Deployment Among Active-Duty Military Women and Pregnancy-Related Hypertensive Disorders

The Impact of Military Trauma Exposures on Servicewomen's Pregnancy Outcomes: A Scoping Review

INTRODUCTION

Active-duty servicewomen and veterans make up nearly 20% of the United States military and may experience trauma specific to military service. Military-specific trauma includes combat deployment and military sexual trauma, exposure to which may result in posttraumatic stress disorder (PTSD). The purpose of this scoping review is to examine the extent to which military trauma exposures impact the pregnancy outcomes of active-duty servicewomen and women veterans.

METHODS

A systematic search of OVID MEDLINE, OVID Embase, and OVID PsycINFO from inception to September 25, 2023, identified studies examining associations between military trauma exposures and perinatal outcomes. Of the 614 studies identified, 464 were reviewed for relevance, with 16 meeting inclusion criteria.

RESULTS

Of the 16 included studies, 14 found associations between military trauma exposure and adverse pregnancy outcomes including preterm birth, gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and perinatal mood and anxiety disorders. The risks of adverse pregnancy outcomes increased with the severity of PTSD, the recency of combat deployment, and repetitive deployment.

DISCUSSION

This scoping review strengthens the link between trauma exposures and adverse pregnancy outcomes for current and former military servicewomen. A gap in the literature persists regarding trauma exposure among active-duty servicewomen, which differs significantly from women veterans. As mental health conditions are the leading underlying cause of maternal mortality, standardized screening during the perinatal period for military-specific trauma exposures and PTSD is recommended for this population. Black servicewomen of junior enlisted rank carry disproportionate burdens of PTSD diagnosis and adverse pregnancy outcomes. Comprehensive prenatal and postpartum management may improve perinatal and neonatal outcomes for military servicewomen and provide an innovative approach to reducing existing racial disparities.

Hypertensive Disorders of Pregnancy in a Military Hospital Birth Cohort

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are risk factors for maternal and fetal complications with long-term sequelae for mother and children. HDP are not clearly understood; however, there appears to be a relationship with maternal weight gain. The effects of maternal weight gain and pregnancy outcomes, including HDP, are understudied. Few studies have assessed maternal weight gain in service-connected women and its effects on HDP. This study aimed to evaluate the relationship between blood pressure and birth outcomes in women who delivered their infants at a military hospital.

METHODS

This birth cohort study included all patients admitted to a military hospital for delivery over a 12-month period. Data were analyzed for hypertensive disorders, maternal weight gain, delivery type, infant maturity, and infant weight at delivery.

RESULTS

Of the 1,018 participants, 186 were diagnosed with HDP with no statistical difference observed for maternal age. The hypertensive group had higher mean weight gain. More patients in the hypertension group delivered at term with lower mean birth weight. The rate of small-for-gestational age infants was higher in the HDP group (p < 0.001).

DISCUSSION

The rate of HDP in this cohort of military members and dependents was 18.3%, which was similar to the 19% rate reported for a southern US hospital, but higher than in other regions of the United States. This evidence indicates that HDP are increasing, and maternal/infant morbidity was affected by hypertension in this study.

Maternal Coronary Heart Disease, Stroke, and Mortality Within 1, 3, and 5 Years of Delivery Among Women With Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension

Background Pre-pregnancy hypertension and hypertensive disorders of pregnancy (HDP; preeclampsia, eclampsia, gestational hypertension) are major health risks for maternal morbidity and mortality. However, it is unknown if racial/ethnic differences exist. We aimed to determine the impact of HDP and pre-pregnancy hypertension on maternal coronary heart disease, stroke, and mortality risk ≤1, 3, and 5 years post-delivery and by race/ethnicity ≤5 years. Methods and Results This retrospective cohort study included women aged 12 to 49 years with a live, singleton birth between 2004 to 2016 (n=254 491 non-Hispanic White; n=137 784 non-Hispanic Black; n=41 155 Hispanic). Birth and death certificates and International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) diagnosis codes in hospitalization/emergency department visit data defined HDP, pre-pregnancy hypertension, incident coronary heart disease and stroke, and all-cause mortality. During at least 1 pregnancy of the 433 430 women, 2.3% had pre-pregnancy hypertension with superimposed HDP, 15.7% had no pre-pregnancy hypertension with HDP, and 0.4% had pre-pregnancy hypertension without superimposed HDP, whereas 81.6% had neither condition. Maternal deaths from coronary heart disease, stroke, and all causes totaled 2136. Within 5 years of delivery, pre-pregnancy hypertension, and HDP were associated with all-cause mortality (hazard ratio [HR], 2.21; 95% CI, 1.61-3.03), incident coronary heart disease (HR, 3.79; 95% CI, 3.09-4.65), and incident stroke (HR, 3.10; 95% CI, 2.09-4.60). HDP alone was related to all outcomes. Race/ethnic differences were observed for non-Hispanic Black and non-Hispanic White women, respectively, in the associations of pre-pregnancy hypertension and HDP with all-cause mortality within 5 years of delivery (HR, 2.34 [95% CI, 1.58-3.47]; HR, 2.11 [95% CI, 1.23-3.65]; P interaction=0.001). Conclusions Maternal cardiovascular outcomes including mortality were increased ≤5 years post-delivery in HDP, pre-pregnancy hypertension, or pre-pregnancy hypertension with superimposed HDP. The race/ethnic interaction for all-cause mortality ≤5 years of delivery warrants further research.