A multistate prediction model for hypertension and cardiovascular disease after pregnancy using routine care data in the Netherlands.

Aims

Adverse pregnancy outcomes (APOs) are associated with increased cardiovascular risk, but risk stratification has largely focused on midlife populations. We developed a multistate prediction model to enable early postpartum risk stratification for hypertension and cardiovascular disease (CVD).

Methods

In this nationwide, registry-based retrospective study, we predicted hypertension (intermediate outcome) and CVD (primary outcome: hospitalization or death from myocardial infarction or stroke), while accounting for non-CVD mortality (competing risk). Candidate predictors included hypertensive disorders of pregnancy (HDP: pregnancy-induced hypertension [PIH] and (pre)eclampsia), preterm birth, small-for-gestational-age, recurrent miscarriages, diabetes, country of origin, and socioeconomic status (SES; income and education). Follow-up started 6 weeks after childbirth, with a maximum of 17 years. A stratified, time-dependent Cox model was used.

Results

Among 737,257 primiparous women, 1.7% developed hypertension and 0.3% developed CVD. HDP showed the strongest associations with both hypertension and CVD, attenuating with age. In Dutch women with PIH, hypertension risk was higher with low vs. high SES (15% vs. 5%). Surinamese women had higher hypertension risks than Dutch women. PIH combined with preterm birth and low SES resulted in the highest risks. Predictive performance was modest to good (AUCs 0.65-0.89), with alignment between predicted and observed risks.

Conclusions

This study showed future cardiovascular risk can be stratified at 6 weeks postpartum. Women with HDP, low SES, Surinamese origin, and multiple risk factors were identified as the highest-risk groups. These findings support early identification of women at cardiovascular risk, although validation is required before clinical implementation.