Pre‐conception Maternal Cardiovascular Health and Obstetric Complications Due to Uteroplacental Insufficiency

In this BJOG issue, Li and colleagues conducted a prospective study on 369 women without pre-existing chronic hypertension and diabetes who were evaluated before conception and who had singleton live births in the following 12 months. They found that after adjusting for maternal factors, such as age, ethnicity, body mass index, pre-diabetes, smoking, blood pressure and fetal sex, narrower pre-conception maternal retinal arterioles were associated with smaller fetuses. The retinal fundus provides a non-invasive assessment of the microvasculature, and these findings might indirectly indicate an important role of the non-pregnant maternal vascular system in the subsequent development of uteroplacental insufficiency during pregnancy. The hypothesis that maternal cardiovascular impairment pre-dates placental maldevelopment and related obstetric complications, such as pre-eclampsia, fetal growth restriction and stillbirth, is supported by other compelling evidence. First, most risk factors for developing pre-eclampsia, such as advanced maternal age, obesity and pre-existing chronic hypertension, chronic kidney disease and type 1 or type 2 diabetes, are also well-established risk factors for cardiovascular disease (CVD), suggesting a compromised maternal cardiovascular system before conception. Moreover, it has been shown that an adverse cardiovascular risk factor profile, determined by glycated haemoglobin, glucose level and lipid profile, was significantly more frequent, with progressive worsening in the years before pregnancy, in women who developed pre-eclampsia compared with those who did not (Retnakaran et al., BJOG 2022;129:1512–20). Further evidence of the role of pre-existing maternal cardiovascular maladaptation in the pathophysiology of uteroplacental malperfusion is based on studies where haemodynamic and subclinical cardiac dysfunction were detected in high-risk women before complicated pregnancies. A prospective study assessing pre-pregnancy cardiovascular function in 530 women revealed that women who subsequently had pre-eclampsia and/or fetal growth restriction exhibited lower cardiac output and higher systemic vascular resistance in the pre-pregnancy state (Foo et al., Hypertension 2018;72:442–50). Furthermore, signs of diastolic dysfunction, such as a higher E:E’ ratio, and increased left ventricular mass, measured by maternal transthoracic echocardiography, have been found pre-conceptionally in women who developed recurrent pre-eclampsia in the subsequent pregnancy (Valensise et al., Hypertension 2016;67:748–53). Obstetric complications due to uteroplacental insufficiency are recognised risk factors for CVD, and pregnancy presents a unique opportunity for prevention of cardiovascular disease in the female population. However currently there are no established cardiovascular strategies to screen these patients after complicated pregnancies. Consistent with pre-pregnancy findings described by Li et al. in their paper, a history of pre-eclampsia has been associated with impaired retinal microvascularity independently of other cardiometabolic risk factors in nearly 20 000 women (Honigberg et al., Circulation 2022;145:552–4). A study of cardiovascular risk models developed from the UK Biobank and validated in another data set has demonstrated that artificial intelligence-enabled retinal vasculometry might offer an alternative predictive biomarker to traditional CVD risk scores (Rudnicka et al., Br J Ophthalmol 2022;106:1722–9). Therefore, in addition to the improvement of obstetric outcome prediction, the assessment of maternal retinal microvasculature might also enhance and streamline the triage of women with pregnancies complicated by uteroplacental insufficiency at high risk of CVD later in life. VG wrote the manuscript. None. None. The author declares no conflicts of interest. Not applicable. Data sharing is not applicable to this article as no new data were created or analyzed in this study.