Q&A: Guide recommends CVD risk management strategies after complicated pregnancies
Mothers who experience preeclampsia, preterm delivery, gestational diabetes and other pregnancy complications also may be at increased risk for heart disease, according to researchers at Boston Medical Center.
However, health care providers can use the year following birth to identify individuals who face these risks, provide counseling and begin preventive care — and the researchers say they have developed the first comprehensive guide for managing this treatment.
Healio spoke with author Mara E. Murray Horwitz, MD, MPH, a primary care physician in the Women’s Health Unit at Boston Medical Center, to find out more.
Healio: What prompted you to conduct the review?
Murray Horwitz: I work in primary care and often see patients who have had pregnancy complications such as preeclampsia and gestational diabetes. While I know that these complications are associated with long-term risks of heart disease, it has not been easy to find out when and how to incorporate pregnancy history into primary care. So, I undertook this review with the goal of developing a guide for primary care clinicians like myself so we can do a better job of using pregnancy history to inform CVD risk assessment and management.
Healio: What does the evidence show regarding the risk for CVD following adverse pregnancy outcomes?
Murray Horwitz: The evidence is strongest for preeclampsia, where the risk for CVD is increased twofold to fourfold over the 10 years after pregnancy. All hypertensive disorders of pregnancy — a category that also includes gestational hypertension and superimposed preeclampsia — are also associated with future chronic hypertension, which can occur as early as within the first postpartum year, and which in turn is a risk factor for future CVD.
Similarly, gestational diabetes is strongly associated with type 2 diabetes, also a CVD risk factor. The other pregnancy complications that are associated with future CVD risk – a although the evidence and associations are less strong – include preterm delivery, placental abruption, having intrauterine growth restriction or a small for gestational age baby and stillbirth. Overall, among individuals who have given birth, it’s estimated that one in three has had at least one of these pregnancy complications.
Healio: What clinical guidance for CVD risk management after adverse pregnancy outcomes is available to practicing physicians? Is the evidence supporting those recommendations strong?
Murray Horwitz: We found 13 different U.S. recommendations from different organizations including the American Heart Association, American Society of Anesthesiologists, ACOG and American Diabetes Association. None of them provided comprehensive guidance for primary care clinicians, which is why we pursued the review.
Overall, the evidence supporting the recommendations was strongest for gestational diabetes. Randomized controlled trial data show that lifestyle modification after gestational diabetes can reduce future diabetes risk by about 40%, as effective as metformin.
The evidence for other recommendations was largely based on lower quality studies and expert opinion. The need for more rigorous testing of interventions to reduce CVD risk after adverse pregnancy outcomes is evident.
Healio: What are the areas of consensus for primary care-based CVD risk management after adverse pregnancy outcomes?
Murray Horwitz: The greatest areas of consensus were around the need for comprehensive CVD risk assessment within the first postpartum year after an adverse pregnancy outcome, and the emphasis on patient education and lifestyle modification to reduce CVD risk in the first postpartum year (reserving pharmacotherapy for all but the highest-risk cases).
Healio: Can you talk about the importance of screening women for CVD risk factors within the first year after pregnancy?
Murray Horwitz: Absolutely. From cohort studies that monitor the health of individuals after adverse pregnancy outcomes, we know that many of them develop CVD risk factors such as hypertension or diabetes within the year after delivery. It's important to diagnose these CVD risk factors early, before they contribute to long-term CVD risk or complicate a future pregnancy.
In addition, the postpartum year may be a really powerful time to engage people in care. Postpartum individuals may be more motivated to pursue lifestyle changes after delivery than at other times in life, and they also continue to have lots of interaction with the health care system – albeit more for pediatric than maternal care. Finding ways to leverage pediatric visits to monitor maternal health is one of the many ways that we may be able to connect with and support postpartum individuals.
Healio: What is the most important take-home message for physicians?
Murray Horwitz: Pregnancy is a natural stress test. Taking an obstetric history as part of routine primary care, and especially as part of your CVD risk assessment, can help you identify individuals who are at increased risk for developing CVD risk factors and CVD.