Adverse Pregnancy Outcomes and ASCVD in Postmenopausal Women

Quick Takes

  • Adverse pregnancy outcomes occurred in about one third of women surveyed in the Women’s Health Initiative.
  • Adverse pregnancy outcomes were associated with long-term increased risk of CVD in postmenopausal women.
  • Hypertensive disorders of pregnancy and low birth weight were associated with CVD independent of traditional cardiac risk factors and other adverse pregnancy outcomes.

Study Questions:

Are adverse pregnancy outcomes (APOs) associated with increased risk of atherosclerotic cardiovascular disease (ASCVD) independent of traditional risk factors?


Postmenopausal women from the Women’s Health Initiative were contacted by survey to determine self-reported APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight [<2.49 kg]), high birth weight (>4.08 kg), and preterm delivery by 3 weeks or more. The association with ASCVD (myocardial infarction, stroke, peripheral artery disease, or coronary revascularization) was analyzed and adjusted for traditional ASCVD risk factors.


Of the 48,113 women who responded to the survey, the median age was 60 years. One or more APOs were reported in 13,482 (28.8%) respondents. ASCVD was more frequent in women with a history of APO (1,028 of 13,482 [7.6%] vs. 1,758 of 30,522 [5.8%]). After adjustment for traditional CVD risk factors (hypertension, hyperlipidemia, diabetes, smoking), four APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and preterm delivery) remained significantly associated with ASCVD. When analyzing all APOs together, hypertensive disorders of pregnancy and low birth weight remained independently associated with ASCVD. Adjustment for parity, body mass index, and socioeconomic factors did not substantially change the findings.


Approximately one third of women had at least one APO. Hypertensive disorders of pregnancy and low birth weight were independently associated with ASCVD in postmenopausal women.


This study adds to the growing body of literature showing the importance of taking an obstetric history to inform CVD risk assessment. In this large, multiethnic cohort of postmenopausal women, APOs (gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and preterm delivery) were significantly associated with ASCVD, even when adjusted for traditional risk factors. Currently, the American College of Cardiology/American Heart Association cholesterol management and primary prevention guidelines include pre-eclampsia and preterm delivery as “risk-enhancers,” and this study adds support for this recommendation. Prior studies that have added adverse pregnancy outcomes to standard ASCVD risk calculators showed only modest improvement in risk discrimination. Many women with pregnancy-associated disorders subsequently develop traditional risk factors and much of the risk in traditional calculators is driven by age. Therefore, younger women and/or those with family history of ASCVD may be the most likely to benefit from early identification and risk modification.

Further research to understand the microvascular and endothelial dysfunction of the placenta (associated with pre-eclampsia, low birth weight, and preterm birth) will help us understand the biological reasons for the increased risk of ASCVD. Since the majority of women have had at least one pregnancy, identifying women with prior pregnancy-related conditions (hypertension/pre-eclampsia, gestational diabetes, low birth weight, preterm delivery) may improve long-term CV outcomes for women.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Homozygous Familial Hypercholesterolemia, Interventions and Vascular Medicine, Hypertension

Keywords: Atherosclerosis, Cardiovascular Diseases, Diabetes, Gestational, Dyslipidemias, Hypercholesterolemia, Hypertension, Pregnancy-Induced, Infant, Low Birth Weight, Infant, Newborn, Myocardial Infarction, Myocardial Revascularization, Peripheral Arterial Disease, Postmenopause, Pre-Eclampsia, Pregnancy, Premature Birth, Primary Prevention, Risk Assessment, Risk Factors, Stroke, Vascular Diseases

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