-178. doi: 10.1161/HYPERTENSIONAHA.118.11726.
Vounzoulaki E, Khunti K, Abner SC, et al. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ. 2020;369:m1361. doi: 10.1136/bmj.m1361.
Tarrant M, Chooniedass R, Fan HSL, et al. Breastfeeding and postpartum glucose regulation among women with prior gestational diabetes: a systematic review. J Hum Lact. 2020;36:723-738. doi: 10.1177/0890334420950259.
Park S, Choi NK. Breastfeeding and maternal hypertension. Am J Hypertens. 2018;31:615-621. doi: 10.1093/ajh/hpx219.
Nguyen B, Gale J, Nassar N, et al. Breastfeeding and cardiovascular disease hospitalization and mortality in parous women: evidence from a large Australian cohort study. J Am Heart Assoc. 2019;8:e011056. doi: 10.1161/JAHA.118.011056.
Eight things you can do to prevent heart disease and stroke. American Heart Association website. https://www.heart.org/en/healthy-living /healthy-lifestyle/prevent-heart-disease-andstroke. Last Reviewed March 14, 2019. Accessed May 19, 2021.
ASCVD risk estimator plus. American College of Cardiology website. https://tools.acc.org /ascvd-risk-estimator-plus/#!/calculate /estimate/. Accessed May 19, 2021.
Ferdinand KC, Nasser SA. Management of essential hypertension. Cardiol Clin. 2017;35:231-246. doi: 10.1016/j.ccl.2016.12.005.
Packard CJ. LDL cholesterol: how low to go? Trends Cardiovasc Med. 2018;28:348-354. doi: 10.1016/j.tcm.2017.12.011.
Simons L. An updated review of lipid-modifying therapy. Med J Aust. 2019;211:87-92. doi: 10.5694 /mja2.50142.
Chou R, Dana T, Blazina I, et al. Statins for the prevention of cardiovascular disease in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;316:2008. doi: 10.1001/jama.2015.15629.
Moin T, Schmittdiel JA, Flory JH, et al. Review of metformin use for type 2 diabetes mellitus prevention. Am J Prev Med. 2018;55:565-574. doi: 10.1016/j.amepre.2018.04.038.
Aorda VR, Christophi CA, Edelstein SL, et al, for the Diabetes Prevention Program Research Group. The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up. J Clin Endocrinol Metab. 2015;100:1646- 1653. doi: 10.1210/jc.2014-3761.
Bibbins-Domingo K, U.S. Preventive Services Task Force. Aspirin use of the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Int Med. 2016; 164: 836-845. doi: 10.7326/M16-0577.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736: optimizing postpartum care. Obstet Gynecol. 2018;131:e140-e150. doi: 10.1097 /AOG.0000000000002633.
National Center for Health Statistics. Health, United States, 2017: Table 015. Hyattsville, MD; 2021. https://www.cdc.gov/nchs/data /hus/2017/015.pdf. Accessed May 18, 2021.

Preconception health influences pregnancy outcomes, and in turn, both preconception health and an APO influence adult cardiometabolic health (FIGURE). This editorial is focused on the link between APOs and later cardiometabolic morbidity and mortality, recognizing that preconception health greatly influences the risk of an APO and lifetime cardiometabolic disease.

Adverse pregnancy outcomes

Major APOs include miscarriage, preterm birth (birth <37 weeks’ gestation), low birth weight (birth weight ≤2,500 g; 5.5 lb), gestational diabetes (GDM), preeclampsia, and placental abruption. In the United States, among all births, reported rates of the following APOs are:^1-3

preterm birth, 10.2%
low birth weight, 8.3%
GDM, 6%
preeclampsia, 5%
placental abruption, 1%.

Miscarriage occurs in approximately 10% to 15% of pregnancies, influenced by both the age of the woman and the method used to diagnose pregnancy.⁴ Miscarriage, preterm birth, low birth weight, GDM, preeclampsia, and placental abruption have been reported to be associated with an increased risk of later cardiovascular morbidity and mortality.

APOs and cardiovascular disease

Cardiovascular disease (CVD) affects the majority of people past the age of 60 years and includes 4 major subcategories:

coronary heart disease, including myocardial infarction, angina, and heart failure
CVD, stroke, and transient ischemic attack
peripheral artery disease
atherosclerosis of the aorta leading to aortic aneurysm.

Multiple meta-analyses report that APOs are associated with CVD in later life. A comprehensive review reported that the risk of CVD was increased following a pregnancy with one of these APOs: severe preeclampsia (odds ratio [OR], 2.74), GDM (OR, 1.68), preterm birth (OR, 1.93), low birth weight (OR, 1.29), and placental abruption (OR, 1.82).⁵

The link between APOs and CVD may be explained in part by the association of APOs with multiple risk factors for CVD, including chronic hypertension, type 2 diabetes mellitus (T2DM), and dyslipidemia. A meta-analysis of 43 studies reported that, compared with controls, women with a history of preeclampsia have a 3.13 times greater risk of developing chronic hypertension.⁶ Among women with preeclampsia, approximately 20% will develop hypertension within 15 years.⁷ A meta-analysis of 20 studies reported that women with a history of GDM had a 9.51-times greater risk of developing T2DM than women without GDM.⁸ Among women with a history of GDM, over 16 years of follow-up, T2DM was diagnosed in 16.2%, compared with 1.9% of control women.⁸

CVD prevention—Breastfeeding: An antidote for APOs

Pregnancy stresses both the cardiovascular and metabolic systems. Breastfeeding is an antidote to the stresses imposed by pregnancy. Breastfeeding women have lower blood glucose⁹ and blood pressure.¹⁰

Breastfeeding reduces the risk of CVD. In a study of 100,864 parous Australian women, with a mean age of 60 years, ever breastfeeding was associated a lower risk of CVD hospitalization (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.78–0.96; P = .005) and CVD mortality (aHR, 0.66; 95% CI, 0.49–0.89; P = .006).¹¹

Continue to: CVD prevention—American Heart Association recommendations...

References

Martin JA, Hamilton BE, Osterman MJ, et al. Births: final data for 2019. Natl Vital Stat Rep. 2021;70:1-51.
Deputy NP, Kim SY, Conrey EJ, et al. Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth—United States, 2012-2016. MMWR Morb Mortal Wkly Rep. 2018;67:1201-1207. doi: 10.15585/mmwr.mm6743a2.
Fingar KR, Mabry-Hernandez I, Ngo-Metzger Q, et al. Delivery hospitalizations involving preeclampsia and eclampsia, 2005–2014. Statistical brief #222. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Agency for Healthcare Research and Quality: Rockville, MD; April 2017.
Magnus MC, Wilcox AJ, Morken NH, et al. Role of maternal age and pregnancy history in risk of miscarriage: prospective register-based study. BMJ. 2019;364:869.
Parikh NI, Gonzalez JM, Anderson CAM, et al. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women. Circulation. 2021;143:e902-e916. doi: 10.1161 /CIR.0000000000000961.
Brown MC, Best KE, Pearce MS, et al. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28:1-19. doi: 10.1007/s10654-013- 9762-6.
Groenfol TK, Zoet GA, Franx A, et al; on behalf of the PREVENT Group. Trajectory of cardiovascular risk factors after hypertensive disorders of pregnancy. Hypertension. 2019;73:171-178. doi: 10.1161/HYPERTENSIONAHA.118.11726.
Vounzoulaki E, Khunti K, Abner SC, et al. Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis. BMJ. 2020;369:m1361. doi: 10.1136/bmj.m1361.
Tarrant M, Chooniedass R, Fan HSL, et al. Breastfeeding and postpartum glucose regulation among women with prior gestational diabetes: a systematic review. J Hum Lact. 2020;36:723-738. doi: 10.1177/0890334420950259.
Park S, Choi NK. Breastfeeding and maternal hypertension. Am J Hypertens. 2018;31:615-621. doi: 10.1093/ajh/hpx219.
Nguyen B, Gale J, Nassar N, et al. Breastfeeding and cardiovascular disease hospitalization and mortality in parous women: evidence from a large Australian cohort study. J Am Heart Assoc. 2019;8:e011056. doi: 10.1161/JAHA.118.011056.
Eight things you can do to prevent heart disease and stroke. American Heart Association website. https://www.heart.org/en/healthy-living /healthy-lifestyle/prevent-heart-disease-andstroke. Last Reviewed March 14, 2019. Accessed May 19, 2021.
ASCVD risk estimator plus. American College of Cardiology website. https://tools.acc.org /ascvd-risk-estimator-plus/#!/calculate /estimate/. Accessed May 19, 2021.
Ferdinand KC, Nasser SA. Management of essential hypertension. Cardiol Clin. 2017;35:231-246. doi: 10.1016/j.ccl.2016.12.005.
Packard CJ. LDL cholesterol: how low to go? Trends Cardiovasc Med. 2018;28:348-354. doi: 10.1016/j.tcm.2017.12.011.
Simons L. An updated review of lipid-modifying therapy. Med J Aust. 2019;211:87-92. doi: 10.5694 /mja2.50142.
Chou R, Dana T, Blazina I, et al. Statins for the prevention of cardiovascular disease in adults: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;316:2008. doi: 10.1001/jama.2015.15629.
Moin T, Schmittdiel JA, Flory JH, et al. Review of metformin use for type 2 diabetes mellitus prevention. Am J Prev Med. 2018;55:565-574. doi: 10.1016/j.amepre.2018.04.038.
Aorda VR, Christophi CA, Edelstein SL, et al, for the Diabetes Prevention Program Research Group. The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up. J Clin Endocrinol Metab. 2015;100:1646- 1653. doi: 10.1210/jc.2014-3761.
Bibbins-Domingo K, U.S. Preventive Services Task Force. Aspirin use of the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Int Med. 2016; 164: 836-845. doi: 10.7326/M16-0577.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736: optimizing postpartum care. Obstet Gynecol. 2018;131:e140-e150. doi: 10.1097 /AOG.0000000000002633.
National Center for Health Statistics. Health, United States, 2017: Table 015. Hyattsville, MD; 2021. https://www.cdc.gov/nchs/data /hus/2017/015.pdf. Accessed May 18, 2021.

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Adverse pregnancy outcomes and later cardiovascular disease

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Adverse pregnancy outcomes

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CVD prevention—Breastfeeding: An antidote for APOs

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