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What is your approach to postpartum screening and cardiovascular risk assessment in patients with a prior history of preeclampsia?

Recent AHA guidelines state that all women who have had a diagnosis of preeclampsia in a prior pregnancy should receive an evaluation of cardiac risk. However, the guidelines including those from ACOG, ESC, AHA remain vague. What test(s) would you consider ordering, and what are your target goals for lipids and blood pressure, etc?
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1 Answer
Mednet MemberInvited Expert
Cardiology · Northwell Health
Answered on · Updated on

Hypertensive disorders during pregnancy, including preeclampsia and gestational hypertension, elevate a woman's long-term risk of cardiovascular disease. The American College of Cardiology (ACC) and the American Heart Association (AHA) now recognize preeclampsia as a risk-enhancing factor for heart disease. Among women with a history of preeclampsia:

  • The risk of heart failure increases fourfold.
  • The likelihood of developing coronary artery disease doubles.
  • The risk of stroke is doubled.
  • The probability of developing hypertension significantly increases.

Importantly, the first several years after pregnancy are at higher risk for these complications.  Educating women regarding their heightened cardiovascular risk stemming from preeclampsia is imperative.

The process of screening patients starts early postpartum and entails:

  • Performing a comprehensive medical history, which includes details about the preeclampsia episodes, their severity, and any associated complications during or post-pregnancy. 
  • Evaluating traditional cardiovascular risk factors like age, gender, blood pressure, lipid profile, smoking habits, diabetes status, and family history of cardiovascular disease.
  • Incorporating non-traditional risk factors such as gestational diabetes, hypertensive disorders of pregnancy, and preterm birth.
  • Undertaking regular blood pressure monitoring due to the robust correlation between preeclampsia and hypertension. The goal is to sustain optimal blood pressure levels of <130/80 and initiate suitable treatment if needed.
  • Considering additional diagnostic tools, such as echocardiography, holter monitors, stress tests, or coronary calcium scoring when appropriate, to provide a more comprehensive assessment of cardiovascular health.
  • Providing counseling that emphasizes the significance of adopting a healthy lifestyle and adhering to prescribed medications. This counseling is pivotal in effectively managing cardiovascular risk.
  • Recommending the use of aspirin as a preventive measure for future pregnancies. Aspirin has been shown to reduce the risk of preeclampsia.

In essence, recognizing the enduring cardiovascular risks associated with preeclampsia, the approach revolves around educating women about these risks and implementing a comprehensive screening process with early postpartum and yearly assessments.

References:

  1. Wu et al., PMID 28228456
  2. Mosca et al., PMID 21325087