Cardiovascular outcomes after preeclampsia or eclampsia complicated by myocardial infarction or stroke

Maternal Cardiovascular Disease After Pre-Eclampsia and Gestational Hypertension: A Narrative Review

Previous literature has highlighted that women who have a pregnancy affected by gestational hypertension or preeclampsia are at higher risk of cardiovascular disease (CVD) in later life. However, CVD is a composite of multiple outcomes, including coronary heart disease, heart failure, and stroke, and the risk of both CVD and hypertensive disorders of pregnancy varies by the population studied. We conducted a narrative review of the risk of cardiovascular outcomes for women with prior gestational hypertension and pre-eclampsia. Previous literature is summarized by country and ethnicity, with a higher risk of CVD and coronary heart disease observed after gestational hypertension and a higher risk of CVD, coronary heart disease and heart failure observed after pre-eclampsia in most of the populations studied. Only one study was identified in a low- or middle-income country, and the majority of studies were conducted in white or mixed ethnicity populations. We discuss potential interventions to mitigate cardiovascular risk for these women in different settings and highlight the need for a greater understanding of the epidemiology of CVD risk after gestational hypertension and pre-eclampsia outside of high-income, white populations.

Hypertensive Disorders of Pregnancy and Future Cardiovascular Health

Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations. These women are known to have higher cardiovascular morbidity and mortality later in life in comparison with parous controls who had normotensive pregnancies. Several studies have demonstrated that women with preeclampsia present in a state of segmental impaired myocardial function, biventricular chamber dysfunction, adverse biventricular remodeling, and hypertrophy, a compromised hemodynamic state and indirect echocardiographic signs of localized myocardial ischemia and fibrosis. These cardiac functional and geometric changes are known to have strong predictive value for cardiovascular disease in non-pregnant subjects. A "dose effect" response seems to regulate this relationship with severe HDP, early-onset HDP, coexistence of fetal growth disorders, and recurrence of HDP resulting in poorer cardiovascular measures. The mechanism underlying the relationship between HDP in younger women and cardiovascular disease later in life is unclear but could be explained by sharing of pre-pregnancy cardiovascular risk factors or due to a direct impact of HDP on the maternal cardiovascular system conferring a state of increased susceptibility to future metabolic or hemodynamic insults. If so, the prevention of HDP itself would become all the more urgent. Shortly after delivery, women who experienced HDP express an increased risk of classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile, and diabetes with higher frequency than controls. Within one or two decades after delivery, this group of women are more likely to experience premature cardiovascular events, such as symptomatic heart failure, myocardial ischemia, and cerebral vascular disease. Although there is general agreement that women who suffered from HDP should undertake early screening for cardiovascular risk factors in order to allow for appropriate prevention, the exact timing and modality of screening has not been standardized yet. Our findings suggest that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, stop smoking, healthy diet, and daily exercise which are well-established and cost-effective prevention strategies.

Preeclamptic Women Are at Significantly Higher Risk of Future Cardiovascular Outcomes Over a 15-Year Period

Background: Preeclampsia (PE) may lead to maternal and infant mortality and severe medical complications. Understanding future short- and long-term cardiovascular (CV) outcomes of PE is important to women's health. Materials and Methods: A retrospective matched case-control study assessed the risks of CV outcomes over a 15-year period (1999-2013) in pregnant case women, with gravidity and parity of one, diagnosed with PE, compared to pregnant primiparous control women who were not diagnosed with PE. The New Jersey Electronic Birth Certificate (EBC) database and the Myocardial Infarction Data Acquisition System (MIDAS), a database of all hospital admissions in New Jersey with longitudinal follow-up, were used to conduct the analysis. Participants were 18 years and older with demographics consistent with New Jersey, a state with a range of racial and ethnic diversity. Main outcome measures postpregnancy and over this 15-year period were myocardial infarction (MI), stroke, CV death, and all-cause death. Results: Women with PE (N = 6,360) were more likely to suffer MI, stroke, CV death, and all-cause death than controls (N = 325,347). After matching cases to controls for demographics and comorbidities, hazard ratios of PE cases for the outcomes of MI (p adjusted for comorbidities and demographics = 0.0196), CV death (adjusted p = 0.007), and all-cause death (adjusted p = 0.0026) were significantly higher than 1 compared to matched controls. Women with PE had 3.94 (95% CI: 1.25-12.4) times higher hazard for MI, 4.66 (95% CI: 1.52-14.26) times higher hazard of CV death, and 2.32 (95% CI: 1.34-4.02) times higher hazard for all-cause death than matched controls. Conclusions: This 15-year study indicates that women who have PE with their first pregnancy have a significantly higher risk of adverse CV outcomes compared to controls and suggest a heightened and continued CV monitoring after birth for this population of women.

Pregnancy-associated stroke -a systematic review of subsequent pregnancies and maternal health

BACKGROUND

Pregnancy-associated stroke is a rare but life-threatening event, with an estimated incidence of 30/100000 deliveries. Data on the risk of stroke recurrence and the risk of other adverse pregnancy outcomes are essential for adequate counselling and surveillance in subsequent pregnancies. The aim of this systematic review is to describe the implications of a pregnancy-associated stroke for the future health of these women.

METHODS

We searched Ovid Medline, PubMed, Cochrane Library and CINAHL for articles published in 1980-2018. Articles including women with pregnancy-associated stroke and information on at least one of the following outcomes were included: 1) recurrence of stroke during subsequent pregnancy, 2) number and course of subsequent pregnancies and their outcomes and 3) subsequent cardiovascular health.

RESULTS

Twelve articles were included in the review, with six providing information on subsequent pregnancies, four on subsequent maternal health and two on both. The included articles varied greatly in terms of study design, length of follow up and reported outcomes. We found 252 women with pregnancy-associated stroke for whom the outcomes of interest were reported: 135 women with information on subsequent pregnancies and 123 women with information on future health. In total, 55 pregnancies after stroke were found. In the majority of studies, the incidence of pregnancy complications was comparable to that of the general population. The risk of stroke recurrence during pregnancy was 2%. Data on subsequent health of these women were limited, and the quality of the data varied between the studies.

CONCLUSIONS

Data on subsequent pregnancies and health of women with a history of pregnancy-associated stroke are limited. Further research on this topic is essential for adequate counselling and secondary prevention.

Risk Factors for Pregnancy-Associated Stroke in Women With Preeclampsia

BACKGROUND AND PURPOSE

Preeclampsia affects 3% to 8% of pregnancies and increases risk of pregnancy-associated stroke (PAS). Data are limited on which women with preeclampsia are at highest risk for PAS.

METHODS

Using billing data from the 2003 to 2012 New York State Department of Health inpatient database, we matched women with preeclampsia and PAS 1:3 to preeclamptic controls based on age and race/ethnicity. Pre-defined PAS risk factors included pregnancy complications, infection present on admission, vascular risk factors, prothrombotic states, and coagulopathies. We constructed multivariable conditional logistic regression models to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for independent risk factors for PAS.

RESULTS

Among women aged 12 to 55 years admitted to New York State hospitals for any reason during the study period (n=3 373 114), 88 857 had preeclampsia, and 197 of whom (0.2%) had PAS. In multivariable analysis, women with preeclampsia and stroke were more likely than controls to have severe preeclampsia or eclampsia (OR, 7.2; 95% confidence interval [CI], 4.6-11.3), infections present on admission (OR, 3.0; 95% CI, 1.6-5.8), prothrombotic states (OR, 3.5; 95% CI, 1.3-9.2), coagulopathies (OR, 3.1; 95% CI, 1.3-7.1), or chronic hypertension (OR, 3.2; 95% CI, 1.8-5.5). Additional analyses matched and stratified by severity of preeclampsia confirmed these results.

CONCLUSIONS

Infections, chronic hypertension, coagulopathies, and underlying prothrombotic conditions increase PAS risk in women with preeclampsia. These women may warrant closer monitoring.

A review of stroke and pregnancy: incidence, management and prevention

Stroke, defined as a focal or global disturbance of cerebral function lasting over 24h resulting from disruption of its blood supply, is a devastating event for a pregnant woman. This can result in long-term disability or death, and impact on her family and unborn child. In addition to pre-existing patient risk factors, the hypercoagulable state and pre-eclampsia need to be taken into account. The patterns and types of stroke affect pregnant women differ from the non-pregnant female population of child-bearing age. Like other thrombo-embolic diseases in pregnancy, stroke is essentially a disease of the puerperium. Population studies have estimated the risk of stroke at between 21.2 and 46.2 per 100,000. The US Nationwide Inpatient Sample, identified 2850 pregnancies complicated by stroke in the United States in 2000-2001, for a rate of 34.2 per 100,000 deliveries. There were 117 deaths, a mortality rate of 1.4 per 100,000. Both the mortality and disability rates were higher than previously reported, with 10-13% of women dying. With the increasing prevalence of obesity, hypertension and cardiac disease amongst women of child-bearing age, so is the incidence of stroke during pregnancy and the puerperium. In the United States, an alarming trend toward higher numbers of stroke hospitalizations during the last decade was demonstrated in studies from 1995 to 1996 and 2006 to 2007. The rate of all types of stroke increased by 47% among antenatal hospitalizations, and by 83% among post-partum hospitalizations. Hypertensive disorders, obesity and heart disease complicated 32% of antenatal admissions and 53% of post-partum admissions. In addition to pre-existing patient risk factors, the hypercoagulable state and pre-eclampsia need to be taken into account. The patterns and types of stroke affect pregnant women differ from the non-pregnant female population of child-bearing age. Like other thrombo-embolic diseases in pregnancy, stroke is essentially a disease of the puerperium.