An overview of long-term cardiovascular disease after preeclampsia: Interventions for awareness and risk reduction

Nội dung text: An overview of long-term cardiovascular disease after preeclampsia: Interventions for awareness and risk reduction

1. RESEARCH ARTICLE AN OVERVIEW OF LONG-TERM CARDIOVASCULAR DISEASE AFTER PREECLAMPSIA: INTERVENTIONS FOR AWARENESS AND RISK REDUCTION Renee’ Jones, DNP, RNC-OB, WHNP-BC Clinical Associate Professor, Baylor University Louise Herrington School of Nursing Dallas, Texas Renee_Jones1@Baylor.edu Kathryn Osteen, PhD, RN, CMSRN, CNE Clinical Associate Professor, Baylor University Louise Herrington School of Nursing Dallas, Texas Kathryn_Mitchell@Baylor.edu ABSTRACT Cardiovascular disease (CVD) continues Keywords: Cardiovascular disease, to be the leading cause of death throughout teaching, hypertension, preeclampsia, risk the world. In the United States this is factors, women’s health also true, as CVD is the leading cause of 1. PRECIS death among women overall and during pregnancy. Additionally, preeclampsia Women with a history of hypertensive continues to lead morbidity and mortality. disorders of pregnancy are at risk for long- A diagnosis of preeclampsia will increase term cardiovascular disease. Healthcare a woman’s risk of cardiovascular disease providers should be knowledgeable in order odds by 75% within 10 years of birth. During to recognize the risk factors and respond pregnancy and the postpartum period, as with management of lifestyle preventative providers, there is a window of opportunity measures to decrease cardiovascular risk. to assess and teach women of lifestyle Cardiovascular disease (CVD) leads the changes preventing CVD. Unfortunately, number of deaths worldwide accounting for many healthcare providers are unaware 31% of all global deaths1. CVD is ischemic of this long-term effect and women are not heart disease caused by disorders of the assessed nor taught about the dangerous heart and blood vessels, and includes cardiovascular effects from preeclampsia. coronary heart disease, hypertension, This article addresses the pathophysiology peripheral artery disease, cerebrovascular of preeclampsia, provides an overview disease, deep vein thrombosis and of the long-term effects of CVD from pulmonary embolism1. The risk of CVD preeclampsia, and introduces interventions increases with tobacco use, unhealthy diet, needed to recognize and respond along with obesity, physical inactivity, hypertension, lifestyle preventative measures to decrease diabetes, and hyperlipidemia1. In the United the cardiovascular risk and improve the States (US), one in three women will die health of women. from CVD and stroke2,3. In more recent data, young women, less than 55 years of age, are at an increased risk of mortality Cor. author: Renee’ Jones from CVD2. Healthcare providers should Email: Renee_Jones1@Baylor.edu understand the cause and risk contributing Received: Feb 08, 2021 to atherosclerotic cardiovascular disease Revised: Feb 15, 2021 (ASCVD) in women in order to implement Accepted: Mar 05, 2021 prevention strategies. 86 Journal of Nursing Science - Vol. 04 - No. 01
2. RESEARCH ARTICLE Globally, 14% of maternal mortality It is a well-known fact that CVD is a leading is related to hypertensive disorders cause of death among women, but what if of pregnancy4. However, in the U.S., the woman has a history of preeclampsia. hypertensive disorders of pregnancy affect There continues to be an expanding body 4.1 to 19.4% of pregnancy and carries a of research connecting preeclampsia 10% maternal morbidity and mortality4,5. and CVD. According to the Preeclampsia Hypertensive disorders of pregnancy Foundation white paper, two out of three numbers continue to rise as much as 25% women diagnosed with preeclampsia will in the past two decades6. Contributing to die from CVD7. A diagnosis of preeclampsia increasing maternal morbidity and mortality will increase a woman’s odds of developing are history of hypertensive disorders, heart CVD related morbidity and mortality within disease, advanced maternal age, and 10 years of childbirth by 75%. 2. Therefore, obesity. Additionally, disparities in health the American Heart Association (AHA) care contribute to the increasing maternal has recently included preeclampsia as a morbidity and mortality number as African new risk factor in women for stroke, heart American women are three times more likely disease, and deep venous thrombosis in 2 than white women to die from hypertensive the 5 to 15 years following pregnancy . disorders of pregnancy4. Maternal mortality and morbidity is most Hypertension in pregnancy is a complex, likely to occur during the postpartum period 8,9 multisystem disorder of pregnancy. In 2013, when the woman is discharged home . the American College of Obstetricians Postpartum deaths from one day to one and Gynecologist (ACOG) Task Force year after birth account for more than one 10,3 recommended changes to the definitions third of all maternal deaths . Mortality is of hypertension in pregnancy5. There are rare; however, 65,000 women experience four subtypes of hypertension included morbidity due to chronic medical conditions 11,3 in the definition of hypertension in such as CVD . From 2011-2015, one-third (36%) of pregnancy related deaths occurred pregnancy (Table 1): chronic hypertension, 9 gestational hypertension, preeclampsia, at delivery or in one week after birth . The leading cause of death after delivery is and superimposed preeclampsia. Chronic heart disease and stroke occurring in one in hypertension is hypertension or a blood three deaths overall 3. High blood pressure pressure of 140/90 mmHg or greater prior to is seen as cause of death one week after pregnancy or prior to 20 weeks’ gestation; delivery and cardiomyopathy is the leading gestational hypertension is new-onset cause of death one week to one year after hypertension that develops after 20 weeks’ delivery 3. Additionally, it is well documented gestation without proteinuria; preeclampsia that black women experience maternal is new onset hypertension (defined by morbidity two times higher and mortality high blood pressure on two separate three to four times more frequently than occasions four hours apart) that develops white women 12,9. in previously normotensive women and is accompanied by new onset of proteinuria In order to mitigate these pregnancy risks, or in the absence of proteinuria, there is healthcare providers must understand the presence of multisystem involvement; causes related to long term cardiovascular chronic hypertension with superimposed complications in women. Awareness of preeclampsia is chronic hypertension with CVD after preeclampsia is lacking among 13 new onset of preeclampsia5. the healthcare team and women . During Journal of Nursing Science - Vol. 04 - No. 01 87
3. RESEARCH ARTICLE the hospital stay, there is lack of education prolonged hypoxia at the tissue site. Further regarding long-term CVD effects from hypoxia begins the prolonged inflammation preeclampsia14. Additionally, women lack cascade17. The second stage or placental follow-up appointments typically seeing ischemia from the hypoxic cascade causes their healthcare provider once or twice a release of factors (cytokines and reactive during a six-week postpartum period15. After oxygen species (ROS)) that further cause six weeks, women are told to follow-up with maternal vascular endothelial dysfunction. their provider, however this frequently does The endothelial dysfunction results in not happen15. When a woman presents to generalized vasospasm or constriction, the emergency department with complaints decreased blood flow to organs leading to of symptoms of CVD or worsening multiple system stress or failure. preeclampsia postpartum, treatment is less When comparing the pathophysiology likely to be aggressive, medications are less of preeclampsia to that of CVD, emerging likely to administered, and improper transfer data indicate the ROS plays a significant to a labor and delivery unit for the best care role in the progression of CVD disorders 16. Nurses are the key in advocating for long- such as hypertension, hyperlipidemia, term health and wellness for these women. diabetes mellitus, ischemic heart disease, This article will discuss the pathophysiology chronic heart failure, atherosclerosis and of preeclampsia, preeclampsia risk factors preeclampsia17.The ROS generation, linked to CVD, provide an overview chemically reactive molecules formed of the long-term effects of CVD from in cells during mitochondria respiration, preeclampsia, and introduce interventions leads to vascular endothelial injury needed to recognize and respond with and atherosclerosis17. The injury of lifestyle preventative measures to decrease the endothelium from ROS decreases the cardiovascular risk and improve the nitric oxide (NO) synthase activity17. health of women. This disturbance at the vascular wall or 2. PATHOPHYSIOLOGY OF PREECLAMPSIA endothelium from injury and buildup of atherosclerotic plaques cause inadequate The pathophysiology of preeclampsia ability for the vessel to vasodilate thereby remains to be completely understood, but contributing to further vasoconstriction17. there are some consistencies that continue. Decreased production of NO, a mediator Preeclampsia develops in two stages with of endothelial dysfunction, contributes to the initiating event occurring at placental the development of preeclampsia. Another implantation. The placenta fails to embed into contributor is increased oxidative stress the uterine wall endometrium, beginning the and elevation of ROS18. immunologic process, signaling monocytes and converging macrophages to the site Even though there is no conclusive of embedment. The macrophages then connection between CVD and preeclampsia release cytokines, TNF-a and interlukin-1 noted in the literature, after reviewing the causing inflammation. The inflammation pathophysiologic mechanism, implantation causes a shallow cytotrophoblast migration of the placenta is interrelated with oxygen or impaired remodeling of the maternal spiral concentration and oxidative stress18. ROS arteries from the poor placental implantation can regulate trophoblast proliferation therefore leading to reduced placental and invasion. Oxidative stress influences perfusion throughout the pregnancy. The autophagy (natural way cells clean up reduced placental perfusion leads to or self-eat) and apoptosis (programmed 88 Journal of Nursing Science - Vol. 04 - No. 01
4. RESEARCH ARTICLE cellular death) and there is an imbalance Preterm birth combined with preeclampsia in preeclampsia17,18. Oxidative stress is a strong risk factor for CVD. Irgens et al is commonly seen in smoking, obesity, (2001) reported women delivering preterm preeclampsia, placental dysfunction, and diagnosed with preeclampsia have an diabetes mellitus, and cardiovascular eight-fold increase chance of mortality from disease17,18. CVD when compared to women who did not have preeclampsia (HR = 8.12; 95% CI: Risk Factors Linked to CVD 4.31-15.33)22. Women with preeclampsia In 1927, Cowin and Herrick were the first delivering at term accounted for 6.6 deaths known study identifying the risk of long-term per 1000 versus women with preeclampsia 19 cardiovascular disease from preeclampsia . delivering preterm accounted for 15.5 The American Heart Association (2019) deaths per 1000 22. completed a systematic review and meta- analysis of 84 studies which included When reviewing the timing that over 28 million women finding that women preeclampsia is diagnosed in pregnancy with hypertensive disorders of pregnancy, and the risk of CVD, women with a late-onset preterm birth, diabetes, placental abruption preeclampsia have a two-fold increased and still birth are at increased risk of CVD risk of myocardial infarction or stroke and earlier in life and cerebrovascular-related a fourfold increased risk of hypertension 23,14 morbidity and mortality when compared to later in life . However, if preeclampsia normotensive women20. As a result of this is diagnosed early, the risk is increased to study, a history of placental abruption and a seven or eightfold risk of ischemic heart stillbirth are now added as risk factors for disease, cerebrovascular disease, and 23, 14, 24,13 future CVD. Additionally, there is increased peripheral arterial disease . Early- risk of delivering a small for gestational age onset preeclampsia is associated with poor birth weight infant or low birth weight infant 20. placentation contributing to fetal growth restriction and potential for stillbirth25. Cardiovascular disease and Women with a history of early-onset preeclampsia share similar risk factors (Table preeclampsia had significantly higher blood 2). These include family history, chronic pressures, higher BMI’s, abnormal lipid hypertension, history of preeclampsia, profiles, higher HgA1c, and higher levels obesity, diabetes, metabolic syndrome, of proteinuria26. Women with recurrent obstructive sleep apnea, hyperlipidemia, preeclampsia have increased risk of CVD endothelial dysfunction, stress, smoking, and stroke thereby leading to a shorter life chronic kidney disease, polycystic ovarian span, 48.9 versus 51.9 years 27. disease20,5 . Increased triglycerides, low- density lipoprotein (LDL), total cholesterol Diabetes mellitus increases the risk of and low levels of high-density lipoprotein preeclampsia two to four-fold and thereby (HDL) are markers for cardiovascular increases the risk of CVD two-fold20. health and increased risk or preeclampsia. Diabetes is a risk factor for endothelial Similarly, the woman diagnosed with chronic dysfunction. Huang et al performed a hypertension is twenty-five times at risk meta-analysis that included 53 prospective for developing preeclampsia21. Smoking cohort studies to evaluate the association or rather smokeless tobacco results in between impaired glucose intolerance, vasoconstriction from the nicotine therefore increased fasting glucose, increased increasing risk of preeclampsia20. HgA1c level and the risk of cardiovascular disease 28. The researchers concluded Journal of Nursing Science - Vol. 04 - No. 01 89
5. RESEARCH ARTICLE prediabetes is significantly associated with cardiovascular hospitalizations up to 25 an increased risk of CVD and stroke28. years after pregnancy29. An additional study Insulin resistance is another risk factor by Brouwers et al, performed a systematic contributing to vasoconstriction and the review and meta-analysis to evaluate development of preeclampsia and future the risk of hypertension and CVD after CVD28. Prolonged vasoconstriction causes recurrent preclampsia30. The researchers damage to the blood vessels increasing the concluded recurrent preeclampsia was risk of CVD. Therefore, high glucose level consistently associated with hypertension during pregnancy should be a marker for (RR 2.3; 95% CI 1.9-2.9) and ischemic atherosclerosis and maternal morbidity. heart disease (R.R. 2.4; 95% CI 2.2-2.7), heart failure (R.R 2.9; 95% CI 2.3-3.7), Women with a greater body mass and stroke (RR 1.7; 95% CI 1.2-2.6)30. index and abdominal circumference The pathophysiology of CVD could be measurements are at increased risk of related to the inability of the cardiovascular CVD by threefold 1. Obesity is higher in system to recover from the previous history women than in men contributing to the of preeclampsia. Within the endothelium, development of coronary artery disease by the intima-media thickness is increased 64% as compared to 46% in men 2. Having causing vasoconstriction and a decrease a high BMI during pregnancy is a strong in cardiac output commonly seen in women predictor of poor maternal outcomes. with history of preeclampsia versus women Obesity causes a release of inflammatory without preeclampsia 27, 25. Overtime, the cytokines from the intrabdominal adipocytes endothelium becomes inflamed and is or rather adipokines and is associated dysfunctional which is a common problem with activation of the sympathetic nervous in CVD and preeclampsia. Therefore, a system and renin angiotensin aldosterone history of preeclampsia can determine system17. It is these cytokines that cause the morbidity of organ-systems serving insulin resistance, atherosclerosis, as a marker for cerebrovascular damage, dyslipidemia, and hypertension17. Obesity ophthalmic damage, and cardiomyopathy25. is common in patients diagnosed with Women with a history of preeclampsia were metabolic syndrome. The criteria for found to have approximately double the metabolic syndrome include an abdominal risk of early cardiac, cerebrovascular, and circumference greater than 35 inches, peripheral arterial disease 25,30. hypertension, elevated fasting glucose of greater than 100 mg/dL, and dyslipidemia In a study by Ehrenthal, Maiden, or triglycerides > 150 mg/dL and HDL < 50 Rogers, and Ball, a prospective cohort of mg/dL2. Women previously diagnosed with women (N=294) diagnosed with gestational gestational diabetes are at increased risk of diabetes and/or hypertension were metabolic syndrome. surveyed during postpartum period about patient follow-up31. The authors found that Long-term Effects of CVD from 168 women reported attending their six- Preeclampsia week postpartum visit with their obstetrician Women with a history of preeclampsia (OB-GYN) and 37 women attended an have a risk of recurrent preeclampsia and office visit with their primary care provider long-term cardiovascular hospitalization. (PCP)31. Of the 294, only 143 could report Auger et al studied the association of ever having lipid testing completed and at recurrent preeclampsia and long-term three months, none of the women were cardiovascular hospitalization identifying being treated for diabetes and 17 were 90 Journal of Nursing Science - Vol. 04 - No. 01
6. RESEARCH ARTICLE prescribed medication for hypertension31. scoring system could underestimate the The study reported the women were least risk in some women as it is used in both likely to complete screening tests were men and women 34. When calculating the those who had no college education or had risk score, age, total cholesterol, HDL, less than a high school health literacy and blood pressure, history of smoking, and no insurance31. This study demonstrates diabetes are calculated. women are more likely to receive care from Management of hypertension during their OB-GYN rather than PCP, but yet pregnancy has significant implication for incorporating a PCP into follow-up should CVD risk, the fact remains identification occur. Secondly, social determinants of of high-risk women and treatment of health could be related to CVD preventative care31. hypertension. There are multiple studies and recommendation for the treatment of There are many new studies, describing hypertension in pregnancy. In 2017, the children born from preeclamptic mothers are American Heart Association (AHA) published prone to hypertension, insulin resistance, clinical guidelines on hypertension, but diabetes mellitus, neurological problems, there is unclear guidance as to how they 25, and stroke at some time during their life apply to pregnancy20. According to the 32,33 . Through a meta-analysis of 36 studies guidelines, achievement of a systolic blood including 53000 individuals reviewing the pressure (BP) less than 120 mmHg results effect on maternal preeclampsia on the in significant decrease in the risk of CVD offspring, the authors concluded higher events when compared to BP management blood pressure in children of mothers with of stage 1 hypertension, systolic BP 130- preeclampsia and recommend early blood 139 mm Hg or diastolic BP 80 – 89 mm Hg20. 33 pressure screening in childhood . When paired to the management of blood Health promotion interventions pressure in pregnancy, it is higher before treatment, generally systolic BP 140-160 Evidence is growing regarding the mm Hg and diastolic BP 90-110 mm Hg. In relationship between preeclampsia Europe, blood pressure control is slightly and increased long term CVD. Many tighter with treatment of systolic BP 140- interventions exist that healthcare providers 150 mmHg and diastolic BP 90-100 mm can initiate to assist in the prevention of 20 cardiovascular disease later in a woman’s Hg . Nevertheless, this remains a question life. Some successful interventions proven among healthcare providers as to when to to be successful include risk assessment, initiate treatment. The fact remains, blood optimal blood pressure management, weight pressure screening should be completed control, diabetes mellitus management, lipid frequently and maintaining BP less than disorder management, and aspirin therapy. 120mmHg systolic and less than 80 mm Hg diastolic. When the woman with preeclampsia presents to the health care provider, a Obesity is a strong predictor of adverse risk assessment such as the traditional health outcomes. Maintaining a healthy Framingham risk score tool to establish the weight such as a BMI of less than 25 kg/ 2 threat of CVD. The Framingham risk score m , participating in moderate activity for estimates a 10-year risk of heart disease at least 150 minutes per week, and eating enabling healthcare providers to identify a diet high in fruits and vegetables is the 7 early diagnosis, preventative strategies, cornerstone for a healthy lifestyle . Other and enhanced monitoring, however, this dietary recommendations are low sodium Journal of Nursing Science - Vol. 04 - No. 01 91
7. RESEARCH ARTICLE and low saturated and trans-fat such as stroke by 24% 2. Low dose aspirin therapy is recommended in the Dietary Approaches to given to women at high risk for preeclampsia Stop Hypertension (DASH) diet7. or a history of preeclampsia 16, 5. Many studies identify a higher incidence Educational interventions of insulin resistance in the women with Nurses and healthcare providers preeclampsia. Increasing numbers of should be familiar with risk factors and obesity and diabetes mellitus leads to be able to educate women with a history an increase in Type 2 diabetes mellitus of preeclampsia in order to decrease the (T2DM). Obesity is highly correlated with long-term effects. Additionally, healthcare hyperinsulinemia and decreased insulin providers need to be aware that women do 17 receptor signaling . ACOG recommends not know about the long-term cardiovascular screening via a 75-gram, two-hour glucose effects of preeclampsia. tolerance test postpartum at six weeks, 12 weeks, and then every three years following According to Hutchesson, Shrewsbury, for women with a history of gestational Park, Callister, & Collins, greater than diabetes35. Screening should occur if the one third of women with preeclampsia woman’s BMI is greater than 25 kg/m2 with are unaware of the long-term risk of 36 additional risk factors35. A HgA1c should be cardiovascular disease . Similarly, another drawn and if elevated, the woman is at an study evaluating the effect of education increased risk of CVD. Knowing glucose on women’s knowledge and self-care levels enables preventative treatment and practice with preeclampsia noted significant 37 diagnosing early can decrease the risk of results . Afefy & Kamel found that women complications. have a lack of knowledge and inadequate self-care beyond preeclampsia37. Yet During the postpartum visit, healthcare another study by Burgess and Feliu who providers should monitor lipid levels. In conducted a survey through an online women, CVD is predominately related to social media outlet, asked women about initiation of atherosclerosis. More women the education or referrals they received develop CVD and its complications such about preeclampsia and CVD14. From the as myocardial infarction from erosion of survey, 36.9% women did not know about the endothelium as a result of small vessel preeclampsia and long-term CVD and disease and atherosclerosis. Prevention of 43.9% did not receive education to prevent atherosclerosis is focused on reducing risk CVD nor did they receive follow-up care factors such as dyslipidemia. After reviewing after being diagnosed with preeclampsia14. risk factors, pharmacological therapy for the management of hyperlipidemia has Levine, Nkonde-Price, Limaye, and been shown to decrease the risk of CVD, Srinivas, reviewed a retrospective cohort of women diagnosed with persistent therefore it may be necessary to begin hypertension or preeclampsia with severe a statin treatment after discussions and features to determine factors associated appropriate contraceptive measures have with lower six-week postpartum follow- been explored5. up rates38. The authors reported 52.3% of Lastly, low dose aspirin therapy is a women followed up with their postpartum gold standard of treatment for secondary appointment38. However, young African prevention of CVD and stroke by lowering American women and those with less the risk of total stroke by 17% and ischemic than five visits prenatally were least likely 92 Journal of Nursing Science - Vol. 04 - No. 01
8. RESEARCH ARTICLE to follow-up38. Interestingly, those with the possibility of targeted health apps in the diabetes or Cesarean delivery attended a future. postpartum visit. Additionally, the authors A similar study conducted by Berks, reported obese women, women with Hoedjes, and Raat et al evaluated the severe features of preeclampsia, and those feasibility and effectiveness of a lifestyle discharged home with a prescription of intervention program to improve maternal antihypertensives were more likely to have risk factors for future cardiometabolic persistent hypertension at six weeks38. The disease through a pre-post controlled authors of this study suggest identifying design study42. The program consisted of these women and teaching them about their computer education along with counseling lifetime risk of cardiovascular disease. One over seven months. Researchers reported study regarding the knowledge of providers, positive results for the lifestyle intervention Traylor et al concluded physicians had program, but stated the need for a longer the knowledge of higher CVD risk after time period to evaluate true effectiveness42. preeclampsia, yet patient follow-up care The researchers concluded that health and counseling was lacking39. care providers should teach lifestyle Potential educational interventions changes and interventions for women with include telephonic support, online preeclampsia to prevent long-term CVD42. educational modules, lifestyle intervention Positive outcomes from this program program, and a postpartum transition clinic. included weight loss, decreased amount of One potential intervention to assist with visceral fat, and reduction in waste to hip education is through telephonic support. ratio improving long-term cardiovascular Spratling et al conducted a structured CVD risk. education by telephone to African American Another intervention was the women and yielded CVD risk perception development of a postpartum transition was significantly higher, indicating clinic to support women after hypertensive telephonic support was an effective strategy pregnancy 43. The goals of the clinic were to for teaching women40. implement early postpartum hypertension The use of online educational modules medical management, teach patients about was used in a randomized controlled their CVD risk, and transition the patient to trial over a period of nine months 41. The their primary care provider. The clinic staff researchers recruited 151 women with and providers evaluated patients that were preeclampsia in the past five years to racially and socioeconomically diverse at take part in online educational modules, a one, two or three appointments. Over a community forum, and communication with period of five years, 47.3% of the patients a life coach41. The control group received had two to three visits, increased supply of the internet links to learn about CVD risk home blood pressure monitors (p<0.0001), reduction. The researchers concluded attendance with a nutrition consultant, women had significantly greater knowledge hypertensive medication adjustments, of CVD risk factors, increased self-efficacy and 79.5% transitioned effectively to to eat healthy, and increase physical activity. their primary care provider for continued At the end of the study, all of the women follow-up 43. Results of this program except three had normal blood pressure implementation indicate the further need to (<120 mmHg SBP and <80 mmHg DBP)41. enhance multidisciplinary clinics in efforts Recommendations from this study included to reduce CVD risk. Journal of Nursing Science - Vol. 04 - No. 01 93
9. RESEARCH ARTICLE 3. DISCUSSION professionals, or receive advice during the postpartum period. There is lack of follow Women with preeclampsia are discharged up and yet mortality, morbidity related home every day and are consistently lacking to pregnancy as well as cardiovascular education and knowledge of the potential morbidity and mortality continue to rise long-term effects of CVD from preeclampsia. among women. Healthcare providers need Likewise, healthcare providers are not to take the initiative to screen, teach, and aware of the significant role CVD has after a play an active role in CVD prevention for all preeclampsia diagnosis in order to educate women. or continue to treat the woman. There are many ideas regarding educating women, REFERENCES primarily through technology which hold 1. World Health Organization. World some promise. Additionally, there are clinics health organization fact sheet (2019). Re- that are effective in the assessing, treating, trieved from: and helping these women decrease their room/fact-sheets/detail/cardiovascular-dis- CVD risk, however we are at the tip of the eases-(cvds). iceberg in combating CVD risk reduction 2. Garcia, M, Mulvagh, SL, Merz, after preeclampsia. ACOG and Association C.N.B. Cardiovascular disease in women of Women’s Health Obstetric and Neonatal clinical perspectives. Circulation Research. Nurses (AWHONN) recommend education 2016;118:1273-1293. to these women during their postpartum time 3. Centers for Disease Control and period upon discharge. However, nurses Prevention. Vital Signs: Pregnancy-related and physicians need to begin education at deaths, saving lives before, during and after every visit. Much work remains regards to delivery, 2019. Retrieved from: research and education. cdc.gov/vitalsigns/maternal-deaths/ Pregnancy provides is a window for 4. Umesawa, M, Kobashi, G. Epidemi- the provider to teach a woman about ology of hypertensive disorders in pregnan- cardiovascular health and the presence of cy: prevalence, risk factors, predictors and preeclampsia is an indicator of future CVD prognosis. Hypertension Research. 2017; risk. Young women that are pregnant will 40(3): 213-220. see a healthcare provider on a regular basis 5. American College of Obstetricians and research indicates this as a unique and Gynecologist & Task Force on Hy- time to begin teaching the implementation pertension in Pregnancy. Hypertension in of primary prevention strategies. It is also a pregnancy. Report of the American College time to thoroughly assess the woman and of Obstetricians and Gynecologists Task begin cardiovascular teaching prevention Force on Hypertension in Pregnancy. Ob- and lifestyle changes. Many studies note stetrics & Gynecology. 2013; 122, 1122- that during pregnancy and early postpartum, 1131. women are motivated and will make lifestyle changes for their health as a mother6. 6. Burgess, A, Founds, S. Cardiovas- cular implications of preeclampsia. The Ma- 4. CONCLUSION ternal Child Nursing Journal. 2016. 41(1): Women with a history of preeclampsia 8-15. are at a higher risk of CVD morbidity 7. Preeclampsia Foundation. Pre- and mortality especially within 10 years eclampsia and Future Cardiovascular Dis- following the pregnancy2. Women are not ease in Women. Preeclampsia Foundation taught about their increase risk by health Position Paper. 2019. 94 Journal of Nursing Science - Vol. 04 - No. 01
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