Latency of preterm hypertensive disorders of pregnancy and subsequent cardiovascular complications

Hypertensive disorders of pregnancy and long-term maternal cardiovascular risk: Bridging epidemiological knowledge into personalized postpartum care and follow-up

Cardiovascular disease (CVD) is globally the leading cause of death and disability. Sex-specific causes of female CVD are under-investigated. Pregnancy remains an underinvestigated sex-specific stress test for future CVD and a hitherto missed opportunity to initiate prevention of CVD at a young age. Population-based studies show a strong association between female CVD and hypertensive disorders of pregnancy. This association is also present after other pregnancy complications that are associated with placental dysfunction, including fetal growth restriction, preterm delivery and gestational diabetes mellitus. Few women are, however, offered systematic cardio-preventive follow-up after such pregnancy complications. These women typically seek help from the health system at first clinical symptom of CVD, which may be decades later. By this time, morbidity is established and years of preventive opportunities have been missed out. Early identification of modifiable risk factors starting postpartum followed by systematic preventive measures could improve maternal cardiovascular health trajectories, promoting healthier societies. In this non-systematic review we briefly summarize the epidemiological associations and pathophysiological hypotheses for the associations. We summarize current clinical follow-up strategies, including some proposed by international and national guidelines as well as user support groups. We address modifiable factors that may be underexploited in the postpartum period, including breastfeeding and blood pressure management. We suggest a way forward and discuss the remaining knowledge gaps and barriers for securing the best evidence-based follow-up, relative to available resources after a hypertensive pregnancy complication in order to prevent or delay onset of premature CVD.

Cardiovascular Disease-Related Emergency Department Visits and Hospitalization among Women with Hypertensive Disorders of Pregnancy

INTRODUCTION

The risk of developing cardiovascular disease is higher for women who had hypertensive disorders of pregnancy than for women without a history of hypertensive disorders of pregnancy. However, it is unknown whether the emergency department visits and hospitalization differ between women with a history of hypertensive disorders of pregnancy and women without hypertensive disorders of pregnancy. The objective of this study was to characterize and compare cardiovascular disease-related emergency department visits, hospitalization rates, and diagnoses in women with a history of hypertensive disorders of pregnancy with those in women without.

METHOD

This study included participants from the California Teachers Study (N=58,718) with a history of pregnancy and data from 1995 through 2020. Incidence of cardiovascular disease-related emergency department visits and hospitalizations based on linkages with hospital records were modeled using multivariable negative binomial regression. Data were analyzed in 2022.

RESULTS

A total of 5% of the women had a history of hypertensive disorders of pregnancy (5.4%, 95% CI=5.2%, 5.6). A total of 31% of women had 1 or more cardiovascular disease-related emergency department visits (30.9%), and 30.1% had 1 or more hospitalizations. The incidence of cardiovascular disease-related emergency department visits (adjusted incident rate ratio=8.96, p<0.001) and hospitalizations (adjusted incident rate ratio=8.88, p<0.001) were significantly higher for women with hypertensive disorders of pregnancy than for those without, adjusting for other related characteristics of the women.

CONCLUSIONS

History of hypertensive disorders of pregnancy is associated with higher cardiovascular disease-related emergency department visits and hospitalizations. These findings underscore the potential burden on women and the healthcare system of managing complications associated with hypertensive disorders of pregnancy. Evaluating and managing cardiovascular disease risk factors in women with a history of hypertensive disorders of pregnancy is necessary to avoid cardiovascular disease-related emergency department visits and hospitalizations in this group.

Cardiopulmonary Arrest During Pregnancy: A Review Article

Massive pulmonary embolism (PE) is an uncommon but severe complication of pregnancy or during the first few weeks after giving birth. Our intention was to thoroughly analyze the information available to its management methods. Significant bleeding of mother survival and early deliveries in fetal survivals were having hemorrhage and were having key outcomes. We found 127 severe PE cases that have had at least one form of treatment (at least 83% big; 23% with cardiac arrest). The 83 women who received thrombolysis had a 94% (95%) survival rate. Cardiac arrest in pregnancy is uncommon, although maintaining current competency can be challenging. While maternal mortality rates have decreased globally over the past 25 years, they have increased in the United States. The intricacy of the maternal mortality issue is a result of a number of clinical and socioeconomic problems such as unequal healthcare access, racial and ethnic disparities, maternal comorbidities, and bias in epidemiologic ascertainment. The importance of doctors being prepared to react to a potential maternal cardiac arrest in any situation where they are providing treatment for pregnant women is highlighted by the rise in maternal mortality. For the treatment of maternal cardiac arrest, an interdisciplinary team with expertise in both the maternal resuscitation procedure and the physiological changes that take place during pregnancy is necessary. Additionally offered are basic and advanced cardiac life support protocols. Techniques to remove obstacles like aortocaval compression that could impair the effectiveness of resuscitation should be used.

Association Between Periviable Delivery and New Onset of or Exacerbation of Existing Mental Health Disorders

OBJECTIVE

To evaluate whether there is an association between periviable delivery and new onset of or exacerbation of existing mental health disorders within 12 months postpartum.

METHODS

We conducted a retrospective cohort study of individuals with liveborn singleton neonates delivered at 22 or more weeks of gestation from 2008 to 2017 in the MarketScan Commercial Research Database. The exposure was periviable delivery , defined as delivery from 22 0/7 through 25 6/7 weeks of gestation. The primary outcome was a mental health morbidity composite of one or more of the following: emergency department encounter associated with depression, anxiety, psychosis, posttraumatic stress disorder, adjustment disorder, self-harm, or suicide; new psychotropic medication prescription; new behavioral therapy visit; and inpatient psychiatry admission in the 12 months postdelivery. Secondary outcomes included components of the primary composite. Those with and without periviable delivery were compared using multivariable logistic regression adjusted for clinically relevant covariates, with results reported as adjusted incident rate ratios (aIRRs). Effect modification by history of mental health diagnoses was assessed. Incidence of the primary outcome by 90-day intervals postdelivery was assessed.

RESULTS

Of 2,300,244 included deliveries, 16,275 (0.7%) were periviable. Individuals with periviable delivery were more likely to have a chronic health condition, to have undergone cesarean delivery, and to have experienced severe maternal morbidity. Periviable delivery was associated with a modestly increased risk of the primary composite outcome, occurring in 13.8% of individuals with periviable delivery and 11.0% of individuals without periviable delivery (aIRR 1.18, 95% CI 1.12-1.24). The highest-risk period for the composite primary outcome was the first 90 days in those with periviable delivery compared with those without periviable delivery (51.6% vs 42.4%; incident rate ratio 1.56, 95% CI 1.47-1.66).

CONCLUSION

Periviable delivery was associated with a modestly increased risk of mental health morbidity in the 12 months postpartum.

Prevalence of a History of Metabolic or Hypertensive Pregnancy Disorder in Patients With Myocardial Infarction and Non-obstructive Coronary Arteries: An Observational Cohort Study

Introduction

Myocardial infarction with non-obstructive coronary arteries (MINOCA) predominantly affects younger females. Women with a history of gestational hypertension (GH), preeclampsia (PE), and gestational diabetes mellitus (GDM) are subjected to an elevated lifetime risk of cardiovascular disease. However, data on the potential association between these obstetric complications and MINOCA is lacking. Therefore, the current study aimed to provide insight in the prevalence of metabolic and hypertensive pregnancy disorders (MHPD) in MINOCA patients and their clinical characteristics.

Methods

In this observational cohort study conducted at the Zuyderland Medical Center and Maastricht University Medical Center in the Netherlands, patients were enrolled if they were identified as having MINOCA. Data on individual patient characteristics, laboratory results, electrocardiography as well as (non-)invasive imaging procedures were derived from the electronic health record system. Patients were asked to complete a questionnaire about prior MHPD including GDM, GH, and PE. Patients were grouped into those with MHPD and those with prior uncomplicated normotensive pregnancy (or pregnancies; NP).

Results

After excluding patients without 1-year follow-up (n = 53), 86 female MINOCA patients remained eligible for analysis. Of the total female population, 25 (29.1%) patients had MHPD, including GH (n = 19; 22.1%), PE (n = 4; 4.7%), and GDM (n = 7; 8.1%). The MHPD patients showed higher rates of chronic hypertension (84.0 vs. 55.7%; p = 0.013), hypercholesterolemia (64.0 vs. 34.4%; p = 0.012), a family history of CVD (84.0 vs. 45.9%; p = 0.001), gout or rheumatic arthritis (16.0 vs. 1.6%; p = 0.024), and were more often non-smokers (45.8 vs. 78.3%; p = 0.004), compared to the NP patients. Moreover, MHPD patients were more likely to use cardiovascular medications at baseline. A trend toward no specific cause found for the MINOCA event was observed in MHPD patients compared to the NP group (64.0 vs. 42.6%, p = 0.072).

Conclusion

A history of metabolic and hypertensive pregnancy disorders occurred in one-third of female MINOCA patients. In these patients, conventional cardiovascular risk factors were more prevalent compared to NP patients. In most MHPD patients, the specific cause for MINOCA remained unclear.

Preeclampsia Predicts Risk of Hospitalization for Heart Failure With Preserved Ejection Fraction

BACKGROUND

Preeclampsia is associated with increased risk of future heart failure (HF), but the relationship between preeclampsia and HF subtypes are not well-established.

OBJECTIVES

The objective of this analysis was to identify the risk of HF with preserved ejection fraction (HFpEF) following a delivery complicated by preeclampsia/eclampsia.

METHODS

A retrospective cohort study using the New York and Florida state Healthcare Cost and Utilization Project State Inpatient Databases identified delivery hospitalizations between 2006 and 2014 for women with and without preeclampsia/eclampsia. The authors identified women admitted for HF after discharge from index delivery hospitalization until September 30, 2015, using International Classification of Diseases-9th Revision-Clinical Modification diagnosis codes. Patients were followed from discharge to the first instance of primary outcome (HFpEF hospitalization), death, or end of study period. Secondary outcomes included hospitalization for any HF and HF with reduced ejection fraction, separately. The association between preeclampsia/eclampsia and HFpEF was analyzed using Cox proportional hazards models.

RESULTS

There were 2,532,515 women included in the study: 2,404,486 without and 128,029 with preeclampsia/eclampsia. HFpEF hospitalization was significantly more likely among women with preeclampsia/eclampsia, after adjusting for baseline hypertension and other covariates (aHR: 2.09; 95% CI: 1.80-2.44). Median time to onset of HFpEF was 32.2 months (interquartile range: 0.3-65.0 months), and median age at HFpEF onset was 34.0 years (interquartile range: 29.0-39.0 years). Both traditional (hypertension, diabetes mellitus) and sociodemographic (Black race, rurality, low income) risk factors were also associated with HFpEF and secondary outcomes.

CONCLUSIONS

Preeclampsia/eclampsia is an independent risk factor for future hospitalizations for HFpEF.

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review

Importance

A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs.

Observations

A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians.

Conclusions and Relevance

These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.

Peripartum considerations for women with cardiac disease

PURPOSE OF REVIEW

The aim of this review of cardiac disease in pregnancy is to delineate current best practices and highlight emerging themes in the literature.

RECENT FINDINGS

Cardiovascular disease is the leading cause of death among pregnant women in the United States. Many clinicians and institutions have developed care pathways to approach care in these high-risk patients including highly coordinated multidisciplinary teams. The diagnosis of pulmonary hypertension is the greatest risk factor for an adverse event in pregnant women. Vaginal delivery, with good neuraxial anesthesia, is usually the preferred mode of delivery in women with cardiac disease, although the rate of cesarean delivery is higher among women with heart disease.

SUMMARY

The leading cause of morbidity and mortality in pregnant women is cardiac disease. Preconception counseling is useful for optimizing patients for pregnancy and setting appropriate expectations about care and outcomes. Ensuring that women are cared for in centers with appropriate multidisciplinary resources is key for improving outcomes for cardio-obstetric patients.