Cardiovascular Risk Screening in Women with Pregnancy Complications: The Need for Integrative Strategies

Cardiovascular disease (CVD) is the leading cause of death in women in the United States, accounting for one in five deaths.¹ Despite advances in the understanding of sex-specific differences in the etiology of the disease, the incidence of CVD-related mortality in women continues to rise. This trend is largely attributed to the surge in acute myocardial infarctions among younger women,² as a result of the increasing prevalence of traditional risk factors (e.g., obesity, hypertension, and diabetes). In addition, female-predominant and female-specific factors, including reproductive history, pregnancy complications, autoimmune disorders, and depression, are more prevalent in younger women and have been found to contribute to the long-term risk of CVD.^3–5

In recent years, the importance of nontraditional risk factors to the long-term cardiovascular health of women has been recognized by professional societies. In 2018, the American Heart Association and the American College of Obstetricians and Gynecologists (ACOG) released a joint statement, including recommendations for health care professionals to document obstetrical and gynecological history and for continual follow-up beyond the postpartum period in women with a history of preeclampsia, gestational hypertension, gestational diabetes, and preterm birth.⁶ However, more recent evidence supports the need to include a broad range of pregnancy complications, including pregnancy loss, intrauterine growth restriction, and placental abruption as part of postpartum cardiovascular screening in women.⁷ Whether or not pregnancy complications contribute to the development of CVD or unmask an underlying predisposition to CVD is unclear.^8,9 Despite this uncertainty, their ability to provide a window into the future cardiovascular health of women is indisputable.

In this issue of The Journal of Women's Health, Seely et al. summarize the proceedings of The Health after Preeclampsia Patient and Provider Engagement Network (HAPPEN) workshop, whose mandate was to assemble key stakeholders, including researchers, clinicians, patients, and partners of advocacy groups, to discuss the challenges and opportunities for CVD risk reduction in women after a pregnancy complicated by preeclampsia.¹⁰ Focus groups with patients identified the need for increased awareness among clinicians and patients regarding the long-term risk of CVD associated with preeclampsia and the importance of a holistic approach to postpartum care. The recommendations from this meeting included educating clinicians and patients more broadly, extending the follow-up of these women beyond the immediate postpartum period, and integrating novel approaches to postpartum care, including online platforms or mobile-based interventions and programs to reduce patient burden and increase patient engagement.

The short- and long-term benefits of prenatal care for the health of mothers and fetuses is well established.^11,12 Less attention has been given to the period immediately after delivery. Current guidelines from the ACOG for postpartum care in women include a follow-up visit with a health care professional at 6–8 weeks postpartum. However, 40% of women do not attend their postpartum visit.¹³ For women with a history of pregnancy complications, this represents a missed opportunity for cardiovascular prevention. The first step toward ensuring continuity of care beyond the immediate postpartum period begins with the education of health care providers and patients regarding the long-term risk of CVD. Strategies beyond the usual dissemination from professional societies are needed to enable widespread outreach to key stakeholders. Initiatives such as the HAPPEN network should be leveraged since they have the potential to target patients and practitioners more broadly. In addition, the engagement of public health officials could facilitate coherent and effective public health messaging for CVD prevention in this population.

Beyond education is the need for established referral programs that occur in-hospital before discharge. This includes referrals to specialized care centers or primary care physicians for CVD prevention screening. However, engagement in CVD prevention programs varies by patient demographics, clinical, and sociobehavioral characteristics.¹⁴ Therefore, the effectiveness of these programs will largely depend on their ability to address the physical, social, and emotional well-being of women and the current barriers for women to access these programs. Strategies involving patient support groups, screening for postpartum depression and post-traumatic stress disorder, and web- and mobile-based applications are among the recommendations proposed by Seely et al. to increase adherence. The success of routine CVD screening programs for women with a history of pregnancy complications relies on stakeholder engagement and innovative strategies tailored to the individual needs of patients.

The preconception period provides an upstream opportunity for cardiovascular risk prevention. Pregnancy complications and CVD share common risk factors, including but not limited to obesity, hypertension, diabetes, smoking, poor diet, and alcohol intake,¹⁵ which are amendable to behavioral interventions. Targeted screening for risk factors in the preconception period has the potential to reduce the incidence of pregnancy complications and subsequent CVD by intervening early in the life course of the disease. This, however, requires engagement from primary care physicians and gynecologists, who perform routine examinations in women of reproductive age, and effective public health messaging. The incorporation of preconception screening programs as part of an integrative strategy for CVD prevention has important implications for the short- and long-term health of women.

The sustainability of cardiovascular prevention strategies for women of reproductive age necessitates policy-level changes. Many insurance providers do not currently provide coverage for postpartum care beyond 12 weeks. Continual follow-up in women with a history of pregnancy complications is not possible without amendments to reimbursement policies by public and private insurance providers and recommendations by professional societies for the schedule of routine follow-ups beyond the postpartum period. The impetus for these system-level changes will require the concerted efforts from patient advocacy groups, professional societies, and public health practitioners to endorse the importance of CVD prevention strategies as part of routine postpartum care.

The gap in the long-term care of women with a history of pregnancy complications highlights the urgent need for comprehensive strategies to improve the cardiovascular health of women. A paradigm shift in the approach to the delivery of postpartum care is necessary to ensure that these women are provided with continual follow-up and essential resources. The preconception and postpartum periods provide a window of opportunity to screen and implement primary prevention strategies that are paramount to CVD risk reduction. The dialogue between key stakeholders needs to shift to sustainable strategies that will shift the trend in CVD-related morbidity and mortality in women with a history of pregnancy complications.

Funding Information

The study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.