Management of cardiac and cardiovascular dysfunction postpartum should include support to initiate and continue breastfeeding

The article by Cutler et al.1 (‘Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy’) is a timely systematic review that helps bring to light the cardiovascular dysfunction that persists postpartum following a hypertensive disorder of pregnancy. It is well recognized that certain pregnancy complications (e.g. hypertensive disorders of pregnancy, gestational diabetes, preterm birth, growth restricted foetus, and significant placental abruption)2 are associated with underlying cardiovascular risk factors and accelerated vascular dysfunction postdelivery; these individuals are at higher risk of future cardiovascular disease. Historically, it had been thought that for preeclampsia, delivery of the placenta fixed the maternal clinical and cardiovascular problems. However, as Cutler et al. report, much of the cardiac and cardiovascular organ damage and dysfunction seen in those with a hypertensive disorder in pregnancy continues to be present throughout the early and later postpartum periods. It is these changes, and the high prevalence of underlying cardiovascular risk factors, that likely lead to the increased future risk of cardiovascular disease. Therefore, strategies are required to prevent or reverse these changes in order to decrease the risk of premature cardiovascular disease and cardiovascular death that is reported in these individuals.3 The authors have previously shown the important impact of early blood pressure management (SNAP-HT trial) on both short-term4 and longer-term5 blood pressure but also identify specific therapies (e.g. enalapril)6 that may be of use in select individuals. One intervention that was not considered by Cutler et al. is the importance and impact that breastfeeding has on an individuals’ cardiovascular health. As can be seen in Table 1, based on large epidemiological studies, prolonged and exclusive breastfeeding reduces the risk of breast cancer,7 ovarian cancer,7 type II diabetes,8 cardiovascular disease,9 and hypertension10 in a dose–response fashion. Further, in individuals who have had hypertensive disorders of pregnancy and other related cardiometabolic conditions, breastfeeding reduces the chance of being diagnosed with the metabolic syndrome and having lower lifetime cardiovascular disease risk scores based on a positive impact on blood pressure, weight, waist circumference, body mass index (BMI), fasting glucose, and lipids at 6–12 months postpartum.11 Markers of subclinical atherosclerosis, including coronary and aortic calcification, are also consistently higher among women who do not breastfeed compared with ever-breastfeeders.12 Health benefits of breastfeeding The 95% confidence intervals are in parentheses. OR, odds ratio; HR, hazard ratio; RR, relative risk; BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease. The metabolic changes in pregnancy include an increase in insulin resistance, hyperlipidaemia, and visceral fat deposition, which facilitate foetal growth and development. It is hypothesized that the process of lactogenesis mobilizes these excess adipose stores to support infant development and a return to metabolic baseline for the mother.13 The absence of lactation and/or not having prolonged breastfeeding may therefore result in the persistence of atherogenic metabolic changes. Based on evidence to date, lactation/breastfeeding should be an important part of any plan for postpartum cardiovascular risk reduction and cardiovascular disease prevention. Unfortunately, women with hypertensive and other metabolic pregnancy complications are less likely to initiate or persist with breastfeeding because of biologic (e.g. medication use and endocrine factors), psychosocial (e.g. psychological distress and postpartum depression), and contextual (e.g. caesarean section, preterm birth, and maternal–neonatal separation) challenges.14 We advocate for the importance not only of supporting breastfeeding initiation at the time of hospital discharge but also of supporting ongoing breastfeeding success as a health promotion strategy for mother and infant. One wonders how many postpartum individuals, whether following a hypertensive disorder of pregnancy or even an uncomplicated pregnancy, might have a medical and/or survival benefit from not just closer postpartum blood pressure monitoring and management but also breastfeeding support.15 None declared.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.