Robust evidence demonstrates that women who experience gestational hypertension, gestational diabetes, preterm delivery, intrauterine growth restriction or pregnancy loss are more likely to experience cardiovascular events later in life. Yet the American Heart Association reports that too little attention is paid to women’s peripartum history when assessing their risk of cardiovascular disease (CVD).
Julie Damp, M.D., a cardiologist and specialist in cardiac disease in pregnancy at Vanderbilt University Medical Center, is a champion of learning from the “stress test” that pregnancy constitutes. “Gestational cardiology is still an emerging field,” Damp said. “We are learning that pregnancy gives us a window of opportunity to see into a woman’s future cardiovascular health.”
“Gestational cardiology is still an emerging field. We are learning that pregnancy gives us a window of opportunity to see into a woman’s future cardiovascular health.”
Since pregnancy is a condition of the relatively young, and CVD is more commonly a condition of older age, this issue can easily fall between the cracks. Damp urges cardiologists to ask female patients about their experiences during pregnancy, even though it may have been decades ago. A woman deemed intermediate risk may be escalated to high risk if she had pre-eclampsia, for example.
“One of the more common red flags is gestational hypertension,” Damp said. Having this condition during pregnancy predisposes the patient to chronic hypertension, stroke, heart disease (including heart failure) and end-stage renal disease. Gestational diabetes is also highly associated with an elevated risk of CVD disease and renal dysfunction later in life.
The research to date raises the question of whether CVDs seen through the pregnancy window are pre-existing conditions unmasked, or whether pregnancy triggers their onset. Damp says there is compelling evidence suggesting common underlying mechanisms. “There has been a lot of work in the last five years or so, for example, insinuating pre-eclampsia is a maladaptation of the vascular system in pregnancy.”
As another example, elevated ratios of sFlt1 (an antiangiogenic factor) to placental growth factor (a proangiogenic factor) have been described in multiple complications of pregnancy. In an analysis of the multicenter Investigations of Pregnancy Associated Cardiomyopathy study, Damp and colleagues reported that women with peripartum cardiomyopathy with elevated levels of sFlt1 had worse outcomes. “This is part of the emerging evidence that complications of pregnancy have an underlying vascular placental etiology, at least in part,” Damp said.
Other ongoing work Damp is pursuing includes a study of the risks associated with peripartum cardiomyopathy in subsequent pregnancies. “We know from clinical observation that if the patient’s ejection fraction doesn’t recover to normal, they have worse outcomes in a subsequent pregnancy,” she said.
Damp hopes new research will establish gradations of risk. “If the patient’s ejection fraction is only mildly abnormal, maybe the risk is not nearly as bad. Or, if we put the patient on medical therapy during the second pregnancy, perhaps they will do better.”
Vanderbilt is also participating in a COVID-19 pregnancy registry (part of the HOPE trial) to see how infection impacts pregnancy, with strong implications for the mother’s cardiovascular health.