Life course trajectories of maternal cardiovascular disease risk factors by obstetric history: a UK cohort study using electronic health records

Abstract

Background: Women who experience adverse pregnancy outcomes (APOs; gestational hypertension, preeclampsia (PE), gestational diabetes (GD), preterm birth (PTB), small or large for gestational age, miscarriage, multiple miscarriages, stillbirth, and offspring with major congenital anomalies) have increased risk of developing cardiovascular disease (CVD). We aimed to compare cardiometabolic health trajectories across the life course between women with and without APOs.

Methods: We studied 187,186 women with a registered pregnancy in the UK Clinical Practice Research Datalink (CPRD) GOLD linked to Hospital Episode Statistics. Fractional polynomial multilevel models were used to compare trajectories of cardiometabolic risk factors (body mass index [BMI], blood pressure [BP], cholesterol, and glucose) between women with and without a history of APOs (individual APOs in any pregnancy and number of APOs). We explored two underlying time axes: (1) time relative to first pregnancy (from 10 years before first pregnancy to 15 years after) and (2) age. Models controlled for age at first pregnancy, residential area deprivation, non-singleton pregnancy, parity, smoking status, ethnicity, and medications use.

Results: Women with a history of PE, gestational hypertension, or GD had higher BMI, BP, and glucose 10 years before first pregnancy compared to women without these APOs. These differences persisted 15 years post-first pregnancy. Women with a history of GD had a steeper post-partum rise in glucose. Women who experienced multiple (3 +) miscarriage, stillbirth, and/or medically indicated PTB had higher BP and BMI before and after pregnancy, with BP trajectories converging 15 years after first pregnancy. Women who experienced multiple APOs had the most adverse measurements across all cardiometabolic risk factors, with more unfavourable mean levels with each additional APO. There was little difference in cardiometabolic trajectories between women with and without a history of 1 or 2 miscarriages or congenital anomalies.

Conclusions: Women with APOs had adverse cardiometabolic profiles before first pregnancy, persisting up to 15 years post-pregnancy. Findings highlight the potential for targeted public health interventions to promote good cardiometabolic health in young adults transitioning from contraceptive use to planning pregnancies. APOs may identify young women who could benefit from monitoring CVD risk factors and interventions to improve cardiometabolic health.

Keywords: Adverse pregnancy outcomes; Cardiovascular risk factors; Gestational diabetes; Gestational hypertension; Preeclampsia.

Fig. 1

Flow chart of women included in the cohort. ¹UTS means the practice is ‘up to standard’, a practice-level quality metric. ²These unknown pregnancy outcomes were not resolved using HES data. The number in this box includes women with ongoing pregnancies at the time of data extraction, estimated to be around 1000. ³After data cleaning, including removing duplicate pregnancy records

Fig. 2

Trajectories of cardiometabolic risk factors by hypertensive disorders of pregnancy

Fig. 3

Trajectories of cardiometabolic risk factors by gestational diabetes

Fig. 4

Trajectories of cardiometabolic risk factors by multiple miscarriages

Fig. 5

Trajectories of cardiometabolic risk factors by stillbirth

Fig. 6

Trajectories of cardiometabolic risk factors by preterm delivery

Fig. 7

Trajectories of cardiometabolic risk factors by small for gestational age

Fig. 8

Trajectories of cardiometabolic risk factors by large for gestational age

Fig. 9

Trajectories of cardiometabolic risk factors by miscarriage

Fig. 10

Trajectories of cardiometabolic risk factors by major congenital anomalies

Fig. 11

Trajectories of cardiometabolic risk factors by healthy pregnancy versus any adverse pregnancy outcome

Fig. 12

Trajectories of cardiometabolic risk factors by number of adverse pregnancy outcomes