Adverse Pregnancy Outcomes and Predicted 30-Year Risk of Maternal Cardiovascular Disease 2–7 Years After Delivery
Authors: Venkatesh Kartik K. , Khan Sadiya S. , Yee Lynn M. , Wu Jiqiang , McNeil Rebecca , Greenland Philip , Chung Judith H. , Levine Lisa D. , Simhan Hyagriv N. , Catov Janet , Scifres Christina , Reddy Uma M. , Pemberton Victoria L. , Saade George , Bairey Merz C. Noel , Grobman William A. ,   Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), and nuMoM2b–Heart Health Study (HHS) Investigators
Published: April 2024

OBJECTIVE:
To determine whether adverse pregnancy outcomes are associated with a higher predicted 30-year risk of atherosclerotic cardiovascular disease (CVD; ie, coronary artery disease or stroke).

METHODS:
This was a secondary analysis of the prospective Nulliparous Pregnancy Outcomes Study–Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. The exposures were adverse pregnancy outcomes during the first pregnancy (ie, gestational diabetes mellitus [GDM], hypertensive disorder of pregnancy, preterm birth, and small- and large-for-gestational-age [SGA, LGA] birth weight) modeled individually and secondarily as the cumulative number of adverse pregnancy outcomes (ie, none, one, two or more). The outcome was the 30-year risk of atherosclerotic CVD predicted with the Framingham Risk Score assessed at 2–7 years after delivery. Risk was measured both continuously in increments of 1% and categorically, with high predicted risk defined as a predicted risk of atherosclerotic CVD of 10% or more. Linear regression and modified Poisson models were adjusted for baseline covariates.

RESULTS:
Among 4,273 individuals who were assessed at a median of 3.1 years after delivery (interquartile range 2.5–3.7), the median predicted 30-year atherosclerotic CVD risk was 2.2% (interquartile range 1.4–3.4), and 1.8% had high predicted risk. Individuals with GDM (least mean square 5.93 vs 4.19, adjusted β=1.45, 95% CI, 1.14–1.75), hypertensive disorder of pregnancy (4.95 vs 4.22, adjusted β=0.49, 95% CI, 0.31–0.68), and preterm birth (4.81 vs 4.27, adjusted β=0.47, 95% CI, 0.24–0.70) were more likely to have a higher absolute risk of atherosclerotic CVD. Similarly, individuals with GDM (8.7% vs 1.4%, adjusted risk ratio [RR] 2.02, 95% CI, 1.14–3.59), hypertensive disorder of pregnancy (4.4% vs 1.4%, adjusted RR 1.91, 95% CI, 1.17–3.13), and preterm birth (5.0% vs 1.5%, adjusted RR 2.26, 95% CI, 1.30–3.93) were more likely to have a high predicted risk of atherosclerotic CVD. A greater number of adverse pregnancy outcomes within the first birth was associated with progressively greater risks, including per 1% atherosclerotic CVD risk (one adverse pregnancy outcome: 4.86 vs 4.09, adjusted β=0.59, 95% CI, 0.43–0.75; two or more adverse pregnancy outcomes: 5.51 vs 4.09, adjusted β=1.16, 95% CI, 0.82–1.50), and a high predicted risk of atherosclerotic CVD (one adverse pregnancy outcome: 3.8% vs 1.0%, adjusted RR 2.33, 95% CI, 1.40–3.88; two or more adverse pregnancy outcomes: 8.7 vs 1.0%, RR 3.43, 95% CI, 1.74–6.74). Small and large for gestational age were not consistently associated with a higher atherosclerotic CVD risk.

CONCLUSION:
Individuals who experienced adverse pregnancy outcomes in their first birth were more likely to have a higher predicted 30-year risk of CVD measured at 2–7 years after delivery. The magnitude of risk was higher with a greater number of adverse pregnancy outcomes experienced.