Missed opportunities to prevent cardiovascular disease in women with prior preeclampsia

Abstract

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.

Pregnancy complications and later life women's health

“…There is a large body of evidence highlighting that adverse pregnancy outcomes are potential sentinel events for future chronic disease in women. Despite the increasing evidence, pregnancy complications are often forgotten when assessing risk factors for noncommunicable diseases 4,6,7 . Obstetrician‐gynecologists and family medicine practitioners are best placed to advise otherwise healthy young women about long‐term risk, relevant screening recommendations and potential mitigating strategies following an adverse pregnancy event or complication, but there is some variation in guidance surrounding optimal postnatal follow up timing and what the visit should entail.…”

“…For example, there is a well-described association between gestational diabetes (GDM) and risk of development of type 2 diabetes (T2DM), but there is much less awareness among women's healthcare providers of other longterm health risks following pregnancy complications. 3,4 One important example of a risk marker for later life noncommunicable disease is pre-eclampsia. The relation between preeclampsia and later cardiovascular disease (CVD) was first described in 1927 by Corwin, and has been the subject of significant focus in the past decade as interest in prevention of CVD in women has increased.…”

“…It is accepted that pregnancy complications can negatively influence maternal and child outcomes, and there is growing evidence that pregnancy complications are also associated with maternal health problems long after the pregnancy is are over. For example, there is a well‐described association between gestational diabetes (GDM) and risk of development of type 2 diabetes (T2DM), but there is much less awareness among women's healthcare providers of other long‐term health risks following pregnancy complications 3,4 …”

“…Despite this, a survey of physicians from 2021 showed that the majority of internal medicine, family medicine and cardiology physicians did not ask about adverse pregnancy outcomes when screening for cardiovascular risk factors, and were unfamiliar with the American Heart Association and American College of Obstetricians and Gynecologists' guidelines concerning treatment and follow‐up of women with pre‐eclampsia 6 . Other studies have also identified knowledge gaps in risk assessment and screening following adverse pregnancy outcomes 4,7 . Valuable opportunities for postnatal counseling and risk reduction, as well as potential screening for chronic disease in the following years, are then lost.…”

Knowledge and perception of cardiovascular disease risk in women of reproductive age

“…Because these conditions resolve after delivery, awareness of the link between APOs and lifetime CVD risk remains incomplete. Further, monitoring and optimization of cardiovascular health following an APO is not consistently implemented, and the long-term cardiovascular risk associated with these complications may not be effectively communicated to the women who experience them [ 7 , 8 ].…”