Pregnancy Complications Increase Risk for Early Death

Health complications experienced during pregnancy may increase the risk for early death for patients, even decades after giving birth, according to a new study.

The findings, published in JAMA Internal Medicine, underscore the importance of integrating pregnancy history into routine primary care assessments, according to Casey Crump, MD, professor of epidemiology at the University of Texas Health Science Center at Houston and a coauthor of the report.

“Pregnancy provides a key opportunity to identify high-risk women and start interventions earlier in life, before other health problems develop,” Crump said.

Crump and his colleagues used a cohort of 2 million women in Sweden who gave birth between 1973 and 2015 and analyzed data from pregnancy to nearly 50 years later. Nearly one third of women had delivered prematurely, delivered an infant who was small for gestational age, had preeclampsia, gestational diabetes, or another hypertensive disorder.

The risks for all-cause mortality increased by 52% for women who had experienced gestational diabetes (hazard ratio [HR], 1.52; 95% CI, 1.46-1.58). Among the four other adverse pregnancy experiences, HRs ranged from 41% higher for preterm delivery (1.41; 95% CI, 1.37-1.44), small for gestational age (1.30; 95% CI, 1.28-1.32), other hypertensive disorders (1.27; 95% CI, 1.19-1.37), and preeclampsia (1.13; 95% CI, 1.10-1.16).

The risks increased independent of factors such as family history or whether a sibling experienced similar complications, the study found. Approximately 8% of women experienced more than one adverse pregnancy outcome. Previous studies have shown similar results but used smaller sample sizes or assessed only one of the pregnancy outcomes.

A little under half of deaths were attributed to cancer, 14% to cardiovascular disease, 4% to respiratory disorders, 1% to diabetes, and 32 to other causes.

“This suggests that there are multiple different underlying pathways that will need additional research to further identify,” said Crump.

The risk for death was highest for women in the following decade after pregnancy but remained higher among women 32-46 years after delivery than women who had not had respective pregnancy outcomes. The HRs for 32-46 years after delivery were: Gestational diabetes (1.44; 95% CI, 1.35-1.54), preterm delivery (1.36; 95% CI, 1.31-1.41), small for gestational age (1.33; 95% CI, 1.30-1.36), other hypertensive disorders (1.31; 95% CI, 1.14-1.49), and preeclampsia (1.16; 95% CI, 1.12-1.20).

The American College of Obstetricians and Gynecologists (ACOG) recommends women receive ongoing postpartum care beginning within the first 3 weeks after birth. Women with complicated pregnancies or chronic medical conditions should be counseled about their lifetime risk for cardiometabolic disorders and referred to primary care providers for ongoing care, ACOG recommends.

“Such actions should include lifelong reduction of other chronic disease risk factors, such as obesity, physical inactivity, unhealthy diet, and smoking, as well as good control of other conditions such as hypertension and diabetes,” Crump said.

The first 12 weeks postpartum is a critical period for obstetricians and gynecologists to transition care to primary care providers who can help prevent long-term complications from high-risk pregnancies, according to Tamika C. Auguste, MD, chair of the Women’s and Infants’ Services at MedStar Washington Hospital Center in Washington, DC.

Physicians should recognize that all major adverse pregnancy outcomes are long-term risk factors for premature mortality, Auguste said.

“The important thing for primary care physicians is to inquire about pregnancy history, no matter how long ago it may have seemed,” Auguste said. “As this study suggests, all this to keep in mind that pregnancy history affects the nonpregnant state of the patient.”

The study was limited to women in Sweden and may not reflect the healthcare experiences of racially and ethnically diverse populations in the United States, Auguste noted. Many studies suggest that historically marginalized populations more likely to experience disparities in postpartum healthcare are at an even higher risk for earlier death.

“We are already behind the 8-ball because of the difference in maternal mortality because of the racial diversity in our country,” Auguste said.

Federal law currently requires states to provide pregnancy-related Medicaid coverage through 60 days postpartum. Most states have extended postpartum insurance coverage to 12 months.

“I think we’re bringing to light concerns on maternal mortality,” Auguste said. “Having that awareness can extend the options for wellness well beyond the pregnancy.”

The study was supported by grants from the National Heart, Lung, and Blood Institute at the National Institutes of Health, the Swedish Heart Lung Foundation, and Lund University in Sweden, among others. The study authors and experts interviewed in the story disclosed no relevant conflicts of interest.

Lara Salahi is a freelance writer.