Placenta and the long-term health of the mother

Alexander Kofinas M.D. Cardiovascular health, Fetal Growth Restriction (IUGR), General Health, In Vitro Fertilization (IVF), Infertility, Miscarriage, Preeclampsia, Pregnancy Complications, Premature Rupture of Membranes (PROM), Preterm Labor/Birth, Recurrent Fetal Loss (miscarriage), Recurrent IVF Failure Leave a Comment

Breast cancer: the loud threat

Women of all ages and strata are too familiar with the perils of breast cancer. After all, cancer is known to be a lethal disease although many women achieve complete cure. It is no surprise then that cancer thoughts are terrifying. Publicity campaigns regarding the risks and early prevention of breast cancer are found everywhere. Cars, trees, billboards, and various kinds of bracelets remind us about the risks of breast cancer and what to do to prevent it.

To those of us who are fortunate to spend our lives caring for women and helping them realize their most important dream, the dream of motherhood, it is well known that the fear of losing the baby is far more powerful than the fear of losing their lives to breast cancer.

In my long career as a high-risk specialist, I have encountered many a mother who were diagnosed with some form of deadly cancer and were advised to terminate the pregnancy in order to receive the appropriate treatment. None of those chose to do so. They instead decided to go ahead with the pregnancy and try to save the baby by sacrificing whatever slim chances of survival they might have. Such is the primeval instinct of motherhood. Many women cannot feel as complete human beings unless they bear their own child.

Heart disease: the silent killer

In today’s medical establishment there is a dichotomy of sorts. There is a severe dislocation of research and educational funds, and more is spent on breast cancer prevention and treatment than other more fatal diseases afflicting women. It is well known that cardiovascular disease is the leading killer of women after menopause. More women die from this condition annually than cancer, accidents, Alzheimer’s and respiratory diseases combined.

Cardiovascular educational material figured mostly men.

This is really an immense derailment of fundamental thinking, both, from the medical community and the community at large; this needs to be addressed by public officials who are responsible for health-care policy as well as professional medical associations dealing with women’s health. Funding for education and prevention of cardiovascular deaths

Medical research discrimination

For years now it has been well established that the vast majority of medical studies on cardiovascular diseases are done primarily in men and there seems to have been a truly, an unintentional sexist approach to the subject. Recently this problem has been addressed and more women become subjects in cardiovascular disease studies.

Because of the beneficial effects of female hormones on the health of the cardiovascular system, it became almost a dictum that men are the only ones that suffer from cardiovascular disease or at least the ones that suffer the most; this was the most important reason why most of the studies regarding cardiovascular health and disease recruited only male subjects. It later became clear that women’s risk to die from cardiovascular disease increased significantly after menopause and surpassed the risk of men. In fact, according to many epidemiological studies, more than 30% of women die from some form of cardiovascular disease after menopause. This is in severe contrast to the deaths from breast cancer which do not exceed 2% in a woman’s lifetime despite the fact that the lifelong risk of women to develop some form of breast cancer is about 10-11%.

Placenta syndrome

Recent studies have revealed that women who experienced pregnancy related complications were significantly more likely to die from cardiovascular disease than all other causes combined. The complications below comprise the so-called “Placenta Syndrome”. The name is derived from the fact that these complications are associated with or caused by placental abnormalities.

One or more of the conditions below define the term “Placenta Syndrome”

  1. Women who delivered premature infants (preterm birth)
  2. Women who delivered growth restricted infants (IUGR)
  3. Women who experienced abruption placentae (placental detachment)
  4. Women who experienced abruption placentae (placental detachment)
  5. Women with history of fetal demise (fetal death in-utero after 20 weeks)
  6. Women with recurrent pregnancy loss (multiple recurrent miscarriages)
  7. Women with preeclampsia (high blood pressure during pregnancy only)
  8. Women who experienced neonatal death (death of a live born infant)
  9. Women with infertility and multiple IVF failures
  10. Women who delivered premature infants (preterm birth)

What all the above conditions have in common is a poorly developed placenta or a placenta that never forms (implantation failure and infertility). All experts who have cared for patients who experienced such adverse and devastating pregnancy complications have without an exception attributed such complications to placental maldevelopment and dysfunction.

Placenta and cardiovascular disease association

Why is the placenta syndrome then associated with increased maternal mortality after menopause? The placenta syndrome is a constellation of obstetrical complications that have their origin in the placenta. Specifically, a poor placenta is the common link among such pregnancy complications. Why is it that such women develop poor placentas?

In the last few years and since the measurement of thrombophilic factors has been commercially available, we have realized that women with abnormal clotting factors are at increased risk for placenta related complications. Such factors alone or in combination have devastating effects on the implantation process and the formation and expansion of the placenta.

A healthy placenta is a guarantee of a healthy pregnancy and neonate as long as the baby is genetically normal. In contrast, an abnormal and deficient placenta can destroy even a genetically perfect baby. The same coagulation defects that affect the pregnancy and the placenta during the woman’s reproductive age, contribute to the increased risk for cardiovascular disease after menopause.

Cardiovascular disease for the most part is attributed to a lot of factors that affect the health of vascular health. The most common factor is plaque formation from high cholesterol under the inner lining of the heart and brain vessels. However, plaque formation might cause narrowing of the blood vessels but for the most part does not cause clotting and complete blockage which leads to heart attack or stroke.

It is the increased ability of a person’s blood to thicken (coagulate) that blocks the lumen of the blood vessel leading to heart attack or stroke. Individuals with or without plaque formation in their vessels but with normal coagulation systems, which allow their blood to be thin and flow easily through the vessel lumen, are very unlikely to experience adverse cardiovascular events and death. In contrast, individuals with abnormal coagulation systems that make their blood thick and sluggish as it flows through the vessel lumen are more likely to experience a clot formation that can obstruct the particular vessel and cause a heart attack or stroke.

Pregnancy: an open window to the mother’s health

It is a truism that the pregnancy is an open window to the woman’s future health. Pregnancy is a stressful event to the mother’s body and if the mother has any hidden (subclinical) underlying physiological functions that are borderline abnormal, it is likely that pregnancy will make them obvious.

Women for example that develop gestational diabetes during pregnancy and return to normal afterwards, are 60% more likely to develop diabetes in their life time. Likewise, women who develop hypertension during their pregnancy are more likely to do so after the pregnancy. Such predispositions are not absolute and incurable. They are only predispositions and nothing more. It is here that the job of an obstetrician is tremendously important; patients who experience such complications during pregnancy should be educated and encouraged to change their life styles to as normal as possible with healthy nutritional habits,

We must educate our female patients on healthy nutrition

consistent exercise, proper amount of sleep, calorie restriction, and frequent monitoring of the factors that can predict the appearance of the disease. Even patients, who have specific genetic susceptibilities to develop diabetes or hypertension for example, can eliminate this predisposition by implementing a healthy life style with healthy eating habits, weight control, and frequent and consistent exercise. Normal genes can be affected negatively by an unhealthy life style as well as pathological genes can be neutralized by a healthy life style.

Evolutionary advantage turned rogue

In the early stages of our existence thousands of years ago, the most likely cause of adult death was from bleeding. Injuries being the most common cause for men and childbirth the most common cause for women. Over the years, various genetic mutations took place in our coagulation related genes. These are known as genetic polymorphisms (many forms of the same gene with slightly or significantly different effects).

Women and men who developed polymorphisms in their coagulation genes that made their blood thicker and easier to clot in case of bleeding, were more likely to survive after injury; those without such an advantage were more likely to bleed to death and perish. The same happened to women; those with the mutated genes that made their blood easier to coagulate survived childbirth and passed their genes to the next generation.

Over thousands of years, the number of people with increased ability to coagulate increased and those with decreased ability to coagulate vanished and their gene pool shrank. This is what is known as an “evolutionary advantage”.

Such evolutionary advantages do not serve their purpose anymore. Men are less likely to be injured on a daily basis as they did thousands of years ago. The risk of injury and death from bleeding in our modern society is extremely low. Likewise, modern obstetrical care and modern blood banking techniques reduced the risk of death from childbirth related bleeding for most women. However, for the same reason that the “thrifty gene” has played a significant role in the modern epidemic of obesity, likewise, the evolutionary advantage of gene polymorphisms that increased the ability of our blood to clot have along with the modern lifestyles contributed to the increased risk of cardiovascular disease.

Need for education

It is therefore imperative that all obstetricians and other primary care physicians become aware of the significance of the placenta syndrome and its contribution to the high mortality among menopausal women. We cannot afford to limit our medical expertise to the process of just delivering the baby. We must take control of our patients’ education regarding the life-long implications of placenta related pregnancy complications.

Our efforts should focus on identifying such women and educating them for the long-term implications of such placenta related complications. We must encourage our patients to expand their education on such matters, improve their dietary habits, incorporate exercise in their daily routines and apply such improvements to their children and the rest of the family.

We obstetricians are truly blessed; we are in the unique situation where by educating one person only, the mother, we are able to change the lives of the entire family spanning 3 generations. Now, this is very powerful and it would be disgraceful if we did not live up to our obligations according to the Hippocratic oath.