Variations in Awareness of Association Between Adverse Pregnancy Outcomes and Cardiovascular Risk by Specialty

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Cardiovascular disease (CVD) remains the number one cause of death among women [1‐3]. Much effort has been expended during the past decade to reduce both the incidence and prevalence of this disease burden through screening and treating nontraditional risk factors in women. Contemporary studies have shown that adverse pregnancy outcomes (APOs), including pre-eclampsia (PE), gestational diabetes mellitus (GDM) and pre-term birth (PTB), are associated with future maternal CVD risk [1, 4, 5, 11‐13]. To what degree these associations are known among medical physicians and how that varies by specialty is limited. Additionally, much of the current literature focuses mostly on awareness of PE as a risk factor for chronic hypertension and CVD. The aim of this study was to perform a more comprehensive assessment, including other APOs, and determine whether physicians in various specialties at our institution are aware of the association between APO and CVD risk and how this awareness may vary by specialty.

An anonymous web-based voluntary survey comprising 11 questions (Table 1) was sent to physicians in the fields of internal medicine (IM), family medicine (FM), obstetrics-gynecology (Ob-Gyn) and cardiology at the University of Florida (UF Health). All physicians (MD [allopathic doctor)] or DO [osteopathic doctor]) who were employed by UF Health and worked in the departments of IM, FM, Ob-Gyn and cardiology were eligible to participate. This was purely a voluntary study, and participants had the option of withdrawing at any time. This project was approved as a quality improvement project with the Institutional Review Board at the University of Florida. The survey consisted of demographic questions and practice characteristics (Questions 1–6 and 11) and of questions that aimed to assess a physician’s knowledge on the identification of APOs and their association with future CVD risk. Finally, the survey elicited physician knowledge about screening frequencies, future complications and follow-up (Questions 7–10); these questions had pre-specified responses (shown in bold in Table 1) that were based on the most recent American Heart Association (AHA) and American College of Obstetricians and Gynecologists (ACOG) guidelines [13‐16].

The survey was sent to a total of 140 physicians, of whom 40 (29%) worked in IM, 43 (31%) in FM, 38 (27%) in cardiology and 19 (13%) in Ob-Gyn. A total of 53 (38%) physicians voluntarily participated in the anonymous survey, with a response rate according to speciality/field of 28% of physicians in IM, 33% in FM, 39% in cardiology and 63% in Ob-Gyn. Survey respondent demographics and proportion of women patients are shown in Table 2. Of these 53 physicians, 11 (21%) were in IM, 14 (26%) in FM, 12 (23%) in Ob-Gyn and 15 (30%) were in cardiology. The total number of years of experience varied among each specialty, however, the majority of physicians had > 10 years of clinical experience. A higher percentage of respondents in IM and Ob-Gyn were women (73 vs. 27% men in IM; 58 vs. 42% men in Ob-Gyn), whereas a higher percentage of respondents in cardiology were men (75 vs. 25% women). There was an equal number of male and female respondents within family medicine. As expected, 100% of the patients were women for Ob-Gyn respondents compared to other specialties (p value < 0.0001). Cardiologists had the lowest percentage of female patients, with 81% of the physicians reporting fewer than 50% women in their patient population. Respondents in both FM and IM reported that approximately 50–100% of their patients were women.

As shown in Fig. 1, the overwhelming majority of physicians aimed to screen their women patients for CVD risk factors, and although most physicians screen often or always for CVD risk factors, 21% of physicians reported only screening sometimes or never. When assessing CVD risk, the majority of physicians in the fields of IM, FM and cardiology did not often ask about APOs, in contrast to the Ob-Gyn physicians, among whom 42% screened every woman and 58% screened often) (Fig. 2). Comparing Ob-Gyn responses regarding screening often or always for APOs to the frequency of screening in the other fields, the difference was highly significant (p < 0.001) (Table 3).

Greater percentages of cardiology and Ob-Gyn physicians were aware of the association between APOs and CVD, compared with IM and FM physicians (Fig. 3) although the results did not reach statistical significance (p value 0.107) (Table 4). Although nearly 69% of cardiologists reported awareness of this association, 56% never asked about APOs when assessing CVD risk (Figs. 2, 3).

Physicians from all specialties were aware that PE and GDM were APOs associated with maternal long-term CVD risk; however, PTB remained consistently under-recognized as being an APO (Tables 5, 6). Furthermore, there remains a lack of knowledge regarding diabetic screening guidelines for women with a history of GDM. The majority of physicians in IM, FM and cardiology incorrectly identified or reported not knowing the frequency at which these women should be screened for diabetes post-partum. Although Ob-Gyn physicians were more knowledgeable about the guidelines compared with physicians in other specialties, they still did not all correctly identify this recommended screening frequency. When assessed by specific APO type, there were no statistical differences in recognition of association with long-term CV risk by specialty (Table 6). There were no statistical differences by specialty regarding screening for diabetes (Table 7).

Within every specialty physicians recognized that women with a history of PE should have annual blood pressure measurement, but they were not aware of the importance of assessing the lipid profile, body mass index and glucose (Tables 8, 9, 10). Physicians from all specialties recognized that women with a history of PE have an increased risk of developing chronic hypertension, stroke and ischemic heart disease; however, many providers were unaware of the associated risk of future heart failure and type 2 diabetes mellitus. Physicians in the fields of IM, FM and cardiology were only slightly familar or not at all familiar with the current AHA and/or ACOG guidelines concerning treatment and follow-up management of women with PE. The majority of Ob-Gyn physicians reported being very familiar with these guidelines (Fig. 4) (Table 11). This difference reached significance when comparing Ob-Gyn physicians to those in other specialties (p < 0.0001).

Cardiovascular disease continues to be the leading cause of death in women worldwide [1‐3]. In the past several decades, intensive research efforts have focused on modifying the risk of CVD and promoting primary prevention strategies. Sex-specific risk factors, particularly those related to pregnancy, are known to have accompanying risks for CVD [15, 16]. Vascular damage and placental dysfunction occurring during gestation may share some of the underlying mechanisms for future CVD or may be the trigger for alternative pathways of injury [6]. There is a sufficient body of evidence in recent literature to suggest that women with a history of APOs are more likely to develop CVD later in life than those without [4, 7‐10, 12]. This offers a unique window of opportunity to properly screen for, identify and provide early intervention strategies in women with a history of APOs. However, whether sufficient knowledge exists within various specialties to facilitate screening is unknown. Through this study, we determined that physicians in the investigated specialties from an academic institution were not aware of the association between APOs and CVD, the various types of APOs or their associated secondary risk factors. In addition, there was a knowledge deficiency in screening frequencies and of guidelines for follow-up management for a given APO. Interestingly, in this study, physicians’ knowledge regarding the associations between APO and CVD did not affect screening rates for CVD. A review of the most current AHA and ACOG guidelines recommends that all pregnancies involving PE, GDM and PTB need to be recognized as an APO, with the women at increased risk of developing type 2 diabetes mellitus, ischemic heart disease, chronic hypertension, stroke and heart failure [12‐16]. These guidelines also suggest the need of an annual follow-up for blood pressure, lipids, fasting glucose and body mass index screening [12, 13, 16]. It is important to note, however, that the starting time and the frequency of follow-up differ amongst the international societies and associations [13].

APOs are likely familiar to and easily recognized by those physicians managing these complications, whereas to others not cognizant of these APOs, preventative measures for future CVD may be missed. Preterm birth is defined as a delivery at < 37 weeks gestation, and sometimes the patient may not be aware of the precise gestational age at delivery. The distinction is important as those women with either spontaneous preterm birth at < 32 weeks gestation, those delivered preterm for medical conditions or those with pre-eclampsia are at particularly higher risk for future composite CVD death (adjusted odds ratio 1.8) [11]. Other researchers have reported similar risks for future CVD as well as nearly a fourfold increased relative risk for hypertensive disease in those with a prior pregnancy complicated by pre-eclampsia [12].

Thus, the results of our survey suggest that an opportunity exists to raise physician awareness of APOs and to provide continuous medical education about APOs and their association with future CVD risk. Such knowledge has the potential to translate into educational initiatives targeted toward multi-disciplinary education on this topic as well as clear guidelines for screening women. Increasing awareness of these associations is a step towards improving identification of APOs as CVD risk factors, promoting risk reduction strategies and improving risk factor screening. This is particularly important in young women who have varied sources of primary care, such as those specialties assessed in our study. Given that pregnancy often occurs in a woman’s life before the onset of CVD symptoms, establishing proper screening for APOs affords opportunities for risk mitigation through lifestyle modification and pharmacotherapy for hypertension as well as lipid-lowering therapies where indicated. Although conventional CVD risk calculators do not include consideration of APOs, the most recent primary prevention and lipid guidelines now include consideration of APOs as risk-enhancers for lipid therapy [6]. Thus, APOs continue to emerge as an important part of risk assessment, particularly in young, often otherwise healthy women, and knowledge of such a medical history can guide not only risk assessment but also risk modification.

In conclusion, our survey identifies a need for more education on recognizing the association between APOs and future maternal CVD risk within all specialties providing preventative care to women, especially among physicians in cardiology, IM and FM. Education on the importance of obtaining a detailed pregnancy history at each patient encounter, regardless of specialty, is needed to better assess a woman’s overall CVD risk. In addition to education, developing reminders on electronic medical records (EMRs) would improve a physician’s awareness of and screening for APOs. Despite some raised concerns of alert fatigue, numerous studies have shown the effectiveness of EMR reminders in the improvement of awareness and screening rates of various medical conditions [17‐19]. Ultimately, a combination of educational initiatives and EMR reminders should contribute to the strive toward better identifying women with APOs and modifiable risk factors to reduce CVD risk.