Pregnancy characteristics and women's future cardiovascular health: an underused opportunity to improve women's health?

Abstract

Growing evidence indicates that women with a history of common pregnancy complications, including fetal growth restriction and preterm delivery (often combined as low birth weight), hypertensive disorders of pregnancy, and gestational diabetes, are at increased risk for cardiovascular disease later in life. The purpose of this paper was to review the associations of parity and these 4 pregnancy complications with cardiovascular morbidity and mortality; to review the role of cardiovascular risk factors before, during, and after pregnancy complications in explaining these associations; and to explore the implications of this emerging science for new research and policy. We systematically searched for relevant cohort and case-control studies in Medline through December 2012 and used citation searches for already published reviews to identify new studies. The findings of this review suggest consistent and often strong associations of pregnancy complications with latent and future cardiovascular disease. Many pregnancy complications appear to be preceded by subclinical vascular and metabolic dysfunction, suggesting that the complications may be useful markers of latent high-risk cardiovascular trajectories. With further replication research, these findings would support the utility of these prevalent pregnancy complications in identifying high-risk women for screening, prevention, and treatment of cardiovascular disease, the leading cause of morbidity and mortality among women.

Keywords: birth weight; cardiovascular disease; diabetes, gestational; preeclampsia; pregnancy; premature birth; women's health.

Figure 1.

Results from studies of offspring birth weight or fetal growth and relative risk of maternal cardiovascular disease. Caption notes: a, per 1-standard deviation lower birth weight; b, cardiovascular disease mortality; c, lowest birth weight quintile compared with all others; d, coronary heart disease events; e, coronary heart disease mortality; f, birth weight <2,500 g compared with 1,500–3,999 g; g, per 1-standard deviation lower birth weight, adjusted for gestational age; h, small for gestational age; i, intrauterine growth restriction; j, ∼2 standard deviations below the mean birth weight adjusted for gestational age; k, cardiovascular disease events. CI, confidence interval.

Figure 2.

Results from studies of preterm delivery and relative risk of maternal cardiovascular disease. Caption notes: a, <37 gestation weeks compared with term; b, cardiovascular disease mortality; c, <37 weeks’ gestation length compared with term normotensive pregnancies; d, cardiovascular disease mortality, excluding stroke mortality; e, coronary heart disease events; f, myocardial infarction; g, cardiovascular disease events; h, 32–36 weeks’ gestation length compared with term. CI, confidence interval.

Figure 3.

Results from studies of gestational diabetes mellitus and relative risk of maternal cardiovascular disease. Caption notes: a, self-reported coronary artery disease; b, cardiovascular disease events. CI, confidence interval.

Figure 4.

Results from studies of hypertensive disorders of pregnancy and relative risk of maternal cardiovascular disease. Caption notes: a, coronary heart disease mortality; b, coronary heart disease events; c, cardiovascular disease events; d, composite estimate provided by the Bellamy et al. review (18); e, cardiovascular disease mortality. A 2011 study by Lin et al. (62) reported a relative risk of 23.0 (95% confidence interval: 5.1, 103.7) for cardiovascular disease events (except stroke) during pregnancy and up to 3 years after delivery. We omitted that study from the figure so that we could keep the relative risk scale consistent across figures.