Pregnancy Complications Raise Mothers’ Risk of Cardiovascular Death

Women who experience complications during pregnancy, such as pre-eclampsia and gestational diabetes, are at heightened risk of cardiovascular death later in life. So concludes a long-term follow-up report from a large pregnancy cohort recently published in Circulation. The study found that the risk rises with the number and severity of complications, often resulting in death before age 60.

“Remarkable and striking” is how the findings are characterized by Jeff Chapa, MD, a staff physician in Cleveland Clinic’s Ob/Gyn Institute and Head of the Section of Maternal-Fetal Medicine in Cleveland Clinic Children’s, who notes that they underscore the need for early and aggressive monitoring of cardiovascular health in women with implicated pregnancy complications.

“Pregnancy is like a stress test for the mother,” he says. “These complications are like a failed stress test indicative of risk going forward.”

The study in brief

The study was an analysis of pregnancy events from 1959 to 1967 and cardiovascular death rates through 2011 among more than 14,000 California women in the prospective Child Health and Development Studies pregnancy cohort. Its findings included the following:

• Delivery of a small-for-gestational-age or preterm infant, onset of pre-eclampsia before week 34, and any combination of these factors significantly predicted the likelihood of early cardiovascular death in the mother.
• Pre-existing hypertension increased the risk fourfold.
• Pre-eclampsia in combination with pre-existing hypertension increased the risk sixfold.

Although the study did not examine the impact of these factors on the baby, the increased risk may be passed along to the next generation. “Evidence suggests that babies from these pregnancies are predisposed to developing cardiovascular disease as well,” Dr. Chapa notes.

Ameliorating the risk profile

Cleveland Clinic obstetricians refer women with high-risk pregnancies to a preventive cardiologist, who assesses their cardiovascular risk and institutes preventive measures.

“We start them on a diet and exercise program, adding medication as needed to lower blood pressure or blood sugar,” says Leslie Cho, MD, Co-Director of Preventive Cardiology and Rehabilitation at Cleveland Clinic.

Women with pre-eclampsia, untreated hypertension or untreated diabetes may be seen during pregnancy. Others are evaluated and treated after they deliver.

“There is only a limited window of time to prevent a cardiovascular event,” Dr. Chapa emphasizes. “The earlier in pregnancy these women develop complications, and the more severe they are, and the greater their risk. Unless these women receive regular follow-up care, they may be having myocardial infarctions in their 40s and 50s.”

This finding is a classic example of how obstetricians should be working with colleagues in other specialties to secure the future health of their patients, Dr. Chapa adds.

“At the postpartum visit, we need to note what complications occurred during pregnancy and consider what it means for the patient’s long-term health,” he says. “We should then refer women with risk factors to a preventive cardiologist or, at minimum, to a primary care physician for follow-up.”