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    Obstetric history and CVD risk

     

     

    Dr Duzyj Buniak is Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey.

     

     

     

    Dr Louis is Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Morsani College of Medicine and Department of Community and Family Health, College of Public Health, University of South Florida, Tampa.

    Neither author has a conflict of interest to report with respect to the content of this article.

     

     

    It is not news that cardiovascular disease (CVD) is the number-one cause of death among women, accounting for 22.9% of all deaths.1 Yet only 1 in 5 women believe that heart d isease is their greatest risk, and this despite the mortality data and the American Heart Association’s (AHA) “Go Red for Women” campaign, which has been around for 12 years.2 What is becoming increasingly newsworthy in an abundance of literature is that a woman’s response to pregnancy appears to predict her later cardiovascular health.3-6

    Previously developed scoring and risk algorithms for CVD may underestimate the risk in reproductive-age women because they focus primarily on obesity and metabolic syndrome, hypertension, diabetes, and family history.7 In 2011, the AHA recommended including a woman’s obstetric history in risk assessment, in its updated report, “Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women.”8

    In 2014, the organization took it a step further with its “Guidelines for the Prevention of Stroke in Women,” which included history of preeclampsia and gestational hypertension in the risk profile for CVD.9 For the first time, non-obstetricians were being encouraged to ask women about their obstetric history and to consider the existing evidence about the long-term implications of pregnancy-related complications.

    Related: Ob/gyns should join the fight against quiet killer

    Emerging data

    Obstetricians are well-versed in counseling patients about pregnancy complications such as preeclampsia, gestational diabetes, stillbirth, and preterm birth (PTB) that may recur or predispose to another major obstetric complication in future pregnancies.10-13 We have been less adroit, however, at describing what these outcomes mean for future maternal health. A significant body of emerging data indicates a clear association between adverse pregnancy outcomes and future maternal CVD (Table 1).

    Epidemiologic studies from the Netherlands demonstrated that women who experienced severe preeclampsia had a 7.58 (7.05–8.14)-fold increased risk of developing chronic hypertension in an average of 14 years of follow-up after the index pregnancy relative to women with uncomplicated pregnancies.14

    The risk of developing clinical hypertension by age 50 thus increases from 5% among women with healthy pregnancies to 20% in those with a history of severe preeclampsia. In women with severe preeclampsia, the odds of all associated CV complications—including ischemic heart disease (odds ratio [OR] 2.11; 1.76–2.52), stroke (OR 1.61; 1.35–1.93), thromboembolism (OR 2.18; 1.70–2.80), and type II diabetes (OR 4.09; 3.52–4.76)—are statistically higher. The result is an increase in death from all causes (OR 1.38; 1.11–1.71) in women at a mean follow-up age of 41.6 years.

    The time to manifestation of CVD is not trivial. Follow-up of women in the Hypertension and Pre-eclampsia Intervention Trial at near Term (HYPITAT) study demonstrated elevated clinical and laboratory features of cardiometabolic disease at only 2.5 years following a pregnancy with hypertensive complications.15 The association between dyslipidemia, preeclampsia, and subsequent development of ischemic heart disease has also been scrutinized. Prepregnancy CVD risk factors such as abnormal lipid profiles may contribute to the development of preeclampsia in addition to future CVD risk.16

     

    Christina Duzyj Buniak, MD, MPH
    Dr Duzyj Buniak is Assistant Professor, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Rutgers Robert ...
    Judette Louis, MD, MPH
    Dr Louis is Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Morsani College of ...

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