Adverse Pregnancy Outcomes as a Predictor of Cardiovascular Disease Mortality

Considering individual adverse pregnancy outcomes (APOs) and the sequence of their occurrence may better predict cardiovascular disease (CVD) risk in pregnant women.1,2

APOs like preeclampsia, fetal growth restriction, preterm delivery, and so on have long been associated with a 2-3-fold increase in long-term risk of CVD morbidity. However, emerging evidence indicates that long-term CVD risk is largely based on the total number of APO-complicated pregnancies, the order in which these pregnancies occurred, and whether successive APO-complicated pregnancies are of the same or different type.2

Despite this evidence, women with APOs are largely grouped into a single category, potentially obscuring high-risk individuals and misclassifying low-risk patients. This naturally limits the utility of pregnancy history as a CVD risk predictor. To address this, the current study examines the association between APOs and premature CVD by the aforementioned 3 major categories.2

“Cardiovascular disease in women is underrecognized and undertreated, and as such pregnancy complications have been proposed as a way to identify at-risk women,” Aditi Singh, PhD candidate at the Department of Global Public Health and Primary Care at the University of Bergen, said in a statement. “Our earlier work found that a woman’s risk of premature cardiovascular mortality increases with the number of complicated pregnancies. However, many studies and guidelines still only ask whether a woman has ever had a complication.”1

Singh and colleagues conducted a population-based cohort study with data from Norwegian registries. The team identified 1,001,409 female patients with complete pregnancy histories based on birth records, all of whom had delivery at ≥20 gestational weeks or infant birthweight ≥300 g. Singh and colleagues studied a series of APOs including gestational hypertension, preeclampsia (term and preterm), preterm delivery, perinatal loss, placental abruption, and small for gestational age (SGA). Composite APO was defined as the presence of any of these APOs.2

The team categorized pregnancy history based on 2 frameworks. The lifetime-parity/APO-order approach categorized women by lifetime pregnancies, defining them as having 1 or ≥2 pregnancies, and APO sequence (first vs. later pregnancy). Additionally, Singh and colleagues differentiated between same-type recurrence and different-type occurrence when analyzing APOs individually.2

Ultimately, 0.5% of the included women (n = 5496) died from CVD before age 70, and 21.2% (n = 212,415) experienced ≥1 APO. Median follow-up from last pregnancy was 23 years (interquartile range [IQR], 12-34, maximum 54 years), and median age at end of follow-up was 54 years (IQR, 44-65, maximum 98 years). Singh and colleagues noted that women with APOs tended to have lower educational attainment and higher proportions of pre-pregnancy comorbidities, smoking, and obesity.2

Compared with women with ≥2 uncomplicated pregnancies, those with an APO in the first pregnancy and no subsequent pregnancies had the highest premature CVD mortality (HR, 3.3; 95% CI, 2.97-3.66), followed by those with APOs in both first and later pregnancies (HR, 2.41; 95% CI, 2.16-2.69). The lowest CVD mortality was seen among patients whose first pregnancy was complicated by an APO but who had uncomplicated pregnancies subsequently (HR, 1.39; 95% CI, 1.27-1.53).2

Singh and colleagues did note, however, that the number of pregnancies in a woman’s lifetime and the complications that may affect them are influenced by a variety of factors, which could jointly influence potential CVD development. The team therefore suggests that associations be interpreted descriptively rather than causally.2

“Regardless of the underlying mechanism, a woman’s pregnancy history still carries valuable information about her future risk, and that is something we can act on now, while further research works out exactly why these patterns exist,” Singh said. “Identifying and following up these women is an important area for future work.”1

References

1. The University of Bergen. Two women with the same pregnancy complication may face very different risks of premature cardiovascular death. Eurekalert! August 5, 2026. Accessed August 6, 2026. https://www.eurekalert.org/news-releases/1137972

2. Singh A, Skjærven R, Wilcox AJ, et al. Adverse pregnancy outcomes in successive pregnancies and maternal cardiovascular mortality: A Norwegian nationwide study. European Heart Journal. Published online August 5, 2026. doi:10.1093/eurheartj/ehag564