Women who experienced hypertensive disorders of pregnancy (HDPs) but did not develop chronic hypertension may have a greater risk of premature mortality, specifically cardiovascular disease-related deaths, according to a study published March 8 in the Journal of the American College of Cardiology (JACC).

Yi-Xin Wang, MD, et al., looked at 88,395 ever pregnant female nurses 25-42 years old who participated in the Nurses' Health Study II, focusing on gestational hypertension and preeclampsia. Using questionnaires from 1989-2017, the nurses' health study collected information on reproductive characteristics and lifestyle and health-related conditions over three decades. The authors classified women as the following: no hypertensive disorders of pregnancy and chronic hypertension, hypertensive disorders of pregnancy only, chronic hypertension only or both hypertensive disorders of pregnancy and subsequent chronic hypertension.

Results of the study showed 12,405 women, or 14%, experienced hypertensive disorders of pregnancy in at least one of their pregnancies. Compared to women without hypertensive disorders of pregnancy, women who experienced gestational hypertension and/or preeclampsia had a greater baseline BMI, gestational diabetes, parental history of diabetes and MI/stroke and chronic hypertension. During 28 years of follow-up, there were 2,387 premature deaths, including 212 cardiovascular disease deaths. A history of gestational hypertension or preeclampsia was associated with a 42% increase in premature mortality. This association remained significant after adjusting for confounders as well as for post-pregnancy dietary, lifestyle and reproductive characteristics over time.

In addition, the authors found that women with a history of hypertensive disorders of pregnancy had over a twofold higher risk of premature cardiovascular disease mortality. When authors examined the subsequent development of chronic hypertension, they found an elevated risk of all-cause premature cardiovascular disease mortality in women with hypertensive disorders of pregnancy only, chronic hypertension only and both hypertensive disorders of pregnancy and subsequent chronic hypertension.

"Our results suggest that hypertensive disorders of pregnancy, either gestational hypertension or preeclampsia, was associated with a greater risk of premature mortality, especially cardiovascular disease-related deaths, even in the absence of chronic hypertension," said Jorge E. Chavarro, MD, ScD, corresponding author of the study. "Our results highlight the need for clinicians to screen for the history of hypertensive disorders of pregnancy when evaluating cardiovascular disease morbidity and mortality risk of their patients."

"The authors should be applauded on raising a biologic plausibility of hypertensive disorders of pregnancy's independent association with premature all-cause mortality," said Garima Sharma, MD, FACC, et al., in an editorial comment. "Contemporary management of women with hypertensive disorders of pregnancy will need better risk assessment tools informed by precision medicine to appropriately identify those women who are at greatest risk of premature cardiovascular disease and to develop algorithms for early intervention in order to change the trajectory of these women."

While this paper adds to the growing evidence that health conditions pregnant women experience can influence their health later in life, the effect of already having cardiovascular disease while pregnant is also a huge health concern. A separate study in JACC focused on the impact of maternal obesity on pregnancy complications in women with cardiovascular disease. Authors of that paper found women with cardiovascular disease and obesity had higher rates of cardiac complications during pregnancy compared to women with normal weight.

"Pregnant women with heart disease and obesity should be educated about these risks, and health care providers should ensure that dietary advice, weight gain recommendations, and that obesity and other comorbidities are addressed as part of routine care," said Candice Silversides, MD, corresponding author of the study. "Postpartum surveillance is important in pregnant women with obesity because of the increased risk of complications during this time period."

In a related editorial comment, Sharma, Roger S. Blumenthal, MD, FACC, and Athena Poppas, MD, FACC, explain, "as the obesity epidemic continues to grow and public health interventions promoting lifestyle changes for obesity management remain a major challenge, maternal obesity may prove to be the 'Achilles' heel' of sustainable national efforts to reduce maternal mortality and improve health equity. This is a call to action."

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Vascular Medicine, Diet, Hypertension

Keywords: Pregnancy, Hypertension, Pregnancy-Induced, Diabetes, Gestational, Mortality, Premature, Pre-Eclampsia, Cardiovascular Diseases, Maternal Mortality, Pregnant Women, Public Health, Diet, Obesity, Heart Diseases, Postpartum Period, Morbidity, Stroke, Risk Assessment, Health Personnel

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