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Health

Complications during pregnancy linked to a higher risk of heart disease, study finds

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CNN
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Five major pregnancy complications are strong lifelong risk factors for ischemic heart disease, a new study finds, with the greatest risk coming in the decade after delivery.

Ischemic heart disease refers to heart problems, including heart attack, caused by narrowed or dysfunctional blood vessels that reduce blood and oxygen flow to the heart.

Gestational diabetes and preeclampsia increased the risk of ischemic heart disease in the study by 54% and 30%, respectively, while other high blood pressure disorders during pregnancy doubled the risk. Delivering a baby early – before 37 weeks – or delivering a baby with a low birth weight were associated with a 72% and 10% increased risk, respectively.

The study, published in Wednesday in the BMJ, followed a cohort of more than 2 million women in Sweden with no history of heart disease who gave birth to single live infants between 1973 and 2015.

Roughly 30% of the women had at least one adverse pregnancy outcome. Those who had multiple adverse outcomes – whether in the same or different pregnancies – showed further increased risk of ischemic heart disease.

“These pregnancy outcomes are early signals for future risk of heart disease and can help identify high-risk women earlier and enable earlier interventions to improve their long-term outcomes and help prevent the development of heart disease in these women,” said Dr. Casey Crump, an author of the study and professor of family medicine at the Icahn School of Medicine at Mount Sinai.

Heart disease is the leading cause of death among women in the United States and accounts for 1 in 5 female deaths, according to the US Centers for Disease Control and Prevention. This research adds to mounting evidence that pregnancy provides important information about a woman’s cardiovascular health.

“What happens to a woman during pregnancy is almost like a stress test or a marker for her future cardiovascular risk after pregnancy. And unfortunately, a lot of women don’t get told this by anybody,” said CNN Medical Correspondent Dr. Tara Narula, an associate professor of cardiology and the associate director of the Women’s Heart Program at Lenox Hill Hospital. She was not involved in the new study.

Although it’s not completely clear why, experts say the normal changes that occur during pregnancy may unmask underlying health issues in some women with certain risk factors.

Experiencing an adverse pregnancy outcome – even temporarily – could result in changes to blood vessels and the heart that may persist or progress after delivery, increasing a woman’s risk for cardiovascular disease.

This heightened risk is a particular concern for women in the US, experts say, where the maternal mortality rate is several times higher than in other high-income countries.

“There’s been a change in the birthing population. US women are getting pregnant at a later age, and they have already accrued maybe one or two cardiovascular risk factors. Perhaps there are other stressors in life – depression, stress, isolation, obesity – lots of different things that are impacting women in the US,” said Dr. Garima Sharma, associate professor of cardiology and director of the Cardio-Obstetrics Program at Johns Hopkins University School of Medicine, who also was not involved in the new study.

Pregnancy complications are carefully monitored during pregnancy, but there is little evaluation of and education about the effects on cardiovascular health after delivery for women, experts say.

“And so they have their delivery, they’ve had maybe preeclampsia or gestational diabetes, and nobody really follows up with them. They are not told that, in fact, they are at increased risk,” Narula said.

Gestational diabetes is a marker not only for increased risk of diabetes but also for general cardiovascular disease. Preeclampsia and eclampsia are markers for hypertension risk as well as general cardiovascular risks.

Narula, a cardiologist who specializes in caring for women, regularly considers adverse pregnancy outcomes when evaluating patients and emphasizes the continued need for this.

“The classic risk calculator that we use doesn’t have anything in there for pregnancy complications, but you know, it should for women, and hopefully someday, they will start to take that into account,” she said.

The American Heart Association recommends that all health care professionals take a detailed history of pregnancy complications when assessing a woman’s heart disease risk, but this is not consistently done in clinical practice, especially in primary care, where most women are seen, Crump says.

“Raising awareness of these findings among physicians as well as women hopefully will enable more of these women to be screened early and hopefully improve their long-term outcomes,” he said.

Roughly 1 in 3 women will have an adverse pregnancy outcome. Experts say that improving your health before getting pregnant can help avoid these issues.

“Reducing your risk should start preconception, and so getting your body and yourself into the healthiest state possible before you ever even get pregnant is really the first step,” Narula said.

This includes achieving and maintaining a healthy body weight with a good diet and regular exercise, controlling high blood pressure and diabetes, quitting smoking and managing stress.

Taking action after pregnancy is equally important, as research has estimated that only 30% to 80% of women have a postpartum checkup 6 to 8 weeks after delivery.

“Making sure that these women actually are appropriately followed after their delivery and that there is a warm handoff between [obstetrics] and [maternal-fetal medicine] to their primary care doctors or preventive cardiologists who can then talk about optimizing cardiovascular risks and reduction of these risk factors post-pregnancy in the postpartum time frame is crucial,” Sharma said.

Experts hope that increased patient and provider awareness of the connection between pregnancy and heart health will keep birth from being a cause of death.

“Cardiovascular disease is preventable. It’s a leading cause of maternal mortality, but it doesn’t have to be. If we do a better job at screening patients before they get pregnant, if we do a better job of treating them during pregnancy and postpartum, we can improve women’s outcomes,” Narula said. “It’s a tragedy to bring a new life into the world, and then the mother suffers some horrible complication and/or death that could have been prevented.”

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Health

Large new review underscores the risks of Covid-19 during pregnancy

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CNN
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Pregnant women and their developing babies are at higher risk for severe outcomes if they get Covid-19, and now a large, international review is helping to underscore how devastating those risks can be.

The study draws on data from 12 studies from as many countries—including the United States. Altogether, the studies included more than 13,000 pregnant women—about 2,000 who had a confirmed or probable case of Covid-19. The health outcomes for these women and their babies were compared to about 11,000 pregnancies where the mother tested negative for Covid-19 or antibodies to it at the time of their deliveries.

Across the studies about 3% of pregnant women with Covid-19 needed intensive care, and about 4% needed any kind of critical care, but this was far higher than the numbers of pregnant women who needed that kind of care outside of a Covid-19 infection.

Compared to pregnant individuals who weren’t infected, those who got Covid-19 were nearly 4 times more likely to be admitted to an intensive care unit. They were 15 times more likely to be ventilated and were 7 times more likely to die. They also had higher risks for pre-eclampisa, blood clots, and problems caused by high blood pressure. Babies born to moms who had Covid-19 were at higher risk for preterm birth and low birth weights.

Previous studies have suggested that Covid-19 may increase the risk of stillbirth, but this study didn’t find that same link.

Still, the findings paint a clear picture that shows the risks of pregnancy are amplified by Covid-19 infections.

“It’s very clear and even it’s consistent, you know, whether we’re talking about Sweden where we have really generally great pregnancy outcomes to other countries that you know, have bigger problems with maternal morbidity and mortality, that having COVID and pregnancy increases risk for both mom and baby,” said lead study author Emily Smith, who is an assistant professor of global health at George Washington University.

The study has some caveats that may limit how applicable the findings are to pregnant individuals in the Omicron era.

First, the studies were conducted relatively early in the pandemic, at a time when most people were still unvaccinated and uninfected. That means people in the study were likely at higher risk not just because they were pregnant, but also because they were immunologically naïve to the virus—they didn’t have any pre-existing immunity to help them fight off their infections.

Since then, many pregnant individuals have gotten vaccinated, or had Covid-19 or both. As of the first week of January, about 72% of pregnant people in the U.S. have had their primary series of Covid-19 vaccines, and about 95% of Americans are estimated to have had Covid-19 at least once, or been vaccinated against it, according to data from the Centers for Disease Control and Prevention. That means it’s likely they have some immune memory against the virus that may help protect against severe outcomes.

That immune memory appears to fade over time, however. CDC data show just 19% of pregnant women have had an updated booster, meaning many people may not have as much protection against the virus as they think they do.

Lead study author Emily Smith, who is an assistant professor of global health at George Washington University, says the study results reflect the risk of Covid-19 and pregnancy in unvaccinated people.

Unfortunately, Smith says, many countries still don’t have clear guidelines advising vaccination during pregnancy. And there are some parts of the world, such as China, that still have substantial proportions of their population who’ve never been been infected.

For people who are trying to weigh the risks and benefits of Covid-19 vaccination during pregnancy, Smith says this study helps tip the scales firmly on the side of vaccination.

“It’s worth it to protect yourself in pregnancy,” Smith said.

She says this study didn’t look at the benefits of vaccination in pregnancy, but other studies have, showing big decreases in the risk of stillbirth, preterm birth and severe disease or death for mom.

“And so that’s kind of the complementary story,” said Smith.

Dr. Justin Lappen, division director of Maternal Fetal Medicine at the Cleveland Clinic, praised the study and said its findings reinforce and advance previous research, which has found that Covid-19 markedly increases the risk of severe outcomes for mom and baby. He wasn’t involved in the study.

He says the findings highlight the importance of preventing and treating Covid-19 in pregnant women.

Therapies that are indicated or otherwise recommended should not be withheld specifically due to pregnancy or breastfeeding, Lappen wrote in an email to CNN.

The study is published in the journal BMJ Global Health.

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Health

Frozen embryos tied to higher risk of high blood pressure-related pregnancy complications, study suggests

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CNN
 — 

Pregnancies from in vitro fertilization using frozen embryos appear to be linked to an increased risk of complications related to high blood pressure, or hypertensive disorders, compared with when fresh embryos are used or when a pregnancy is conceived naturally.

That’s according to a study published Monday in the American Heart Association journal Hypertension, which included data on more than 4.5 million pregnancies, spanning almost three decades, across three European nations: Denmark, Norway and Sweden.

The risk of pregnancy complications related to high blood pressure was higher after the transfer of frozen embryos compared with naturally conceived pregnancies, and the risk following fresh embryo transfers was similar to that of naturally conceived pregnancies, the data shows.

More research is needed to determine whether similar findings would emerge in the United States.

The researchers – from the Norwegian University of Science and Technology and other institutions in Europe – analyzed medical birth registries from Denmark that were dated between 1994 and 2014, from Norway dated 1984 to 2015, and from Sweden dated 1985 to 2015. The registries included about 4.4 million pregnancies naturally conceived, 78,300 pregnancies that used fresh embryo transfer and 18,037 pregnancies from frozen embryo transfer.

The researchers compared odds of hypertensive disorders during pregnancy across the groups and found that the unadjusted risk of such disorders was 7.4% after frozen embryo transfer, 5.9% after fresh embryo transfer and 4.3% after natural conception. The data also showed that pregnancies from frozen and fresh embryo transfer were more frequently preterm – 6.6% of the frozen and 8.1% of the fresh, respectively – compared with naturally conceived pregnancies, at 5%.

“Frozen embryo transfers are now increasingly common all over the world, and in the last few years, some doctors have begun skipping fresh embryo transfer to routinely freeze all embryos in their clinical practice, the so-called ‘freeze-all’ approach,” lead study author Dr. Sindre H. Petersen, a Ph.D. fellow at the Norwegian University of Science and Technology in Trondheim, Norway, said in a news release Monday.

“In summary, although most IVF pregnancies are healthy and uncomplicated,” he said, “this analysis found that the risk of high blood pressure in pregnancy was substantially higher after frozen embryo transfer compared to pregnancies from fresh embryo transfer or natural conception.”

Petersen added, “Our results highlight that careful consideration of all benefits and potential risks is needed before freezing all embryos as a routine in clinical practice.”

The findings are “in agreement with earlier population-level studies” showing a higher risk of hypertensive disorders during pregnancy after frozen embryo transfer, the researchers wrote in their study.

Last year, a large study out of France presented at the online annual meeting of the European Society of Human Reproduction and Embryology also found a higher risk of pre-eclampsia and hypertension in pregnancies derived from frozen-thawed embryos – and the risk was found to be greater when the uterus was prepared for implantation with hormone replacement therapies.

“The association between frozen embryo cycles and hypertensive disease in pregnancy has been known for a while, and there is still currently an active debate around the pros and cons of ‘Freeze all for all?’ amongst fertility doctors,” Dr. Ying Cheong, professor of reproductive medicine at the University of Southampton, said in a statement distributed by the UK-based Science Media Centre in July. She was not involved in either study.

“There are two important points to take home here, firstly, whilst frozen embryo transfer technology has transformed reproductive medicine, FET must only be performed where clinically appropriate and secondly, clinicians and scientists need to start joining the dots between what happens at early development and later at birth and beyond, a research area, in my opinion, that is still poorly supported and studied,” Cheong said.

The new study did not evaluate what could be driving this association between frozen embryo transfers and high blood pressure risks, but some IVF doctors question whether it is really fresh vs. frozen.

“There is one thing that is not clear: is it from the actual procedure of freezing the embryo or is it from the protocol used? Most IVF doctors believe from recent studies and evidence that it’s actually the medication protocol, not the IVF procedure,” Dr. Aimee Eyvazzadeh, a San Francisco-based reproductive endocrinologist, who was not involved in the new study, wrote in an email to CNN on Monday.

“There are different ways to prepare a uterus for transfer,” she said. One protocol involves a corpus luteum cyst, a fluid-filled mass that forms in the ovaries and plays an important role during pregnancy, as the corpus luteum produces the hormone progesterone that is needed during pregnancy. Another protocol relies on medications to mimic ovulation.

“Studies show that it’s the lack of corpus luteum that increases the risk and this is potentially why a frozen transfer may have a higher risk of pre-eclampsia,” Eyvazzadeh wrote.

Overall, the new study is “very important” for “anyone taking care of pregnant people after IVF,” she wrote. “Everyone taking care of pregnant people after IVF should pay extremely close attention to this study. More and more studies are showing what IVF doctors already know and that is that IVF after frozen embryo transfer can increase risk of pre-eclampsia.”

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