Chapter 38: Pregnancy as a Window to Future Health

INTRODUCTION

Pregnancy has been likened to a cardiovascular stress test in that the development of certain common pregnancy complications have the potential to reveal a woman’s vascular or metabolic susceptibility for future diseases.¹ Indeed, the degree to which a woman “fails” the pregnancy stress test and the number of times the woman “fails” it, in all likelihood reflects not only her risk for future cardiovascular disease (CVD) but the timeframe over which it is likely to develop.² The 2011 update to the American Heart Association’s Effectiveness-Based Guidelines for the Prevention of Cardiovascular Disease in Women³ now includes certain common pregnancy complications (eg, preeclampsia, gestational hypertension, gestational diabetes, etc) as key components when screening women at risk for heart disease and stroke. Importantly, the development of these pregnancy complications not only identifies women at increased risk for future CVD but also can accurately identify women who already have underlying, often unrecognized, cardiovascular risk factors (CVRs).^4,5 As such, we have coined the term “Pregnancy-related cardiovascular risk indicators”⁶ (Table 38-1), the development of which provides an early window of opportunity for postpartum CVR identification and interventions that could lead to a reduction in risk of future CVD and potentially improved outcomes in subsequent pregnancies.²

Although women with pregnancy complications are also at increased risk of other future diseases (ie, heart failure and cardiac dysrhythmias,⁷ venous thromboembolism,¹ renal disease,⁸ and neurocognitive abnormalities⁹), given the public health burden of CVD and opportunities for CVD prevention, this chapter will discuss the justifications for postpartum cardiovascular risk screening in women. Furthermore, this chapter will present an approach to setting up and operating such a program. This guide will be based on the success and data garnered from our own clinic, developed specifically for postpartum cardiovascular risk assessment; The Maternal Health Clinic.⁶

PREGNANCY COMPLICATIONS AND CARDIOVASCULAR DISEASE IN WOMEN

It is now scientifically well established that women who have had an adverse obstetrical outcome (see Tables 38-1 and 38-2)^{10,11,12,13,14,15}—preeclampsia, gestational hypertension, gestational diabetes, idiopathic preterm birth, clinically significant placental abruption, or delivering an intrauterine growth restricted (IUGR) or low birth weight baby—are at an increased risk [presented as relative risk (RR) (95% confidence interval (CI)] of hypertension [3.70 (2.70-5.05)],¹⁶ ischemic heart disease [2.16 ...