Pregnancy As an Opportunity for Improving Maternal Cardiovascular Health.

Obstetric complications, such as hypertensive disorders of pregnancy (HDP) and gestational diabetes, are known to be associated with the development of postpartum risk factors for cardiovascular disease (CVD), such as chronic hypertension and diabetes type 2, respectively. However, even uncomplicated pregnancy could be a window of opportunity for improving maternal cardiovascular health later in life. In this BJOG issue, Lueth and colleagues have presented a secondary analysis of a prospective cohort study that included 4022 women who were followed up from their first index pregnancy to 2– 7 years postpartum. An allostatic load score was measured in the first trimester of pregnancy and calculated based on blood pressure, body mass index, lipid profile, glucose, insulin, high sensitivity Creactive protein, urinemeasured creatinine and albumin values. The authors found that a high allostatic load score was significantly associated with chronic hypertension (adjusted odds ratio [aOR] 1.9, 95% confidence [CI] 1.6– 2.2) and metabolic disorders (aOR 1.8, 95% CI 1.5– 2.1) after adjusting for covariates, such as maternal age, race, education, smoking, gravidity, health insurance status, obstetric complications and elapsed time since the index pregnancy. In pregnancies complicated by HDP, peripartum cardiovascular screening based on maternal factors and cardiac parameters measured by transthoracic echocardiography can effectively identify women at risk of postpartum hypertension (Giorgione et al. JACC 2022;80:1465– 76). These women could benefit from targeted interventions in their ‘fourth trimester’ of pregnancy, such as postpartum home blood pressure monitoring, shown to have persistent positive results on their blood pressure levels at 3– 4 years postpartum. However, it is crucial to consider that hypertensive disorders affect up to 10% of pregnancies and, consequently, the major burden of incident CVD in the female population occurs after nonhypertensive pregnancies. Therefore, the findings of this new study might have significant future implications for cardiovascular screening and prevention in women, a group usually neglected by cardiovascular research studies despite CVD being the leading cause of death (Vogel et al. Lancet 2021;397:2385– 438). Race is a surrogate for social determinants of health, which include social and community context, education, economic stability, healthcare access and quality, and neighbourhood and built environment. In this new BJOG paper, nonHispanic black race was associated with high allostatic load score and CVD risk factors; high allostatic load modestly mediated the association between selfreported race and composite outcome, but not between race and hypertension and metabolic disorder, individually. The CARDIA (Coronary Artery Risk Development in Young Adults) study showed that clinical, neighbourhood and socioeconomic factors measured in young women explained the largest component of the racial difference in incidental CVD (Shah et al. Circulation 2022;146:201– 10). Hence, there is a need to assess the cardiometabolic profile risk in young women; as pregnancy is the biggest driver for them to seek medical care and undergo health checks, this is a unique opportunity. A cardiometabolic evaluation could be integrated into existing firsttrimester assessments performed routinely in most public healthcare systems. This may identify women at risk of CVD, and preventive CVD strategies could be started after delivery to improve lifelong maternal cardiovascular health and achieve equity in cardiovascular care.