Adverse pregnancy outcomes associated with premature mortality in women

By Melanie Hinze

Five major adverse pregnancy outcomes should be recognised as long-term risk factors for premature mortality in women, according to new research published in JAMA Internal Medicine.

In the Swedish national cohort study, researchers used data from almost 2.2 million women with singleton births between 1973 and 2015, according to the Swedish Medical Birth Register, to investigate the following major adverse pregnancy outcomes: preterm delivery, small for gestational age, pre-eclampsia, other hypertensive disorders and gestational diabetes.

Over 56 million person-years of follow up to a median age of 52 years (42 to 61 years), 88,055 women (4%) died at a median age of 59 years.

The researchers found that all five adverse pregnancy outcomes were independently associated with increased maternal mortality. Gestational diabetes was associated with a 52% increased risk of mortality, preterm delivery a 41% increased risk, small for gestational age a 30% increased risk, other hypertensive disorders a 27% increase and pre-eclampsia a 13% increased risk. All hazard ratios remained significantly elevated even 30 to 46 years after delivery. Cardiovascular and respiratory disorders and diabetes were among the major causes of deaths. Women who experienced multiple adverse pregnancy outcomes were at further increased risk of mortality.

The researchers noted that shared familial factors did not explain these increases in risk.

‘Women with adverse pregnancy outcomes need early preventive evaluation and long-term follow-up for detection and treatment of chronic disorders associated with premature mortality,’ the researchers wrote.

Professor Shaun Brennecke, Dunbar Hooper Professor of Obstetrics and Gynaecology at The University of Melbourne, and Director of the Pregnancy Research Centre, Royal Women’s Hospital, Melbourne, said, ‘There is increasing awareness that women who suffer pregnancy complications, such as pre-eclampsia, gestational diabetes, fetal growth restriction and preterm delivery, have an increased risk of later-life cardiovascular and metabolic morbidity and mortality.’

He told Medicine Today that this research added to this awareness and highlighted the importance of postpregnancy advice and follow up of women with these pregnancy complications.

‘GPs are best placed to provide such ongoing education and surveillance, with a particular focus on lifestyle measures – including exercise, diet, weight control, smoking cessation and alcohol minimisation – and clinical monitoring for hypertension, diabetes, dyslipidaemia and mental health status,’ he said.

‘Pregnancy complications such as pre-eclampsia, gestational diabetes, fetal growth restriction and preterm delivery often intersect with each other, especially in women with higher BMIs,’ he added.

Professor Brennecke noted that although the physiological stress of pregnancy could unmask predispositions to later-life cardiometabolic diseases, whether these predispositions preceded the pregnancy – for example are of genetic in origin – or whether the pregnancy itself initiated them via epigenetic or other mechanisms, or both, was unclear.

‘Clarifying the causative links between these pregnancy complications and later life cardiometabolic ill-health therefore remains an active area of current research,’ Professor Brennecke said.

JAMA Intern Med 2024; doi: 10.1001/jamainternmed.2024.0276.