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Pregnancy is a window to future health, and the pregnancy and postpartum periods are critical times to ensure effective and sustainable transitions to long-term preventive health care. Adverse pregnancy outcomes (APOs), including gestational diabetes, preterm birth, fetal growth restriction, and hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, and related disorders) are major health risks for pregnant individuals during pregnancy and throughout their lifespan.1,2 It is estimated that up to 20% of pregnancies in the US are affected by 1 or more APOs, with the highest prevalence among individuals who identify as American Indian, Asian, Black, Hispanic, or Pacific Islander.3 This contributes to widening racial and ethnic disparities in perinatal and chronic disease outcomes.1
Long-term risks after APOs include chronic hypertension, metabolic syndrome, type 2 diabetes, ischemic heart disease, early stroke, premature cognitive decline, and early mortality.1,4 The prognostic implications of different APOs for these adverse outcomes may vary by APO severity, gestational age at presentation, and postpartum persistence. For example, individuals with preeclampsia with severe features (severe hypertension symptoms, or laboratory abnormalities) and postpartum persistence of hypertension are at greater risk of long-term sequelae than those with gestational hypertension with mild-range blood pressure at term (systolic blood pressure, 140-159 mm Hg or diastolic blood pressure, 90-109 mm Hg). Although APOs have a spectrum of risk, all of these conditions are associated with tangible long-term morbidity. The increasing amount of research has prompted cardiovascular3,5 and obstetrics-gynecology guidelines4 to designate APOs as risk factors for cardiovascular disease. Yet there are major knowledge gaps both among the general public and health care professionals about the long-term risks associated with APOs.1,4,6 Further research is needed to identify the most effective ways to deliver care for patients who experienced an APO and the most effective screening and prevention interventions across the lifespan for these individuals.1
In 2018, a joint cardiology and obstetrics statement aimed to raise collective awareness about these risks and suggested potential treatment and prevention approaches.7 Cardiovascular guidelines have designated APOs as a risk-enhancing factor, meaning that individuals who appear to be at intermediate risk of atherosclerotic cardiovascular disease should be regarded as high-risk when an APO history is present.3 Despite a lack of consensus on optimal interventions and risk-prediction modalities, actions can be taken to improve health, reduce risk, and address modifiable barriers to optimal care.1-3
Given the lifetime risks associated with occurrence of an APO, future risk assessment should be addressed by obstetric clinicians or via consultation with an appropriate medical colleague. However, the fragmentation of health care delivery in the US, along with numerous individual- and community-level social and structural determinants of health, have hindered ongoing care or referrals when necessary. An estimated 40% of individuals who have given birth do not return for recommended postpartum obstetric care, and less than half transition to a nonobstetric clinician for primary care within the first postpartum year.1,4 Long-term engagement in preventive care after an APO remains a neglected opportunity to reduce risk for affected individuals and improve population health with reduction in health disparities.1 Other factors that limit implementation of preventive efforts include the complexity of involving clinicians from many different specialties (primary care physicians, neurologists, pediatricians, cardiologists, emergency medicine physicians, and others) who may need to recognize and address the APO-associated risks. To improve lifetime cardiovascular health among populations that experience the greatest health inequities, it is essential that intentional efforts address these multilevel factors. Such efforts may also yield intergenerational benefits by improving family and subsequent pregnancy health.
Obstetric clinicians must ensure that their patients who have experienced an APO receive a timely and comprehensive transition of care to a primary care clinician when necessary. The clinician who takes responsibility for assessing the lifelong cardiovascular and metabolic trajectory following an APO can vary based on available resources. Obstetrician-gynecologists may continue to serve as primary care clinician for some patients, whereas individuals who require escalated cardiovascular and metabolic preventive health care due to APOs warrant consultation with general internal medicine, family medicine, or preventive cardiology clinicians. Among patients for whom the obstetrician is not serving as the primary care clinician, this transition should be a “warm hand-off” from the obstetrician via the electronic health record or written communication, including conveying the obstetric history with APO details and communicating the rationale for APO-oriented long-term care. Improvements to health care systems could help facilitate this transition, such as automatic flagging of APOs in the electronic health record for follow-up, improved electronic communication between health care systems, or the creation of multidisciplinary postpartum transitional clinics.1
All clinicians can partner with patients to mitigate long-term risks after APOs by routinely asking all currently or previously pregnancy-capable individuals about pregnancy outcomes, APOs, and postpartum APO-related morbidity as a routine component of medical history taking. A key starting point involves efforts to raise clinical awareness that hypertensive disorders of pregnancy, gestational diabetes, preterm birth, and fetal growth restriction are each associated with future cardiovascular, metabolic, and cerebrovascular disease (Box), regardless of the number of years since the pregnancy or the time during pregnancy when the APO developed. Identification of an individual as having high risk for cardiovascular disease should trigger earlier and more intensive primary preventive measures, including exercise, weight control, smoking prevention and cessation, and early identification of elevated lipids, high blood pressure, and diabetes.5
Hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, preeclampsia, eclampsia, HELLP syndrome)
Fetal growth restriction
Intrauterine fetal death
Excessive gestational weight gain
Conduct cardiovascular risk screening within 3 months postpartum and at least annually at primary care visits
Identify all cardiovascular risk factors including smoking history; physical activity history; family history of cardiovascular disease, hypertension, or diabetes; body weight and body mass index; waist circumference; lipid profile; diabetes screening results, and pregnancy history
Understand sex-specific cardiovascular risks and estimate cardiovascular risk in women older than 40 years at every visit
Counsel all individuals with APO about the long-term risks and the need to manage risk factors and maintain long-term care
Consider the role of social determinants of health for individuals who experienced APOs and work to improve accessibility of preventive health care interventions
Engage a diverse team to support patients who experienced an APO in addressing their social determinants of health and transitioning to long-term health care
Abbreviations: APO, adverse pregnancy outcomes; HELLP, hemolysis, elevated liver enzymes, and low platelets.
a Adapted from Cho et al.3
Patient-level social determinants that influence both health and health care access at this critical time point after delivery must be identified and addressed. Factors such as health literacy, self-efficacy and advocacy skills, availability of affordable child care and transportation, limited maternity leave and rigidity of work schedules, comfort with health care clinicians and organizations, exposure to racism and discrimination, and other structural issues can limit successful postpartum transitions to long-term care. Support systems such as patient navigators, multidisciplinary medical homes, and comprehensive wraparound services, which include institutional and community-based family and social services and mental health care, may be helpful for addressing these issues. The involvement of a culturally sensitive, diverse postpartum care team with individuals who are experts in addressing social determinants of health also may support the successful transition to long-term health care.4 The Box summarizes the ways clinicians could work together to improve the long-term care of individuals who have experienced an APO.
Health policies must address the need for continuous and long-term access to health care, beyond the limited postpartum period traditionally guaranteed by Medicaid. Insurance loss, inadequate public and private insurance coverage, limited reimbursement for telemedicine, and fragmentation of health care systems due to payer issues remain major limitations to smooth transitions of care in the postpartum period. These payer and system barriers commonly limit patients’ ability to remain continuously engaged in needed health care.
Improvements in individual and population health could be realized with enhanced recognition of APO-associated risks, coupled with effective partnerships among patients, clinicians, researchers, policy makers, and health systems to ensure that individuals who experienced APOs receive optimal primary and secondary prevention of long-term morbidity.
Corresponding Author: Philip Greenland, MD, 680 N Lake Shore Dr, Ste 1400, Chicago, IL 60611 (email@example.com).
Published Online: January 13, 2022. doi:10.1001/jama.2021.23870
Conflict of Interest Disclosures: Dr Yee reported receipt of grants from the National Heart, Lung, and Blood Institute for work related to this article; and outside the submitted work, funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Diabetes and Digestive and Kidney Diseases, and Friends of Prentice. Dr Miller reported receipt of grants from the National Institutes of Health (NIH) for work related to this article; and outside the submitted work, grants from NIH and the Gerstner Family Foundation; personal fees from Elsevier; Ross Feller Casey, LLP; Grower, Ketcham, Eide, Telan & Meltz; Heyl, Royster, Voelker, & Allen; Argionis & Associates, LLC; and Finch McCranie, LLP. Dr Greenland reported receipt of grants from NIH for work related to this article; and from the American Heart Association outside the submitted work.
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Yee LM, Miller EC, Greenland P. Mitigating the Long-term Health Risks of Adverse Pregnancy Outcomes. JAMA. Published online January 13, 2022. doi:10.1001/jama.2021.23870
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