Primary Care–Based Cardiovascular Disease Risk Management After Adverse Pregnancy Outcomes: a Narrative Review

Abstract

Several common adverse pregnancy outcomes can reveal subclinical or latent cardiovascular disease (CVD) risk, transiently exposed through the physiologic stress of pregnancy. The year after pregnancy may be a singular opportunity to identify and initiate treatment for CVD risk, even before the onset of traditional CVD risk factors. However, clinical guidance regarding CVD risk management after adverse pregnancy outcomes is lacking. We therefore conducted a systematic review of US clinical practice guidelines and professional society recommendations to inform primary care-based CVD risk management after adverse pregnancy outcomes. We identified 13 relevant publications. While most recommendations were based on limited or weak evidence, we identified several areas of consensus. First, individuals with an adverse pregnancy outcome associated with future CVD are likely to benefit from CVD risk assessment-accompanied by education, counseling, and support for lifestyle modification-beginning within the first postpartum year. Second, among clinicians, clear and consistent documentation about adverse pregnancy outcomes and recommended follow-up is important to coordinate care after pregnancy. In addition, patients need to be informed about their pregnancy complications and associated CVD risks, so that they can make informed health care and lifestyle decisions. Finally, in general, CVD prevention in the year after an adverse pregnancy outcome focuses on lifestyle modification, reserving pharmacotherapy for the highest-risk patients and those with traditional CVD risk factors. While postpartum lifestyle interventions show promise for reducing CVD risk after adverse pregnancy outcomes, continued research to determine the optimal content, timing, and long-term effects of such interventions is needed.

Health Experiences of African American Mothers, Wellness in the Postpartum Period and Beyond (HEAL): A Qualitative Study Applying a Critical Race Feminist Theoretical Framework

“…While reviews and consensus guidelines for postpartum primary care clinical management exist [ 9 , 80 , 81 ], there is a dearth of evidence about how postpartum care can better meet the multivariate social and structural needs that support healing and wellness [ 82 ]. Bridging the Chasm between Pregnancy and Health over the Life Course: A National Agenda for Research and Action (2021) was a Patient-Centered Outcomes Research Institute-funded stakeholder engagement process that provided a framework for postpartum transitions through systems innovation [ 16 ].…”

Hypertensive disorders of pregnancy

“…Guidelines from cardiology societies are more detailed than those from the obstetrics and gynaecology communities, with some recommending annual blood pressure monitoring and assessment of cardiovascular and metabolic risk factors including lipids, fasting blood glucose, and body mass index,160163 whereas others recommend periodic monitoring 75164165. Of 13 US guidelines or society recommendation publications relevant to primary care based cardiovascular risk management in the year following pregnancy outcome, eight included recommendations specifically for HDP 166. These include early postnatal follow-up in primary care or cardiology outpatient settings,167 close monitoring to ensure that hypertension resolves within 12 weeks postpartum,142 and, for women who had preterm pre-eclampsia, annual cardiovascular risk assessment 163.…”

Adverse Pregnancy Outcomes and Postpartum Care as a Pathway to Future Health

“…All patients with APO’s should have a comprehensive CVD risk assessment within 12 weeks postpartum, including a detailed medical history, physical exam, biochemical testing (lipid profile, diabetes screening with fasting blood glucose, HbA1c, or Oral glucose tolerance test (OGTT) if GDM, urine protein assessment, and nutrition assessment) (Table 2). 60 The optimal timing of this assessment is unclear, except for an Oral glucose tolerance test for patients with GDM. Early screening within 3 months postpartum can be initiated by the obstetric care clinician, as this may be a more accessible approach for patients to complete follow-up.…”