ABSTRACT
BACKGROUND: Patients with a hypertensive disorder of pregnancy are more likely to have underlying
cardiovascular risk factors and are at increased risk of future cardiovascular disease.
These patients are more likely to be diagnosed with new-onset chronic hypertension
and meet the criteria for metabolic syndrome postpartum. High-sensitivity C-reactive
protein is a marker of general inflammation and may be used to identify increased
risk for cardiovascular disease.
OBJECTIVE: This collaborative data-sharing study between Yale University, United States (Yale
Hearts Moms study) and Queen's University, Canada (Maternal Health Clinic) aimed to
study the utility of high-sensitivity C-reactive protein in postpartum cardiovascular
risk screening, as determined by 30-year risk (Framingham) and metabolic syndrome
6 to 12 months postpartum.
STUDY DESIGN: Patients with a hypertensive disorder of pregnancy (n=478) or an uncomplicated, term
pregnancy (n=90) had cardiovascular risk screening and risk scoring performed at 6
to 12 months postpartum. Patients were excluded if they had a multiple gestation or
chronic hypertension, diabetes mellitus, or cardiovascular disease diagnosed before
pregnancy. Patients were categorized according to high-sensitivity C-reactive protein
(mg/L) into Normal (<3.0), High (3.1 to <10.0), and Acute (≥10.0) groups. The primary
outcome of the study was risk for future cardiovascular events, calculated through
surrogate measures such as hypertension and cholesterol. Kruskal–Wallis and chi-square
tests were used to compare groups, with post hoc tests corrected using the Bonferroni
method. Multivariable logistic regression was used to assess the association between
high-sensitivity C-reactive protein and cardiovascular risk, adjusting for relevant
medical and sociodemographic variables. Analysis was completed with IBM SPSS Statistics,
version 27.
RESULTS: Patients in the High and Acute high-sensitivity C-reactive protein groups were more
likely to have a body mass index ≥30, to have experienced a hypertensive disorder
of pregnancy, to have a lower household income, and to have not breastfed or to have
breastfed for <6 months, when compared with the Normal high-sensitivity C-reactive
protein group (all P<.05). Patients in the High and Acute high-sensitivity C-reactive protein groups had
higher 30-year cardiovascular risk scores and were more likely to have metabolic syndrome
when compared with the Normal high-sensitivity C-reactive protein group (all P<.05). Patients with High high-sensitivity C-reactive protein had 2-fold odds of metabolic
syndrome 6 to 12 months after delivery, compared with those in the Normal high-sensitivity
C-reactive protein group (adjusted odds ratio, 2.85 [95% confidence interval, 1.66–4.91]),
adjusting for hypertensive disorder of pregnancy, body mass index, clinic site, breastfeeding,
income, and family history of cardiovascular disease. Those with Acute high-sensitivity
C-reactive protein also seemed to have elevated odds of metabolic syndrome compared
with the Normal high-sensitivity C-reactive protein group (adjusted odds ratio, 2.52
[95% confidence interval, 1.24–5.12]). The odds of chronic hypertension were significantly
higher (P<.05) in the High high-sensitivity C-reactive protein group (adjusted odds ratio,
1.72 [95% confidence interval, 1.12–2.65]) compared with the Normal group.
CONCLUSION: Individuals with elevated postpartum high-sensitivity C-reactive protein are at increased
risk of cardiovascular disease 6 to 12 months postpartum after a pregnancy complicated
by a hypertensive disorder of pregnancy. Future research is critical to determine
the most comprehensive and accurate method and timing of postpartum cardiovascular
risk screening to decrease the incidence of preventable cardiovascular mortality among
women.
Key words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Obstetrics & Gynecology MFMAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Association of conventional cardiovascular risk factors with cardiovascular disease after hypertensive disorders of pregnancy: analysis of the Nord-Trøndelag Health Study.JAMA Cardiol. 2019; 4: 628-635
- Risk of future cardiovascular disease in women with prior preeclampsia: a FOCUS Group Study.BMC Pregnancy Childbirth. 2013; 13: 240
- A history of preeclampsia identifies women who have underlying cardiovascular risk factors.Am J Obstet Gynecol. 2009; 200 (e1–8): 58
- Pregnancy complications and maternal risk of ischaemic heart disease: a retrospective cohort study of 129,290 births.Lancet. 2001; 357: 2002-2006
- Long term mortality of mothers and fathers after pre-eclampsia: population based cohort study.BMJ. 2001; 323: 1213-1217
- Effect of gestational diabetes and hypertensive disorders of pregnancy on postpartum cardiometabolic risk.Endocr Connect. 2018; 7: 433-442
- Metabolic syndrome following hypertensive disorders in pregnancy in a low-resource setting: a cohort study.Pregnancy Hypertens. 2021; 25: 129-135
- Pre-eclampsia and cardiovascular disease.Cardiovasc Res. 2014; 101: 579-586
- High sensitivity C-reactive protein as a postpartum biomarker for cardiovascular disease risk.J Obstet Gynaecol Can. 2018; 40: 850-851
- Hypertension in pregnancy is associated with elevated C-reactive protein levels later in life.J Hypertens. 2013; 31: 2213-2219
- C-reactive protein, the metabolic syndrome, and prediction of cardiovascular events in the Framingham offspring study.Circulation. 2004; 110: 380-385
- Seizing the window of opportunity within 1 year postpartum: early cardiovascular screening.J Am Heart Assoc. 2022; 11e024443
- C-reactive protein, inflammation, and cardiovascular disease: clinical update.Tex Heart Inst J. 2005; 32: 384-386
- Predicting the 30-year risk of cardiovascular disease: the Framingham heart study.Circulation. 2009; 119: 3078-3084
- General cardiovascular risk profile for use in primary care: the Framingham heart study.Circulation. 2008; 117: 743-753
- Prediction of lifetime risk for cardiovascular disease by risk factor burden at 50 years of age.Circulation. 2006; 113: 791-798
- IDF Epidemiology Task Force Consensus Group. The metabolic syndrome–a new worldwide definition.Lancet. 2005; 366: 1059-1062
- Chronic hypertension in pregnancy.Am J Obstet Gynecol. 2020; 222: 532-541
- A systematic review of outcomes of maternal weight gain according to the Institute of Medicine Recommendations: birthweight, fetal growth, and postpartum weight retention.Am J Obstet Gynecol. 2009; 201 (e1–14): 339
- Pre-pregnancy body mass index is associated with dietary inflammatory index and C-reactive protein concentrations during pregnancy.Nutrients. 2017; 9: 351
- Maternal obesity and markers of inflammation in pregnancy.Cytokine. 2009; 47: 61-64
- Relationships between pregnancy outcomes, biochemical markers and pre-pregnancy body mass index.Int J Obes (Lond). 2011; 35: 570-577
- Postpartum metabolic syndrome and high-sensitivity C-reactive protein after gestational hypertension and pre-eclampsia.Int J Gynaecol Obstet. 2020; 151: 443-449
- Differences in the prevalence of metabolic syndrome and levels of C-reactive protein after puerperium in women with hypertensive disorders during pregnancy.Hypertens Res. 2010; 33: 1012-1017
- Elevated C-reactive protein levels during first trimester of pregnancy are indicative of preeclampsia and intrauterine growth restriction.J Reprod Immunol. 2003; 59: 29-37
- Association of fibrinogen and C-reactive protein with severity of preeclampsia.Eur J Obstet Gynecol Reprod Biol. 2005; 121: 154-158
- Change of hs-CRP, sVCAM-1, NT-proBNP levels in patients with pregnancy-induced hypertension after therapy with magnesium sulfate and nifudipine.Asian Pac J Trop Med. 2013; 6: 897-901
- Maternal serum highly sensitive C-reactive protein in normal pregnancy and pre-eclampsia.Int J Gynaecol Obstet. 2007; 98: 105-109
- OS106. The postpartum preeclampsia clinic (PPPEC) - an interdisciplinary clinic for cardiovascular risk reduction for women with preeclampsia.Pregnancy Hypertens. 2012; 2: 237
- Cardiovascular risk management after a hypertensive disorder of pregnancy.Hypertension. 2012; 60: 1368-1373
- Motivators and barriers to a healthy postpartum lifestyle in women at increased cardiovascular and metabolic risk: a focus-group study.Hypertens Pregnancy. 2012; 31: 147-155
- Pregnancy: a “teachable moment” for weight control and obesity prevention.Am J Obstet Gynecol. 2010; 202 (e1–8): 135
- Does maternal race or ethnicity affect the expression of severe preeclampsia?.Am J Obstet Gynecol. 2005; 193: 973-978
- Racial/ethnic differences in pregnancy-related hypertensive disease in nulliparous women.Ethn Dis. 2014; 24: 283-289
Article info
Publication history
Published online: October 19, 2022
Accepted:
October 17,
2022
Received in revised form:
September 30,
2022
Received:
July 18,
2022
Footnotes
The authors report no conflict of interest.
The Yale Hearts Moms cohort was funded by the Paul Titus Fellowship in Obstetrics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine.
The findings of this study were presented as a poster at the annual meeting of the Society for Reproductive Investigation in Denver, CO, March 15-19, 2022.
Cite this article as: Johnstone AM, Pudwell J, Ackerman-Banks CM, et al. High-sensitivity C-reactive protein use in cardiovascular risk screening at 6 to 12 months postpartum following hypertensive disorders of pregnancy. Am J Obstet Gynecol MFM 2022;XX:x.ex–x.ex.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
