Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes


      Cardiovascular disease is the leading cause of death among women. Identifying risk factors for future cardiovascular disease may lead to earlier lifestyle modifications and disease prevention. Additionally, interpregnancy development of cardiovascular disease can lead to increased perinatal morbidity in subsequent pregnancies. Identification and implementation of interventions in the short term (within 5 years of first pregnancy) may decrease morbidity in subsequent pregnancies.


      We identified the short-term risk (within 5 years of first pregnancy) of cardiovascular disease among women who experienced a maternal placental syndrome, as well as preterm birth and/or delivered a small-for-gestational-age infant.

      Study Design

      We conducted a retrospective cohort study using a population-based, clinically enhanced database of women in the state of Florida. Nulliparous women and girls aged 15-49 years experiencing their first delivery during the study time period with no prepregnancy history of diabetes mellitus, hypertension, or heart or renal disease were included in the study. The risk of subsequent cardiovascular disease was compared among women who did and did not experience a placental syndrome during their first pregnancy. Risk was then reassessed among women with placental syndrome and preterm birth or delivering a small-for-gestational-age infant vs those without these adverse pregnancy outcomes.


      The final study population was 302,686 women and girls. Median follow-up time for each patient was 4.9 years. The unadjusted rate of subsequent cardiovascular disease among women and girls with any placental syndrome (11.8 per 1000 women) was 39% higher than the rate among women and girls without a placental syndrome (8.5 per 1000 women). Even after adjusting for sociodemographic factors, preexisting conditions, and clinical and behavioral conditions associated with the current pregnancy, women and girls with any placental syndrome experienced a 19% increased risk of cardiovascular disease (hazard ratio, 1.19; 95% confidence interval, 1.07–1.32). Women and girls with >1 placental syndrome had the highest cardiovascular disease risk (hazard ratio, 1.43; 95% confidence interval, 1.20–1.70), followed by those with eclampsia/preeclampsia alone (hazard ratio, 1.42; 95% confidence interval, 1.14–1.76). When placental syndrome was combined with preterm birth and/or small for gestational age, the adjusted risk of cardiovascular disease increased 45% (95% confidence interval, 1.24–1.71). Women and girls with placental syndrome who then developed cardiovascular disease experienced a 5-fold increase in health care–related costs during follow-up, compared to those who did not develop cardiovascular disease.


      Women and girls experiencing placental syndromes and preterm birth or small-for-gestational-age infant are at increased risk of subsequent cardiovascular disease in short-term follow-up. Strategies to identify and improve cardiovascular disease risk in the postpartum period may improve future heart disease outcomes.

      Key words

      To read this article in full you will need to make a payment


        • Mosca L.
        • Benjamin E.J.
        • Berra K.
        • et al.
        Effectiveness-based guidelines for the prevention of cardiovascular disease in women–2011 update: a guideline from the American Heart Association.
        Circulation. 2011; 123: 1243-1262
        • Granger J.P.
        • Alexander B.T.
        • Llinas M.T.
        • Bennett W.A.
        • Khalil R.A.
        Pathophysiology of hypertension during preeclampsia linking placental ischemia with endothelial dysfunction.
        Hypertension. 2001; 38: 718-722
        • Sattar N.
        • Greer I.A.
        Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening?.
        BMJ. 2002; 325: 157-160
        • Ray J.G.
        • Vermeulen M.J.
        • Schull M.J.
        • Redelmeier D.A.
        Cardiovascular health after maternal placental syndromes (CHAMPS): population-based retrospective cohort study.
        Lancet. 2005; 366: 1797-1803
        • Redman C.W.
        • Sargent I.L.
        The pathogenesis of pre-eclampsia.
        Gynecol Obstet Fertil. 2001; 29: 518-522
        • Sibai B.M.
        Evaluation and management of severe preeclampsia before 34 weeks' gestation.
        Am J Obstet Gynecol. 2011; 205: 191-198
        • Smith G.C.
        • Pell J.P.
        • Walsh D.
        Pregnancy complications and maternal risk of ischemic heart disease: a retrospective cohort study of 129,290 births.
        Lancet. 2001; 357: 2002-2006
        • Magnussen E.B.
        • Vatten L.J.
        • Smith G.D.
        • Romundstad P.R.
        Hypertensive disorders in pregnancy and subsequently measured cardiovascular risk factors.
        Obstet Gynecol. 2009; 114: 961-970
        • Sibai B.M.
        • el-Nazer A.
        • Gonzalez-Ruiz A.
        Severe preeclampsia-eclampsia in young primigravid women: subsequent pregnancy outcome and remote prognosis.
        Am J Obstet Gynecol. 1986; 155: 1011-1016
        • Ananth C.V.
        • Smulian J.C.
        • Vintzileos A.M.
        Ischemic placental disease: maternal versus fetal clinical presentations by gestational age.
        J Matern Fetal Neonatal Med. 2010; 23: 887-893
        • Robbins C.L.
        • Hutchings Y.
        • Dietz P.M.
        • Kuklina E.V.
        • Callaghan W.M.
        History of preterm birth and subsequent cardiovascular disease: a systematic review.
        Am J Obstet Gynecol. 2014; 210: 285-297
        • Pine M.
        • Kowlessar N.M.
        • Salemi J.L.
        • et al.
        Enhancing clinical content and race/ethnicity data in statewide hospital administrative databases: obstacles encountered, strategies adopted, and lessons learned.
        Health Serv Res. 2015; 50: 1300-1321
        • Salemi J.L.
        • Salinas-Miranda A.A.
        • Wilson R.E.
        • Salihu H.M.
        Transformative use of an improved all-payer hospital discharge data infrastructure for community-based participatory research: a sustainability pathway.
        Health Serv Res. 2015; 50: 1322-1338
        • Salemi J.L.
        • Tanner J.P.
        • Bailey M.
        • Mbah A.K.
        • Salihu H.M.
        Creation and evaluation of a multi-layered maternal and child health database for comparative effectiveness research.
        J Registry Manag. 2013; 40: 14-28
        • Alexander G.R.
        • Himes J.H.
        • Kaufman R.B.
        • Mor J.
        • Kogan M.
        A United States national reference for fetal growth.
        Obstet Gynecol. 1996; 87: 163-168
      1. Coffey RM, Barrett ML, Steiner S. Final Report Observation Status Related to Hospital Records. 2002. HCUP Methods Series Report #2002-3. September 27, 2002. Agency for Healthcare Research and Quality. Available at: Accessed December 12, 2014.

        • Reinhardt U.E.
        The pricing of US hospital services: chaos behind a veil of secrecy.
        Health Aff (Millwood). 2006; 25: 57-69
        • Salemi J.L.
        • Comins M.M.
        • Chandler K.
        • Mogos M.F.
        • Salihu H.M.
        A practical approach for calculating reliable cost estimates from observational data: application to cost analyses in maternal and child health.
        Appl Health Econ Health Policy. 2013; 11: 343-357
      2. US Department of Labor: Bureau of Labor Statistics. Consumer Price Index: all urban consumers-(CPI-U). Available at: Accessed Dec. 18, 2014.

        • Hirotogu Akaike
        Information theory and an extension of the maximum likelihood principle.
        in: Petrov B.N. Csaki F. Proceedings of the Second International AQ6 Symposium on Information Theory. Akademiai Kiado, Budapest1973: 610-624
        • Veerbeek J.H.
        • Hermes W.
        • Breimer A.Y.
        • et al.
        Cardiovascular disease risk factors after early-onset preeclampsia, late-onset preeclampsia, and pregnancy-induced hypertension.
        Hypertension. 2015; 65: 600-606
        • Lykke J.A.
        • Langhoff-Roos J.
        • Lockwood C.J.
        • Triche E.W.
        • Paidas M.J.
        Mortality of mothers from cardiovascular and non-cardiovascular causes following pregnancy complications in first delivery.
        Paediatr Perinat Epidemiol. 2010; 24: 323-330
        • Brown M.C.
        • Best K.E.
        • Pearce M.S.
        • Waugh J.
        • Robson S.C.
        • Bell R.
        Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis.
        Eur J Epidemiol. 2013; 28: 1-19
        • Bellamy L.
        • Casas J.P.
        • Hingorani A.D.
        • Williams D.J.
        Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis.
        BMJ. 2007; 335: 974
      3. US Census Bureau. American community survey 5-year estimates, table B07401. Available at: Accessed April 13, 2016.

        • Perng W.
        • Stuart J.
        • Rifas-Shiman S.L.
        • Rich-Edwards J.W.
        • Stuebe A.
        • Oken E.
        Preterm birth and long-term maternal cardiovascular health.
        Ann Epidemiol. 2015; 25: 40-45

      Linked Article

      • Progressive uterorenal denervation may contribute to both placental and cardiovascular syndromes?
        American Journal of Obstetrics & GynecologyVol. 216Issue 4
        • Preview
          Cain et al1 find that women experiencing “placental syndromes” are at increased risk of serious cardiovascular disease within 5 years. We believe they have a common source of injury, namely, progressive autonomic denervation. Both uterus and kidneys receive sympathetic nerves from the same thoracic segments (T10-12). Persistent physical efforts during defecation are a common source of progressive autonomic injury in Western populations where they complicate 20-30% of Western bowel movements.2 With the introduction of Western fast foods and removal of squat toilets over the past 25 years, it is becoming a major source of recent, cardiovascular morbidity in China.
        • Full-Text
        • PDF