CVD Risk ‘Underappreciated’ After Adverse Pregnancy Outcomes

Solutions are urgently needed to improve gaps in care for women at risk for cardiometabolic disorders and CVD later in life as a result of having had adverse pregnancy outcomes, a new review paper suggests.

“We’re increasingly aware that early and midlife cardiometabolic health powerfully predicts long-term outcomes, and that we have historically undertreated risk factors in younger individuals because their short-term risks are low. But that ignores the fact that for many, their long-term risks are high,” said senior author Michael C. Honigberg, MD (Massachusetts General Hospital, Boston). “An important area of future research is strategies where we can more effectively engage reproductive-age women in routine follow-up care such that they’re not lost from the healthcare system for a decade or more.”

Often, at-risk women slip through the cracks after their initial postpartum obstetrics visit at 6 weeks. The American College of Obstetricians and Gynecologists recommends transitioning to primary care within 4 to 12 weeks of giving birth. For women with adverse pregnancy outcomes, including hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and intrauterine growth restriction, this is a crucial step toward CVD risk assessment and counseling.

Another issue, Honigberg said, is knowledge about future CVD risk in women with hypertensive disorders of pregnancy.

“The literature supports the notion that physicians, particularly cardiologists, unfortunately, and basically everyone outside ob-gyn underappreciate these risks,” he added. “Women themselves are often unaware of these risks, either because they simply aren’t told by their treating clinicians or they are told but they’re brand-new mothers—which is a totally crazy, overwhelming time— and it’s just not a priority or a focus for them.”

Interventions Hold Promise, But Need More Cohesion

In the review, published online October 27, 2021, ahead of print in JAMA Cardiology,  Honigberg and colleagues, led by medical student Amanda R. Jowell, BA (Harvard Medical School, Boston, MA), dug into 20 years’ worth of maternal health literature, looking at four categories of interventions: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education.

The peer-reviewed data consisted of four postpartum transitional clinics in the US and Canada. While these facilities were associated with risk assessment, increased physical exercise, and primary-care follow-up among attendees, 50% to 75% of women referred either did not show up or only attended a single session. Black and Hispanic women were at especially high risk for loss to follow-up.

“There's more of these clinics out there that haven't published their experiences to date,” Honigberg said. “But I’d say it’s still early days in terms of understanding best practices and how to make them most accessible to women who need them.”

Honigberg said creative approaches could allow the clinics to function as a type of modified cardiac rehab with a supervised exercise component plus childcare. Virtual or remote care is another option that may make these types of services more logistically convenient for early postpartum women, he added, something that his institution has begun to pursue.

An important area of future research is strategies where we can more effectively engage reproductive-age women in routine follow-up care such that they’re not lost from the healthcare system for a decade or more. Michael Honigberg

The data on lifestyle interventions included four RCTs of women with gestational diabetes that focused on dietary modification and/or exercise, often paired with health education and personalized goal setting. A subgroup analysis of the Diabetes Prevention Program, the largest of the four, found that compared with placebo, intensive lifestyle modification with exercise up to 150 hours a week plus metformin reduced diabetes by approximately 50% in women who had a history of gestational diabetes and prediabetes. The much smaller Balance After Baby and Gestational Diabetes’ Effects on Moms studies showed that lifestyle intervention was associated with significantly more weight loss than usual care, as did the randomized Postnatal Lifestyle Intervention Program for Overweight Women With Previous Gestational Diabetes Mellitus. In all three of the latter studies, women had access to support coaches or other educators via telephone or text. While all were promising, data on interventions for women with adverse pregnancy outcomes that are not diabetes-related are sparse, the review found.

Evidence also is lacking about targeted pharmacotherapies, with few studies on medical  management of persistent high BP following hypertensive disorders of pregnancy in the early postpartum period; no standardized recommendations for postpartum medication titration; no large RCTs on medical therapy to prevent chronic hypertension, cardiometabolic disease, or CVD in women who had a hypertensive disorder of pregnancy but who have normal BP in the postpartum period; and no statin trials aimed at women who had a hypertensive disorder of pregnancy.

“I think a related area for which we need considerably more research and data is understanding how immediate postpartum management of things like blood pressure influence long-term outcomes,” Honigberg said. “Part of that question is informed by the need to prevent postpartum hypertensive readmissions, which are an all-too-common cause of postpartum hospital readmission.

“At the same time, many of these women in the weeks to months postpartum will revert to blood pressures that we wouldn’t normally treat,” he continued. “There is emerging evidence that what constitutes a truly normal blood pressure might actually be substantially different for men and women. Understanding that better and understanding the thresholds to trigger things like pharmacotherapy at different points in the life span is a critical area of future research.”