Cardiac events in pregnancy affect future CV health
BOSTON — Gestational diabetes and preeclampsia can both lead to increased CV risk later in life and are necessary factors to consider when constructing treatments for prevention and management, according to a presentation at the Cardiometabolic Health Conference.
“The biggest thing is everyone — endocrinology, cardiologists, primary care — needs to understand that there is a big risk associated with these pregnancy-associated conditions,” Pam R. Taub, MD, FACC, associate professor of medicine at the University of California San Diego School of Medicine, told Healio.com. “People don’t ask, and women forget about it. I just think that it needs to be on everyone’s radar.”
Taub said pregnancy serves as a “stress test,” which can “unmask” certain CV risk factors, primarily because it is a hypercoagulable state leading to higher platelet adhesion and clotting factors as well as decreased fibrinolysis and protein S activity.
Several hemodynamic alterations can occur during pregnancy, especially in the third trimester, she said, including increased plasma volume, cardiac output and heart rate. It is normal for women in their third trimester to have heart rates above 90 bpm. During labor, cardiac output intensifies, especially during contractions, according to a 1992 study in the British Heart Journal. The heart itself changes during pregnancy, including volume increases in the right and left ventricles, according to Taub.
Due to the heavy CV toll of pregnancy, cardiac risk factors that can be identified before conception can play a large role in determining whether a cardiac event is likely to occur during pregnancy. Such events are more likely to occur when multiple factors are present and can influence the development of adverse pregnancy outcomes and complications during pregnancy such as gestational diabetes and preeclampsia, Taub said.
Although preeclampsia occurs only in 2% to 8% of pregnancies, according to Taub, women who develop the disorder face increased risk for CVD in the future. Women with preeclampsia who have preterm births are specifically susceptible to CVD years after pregnancy since the disorder can cause diastolic dysfunction and increased right ventricular systolic pressure. Risk levels for type 2 diabetes and stroke are also elevated in women who develop preeclampsia.
Gestational diabetes is another development during pregnancy that can negatively affect cardiac health in the future. Taub said aggressive screening for diabetes during and after pregnancy is necessary in women who develop gestational diabetes, especially since type 2 diabetes prevalence increases 19.8% 9 years after giving birth.
“A lot of the time what happens is women get pregnant, that’s one of the times they get medical care, and then after their pregnancy, maybe they go in for a Pap smear, but they’re not getting regular care,” Taub said. “It’s important to emphasize how these conditions need to be tracked. I think that 20% diabetes at 9 years is unacceptable. I feel like if we did more aggressive follow-up, we could probably cut that in half.”
There is also a need to monitor the children of mothers with gestational diabetes, as they are at elevated risk for childhood obesity, type 1 and type 2 diabetes as well as metabolic syndrome, she said.
Additionally, Taub recommends consistent follow-up with women who had gestational diabetes, as it is a long-term disease, even if resolved after delivery. In terms of CV risk, a 2017 study from JAMA Internal Medicine showed that there was a 43% greater risk for CVD for women with gestational diabetes compared with those without.
“We need to be incorporating these events into our risk assessment for these patients,” Taub said during her presentation. “It’s an area not a lot of people are thinking about and an area where we need to do a lot more research. The two important conditions to always ask about [are] gestational diabetes and preeclampsia because there is very clear-cut evidence that those conditions lead to an increase in cardiometabolic disease.” – by Phil Neuffer
Taub P. Impact of pregnancy on CV risk factors and ASCVD risk. Presented at: Cardiometabolic Health Congress; Oct. 24-27, 2018; Boston.
Disclosure: Taub reports she consults for Amgen, Boehringer Ingelheim, Janssen, Novo Nordisk and Sanofi.