1 Simple Question That Could Improve Women’s Health: Meryam Sugulle (Transcript)

Here is the full transcript of obstetrician Meryam Sugulle’s talk titled “1 Simple Question That Could Improve Women’s Health” at TED 2024 conference.

Listen to the audio version here:

TRANSCRIPT:

How would you react if I told you that we have an underused screening tool that has the potential to improve women’s health substantially? And that this tool only consists of one simple question. Have you had any pregnancy complications? With that simple question, we could identify women at increased risk for cardiovascular disease later in their lives.

That means diseases involving the heart, the brain and the blood vessels, like heart attack, heart failure, stroke and high blood pressure. By asking that simple question, we could seek out the women who could benefit from general health screening already at a younger age. That means checkups of blood pressure, body weight and blood sugar. Based on the results, we could offer personalized lifestyle advice and suggest preventive measures.

Importance of Cardiovascular Health

Why? For this is a fact: cardiovascular disease is a major cause of early death, apart from cancer, not only for men, but also for women. I hope that all of you now got very curious about what on Earth nine months of pregnancy have to do with older women getting heart attacks and strokes.

Pregnancy is something younger people do, you might think, even though I would argue that 50 is the new 30. Pregnancy is often described by a well-used quote as a “stress test for life.” A woman’s health gets tested by being pregnant. Will she tolerate pregnancy and all the involved physiological changes well, or will there be any complications?

The Placenta

The most important organ for pregnancy is the one that was once attached to the center of your belly, where your belly button is. We all have a belly button, regardless of gender. You and I, King Charles, the Pope, Beyoncé. And where it is, we were all once connected via a lifeline, the umbilical cord, to the most important organ in both our and our mother’s life. You and I, we are all here thanks to our placenta.

We all survived the single most dangerous event in our life, birth, that is, due to our well-enough functioning placenta. We all know that the placenta was our first meal box when we were growing babies inside our mother’s womb. Most of us also know that the approximately nine months of growth inside our mothers’ womb have lifelong, lasting effects on our health and diseases once we are outside.

Placenta and Cardiovascular Health

But what is lesser-known is that the placenta, the one we were attached to, is crucial for the future cardiovascular health of the mother who lent us a room in her womb. That means how healthy our placenta was is very important for the health of our mother’s heart and blood vessels. How is that the case?

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How does our placenta affect our mother’s future cardiovascular health? In order to understand that, we must briefly talk about the makeup of a healthy placenta. This fascinating organ is made early on in pregnancy, when the fertilized egg develops into the baby and into cells that invade the layers of the womb of the mother. This happens early on in pregnancy, before the baby even looks like a baby.

After invading the different wall layers of the mother’s womb, the cells group together and form finger-shaped tissue. These tissue fingers seem to poke into the layers. Finally, the healthy placenta includes a special room where these tissue fingers are showered in the mother’s blood. In this shower room, the growing baby receives different life-important nutrients and signals via different transport mechanisms.

Stressed Placenta

In other words, it is very important that everything works well in this specialized room. It has to be nice and tidy. That guarantees the meal box effect of the placenta. The good effect.

But just like almost every other living things, cells can get stressed, and cells can get out of control. This happens, for example, in cancer. But how can a healthy placenta become a stressed placenta? What happens?

Placental cells can get stressed when the blood shower in the specialized room gets messy. The placental cells then get out of control. They grow crazy bumps on their surface. In fact, they seem to literally throw up stuff into the specialized room.

By that, the stressed placental cells send many different types of signals into the specialized room. And these stress signals then reach the mother’s blood and the mother’s blood vessels. And when they reach the mother’s blood vessels, they can make these vessels unhealthy, and they can contribute to making the pregnant woman sick, and the pregnancy gets complicated.

Preeclampsia

The placenta is then not really healthy anymore. Maybe you’ve heard of or even know personally, women who have had increased blood pressure from around the middle of pregnancy, who had protein in their urine or headache, abdominal pain, blurred vision or all of this. Then they had what we call preeclampsia, a pregnancy complication of varied severity that occurs in three to 10 percent of all pregnant women, the rate depending on where we live.

What does preeclampsia have to do with the placenta and with the mother’s future cardiovascular health? Remember what I told you about the stressed placenta? According to a widely accepted theory supported by research, in preeclampsia the stressed placental cells send signals into the mother’s blood. These stress signals may cause inflammation-like processes in the inner lining of the mother’s blood vessels.

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This then leads to disturbed vessel function and to the signs of preeclampsia that I mentioned earlier. Preeclampsia is only one of several examples for a pregnancy complication related to a not-well-working placenta, but I will stick to this example. In a way, the placenta and the mother talk to each other. And since our earliest cells formed both us, the babies, and the placenta, we talked to our mothers even before we could speak properly.

Pregnancy as a Stress Test

And it turns out that this may well be one of the more important talks we had with our mothers.

So back to the concept of pregnancy as a stress test for life and how stressed placental cells can impact on a mother’s future cardiovascular health, decades after she was pregnant and had preeclampsia.

How do we know that women after pregnancy complications are at increased risk for future cardiovascular disease? In Scandinavia, we have unique access to large population-based data sets containing health information. For many decades, these databases have provided important medical knowledge.

They tell us that women who have had preeclampsia towards the end of pregnancy have a doubled risk for future cardiovascular disease, compared to women who have had uncomplicated pregnancies. I mentioned the meal box function of the placenta. I explained the effect of stressed placental cells and how they send signals to the mother.

If the placenta gets even more stressed, the meal box function may be affected. That means the baby has a lower weight than it should have, in addition to the woman developing preeclampsia. Some babies may even, for various reasons, be born too early, prematurely.

Increased Risks

For these women with a very, very stressed placenta, the databases tell us that the future cardiovascular disease risk is even higher, up to four to eightfold higher compared to women with uncomplicated pregnancies. So to sum up what we have talked about so far, we have databases that give us information on pregnancy complications and future cardiovascular health risks.

We know that the baby and the placenta and the mother send messages to each other, talk to each other during pregnancy, but we do not know the exact mechanisms by which complicated pregnancy and the placenta contribute to future health risks for women. And this is my point. Much research remains to be done, and the placenta is still full of secrets that need to be unveiled.

But why should we bother anyhow? And how can we identify women at increased risk? And what should we do then? As I said in the beginning.

Why? Because cardiovascular diseases are a main cause for early death also in women. Heart attacks are known to present differently in women compared to men, and may be recognized too late, and that might prove fatal. This is also another good reason for identifying women at increased risk earlier, at a younger age.

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Early Intervention

This is because the earlier the risk factors are dealt with, the better the effect on the blood vessels and the heart. How can we identify women at increased risk? By asking the right questions about pregnancy at the right time, and whatever the exact cause and the precise mechanism for the association between pregnancy complications and cardiovascular disease prove to be, our mothers’, sisters’, aunts’ pregnancy history may provide important information for future health needs.

And what should we do then? We could take action at the right time. Women could be offered general health screening at a younger age, including checkups of blood pressure, body weight and blood sugar.

We could give personalized advice on lifestyle and try to influence other risk factors, such as weight gain, obesity, smoking or type 2 diabetes. This could be done even before women enter their 50s.

Acknowledging the Link

Is this new medical knowledge? The answer is no. Has this knowledge been acted upon? Not really.

Placenta-related pregnancy complications have officially been acknowledged as sex-specific risk factors for cardiovascular disease by the American Heart Association 11 years ago, and other cardiological societies have followed their lead. Many guidelines suggest or call for follow-up after pregnancy complications. But we are not aware of any country in the world having a systematic cardiovascular follow-up for women after pregnancy complications already at a younger age.

We think such follow-up is of extreme importance for equality in health care and society’s survival, since women are important for society’s survival. We think that it should be possible to integrate a simple cardiovascular risk factor assessment — measure blood pressure, body weight and blood sugar — at the general practitioners into existing screening programs for cervical dysplasia or other comparable available screening programs around the world.

Conclusion

Tomorrow, when you stand in the shower and look at your belly button, remember the placenta. Remember the one simple question that could improve a mother’s health. The one simple question that could improve cardiovascular health. Have you had any pregnancy complications?