TWO PATIENTS IN ONE
PREGNANCY AS A WINDOW TO FUTURE MATERNAL HEALTH AND WHAT INTERVENTIONS CAN BE IMPLEMENTED TO REDUCE THE RISK FOR MATERNAL MORBIDITY AND MORTALITY
Mureena Turnquest Wells , MD
There is a growing body of evidence that complications that occur during pregnancy may be predictive of future maternal diseases and mortality . Women with pregnancies complicated by preterm birth , hypertensive disorders of pregnancy , gestational diabetes , fetal growth restriction and stillbirth are associated with a higher lifetime risk of maternal cardiometabolic disease .
Pregnancy is a “ natural stress test ” for identifying women at risk for disease in later decades of life . Approximately 20 % of pregnancies are affected by one or more adverse pregnancy outcomes . Hypertensive disorders of pregnancy and diabetes are two of the most common .
Hypertensive disorders of pregnancy are one of the leading causes of maternal and perinatal mortality worldwide and complicate approximately 2-8 % of pregnancies globally . The diagnosis of preeclampsia is based on systolic blood pressure of 140mg or higher or diastolic blood pressure of 90 mm Hg or higher on two separate occasions at least four hours apart , after 20 weeks , in a woman with previously normal blood pressures . Although often accompanied by proteinuria of 300mg or more in a 24-hour urine specimen or a protein to creatinine ratio of 0.30 or more , the diagnosis may be made in the absence of proteinuria if other features of severe disease are present such as headaches , impaired liver function and thrombocytopenia . Women at high risk for preeclampsia , unless contraindicated , should receive low dose aspirin ( 81mg / day ) for the prevention of preeclampsia , initiated between 12-28 weeks gestation ( preferably before 16 weeks ) and continuing until delivery .
Numerous studies have suggested a link between hypertensive disorders of pregnancy and the later development of cardiovascular disease ( CVD ). Women with early onset preeclampsia (< 34 weeks ) have been shown to have a more than twofold increased risk of dying from cardiovascular disease . A prospective observational study conducted at two tertiary hospitals in the Netherlands evaluated women who were diagnosed with preeclampsia prior to 34 weeks and compared them to normotensive controls nine to 16 years after the index pregnancy . Women with a history of early onset preeclampsia had significantly higher blood pressures , body mass index and more abnormal lipid profiles and hemoglobin A1C levels when compared to the controls . 1
A systematic review found that women with preeclampsia or eclampsia faced significantly increased odds of fatal or diagnosed cardiovascular disease ( OR 2.28 ), cerebrovascular disease ( OR 1.76 ) and hypertension ( RR 3.1 ). 2
The mechanism for CVD is unclear but may be related to persistence of endothelial dysfunction years after the affected pregnancy . Certainly there may be predisposing genetic and environmental risk factors that could explain this association .
Approximately 6 % of pregnant women in the U . S . will develop gestational diabetes , a state of carbohydrate intolerance . Pregnancy is accompanied by increased resistance to insulin as a result of numerous hormones produced by the placenta . Gestational diabetes occurs if the pancreatic function is insufficient to overcome the insulin resistance . It is well known that women who are diagnosed
6 LOUISVILLE MEDICINE