After Tania Saiz had a stroke at age 47, she went on a quest for answers.
She wasn’t aware of any significant health issues before the incident, and she had no known family history of cardiovascular disease. But as she looked for possible explanations, she discovered a clue from her past.
While she was pregnant with her daughter nearly 20 years earlier, she had developed pre-eclampsia, a complication in which the mother’s blood pressure spikes to dangerous levels. She was surprised to learn that the condition had raised her long-term risk for stroke.
“It was never brought up again,” beyond the initial postpartum period, Ms. Saiz said of her diagnosis, and it was not discussed as something that could influence her health later in life.
For most of modern medicine, the health care system has treated pregnancy as a finite event — a nine-month blip in a woman’s medical history. Once a woman reached the end of pregnancy, the prevailing wisdom held that she more or less returned to her pre-pregnancy state.
But in recent years, a growing body of evidence has found that this is not always the case. Experts now believe that pregnancy can offer a window into a woman’s future health, and can provide valuable information about her long-term risk of heart disease, diabetes, stroke and other cardiovascular conditions.
“What happens during pregnancy doesn’t just end when the baby’s born,” said Ms. Saiz, now 52 and a volunteer patient educator for the American Heart Association. If she had known this earlier, she said, she could have taken steps to protect herself.
Despite efforts by some medical organizations to raise awareness about these risk factors, few health care providers ask women who are more than a few months post-pregnancy if they experienced any complications, or manage their care accordingly, experts said.
Not screening women with a history of complications is a “missed opportunity” to prevent disease, said Dr. Amy Yu, a stroke neurologist at Sunnybrook Health Sciences Centre in Toronto.
The link between pregnancy complications and long-term health
The connection between several common pregnancy complications and cardiovascular or metabolic health later in life is significant, experts said.
Women who experience hypertensive disorders during pregnancy, which include pre-eclampsia and high blood pressure and affect about 15 percent of pregnancies in the U.S., are at an increased risk for nearly every cardiovascular health condition, including chronic high blood pressure, coronary artery disease, heart failure and stroke, according to major studies.
A Mayo Clinic study published last year suggests that they also develop coronary artery disease an average of seven years earlier than women without this history. And they are twice as likely to experience a heart attack that isn’t due to a blockage in major arteries.
The risks are “striking,” said Dr. Vesna Garovic, a co-author of the study and the chair of nephrology and hypertension at the Mayo Clinic.
Women diagnosed with gestational diabetes, which affects up to 10 percent of pregnancies in the U.S., are about 10 times more likely to be diagnosed with Type 2 diabetes compared with women without this history, which itself is linked to heart disease, stroke and dementia.
Gestational diabetes “really is a red flag” for developing diabetes down the road, said Dr. Sarah Lassey, co-director of the Diabetes in Pregnancy Program at Brigham and Women’s Hospital, signaling that “your body has some underlying insulin resistance — even if you’ve never had it before, even if you don’t have a family history of diabetes.”
Researchers are still trying to determine if pregnancy complications cause various cardiovascular and metabolic issues later in life, or if they simply unmask a predisposition. Some theorize it’s a combination of both.
For now, many experts see pregnancy complications as part of a constellation of risk factors that women should consider when managing their heart and metabolic health, along with lifestyle and family history.
A lack of awareness
Nearly 15 years ago, the American Heart Association and the American College of Cardiology updated their guidelines to include pregnancy complications as an official risk factor for disease, as evidence of a connection began to emerge. But new findings take a long time to make their way into both medical school curricula and clinical practice (for clinical practice, about 17 years), and many physicians and health care providers themselves are unaware of the risks, said Dr. Gina Lundberg, clinical director of the Emory Women’s Heart Center.
The knowledge gap among clinicians filters down to patients.
“This is not something that our mothers and grandmothers were aware of,” said Dr. Lauren Hassen, director of the Cardiology Postpartum Transition Clinic at the Ohio State University Wexner Medical Center.
Until the late 20th century, the medical community thought that heart disease almost exclusively affected men. As a result, the causes of the disease in women still aren’t fully understood.
“More women die of heart disease than anything else, and we do not know all the risk factors,” Dr. Lundberg said.
But even with growing evidence of a link between pregnancy and heart disease, standard medical intake forms do not typically ask women about pregnancy complications, and patients’ pregnancy records do not typically follow them throughout the medical system, so their pregnancy history is often overlooked.
“We don’t really have a seamless transition from obstetric to internal medicine care for these cases,” Dr. Garovic said.
Some experts say that, gradually, more obstetricians are counseling newly postpartum women about long-term risks. But they often struggle with when and how to discuss the lasting implications of what their patients have experienced, especially when patients have just survived a traumatic pregnancy or delivery.
“If they give you that information in the heat of it, you’re already overwhelmed and terrified for your baby, right? So they often shy away from that until a later appointment, which sometimes never happens,” Dr. Lundberg said.
And so, many women remain in the dark about the risks. A recent study conducted by Dr. Yu found that less than half of women who experienced a cardiovascular or metabolic complication during pregnancy received basic follow-up screening for blood pressure, cholesterol or blood sugar in the three years after pregnancy.
How to manage your risk
If your primary care provider doesn’t ask you about your pregnancy history, be proactive about bringing up any complications you experienced, said Eleni Tsigas, the chief executive of the Preeclampsia Foundation, a nonprofit advocacy group.
“You’ve been given the gift of a crystal ball,” Ms. Tsigas said. “We don’t need to wait until we get the diagnosis of diabetes or hypertension or heart failure,” she added. “There are things we can do to be well ahead of that.”
Depending on your medical and pregnancy history, a clinician may recommend more frequent or comprehensive screening for diabetes or heart disease, including more regular blood pressure, cholesterol and blood sugar readings.
Experts also recommend taking basic steps for heart and metabolic health, including eating a heart-healthy diet, getting the American Heart Association’s recommended amount of weekly physical activity and managing stress and sleep.
“Most women put themselves last” when it comes to tending to their health, Dr. Lundberg said. “We kind of lose track of ourselves,” particularly when caring for families, Dr. Hassen added. She and other experts said they were hopeful that educating women about these risks would motivate them to carve out time for themselves.
Ms. Saiz, the stroke survivor turned advocate, said she wishes she’d had that opportunity. “That was never afforded to me,” she said. “I think that that’s where the real shame comes.”
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