Pregnancy as an Early Cardiovascular Moment: Peripartum Cardiovascular Health

Abstract

Pregnancy is commonly referred to as a window into future CVH (cardiovascular health). During pregnancy, physiological adaptations occur to promote the optimal growth and development of the fetus. However, in approximately 20% of pregnant individuals, these perturbations result in cardiovascular and metabolic complications, which include hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and small-for-gestational age infant. The biological processes that lead to adverse pregnancy outcomes begin before pregnancy with higher risk of adverse pregnancy outcomes observed among those with poor prepregnancy CVH. Individuals who experience adverse pregnancy outcomes are also at higher risk of subsequent development of cardiovascular disease, which is largely explained by the interim development of traditional risk factors, such as hypertension and diabetes. Therefore, the peripartum period, which includes the period before (prepregnancy), during, and after pregnancy (postpartum), represents an early cardiovascular moment or window of opportunity when CVH should be measured, monitored, and modified (if needed). However, it remains unclear whether adverse pregnancy outcomes reflect latent risk for cardiovascular disease that is unmasked in pregnancy or if adverse pregnancy outcomes are themselves an independent and causal risk factor for future cardiovascular disease. Understanding the pathophysiologic mechanisms and pathways linking prepregnancy CVH, adverse pregnancy outcomes, and cardiovascular disease are necessary to develop strategies tailored for each stage in the peripartum period. Emerging evidence suggests the utility of subclinical cardiovascular disease screening with biomarkers (eg, natriuretic peptides) or imaging (eg, computed tomography for coronary artery calcium or echocardiography for adverse cardiac remodeling) to identify risk-enriched postpartum populations and target for more intensive strategies with health behavior interventions or pharmacological treatments. However, evidence-based guidelines focused on adults with a history of adverse pregnancy outcomes are needed to prioritize the prevention of cardiovascular disease during the reproductive years and beyond.

Keywords: cardiovascular diseases; cardiovascular health; pregnancy; risk factors; women.

Figure 1.. The peripartum period (pre-pregnancy [“zero” trimester], pregnancy [trimesters 1–3], and postpartum [“fourth” trimester]) as a critical life stage for the measurement, monitoring, and modification of cardiovascular health.

Cardiovascular health across the life course includes three key reproductive stages, pre-pregnancy, pregnancy, and postpartum that require unique attention due to physiological changes of pregnancy and implications for long-term health of the birthing person and offspring.

Figure 2.. Putative mechanisms underlying the association between diverse but interrelated adverse pregnancy outcomes and cardiovascular disease.

This figure demonstrates the current paradigm of classification of interrelated but phenotypically heterogeneous syndromes of adverse pregnancy outcomes, which include hypertensive disorders of pregnancy, preterm birth, and small-for-gestational age infant and their association with cardiovascular disease. This likely reflects shared pathobiological mechanisms, which include inflammation and anti-angiogenesis.

Figure 3.. A proposed social ecological model in the promotion of cardiovascular health across the peripartum period.

This figure proposes a social ecological framework to consider how to address health disparities in cardiovascular health and promote health equity.

Figure 4.. A conceptual diagram of pre-pregnancy cardiovascular health, adverse pregnancy outcomes, and cardiovascular disease risk.

It is well-established that poor pre-pregnancy cardiovascular health is associated with higher risks of adverse pregnancy outcomes and subsequent cardiovascular disease risk. However, it is not clear if adverse pregnancy outcomes are markers or mediators of this association.