Cardiovascular Complications & Pregnancy: What Cardiologists Need to Know

Dr. Brown:
Welcome to Heart Matters on ReachMD. I'm Dr. Alan Brown, and on this episode, we're joined by Dr. Nanette Wenger, a Professor of Medicine in the division of cardiology at the Emory University School of Medicine. Dr. Wenger is here to discuss what cardiologists need to know about pregnancy complications as it relates to coronary artery disease. Here's Dr. Wenger now.

Dr. Wenger:
We know that preeclampsia occurs in about 10 percent of all pregnancies and importantly, there’s been an increase in preeclampsia of about 25 percent in the last two decades. It’s not only a major cause of maternal, morbidity, and mortality, but as per our paper, it disproportionately affects African Americans. Importantly, preeclampsia is more prevalent with underlying cardiovascular risk factors. So, the question is not, ‘Did the preeclampsia cause the risk?’, but perhaps preeclampsia and coronary disease have shared risk factors.

Now, our OB/GYN colleagues are really looking carefully at preeclampsia only because very recently the U.S. Preventive Services Task Force has recommended that women who are at high risk for preeclampsia receive low dose aspirin in their second and third trimesters of pregnancy. But I think the important feature here is that it is the cardiovascular risk factors with which women come to a pregnancy that puts them at higher risk for preeclampsia.

But we have even more data about gestational diabetes, I think all cardiologists realize that gestational diabetes increases almost seven-fold the risk of subsequently developing type 2 diabetes. But it increases two-fold the subsequent risk of cardiovascular events even if these women don’t develop diabetes. And these occur within the first decade or ten years post-partum. So that many of these women are still in their reproductive years. And even more frightening is that the offspring of mothers, both the girls and the boys, who’ve had gestational diabetes have an increase in the early onset of cardiovascular disease. So, this is generational, as well.

Again, the message is that when you evaluate cardiovascular risk in women of all races and ethnicities, but highlighting it in black women who are at the highest risk that you get a detailed history of pregnancy complications because preeclampsia, preterm delivery, small for gestational age infants, any of the hypertensive complications and of course, gestational diabetes will say, ‘Here is a woman who is at increased risk’.

And when you get that history, what is it that you do? Something with that we defer to our OB colleagues is that the woman who has had preeclampsia is advised to have extended breast feeding because extended breast feeding seems to lessen the risk of the mother developing hypertension. She should achieve an optimal BMI, which means lose the baby weight, smoking cessation, often done during pregnancy but it should not be resumed, post-partum, a healthy diet, regular exercise, but a plan for long-term surveillance. And this is where the primary care community, as well as the cardiologists come in.

There is now a program of cooperation between the OB/GYN community and the American Heart Association. We’ve put out joint statements. And this to me is very exciting because the OB/GYNs are in the preventive mode; they do the pap smears, they do the mammograms, now they should also be evaluating for cardiovascular risk. So, I think that that is really important. And what we see is pregnancy really provides a unique window to identify women with metabolic derangements, etc., who are at risk for future cardiovascular disease.

Now, what is it that we must learn? We must learn the best way to do this screening and follow-up. Many of these cardiovascular complications occur in the first ten years, so don’t wait ‘til the woman gets older. Even the very young woman who’s had a pregnancy complication requires risk factor screening. Pregnancy complications are identified as risk enhancers in the AHA-ACC Prevention Guidelines.

And then, one of the questions that I think is on the front of the research burner is if we do appropriate screening and detection, will the interventions work to prevent the development of subsequent cardiovascular disease?

Dr. Brown:
That was Dr. Nanette Wenger, discussing what cardiologists need to know about pregnancy complications as related to coronary artery disease. For ReachMD, I'm Dr. Alan Brown. To find other programs in our series, visit ReachMD.com/HeartMatters, where you can Be Part of the Knowledge. Thanks so much for listening!