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.

Body Mass Index, Adverse Pregnancy Outcomes, and Cardiovascular Disease Risk

“…It is also important to note that these data confirm and still support the identification of APOs as a risk-enhancing factor given the significant association between both hypertensive disorders of pregnancy and gestational diabetes and incident CVD risk factors, and highlights pregnancy as an early cardiovascular moment. 2 Although the present study focused on CVD risk factors and not CVD in this young sample, these risk factors largely mediate the association between APOs and future CVD, and thus represent important intermediate targets for prevention, particularly in young adults before hard or symptomatic CVD events occur. 14 Future research should also evaluate how pregnancy events may affect postpartum weight retention, and in turn, whether postpartum weight retention is a potential target for interventions to improve longterm cardiovascular health.…”

“…with abnormal placentation has been proposed to contribute to hypertensive disorders of pregnancy, in contrast to a metabolic phenotype for gestational diabetes, which results from an abnormal physiological response to placental-mediated insulin resistance. [2][3][4] The causes of preterm birth and small-for-gestational-age birth are less well understood and can overlap with hypertensive disorders of pregnancy or gestational diabetes, or they can have distinct causes. 5,6 All of these APO subtypes are associated with higher short-term risk of maternal morbidity and mortality, [7][8][9] and emerging data support an association between APOs and lifetime risk for cardiovascular disease (CVD) with the greatest and most consistent association for hypertensive disorders of pregnancy.…”

“…17,24 Therefore, we sought to define the associations between maternal obesity, hypertensive disorders of pregnancy (and other APO subtypes), and cardiovascular health (as measured by incident CVD risk factor development) several years after delivery. We estimated (1) the association between early pregnancy BMI and subsequent CVD risk factors independent of APOs; (2)…”

Adverse Pregnancy Outcomes and Predicted 30-Year Risk of Maternal Cardiovascular Disease 2–7 Years After Delivery

“…Understanding the role of biomarkers and imaging (ie, computed tomography for coronary artery calcium or echocardiography for adverse cardiac remodeling) in combination with erosclerotic CVD risk algorithms to identify those individuals with an adverse pregnancy outcome at highest risk with subclinical disease may allow better targeted intervention. 24 Finally, new atherosclerotic CVD risk prediction models, such as PREVENT (Predicting Risk of CVD Events), which assesses risk in individuals as young as age 30 years and incorporate social determinants of health, as well as the American Heart Association's Life Essential 8 cardiovascular health framework, which includes both clinical and behavioral factors, provide an opportunity to address CVH in female individuals of reproductive age. 14 To date, incorporating hypertensive disorder of pregnancy history in prior 10-year atherosclerotic CVD risk prediction models in midlife after age 40 years has not consistently demonstrated significant improvement in net risk reclassification, perhaps because the downstream development of hypertension has occurred.…”

Introduction to the Compendium on Early Cardiovascular Disease

“…Pedamallu et al 16 set the stage by discussing evidence of CVH trajectories from early life, which track into mid-life, highlighting opportunities to promote CVH in children and young adults. These approaches are complemented by Khan et al, 17 who introduce the concept of pregnancy as a lens into future CVH, issuing a clarion call for a more proactive approach to assessing, monitoring, and modifying CVH throughout pregnancy to affect long-term CVD risk. CVH during the prepregnancy period in young adulthood and gestational CVH also seem to have important implications for pregnancy outcomes, offspring health and intergenerational transmission of CVH and CVD risk.…”