History of adverse pregnancy outcomes associated with subclinical CAD at later age

Association Between History of Adverse Pregnancy Outcomes and Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography

Literature - Sederholm Lawesson S, Swahn S, Pihlsgård M, et al. - JAMA. 2023 Feb 7;329(5):393-404. doi: 10.1001/jama.2022.24093

Introduction and methods


Women with adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, or preterm delivery, have a higher risk of coronary artery disease (CAD) compared with women without these complications [1-8]. However, the association between pregnancy history and CAD is not yet fully understood.

Aim of the study

The study aim was to assess the association between history of adverse pregnancy outcomes and subclinical CAD assessed by coronary computed tomography angiography (CCTA) screening.


This was a prospective cross-sectional study of a Swedish population-based cohort of 10,528 women for whom 1 or more deliveries in 1973 or later were registered in the Swedish National Medical Birth Register and who participated in the Swedish Cardiopulmonary Bioimage Study at age 50–65 years. Median time between the first registered delivery and the CCTA screening was 29.6 years (IQR: 25.0–34.9). Assessed adverse pregnancy outcomes included preeclampsia, gestational hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes.


The following 5 complementary coronary atherosclerosis indices were used: any coronary atherosclerosis, any significant stenosis, any noncalcified plaque, segment involvement score of ≥4 (which indicates elevated risk of CV events), and coronary artery calcium score >100 Agatston units.

Main results

Main study cohort

  • In total, 1991 women (18.9%) had a history of any adverse pregnancy outcome, ranging from preterm delivery (9.5%) to gestational diabetes (1.4%).
  • The prevalence of any coronary atherosclerosis was higher in women with a history of any adverse pregnancy outcome (32.1%; 95%CI: 30.0%–34.2%) compared with women with no such history (28.3%; 95%CI: 27.3%–29.2%) (prevalence difference: 3.8%; 95%CI: 1.6%–6.1%; prevalence ratio: 1.14; 95%CI: 1.06–1.22).
  • The prevalence ratios of the other 4 coronary atherosclerosis outcome indices were also significantly higher in women with a history of any adverse pregnancy outcome than those in the reference group.
  • Both previous preeclampsia and history of gestational hypertension were significantly associated with higher prevalences of all 5 outcome indices.
  • For example, for women with previous preeclampsia, the highest prevalence difference was observed for any coronary atherosclerosis (prevalence difference: 8.0%; 95%CI: 3.7%–12.3%; prevalence ratio: 1.28; 95%CI: 1.14–1.45), while the highest prevalence ratio was found for any significant stenosis (prevalence difference: 3.1%; 95%CI: 1.1%–5.1%; prevalence ratio: 2.46; 95%CI: 1.65–3.67).
  • Women with a previous preterm delivery, a small-for-gestational-age infant, or gestational diabetes also showed significantly higher prevalences of several indices, although these prevalences were numerically lower than those in women with previous preeclampsia or gestational hypertension.
  • In multivariable-adjusted models, the OR in women with previous preeclampsia ranged from 1.31 (95%CI: 1.07–1.61) for any coronary atherosclerosis to 2.21 (95%CI: 1.42–3.44) for any significant stenosis.

Subgroup analysis

  • In a subgroup analysis of 8334 women with low estimated 10-year CVD risk (<5%), history of any adverse pregnancy outcome was associated with significantly higher prevalences of all 5 indices compared with women with no such history. For example, the prevalence difference for any coronary atherosclerosis was 3.2% (95%CI: 0.8%–5.7%; prevalence ratio: 1.14; 95%CI: 1.03–1.24).
  • Moreover, previous preeclampsia and gestational hypertension were both significantly associated with higher prevalence ratios of all indices, except for the association between gestational hypertension and any significant stenosis.
  • For the other adverse pregnancy outcomes, the prevalence ratios were not significantly higher


In this population-based cohort of Swedish women aged 50–65 years undergoing CCTA screening, there was a significant association between a history of adverse pregnancy outcomes—especially previous preeclampsia or gestational hypertension—and CCTA-identified CAD. This association was also observed in women who were estimated to have a low CVD risk.


1. White WM, Mielke MM, Araoz PA, et al. A history of preeclampsia is associated with a risk for coronary artery calcification 3 decades later. Am J Obstet Gynecol. 2016;214(4):519.e1-519.e8. doi:10.1016/j.ajog.2016.02.003

2. Honigberg MC, Zekavat SM, Aragam K, et al. Long-term cardiovascular risk in women with hypertension during pregnancy. J Am Coll Cardiol. 2019;74(22):2743-2754. doi:10.1016/j.jacc.2019.09.052

3. Wu P, Haththotuwa R, Kwok CS, et al. Preeclampsia and future cardiovascular health: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2017;10(2):e003497. doi:10.1161/CIRCOUTCOMES.116.003497

4. Grandi SM, Filion KB, Yoon S, et al. Cardiovascular disease-related morbidity and mortality in women with a history of pregnancy complications. Circulation. 2019;139(8):1069-1079. doi:10.1161/CIRCULATIONAHA.118.036748

5. Bonamy AK, Parikh NI, Cnattingius S, Ludvigsson JF, Ingelsson E. Birth characteristics and subsequent risks of maternal cardiovascular disease: effects of gestational age and fetal growth. Circulation. 2011;124(25):2839-2846. doi:10.1161/CIRCULATIONAHA.111.034884

6. Wu P, Gulati M, Kwok CS, et al. Preterm delivery and future risk of maternal cardiovascular disease: a systematic review and meta-analysis. J Am Heart Assoc. 2018;7(2):e007809. doi:10.1161/JAHA.117.007809

7. Gunderson EP, Sun B, Catov JM, et al. Gestational diabetes history and glucose tolerance after pregnancy associated with coronary artery calcium in women during midlife: the CARDIA study. Circulation. 2021;143(10):974-987. doi:10.1161/CIRCULATIONAHA.120.047320

8. Kramer CK, Campbell S, Retnakaran R. Gestational diabetes and the risk of cardiovascular disease in women: a systematic review and meta-analysis. Diabetologia. 2019;62(6):905-914. doi:10.1007/s00125-019-4840-2

Find this article online at JAMA.

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