The women who face a higher risk of early death but don’t know it

Sarah Gulyamov was lying on her couch, 37 weeks pregnant with an induction booked for the following day, when her mother mentioned her daughter’s feet looked bigger than usual.

“I looked over my belly and said, ‘Yeah, you’re not wrong’,” Gulyamov, then 35, said.

Sarah Gulyamov with her daughter Mahler, 5, and son Ivar, 3. Credit: Wolter Peeters

Her hands were also swollen, her fingers like sausages.

“I thought I could leave this for 12 hours, but my doctor friend said to trust my gut, and I’m glad I did,” she said.

Gulyamov was diagnosed with pre-eclampsia, a potentially dangerous complication that manifests as high blood pressure, protein in the woman’s urine, and often swelling that is indistinct from the normal water retention in pregnancy.

Preeclampsia and other hypertensive disorders – gestational diabetes (GD) and chronic hypertension – affect 5 to 10 per cent of pregnancies in Australia, about 30,000 women each year. It’s the reason pregnant women routinely have their blood pressure checked.

But these women are at increased risk of potentially deadly complications, including cardiovascular disease and stroke, as early as five to 10 years after giving birth, many still aged in their thirties and forties.

Gulyamov, like many, was oblivious to the long tail of her preeclampsia. She was immediately induced, but over the next 14 hours of labour, her blood pressure was still rising, and her baby was distressed.

Gulyamov had an emergency caesarean, and within a week, she and her daughter, Mahler, were discharged. Her blood pressure had quickly returned to normal, and Mahler was thriving.

The otherwise healthy mother thought that was the end of it. Until about six weeks postpartum, she spotted an information sheet at the hospital that revealed the reverberations of her brush with hypertension.

Sarah Gulyamov was diagnosed with preeclampsia before giving birth to her daughter, Mahler via emergency caesarean. She developed gestational diabetes during her pregnancy with her son, Ivar. Credit: Wolter Peeters

Gulyamov learnt she was among a cohort of women who now faced a two to 2.5 times increased risk of heart disease, twice the risk of stroke and diabetes, and three to four times the risk of chronic high blood pressure on average compared with women who did not develop these pregnancy complications.

They also have 1.5 to two times the risk of vascular disease and five to 10 times the risk of renal disease, international research shows.

“I had no idea,” Gulyamov said. “It’s weird that people don’t know. They should probably know.”

Despite these well-documented increased risks, there is still no standardised care for women who have suffered pregnancy complications after the routine 6-week postpartum check-up.

Professor Amanda Henry, program head of women’s health at the George Institute, said the absolute risk of a perimenopausal woman having a heart attack or stroke is low, so its doubling is still a low risk. But for women with multiple hypertensive complications (say, high blood pressure and GD), their risk multiplies.

“In some cases, we are talking about pretty young women having major health concerns and premature death,” Henry said.

Women with preeclampsia are also more likely to develop gestational diabetes during subsequent pregnancies. Gulyamov developed it during her pregnancy with her son, Iver, in 2021.

Guidelines from the Society of Obstetric Medicine of Australia and New Zealand recommend women who have preeclampsia or gestational diabetes talk to their doctors about their increased risk of higher blood pressure, heart issues, stroke or kidney problems.

Coronary heart disease: just one example of the increased risk after hypertensive pregnancy

An Australian study involving 500,000 women published in the British Medical Journal Heart found about 1 in 200 women who had a hypertensive pregnancy were hospitalised for coronary heart disease within 10 years of giving birth versus 1 in 500 for women with no hypertensive complications during pregnancy.

For women who had an early hypertensive disorder (before 34 weeks gestation), the risk was higher again (about 3 in 200 women).

The average age of the women during their pregnancies was 29 years. 

But Henry said once women have had their six-week post-birth check-up, they fall into a “postpartum black hole”.

“It’s not good enough to tack on mum’s long-term health to a [consultation] for a baby’s vaccination or health check-ups. We need to separately prioritise mum,” she said.

And the handful of hypertensive medications proven to be effective and safe in pregnancy have more side effects than the plethora of newer-generation medicines that have not been tested for safety in pregnancy, Henry said.

Henry and her colleagues are conducting a suite of NSW Health-funded studies aimed at protecting women with hypertensive pregnancies from future complications. They include a randomised trial (called BP2) exploring the effects of lifestyle interventions among women with high blood pressure after hypertensive pregnancy and a trial evaluating the effectiveness of drug therapies for preventing women who had GD from developing type 2 diabetes.

“Ultimately, we want to make sure that risk of chronic disease after pregnancy doesn’t become destiny,” Henry said.

Little is known about exactly why women who experience preeclampsia and gestational diabetes are at higher risk of long-term complications.

UTS Cardio-Obstetrics Research Group lab head Associate Professor Lana McClements is leading the development of advanced 3D bio-printed models of placental, vascular and heart tissue to better understand the mechanisms involved.

“We have to understand why this happens,” McClements said. “What the mechanisms are that, following preeclampsia or gestation hypertension, lead to premature development of cardiovascular disease or other diseases.”

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