Knowledge and care regarding long-term cardiovascular risk after hypertensive disorders of pregnancy and gestational diabetes

Cardiovascular disease (CVD) is the leading cause of death in women worldwide [1]. Women are particularly vulnerable to CVD, as they are often underdiagnosed, less likely to receive guideline-directed treatment and underrepresented in clinical trials [2]. Women are less informed about cardiovascular risk factors and the prevention of CVD. Classical cardiovascular risk factors are well known; however, there are additional unique female CVD risk factors and pregnancy and childbirth are specific risk periods for CVD complications in a woman’s lifetime [3]. Preeclampsia/hypertensive disorders of pregnancy (PE/HDP) are diagnosed in 2–8% of pregnancies [4]. Preeclampsia can be classified as early-onset preeclampsia and late-onset preeclampsia with the diagnosis prior to and/or after 34 weeks of gestation. Women diagnosed with early-onset preeclampsia present with a more severe degree of organ involvement and are at higher risk of long-term cardiovascular disease compared to normotensive women [5]. Women diagnosed with hypertensive disorders of pregnancy have a significantly increased risk of future CVD compared to normotensive pregnancies, a 2–8-fold increased risk of chronic hypertension, 2‑fold increased risk of coronary artery disease and increased risk of stroke [5‐8]. One in five women with hypertensive disorders of pregnancy will be diagnosed with hypertension within 15 years postpartum [9]. Furthermore, women with hypertensive disorders are more likely to develop type 2 diabetes [10, 11] and chronic kidney disease [12‐14]. Gestational diabetes affects approximately 14% of pregnancies worldwide and increases the risk of CVD in the long term. Women with GDM have a 2-fold increased risk of cardiovascular events [15] and a lifetime risk of being diagnosed with type 2 diabetes of 50–60% [16]. Preventive programs that include counselling about health risks and lifestyle changes demonstrated a 40% risk reduction of type 2 diabetes in the general population [17]. While it is generally recommended in guidelines that women after adverse pregnancy outcomes (APO) should receive postpartum counselling due to their enhanced CVD risk profile [2, 18‐22], there is a lack of care and knowledge transfer to women and primary healthcare providers after hypertensive disorders of pregnancy and GDM [23].

Even though there are well-known and established risk factors for CVD and chronic kidney disease (CKD) [6, 7, 24], these are not acknowledged by healthcare providers and women [23, 25]. Different national and international guidelines and recommendations exist regarding midterm and long-term surveillance plans after APO [26]. For example, the 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis and management recommendations for international practice proposed that all women should be evaluated at 3–6 months postpartum to ensure that blood pressure, proteinuria, and other laboratory abnormalities have normalized. Furthermore, every year for the first 5–10 years postpartum, a yearly medical follow-up is recommended [4].

This study aimed to outline the status quo of postpartum care concerning PE and GDM. We conducted a survey to evaluate the present status of postpartum care and risk awareness of women with diagnosed gestational diabetes (GDM) or preeclampsia (PE).

Women who gave birth between 1 January 2015 and 31 October 2020 at the University Hospital of St. Poelten/Lilienfeld and were diagnosed with PE or GDM, were identified through the hospital information system. An invitation letter to participate in our survey was sent to 750 women. The letter outlined the aim of this study and the mode of contact and provided an e‑mail address to decline participation in a nonverbal way or to specify a time to be contacted. Women were included if they were German-speaking, 18 years or older and if the diagnosis of hypertensive disorders in pregnancy or GDM was confirmed via electronic hospital records (BP). In accordance with the study period (2015–2020), the international 2013 definition by the American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy was applied to define PE [20]. A structured interview was conducted from June 2021 to October 2021 after women gave oral consent. As a validated German questionnaire for assessing women’s risk perception and knowledge was not available, a survey was custom designed using the publications summarized in the review “Assessing Knowledge Gaps of Women and Healthcare Providers Concerning Cardiovascular Risk After Hypertensive Disorders of Pregnancy—A Scoping Review” [23]. The interview process: trained interviewers performed (AR, CB) and included a survey on received postpartum care, counselling about cardioprotective strategies, and risk perception. The data collection sheet was based on “The Mothers Program^TM” and related protocols [23, 27, 28]. Additional patient characteristics collected were maternal age and body mass index (BMI), gestational age at delivery, gravidity and parity, ethnicity, smoking history, presence of medical conditions in hypertension and diabetes mellitus, medication, prior gestational diabetes, prior hypertensive disorders of pregnancy and family history.

The study was approved by the Karl Landsteiner University of Health Sciences Ethics Committee of the University (1099/2020) and performed according to the Declaration of Helsinki; informed consent to participate in the study was obtained from all women. All data were analyzed using standard statistical packages (SPSS version 27 Windows, IBM Corp. Armonk, NY, USA). Data are presented as means ± standard deviation (maternal age, gestational week of delivery, gestational week of diagnosis) and categorical variables as proportions. The χ²-test Student’s t‑test or Fisherʼs exact test were used to compare these two groups as appropriate. Pregnant women who were diagnosed with both conditions (pre-eclampsia and gestational diabetes) were excluded. The two-sided p values < 0.05 were considered significant.

After the screening shown in Fig. 1, 161 women completed the telephone interview and were included in our study. In total, 46 (29%) women were diagnosed with preeclampsia (PE) and 115 (71%) women with gestational diabetes (GDM). Differences in characteristics of women with GDM compared to those with PE are shown in Table 1. Women with PE were younger at the time of delivery than women with GDM (30.0 vs. 32.8 years, p = 0.002). Prepregnancy mean body mass index (BMI) was 26.5 kg/m², and over one quarter of women were obese (BMI > 30). The percentage of women with obesity was similar in PE and GDM women (24% vs. 27%, p = 0.7). Overall, 96% (n = 154) of women were European. Women diagnosed with GDM tended to be regularly physically active compared to women with PE (68% vs. 54%, p = 0.12). Almost one half of the women (47.5%) reported ever using tobacco in the past, with a similar prevalence observed in both groups, and 16.1% were current smokers at the time of the survey. About 50% of women reported a positive family history of chronic hypertension, 67.4% of women with PE and 46.1% with GDM. Half of all women (49.1%) reported a family history of type 2 diabetes mellitus, 55.7% of women with GDM compared to 32.6% of women with PE (p = 0.008). Of the women with PE 28 (61%) had early onset preeclampsia. Gestational age at delivery was lower in the PE group (35.4 vs. 38.8 weeks, p < 0.001), 16 of the 115 (13.9%) women diagnosed with GDM had a past medical history of GDM, and 17.4% (n = 8) of women diagnosed with PE had already been diagnosed with chronic hypertension and suffered from superimposed PE. Women with PE had a significantly more extended hospital stay than women diagnosed with GDM (37.0% vs. 1.7%, p < 0.001) and 3 women diagnosed with PE were admitted to the intensive care unit (ICU) after giving birth. No ICU admission was reported during pregnancy.

This study evaluated the current practice of postpartum care and healthcare provider counselling of women diagnosed with preeclampsia (PE) and gestational diabetes mellitus (GDM) and the women’s knowledge and awareness about long-term risks for CVD. The peripartum period represents the perfect window of opportunity for assessing cardiovascular risk factors, counselling regarding lifestyle changes and smoking cessation in a cohort of high-risk individuals at a young age. The high prevalence of obesity and smoking in our study further highlights the need for structured postpartum care as a chance for the primary prevention of cardiovascular disease in women.

Our findings show that the current practice of postpartum care of women diagnosed with gestational diabetes or preeclampsia is insufficient to inform women after adverse pregnancy outcomes about the future risks of CVD, guide them to address their risk factors and maintain regular surveillance. We strongly encourage that more attention be paid to healthcare provider education and the implementation of structured postpartum care plans to provide proactive counselling on cardiovascular risk, risk factors and primary prevention of CVD to women diagnosed with gestational diabetes and hypertensive disorders of pregnancy in order to improve their long-term cardiovascular health. Postpartum care plans should be recommended at 3–6 months postpartum, and depending on the diagnosis, follow-up appointments should be recommended with their primary healthcare providers. Hypertensive disorders of pregnancy and gestational diabetes should be considered as a screening tool for future cardiovascular disease prevention through national initiatives.