Long-term stress links to higher postpartum blood pressure only after pregnancy complications, suggesting stress screening and management may help reduce future CVD risk.
Elevated psychosocial stress during and after pregnancy is associated with
The findings from a new analysis from the nuMoM2b Heart Health Study (nuMoM2b-HHS) cohort add nuance to the established link between pregnancy complications and long-term cardiovascular risk by identifying perceived stress as a potential modifiable factor in this high-risk population.1
“We found that higher stress levels over time were associated with higher blood pressure levels 2-to-7 years after delivery,” said lead investigator Virginia Nuckols, PhD, a postdoctoral fellow in the University of Delaware’s Department of Kinesiology and Applied Physiology.2 “This suggests that women who had pregnancy complications may be more susceptible to the negative effects of stress on their heart health, and taking steps to manage and reduce stress could be important for protecting long-term heart health.”
The analysis included 3322 nulliparous women without hypertension at baseline who were enrolled at 17 medical centers across 8 US states. Participants had singleton pregnancies and were followed from the first trimester through 2 to 7 years after delivery (mean follow-up, approximately 3 years). Perceived stress was assessed at 3 time points: first trimester, third trimester, and 2 to 7 years postpartum. Participants took part in the validated 10-item Perceived Stress Scale (PSS) at each of these time points.1
Latent class trajectory analysis was applied to identify distinct subgroups based on PSS score patterns over time. APOs were abstracted from medical records and defined as a composite of hypertensive disorders of pregnancy, preterm birth, small-for-gestational-age birth, and stillbirth.1
Primary outcomes were clinic-measured systolic and diastolic blood pressure at the postpartum visit, with incident hypertension (≥130/80 mmHg or antihypertensive initiation) as a secondary outcome.1
Three distinct stress trajectories emerged: persistently low (24%), moderate (48%), and high (28%) PSS score groups. Participants in the moderate and high stress groups tended to be younger, had higher BMI, lower educational attainment, and were more likely to identify as Black or Hispanic compared with the low stress group, which investigators attributed in part to social determinants of health.1
Across the full cohort, no significant association was found between stress trajectory group and systolic or diastolic blood pressure after adjustment for age, BMI, race, ethnicity, tobacco use, insurance payor, and other covariates. However, a significant interaction was detected between stress trajectory group and APO status on diastolic blood pressure (P for interaction = .04).1
In stratified analyses, the moderate stress trajectory was associated with diastolic blood pressure approximately 2 mmHg higher than the low stress group among women with an APO (β = 1.991 ± 0.819 mmHg; P = .02), an association absent in women without pregnancy complications (β = 0.040 ± 0.471 mmHg; P = .93). Neither stress trajectory nor continuous PSS scores at any time point were significantly associated with incident hypertension in adjusted models.1
The investigators suggested several mechanistic pathways may account for the APO-specific finding. Impaired vascular endothelial function, a hallmark of uteroplacental-mediated complications such as preeclampsia and preterm birth, may render the vasculature more susceptible to the vasoconstrictive effects of psychosocial stress. Autonomic dysregulation, including elevated sympathetic outflow observed in women with prior hypertensive disorders of pregnancy, may similarly be amplified by ongoing stress exposure.1
“This study highlights the powerful connection between the mind and heart, emphasizing the importance of stress management, particularly for those who have experienced adverse pregnancy outcomes,” said Laxmi Mehta, MD, chair of the American Heart Association’s Council on Clinical Cardiology.2 “For the clinical care team, it reinforces the need to proactively assess and address stress as part of the comprehensive care we provide to our patients. Future research on whether targeted interventions to reduce or manage stress has a meaningful impact on long-term cardiovascular outcomes will be important as well.”
The investigators acknowledged several limitations. Stress was measured via subjective self-report, precluding characterization of objective stressor exposures or physiological stress responses. APOs were modeled as a binary composite, limiting the ability to evaluate effects of specific or comorbid complications. The cohort was restricted to nulliparous women, limiting generalizability to women with prior pregnancies. As an observational study, causal inference cannot be established.1
The clinical relevance of a roughly 2 mmHg blood pressure difference is uncertain in absolute terms, but the investigators noted cardiovascular risk in women increases incrementally at blood pressure levels below clinical hypertension thresholds. Current guidelines emphasize blood pressure monitoring after APOs; these findings suggest screening for and addressing psychosocial stress may represent a complementary strategy in postpartum cardiovascular risk reduction.1
