What happens to women with preeclampsia? Microalbuminuria and hypertension following preeclampsia

Cardiovascular and renal health: Preeclampsia as a risk marker

BACKGROUND

Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies.

MATERIALS AND METHODS

Review of PE and its association with future development of CVD and CKD.

RESULTS

Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage.

CONCLUSIONS

The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Long-term consequences of previous preeclampsia and complicated pregnancy: analysis of echocardiographic aspects

AIM

To evaluated echocardiographic aspects in women with history of preeclampsia or preeclampsia-related complications in their previous pregnancies.

MATERIALS AND METHODS

Consecutive women receiving echocardiography during daily clinical echolab activity were studied using complete echocardiographic examination data and anamnestic data collection of hypertension, diabetes, dyslipidemia, and rheumatic diseases. Studied women should have at least one pregnancy in more than the 10 past years, and were subdivided into two groups according to the history of complicated or physiological pregnancy. Complicated pregnancies were defined by preeclampsia or preeclampsia-related complication, such as preterm delivery or small-for-gestational age newborn. Echocardiographic parameters and prevalence of hypertension, diabetes, dyslipidemia, and rheumatic disease were compared between the two groups of studied women.

RESULTS

From March 2016 to May 2020, 545 women were studied, of whom 218 had a history of complicated pregnancy (mean age 60.81 ± 11.109 years vs. 62.78 ± 9.758 years of not complicated pregnancy; P = 0.03). Compared with physiological pregnancy women, complicated pregnancy ones were shorter (159.97 ± 6.608 vs. 161.42 ± 6.427 cm; P = 0.012) with lower body surface area (1.678 ± 0.1937 vs. 1.715 ± 0.1662 m2; P = 0.02), had higher prevalence of diabetes (6.9 vs. 3.1%; P = 0.04; odds ratio = 2.34; CI 1.0323--5.3148) and rheumatic diseases (33 vs. 22.3%; P = 0.006; odds ratio = 1.72; CI 1.1688--2.5191), and showed a slight, not significant higher prevalence of hypertension. As for echocardiographic parameters, they showed significantly higher values of end-diastolic left ventricular posterior wall (LPWd) (P = 0.034), a trend toward a more concentric geometry, and a worse longitudinal systolic left and right ventricle performance, represented by lower tissue Doppler systolic waves (septal: 7.41 ± 1.255 vs. 7.69 ± 1.376 cm/s; P = 0.018; and tricuspidalic: 12.64 ± 2.377 vs. 13.32 ± 2.548 cm/s; P = 0.003).

CONCLUSION

Patients with previous preeclampsia present an increased risk of hypertension, diabetes, and rheumatic diseases, suggesting that these women could share a specific predisposition to a high-risk profile. Furthermore, they show a higher prevalence of classically considered echocardiographic hypertensive-derived cardiac damage, suggesting structural and functional left ventricular modifications as subclinical aspects of long-term worse cardiovascular prognosis for these women.

Preeclampsia and Kidney Disease: Deciphering Cause and Effect

PURPOSE OF REVIEW

Preeclampsia and chronic kidney disease have a complex, bidirectional relationship. Women with kidney disease, with even mild reductions in glomerular filtrate rate, have an increased risk of developing preeclampsia. Preeclampsia, in turn, has been implicated in the subsequent development of albuminuria, chronic kidney disease, and end-stage kidney disease. We will discuss observational evidence and mechanisms linking the two disease processes.

RECENT FINDINGS

Preeclampsia is characterized by an imbalance in angiogenic factors that causes systemic endothelial dysfunction. Chronic kidney disease may predispose to the development of preeclampsia due to comorbid conditions, such as hypertension, but is also associated with impaired glycocalyx integrity and alterations in the complement and renin-angiotensin-aldosterone systems. Preeclampsia may lead to kidney disease by causing acute kidney injury, endothelial damage, and podocyte loss. Preeclampsia may be an important sex-specific risk factor for chronic kidney disease. Understanding how chronic kidney disease increases the risk of preeclampsia from a mechanistic standpoint may open the door to future biomarkers and therapeutics for all women.

Changes over-time in blood pressure of women with preeclampsia compared to those with normotensive pregnancies: A 15 year population-based cohort study

OBJECTIVES

To estimate the incidence of hypertension and the trend of systolic and diastolic blood pressure changes and relating factors influencing women with and without prior preeclampsia (PE).

STUDY DESIGN

This prospective population based study included a total of 3022 eligible women (355 with PE and 2667 non-PE) recruited from participants of the Tehran Lipid and Glucose Study (TLGS) who were assessed for progression to subsequent hypertension over 15-year follow up. Pooled logistic regression model was utilized to estimate odds ratio (OR) of hypertension. The generalized estimating equation (GEE) was used to evaluate the trend of changes in hypertension parameters over time.

RESULTS

At the end of follow-ups, 109 women (30.7%) in the PE group and 575 (21.5%) in the non-PE group had hypertension. The total cumulative incident rate of hypertension was 34/1000 person-years for PE groups and 22/1000 person years for non-PE groups (P < 0.001). Pooled logistic regression analysis showed that compared to non-PE women, OR of hypertension progression in women with PE was 3.70 after adjustment for age, body mass index (BMI), parity, triglycerides (TG) and high-density lipoprotein (HDL-C) (P-value < 0.001). Based on GEE analysis, mean changes of systolic and diastolic blood pressure in PE women increased by 4.66 and 2.55 mmHg, respectively, compared to the non-PE group, after adjustment for age, and BMI at baseline (P < 0.001), although the interaction term (follow-up year × PE) was not statistically significant.

CONCLUSION

This study demonstrated increased chances of developing hypertension among women with prior PE, particularly in those who develop additional risk factors in their later life, compared to the non-PE women. While the trajectory of blood pressure change over time is similar between women with and without preeclampsia, women with a history of preeclampsia consistently have higher levels of blood pressure.

Preventing cardiovascular disease after hypertensive disorders of pregnancy: Searching for the how and when

Background

Women with a history of a hypertensive disorder during pregnancy (HDP) have an increased risk of cardiovascular events. Guidelines recommend assessment of cardiovascular risk factors in these women later in life, but provide limited advice on how this follow-up should be organized.

Design

Systematic review and meta-regression analysis.

Methods

The aim of our study was to provide an overview of existing knowledge on the changes over time in three major modifiable components of cardiovascular risk assessment after HDP: blood pressure, glucose homeostasis and lipid levels. Data from 44 studies and up to 6904 women with a history of a HDP were compared with risk factor levels reported for women of corresponding age in the National Health And Nutrition Examination Survey, Estudio Epidemiólogico de la Insuficiencia Renal en España and Hong Kong cohorts (N = 27,803).

Results

Compared with the reference cohort, women with a HDP presented with higher mean blood pressure. Hypertension was present in a higher rate among women with a previous HDP from 15 years postpartum onwards. At 15 years postpartum (±age 45), one in five women with a history of a HDP suffer from hypertension. No differences in glucose homeostasis parameters or lipid levels were observed.

Conclusions

Based on our analysis, it is not possible to point out a time point to commence screening for cardiovascular risk factors in women after a HDP. We recommend redirection of future research towards the development of a stepwise approach identifying the women with the highest cardiovascular risk.

Pre-eclampsia and risk of subsequent hypertension: in an American Indian population

BACKGROUND AND OBJECTIVES

Pre-eclampsia (PE) shares a number of proposed pathophysiologic mechanisms related to those implicated in cardiovascular disease (CVD), such as endothelial dysfunction, inflammation, insulin resistance, and impaired renal regulation. PE has also been associated with subsequent hypertension, CVD, and related mortality in later life.

METHODS

At follow-up, the four most recent blood pressures, body mass index (BMI), and use of hypertensive medications were recorded from clinic visits of 130 PE cases and 289 normal pregnancies. Student's t test, Chi-square testing, multivariate linear, and logistic regression were used in analysis.

RESULTS

Follow-up measurements occurred a mean of 13.11 years post PE pregnancy. Multivariate linear regression showed a significant and independent association between current systolic blood pressure and previous history of PE (β = 4.47, p = 0.04), while adjusting for age, BMI, and blood pressure from 1 year prior to and up to the 20th week of gestation. A similarly adjusted multivariate logistic regression model found an odds ratio of 3.43, 95% CI 1.83-6.43, p = 0.001 for subsequent hypertension. Logistic regression analysis of the quartile with follow-up of less than 7.19 years also shows independent association of prior PE with subsequent hypertension.

DISCUSSION AND CONCLUSIONS

PE appears to confer risk of subsequent hypertension on this cohort of American Indian women within as little as 8 years. This risk is independent of additional risk factors such as increased age, BMI, and blood pressure prior to 20 weeks of gestation. There is evidence of increased risk among those with more severe PE.

Long term effects of gestational hypertension and pre-eclampsia on kidney function: Record linkage study

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We examine risk of chronic kidney disease (CKD) after pregnancy hypertension.

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We found increased risk of chronic kidney disease after gestational hypertension.

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Risk of chronic kidney disease was further increased after preeclampsia.

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Women with pregnancy hypertension develop CKD earlier than normotensive women.

Objective

To assess the long term effects of hypertensive disorders of pregnancy on renal function.

Design

Cohort study where exposure was gestational hypertension or preeclampsia in the first pregnancy. Normotensive women formed the comparison group.

Setting

Aberdeen, Scotland.

Participants

All women with date of birth on or before 30th June 1969 and at least their first singleton delivery recorded in the Aberdeen Maternity and Neonatal Databank.

Methods

Participants were linked to the Renal Biochemistry Register, Scottish Morbidity Records, Scottish Renal Registry and National Register for deaths.

Main outcome measures

Occurrence of chronic kidney disease (CKD) as identified from renal function tests in later life, hospital admissions or death from kidney disease or recorded as receiving renal replacement therapy.

Results

CKD was diagnosed in 7.5% and 5.2% of women who previously had GH and PE respectively compared to 3.9% in normotensive women. The unadjusted odds ratio (95% confidence interval) of having CKD in PE was 2.04 (1.53, 2.71) and that for GH was 1.37 (1.15, 1.65), while the adjusted odds ratio (95% confidence interval) of CKD was 1.93 (1.44, 2.57) and 1.36 (1.13, 1.63) in women with PE and GH respectively. Kaplan–Meier curves of survival time to development of chronic kidney disease revealed that women with preeclampsia were susceptible to kidney function impairment earliest, followed by those with gestational hypertension.

Conclusions

There was an increased subsequent risk of CKD associated with hypertensive disorders of pregnancy. Women with GH and PE were also found to have CKD earlier than normotensive women.

Pre-eclampsia: an update

Pre-eclampsia remains the second leading direct cause of maternal death, >99 % of which occurs in less developed countries. Over 90 percent of the observed reduction in pre-eclampsia-related maternal deaths in the UK (1952-2008) occurred with antenatal surveillance and timed delivery. In this review, we discuss the pathogenesis, diagnostic criteria, disease prediction models, prevention and management of pre-eclampsia. The Pre-eclampsia Integrated Estimate of RiSk (PIERS) models and markers of angiogenic imbalance identify women at incremental risk for severe pre-eclampsia complications. For women at high risk of developing pre-eclampsia, low doses of aspirin (especially if started <17 weeks) and calcium are evidence-based preventative strategies; heparin is less so. Severe hypertension must be treated and the Control of Hypertension In Pregnancy (CHIPS) Trial (reporting: 2014) will guide non-severe hypertension management. Magnesium sulfate prevents and treats eclampsia; there is insufficient evidence to support alternative regimens. Pre-eclampsia predicts later cardiovascular disease; however, at this time we do not know what to do about it.

Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura.

CONCLUSIONS

To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

Recognizing pregnancy-associated cardiovascular risk factors

Preeclampsia, gestational diabetes, or pregnancy-induced hypertension identify a woman at risk for cardiovascular disease. This information should be incorporated into the routine cardiovascular risk assessment for women, as a basis for appropriate risk factor screening, counseling, and preventive interventions. There is need for development and validation of a clinometric tool to assess cardiovascular risk and guide management.

Hypertension in pregnancy is a risk factor for microalbuminuria later in life

The authors aimed to compare renal function by estimated glomerular filtration rate and albuminuria in 3 groups of women: nulliparous women, women with a history of normotensive pregnancies, and women with a history of at least one hypertensive pregnancy. Women who participated in the second Family Blood Pressure Program Study visit (2000-2004) and had serum creatinine and urine albumin measurements (n=3015) were categorized as having had no pregnancy lasting >6 months (n=341), having had only normotensive pregnancies (n=2199), or having had at least 1 pregnancy with hypertension (n=475) based on a standardized questionnaire. Women who reported having had at least one pregnancy with hypertension were significantly more likely to be hypertensive (75.6% vs 59.4%, P<.001), diabetic (34.2% vs 27.3%, P≤.001), and have higher body mass index (32.8 vs 30.5, P<.001) than those who reported normotensive pregnancies. There was a significantly greater risk of microalbuminuria (urine albumin-creatinine ratio >25 mg/g) in those who reported at least one pregnancy with hypertension (odds ratio, 1.37; confidence interval, 1.02-1.85; P=.04) than in those with normotensive pregnancies, after adjusting for risk factors for chronic kidney and cardiovascular disease. Hypertension in pregnancy is associated with an increased risk of future microalbuminuria.

Preeclampsia and the future risk of hypertension: the pregnant evidence

Cardiovascular death rates continue to rise for women under age 55, underlying the importance of focusing on female-specific conditions that may increase cardiovascular risk, including pregnancy-related disorders. Hypertension complicates about 5-10 % of pregnancies. Preeclampsia, a pregnancy-specific condition, is characterized by hypertension and proteinuria after 20 weeks of gestation and remains one of the major causes of maternal deaths in the United States. In addition, preeclampsia may have an impact on women's health beyond their pregnancies, and has been associated with increased risks for future hypertension and cardiovascular disease, such as coronary heart disease and stroke. In this review, we discuss the evidence supporting the association between preeclampsia and future hypertension; possible mechanisms that underlie this association; current approach to women with a history of preeclampsia; and future research that is needed in this field in order to deliver optimal and timely medical care to the affected women.

Sex-specific risk of cardiovascular disease and cognitive decline: pregnancy and menopause

Understanding the biology of sex differences is integral to personalized medicine. Cardiovascular disease and cognitive decline are two related conditions, with distinct sex differences in morbidity and clinical manifestations, response to treatments, and mortality. Although mortality from all-cause cardiovascular diseases has declined in women over the past five years, due in part to increased educational campaigns regarding the recognition of symptoms and application of treatment guidelines, the mortality in women still exceeds that of men. The physiological basis for these differences requires further research, with particular attention to two physiological conditions which are unique to women and associated with hormonal changes: pregnancy and menopause. Both conditions have the potential to impact life-long cardiovascular risk, including cerebrovascular function and cognition in women. This review draws on epidemiological, translational, clinical, and basic science studies to assess the impact of hypertensive pregnancy disorders on cardiovascular disease and cognitive function later in life, and examines the effects of post-menopausal hormone treatments on cardiovascular risk and cognition in midlife women. We suggest that hypertensive pregnancy disorders and menopause activate vascular components, i.e., vascular endothelium and blood elements, including platelets and leukocytes, to release cell-membrane derived microvesicles that are potential mediators of changes in cerebral blood flow, and may ultimately affect cognition in women as they age. Research into specific sex differences for these disease processes with attention to an individual's sex chromosomal complement and hormonal status is important and timely.

Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis

There is increasing evidence that pre-eclampsia, a principal cause of maternal morbidity, may also be a risk factor for future cardiovascular and cerebrovascular events. This review aimed to assess the current evidence and quantify the risks of cardiovascular disease (CVD), cerebrovascular events and hypertension associated with prior diagnosis of pre-eclampsia. Medline and Embase were searched with no language restrictions, as were core journals and reference lists from reviews up until January 2012. Case-control and cohort studies which reported cardiovascular and cerebrovascular diseases or hypertension diagnosed more than 6 weeks postpartum, in women who had a history of pre-eclampsia relative to women who had unaffected pregnancies, were included. Fifty articles were included in the systematic review and 43 in the meta-analysis. Women with a history of pre-eclampsia or eclampsia were at significantly increased odds of fatal or diagnosed CVD [odds ratio (OR) = 2.28, 95% confidence interval (CI): 1.87, 2.78], cerebrovascular disease (OR = 1.76, 95% CI 1.43, 2.21) and hypertension [relative risk (RR) = 3.13, 95% CI 2.51, 3.89]. Among pre-eclamptic women, pre-term delivery was not associated with an increased risk of a future cardiovascular event (RR = 1.32, 95% CI 0.79, 2.22). Women diagnosed with pre-eclampsia are at increased risk of future cardiovascular or cerebrovascular events, with an estimated doubling of odds compared to unaffected women. This has implications for the follow-up of all women who experience pre-eclampsia, not just those who deliver pre-term. This association may reflect shared common risk factors for both pre-eclampsia and cardiovascular and cerebrovascular disease.

Preeclampsia and hypertensive disease in pregnancy: their contributions to cardiovascular risk

More women than men die each year of cardiovascular disease, which remains the leading cause of death in the United States. Sex-specific factors, including pregnancy-related disorders, should be considered when assessing cardiovascular (CV) risk in women. Hypertensive disorders of pregnancy have been associated with CV risk later in life and may identify women in whom earlier primary prevention may reduce their risk. This article reviews the physiologic changes in blood pressure during pregnancy, current definitions of hypertensive diseases of pregnancy and preeclampsia, and postulated pathophysiologic mechanisms leading to preeclampsia that might contribute to later CV risk. Also summarized are studies providing evidence on the association between hypertensive diseases of pregnancy and future CV risk.

Making use of a natural stress test: pregnancy and cardiovascular risk

The gestational period serves as a natural stress test that can be used to predict future cardiovascular health risks of female patients. Recent evidence confirms that mothers with hypertensive pregnancies have higher cardiovascular disease (CVD) risks compared to other women of similar age. In women with preeclampsia, those delivering before 37 weeks of gestation and mothers with recurring preeclampsia in subsequent pregnancies carry the greater risks. These sex-specific risks are of similar magnitude to traditional CVD risk factors, such as smoking and obesity. Unfortunately, none of the commonly used CVD risk stratification models make use of these sex-specific markers, which can powerfully predict future CVD outcomes. Because women have historically posed a greater diagnostic challenge than men in assessing CVD risks, better models for risk stratification in this sex group are needed. A history of hypertension in pregnancy should be included as a variable in cardiovascular risk stratification. In addition, screening women for a history of preeclampsia should become routine practice, with greater emphasis placed on therapies to modify adverse outcomes for these higher-risk women.

[Late prognosis after preeclampsia]

Preeclampsia, eclampsia and HELLP syndrome are severe complications of pregnancy associated with a high morbidity and mortality for both mother and foetus. The issue of prognosis with regards to risk of relapse is therefore of upmost importance for both the patients and doctors managing their subsequent pregnancies. The overall risk of relapse is estimated to be less than 10%. The risk is especially increased in case of early onset, before the 28(th) week of amenorrhea. In such patients, an underlying renal disease, essential hypertension or secondary hypertension might be identified. A renal consultation must ensure the complete resolution of the hypertension and proteinuria, otherwise investigations need to be carried out looking for an underlying renal or vascular disease affecting the renal parenchyma or outflow. Screening for a hereditary thrombophilia is performed in the immediate post-partum period following and early onset PE, especially if associated with an IUGR, fetal death, or in an early and severe relapse. A renal biopsy is only rarely considered: it is either performed within the first post-partum days whenever a systemic disease flare-up is suspected (i.e. SLE), or late if the proteinuria failed to settle beyond 6 months post-part. Severe PE is a marker of a vascular disease of short duration, but must be considered a risk factor for later atherosclerosis with cardiovascular complications, justifying long term cardiovascular, renal and metabolic follow-up.

Factors associated with persistent hypertension after puerperium among women with pre-eclampsia/eclampsia in Mulago hospital, Uganda

BACKGROUND

Women with severe pre-eclampsia/eclampsia are at risk of developing chronic hypertension in future. Chronic hypertension may manifest initially as persistent hypertension at the end of the puerperium. The objective was to determine the incidence and maternal biochemical, hematological and socio-demographic risk factors for persistent hypertension in patients with pre-eclampsia/eclampsia.

METHODS

This was a prospective cohort study conducted from November 2008 to May 2009 at Mulago hospital labor ward and postnatal clinic. Participants were 200 women managed for pre-eclampsia/eclampsia and followed up to the end of the puerperium. Data was collected through using pre-coded interviewer-administered questionnaires, checking medical records and laboratory investigations. STATA (release 9) software was used for data analysis. At bivariate analysis, the relative risk of persistent hypertension was estimated at the 95% confidence level. Using multivariate logistic regression analysis, factors that were independently associated with persistent hypertension were evaluated.

RESULTS

Fifty four (27.7%) out of the total 195 women had persistent hypertension after puerperium. Serum creatinine and the age of the patient were the only factors associated with persistence of hypertension after puerperium.

CONCLUSION

Nearly every one in four mothers with pre-eclampsia/eclampsia are at risk of persistent hypertension after the puerperium. Serum creatinine, serum uric acid and participants' age were the only factors independently associated with persistence of hypertension after the puerperium.

Hypertension during pregnancy is associated with coronary artery calcium independent of renal function

BACKGROUND

Hypertension during pregnancy (HDP) increases the risk of future coronary heart disease (CHD), but it is unknown whether this association is mediated by renal injury. Reduced renal function is both a complication of HDP and a risk factor for CHD.

METHODS

Logistic regression models were fit to examine the association between a history of HDP and the presence and extent of coronary artery calcification (CAC), a measure of subclinical coronary artery atherosclerosis, in 498 women from the Epidemiology of Coronary Artery Calcification Study (mean age 63.3 +/- 9.3 years).

RESULTS

Fifty-two (10.4%) women reported a history of HDP. After adjusting for age at time of study participation, HDP was associated with increased serum creatinine later in life (p = 0.014). HDP was positively associated with the presence of CAC after adjusting for age at time of study participation (OR = 2.7, 95% CI 1.4-5.4). This association was slightly attenuated with adjustment for body size and blood pressure (OR = 2.4, 95% CI 1.2-4.9) but was not further attenuated with adjustment for serum creatinine and urinary albumin/creatinine ratio (OR = 2.6, 95% CI 1.3-5.3). Results were similar for CAC extent.

CONCLUSIONS

HDP may increase a woman's risk of future CHD beyond traditional risk factors and renal function. Women with a history of HDP should be monitored for potential increased risk of CHD as they age.

PROTEINURIA IN PREECLAMPSIA: FROM BENCH TO BEDSIDE

Pre-eclampsia (PE) remains the leading cause of maternal and fetal mortality in the developed world and parts of the developing world. Morbidity and mortality from PE is increased in the developing world compared to the developed world, as availability and access to antenatal care and pathology services are limited.

A history of preeclampsia identifies women who have underlying cardiovascular risk factors

OBJECTIVE

The objective of this study was to prospectively assess physical and biochemical cardiovascular risk markers in women who had developed preeclampsia (PE) at 1 year postpartum.

STUDY DESIGN

Following an overnight fast, previously PE (n = 70) and normotensive women (n = 70) had weight and blood pressure recorded and levels of morning blood for insulin, glucose, C-reactive protein, lipids, cholesterol, and urine for microalbumin and creatinine measured. Body mass index, homeostatic model assessment index, and incidence of metabolic syndrome were determined.

RESULTS

At 1 year postpartum, markers of cardiovascular disease were different between the groups. There were also differences in the number of women with abnormal values. Mathematical modeling of cardiovascular event risk suggests that PE increases the risk by 2- to 3-fold; the risk was greatest for women with severe PE.

CONCLUSION

The development of PE is 1 of the earliest clinically identifiable markers of a woman's heightened risk of cardiovascular disease.

Cardiovascular sequelae of preeclampsia/eclampsia: a systematic review and meta-analyses

BACKGROUND

Preeclampsia affects 3% to 5% of gestations and eclampsia 0.05% to 0.93%, but their subsequent cardiovascular sequelae are unclear. The aim of this study was to determine if women with a history of preeclampsia/eclampsia are at increased risk of long-term cardiovascular sequelae.

METHODS

From Medline and Embase searches, we included case-control and cohort studies that examined cardiac, cerebrovascular or peripheral arterial disease, or cardiovascular mortality>6 weeks postpartum, in women with and without a history of preeclampsia/eclampsia and that controlled for or matched for confounders. Two independent reviewers determined study eligibility and extracted data.

RESULTS

Five case-control and 10 cohort studies met eligibility criteria, with a total of 116,175 women with and 2,259,576 women without preeclampsia/eclampsia. Most studies focused on women<56 years of age. Relative to women with uncomplicated pregnancies, women with a history of preeclampsia/eclampsia had an increased risk of subsequent cardiac disease in both the case-control studies (odds ratio 2.47, 95% CI 1.22-5.01) and the cohort studies (relative risk [RR] 2.33, 1.95-2.78), as well as an increased risk of cerebrovascular disease (RR 2.03, 1.54-2.67), peripheral arterial disease (RR 1.87, 0.94-3.73), and cardiovascular mortality (RR 2.29, 1.73-3.04). Meta-regression revealed a graded relationship between the severity of preeclampsia/eclampsia and the risk of cardiac disease (mild: RR 2.00, 1.83-2.19, moderate: RR 2.99, 2.51-3.58, severe: RR 5.36, 3.96-7.27, P<.0001).

CONCLUSIONS

Women with a history of preeclampsia/eclampsia have approximately double the risk of early cardiac, cerebrovascular, and peripheral arterial disease, and cardiovascular mortality. Further research is needed to determine the mechanisms underlying these associations and to identify effective prevention strategies.

Altered metabolic profiles among older mothers with a history of preeclampsia

Preeclampsia has been linked to increased risk for cardiovascular disease and, more recently, to reduced risk for breast cancer later in life. The altered chronic disease risk associated with prior preeclampsia may reflect underlying metabolic differences. In this case-control study, we examined the metabolic profiles of older mothers with and without a history of preeclampsia in their first pregnancies. At the time of the study, subjects were non-pregnant, non-smoking women who completed their first pregnancies at age 30 or older, were pre-menopausal, and were free of serious chronic disease. Cases were 13 women who experienced preeclampsia in their first pregnancies; controls were 13 women with uncomplicated first pregnancies, frequency matched to cases on race/ethnicity, current age, and age at delivery. A fasting blood sample was collected from each subject during the luteal phase (day 19-22) of the menstrual cycle and assayed for specific factors thought to be linked to hypertensive disease or breast cancer. Compared to women with uncomplicated pregnancies, those with a history of preeclampsia had significantly elevated levels of fasting serum triglycerides, insulin and glucose, and a higher fasting insulin resistance index, suggesting that women with prior preeclampsia were relatively insulin resistant. In addition, cases had higher levels of insulin-like growth factor (IGF)-binding protein-3 (IGFBP-3) and a higher molar ratio of IGFBP-3 to IGF-1 than did controls. Adjustment for obesity and other potential confounders did not appreciably alter the magnitude of these associations. This preliminary study suggests that women with a history of preeclampsia have persistent metabolic abnormalities consistent with their observed excess risk for cardiovascular morbidity and mortality, and their apparent reduced risk for breast cancer later in life.

Pregnancy: a stress test for life

PURPOSE OF REVIEW

This review describes how the physiological demands of pregnancy act as a maternal stress test that can predict a woman's health in later life. Pregnancy transiently catapults a woman into a metabolic syndrome that predisposes to vascular endothelial dysfunction. Women who are already predisposed to this phenotype develop gestational hypertension or diabetes mellitus, which re-emerge in later life as the metabolic syndrome returns. Pregnancy can also temporarily unmask sub-clinical disease, which may return in later life when the effects of ageing diminish the limited reserves of a vulnerable organ.

RECENT FINDINGS

Recent studies have attempted to assess how gestational syndromes affect the risk for a woman of developing a diverse range of diseases in later life. As well as cardiovascular disease and diabetes mellitus, pregnancy can reveal a vulnerability to thyroid and pituitary disorders, liver and renal disease, depression, thrombosis and even cancer.

SUMMARY

Although our knowledge of this phenomenon is incomplete, women who have had gestational syndromes, in particular pregnancy-induced hypertension/preeclampsia or gestational diabetes, should make lifestyle changes that will reduce their risk of cardiovascular disease in later life.

Cardiovascular and thromboembolic events following hypertensive pregnancy

BACKGROUND

Hypertension is a common complication of pregnancy. Previous evidence has linked pregnancy-related hypertension to maternal cardiovascular disease. We conducted a population-based cohort study to estimate the risks for cardiovascular and thromboembolic events in women with pregnancy-related hypertension.

METHODS

We analyzed data from all singleton births recorded in Washington State from 1987 to 1998. Mothers were classified as having gestational hypertension, preeclampsia, or chronic hypertension based on hospital discharge and birth record information. Birth records were linked to subsequent hospitalizations within Washington State. Proportional hazards models were used to estimate the relationship between each form of pregnancy-related hypertension and subsequent risk for cardiovascular and thromboembolic events.

RESULTS

We identified 31,239 eligible hypertensive pregnancies from 807,010 births. During follow-up, there were 118 hospitalizations for a first acute cardiovascular event and 172 hospitalizations for a first thromboembolic event. Gestational hypertension, mild preeclampsia, and severe preeclampsia were associated with 2.8-fold (95% confidence interval [CI], 1.6 to 4.8), 2.2-fold (95% CI, 1.3 to 3.6), and 3.3-fold (95% CI, 1.7 to 6.5) greater risks for cardiovascular events, respectively. Severe preeclampsia was associated with a 2.3-fold (95% CI, 1.3 to 4.2) greater risk for thromboembolic events.

CONCLUSION

Preeclampsia and gestational hypertension are associated with increased risk for cardiovascular events. Pregnancy-induced hypertension appears to be an important risk factor for the development of future cardiovascular disease in young women.

Maternal and neonatal outcome in early- and late-onset pre-eclampsia

Early-onset pre-eclampsia and late-onset pre-eclampsia, by virtue of their unpredictable nature and prediliction for multi-organ involvement, are associated with substantial maternal and fetal morbidity and mortality. Recent years have seen the introduction of the concepts of care in specialized units, expectant management of pre-eclampsia, conservative management of the HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), usage of magnesium sulphate and improved feto-maternal surveillance. It is important to note that these factors also influence maternal and neonatal outcome.