A simple screening question could help millions of women prevent cardiovascular disease. Why aren’t we using it?

Early one afternoon in 2000, Monique Shields, just a few weeks shy of her 30th birthday, left her busy day as an executive assistant at Starbucks’ corporate headquarters to go to her routine prenatal checkup. Feeling healthy, as she had throughout her 34 weeks of pregnancy, she stopped by her home outside of Seattle, changed into her flip-flops, and drove the five minutes to the appointment at her obstetrician’s office.

Following standard care practice, the nurse checked Shields’ blood pressure. It was sky-high. Her health care team sent her to the emergency department for monitoring. Shields called her husband at work and told him she still felt fine and would be home soon.

But as afternoon turned into evening, she began to see spots in her vision. An ambulance took her to a different hospital equipped to handle a high-risk delivery. The hospital workers monitored her and gave her steroid shots to help her baby’s lungs develop. Then, two days later, as her organs began to shut down, doctors induced her into labor to save her life.

Shields had developed preeclampsia, a complication that occurs in about 5% of pregnancies and in which dangerously high blood pressure can lead to seizures, organ failure, and death.

Thanks to medical intervention, Shields survived and gave birth to her first child, a boy she and her husband named Kendall. He was premature, about five pounds, and had jaundice, but he was otherwise healthy. “We just couldn’t believe that little miracle,” she said, remembering her experience getting to hold him before medical staff took him to the neonatal intensive care unit.

After delivery, however, Shields’ blood pressure didn’t go back down. The doctors kept her at the hospital for three more days for monitoring, then discharged her with blood pressure medication and little discussion of what preeclampsia might mean for her own health down the line.

As soon as Kendall was released from the NICU, Shields was immersed in caring for her premature infant and trying to figure out how to breastfeed every two hours. “It really was overwhelming,” she said. Remembering to take her blood pressure medication was one of the last things on her mind. And no one explained to her why the treatment was important.

Between her high-pressure career and her family, including a second son five years later, Shields’ life stayed busy. Her medication doses often went unused. It wasn’t until her firstborn son was a teenager that Shields learned what researchers had already known for decades: Women who have preeclampsia have more than twice the chance of developing cardiovascular disease later in life compared to women who had pregnancies without it. Yet Shields had never been asked about her pregnancy history in assessing her heart health — nor was she told that her history put her at higher risk.

Today, a growing subset of care providers is advocating for closer follow-up of the millions of people who have had preeclampsia and other complications during pregnancy that signal an increased risk for cardiovascular disease. Given that about one in three women in the U.S. have cardiovascular disease, better screening of people with pregnancy complications could help protect them before they develop the disease in the first place.

“If somebody said to you, ‘you know, there’s a way that we can identify which women are [likely] to develop heart disease down the road,’ wouldn’t you want to screen for it?” said Graeme Smith, head of obstetrics and gynecology at Queen’s University School of Medicine in Canada. “Well, we already have that tool, and it’s pregnancy complications.”

Cardiovascular disease is responsible for about one in five deaths in women in the U.S., more than any other cause — including all forms of cancer combined. Black women like Shields are particularly vulnerable: In the U.S., Black adults are substantially more likely to die from heart disease than their white, Hispanic, or Asian or Pacific Islander counterparts.

To try to reduce deaths from heart disease, health professionals typically use basic risk calculators, which take about a dozen standard data points to predict a person’s likelihood of having a major event, such as a heart attack or stroke, in the next 10 years.

Regardless of their other risk factors, for the most part, patients who are young and female have a very low chance of having a cardiovascular event in the next 10 years, so they are unlikely to get recommendations for serious lifestyle interventions or medication. But they may still be heading down a path to a fatal event later in life.

Some 10 to 15% of pregnancies have at least one complication that is linked to later heart disease. In addition to preeclampsia, these include other forms of gestational hypertension; gestational diabetes; preterm delivery; low birth weight; and placental abruption. People who experience miscarriages and stillbirths are also at greater risk of heart disease. Additional reproductive health conditions — including the early arrival of periods, polycystic ovary syndrome, infertility, and early menopause — have also been linked to increased risk.

These data, however, are all missing from standard cardiovascular disease risk calculators. Some pregnancy complications are listed as part of the comprehensive American Heart Association screening guidelines. But a large national 2014 survey revealed that only 16% of primary care physicians and 22% of cardiologists were using these full guidelines. The failure of health-care providers to screen for these sorts of early warning signs is in keeping with the long-standing pattern in which women’s risk for heart disease is chronically underestimated by medical professionals — as well as by women themselves.

All this means that women like Shields, despite experiencing pregnancy-onset high blood pressure at a fairly young age, don’t “actually meet criteria to suggest any kind of follow-up. Which obviously makes no sense,” Smith said.

Smith started one of the world’s first postpartum heart disease screening clinics in Ontario more than a decade ago in an effort to provide women with care and information that they can use to protect themselves against heart disease. “You don’t want to wait and see 20, 30 years from now,” Smith said. “You want to get working on it now to prevent it from happening … This is all about health preservation.”

Researchers are still teasing out whether pregnancy complications themselves are increasing the risk for later cardiovascular disease — or if they are simply flagging existing risk factors or abnormalities. Many researchers suspect that both are true.

Pregnancy is an early “stress test” for cardiovascular disease, according to Smith and Haywood Brown, a professor of obstetrics and gynecology at the University of Southern Florida Health Morsani College of Medicine and a former president of the American Congress of Obstetrics and Gynecology. “For those who fail the ‘stress test’ and develop one of these complications, it’s a fairly reliable marker that they probably have underlying cardiovascular risk factors,” Smith said. Although the exact mechanisms are still being worked out, many of these conditions likely tie in with increased inflammation, which is linked to higher heart disease risk, Brown said.

When assessing a patient for potential intervention in her practice, Nisha Parikh, a non-invasive cardiologist at the University of California, San Francisco, sees pregnancy-related challenges as “risk enhancers.” “If I’m on the fence about whether to prescribe a statin medication or do more aggressive lifestyle modification, or follow a woman more closely, I take into consideration whether she’s had one of these pregnancy factors,” she said. “If one of those factors is present, it might tip my hand toward having that discussion about being more aggressive about her care — and she might become more motivated to do lifestyle interventions.”

In his conversations with patients, Smith likewise points to these complications as a pivot to recommendations about preventive strategies. “I say to people, ‘use this as the red flag.'”

Researchers, however, still do not have long-term data on cardiovascular disease interventions for those who experience pregnancy complications. So it’s unclear, for example, if lifestyle modifications — such as improving physical activity and diet — and medication work just as well to prevent later heart disease and heart attacks for these individuals as they do for the broader population.

Many experts expect that they will. “There’s no reason to believe that [benefits] wouldn’t occur in this group,” Smith said. “But larger studies need to be done.”

Other lesser-discussed interventions might help as well. Breastfeeding, for example, has been shown to reduce the risk of heart disease later in life, and many experts recommend it when possible, particularly among people who had a serious pregnancy complication. That said, as Parikh and coauthors pointed out in a 2021 Circulation analysis, women who have had a pregnancy complication are often less likely to succeed with breastfeeding.

It’s not immediately clear how many deaths from cardiovascular disease could be prevented by screening for these complications and beginning preventative interventions earlier. But experts suggest it is substantial. And it could have an especially outsized impact in reducing the disproportionate number of Black women who die from heart disease.

As the medical field updates its approach to assessing risk for heart disease, Parikh and others hope that researchers will also collect much more diverse and long-term data about race and ethnicity in order to move the needle toward reducing disparities in heart-disease deaths. “There are unique risk factors in women of color for adverse pregnancy outcomes [and] for cardiovascular disease risk,” Parikh said.

The payoffs of these large-scale efforts could ripple through the decades. “We need to talk more about how we can decrease the generational risk” for heart disease, which is even more likely among people born to mothers who had a pregnancy complication, such as preeclampsia, Brown said. “That’s very important for women of color.”

Greater awareness of the link between pregnancy complications and heart disease can also help people be more proactive about their own health earlier on. After her experience, Shields suggests that when people find out that they’re pregnant, they talk to people in their families who have given birth about any complications, because people can be genetically predisposed to conditions like preeclampsia. She only found out recently that her own mother had similar issues: “Just the other day, she said, ‘Oh yeah, I remember they were concerned about my blood pressure’ when she was pregnant with me.” Shields also learned that a first cousin on her father’s side of the family had severe preeclampsia during her pregnancy and even had a stroke after delivery.

From a clinical standpoint, Parikh recommends close monitoring for complications even at the start of pregnancy, particularly for people who are at higher risk. “Doing everything you can to prevent that from happening is really important,” she said. If a complication does develop, helping the patient aggressively treat the condition before and after delivery could go a long way in reducing their risk of acquiring conditions such as chronic hypertension or type 2 diabetes, thereby reducing the risk of heart disease later in life. “You can see how this can be a very long-term vision — but a very powerful way to prevent disease for our highest-risk populations,” Parikh said.

Screening for past pregnancy complications sounds easy enough. But many barriers still exist. For starters, even just a few decades ago, pregnant people were not typically monitored closely for things like high blood pressure or glucose levels. “Those types of pregnancy complications could have happened, but the woman would not have been aware of it,” Parikh said, which makes it harder to pinpoint who may be at higher risk today.

There is also the massive challenge of follow-up after pregnancy. On average, patients have one postpartum appointment with an obstetrician, primarily to ensure their bodies are healing appropriately from delivery. Then patients usually transition back to standard care with a primary care provider, with conversations driven by their age and overall health. But heart health is an area that requires decades of follow-up, often spanning relationships with multiple providers over the years.

Some specialists, however, are working to create a new model for care.

Margo Minissian runs the Postpartum Heart Health Program at Cedars Sinai in Los Angeles, which screens people who had adverse pregnancy outcomes after delivery — and each year after. Most of the patients she sees “are considered healthy and normal and fine.” And, she said, “we’d like to keep them that way.” Minissian tries to give women support and education to help them stay on track. She tells her patients: “If your blood pressure isn’t less than 130 over 80 all the time, I want to hear about it — text me.”

But care like this is rare. And for many of those who would benefit from this follow-up most, in the U.S., financial coverage is a challenge. In California, where Minissian practices, Medicaid only covers one postpartum visit. “I have a very hard time being able to bring these ladies into my clinic because of insurance reasons,” she said. Many women of color, in addition to being at higher risk for pregnancy complications, are also less likely to have robust health care coverage or to use, for example, Medicaid benefits that they do have for postpartum visits.

Minissian is currently looking for charitable funding to help cover their postpartum care. Ultimately, she said, “we need to change legislation.” Twenty-six states and the District of Columbia have now extended Medicaid coverage for women to one year after birth, but that still leaves many women losing insurance coverage just 60 days after a birth.

Brown also says there’s a need for more telemedicine and remote monitoring for higher-risk people, particularly those in rural areas who might face more barriers to making in-person appointments. Even for people who live close to robust health systems, the realities of parenting, work, and life mean that more on-demand care could improve access and long-term success.

Until these known pregnancy risk factors are integrated into more universal heart-health care, many will have to advocate for themselves. That’s been the case for Shields, who’s now 53. She started taking her risk for heart disease seriously after her father died suddenly from a heart attack just before his 60th birthday; her mother, now 70, developed congestive heart failure five years later. When Shields learned about her additional risk having had preeclampsia, she says she realized: “Oh my god, I’m like a ticking time bomb.”

She now works out at least a few times every week, taking barre and water fitness classes. She and her husband take lots of walks. And she is conscious about what she eats. But none of that came from a doctor. “It was me being my own advocate, really,” she said. She began educating herself through the American Heart Association, and she started seeing a cardiologist. “But that’s me being proactive and requesting that [care],” she said.

Shields wishes she would have known about the increased risk of heart disease due to her preeclampsia sooner, ideally soon after her first delivery. That knowledge, she said, might have helped her stay on top of her blood pressure better from the get-go, reducing her risk of dying from heart disease. “I didn’t take it seriously because I didn’t know what it meant,” she said. “There was really no education.”

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