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Maternal–Fetal Medicine
Table 1: Classification and Definitions of Hypertensive
those with pre-eclampsia (RR 1.90, 95% CI 1.02–3.52), than those with
Pregnancy Disorders
hypertension alone (RR 1.20, 95% CI 1.01–1.42). This increased risk was
further supported by a Scottish study that reported a risk ratio of 2.0
Pre-eclampsia–eclampsia A pregnancy-specific disorder characterized by hypertension
(95% CI 1.5–2.5) for the association between pre-eclampsia and later
and proteinuria of 300mg or greater in a 24-hour urine;
maternal risk of an IHD admission or death.
16
Data from the Royal College
eclampsia is a convulsive form of pre-eclampsia that affects
of General Practitioners (RCGP) oral contraception study showed that
0.1% of all pregnancies
Chronic hypertension Blood pressure greater than or equal to 140/90mmHg prior to
women with history of pre-eclampsia compared with those with
pregnancy, or before the 20th week of gestation.
normotensive pregnancies had an increased RR of 2.24 (95% CI
Pre-eclampsia superimposed Up to 30% of women with chronic hypertension develop
on chronic hypertension pre-eclampsia, heralded by proteinuria, which occurs for the
first time in the third trimester
Gestational hypertension Hypertension occurring for the first time during the second
Pre-eclampsia and other hypertensive
half of pregnancy in the absence of proteinuria; it includes
women with pre-eclampsia who have not yet developed
disorders likely result from different
proteinuria, those with hypertension only, and a subset of
patients in whom blood pressure remains elevated after
underlying mechanisms, which may have
delivery, leading to the diagnosis of chronic hypertension
varying long-term cardiovascular effects.
those with histories of normotensive pregnancies (22% hypertensive at
an average of 56 years of age).
13
1.42–3.53) for acute myocardial infarction.
17
Using the Norwegian medical
As most of the published studies, including ours, have clearly been birth registry, Irgens et al. found that mothers with pre-eclampsia had a
underpowered, Bellamy et al.
14
performed a systematic review and meta- higher risk for all-cause death compared with those who did not develop
analysis assessing the risks of future hypertension in women with history this condition during their pregnancies. The risk further increased in those
of pre-eclampsia and eclampsia. They conducted a search of Medline and who had a pre-term delivery and was highest for cardiovascular death;
Embase between 1960 and December 2006; both positive and negative those who had a pre-term delivery had a hazard ratio of 8.12 (95% CI
studies were included in the analysis. Thirteen studies involving 21,030 4.31–15.33) for death secondary to cardiovascular causes.
18
A recent
women examined the risk of hypertension subsequent to a pre-eclamptic population-based retrospective cohort study of 1.03 million women who
or eclamptic pregnancy. Over a mean follow-up of 14.1 years, the were free of CVD before their first documented delivery reported an
authors found that 1,885 of 3,658 women with pre-eclampsia developed incidence of CVD of 500 per million person-years in women who had had
hypertension later in life, providing a relative risk (RR) of 3.7. These maternal placental syndrome, which included pre-eclampsia and
findings show that current data support a significant risk for pre- gestational hypertension, in addition to placental abruption and infarction
eclamptic women to become hypertensive later in life. compared with 200 per million person-years in women who had not
(adjusted hazard ratio 2.0, 95% CI 1.7–2.2).
19
Hypertension in Pregnancy and
Future Coronary Heart Disease If concomitant with pre-eclampsia, several factors may further increase the
Over the last couple of decades, several population-based studies have risk for CVD. These include smoking,
20
parity,
15
pre-term delivery,
18
and older
provided evidence suggesting adverse long-term cardiovascular outcomes age.
21
Pre-eclampsia and other hypertensive disorders likely result from
in women with history of hypertension in pregnancy, including pre- different underlying mechanisms, which may have varying long-term
cardiovascular effects. A few studies have indicated that women with severe
forms of pre-eclampsia have worse outcomes than those who suffer from
The steadily increasing rates of
gestational hypertension only,
15,22,23
leaving this field open to future research.
cardiovascular disease in women have
Hypertension in Pregnancy and Future Cerebrovascular and
renewed interest in the field as part of an
Venous Thromboembolic Disease
attempt to study and characterize
While hypertension in pregnancy has long been recognized as a risk factor for
cerebrovascular complications during pregnancy and post partum, few studies
possible contributing female-gender-
have explored the relationship between hypertension in pregnancy and future
specific factors.
stroke. Most of the data are from the World Health Organization (WHO)
Collaborative Study of Cardiovascular Disease and Steroid Hormone
Contraception. A history of hypertension in pregnancy was identified as a risk
eclampsia. Jonsdottir et al. noted a significant increase in mortality from factor for both venous thromboembolic disease
24
and cerebrovascular events
25
ischemic heart disease (IHD) in patients with history of hypertensive in patients taking oral contraceptives later in life, i.e. years after an affected
pregnancies compared with population data from public health and pregnancy. Subsequent studies showed that women with a history of pre-
census reports.
15
The RR of dying from IHD was significantly higher among eclampsia were 60% more likely to have a non-pregnancy-related ischemic
eclamptic women (RR 2.61, 95% confidence interval [CI] 1.11–6.12) and stroke
26
and that they were at an increased risk for death from stroke
46 US OBSTETRICS & GYNECOLOGY
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