Physicians' knowledge of future vascular disease in women with preeclampsia

Healthcare providers' knowledge of cardiovascular disease risk after preeclampsia: A pilot of five healthcare facilities in Lusaka, Zambia

OBJECTIVE

To assess Healthcare providers (HCPs') knowledge of cardiovascular disease risk after preeclampsia across five healthcare facilities in Lusaka, Zambia.

STUDY DESIGN

A cross-sectional study was conducted at selected health facilities in Lusaka Zambia from August 5, 2023, to October 31, 2023. A self-administered questionnaire was distributed among obstetricians, general practitioners, registered nurse midwives, registered nurses, enrolled nurses, enrolled midwives, medical licentiates, and registered public health nurses. The knowledge scores were calculated for each participant, and Logistic regression was used to assess the predictors of high knowledge of cardiovascular disease risk after preeclampsia.

MAIN OUTCOME

The overall mean knowledge score of cardiovascular disease risk after preeclampsia was 4.7/7 (67.1 %). The majority correctly reported hypertension 101 (92.7 %), Ischemic heart disease 84 (77.1 %), Stroke 83 (76.2 %), and kidney disease 75(68.8 %) as future conditions associated with preeclampsia. Knowledge and practice had a significant but moderate negative correlation (r = -0.21, p = 0.037). Compared to obstetricians/general practitioners, registered nurse midwives (adjusted odds ratio [aOR] = 0.21, 95 % CI: 0.05-0.80, p = 0.023) and enrolled midwives/enrolled nurses/medical licentiates/registered public health nurses (aOR = 0.15, 95 % CI: 0.03-0.91, p = 0.039) were less likely to have high knowledge. Additionally, HCPs with 5-10 years (aOR = 7.15, 95 % CI: 1.99-25.72, p = 0.003) and more than 15 years of work experience (aOR = 3.21, 95 % CI: 1.03-9.99, p = 0.017) were more likely to have high knowledge than those with less than five years.

CONCLUSION

Most HCPs were knowledgeable about the future risk of cardiovascular diseases after preeclampsia. Nevertheless, positive behavioral change interventions may be required to address the disconnect between knowledge and practice.

Aortic dimensions in women with previous pre-eclampsia

BACKGROUND

Pre-eclampsia is a pregnancy related disorder associated with hypertension and vascular inflammation, factors that are also involved in the pathological pathway of aortic dilatation and aneurysm development. It is, however, unknown if younger women with previous pre-eclampsia have increased aortic dimensions. We tested the hypothesis that previous pre-eclampsia is associated with increased aortic dimensions in younger women.

METHODS

The study was a cross-sectional cohort study of women with previous pre-eclampsia, aged 40-55, from the PRECIOUS population matched by age and parity with women from the general population. Using contrast-enhanced CT, aortic diameters were measured in the aortic root, ascending aorta, descending aorta, at the level of the diaphragm, suprarenal aorta, and infrarenal aorta.

RESULTS

1355 women (684 with previous pre-eclampsia and 671 from the general population), with a mean (standard deviation) age of 46.9 (4.4) were included. The pre-eclampsia group had larger mean (standard deviation) aortic diameters (mm) in all measured segments from the ascending to the infrarenal aorta (ascending: 33.4 (4.0) vs. 31.4 (3.7), descending: 23.9 (2.1) vs. 23.3 (2.0), diaphragm: 20.8 (1.8) vs. 20.4 (1.8), suprarenal: 22.9 (1.9) vs. 22.0 (2.0), infrarenal: 19.3 (1.6) vs. 18.6 (1.7), p ​< ​0.001 for all, also after adjustment for age, height, parity, menopause, dyslipidemia, smoking and chronic hypertension. Guideline-defined ascending aortic aneurysms were found in 8 vs 2 women (p ​= ​0.12).

CONCLUSIONS

Women with previous pre-eclampsia have larger aortic dimensions compared with women from the general population. Pre-eclampsia was found to be an independent risk factor associated with a larger aortic diameter.

Does having a patient attend a postpartum vascular risk reduction clinic improve physician knowledge and management of preeclampsia as a cardiovascular risk factor?

Background

Preeclampsia is an independent risk factor for vascular diseases. The Postpartum Preeclampsia Clinic (PPPC) intervenes in the first year postpartum to address these risks. This study aims to characterize physicians' understanding and management of the cardiovascular risk associated with preeclampsia and whether this differs in physicians who had a patient attend the PPPC.

Methods

Family physicians, obstetricians, internists, obstetric internists, and cardiologists in Edmonton were anonymously surveyed. Results were analyzed using SPSS.

Results

Sixty-four surveys were returned, with physicians correctly identifying preeclampsia as a vascular risk factor 73% of the time. Physicians who had a patient attend the PPPC were more likely to counsel patients on their increased cardiovascular risk, although increased knowledge did not reach statistical significance.

Conclusion

Vascular risk reduction clinics may benefit the long-term management of patients with a history of preeclampsia by improving counseling by physicians, which may reduce the disproportionate vascular morbidity these patients face.

Update on Preeclampsia and Hypertensive Disorders of Pregnancy

There have been recent advances in the prevention, diagnosis, and management of hypertensive disorders of pregnancy which complicate approximately 16% of pregnancies in the United States. Initiation of low-dose aspirin by 16 weeks' gestation reduces preeclampsia in high-risk women. The Food and Drug Administration approved the use of the soluble fms-like tyrosine kinase 1/placental growth factor ratio for the short-term prediction of preeclampsia. Pregnancy outcomes are improved in women with chronic hypertension when antihypertensives are initiated at a threshold blood pressure of 140/90 mm Hg. Women with prior preeclampsia have increased cardiovascular disease risk and should receive risk reduction counseling.

Pre-eclampsia and future cardiovascular disease risk: Assessing British clinicians' knowledge and practice

OBJECTIVE

To explore UK-based clinicians' knowledge of long-term cardiovascular disease (CVD) risks after pre-eclampsia and capture current risk management practice.

STUDY DESIGN

A voluntary online survey was designed to explore clinicians' perception and management of CVD risks after pre-eclampsia. Distribution occurred May-July 2022 via social media and email. The survey assessed awareness of pre-eclampsia's association with future CVD, knowledge of published guidelines on CVD risk management after pre-eclampsia, and current practice of risk-reduction counselling. Results were analysed descriptively.

MAIN OUTCOME MEASURE

Clinician knowledge of postpartum cardiovascular risk and management following pre-eclampsia.

RESULTS

Of 240 respondents, 72 were midwives, 46 obstetricians, 8 cardiologists, and 114 general practitioners (GPs). Most clinicians knew that pre-eclampsia increases the risk of chronic hypertension (89 %) and stroke (75 %). Awareness was worse for heart failure (47 %) and peripheral vascular disease (55 %). Obstetricians provide CVD risk-reduction counselling to women with pre-eclampsia most frequently: 43 % always counsel and 27 % often counsel. Most other clinicians never counsel patients (midwives: 76 %, cardiologists: 75 %, GPs: 62 %). Most clinicians (84 %) were not aware of CVD risk management guidance after pre-eclampsia and 75 % of cardiologists and GPs never consider pre-eclampsia when assessing cardiovascular risk. Almost all clinicians (91 %) wished for greater education on the topic.

CONCLUSIONS

This study presents the first assessment of cardiovascular risk awareness after pre-eclampsia amongst UK-based clinicians. Although most knew pre-eclampsia increases CVD risk, patient counselling was limited. Targeted educational initiatives are needed to improve the knowledge-to-practice gap and reduce CVD prevalence after pre-eclampsia.

Longitudinal Management of Cardiovascular Risk Factors Among Postpartum Women

Background: Pregnancy-related cardiovascular (CV) conditions, including hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM), are associated with increased long-term CV risk. Methods: This retrospective cohort study defined the prevalence of HDP and GDM within a large, academic health system in the southeast United States between 2012 and 2015 and described health care utilization and routine CV screening up to 1-year following delivery among those with pregnancy-related CV conditions. Rates of follow-up visits and blood pressure, hemoglobin A1c (HbA1c), and lipid screening in the first postpartum year were compared by provider type and pregnancy-related CV condition. Results: Of the 6027 deliveries included, 20% were complicated by HDP and/or GDM. Rates of pre-pregnancy CV risk factors were high, with a significantly higher proportion of pre-pregnancy obesity among women with HDP than in normal pregnancies. Those with both HDP/GDM had the highest rates of follow-up by 1-year postpartum, yet only half of those with any pregnancy-related CV condition had any follow-up visit after 12 weeks. Although most (70%) of those with HDP had postpartum blood pressure screening, less than one-third of those with GDM had a repeat HbA1c by 12 months. Overall, postpartum lipid screening was rare (<20%). Conclusion: There is a high burden of pregnancy-related CV conditions in a large U.S. academic health system. Although overall rates of follow-up in the early postpartum period were high, gaps in longitudinal follow-up exist. Low rates of CV risk factor follow-up at 1 year indicate a missed opportunity for early CV prevention.

Early Mortality, Cardiovascular, and Renal Diseases in Women's Lives Following Hypertensive Disorders of Pregnancy: The Prospective Nationwide Study CONCEPTION

BACKGROUND

We aimed to evaluate the impact of hypertensive disorders of pregnancy occurrence, recurrence, onset time, and severity on mortality and on a wide range of cardiovascular outcomes in France.

METHODS AND RESULTS

CONCEPTION (Cohort of Cardiovascular Diseases in Pregnancy) is a French nationwide prospective cohort using data from the National Health Data System. We included all women in CONCEPTION with no history of a cardiovascular event who delivered in France for the first time between 2010 and 2018 (N=2 819 655). Hypertensive disorders of pregnancy and cardiovascular outcomes during the study follow-up were identified using algorithms combining International Classification of Diseases, Tenth Revision (ICD-10) coded diagnoses during hospitalization and purchases of medication between 2010 and 2021. We fitted Cox models with time-varying exposure to assess the associations of hypertensive disorders of pregnancy with mortality and cardiovascular events. Women with gestational hypertension had a 1.25- to 2-fold higher risk of stroke, acute coronary syndrome, peripheral arterial disease, pulmonary embolism, and chronic kidney disease, and a 2- to 4-fold higher risk of rhythm and conduction disorder and heart failure. Women with preeclampsia had a 1.35- to 2-fold higher risk of rhythm or conduction disorder and pulmonary embolism during follow-up; a 2- to 4-fold higher risk of stroke, acute coronary syndrome, and peripheral arterial disease; and a 7- to 9-fold higher risk of heart failure and chronic kidney disease. They were 1.8 times more likely to die and 4.4 times more likely to die of cardiovascular causes.

CONCLUSIONS

Hypertensive disorders of pregnancy drastically increase the risk of mortality, cardiovascular, and renal events early after pregnancy. Recurrent, severe, and early-onset preeclampsia further increases this risk.

Association between pregnancy-related complications and development of type 2 diabetes and hypertension in women: an umbrella review

BACKGROUND

Despite many systematic reviews and meta-analyses examining the associations of pregnancy complications with risk of type 2 diabetes mellitus (T2DM) and hypertension, previous umbrella reviews have only examined a single pregnancy complication. Here we have synthesised evidence from systematic reviews and meta-analyses on the associations of a wide range of pregnancy-related complications with risk of developing T2DM and hypertension.

METHODS

Medline, Embase and Cochrane Database of Systematic Reviews were searched from inception until 26 September 2022 for systematic reviews and meta-analysis examining the association between pregnancy complications and risk of T2DM and hypertension. Screening of articles, data extraction and quality appraisal (AMSTAR2) were conducted independently by two reviewers using Covidence software. Data were extracted for studies that examined the risk of T2DM and hypertension in pregnant women with the pregnancy complication compared to pregnant women without the pregnancy complication. Summary estimates of each review were presented using tables, forest plots and narrative synthesis and reported following Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines.

RESULTS

Ten systematic reviews were included. Two pregnancy complications were identified. Gestational diabetes mellitus (GDM): One review showed GDM was associated with a 10-fold higher risk of T2DM at least 1 year after pregnancy (relative risk (RR) 9.51 (95% confidence interval (CI) 7.14 to 12.67) and although the association differed by ethnicity (white: RR 16.28 (95% CI 15.01 to 17.66), non-white: RR 10.38 (95% CI 4.61 to 23.39), mixed: RR 8.31 (95% CI 5.44 to 12.69)), the between subgroups difference were not statistically significant at 5% significance level. Another review showed GDM was associated with higher mean blood pressure at least 3 months postpartum (mean difference in systolic blood pressure: 2.57 (95% CI 1.74 to 3.40) mmHg and mean difference in diastolic blood pressure: 1.89 (95% CI 1.32 to 2.46) mmHg). Hypertensive disorders of pregnancy (HDP): Three reviews showed women with a history of HDP were 3 to 6 times more likely to develop hypertension at least 6 weeks after pregnancy compared to women without HDP (meta-analysis with largest number of studies: odds ratio (OR) 4.33 (3.51 to 5.33)) and one review reported a higher rate of T2DM after HDP (hazard ratio (HR) 2.24 (1.95 to 2.58)) at least a year after pregnancy. One of the three reviews and five other reviews reported women with a history of preeclampsia were 3 to 7 times more likely to develop hypertension at least 6 weeks postpartum (meta-analysis with the largest number of studies: OR 3.90 (3.16 to 4.82) with one of these reviews reporting the association was greatest in women from Asia (Asia: OR 7.54 (95% CI 2.49 to 22.81), Europe: OR 2.19 (95% CI 0.30 to 16.02), North and South America: OR 3.32 (95% CI 1.26 to 8.74)).

CONCLUSIONS

GDM and HDP are associated with a greater risk of developing T2DM and hypertension. Common confounders adjusted for across the included studies in the reviews were maternal age, body mass index (BMI), socioeconomic status, smoking status, pre-pregnancy and current BMI, parity, family history of T2DM or cardiovascular disease, ethnicity, and time of delivery. Further research is needed to evaluate the value of embedding these pregnancy complications as part of assessment for future risk of T2DM and chronic hypertension.

Women's Knowledge of Future Cardiovascular Risk Associated With Complications of Pregnancy: A Systematic Review

Background

Several common pregnancy conditions significantly increase a woman's risk of future cardiovascular diseases (CVD). Patient education and interventions aimed at awareness and self-management of cardiovascular risk factors may help modify future cardiovascular risk. The aim of this systematic review was to examine education interventions for cardiovascular risk after pregnancy, clinical measures/scales, and knowledge outcomes in published qualitative and quantitative studies.

Methods

Five databases were searched (from inception to June 2023). Studies including interventions and validated and nonvalidated measures of awareness/knowledge of future cardiovascular risk among women after complications of pregnancy were considered. Quality was rated using the Mixed Methods Appraisal Tool. Results were analyzed using the Synthesis Without Meta-analysis reporting guideline. Characteristics of interventions were reported using the Template for Intervention Description and Replication. Fifteen studies were included; 3 were randomized controlled trials.

Results

In total, 1623 women had a recent or past diagnosis of hypertensive disorders of pregnancy, gestational diabetes mellitus, and/or premature birth. Of the 7 studies that used online surveys or questionnaires, 2 reported assessing psychometric properties of tools. Four studies used diverse educational interventions (pamphlets, information sheets, in-person group sessions, and an online platform with health coaching). Overall, women had a low level of knowledge about their future CVD risk. Interventions were effective in increasing this knowledge.

Conclusions

In conclusion, women have a low level of knowledge of risk of CVD after pregnancy complications. To increase this level of knowledge and self-management, this population has a strong need for psychometrically validated tailored education interventions.

Postpartum follow-up of women with preeclampsia: facilitators and barriers - A qualitative study

BACKGROUND

Pregnancy causes physiological changes to the maternal organ systems that can be regarded as a cardiometabolic stress test for women. Preeclampsia, a pregnancy complication characterized by new onset of hypertension in combination with proteinuria or end-organ dysfunction, affects approximately 2-8% of pregnancies. Adverse pregnancy outcomes, including preeclampsia, have been described as a failed stress test and have been consistently linked with increased risk of cardiovascular disease later in life. The postpartum period is therefore often regarded as a window of opportunity for cardiovascular disease prevention. However, we lack knowledge about how women with preeclampsia experience current postpartum care in the Norwegian health system. The aim of this qualitative study is to uncover women's perspectives and preferences regarding postpartum follow-up.

METHODS

Semi-structured telephone interviews were conducted with 17 women following a six-month lifestyle intervention study. Participants were 9-20 months postpartum, following a pregnancy complicated by preeclampsia. Data were analyzed using Malterud's systematic text condensation.

RESULTS

We identified five themes, each with 2-3 subthemes, that demonstrate how women with recent preeclampsia experience postpartum follow-up: (1) fear and uncertainty (a body out of balance and facing an uncertain future), (2) a conversation on lifestyle - not really that difficult (preeclampsia as a gateway, a respectful approach, and a desire for more constructive feedback), (3) when your own health is not a priority (a new everyday life, out of focus, and lack of support), (4) motivation for lifestyle changes (an eye opener, lack of intrinsic motivation, and a helping hand), and (5) lack of structured and organized follow-up (there should be a proper system, a one-sided follow-up care, and individual variation in follow-up care).

CONCLUSIONS

Findings from this study highlight the need for more systematic postpartum follow-up for women after a pregnancy complicated by preeclampsia. Further research is required to explore the potential use of standardized guidelines and routine invitations to postpartum care. Furthermore, exploring health care professionals' experiences is crucial to ensure their engagement in postpartum care after complicated pregnancies.

Assessing awareness of long-term health risks among women with a history of preeclampsia: a cross-sectional study

Pregnancy complications, such as hypertensive disorders, present a substantial global public health challenge, with significant long-term implications for maternal and offspring health. This cross-sectional study aims to determine the level of awareness regarding long-term health risks among women who experienced preeclampsia during pregnancy in Cyprus and Greece. The study participants included adult women with a history of preeclampsia, while women with normal pregnancies were used as the comparison group. Data collection took place between June 2021 and February 2022, utilizing an online, self-administered questionnaire. The study included 355 women, with 139 (39.2%) in the preeclampsia group and 216 (60.8%) in the comparison group. Findings revealed that more than half of the women with prior preeclampsia (55.4%) were not aware of hypertensive disorders that can occur during pregnancy before their diagnosis, and a similar percentage (45.2%) had not received information about the long-term health risks following their diagnosis. Remarkably, only 3 participants (4.7%) with a history of preeclampsia were aware of the risk of developing cardiovascular diseases. There were no statistically significant differences between the preeclampsia and the comparison group regarding their concerns about long-term health risks, frequency of health checks, perceptions of factors influencing cardiovascular disease development, and doctor communication about different health topics, except from hypertension or high blood pressure. The study underscores the low level of awareness of long-term health risks among women with prior preeclampsia in Cyprus and Greece. This emphasizes the importance of implementing public health programs aimed at promoting cardiovascular risk assessment and effective management, both for clinicians and women with have experienced preeclampsia.

Postpartum home blood pressure monitoring and lifestyle intervention in overweight and obese individuals the first year after gestational hypertension or pre-eclampsia: A pilot feasibility trial

OBJECTIVE

To test the feasibility of a randomised trial of home blood pressure monitoring paired with a remote lifestyle intervention (Heart Health 4 New Moms) versus home blood pressure monitoring alone versus control in individuals with a hypertensive disorder of pregnancy in the first year postpartum.

DESIGN

Single-blinded three-arm randomised clinical trial.

SETTING

Two tertiary care hospitals and a community organisation.

POPULATION

Postpartum overweight and obese individuals with a hypertensive disorder of pregnancy and without pre-pregnancy hypertension or diabetes.

METHODS

We assessed the feasibility of recruitment and retention of 150 participants to study completion at 1-year postpartum with randomisation 1:1:1 into each arm. Secondary aims were to test effects of the interventions on weight, blood pressure and self-efficacy.

RESULTS

Over 23 months, we enrolled 148 of 400 eligible, screened individuals (37%); 28% black or other race and mean pre-pregnancy body mass index (BMI) of 33.4 ± 6.7 kg/m2 . In total, 129 (87%) participants completed the 1-year postpartum study visit. Overall, 22% of participants developed stage 2 hypertension (≥140/90 mmHg or on anti-hypertensive medications) by 1 year postpartum. There were no differences in weight or self-efficacy across the study arms.

CONCLUSION

In this pilot, randomised trial, we demonstrate feasibility of HBPM paired with a lifestyle intervention in the first year postpartum. We detected high rates of ongoing hypertension, emphasising the need for the development of effective interventions in this population.

Cardiovascular and renal health: Preeclampsia as a risk marker

BACKGROUND

Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies.

MATERIALS AND METHODS

Review of PE and its association with future development of CVD and CKD.

RESULTS

Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage.

CONCLUSIONS

The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.

Prepregnancy Cardiovascular Disease Risk Factors and Adverse Pregnancy Outcomes in a Safety-Net Hospital

Background: Many adverse pregnancy outcomes (APOs) are associated with elevated cardiovascular disease (CVD) risk. However, APO data in the context of pre-existing CVD risk factors, and from diverse populations, are limited. We assessed the occurrence of APOs among individuals with and without prepregnancy CVD risk factors, overall and by race/ethnicity. Methods: We conducted a retrospective study using electronic medical record data from a large urban safety-net hospital. Individuals with prenatal care and delivery between 2016 and 2018 at the hospital were included, and data from prenatal intake through the delivery hospitalization were captured. The exposure, prepregnancy CVD risk factors (hypertension, diabetes, tobacco use, and obesity), and the outcome, APOs (hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, low birth weight, and stillbirth), were identified from electronic medical records. Results: We identified 3760 unique delivering individuals, of whom 55.1% self-identified as Black non-Hispanic and 17% as Hispanic. Prepregnancy CVD risk factor prevalence was 45.6%, most commonly obesity (26.6%). APO prevalence was 35.6%, most commonly a hypertensive disorder of pregnancy (20.1%). Overall, 45.7% of APOs occurred in the absence of recognized prepregnancy CVD risk factors, representing 16.3% of the total sample. Among individuals without prepregnancy CVD risk factors, APO prevalence was 30.0% and did not vary by race/ethnicity. Conclusions: In this racially and ethnically diverse hospital-based sample, APOs were present in one in three parous individuals without prepregnancy CVD risk factors-a group with potentially elevated CVD risk who might otherwise be missed by traditional CVD risk factor screening.

Improving Postpartum and Long-Term Health After an Adverse Pregnancy Outcome: Examining Interventions From a Health Equity Perspective

Gestational diabetes mellitus and hypertensive disorders in pregnancy are adverse pregnancy outcomes (APOs) that affect 15% of pregnancies in the United States. These APOs have long-term health implications, with greater risks of future cardiovascular and chronic disease later in life. In this manuscript, we review the importance of timely postpartum follow-up and transition to primary care after APOs for future disease prevention. We also discuss interventions to improve postpartum follow-up and long-term health after an APO. In recognizing racial and ethnic disparities in APOs and chronic disease, we review important considerations of these interventions through a health equity lens.

Pregnancy complications and later life women's health

There has been increasing recognition of the association between various pregnancy complications and development of chronic disease in later life. Pregnancy has come to be regarded as a physiological stress test, as the strain it places on a woman's body may reveal underlying predispositions to disease that would otherwise remain hidden for many years. Despite the increasing body of data, there is a lack of awareness among healthcare providers surrounding these risks. We performed a narrative literature review and have summarized the associations between the common pregnancy complications including gestational hypertension, pre-eclampsia, gestational diabetes, placental abruption, spontaneous preterm birth, stillbirth and miscarriage and subsequent development of chronic disease. Hypertensive disorders of pregnancy, spontaneous preterm birth, gestational diabetes, pregnancy loss and placental abruption are all associated with increased risk of various forms of cardiovascular disease. Gestational diabetes, pre-eclampsia, early miscarriage and recurrent miscarriage are associated with increased risk of diabetes mellitus. Pre-eclampsia, stillbirth and recurrent miscarriage are associated with increased risk of venous thromboembolism. Pre-eclampsia, gestational diabetes and stillbirth are associated with increased risk of chronic kidney disease. Gestational diabetes is associated with postnatal depression, and also with increased risk of thyroid and stomach cancers. Stillbirth, miscarriage and recurrent miscarriage are associated with increased risk of mental health disorders including depression, anxiety and post-traumatic stress disorders. Counseling in the postnatal period following a complicated pregnancy, and advice regarding risk reduction should be available for all women. Further studies are required to establish optimal screening intervals for cardiovascular disease and diabetes following complicated pregnancy.

Content Analysis of Patient-Facing Information Related to Preeclampsia

BACKGROUND

Previous research has shown pregnant people are not knowledgeable about preeclampsia, a significant cause of maternal morbidity and mortality. This lack of knowledge may impact their ability to report symptoms, comply with recommendations, and receive appropriate follow-up care. Pregnant people commonly seek information from sources outside their treating clinician, including pregnancy-specific books and online sources. We examined commonly used preeclampsia information sources to evaluate whether pregnant people are receiving up-to-date, guideline-based information.

METHODS

We conducted a content analysis of preeclampsia-related information in top-ranking websites and bestselling pregnancy books. We used American College of Obstetricians and Gynecologists preeclampsia guidelines to construct a codebook, which we used to examine source content completeness and accuracy. For each source, we analyzed information about preeclampsia diagnosis, patient-reported symptoms, risk factors, prevention, treatment, and complications.

RESULTS

Across 19 included sources (13 websites and 6 books), we found substantial variation in completeness and accuracy of preeclampsia information. We found high rates of mentions for preeclampsia symptoms. Risk factors were more commonly included in online sources than book sources. Most sources mentioned treatment options, including blood pressure medication and giving birth; however, one-third of online sources positively mentioned the nonrecommended treatment of bed rest. Prevention methods, including prenatal aspirin for high-risk pregnancies, and long-term complications of preeclampsia were infrequently mentioned.

CONCLUSIONS

Varying rates of accuracy in patient-facing preeclampsia information mean there is substantial room for improvement in these sources. Ensuring pregnant people receive current guideline-based information is critical for improving outcomes and implementing shared decision-making.

AlOsta M, Othman EH, Hamadneh S. Cardiovascular Disease Risk Factors Awareness among Women with a History of Preeclampsia in Jordan

Introduction

Preeclampsia is a pregnancy-specific hypertensive disease that affects 3-5% of pregnant women all over the world and 1.3% of pregnancies among Jordanian women.

Objectives

This study aims to assess the cardiovascular disease risk factors awareness among women with a recent history of preeclampsia in Jordan and assess the role of healthcare providers in providing counseling about cardiovascular disease risk factors.

Methods

A descriptive cross-sectional design was used to recruit 180 women with a recent history of preeclampsia during the last 12 months. Data were obtained from patients' medical records and the Attitude and Beliefs about Cardiovascular Disease Risk Questionnaires.

Results

The results revealed that 43.9% of women with a recent history of preeclampsia have hypertension, 6.7% have diabetes mellitus, 16.1% have dyslipidemia, 28.9% have a family history of cardiovascular disease, 66.1% are overweight or obese, and 7.2% are smokers. The mean total score of knowledge subscale was 5.5 (SD  =  1.21) out of 8. Only 20% of the participants had good cardiovascular disease knowledge. The mean total score of risk perception was 15.47 (SD  =  7.8). The mean score of perceived benefits and intention to change behaviors was 2.30 (SD  =  0.62). The mean score of healthy eating intentions was 2.54 (SD  =  0.81). Income, having diabetes mellitus, and receiving counseling about preeclampsia as cardiovascular disease risk factor were associated with some dimensions of cardiovascular disease risk factors awareness.

Conclusion

The prevalence of cardiovascular disease risk factors was relatively high among the study participants. The majority of participants had inadequate cardiovascular disease knowledge. In addition, the role of healthcare providers in providing counseling about cardiovascular disease and related risk factors, including PE was limited. Providing more counseling related to cardiovascular disease by nurses and doctors is essential to enhance women's cardiovascular disease knowledge and intention to change lifestyle.

Women’s perceptions of cardiovascular risk after preeclampsia: a qualitative study

Background

Preeclampsia is associated with increased risk of cardiovascular disease later in life, but studies suggest that women with previous preeclampsia are not aware of this. Little is known about how these women perceive the condition and the associated long-term risks. We examined the experiences and perceptions of preeclampsia and the increased risk of cardiovascular disease (CVD) later in life among Danish women with previous preeclampsia and their attitudes towards CVD risk screening.

Methods

Ten individual semi-structured interviews were conducted with women with previous preeclampsia. Data were analysed using thematic analysis.

Results

We identified six themes: 1) Experiences and perceptions of being diagnosed with preeclampsia, 2) Awareness about increased risk of CVD later in life, 3) Knowledge as a precondition for action, 4) The perception of CVD risk as being modifiable, 5) Motivators for and barriers to a healthy lifestyle, and 6) Screening for CVD. Awareness of the severity of preeclampsia was limited prior to being diagnosed. Particularly among those with few or no symptoms, preeclampsia was perceived as a non-severe condition, which was further reinforced by the experience of having received very little information. Nonetheless, some women were shocked by the diagnosis and feared for the health of the offspring. Many women also experienced physical and psychological consequences of preeclampsia. Awareness of the increased risk of later CVD was lacking; yet, when informed, the women considered this to be essential knowledge to be able to act accordingly. The risk of future CVD was perceived to be partly modifiable with a healthy lifestyle, and the women expressed a need for counselling on appropriate lifestyle changes to reduce CVD risk. Other factors were also mentioned as imperative for lifestyle changes, including social support. The women were generally positive towards potential future screening for CVD because it could provide them with information about their health condition.

Conclusions

After preeclampsia, women experienced a lack of knowledge on preeclampsia and the increased risk of CVD later in life. Improved information and follow-up after preeclampsia, including guidance on CVD risk reduction and support from health professionals and family, are warranted.

Hypertension in pregnancy as an early sex-specific risk factor for cardiovascular diseases: evidence and awareness

Despite being a physiological condition, human pregnancy is known to cause numerous complications that can endanger the life of the mother and the fetus alike. While the majority of complications are mostly limited within the peripartum period, more and more information is available about persistently higher short- and long-term cardiovascular risk after a pregnancy complicated by a hypertensive disorder. There is evidence that women after gestational hypertension or preeclampsia are more likely to develop arterial hypertension, coronary atherosclerosis, myocardial infarction, stroke, peripheral artery disease, and even diabetes mellitus and venous thromboembolism years after the target pregnancy. This has urged some authors to view hypertensive disorders of pregnancy as a "stress test" for the maternal organism that unmasks latent endothelial dysfunction. An explanation is sought in the presence of common risk factors and underlying pathological pathways with cardiovascular diseases, although a certain etiological mechanism for the development of hypertensive disorders in pregnancy has not been established yet. More attention is needed towards the follow-up of women after a hypertensive pregnancy as it could be an opportunity for early prevention of cardiovascular diseases.

Preferences of Australian healthcare providers regarding education on long-term health after hypertensive disorders of pregnancy: a qualitative study

OBJECTIVES

To explore Australian healthcare providers' (HCPs') preferred content, format and access to education regarding long-term health after hypertensive disorder of pregnancy (HDP), in order to guide the development of education programmes.

DESIGN AND SETTING

A qualitative study using a framework analysis was undertaken. Registered HCP who were practising in Australia and previously completed a survey about long-term health after HDP were invited to participate.

PARTICIPANTS

Twenty HCP were interviewed, including midwives, specialist obstetrician/gynaecologists, general practitioners with a diploma in obstetrics and gynaecology, and cardiologists.

PRIMARY AND SECONDARY OUTCOME MEASURES

Exploration of preferred content, format and distribution of educational material post-HDP.

RESULTS

Twenty HCP were interviewed in April to May 2020. Four main categories were identified. 'Obtaining evidence-based information for own learning' addressing own learning with preference for multi-disciplinary education, preferably endorsed or facilitated by professional organisations. 'Optimising the referral process from hospital to community health services' was about the need for structured long-term follow-up to transition from hospital to community health and align with HDP guidelines. 'Facilitating women's health literacy' addressed the need for evidence-based, print or web-based material to assist risk discussions with women. 'Seizing educational opportunities' addressed the responsibility of all HCP to identify education opportunities to initiate key health discussions with women.

CONCLUSIONS

HCP provided ideas on content, format and access of education regarding long-term health post-HDP within the parameters of the Australian healthcare context. This evidence will guide educational developments for HCP on post-HDP health to ensure they can better care for women and families.

Management of cardiovascular risk factors during pregnancy

Cardiovascular (CV) risk factors are rising among women of reproductive age. Obesity, hyperlipidaemia, diabetes, and hypertension are associated with adverse pregnancy outcomes and increased CV disease (CVD) risk following pregnancy. Pre-conception counselling and longitudinal postpartum follow-up with ongoing CV risk factor screening are critical for early CVD prevention, though significant racial/ethnic disparities in access to care result in significant gaps. This review summarises the recommended management of CV risk factors during and after pregnancy. For obesity, prevention of excessive weight gain is critical. Except in rare cases, lipid-lowering therapies for women with hyperlipidaemia should be stopped before pregnancy. Women with diabetes in pregnancy should maintain tight glucose control, with hemolgobin A1c (HbA1c) <6.5% to prevent congenital abnormalities. Hypertensive disorders of pregnancy are associated with high maternal and neonatal morbidity and require long-term follow-up to prevent future CVD. Finally, this review highlights the lack of clinical trials informing optimal treatment strategies of CV risk factors during and after pregnancy. Further research is needed to better understand how to improve long-term CV health among this high-risk population.

Health Care Professional's Knowledge of Pregnancy Complications and Women's Cardiovascular Health: An International Study Utilizing Social Media

Background: Despite guidelines recommending the evaluation of adverse pregnancy outcomes (APOs) as a part of the atherosclerotic cardiovascular disease (ASCVD) risk assessment in women, there is limited awareness of this issue in health care professionals. We sought to evaluate the extent of this gap in knowledge. Methods: An online study using a standardized questionnaire was advertised through newsletters and websites of professional organizations. After a low response rate, the link to the survey was announced on Twitter and via personal email invitations. Differences between groups of respondents were evaluated with z-tests of proportion. Results: Out of 446 complete responses, there were 315 cardiologists and 112 obstetricians and gynecologists (OBGyns). There was an >90% awareness of association of adverse maternal outcomes with gestational hypertension and gestational diabetes with ASCVD, but only <60% awareness of association of adverse maternal outcomes with preterm birth. There were significant differences in ASCVD risk assessment and awareness of the association of APOs with adverse outcomes between cardiologists and OBGyns, and between female and male cardiologists. A greater proportion of female cardiologists thought that the guidelines recommended annual follow-up for high-risk women. Conversely, a greater proportion of male cardiologists were unsure of the frequency of follow-up of such women in the relevant guidelines. A higher proportion of U.K. respondents thought that women with high-risk pregnancies should never be screened for cardiovascular disease postpartum compared with U.S. respondents. Conclusions: In a self-selected group of health care professionals interested in women's cardiovascular health, there remains a large gap in knowledge and awareness of the association of APOs with ASCVD risk, in particular, a lack of awareness of the association of ASCVD risk with preterm delivery. Specific target groups for improving knowledge regarding these sex-specific risk enhancers include male cardiologists and health care professionals practicing in the United Kingdom.

Adverse pregnancy outcomes including gestational diabetes and preeclampsia: Do primary care physicians refer to them in their medical files?

Aims: Pregnancies complicated with gestational diabetes mellitus (GDM) or preeclampsia should be considered risk factors for subsequent morbidity later in a women's life. Appropriate screening tests have been recommended for these women. We sought to evaluate whether primary care physicians document diagnoses of GDM or preeclampsia in the medical files during the post-partum period and to elicit whether appropriate screening tests were performed.Materials and methods: The medical records of 352 women discharged from the maternity ward with a diagnosis of GDM or preeclampsia were examined 12 weeks post-partum. We recorded whether a primary care visit occurred, if a relevant diagnosis was documented and if screening tests were conducted.Results: In our cohort, 89.2% of the GDM group and 81.0% of the preeclampsia group visited a primary care physician at least once. About 12.9% (n = 25) of the GDM group and 12.7% (n = 20) of the preeclampsia group were given a correct diagnosis; 40.7% of the GDM group underwent a diabetes screening test and 27.8% of the preeclampsia group underwent a blood pressure measurement.Conclusion: We concluded that diagnoses of GDM and pre-eclampsia are not well-documented by primary physicians and that recommended screening tests are not being sufficiently performed.

Novel Cardiovascular Biomarkers Associated with Increased Cardiovascular Risk in Women With Prior Preeclampsia/HELLP Syndrome: A Narrative Review

Evidence has shown that women with a history of preeclampsia or haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome have an increased risk of cardiovascular disease later in life. Recommendations for screening, prevention and management after such pregnancies are not yet defined. The identification of promising non-traditional cardiovascular biomarkers might be useful to predict which women are at greatest risk. Many studies are inconsistent and an overview of the most promising biomarkers is currently lacking. This narrative review provides an update of the current literature on circulating cardiovascular biomarkers that may be associated with an increased cardiovascular disease risk in women after previous preeclampsia/HELLP syndrome. Fifty-six studies on 53 biomarkers were included. From the summary of evidence, soluble fms-like tyrosine kinase-1, placental growth factor, interleukin (IL)-6, IL-6/IL-10 ratio, high-sensitivity cardiac troponin I, activin A, soluble human leukocyte antigen G, pregnancy-associated plasma protein A and norepinephrine show potential and are interesting candidate biomarkers to further explore. These biomarkers might be potentially eligible for cardiovascular risk stratification after preeclampsia/HELLP syndrome and may contribute to the development of adequate strategies for prevention of hypertension and adverse events in this population.

Exploring education preferences of Australian women regarding long-term health after hypertensive disorders of pregnancy: a qualitative perspective

BACKGROUND

Hypertensive disorders of pregnancy (HDP) affect 5-10% of pregnant women. Long-term health issues for these women include 2-3 times the risk of heart attacks, stroke and diabetes, starting within 10 years after pregnancy, making long-term health after HDP of major public health importance. Recent studies suggest this knowledge is not being transferred sufficiently to women and how best to transmit this information is not known. This study explored women's preferred content, format and access to education regarding long-term health after HDP.

METHODS

This was a qualitative study and framework analysis was undertaken. Women with a history of HDP who had participated in a survey on long-term health after HDP were invited to participate in this study. During telephone interviews women were asked about preferences and priorities concerning knowledge acquisition around long-term health after HDP.

RESULTS

Thirteen women were interviewed. They indicated that they wanted more detailed information about long-term and modifiable risk factors. Their preference was to receive risk counselling from their healthcare provider (HCP) early after giving birth along with evidence-based, print or web-based information to take home. All women suggested more structured postnatal follow-up, with automated reminders for key appointments. Automated reminders should detail rationale for follow-up, recommended tests and discussion topics to be addressed at the appointment.

CONCLUSION

Our findings show that most participants wanted information soon after birth with all women wanting information within 12 months post birth, complemented with detailed take-home evidence. Participants indicated preference for structured follow-up via their HCP with automated alerts about the appointment and recommended tests. This evidence can be used to guide the development of education programs for women on health after HDP which may enhance knowledge, preventive health management and more generally improve women's health trajectories.

Interventions to Mitigate Risk of Cardiovascular Disease After Adverse Pregnancy Outcomes: A Review

Importance

A growing body of evidence suggests that adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy, gestational diabetes (GD), preterm birth, and intrauterine growth restriction, are associated with increased risk of cardiometabolic disease and cardiovascular disease (CVD) later in life. Adverse pregnancy outcomes may therefore represent an opportunity to intervene to prevent or delay onset of CVD. The objective of this review was to summarize the current evidence for targeted postpartum interventions and strategies to reduce CVD risk in women with a history of APOs.

Observations

A search of PubMed and Ovid for English-language randomized clinical trials, cohort studies, descriptive studies, and guidelines published from January 1, 2000, to April 30, 2021, was performed. Four broad categories of interventions were identified: transitional clinics, lifestyle interventions, pharmacotherapy, and patient and clinician education. Observational studies suggest that postpartum transitional clinics identify women who are at elevated risk for CVD and may aid in the transition to longitudinal primary care. Lifestyle interventions to increase physical activity and improve diet quality may help reduce the incidence of type 2 diabetes in women with prior GD; less is known about women with other prior APOs. Metformin hydrochloride may prevent development of type 2 diabetes in women with prior GD. Evidence is lacking in regard to specific pharmacotherapies after other APOs. Cardiovascular guidelines endorse using a history of APOs to refine CVD risk assessment and guide statin prescription for primary prevention in women with intermediate calculated 10-year CVD risk. Research suggests a low level of awareness of the link between APOs and CVD among both patients and clinicians.

Conclusions and Relevance

These findings suggest that transitional clinics, lifestyle intervention, targeted pharmacotherapy, and clinician and patient education represent promising strategies for improving postpartum maternal cardiometabolic health in women with APOs; further research is needed to develop and rigorously evaluate these interventions. Future efforts should focus on strategies to increase maternal postpartum follow-up, improve accessibility to interventions across diverse racial and cultural groups, expand awareness of sex-specific CVD risk factors, and define evidence-based precision prevention strategies for this high-risk population.

Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: Recent Advances in Hypertension

Patients with a history of hypertensive disorders of pregnancy (HDP) suffer higher rates of long-term cardiovascular events including heart failure, coronary artery disease, and stroke. Cardiovascular changes during pregnancy can act as a natural stress test, subsequently unmasking latent cardiovascular disease in the form of HDP. Because HDP now affect 10% of pregnancies in the United States, the American Heart Association has called for physicians who provide peripartum care to promote early identification and cardiovascular risk reduction. In this review, we discuss the epidemiology, pathophysiology, and outcomes of HDP-associated cardiovascular disease. In addition, we propose a multi-pronged approach to support cardiovascular risk reduction for women with a history of HDP. Additional research is warranted to define appropriate blood pressure targets in the postpartum period, optimize the use of pregnancy history in risk stratification tools, and clarify the effectiveness of preventive interventions. The highest rates of HDP are in populations with poor access to resources and quality health care, making it a major risk for inequity of care. Interventions to decrease long-term cardiovascular disease risk in women following HDP must also target disparity reduction.

Variations in Awareness of Association Between Adverse Pregnancy Outcomes and Cardiovascular Risk by Specialty

Introduction

Cardiovascular disease (CVD) remains the leading cause of death among women. Adverse pregnancy outcomes (APOs), including pre-eclampsia (PE), gestational diabetes mellitus (GDM) and pre-term birth (PTB) are associated with future maternal CVD risk. However, data on awareness of the association between APOs and long-term CVD risk among physicians in different specialties are lacking. This study assessed awareness of this association and whether this knowledge varies by specialty.

Methods

An anonymous web-based voluntary survey was sent to physicians in internal medicine (IM), family medicine (FM), obstetrics-gynecology (Ob-Gyn) and cardiology. The questions aimed to assess a physician’s knowledge regarding identification of APOs and their association with future CVD risk and knowledge of CVD risk factor screening in women with APOs and future CVD risk.

Results

The survey was completed by 53 physicians, of whom 21% were in IM, 26% in FM, 23% in Ob-Gyn and 30% in cardiology. Based on the responses, cardiologists screened most frequently for APOs, with 56% always screening a female patient and 31% often screening. Only half of the IM and FM physicians acknowledged awareness of the association between APOs and CVD risk. Respondents in all specialties recognized PE and GDM as APOs linked to long-term maternal CVD risk, but failed to associate PTB as an APO. The majority of physicians in IM, FM and cardiology also lacked the knowledge of how often to appropriately screen for CVD risk factors associated with APOs.

Conclusion

Awareness of the association between APO and future maternal CVD risk varies by specialty. A significant percentage of the physicians who responded to the survey did not routinely ask about APOs when assessing CVD risk and failed to identify PTB as a risk factor for APOs. Education on this topic and targeted efforts to improve screening for APOs are needed within all specialties to help reduce CVD morbidity and mortality.

Assessing knowledge of healthcare providers concerning cardiovascular risk after hypertensive disorders of pregnancy: an Australian national survey

BACKGROUND

Hypertensive disorders of pregnancy (HDP) affect 5-10% of pregnant women. Women after HDP have 2-3 times increased risk of heart attack, stroke and diabetes, as soon as 5-10 years after pregnancy. Australian healthcare providers' knowledge of cardiovascular disease (CVD) risks for women after HDP is unknown, and this study aimed to explore their current knowledge and practice regarding long-term cardiovascular health after HDP, as a precursor to producing targeted healthcare provider education on health after HDP.

METHODS

A custom-created, face-validated online survey explored knowledge about long-term risks after HDP. Distribution occurred from February to July 2019 via professional colleges, key organisations and social media. The objective was to assess current knowledge and knowledge gaps amongst a group of healthcare providers (HCP) in Australia, regarding long-term cardiovascular health after hypertensive disorders of pregnancy (HDP), specifically gestational hypertension or preeclampsia.

RESULTS

Of 492 respondents, 203 were midwives, 188 obstetricians, 75 general practitioners (GP), and 26 cardiologists. A risk knowledge score was computed with 0-6 considered low, 6.1-8.9 moderate and 9-12 high. Most participants (85%) were aware of increased cardiovascular disease after preeclampsia and gestational hypertension (range 76% midwives to 100% cardiologists). There were significant differences in average knowledge scores regarding health after preeclampsia; high for cardiologists (9.3), moderate for GPs and obstetricians (8.2 and 7.6 respectively) and low for midwives (5.9). Average knowledge scores were somewhat lower for gestational hypertension (9.0 for cardiologists, 7.4 for obstetricians and GPs, 5.1 for midwives). Knowledge was highest regarding risk of chronic hypertension, moderate to high regarding risk of ischaemic heart disease, stroke and recurring HDP, and low for diabetes and peripheral vascular disease. Only 34% were aware that risks start < 10 years after the affected pregnancy.

CONCLUSION(S)

Participants were aware there is increased cardiovascular risk after HDP, although less aware of risks after gestational hypertension and some specific risks including diabetes. Findings will inform the development of targeted education.

Missed opportunities to prevent cardiovascular disease in women with prior preeclampsia

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women in every major developed country and in most emerging nations. Complications of pregnancy, including preeclampsia, indicate a subsequent increase in cardiovascular risk. There may be a primary care provider knowledge gap regarding preeclampsia as a risk factor for CVD. The objective of our study is to determine how often internists at an academic institution inquire about a history of preeclampsia, as compared to a history of smoking, hypertension and diabetes, when assessing CVD risk factors at well-woman visits. Additional aims were (1) to educate internal medicine primary care providers on the significance of preeclampsia as a risk factor for CVD disease and (2) to assess the impact of education interventions on obstetric history documentation and screening for CVD in women with prior preeclampsia.

METHODS

A retrospective chart review was performed to identify women ages 18-48 with at least one prior obstetric delivery. We evaluated the frequency of documentation of preeclampsia compared to traditional risk factors for CVD (smoking, diabetes, and chronic hypertension) by reviewing the well-woman visit notes, past medical history, obstetric history, and the problem list in the electronic medical record. For intervention, educational teaching sessions (presentation with Q&A session) and education slide presentations were given to internal medicine physicians at clinic sites. Changes in documentation were evaluated post-intervention.

RESULTS

When assessment of relevant pregnancy history was obtained, 23.6% of women were asked about a history preeclampsia while 98.9% were asked about diabetes or smoking and 100% were asked about chronic hypertension (p < 0.001). Education interventions did not significantly change rates of screening documentation (p = 0.36).

CONCLUSION

Our study adds to the growing body of literature that women with a history of preeclampsia might not be identified as having increased CVD risk in the outpatient primary care setting. Novel educational programming may be required to increase provider documentation of preeclampsia history in screening.

Patterns of Postpartum Ambulatory Care Follow-up Care Among Women With Hypertensive Disorders of Pregnancy

Background

Preeclampsia and gestational hypertension are hypertensive disorders of pregnancy (HDP) that identify an increased risk of developing chronic hypertension and cardiovascular disease later in life. Postpartum follow‐up may facilitate early screening and treatment of cardiovascular risk factors. Our objective is to describe patterns of postpartum visits with primary care and women's health providers (eg, family medicine and obstetrics) among women with and without HDP in a nationally representative sample of commercially insured women.

Methods and Results

We conducted a retrospective cohort study using insurance claims from a US health insurance database to describe patterns in office visits in the 6 months after delivery. We identified 566 059 women with completed pregnancies between 2005 and 2014. At 6 months, 13% of women with normotensive pregnancies, 18% with HDP, and 23% with chronic hypertension had primary care visits (P<0.0001 for comparing HDP and chronic hypertension groups with control participants). Only 58% of women with HDP had 6‐month follow‐up with any continuity provider compared with 47% of women without hypertension (P<0.0001). In multivariable analysis, women with severe preeclampsia were 16% more likely to have postpartum continuity follow‐up (adjusted odds ratio, 1.16; 95% CI, 1.2–1.21). Factors associated with a lower likelihood of any follow‐up included age ≥30 years, Black race, Hispanic ethnicity, and having multiple gestations.

Conclusions

Rates of continuity care follow‐up after a pregnancy complicated by hypertension were low. This represents a substantial missed opportunity to provide cardiovascular risk screening and management to women at increased risk of future cardiovascular disease.

Investigating the current knowledge and needs concerning a follow-up for long-term cardiovascular risks in Dutch women with a preeclampsia history: a qualitative study

BACKGROUND

There is increasing evidence that a history of preeclampsia is an important risk factor for future cardiovascular events. Awareness of this risk could provide opportunities for identification of women at risk, with opportunities for prevention and / or early intervention. A standardized follow-up has not yet been implemented in the north of the Netherlands. The objective of this qualitative study was to explore the opinions and wishes among women and physicians about the follow-up for women with a history of preeclampsia.

METHODS

Semi-structured interviews with 15 women and 14 physicians (5 obstetricians, 4 general practitioners, 3 vascular medicine specialists and 2 cardiologists) were performed and addressed topics about knowledge on CVR, current - and future follow-up. Women were approached through the HELLP foundation and their physicians. Physicians were approached by email. The interviews were recorded, typed and coded using ATLAS.ti software. A theoretical-driven thematic analysis was performed.

RESULTS

Women had some knowledge about the association between preeclampsia and the increased CVR, but missed information from their health care providers. Specialists were aware of the association, but the information and advice they provided to their patients was minimal and inconsistent according to themselves. Whereas some general practitioners regarded their own knowledge as limited. There was a clear desire among women for a more extensive follow-up with specific attention to both emotional and physical consequences of preeclampsia. Physicians indicated that they preferred to see a follow up program concerning the CVR at the general practitioner as part of the already existent cardiovascular risk management (CVRM) program.

CONCLUSION

Women and medical specialists consider it important to improve aftercare for women after a pregnancy complicated by preeclampsia. Introducing these women into the CVRM program at the general practitioner is regarded as a preferred first step. Further research is warranted to establish an evidence-based guideline for the follow-up of these women.

Previous Pre-Eclampsia, Gestational Diabetes and Hypertension Place Women at High Cardiovascular Risk: But Do We Ask?

BACKGROUND

Women who experience vascular complications of pregnancy, including pre-eclampsia, hypertension and diabetes, are at increased risk of coronary artery disease (CAD). Yet patients and their medical providers have low awareness of the significance of these 'non-traditional' cardiovascular risk factors. We aimed to determine the prevalence and medical provider awareness of pregnancy-related cardiovascular risk factors in women with CAD.

METHODS

Women aged 18-70 years treated with percutaneous coronary intervention (PCI) across three tertiary hospitals were invited to participate in a pregnancy-related telephone interview at 12 months post-PCI. Electronic medical records (EMR) were retrospectively reviewed for documentation of pregnancy-related cardiovascular risk factors in the 12 months prior to, and including, the PCI admission.

RESULTS

A total of 102 women (mean age 59.8±7.7 years) underwent PCI for CAD and completed the pregnancy history questionnaire. Approximately three-quarters (73.5%, 75/102) of women had been pregnant, of which 25.3% (19/75) had experienced vascular complications consisting of pre-eclampsia 31.5% (6/19), gestational diabetes 36.8% (7/19), and gestational hypertension 73.6% (14/19). Documentation of traditional CVD risk factors occurred in 209/211 episodes of emergency or cardiology contact (99.1%), while documentation of 'non-traditional' pregnancy-related cardiovascular risk factors occurred in 0/211 episodes of emergency or cardiology contact.

CONCLUSION

More than a quarter of women treated with PCI for CAD had experienced a past pregnancy-related vascular complication. Despite vascular complications of pregnancy predicting future CAD, medical providers were not obtaining a history of these 'non-traditional' cardiovascular risk factors.

Improving Cardiovascular Workforce Competencies in Cardio-Obstetrics: Current Challenges and Future Directions

Maternal mortality in the United States is the highest among all developed nations, partly because of the increased prevalence of cardiovascular disease in pregnancy and beyond. There is growing recognition that specialists involved in caring for obstetric patients with cardiovascular disease need training in the new discipline of cardio-obstetrics. Training can include integrated formal cardio-obstetrics curricula in general cardiovascular disease training programs, and developing and disseminating joint cardiac and obstetric societal guidelines. Other efforts to help strengthen the cardio-obstetric field include increased collaborations and advocacy efforts between stakeholder organizations, development of US-based registries, and widespread establishment of multidisciplinary pregnancy heart teams. In this review, we present the current challenges in creating a cardio-obstetrics community, present the growing need for education and training of cardiovascular disease practitioners skilled in the care of obstetric patients, and identify potential solutions and future efforts to improve cardiovascular care of this high-risk patient population.

Provider Counseling About and Risk Perception for Future Chronic Disease Among Women with Gestational Diabetes and Preeclampsia

Background: Women diagnosed with gestational diabetes or preeclampsia are at a greater risk of developing future type 2 diabetes mellitus, high blood pressure, and cardiovascular disease. Increased perception of future chronic disease risk is positively associated with making health behavior changes, including in pregnant women. Although gestational diabetes is a risk factor for type 2 diabetes, few women have heightened risk perception. Little research has assessed receipt of health advice from a provider among women with preeclampsia and its association with risk perception regarding future risk of high blood pressure and cardiovascular disease. Among women with recent diagnoses of preeclampsia or gestational diabetes, we assessed associations between receipt of health advice from providers, psychosocial factors, and type of pregnancy complication with risk perception for future chronic illness. Methods: We conducted a cross-sectional analysis among 79 women diagnosed with preeclampsia and/or gestational diabetes using surveys and medical record abstraction after delivery and at 3 months postpartum. Results: Overall, fewer than half of the 79 women with preeclampsia and gestational diabetes reported receiving health advice from a provider, and women with preeclampsia were significantly less likely to receive counseling as compared with women with gestational diabetes (odds ratio 0.23). We did not identify a difference in the degree of risk perception by pregnancy complication or receipt of health advice. There were no significant differences in risk perception based on age, race, education, or health insurance coverage. Conclusions: We demonstrated that women with preeclampsia and gestational diabetes are not routinely receiving health advice from providers regarding future chronic disease risk, and that women with preeclampsia are less likely to be counseled on their risk, compared with women with gestational diabetes. Provider and patient-centered interventions are needed to improve postpartum care and counseling for women at high risk for chronic disease based on recent pregnancy complications.

Tracking the Development of Cerebrovascular Risk Factors Following Pregnancy With Preeclampsia

OBJECTIVE

To evaluate the development and management of cerebrovascular risk factors following a pregnancy with preeclampsia.

METHODS

This is a retrospective chart review including women diagnosed with preeclampsia between 2012 and 2013 with later encounters within 2014-2016. For each subject that met inclusion criteria, the development of cerebrovascular risk factors was determined using ICD codes within the 2014-2016 electronic medical record (EMR). For subjects who developed risk factors, current treatment was determined from the EMR. Demographic data was also documented. Differences in the development and treatment of risk factors were compared among racial groups and age. Descriptive statistics were calculated using SAS statistical software.

RESULTS

Compared to prepregnancy health status, the incidence of hypertension increased by 1.7 times (P < .05), hyperlipidemia increased by 4.5 (P < .05), migraines increased by 2.2 (P < .05), and diabetes mellitus increased by 2 (P < .05) after a pregnancy with preeclampsia. Black non-Hispanics had highest rates of hypertension, obesity, and migraines (20.5%, 9.1%, and 6.8%, respectively.) Of hypertensives, 73.6% (42/57) were prescribed medication. Of diabetics, 88.9% (16/18) were prescribed medication. No patients with hyperlipidemia were prescribed a statin. Black non-Hispanics had higher rates of risk factor management (74.3% of hypertensives and 100% of diabetics treated) than white Hispanics (55% and 77.8%, respectively).

CONCLUSIONS

This study shows a significant increased risk of the development of cerebrovascular risk factors such as hypertension, hyperlipidemia, migraines, and diabetes following a diagnosis of preeclampsia. Opportunities exist for the early treatment of these risk factors, which could reduce the long-term rate of stroke in these women.

Blood Pressure Variability in Pregnancy: an Opportunity to Develop Improved Prognostic and Risk Assessment Tools

PURPOSE OF REVIEW

This review discusses the mortality and morbidity of hypertensive disorders of pregnancy (HDP) and the current diagnostic thresholds. It then explores measurement of variability in blood pressure (BP) during pregnancy as an opportunity to identify women at high risk of cardiovascular disease (CVD) later in life.

RECENT FINDINGS

HDP is known to be associated with increased risk of long-term CVD. Current CVD prognostic tools do not incorporate a history of HDP given a lack of improved risk discrimination. However, HDP diagnostic criteria are currently based on a binary threshold, and there is some evidence for the use of variability in BP throughout gestation as a marker of CVD risk. HDP increases long-term risk of CVD. Future studies investigating changes in diagnostic criteria, including the use of BP variability, may improve long-term CVD risk prediction and be incorporated into future risk assessment tools.

Assessing Knowledge Gaps of Women and Healthcare Providers Concerning Cardiovascular Risk After Hypertensive Disorders of Pregnancy-A Scoping Review

Background: A history of a Hypertensive Disorder of Pregnancy (HDP) at least doubles a woman's risk of cardiovascular disease (CVD). The risk increases within 10 years after HDP and continues for life, making long-term health after HDP of major public health importance. Understanding knowledge gaps in health care professionals and women regarding cardiovascular health after HDP is an important component in addressing these risks. Objectives: The primary aim was to examine what women and healthcare providers (HCP) know about cardiovascular risks after HDP. The secondary aims were to identify enablers and barriers to knowledge and action on knowledge. Methods: A scoping review was conducted. This was a narrative synthesis, using PRISMA-ScR guidelines, of English-language full text articles that included assessment of knowledge of women, and/or HCP, on long term cardiovascular risk after HDP. The databases Embase, Medline, Scopus, ProQuest, Cochrane, and PsycInfo were searched from 01 January 2005 to 31 May 2019. Results: Twelve studies were included, six addressing women's knowledge, five addressing HCP knowledge, and one addressing both. The studies included 402 women and 1,215 HCP from seven countries. Regarding women's knowledge, six of seven studies found women had limited or no knowledge about the link between HDP and CVD. Where women were aware of the link, the majority had sourced their own information, rather than obtaining it through their HCP. In five of six studies, HCP also mostly had limited knowledge about HDP-CVD links. Primary enablers for HCP acquisition of knowledge and counseling were the availability and knowledge of guidelines. Where comparisons between HCP groups were made, obstetricians had greater knowledge than family physicians, internal medical specialists, or midwives. Conclusion: There was a low level of knowledge amongst HCP and women about increased CVD risk after HDP. Where women had higher levels of knowledge, the information was often obtained informally rather than from HCP. There were variations in knowledge of HCP, with obstetricians generally more aware than other professions. Further country and context-specific research on current status of women's and HCP's knowledge is therefore necessary when creating educational strategies to address knowledge gaps after HDP.

Women's Knowledge of Cardiovascular Risk After Preeclampsia

OBJECTIVE

To determine women's self-reported knowledge of the association between preeclampsia and cardiovascular disease and to determine if they received appropriate education on the recommendations of the American Heart Association for follow-up and for cardiovascular risk reduction strategies after preeclampsia.

DESIGN

Cross-sectional descriptive study using an online survey.

SETTING/LOCAL PROBLEM

A survey link was placed on the Facebook pages for two preeclampsia support groups.

PARTICIPANTS

A total of 241 women who were members of these Facebook groups completed the online survey.

INTERVENTION/MEASUREMENTS

An online survey was created using Campus Labs software. Most questions were closed response. Participants were asked to answer survey questions about their first pregnancy with preeclampsia and the education/referrals they received specific to the association between preeclampsia and cardiovascular risk.

RESULTS

Of all those who responded, 36.9% (n = 89) reported being unaware of the association between preeclampsia and cardiovascular disease. Of those who gave birth since the American Heart Association issued recommendations for follow-up after preeclampsia, 43.9% (n = 61) reported that they received no counseling regarding incorporating healthful lifestyle changes or follow-up after their diagnosis of preeclampsia.

CONCLUSION

Women with a history of preeclampsia may not be receiving adequate education on its association with cardiovascular disease. Nurses can work to fill this gap through collaboration with cardiovascular and primary care providers to orchestrate seamless cardioprotective follow-up for this population of women.

Preeclampsia and future stroke risk in women: What NPs need to know

Preeclampsia is a complication of pregnancy that affects approximately 4% of pregnancies. Preeclampsia is defined as new-onset hypertension after 20 weeks gestation often accompanied by new-onset proteinuria. Women who experience preeclampsia during pregnancy are at an increased risk for hypertension and stroke later in life. Healthcare providers should screen women appropriately to minimize risk.

Aspirin reduces long-term stroke risk in women with prior hypertensive disorders of pregnancy

OBJECTIVE

To determine whether hypertensive disorders of pregnancy (HDP) increased long-term stroke risk in women in the California Teachers Study (CTS), a prospective cohort study, and whether aspirin or statin use modified this risk.

METHODS

CTS participants ≤60 years of age at the time of enrollment in 1995 were followed up prospectively for validated stroke outcomes obtained via linkage with California hospital records through December 31, 2015. We calculated unadjusted and adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the primary outcomes of all stroke and stroke before 60 years of age among those with and without a history of HDP. We tested for interactions (p < 0.2) and performed stratified analyses to assess the risk of the primary outcomes in women with and without self-reported use of aspirin or statins.

RESULTS

Of 83,749 women included in the analysis, 4,070 (4.9%) had HDP. Women with prior HDP had increased risk of all stroke (adjusted HR 1.3, 95% CI 1.2-1.4) but no increased risk of stroke before age 60 (adjusted HR 1.2, 95% CI 0.9-1.7). There was an interaction (p = 0.18) between aspirin use and HDP history on risk of stroke before age 60: nonusers of aspirin had higher risk (adjusted HR 1.5, 95% CI 1.0-2.1) while aspirin users did not (adjusted HR 0.8, 95% CI 0.4-1.7). This effect was not seen with statins.

CONCLUSIONS

After controlling for comorbid conditions, women with prior HDP had increased long-term stroke risk, which was reduced by aspirin use. Randomized trials may be needed to assess whether long-term aspirin use could benefit selected women with a history of HDP.

Appropriate Interventions for Pregnant Women with Indicators of Metabolic Syndrome on Pregnancy Outcomes: A Systematic Review

Metabolic syndrome (MetS), a series of symptoms, including abdominal obesity, impaired glucose tolerance and insulin metabolism, hypertension, and dyslipidemia, is considered as the risk of developing cardiovascular disease and diabetes that can predispose a pregnant women to serious health problem, women in the developed as well as the developing countries. This study was aimed to investigate the effects of appropriate interventions on pregnant women with indicators of MetS to further improve the outcome of pregnancy. This systematic review was performed to extract articles of randomized controlled trials (RCT) on pregnant women with indicators of (MetS) and focusing on physical activity, dietary or lifestyle interventions on maternal health or perinatal outcomes, with searching in the Web of Science, PubMed, CDSR, Scopus, and Google Scholar were investigated. Two researchers independently evaluated the quality of the studies, being presented in all the articles and ranked the studies as high/low quality; the level of evidence was based on the number of high-quality studies and the coordination of the obtained results. Then, 17 articles, which met the inclusion criteria, were selected; among these, 7 articles studied the physical activity, 3 articles reviewed diets, 6 probed the lifestyle interventions, and 1 article was on counseling. In general, evidence suggested how the physical activity and proper diet impacts on proper weight gain during pregnancy, prevents maternal complications, and improves the outcome of pregnancy. According to the results of this systematic review, proper interventions during pregnancy can have a positive effect on maternal weight gain and the general health condition of pregnant women with indicators of MetS.

Postpregnancy BMI in the Progression From Hypertensive Disorders of Pregnancy to Type 2 Diabetes

OBJECTIVE

To study the extent to which BMI after pregnancy adds to the elevated risk of postpregnancy type 2 diabetes in women with a history of hypertensive disorders of pregnancy (HDP) (preeclampsia or gestational hypertension).

RESEARCH DESIGN AND METHODS

We used data from the Nurses' Health Study II, a prospective cohort study. In women aged 45-54 years without prior gestational diabetes mellitus, we investigated the interaction between BMI and HDP history on the risk of type 2 diabetes. For clinical and public health relevance, we focused on additive interaction. The main outcome measure was the relative excess risk due to interaction calculated from multivariable Cox proportional hazards models using normal weight as the reference group.

RESULTS

In total, 6,563 (11.7%) of 56,159 participants had a history of HDP and 1,341 women developed type 2 diabetes during 436,333 person-years. BMI was a strong risk factor for type 2 diabetes regardless of HDP history. However, there was evidence of an additive interaction between BMI and HDP for the risk of type 2 diabetes (P = 0.004). The attributable proportion of risk due to the interaction ranged from 0.12 (95% CI -0.22, 0.46) in women who were overweight to 0.36 (95% CI 0.13, 0.59) in women with obesity class I.

CONCLUSIONS

Maintaining a healthy weight may be of even greater importance in women with a history of HDP, compared with other women with a history of only normotensive pregnancies, to reduce midlife risk of type 2 diabetes.