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      Maternal Cardiovascular Disease 3 Decades After Preterm Birth : Longitudinal Cohort Study of Pregnancy Vascular Disorders

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          Abstract

          Women who deliver preterm are at risk of cardiovascular disease, but the reason for the association is unclear. We determined whether vascular disorders during pregnancy explain the association between preterm delivery and future maternal cardiovascular disease. We analyzed a longitudinal cohort of 1 199 364 pregnant women with 19 186 983 person-years of follow-up in Quebec between 1989 and 2017. We calculated incidence rates of myocardial infarction, ischemic stroke, and other cardiovascular hospitalizations. We used multivariable Cox regression to estimate adjusted hazard ratios and 95% CIs for the association of very and moderate preterm delivery with maternal cardiovascular hospitalization. We determined the proportion of the association that was due to preeclampsia, acute cardiac events at delivery, antepartum/postpartum hemorrhage, and heart defects. The incidence of maternal cardiovascular hospitalization was greater for very (43.7 per 10 000 person-years) and moderate (39.4 per 10 000) preterm delivery compared with term delivery (26.2 per 10 000). Very preterm delivery was associated with 1.67× the risk of cardiovascular hospitalization (95% CI, 1.56–1.79), and moderate preterm delivery was associated with 1.51× the risk (95% CI, 1.46–1.56). Vascular disorders during pregnancy explained 26.2% of the association of very preterm delivery and 24.0% of the association of moderate preterm delivery, with cardiovascular hospitalization. Preeclampsia was the largest contributor to these proportions. We conclude that vascular disorders during pregnancy, especially preeclampsia, explain up to a quarter of the association between preterm delivery and future maternal cardiovascular hospitalization.

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          Acute myocardial infarction in pregnancy: a United States population-based study.

          Ellen H. James, Nicholas E. Myers, Patricia Jamison … (2006)
          The purpose of this study was to determine the incidence, mortality, and risk factors for pregnancy-related acute myocardial infarction in the United States. The Nationwide Inpatient Sample for the years 2000 to 2002 was queried for all pregnancy-related discharges. A total of 859 discharges included a diagnosis of acute myocardial infarction, for a rate of 6.2 (95% confidence interval [CI] 3.0 to 9.4) per 100,000 deliveries. Among these, there were 44 deaths, for a case fatality rate of 5.1%. The odds of acute myocardial infarction were 30-fold higher for women aged 40 years and older than for women <20 years of age. Single independent variables that were statistically and clinically significant, including age, race, and certain medical conditions and obstetric complications, were entered into a multivariable logistic regression model. Hypertension (odds ratio [OR] 21.7, 95% CI 6.8 to 69.1), thrombophilia (OR 25.6, 95% CI 9.2 to 71.2), diabetes mellitus (OR 3.6, 95% CI 1.5 to 8.3), smoking (OR 8.4, 95% CI 5.4 to 12.9), transfusion (OR 5.1, 95% CI 2.0 to 12.7), postpartum infection (OR 3.2, 95% CI 1.2 to 10.1), and age 30 years and older remained as significant risk factors for pregnancy-related acute myocardial infarction. Black race was eliminated as a risk factor in the multivariable analysis, which suggests that the increased incidence among black women is explained by an increased prevalence of other cardiovascular risk factors. Although acute myocardial infarction is a rare event in women of reproductive age, pregnancy increases the risk 3- to 4-fold. Certain medical conditions and complications of pregnancy increase the risk further and are potentially modifiable risk factors.
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            Recurrence of pre‐eclampsia and the risk of future hypertension and cardiovascular disease: a systematic review and meta‐analysis

            L Brouwers, AJ van der Meiden‐van Roest, C Savelkoul … (2018)
            Background Women with a history of hypertensive disorders, including pre‐eclampsia, during pregnancy have a two‐ to‐five‐fold increased risk of cardiovascular disease (CVD). In 15% of women, pre‐eclampsia recurs in the following pregnancy. Objectives To evaluate all evidence on the future risk of developing hypertension and CVD after multiple pregnancies complicated by pre‐eclampsia compared with pre‐eclampsia in a single pregnancy followed by normal subsequent pregnancy. Search strategy Embase and Medline were searched until June 2017. Selection criteria All relevant studies on the risk of developing hypertension, atherosclerosis, ischaemic heart disease, cerebrovascular accident (CVA), thromboembolism, heart failure or overall hospitalisation and mortality due to CVD after having had recurrent pre‐eclampsia. Data collection and analysis Twenty‐two studies were included in the review. When possible, we calculated pooled risk ratios (RR) with 95% CI through random‐effect analysis. Main results Recurrent pre‐eclampsia was consistently associated with an increased pooled risk ratio of hypertension (RR 2.3; 95% CI 1.9–2.9), ischaemic heart disease (RR 2.4; 95% CI 2.2–2.7), heart failure (RR 2.9; 95% CI 2.3–3.7), CVA (RR 1.7; 95% CI 1.2–2.6) and hospitalisation due to CVD (RR 1.6; 95% CI 1.3–1.9) when compared with women with subsequent uncomplicated pregnancies. Other studies on thromboembolism, atherosclerosis and cardiovascular mortality found a positive effect, but data could not be pooled. Conclusions This systematic review and meta‐analysis support consistent higher risk for future development of hypertension and CVD in women with recurring pre‐eclampsia as opposed to women with a single episode of pre‐eclampsia. Tweetable abstract The risk of future cardiovascular disease increases when women have recurrence of pre‐eclampsia compared with a single episode.
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              Cardiovascular mortality after pre-eclampsia in one child mothers: prospective, population based cohort study

              Rolv Skjærven, Allen Wilcox, Kari Klungsoyr … (2012)
              Objective To assess the association of pre-eclampsia with later cardiovascular death in mothers according to their lifetime number of pregnancies, and particularly after only one child. Design Prospective, population based cohort study. Setting Medical Birth Registry of Norway. Participants We followed 836 147 Norwegian women with a first singleton birth between 1967 and 2002 for cardiovascular mortality through linkage to the national Cause of Death Registry. About 23 000 women died by 2009, of whom 3891 died from cardiovascular causes. Associations between pre-eclampsia and cardiovascular death were assessed by hazard ratios, estimated by Cox regression analyses. Hazard ratios were adjusted for maternal education (three categories), maternal age at first birth, and year of first birth Results The rate of cardiovascular mortality among women with preterm pre-eclampsia was 9.2% after having only one child, falling to 1.1% for those with two or more children. With term pre-eclampsia, the rates were 2.8% and 1.1%, respectively. Women with pre-eclampsia in their first pregnancy had higher rates of cardiovascular death than those who did not have the condition at first birth (adjusted hazard ratio 1.6 (95% confidence interval 1.4 to 2.0) after term pre-eclampsia; 3.7 (2.7 to 4.8) after preterm pre-eclampsia). Among women with only one lifetime pregnancy, the increase in risk of cardiovascular death was higher than for those with two or more children (3.4 (2.6 to 4.6) after term pre-eclampsia; 9.4 (6.5 to 13.7) after preterm pre-eclampsia). The risk of cardiovascular death was only moderately elevated among women with pre-eclamptic first pregnancies who went on to have additional children (1.5 (1.2 to 2.0) after term pre-eclampsia; 2.4 (1.5 to 3.9) after preterm pre-eclampsia). There was little evidence of additional risk after recurrent pre-eclampsia. All cause mortality for women with two or more lifetime births, who had pre-eclampsia in first pregnancy, was not elevated, even with preterm pre-eclampsia in first pregnancy (1.1 (0.87 to 1.14)). Conclusions Cardiovascular death in women with pre-eclampsia in their first pregnancy is concentrated mainly in women with no additional births. This association might be due to health problems that discourage or prevent further pregnancies rather than to pre-eclampsia itself. As a screening criterion for cardiovascular disease risk, pre-eclampsia is a strong predictor primarily among women with only one child—particularly with preterm pre-eclampsia.
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                Author and article information

                Journal
                Title: Hypertension
                Abbreviated Title: Hypertension
                Publisher: Ovid Technologies (Wolters Kluwer Health)
                ISSN (Print): 0194-911X
                ISSN (Electronic): 1524-4563
                Publication date Created: March 2020
                Publication date (Print): March 2020
                Volume: 75
                Issue: 3
                Pages: 788-795
                Affiliations
                [1 ]From the University of Montreal Hospital Research Center, Montreal, Canada (N.A., B.J.P., S.H., J.H.-P.)
                [2 ]Institut national de santé publique du Québec, Montreal, Canada (N.A., S.H., J.H.-P., G.P.)
                [3 ]Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada (N.A., G.P.)
                [4 ]Department of Social and Preventive Medicine, School of Public Health (N.A., M.E.S.), University of Montreal, Montreal, Canada
                [5 ]Division of Cardiology, Department of Medicine, University of Montreal Hospital Center, Montreal, Canada (B.J.P.).
                [6 ]Faculty of Pharmacy (M.E.S.), University of Montreal, Montreal, Canada
                Article
                DOI: 10.1161/HYPERTENSIONAHA.119.14221
                PubMed ID: 32008431
                SO-VID: b287b204-88b3-4dc7-a6c9-160ed141a31e
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