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

Introduction Adverse pregnancy outcomes (APOs) - including hypertensive disorders of pregnancy (HDP), 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. Purpose We aim to assess the association between APOs and subsequent maternal AF. Methods We searched MEDLINE, Embase, and Cochrane Central. We included population-based cohort studies comparing women with and without APOs and reporting incident maternal atrial fibrillation during follow-up. Time-to-event associations were synthesized, pooling hazard ratios (HR) and corresponding 95% confidence intervals (CI). Statistical analysis was performed using R statistical software, version 4.5.0. Results Eleven population-based cohort studies including nearly 11 million women were analyzed. Hypertensive disorders of pregnancy were associated with higher long-term risk of AF (HR 1.52; 95% CI 1.32-1.75), as was preeclampsia (HR 1.47; 95% CI 1.23-1.76). 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 confidence intervals 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 GDM and fetal growth phenotypes were heterogeneous and should be interpreted cautiously. These findings support APOs as markers of later arrhythmic vulnerability.