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Pregnancy complications studies prompt change in AHA guidelines

Robin Wulffson MD's picture
pregnancy complications. hypertension, diabetes, cardiovascular disease

As a result of recent studies that reported a correlation between pregnancy complications and cardiovascular disease, the American Heart Association 2011 Guidelines on the Prevention of Cardiovascular Disease in Women has noted pregnancy complications to be risk factors for cardiovascular disease.

The American Heart Association (AHA) committee recommends that healthcare providers obtain a detailed history of gestational diabetes, preeclampsia, preterm delivery, or delivery of a small for gestational age infant as part of their evaluation. They urged obstetricians to refer women who had suffered from a pregnancy complication to a primary care physician or a cardiologist for monitoring of cardiovascular risk factors. This new recommendation is based primarily on the results of large studies that derived their data from national birth and death registry databases in Europe. These studies have reported a statistically significant correlation between a history of pregnancy complications and cardiovascular disease in middle age.

The latest study, which reported a correlation between pregnancy complications and cardiovascular disease in middle age was conducted by researchers at the University of Bristol (Bristol, England). The researchers reported that, after 18 years of follow-up, women who had preeclampsia (toxemia) or gestational diabetes were at an approximately 30% increased risk of cardiovascular disease. Their findings were published online on February 17 in the journal Circulation. They derived their data from 3,416 women who were participants in the prospective study known as the Avon Longitudinal Study of Parents and Children (ALSPAC), which began in the early 1990s.

The researchers evaluated the relationships of gestational diabetes, hypertensive disorders of pregnancy, preterm delivery, and size for gestational age with a calculated 10 year cardiovascular disease risk (based on the Framingham score); in addition, they evaluated the associations between a wide range of cardiovascular risk factors, which were measured 18 years after pregnancy (average age at outcome assessment: 48 years).

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Approximately a third of the women suffered at least one pregnancy-related complication (29.8%); 5.2% experienced two, and 0.8% had three. Preeclampsia was defined as proteinuria (protein in the urine) and a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mmHg, measured on at least two occasions after 20 weeks of gestation. Hypertension was defined as similar elevations in systolic and diastolic blood pressure without proteinuria.

The researchers found that gestational diabetes was positively associated with fasting glucose and insulin, even after adjusting for potential confounders; however, hypertensive disorders of pregnancy were associated with body mass index (BMI), waist circumference, blood pressure, serum lipids, and serum insulin. Large for gestational age (LGA) was associated with a larger waist circumference and higher serum glucose levels; however, small for gestational age (SGA) and preterm delivery were associated with elevated blood pressure. There was no increased risk of a predicted cardiovascular disease event in the next 10 years in women who delivered LGA infants or in those whose infants were born pre-term.

The authors concluded that hypertensive disorders of pregnancy and gestational diabetes are independently associated with an increased calculated 10 year cardiovascular disease risk. They noted that preeclampsia may be the better predictor of future cardiovascular disease because it was associated with a wider range of cardiovascular risk factors. They added that their results suggest that pregnancy may be an important opportunity for early identification of women at increased risk of cardiovascular disease later in life.

Take Home Message:
To some degree, genetic factors are related to an increased risk of pregnancy complications; however, poor lifestyle choices may significantly increase. Obesity, smoking, and an unhealthy diet increase the risk of pregnancy complications as well as cardiovascular disease and diabetes. Irrespective of pregnancy, women who engage in poor lifestyle choices are at increased risk. Any woman who experiences a pregnancy complication should thoroughly assess her lifestyle choices and determine which factors can be corrected. If so, she will be more likely to experience a longer and healthier life.

Reference: Circulation