Stock photo of an Asian woman holding her pregnant belly.

Friday, Feb. 5, 2016, is National Wear Red Day. (Getty Images)

Cardiovascular diseases – heart disease and stroke – claim the lives of 1 out every 3 women, but many aren't aware of their risk. A survey conducted by the American Heart Association in 2012 discovered that only about half of women realize that heart disease is the No. 1 killer of women, and less than half of women know the healthy levels for cardiovascular risk factors, like blood pressure and cholesterol.

To raise awareness of the impact of cardiovascular disease in women, in 2003, the AHA created the Go Red For Women campaign, a social initiative designed to empower women to take charge of their heart health. In honor of this movement, it designated February "heart month," and Friday, Feb. 5, 2016, is National Wear Red Day.

For heart month – and throughout the whole year – the AHA encourages women to not only wear red but to get their own critical risk numbers for blood pressure, blood cholesterol, blood glucose (sugar) and body mass index; stop smoking; follow a heart-healthy diet; get regular exercise; and discuss their family history with their doctors. These are important tasks for men, too.

But some heart disease risk factors are unique to women – factors that many doctors don't even ask their female patients about – that are red flags spelling potential future heart trouble. These include having a history of elevated blood pressure or elevated blood glucose during a pregnancy, even if these factors improved shortly after delivery.

For many mothers, the discomforts experienced with pregnancy are soon a distant memory after they finally hold their newborn in their arms. But for some women who develop serious complications of pregnancy, such as pre-eclampsia and gestational diabetes, they have an increased long-term risk of cardiovascular disease, even if the disease doesn't present itself until many years later. Both mothers and health care providers need to be aware of the long-term risks that pre-eclampsia and gestational diabetes pose to heart health, and take steps to reduce and prevent the development of cardiovascular disease.

Therefore, the AHA's Guidelines for Prevention in Women consider pre-eclampsia and gestational diabetes major risk factors for cardiovascular disease – on par with smoking and hypertension (high blood pressure). But primary care providers and cardiologists often do not ask their female patients about their prior pregnancy histories.


Pre-eclampsia occurs in the second trimester of pregnancy when the mother develops high blood pressure, and eclampsia is a more severe form of the syndrome that causes seizures. The exact cause of pre-eclampsia is unknown, but research suggests it arises from abnormal narrowing of blood vessels to the placenta, decreasing blood flow and nutrition for the fetus. The placenta then releases chemicals into the mother's circulation that can cause damage to the cells lining blood vessels, called endothelial cells.

Damaged endothelial cells lead to signs and symptoms of pre-eclampsia, such as high blood pressure from vessel narrowing, proteinuria (protein leaking in the urine) and brain swelling from fluid leaking out of damaged blood vessels in the brain. Life-threatening situations can develop for both the mother and the baby, including liver failure, seizures and death in the mother, as well as preterm delivery, low birth weight, placental abruption (detachment of the placenta from the uterus, depriving the baby of oxygen and nutrients and causing heavy bleeding in the mother) and, in some cases, infant death.

While eclampsia deaths are rare in the United States, pre-eclampsia is not uncommon. The condition complicates up to 6 percent of pregnancies, and the rates of pre-eclampsia continue to rise.

Most symptoms of pre-eclampsia usually resolve within a few days of delivery, and in the past, physicians thought pre-eclampsia reversed after delivery when the blood pressure returned to pre-pregnancy levels. However, recent studies show that endothelial cell damage persists long after delivery. Women with a history of pre-eclampsia have more than double the risk of developing chronic hypertension in the future. Hypertension is one of the major risk factors for cardiovascular disease development.

In addition, extensive research shows that women with pre-eclampsia have an increased risk of other cardiovascular disease later in life, independent of hypertension. Between 1990 and 2004, over 1 million pregnant women admitted for their first delivery were followed for eight years in Ontario, Canada. The study found that women with a history of pre-eclampsia had double the risk of premature cardiovascular disease events, including stroke, coronary heart disease and peripheral artery disease, and triple the risk if the fetus died or showed impaired growth during the pregnancy. In another study of over 600,000 first-time mothers in Norway between 1967 and 1992, there was an eightfold increase in the risk of death from cardiovascular causes among women with pre-eclampsia and preterm delivery.

As many women are not aware that pre-eclampsia can have lasting effects on their health, it is important for patients and their providers to be aware of the risks so that women can adopt healthy lifestyle changes to mitigate their risk developing future cardiovascular disease.

Gestational Diabetes

Gestational diabetes is diabetes that first develops or is first diagnosed during pregnancy. Nearly 1 in 10 pregnancies in the U.S. are complicated by gestational diabetes, and this rate continues to increase, according to a 2014 report from the Centers for Disease Control and Prevention. During pregnancy, a woman's body becomes more resistant to the effects of insulin, resulting in elevated blood sugar. The hormone insulin normally moves glucose out of the blood and into the body's cells to be used as energy. These temporary changes in pregnancy are meant to increase glucose levels essential for the nutritional needs of the growing baby.

Women with gestational diabetes have a higher risk of immediate pregnancy and delivery complications, including low blood sugar in the newborn, large infants and obstructed labor requiring caesarean section. For most women, gestational diabetes resolves with childbirth. However, the risks of gestational diabetes may continue to affect women long after pregnancy.

Women with a history of gestational diabetes have at least a sevenfold increase in the risk of developing Type 2 diabetes, according to research published in The Lancet in 2009. Within the first five years of pregnancy, there is a fourfold increase in the risk of diabetes, which doubles after five years postpartum. The risk of Type 2 diabetes continues to increase, even years after delivery. Additionally, having Type 2 diabetes predisposes individuals to cardiovascular, peripheral artery and kidney diseases, and is one of the strongest risk factors for coronary heart disease and strokes. However, a history of gestational diabetes can still predispose women to cardiovascular disease, even in those who don't develop Type 2 diabetes.

Awareness of future cardiovascular disease risks can enable women to take steps to reduce their risk with lifestyle management and medications. Women with a history of gestational diabetes should be screened regularly for the development of Type 2 diabetes. This should first be tested within the first year after delivery and then at a minimum of every three years after.

Concluding Thoughts

Both the mother and baby are at risk when the mother develops serious pregnancy complications, like pre-eclampsia and gestational diabetes. But they also continue to have long-term risks of developing serious cardiovascular complications many years after delivery. In other words, these adverse pregnancy outcomes serve as a failed "stress test" of sorts that identifies susceptible women at elevated risk.

Cardiovascular disease is the leading cause of death in women in the United States, and therefore it's important to recognize the role that pregnancy complications play in future development of coronary heart disease, peripheral arterial disease and strokes. If more patients and their health care providers are aware of this link, women who are at risk will be identified and treated sooner.

Steps You Can Take to Prevent and Treat Cardiovascular Diseases

1. Choose a heart-healthy eating plan.

2. Be physically active.

3. Don't smoke, and avoid secondhand smoke.

4. Get regular wellness exams.

5. Know your risk numbers – for blood pressure, blood glucose, blood cholesterol and body mass index – and discuss your heart disease risks with your health care provider.

6. If you have a history of gestational diabetes or hypertension during pregnancy, make sure to discuss this with your health care provider. You might benefit from closer monitoring or more intense preventive efforts.

Be sure to wear red to support cardiovascular disease awareness for women on National Wear Red Day, and make heart-healthy changes all year long.

Tags: health, patients, patient advice, For Better, American Heart Association, heart-healthy diet, Heart Health, gestational diabetes, diabetes, women's health, pregnancy

Dr. Erin Michos is a cardiologist and associate professor of medicine at the Johns Hopkins University School of Medicine with a joint appointment in epidemiology at the Johns Hopkins Bloomberg School of Public Health. She is the associate director of preventive cardiology for the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease. Her research interests focus on general preventive cardiology, cardiovascular health in women, vitamin D and management of lipid disorders.
Dr. Lena Mathews is a postdoctoral clinical and research fellow in cardiology at the Johns Hopkins University School of Medicine. Her research interests are in atherosclerotic heart disease and heart failure with a focus on heart disease in women.

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