Adverse pregnancy outcomes as early indicators of long-term maternal atrial fibrillation: a systematic review and meta-analysis

Background Adverse pregnancy outcomes (APOs) - including hypertensive disorders of pregnancy, preeclampsia, gestational diabetes mellitus (GDM), preterm birth, and fetal growth deviations - are emerging female-specific cardiovascular risk factors, but their association with long-term maternal atrial fibrillation (AF) remains unclear. Objective To assess the association between APOs and subsequent AF. Methods We searched PubMed, Embase, Cochrane Central, and Scopus. We included population-based cohort studies comparing women with and without APOs and reporting incident maternal AF during follow-up. Time-to-event associations were synthesized, pooling hazard ratios (HRs) and corresponding 95 % confidence intervals (CIs). Results 12 population-based cohort studies including over 11 million women were analyzed. Hypertensive disorders of pregnancy were associated with higher long-term risk of AF (HR 1.50; 95 % CI 1.38-1.62), as was preeclampsia (HR 1.45; 95 % CI 1.23-1.71). Preterm birth was also associated with increased AF risk (HR 1.29; 95 % CI 1.13-1.48). Delivery of a large for gestational age infant was associated with higher AF risk (HR 1.23; 95 % CI 1.13-1.34), whereas small for gestational age delivery showed an inverse association (HR 0.88; 95 % CI 0.80-0.97). For GDM, the association was more uncertain, with wide CIs and effect estimates suggesting an increased risk (HR 1.20; 95 % CI 0.84-1.72). Conclusion Hypertensive and vascular pregnancy complications are associated with elevated long-term maternal AF risk. Associations for gestational diabetes and fetal growth phenotypes were heterogeneous and should be interpreted cautiously. These findings support APOs as markers of later arrhythmic vulnerability.