Pregnancy is a physiological stress test, and the women who fail it are identifiable. Hypertensive disorders of pregnancy, gestational diabetes and preterm birth each mark substantially higher long-term cardiovascular morbidity and mortality than an uncomplicated pregnancy. This final review in a Lancet Series makes the case for using that information.

The mechanisms proposed are plausible rather than proven: pre-existing cardiometabolic and genetic susceptibility unmasked by pregnancy, accelerated risk factor trajectories afterwards, impaired endothelial and microvascular function, and earlier disease onset. The authors also review emerging evidence linking a mother's adverse pregnancy outcome history to cardiometabolic risk in her children.

What makes this a practice-changer is not the epidemiology, which is established, but the gap between it and what happens in clinic. Current risk-stratification tools do not include an obstetric history; there are no prevention trials specific to these women; and there is no agreed follow-up model. In the meantime the authors propose integrating the history into ordinary cardiovascular risk assessment across the life course.

That is a question anyone can add to a consultation. Ask every woman over 40 being assessed for cardiovascular risk whether she had high blood pressure, diabetes or an early delivery in any pregnancy — and record the answer where the next clinician will see it. In Indian practice, where obstetric records often do not follow a woman into midlife primary care, the history is frequently the only surviving record of the event.

Ask every woman about hypertensive disorders, gestational diabetes and preterm delivery during cardiovascular risk assessment
Record the answer in the problem list, not in the free text of one letter
Recognise that standard risk equations do not capture this; treat it as information the score omits
Do not overstate it as a validated risk multiplier — no adverse pregnancy outcome-specific prevention trials exist
Where records are lost, the woman's own account is the data; take it seriously

Why it matters

It identifies women at raised cardiovascular risk decades early, using information that already exists and is currently discarded.

Don't overread it

The association is well established but there are no prevention trials in this group, and no validated way to convert an obstetric history into a risk estimate.