Prenatal Hyperlipidemia: ‘Canary in a Coal Mine’ for Maternal Health?

Women of childbearing age who have elevated lipids may be at greater risk of cardiovascular issues after pregnancy than those who don’t, new data suggest.

The study of more than 8,400 matched pairs of women with and without high cholesterol found that those with a diagnosis of hyperlipidemia were more likely to develop hypertensive disorders of pregnancy (HDP), gestational diabetes, and arrhythmias (P < 0.05 for all), among other adverse CV and obstetrical outcomes. Participants were followed out to 5 years for CV outcomes.

“Some of these associations were known, but there’s not much information on [hyperlipidemia and its impact] in the cardio-obstetrics world,” said investigator Srijana Maharjan, MD (Allegheny General Hospital, Pittsburgh, PA).  ”This is a database study and is obviously preliminary, but I think this signifies how we should be looking at it differently, and how we should be reinforcing the importance of lipid screening in the preconception period.”

Maharjan is scheduled to present the study today in a poster session at the American College of Cardiology’s Cardio-Obstetrics Essentials meeting.

To TCTMD, course chair Natalie Bello, MD, MPH (Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA), said the findings highlight the need for primordial and primary prevention of all cardiovascular risk factors in young people.

“We know that the healthier you are going into pregnancy, the less likely you are to have complications. But oftentimes cholesterol may not even be checked,” she said. “As a preventive cardiologist, I see people in their forties and fifties sometimes, and this is the first time they’re getting their cholesterol checked despite guidelines suggesting pediatricians should be doing this.”

Generalizable, but More Work Needed

The retrospective analysis, which used data from the TriNetX US Collaborative Network, included two cohorts of 8,431 patients each from more than 60 US hospitals who did or did not have a diagnosis of hyperlipidemia and were matched for baseline characteristics. All were 18 years or older at the time of delivery, between 2000 and 2020.

In addition to the greater risk of HDP, gestational diabetes, and arrhythmias, Maharjan and colleagues found that those with preexisting hyperlipemia had more labor complications (30.6% vs 28.8%; HR 1.09) and antepartum hemorrhage (3.7% vs 2.8%; HR 1.32) than those without hyperlipemia at 5 years, as well as a greater incidence of ACS (0.5% vs 0.3%; HR 1.69).

No differences were seen between the two groups in postpartum hemorrhage or maternal mortality.

 Bello said the data are generalizable to a wide swath of women in the United States and are consistent with what has been seen in other studies suggesting that poorer prepregnancy health serves as a “canary in a coal mine” for maternal health concerns.

“People who have less optimized cardiometabolic health before delivery—whether it’s overweight, high blood pressure, [or] in this case, high cholesterol—are more likely to have adverse outcomes,” she added. “As to whether that [stems from] a constellation of lack of physical activity, poor diet, or social drivers of health, a lot more work needs to be done to understand this better.”

One thing that Maharjan pointed to as requiring further context is the connection between elevated lipids in pregnancy and arrhythmias later on. While that association came as somewhat of a surprise, she said it may make sense when considering pregnancy-related changes that can impact the sympathetic nervous system and various hormonal response systems.

Bello stressed the importance of primary care physicians and obstetricians/gynecologists initiating conversations with women of childbearing age about their modifiable risk factors amid discussions about contraception and pregnancy.

 “If you talk to people who are thinking about getting pregnant, everyone I hope knows the importance of a prenatal vitamin, but nobody’s talking about getting their cardiovascular health checked,” she said. “We don’t check cholesterol during pregnancy because it does become much higher than the non-pregnant numbers. This is why it’s really important to be getting screened in childhood and in early adulthood before getting pregnant to know what the baseline is.”

Maharjan and colleagues say while diet and lifestyle should be emphasized for most women, in some instances, aggressive lipid lowering and referral to a cardiologist may be warranted before conception.