What women need to know about pregnancy complications and heart disease

 by Carolyn Thomas     @HeartSisters

“I’d love to speak about the patient’s perspective at your Toronto conference in June,” I said last winter in response to an invitation from Dr. Graeme Smith, a Canadian obstetrician who teaches at Queen’s University in Kingston and specializes in high-risk pregnancies. “But traveling halfway across the country is just too hard on me these days.”

As the unofficial poster child for the well-documented link between pregnancy complications and premature cardiovascular disease, I was already very familiar with Dr. Smith’s work.  See also: Pregnancy complications strongly linked to heart disease

Shortly after I turned down his kind invitation to speak, he invited me again (hey, he’s persistent!) – but this time he offered the irresistible option of speaking to the Toronto audience via teleconference:

“Does this mean I can stay in my jammies, drink coffee at my kitchen table, and just speak to your group over the phone?!”

That’s exactly what it meant, and that’s how it came to pass that I happened to be a virtual speaker at this Toronto gathering of physicians, as I told my Twitter followers below:

Screen Shot 2014-06-03 at 6.41.32 AM

While waiting for my presentation time slot, I also had the opportunity to go online and listen to a few other conference speakers that morning. As Dr. Jennifer Blake, the CEO of The Society of Obstetricians and Gynaecologists of Canada, posted on Twitter:

Screen Shot 2014-06-03 at 6.45.49 AM

Meanwhile, here’s how Dr. Smith likes to describe this under-appreciated risk:

“Pregnancy is the ultimate cardiac stress test.”

He mentioned in his opening remarks at the conference that his own research has found that women diagnosed with pregnancy complications like preeclampsia also tended to have these known risk factors for heart disease(1):

  • higher blood pressure
  • higher LDL (bad) cholesterol
  • higher blood sugar

In fact, he warns, preeclampsia increases the risk of heart disease by 2- to 3-fold compared to those women who don’t have preeclampsia. 

Cardiologist Dr. Martha Gulati from Ohio State University was also in Toronto that day as an invited speaker. Her presentation included several stats that would no doubt surprise most women (even those who are regular Heart Sisters readers!)

For example, a 2014 study (Howlader et al) reported that in the year 2010, over 400,000 women in the U.S. died from cardiovascular disease, compared to 40,000 from breast cancer.

Yet if we asked women what they believe to be their biggest health threat, how many would mistakenly answer “breast cancer”?

Dr. Gulati quoted the venerable Dr. Nanette Wenger, Chief of Cardiology at Emory University’s Grady Hospital, who once said:

“The medical community has viewed women’s health with a bikini’ approach, looking essentially at the breasts and reproductive system, and almost ignoring the rest of the woman as part of women’s health.”

As a result of this ignorance, women have much poorer outcomes following a cardiac event, said Dr. Gulati, who reminded her colleagues in the audience:

“Women are NOT small men!”

Yet she also reminded them that heart disease is largely preventable.

“It’s NOT an inevitable part of life. 

“We have effective means to reduce heart disease, but we don’t use them enough or effectively – especially in women and minorities.

Also on the conference speaking agenda was obstetrician Dr. Eric Steegers from the Netherlands who spoke about his interdisciplinary team’s work in postpartum lifestyle modification for women considered at high-risk for future cardiac events because of pregnancy complications(2).  These complications include:

  • preeclampsia
  • gestational diabetes
  • polycystic ovary syndrome (PCOS)
  • premature ovarian insufficiency
  • recurrent miscarriages
  • intrauterine growth restriction (IUGR: a low birth weight/full term baby)
  • premature delivery

Dr. Steegers described reproductive disorders as a short-term problem for the OB-GYN, but a longterm problem for the cardiologist.

But because most women with the conditions listed above have rarely been  considered at high risk for cardiovascular disease, current cardiac treatment guidelines are not tailored to this group of young women.

Worse, he said, many doctors aren’t even aware of this link.

Screen Shot 2014-06-03 at 5.23.08 PM

He told us of a study (unlikely to surprise any exhausted, sleep-deprived and overwhelmed new parent) in which researchers looked at potential barriers to making heart-healthy lifestyle decisions after the birth of a new baby.(3) Researchers found that although women expressed an intention to live a healthy lifestyle after their new baby arrived, this generally did not happen. As Dr. Steegers explained:

“Motivators included improving their own current health condition as well as modelling a healthy lifestyle for their children.

“But important barriers were reported to be a lack of knowledge, poor recovery, and lack of professional support after delivery.”

But when these barriers were addressed, as another Dutch study reported (3), planned intervention after a complicated pregnancy resulted in heart-healthy outcomes for new mothers like:

  • doing more exercise
  • healthier diet
  • lower weight/BMI
  • lower waist-to-hip ratio

Then it was my turn to share the patient’s perspective with the Toronto audience.

Here’s that story: shortly before the due date of my first baby, I was one of the approximately five per cent of pregnant women who develop the serious pregnancy complication of preeclampsia (previously known, by the way, as toxemia of pregnancy – a term that originated in the mistaken belief that the condition was caused by toxins. A vintage medical text called Manual of Obstetrics actually recommended “amputation of one or both breasts” to treat toxemia). 

Not one of my doctors or nurses – both before and after that delivery –  mentioned to me at the time that my diagnosis meant I was now at a significantly higher risk of having a heart attack compared to women who have never experienced preeclampsia. Few if any experts had any idea back then, of course, that these two health issues were even related.

Fast forward several years to the day I survived what doctors call the “widowmaker” heart attack

In an effort to narrow down a possible cause for my myocardial infarction, each of the cardiologists, nurses, residents and cardiology fellows who met me during my stay in the Coronary Care Unit of Victoria’s Royal Jubilee Hospital asked me very similar questions:

  • “Do you smoke?”
  • “Have you ever had a prior cardiac event?”
  • “Do you have a family history of heart disease?”

Yet not one of them asked me the question Dr. Graeme Smith wishes all health care providers would ask all female heart patients:

“Have you ever been diagnosed with a pregnancy complication?”

Although it’s difficult to point to one single risk factor as the clear culprit, cardiologists now know that most cardiac events are 20-30 years in the making. My timing seemed alarmingly on track to help confirm the known link between my heart attack and a pregnancy complication that had happened decades earlier.

And when I reminded that Toronto audience that I’d started running during my post-natal exercise classes after that first baby, and that I was a distance runner over the next two decades, the overall consensus among the physicians in my audience was that running and its associated level of increased cardiovascular fitness may very well have helped to postpone my cardiac event by several years.

In Kingston, Dr. Graeme Smith and his team at Queen’s have started an innovative project called the MotHERS Program (Mother’s Health Education, Research and Screening) – a resource for pregnancy, delivery and postpartum – along with a Maternal Health Program where women whose pregnancy complications put them at higher risk for heart disease will receive ongoing cardiac screening and follow-up.

Dr. Smith recommends that screening for cardiovascular risks should be undertaken in the first year after delivery in these high-risk women, preferably starting at around six months postpartum.

This unique screening project is an important and pro-active initiative, as Dr. Smith describes his Maternal Health Program:

“Too much of health care is spent reacting to disease after it’s happened, and not enough is spent on prevention. This is a place to start.”

Despite the shared enthusiasm for this topic of those attending the Toronto event, sometimes I wonder how well we’re doing in spreading the word throughout the medical profession about the significant link between pregnancy complications like preeclampsia and heart disease.

Aside from Dr. Smith’s team in Kingston, the very keen physicians who took the time to attend/present in Toronto, and a handful of international researchers working hard on this issue, are most family physicians or obstetricians even aware of this link?

And if they are, what resources are they recommending to at-risk patients to help lower the likelihood of a future cardiac event?

As Dr. Smith once told The New York Times about the link between preeclampsia and cardiovascular disease:

“Increased awareness about the two conditions might allow physicians to identify a woman’s heart disease risk sooner. The earlier you diagnose them, the more likely you are to prevent cardiovascular disease. This is an opportunity where people can change their future.

But if you ask a cardiologist, they say: ‘I never heard of it.’ 

“It’s not just cardiologists who are not aware of the link between pregnancy complications and cardiovascular disease. We did a survey study among doctors in Ontario: most general practitioners and obstetricians don’t know of this link or at least don’t make any recommendations for follow-up.

“Our goal is to change all that!”

If you’ve been diagnosed with preeclampsia, please visit The Preeclampsia Foundation’s website, and participate in their Preeclampsia Registry, a research tool that will help investigators track women like me who have ever had preeclampsia.


(1)  Graeme Smith et al. “Smith, G.N. (2009) Development of Preeclampsia provides a window of opportunity for early cardiovascular risk screening and intervention. Expert Rev Obstet Gynecol 4(4), 355-357.
(2) Motivators and Barriers to a Healthy Postpartum Lifestyle in Women at Increased Cardiovascular and Metabolic Risk. Meeke Hoedjes et al.  Hypertension in Pregnancy. 31: 147-55. 2012.
(3) Preliminary results of the Postpartum Rotterdam Appraisal of Cardiovascular Health and Tailored Intervention Study (ProActive-study). ZonMw Programma Preventie, deelprogramma Innovat

See also:

Pregnancy: the ultimate cardiac stress test

Pregnancy complications strongly linked to heart disease

The ‘bikini approach’ to women’s health research


 Q: How familiar are you with the link between pregnancy complications and heart disease?


9 thoughts on “What women need to know about pregnancy complications and heart disease

  1. Great great article, and I have been very involved at creating and awareness, but really want to focus on BIG change. I think the absolute best thing to do is to test women and men at their annual check up (FREE with healthcare reform since 2014) a little more extensively if they have a family history – add the Lp(a) blood test and get a baseline ECG. Both may catch huge risk factors for future major events that can cost the insurance companies on a catastrophic level for extended periods (my dad lived for 20 years after a massive stroke). Healthcare is missing the boat on this so deeply. I am trying to find a way to speak and present on this.

    Liked by 1 person

    1. A great mission for you to undertake, Stacey – creating awareness is indeed a necessary and important step. A couple of comments in response to the suggestion of an expanded annual check up: this might not make as much of a difference as we might think at first blush. First, we have many examples of a perfectly “normal” ECG followed days or weeks later by a massive coronary artery blockage caused by a soft vulnerable plaque rupture. Such ruptures can go from zero to 60 despite “normal” cardiac diagnostic tests, as I experienced personally (sent home from the ER with all tests “normal” despite textbook cardiac symptoms and a “widowmaker” heart attack). Secondly, my understanding is that there are few if any definitive treatments even if Lp(a) is correctly diagnosed other than with lifestyle improvements (diet, exercise etc.)

      What I now tell my Heart-Smart Women presentation audiences is this: there is simply no downside in living from now on as if you are ALL at very very high risk of heart attack (i.e. start those lifestyle improvements right away to address controllable risk factors). Best of luck to you in your mission…


  2. So, I too was first diagnosed with hypertension when I was 23, slim and in good shape. Fortunately it never progressed to pre-eclampsia and subsided for a bit after delivery.

    With my second child, again it was a problem, although it never progressed to pre-eclampsia, although I nearly stroked out during delivery. Afterwards, saw a hypertension specialist and went on meds. I have been on meds most of my adult life for hypertension.

    Fast forward to ten years ago and again I nearly stroked out during a colonoscopy. Truly, it was only my persistence that got me the tests and referrals to cardiologists. I had ventricular arrhythmias for years… Something like 26000-28000 per day, so I had to have two cardiac ablations to correct them. Those are usually very easy procedures, but my second one resulted in a cardiac puncture, acute tamponade, 2 cardiac arrests, died twice according to the docs, and emergency open heart surgery. Was in a major medical center with great doctors and they told me that I was their miracle patient because most people don’t survive that, or they lose a lot of brain function. I walked out in 2 days.

    A major factor besides the doctors and staff being excellent was that I had been exercising, according to them. Have always exercised because it helps a lot with my blood pressure. But still, the pregnancy complications I am sure indicated how my body responded to stress and was a predictor. I still have hypertension of course and cardiac spasms and some arrhythmias. I do exercise 5 days a week because I believe it saved my life.

    In the more than 30 years that I’ve dealt with this, no doctor has ever asked about pregnancy complications or even when the hypertension started.

    Liked by 1 person

    1. Such a great lesson, Helen. It’s now believed that pregnancy complications don’t cause our subsequent heart problems – they REVEAL them. Truly the “ultimate cardiac stress test!”

      Best of luck to you and your brave little heart!


  3. Carolyn,
    I always eagerly await Monday mornings when your column appears in my Inbox. I’m a huge fan of the information and discussion that it provides.

    This subject is near and dear to my heart because 20 years ago, I was diagnosed with Antiphospholipid syndrome or antiphospholipid antibody syndrome, which is a fancy name for a very common condition during pregnancy.

    I suffered two miscarriages until I was diagnosed with this condition that effectively caused blood clots in order to cut off the blood supply to the growing fetus, seeing it as a foreign body. You hear about women being told to take a baby aspirin during pregnancy to combat this. My condition was so off the charts that I took the aspirin, steroids, and shot myself with heparin every 8 hours daily all throughout the pregnancy.

    It was a stressful high risk pregnancy but when my son was born, 7 weeks early and at 3 1/2 lbs, my doctors got us both through it well. No one told me anything about any long term effects, and 17 years later I suffered the “widow-er maker” heart attack.

    Yes, I had family history of heart disease, but was otherwise in great condition, fairly fit, at a normal weight and a non-smoker. I shouldn’t have survived my heart attack, 65% of muscle was damaged; stents weren’t possible and no healthy muscle to bypass to, so I’m treated with medications only. Because of the success of my medication regime (and hopefully, my otherwise fitness), I was taken off the transplant list and hope for the best for my future.

    It was my idea to see what the connection is between my condition 20 years ago and my heart attack almost 4 years ago. I’m trying to get my High Risk Ob/Gyn to dig out my records from storage so I can take them to my Heart Failure doctor.

    More women need to be aware of these conditions and potential complications later in life.

    Liked by 1 person

    1. Thanks for sharing your compelling story here, Eve. It’s a good example of how important it is for patients to do their homework when a serious medical diagnosis hits. Good luck with your old records – and educating your docs.


  4. Carolyn,

    I am now receiving your blog in this format (see below) on my iPad. Do you have any idea why this is so? I’d like to fix the problem as I enjoy reading your blog. It is great!


    Maxine Charlesworth


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