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Unfavorable pregnancy outcomes and CVD risk - AHA scientific statement

M3 India Newsdesk Jun 16, 2022

According to a statement by the American heart association, CVD risk associated with pregnancy holds peculiar opportunities for cardiovascular disease prevention in women. The recommendations by AHA for managing the unfavourable pregnancy outcomes and CVD risk are elucidated in this article.

Pregnancy and CVD

Pregnancy alters the mother's vascular, metabolic, and physiological functions, including increased insulin resistance, adiposity deposition, hypercoagulability, cardiac remodelling, and lower vascular resistance. These changes promote foetal growth and development, while also preparing the mother for the higher energy and nutritional demands of nursing, which are necessary to maintain the newborn's postnatal growth.

Pregnancy physiological stress may mask adverse pregnancy outcomes (APOs) such as gestational diabetes (GD), hypertensive disorders of pregnancy, intrauterine growth restriction, small-for-gestational-age (SGA) delivery, placental abruption, and preterm delivery in women with pre-pregnancy elevated cardiometabolic risk factors or genetic or environmental susceptibility to these conditions.

Because women's reaction to pregnancy stress is a predictor of future CVD risk, the 2011 update of the American Heart Association's evidence-based recommendations for the prevention of CVD in women suggests that a history of APOs (GD, preeclampsia, preterm delivery, or birth of an SGA child) be included when assessing CVD risk in women. Additionally, the new 2018 cholesterol treatment guidelines briefly include these APOs as CVD risk factors while considering the use of a statin for CVD prevention.

This current American Heart Association statement summarises the epidemiological data linking individual APOs to an increased risk of CVD and explores various lifestyle adjustments that may help women with a history of APOs mitigate this risk. Additionally, this guideline also assesses health system initiatives which might benefit both women's long-term cardiovascular health and subsequent pregnancies following an APO.

Recommendations by the American Heart Association 

The following are crucial elements to recall from the American Heart Association's Scientific Statement on adverse pregnancy outcomes (APOs) and the risk of cardiovascular disease (CVD): 

1. APOs such as hypertensive disorders of pregnancy, premature delivery, gestational diabetes, preterm birth, placental abruption, and pregnancy loss enhance a woman's chance of acquiring CVD risk factors and subsequent CVD (fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, heart failure).

2. A history of APOs should be considered when assessing women's CVD risk. APOs are considered CVD risk enhancers in the 2018 cholesterol treatment guidelines when considering whether to use statins for CVD prophylaxis.

3. Although the addition of APOs to traditional CVD risk assessment methods did not result in substantial reclassification, the incremental predictive potential of APOs is restricted due to the substantial prevalence of traditional CVD risk factors in middle-aged and older women with prior APOs.

4. Lactation and breastfeeding may help reduce a woman's chance of developing the cardiometabolic disease later in life. Breastfeeding has been linked to a decreased risk of developing early atherosclerosis and is associated with higher HDL levels and lowering the risk of type 2 diabetes, regardless of lifestyle factors. Breast-feeding for a longer time is connected with a decreased incidence of incident hypertension in middle age (40-49 years).

5. Asian women had a greater prevalence of APOs, which are associated with a more severe clinical presentation and poorer prognosis.

6. Pregnant women at high risk of pre-eclampsia are advised to take low-dose aspirin to prevent pre-eclampsia (women with a history of pre-eclampsia, multifetal gestation, renal disease, autoimmune disease, diabetes, chronic hypertension, etc.).

7. The postpartum time (also known as the Fourth Trimester) should be viewed as a chance to make lifestyle changes that improve cardiovascular health, such as weight control, smoking cessation, physical activity, and diet. Women with a history of pre-eclampsia, in particular, should have their CVD risk assessed by blood pressure, lipids, fasting glucose, and body mass index monitoring.

8. The ACOG recommends that women with uncomplicated pregnancies should regularly engage in moderate-intensity physical activity for at least 20-30 min/d on most or all days of the week.

9. Additional studies examining the use of aspirin, statins, and metformin in primary CVD prevention in women with a history of an APO may be beneficial.

10. Health care systems must enhance care transitions for women with APOs. There is a need for initiatives to:  

  • Identify women at risk,
  • Simplify care transfer between obstetrics and primary care teams, and
  • The launch focused risk reduction efforts

11. Increasing access to health care and insurance coverage, as well as Medicaid expansion, are critical components of enhancing postpartum follow-up and lowering the long-term risk of CVD.

Click here to see references


Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.

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