Background: Individual health behaviors are associated with pregnancy outcomes, but their joint effects are rarely considered. We aimed to examine associations between combinations of first trimester health behaviors and hypertensive disorders of pregnancy (HDP), normotensive adverse pregnancy outcomes (APOs), and blood pressure (BP) 2-7 years after delivery. Methods: Participants in the nuMoM2b and follow-up Heart Health Study were included. Physical activity, diet, smoking, and sleep duration were scored using the Life's Essential 8 metric. APOs were categorized as HDP (gestational hypertension, preeclampsia, super-imposed preeclampsia, or eclampsia) or normotensive APOs: preterm birth, gestational diabetes, small-for-gestational-age birth, and/or stillbirth. Latent profiles of health behaviors were constructed with structural equation modelling. Differences in risk of HDP, normotensive APOs, and BP 2-7 years after delivery based on behavioral profiles were assessed with multinomial logistic or linear regression. Mediation analysis examined the proportion of associations between behavioral profiles and BP mediated by APOs. Results: Among 8,508 nulliparas, four behavioral profiles were identified: Healthiest Behaviors (37%), Healthy Activity/Sleep with Poor Diet/Smoking (20%), Healthy Sleep Only (32%), and Least Healthy Behaviors (11%). Adjusted risk of HDP and normotensive APOs was 21-41% higher in those with poorer behavioral patterns compared to the Healthiest Behaviors profile. Diastolic BP was 1.04 mmHg higher 2-7 years after delivery in the Healthy Sleep Only profile compared to the Healthiest Behaviors profile. Associations between behavioral profiles and BP were not significantly mediated by APOs. Conclusions: Combined health behavior profiles in early pregnancy were associated with APOs and higher diastolic BP 2-7 years after delivery.

The authors have declared no competing interest.

Grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): U10 HD063036; U10 HD063072; U10 HD063047; U10 HD063037; U10 HD063041; U10 HD063020; U10 HD063046; U10 HD063048; and U10 HD063053. Additional support was provided by Clinical and Translational Science Institutes: UL1TR001108 and UL1TR000153. Cooperative agreement funding from the National Heart Lung, and Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development: U10‐ HL119991; U10‐HL119989; U10‐HL120034; U10‐HL119990; U10‐HL120006; U10‐HL119992; U10‐HL120019; U10‐ HL119993; U10‐HL120018, and U01HL145358; and the National Center for Advancing Translational Sciences through UL‐1‐ TR000124; UL‐1‐TR000153; UL‐1‐TR000439; and UL‐1‐ TR001108; and the Barbra Streisand Womens Cardiovascular Research and Education Program and the Erika J. Glazer Womens Heart Research Initiative Cedars-Sinai Medical Center Los Angeles. The Sedentary Behavior and Cardiovascular Health in Young Women ancillary study is supported by NHLBI R01HL158652. ACK is supported under NHLBI T32HL083825.

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