Pregnancy as a Time Machine
In late February, I was in my obstetrics clinic, where I work as a subspecialist in high-risk pregnancy. My final patient of the day was Florence, who sees me for her prenatal care because she has gestational diabetes, as do approximately 6 percent of pregnant women in the United States. Her routine glucose screen at 24 weeks had been elevated, showing that her body had developed an inability to manage glucose normally. She had tried dietary modification and increasing her activity, walking every day after lunch. Nothing had worked well enough, so she came to me to help manage her condition. I started her on insulin, four injections a day; it wasn’t an easy regimen. But at that February appointment, her sugars looked beautifully controlled.
Florence (whose name has been changed to protect her privacy) rubbed her 37-week belly and sighed. She was close to the end of this pregnancy. I had already scheduled her for a labor induction in about two weeks. “You’ve done so well,” I said.
“Yeah, I know,” she replied. “But I’m so tired of poking myself, poking to check the sugar, poking for insulin. I can’t wait for this baby to come out and this diabetes will be over. Right?”
“Well,” I said, “sort of. Probably, for at least a while. But Florence, I have to tell you: This gestational diabetes was never just about your pregnancy.”
What I explained to Florence is that a growing body of research shows that what happens in pregnancy can be a precursor to future health. Some researchers call pregnancy a stress test. I say that pregnancy is a time machine: It helps us travel to our bodies in the future.
Most women with gestational diabetes will return to normal pre-pregnancy sugar levels by six weeks postpartum, when doctors screen for diabetes to make sure glucose tolerance has normalized. However, women with gestational diabetes who are followed for five, 10 and 15 years after pregnancy are found to be at higher risk for developing an array of related issues: type 2 diabetes, metabolic syndrome and, according to multiple studies, including a large 2013 study in the leading journal Heart, cardiovascular disease.
This relationship between pregnancy health and future health is also true for other common complications. The best-studied examples are hypertensive diseases. These diseases, marked by the appearance of elevated blood pressure, range from gestational hypertension—elevation of blood pressure during pregnancy—to more severe forms such as preeclampsia or eclampsia, which can affect every organ in the body. Worldwide, hypertensive diseases of pregnancy are the leading causes of morbidity and mortality for pregnant women.
The cure for gestational hypertension and preeclampsia is delivery. Blood pressure often improves within 24 hours after delivery, though some women still undergo days or weeks of rollercoaster symptoms as the disease resolves. By six weeks postpartum, however, the diseases usually will be gone.
But they aren’t always gone forever. Recent research shows that women who have had gestational hypertensive diseases are at higher risk for a long list of conditions later in life, including hypertension, coronary heart disease, stroke, heart failure and renal disease.
Other pregnancy effects, thankfully, have a less direct relationship to lifelong health. For example, research regarding assisted reproductive technology, such as in vitro fertilization, and what exposure to hormone treatments can mean for future health, is ongoing. Thus far, studies have shown that the lifetime risk of hormone-related cancers, such as breast and ovarian, are not increased for women who have undergone infertility treatment.
There is still so much we don’t understand about gestational diabetes, preeclampsia, even pregnancy itself. That’s why it is vital that active research is continuing at laboratories around the world, including at the Hadassah Medical Organization, where cardiologist Dr. Donna Zwas, director of Hadassah’s Linda Joy Pollin Cardiovascular Wellness Center for Women, is currently leading a study on women with a history of gestational diabetes or preeclampsia. We have only begun to figure out how these diseases affect women immediately—and forever.
The idea that a pregnancy complication is never really gone sounds frightening, even if most women get a decade or more of reprieve. But the only thing worse than knowing hard information is not knowing it. This new assessment of a woman’s future risk for diabetes and heart disease based on her pregnant body is a gift. We can modify that future risk by detecting and addressing early signs of these diseases.
Indeed, recent clinical guidance from the American College of Cardiology and the American Heart Association recommend using pregnancy history to help decide a woman’s need for medications to prevent coronary artery disease.
Most of the strategies that doctors share with patients for preventing these long-term complications are familiar: cessation of smoking and maintaining an active lifestyle and healthy diet.
One, however, that can surprise patients—and doctors—is breastfeeding. Studies have shown that breastfeeding is not only beneficial for infants but also can help normalize glucose tolerance and lessen the risks for cardiovascular disease for the mother over time. The best effects are seen with extended lactation: more than 12 to 24 months (depending on the study).
Health Beyond Health Beyond Pregnancy
- Consider extended lactation for at least 12 to 24 months.
- Stop smoking and pursue a healthy diet and exercise. Hadassah has developed several health and wellness programs, including Every Move Counts, which motivates participants to prioritize regular activity.
- Establish regular visits with a primary care doctor.
- Make sure your doctors know about your pregnancy history and utilize it to tailor your cardiovascular risk-factor assessment.
- If you had gestational diabetes, get tested for diabetes once every three years.
Eating healthfully and exercising as well as routine doctor appointments often aren’t priorities for new, stressed mothers. Many mothers make sure to get the kids to the doctor—they would never dream of them missing a checkup!—but don’t afford themselves the same privilege. But here is where information can be powerful: If women are told their long-term health risks, the knowledge can be a strong motivator to ask for the resources they need to take care of themselves for the future.
In the larger medical picture, this connection between pregnancy health and lifelong health has led to a reorganization of postpartum care. A single postpartum visit used to be “goodbye,” a graduation from a pregnancy. Guidance issued in 2018 from the American College of Obstetricians and Gynecologists calls for a series of postpartum visits with their obstetricians for all women, including those whose pregnancy had no high-risk issues, to allow for a transition into lifelong gynecological care as well as counseling from a general practitioner about healthy lifestyle choices and, if needed, continuing cardiovascular health screening.
This reorganization of care means that I have time to talk with patients both during and after their pregnancy. It means medical professionals have a chance to understand their patients’ gestational hypertension or diabetes as part of a longer story, and the opportunity to emphasize the importance of women receiving regular care—not just when they have time or when their kids are grown.
Florence had an uncomplicated delivery. My office was in touch, and she had a two-week telehealth visit with one of my partners. I next saw Florence when she came into my office accompanied by her 6-week-old daughter, sleeping soundly in her stroller. Florence looked happy and tired, as you’d expect. We ran through all the things we needed to follow up on—her mood and risk of depression, plans for birth control and breastfeeding, which had gotten off to a rocky start. I also shared with Florence that her six-week glucose screen was negative.
“No more diabetes for now,” I said. “Is life better without it?”
“It is,” she replied. “But you know, I got in that habit of walking, and I’m still doing it, walking with her in the stroller for about 30 minutes a day. Because I’m not going back to all those pinpricks!”
Dr. Chavi Eve Karkowsky, a high-risk obstetrician in New York City, is the author of High Risk: Stories of Pregnancy, Birth, and the Unexpected.