<scp>FIGO</scp> pregnancy passport: A useful tool for women and their healthcare providers on health risks following pregnancy complications

Abstract

Pregnancy is often considered a physiological stress test that can unmask pre-existing or subclinical diseases that may manifest later in life. Any complications that arise during pregnancy can also have a lasting impact on a woman's health. In fact, women who experience complications during pregnancy, such as hypertensive disorders (HDP) or gestational diabetes (GDM), are particularly at risk for future cardiometabolic diseases.1, 2 These pregnancy complications serve as warning signs that require follow-up to reduce the risk of future health events. To address this critical issue, the FIGO Committee on the Impact of Pregnancy on Long-term Health has adapted a pregnancy passport.3 The passport (Figure 1) should be handed out to women with any pre-pregnancy or pregnancy-induced risk factors for cardiometabolic diseases after delivery and before discharge from the hospital. This innovative tool facilitates screening and planning for the optimal management of women who have experienced complications during pregnancy.4 The goal is to provide advice and targeted interventions during the postpartum period to reduce the risk of future health events, with the aim of global use.4 A significant body of evidence has demonstrated that women who have had HDP are four times as likely to develop chronic hypertension, three times as likely to meet the criteria for metabolic syndrome, and twice as likely to experience long-term cardiovascular disease (CVD)—including coronary artery disease, heart failure, peripheral vascular disease, and stroke—and CVD-related mortality.2, 5 In addition, women with a history of HDP are at a twofold increased risk of chronic kidney disease and end-stage kidney disease, as well as a two- to threefold increased risk of type 2 diabetes mellitus (T2DM) later in life.2 Similarly, GDM is commonly associated with T2DM, metabolic syndrome, and CVD. Studies have shown that one-quarter of women with a history of GDM will develop metabolic syndrome within 5 years postpartum.6 Given the potential for adverse long-term health outcomes, it is recommended that women who have experienced HDP and/or GDM during pregnancy should undergo postpartum screening and intervention to reduce such risks.1, 2 This approach also serves as an opportunity to discuss future pregnancy plans. By identifying and addressing potential health issues early on, women can take proactive steps to safeguard their health and well-being in the years to come. A comprehensive and timely postpartum assessment is important for all women after delivery, yet it is frequently overlooked, even in high-income countries.7 Postpartum care serves three main purposes: (1) to monitor pre-existing medical conditions; (2) to identify and evaluate common postpartum complications; and (3) to identify potential risk factors and prevent future adverse maternal and pregnancy outcomes. Therefore, the postpartum period, also known as the “fourth trimester,” is a unique opportunity for healthcare professionals to provide support and guidance to women who have experienced a complicated pregnancy. By optimizing their health during this critical time, women can improve their long-term health outcomes and ensure a healthy future for themselves. Observational data have shown that appropriate interventions, such as breastfeeding, lifestyle and dietary modifications, and patient education, can lower underlying cardiovascular risk, which in turn reduces the risk of future CVD.8-10 Breastfeeding, in particular, has been extensively studied and found to have numerous benefits for women who are at risk of developing coronary artery disease, stroke, and maternal CVD-related death. In addition, a longer breastfeeding duration has been found to be beneficial in reducing multiple cardiovascular risk factors that can lead to future CVD.8 A heart-healthy diet, as shown in Box 1, has been shown to be effective in reducing the 10-year Framingham risk score for CVD by 13% in the general population. Physical activity has also been found to reduce the risk of CVD and increase life expectancy.2 Furthermore, a healthy lifestyle can attenuate the increased risk of chronic hypertension, specifically in women after HDP and/or GDM. Maintaining a healthy body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) is particularly important for women with a history of HDP and GDM.10 It is also worth noting that lifestyle changes are highly effective in reducing the progression from GDM to T2DM during a 10-year follow-up period.11 Moreover, a healthy sleep pattern has been linked to a significant decrease of approximately 35% in the likelihood of developing CVD, coronary heart disease, and stroke.12 Vegetables Fruits, Whole grains, Fat-free or low-fat dairy, Fish, Poultry, Beans, Nuts and seeds, Vegetable oils Fatty meats, Full-fat dairy, Sugar-sweetened beverages, Sweets, Sodium A woman's awareness of her own cardiovascular risk is crucial in prompting her to take preventative measures against CVD.13 This underscores the importance of targeted educational interventions aimed at increasing awareness of cardiovascular risk and CVD. Research has shown that providing such interventions can lead to improved knowledge of cardiovascular risk factors, increased self-efficacy for healthy eating, and greater engagement in physical activity among women who have experienced complicated pregnancies.14 Despite several professional bodies recommending postpartum assessment and interventions to reduce the risk of long-term health complications,1, 2, 15 maternal compliance with follow-up appointments remains low. A study indicated that only half of the high-risk women attended postpartum check-ups.16 This may be due to a lack of resources among care providers to identify those who would benefit the most from targeted chronic disease-prevention measures. Other factors contributing to low screening rates include patient fear, care provider misconception, confusion regarding guideline variations, and barriers to reliable healthcare transitions.17 In addition, determining the appropriate timing and venue for counseling and implementing recommended interventions for risk reduction can be challenging.2 To address this issue, feasible interventions that increase adherence to postpartum care, such as patient reminder systems and consistent healthcare communication channels, are urgently needed. The FIGO Committee on Impact of Pregnancy on Long-term Health believes that an innovative pregnancy passport would be the most convenient, pragmatic, and effective tool for postpartum care to achieve this goal.4 While some centers have developed pregnancy passports, they are not widely used and are mainly limited to high-income countries.4 Therefore, FIGO has adapted a user-friendly pregnancy passport that recommends minimal and optimal management strategies for use in different healthcare settings; it can easily be adopted and utilized globally.3 The passport allows women to record their background and pregnancy information and pregnancy-related cardiometabolic risk indicators. It also equips women with information on the impact of pregnancy complications on future health, as well as appropriate interventions to reduce such risks. Moreover, the passport includes recommended tests and schedules for monitoring women within the first 12 months after delivery, which should enhance their compliance with postpartum intervention programs. This pregnancy passport enables care providers not only to identify women who are at risk for chronic diseases but also to develop personalized management plans that address their specific needs. Moreover, the pregnancy passport empowers women to take an active role in their healthcare. By having access to their medical records, women can make informed decisions about their health and advocate for themselves during medical appointments. This level of involvement can lead to better health outcomes and a greater sense of control over one's own body. Overall, the pregnancy passport is a valuable tool that benefits both care providers and women. It promotes better communication, personalized care, and patient empowerment. As such, it should be considered an essential component of postpartum care for women who have experienced complications during pregnancy to reduce their risks of long-term adverse health outcomes. GNS reports grants from the Canadian Institutes of Health Research; and a leadership of fiduciary role in the Society of Obstetricians and Gynecologists of Canada. LB reports grants or contracts from Thermo Fisher, Roche, and PerkinElmer; payment for expert testimony from Homburg and Partner; and a leadership or fiduciary role in the Swedish Preeclampsia Working Group. LCP declares payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Roche Diagnostics, Ferring Pharmaceuticals, PerkinElmer, Thermo Fisher Scientific, and GE Healthcare. LN-H and FMMcA have no conflicts of interest. Members of the FIGO Committee on the Impact of Pregnancy on Long-Term Health, 2021–2023 Fionnuala McAuliffe (chair), Moshe Hod (past chair), Lesley Regan (UK ex oficio), Graeme Smith, Virna Medina, Liona Poon, Sumaiya Adam, Pat O'Brien, Esraa Algurija, David McIntyre, Cynthia Maxwell, Ronald Ma, Anil Kapur, Lina Bergman, Mark Hanson, Mary Rosser, Sharleen O'Reilly S1. FIGO Pregnancy Passport: Printable. S2. FIGO Pregnancy Passport: Digital. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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