Impact of Hypertensive Disorders of Pregnancy on the Risk of Stroke Stratified by Subtypes and Follow-Up Time

Background and Purpose: Hypertensive disorders of pregnancy (HDP) comprise 4 subtypes. Previous studies have not investigated the relationship between stroke risk, different HDP subtypes, and follow-up time, which was the purpose of this study. Methods: Data of 17 588 women aged 18 to 45 years who had a history of HDP in Taiwan from 2000 to 2017 was retrospectively reviewed. After matching with confounders, 13 617 HDP women and 54 468 non-HDP women were recruited. Results: HDP women had an adjusted hazard ratio (aHR) of 1.71 (95% CI, 1.46−2.00) for stroke, and 1.60 (1.35−1.89) and 2.98 (2.13−4.18) for ischemic and hemorrhagic stroke, respectively ( P <0.001 for all). The overall stroke risk in the HDP group was still 2.04 times 10 to 15 years after childbirth (1.47−2.83, P <0.001). Although the risks of both ischemic and hemorrhagic stroke persisted, their risk time trends were different. The risk of ischemic stroke reached peak during 1 to 3 years after childbirth with an aHR of 2.14 (1.36–3.38), while hemorrhagic stroke risk gradually increased and had an aHR of 4.64 (2.47−8.73) after 10 to 15 years of childbirth (both P <0.001). Among the 4 HDP subtypes, chronic hypertension with superimposed preeclampsia had the highest stroke risk (aHR=3.86, 1.91−7.82, P <0.001), followed by preeclampsia–eclampsia (aHR=2.00, 1.63−2.45, P <0.001), and gestational hypertension (aHR=1.68, 1.13−2.52, P <0.05); chronic preexisting hypertension had the lowest stroke risk (aHR=1.27, 0.97−1.68, P >0.05). Furthermore, multiple HDP combined with preeclampsia had aHR of 5.48 (1.14−26.42, P <0.05). Conclusions: The effect of HDP on the risk of future stroke persisted for up to 17 years, both for ischemic and hemorrhagic strokes. The presence of multiple HDP and preeclampsia further increase the stroke risk.

Download Full-text

Patterns of Postpartum Ambulatory Care Follow‐up Care Among Women With Hypertensive Disorders of Pregnancy

Journal of the American Heart Association ◽

10.1161/jaha.120.016357 ◽

2020 ◽

Vol 9 (17) ◽

Cited By ~ 1

Author(s):

Jennifer Lewey ◽

Lisa D. Levine ◽

Lin Yang ◽

Jourdan E. Triebwasser ◽

Peter W. Groeneveld

Keyword(s):

Cardiovascular Disease ◽

Primary Care ◽

Cardiovascular Risk ◽

Gestational Hypertension ◽

Multivariable Analysis ◽

Chronic Hypertension ◽

Hypertensive Disorders Of Pregnancy ◽

Hypertensive Disorders ◽

Increased Risk

Background Preeclampsia and gestational hypertension are hypertensive disorders of pregnancy (HDP) that identify an increased risk of developing chronic hypertension and cardiovascular disease later in life. Postpartum follow‐up may facilitate early screening and treatment of cardiovascular risk factors. Our objective is to describe patterns of postpartum visits with primary care and women's health providers (eg, family medicine and obstetrics) among women with and without HDP in a nationally representative sample of commercially insured women. Methods and Results We conducted a retrospective cohort study using insurance claims from a US health insurance database to describe patterns in office visits in the 6 months after delivery. We identified 566 059 women with completed pregnancies between 2005 and 2014. At 6 months, 13% of women with normotensive pregnancies, 18% with HDP, and 23% with chronic hypertension had primary care visits ( P <0.0001 for comparing HDP and chronic hypertension groups with control participants). Only 58% of women with HDP had 6‐month follow‐up with any continuity provider compared with 47% of women without hypertension ( P <0.0001). In multivariable analysis, women with severe preeclampsia were 16% more likely to have postpartum continuity follow‐up (adjusted odds ratio, 1.16; 95% CI, 1.2–1.21). Factors associated with a lower likelihood of any follow‐up included age ≥30 years, Black race, Hispanic ethnicity, and having multiple gestations. Conclusions Rates of continuity care follow‐up after a pregnancy complicated by hypertension were low. This represents a substantial missed opportunity to provide cardiovascular risk screening and management to women at increased risk of future cardiovascular disease.

Download Full-text

Basal Plate Myometrial Fibers and Hypertensive Disorders of Pregnancy: A Case–Control Study

Pediatric and Developmental Pathology ◽

10.1177/1093526617730185 ◽

2017 ◽

Vol 21 (3) ◽

pp. 296-299 ◽

Cited By ~ 2

Author(s):

Ann A Wang ◽

Linda M Ernst ◽

Emily S Miller

Keyword(s):

Case Control Study ◽

Gestational Hypertension ◽

Case Control ◽

Basal Plate ◽

Common Finding ◽

Pathological Examination ◽

Chronic Hypertension ◽

Hypertensive Disorders Of Pregnancy ◽

Hypertensive Disorders ◽

Control Study

Introduction Basal plate myometrium (BPMYO), the pathological presence of myometrial fibers in the basal plate, is a common finding on pathological examination of the placenta, yet its clinical correlates are not well studied. As myometrial fibers are frequently located in proximity to poorly converted maternal spiral arteries, our objective was to determine whether BPMYO is associated with hypertensive disorders of pregnancy (HDP), a well-known clinical sequela of abnormal maternal artery remodeling. Methods This case–control study included women who delivered a live-born singleton gestation whose placentas were sent for pathological examination. Cases were women with HDP (gestational hypertension, preeclampsia, or HELLP syndrome) as defined by American College of Obstetricians and Gynecologists. Controls were women without HDP. Women with chronic hypertension were excluded. The primary outcome was the presence of BPMYO. Secondary outcomes included the pathologic stage of BPMYO and the incidence of pathologically defined accreta. Each outcome was compared between cases and controls in bivariable and multivariable analyses. Results Of the 306 women who met inclusion criteria, 230 (75%) had HDP. BPMYO was present in 99 (32%) of placentas. Compared to controls, cases were younger, had higher body mass index, and were more likely to have diabetes, be nulliparous, deliver preterm, and have had a prior cesarean. There were no differences in the incidence of BPMYO, stage of BPMYO, or incidence of pathologically defined accreta between cases and controls. These findings persisted after controlling for potential confounders. Conclusions Although BPMYO may be more common in the setting of abnormal placental vasculature, there is no significant association between BPMYO and HDP.

Download Full-text

Heart Failure in Women With Hypertensive Disorders of Pregnancy

Hypertension ◽

10.1161/hypertensionaha.120.15654 ◽

2020 ◽

Vol 76 (5) ◽

pp. 1506-1513 ◽

Cited By ~ 2

Author(s):

Michael C. Honigberg ◽

Hilde Kristin Refvik Riise ◽

Anne Kjersti Daltveit ◽

Grethe S. Tell ◽

Gerhard Sulo ◽

...

Keyword(s):

Heart Failure ◽

Preterm Delivery ◽

Gestational Age ◽

Small For Gestational Age ◽

Gestational Hypertension ◽

Hazard Ratio ◽

Hypertensive Disorders Of Pregnancy ◽

First Birth ◽

Hypertensive Disorders

Hypertensive disorders of pregnancy (HDP) have been associated with heart failure (HF). It is unknown whether concurrent pregnancy complications (small-for-gestational-age or preterm delivery) or recurrent HDP modify HDP-associated HF risk. In this cohort study, we included Norwegian women with a first birth between 1980 and 2004. Follow-up occurred through 2009. Cox models examined gestational hypertension and preeclampsia in the first pregnancy as predictors of a composite of HF-related hospitalization or HF-related death, with assessment of effect modification by concurrent small-for-gestational-age or preterm delivery. Additional models were stratified by final parity (1 versus ≥2 births) and tested associations with recurrent HDP. Among 508 422 women, 565 experienced incident HF over a median 11.8 years of follow-up. After multivariable adjustment, gestational hypertension in the first birth was not significantly associated with HF (hazard ratio, 1.41 [95% CI, 0.84–2.35], P =0.19), whereas preeclampsia was associated with a hazard ratio of 2.00 (95% CI, 1.50–2.68, P <0.001). Among women with HDP, risks were not modified by concurrent small-for-gestational-age or preterm delivery ( P interaction =0.42). Largest hazards of HF were observed in women whose only lifetime birth was complicated by preeclampsia and women with recurrent preeclampsia. HF risks were similar after excluding women with coronary artery disease. In summary, women with preeclampsia, especially those with one lifetime birth and those with recurrent preeclampsia, experienced increased HF risk compared to women without HDP. Further research is needed to clarify causal mechanisms.

Download Full-text

Evaluation of Postpartum Counseling on Future Health Risks Associated with Hypertensive Disorders of Pregnancy

Journal of Integrative Cardiology Open Access ◽

10.31487/j.jicoa.2020.02.05 ◽

2020 ◽

pp. 1-5

Author(s):

Jourdie Triebwasser ◽

Elizabeth S. Langen ◽

Jennifer Lewey ◽

Jourdie Triebwasser

Keyword(s):

Primary Care ◽

Cardiovascular Risk ◽

Tertiary Care ◽

Discharge Summary ◽

Chronic Hypertension ◽

Hypertensive Disorders Of Pregnancy ◽

Postpartum Visit ◽

Hypertensive Disorders ◽

Future Pregnancy

Background: The American College of Obstetricians and Gynecologists and the American Heart Association recommend that women with hypertensive disorders of pregnancy be counseled on lifelong cardiovascular risks and transitioned to primary care for ongoing screening and management. Objective: To assess frequency and content of postpartum counseling regarding cardiovascular risk and follow-up among women with hypertensive disorders of pregnancy. Study Design: A secondary analysis of a randomized trial of women with hypertensive disorders of pregnancy, excluding chronic hypertension, performed at a single tertiary care academic hospital. We abstracted documented counseling on hypertensive disorders from the discharge summary and postpartum visit note in the electronic medical record. We defined counseling as documentation of any one of the following: 1) recommending aspirin in a future pregnancy, 2) follow-up with primary care, or 3) lifelong risk of cardiovascular disease. We used logistic regression models to estimate adjusted odds for receiving counseling. Results: Seventy-four women enrolled in the study. A hypertensive diagnosis was documented for 71 women (96.0%) in the discharge summary, but only 11 (14.9%) had any documented counseling in the discharge summary or postpartum visit note. Of the 11 women counseled, 5 (6.7%) were counseled on taking aspirin in a future pregnancy, 5 (6.7%) were counseled on follow-up with primary care, and only 3 (4.1%) were counseled on the lifelong cardiovascular risk associated with hypertension in pregnancy. Two women (2.7%) were counseled on follow-up with primary care and lifelong cardiovascular risk. There were no participants counseled on all three components. Later gestational age at delivery was associated with lower odds of counseling (adjusted OR 0.49, 95% CI 0.27-0.89). Conclusion: Despite consistent evidence on long-term risks of hypertensive disorders of pregnancy, counseling about those risks is suboptimal. Improved communication of risks is the first step towards improving maternal health in the “fourth trimester” and beyond.

Download Full-text

Sequential measurement of the neurosensory retina in hypertensive disorders of pregnancy: a model of microvascular injury in hypertensive emergency

Journal of Human Hypertension ◽

10.1038/s41371-021-00617-1 ◽

2021 ◽

Author(s):

Robert J. Herman ◽

Anshula Ambasta ◽

R. Geoff Williams ◽

Kelly B. Zarnke ◽

Fiona E. Costello ◽

...

Keyword(s):

De Novo ◽

Clinical Laboratory ◽

Normal Pregnancy ◽

Macular Thickness ◽

Chronic Hypertension ◽

Hypertensive Disorders Of Pregnancy ◽

Laboratory Findings ◽

Response Data ◽

Hypertensive Disorders ◽

The Relationship

AbstractOptical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages <20 weeks, 20-weeks to delivery, at delivery and postpartum. The primary outcome was the change in macular thickness from non-pregnant dimensions in women with incident HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the relationship(s) between mean arterial pressure (MAP) and macular response. Data show macular thicknesses diminished at <20 weeks gestation in each of 27 pregnancies ending in HDP (mean 3.94 µm; 95% CI 4.66, 3.21) and 11 controls (mean 3.92 µm; 5.05, 2.79; P < 0.001 versus non-pregnant dimensions in both; P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg (15, 22) leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.

Download Full-text

Depression, Antidepressants and Hypertensive Disorders of Pregnancy: A Systematic Review

Current Drug Safety ◽

10.2174/1574886314666190121144711 ◽

2019 ◽

Vol 14 (2) ◽

pp. 102-108 ◽

Cited By ~ 1

Author(s):

Sabrina Youash ◽

Verinder Sharma

Keyword(s):

Systematic Review ◽

Systematic Reviews ◽

Gestational Hypertension ◽

Research Question ◽

Current Evidence ◽

Hypertensive Disorders Of Pregnancy ◽

Hypertension In Pregnancy ◽

Hypertensive Disorders ◽

The Relationship ◽

In Pregnancy

Background: Hypertensive disorders of pregnancy including gestational hypertension, preeclampsia and eclampsia are conditions that cause significant perinatal and maternal morbidity and mortality. Objective: This is a systematic review of the current evidence examining the relationship between both depression and antidepressants on pregnancy-related hypertensive conditions. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, six databases were searched for articles published between January 1990 and December 2017 (PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, MEDLINE and ClinicalTrials. gov). Randomized control trials, cohort studies and case-control studies were included in this review. Studies that measured the following exposures were included: Antidepressant exposure or diagnosis of depression. Studies that measured the following outcomes were included: Gestational hypertension, preeclampsia or eclampsia. A combination of keywords, as well as Medical Subject Headings (MeSH) index terms, was used for three general categories: antidepressants, depression and hypertensive disorders of pregnancy. A total of 743 studies were identified and 711 were excluded based on relevance to the research question. Twenty studies were included in the final systematic review. Results: Of the twenty relevant studies, ten specifically examined the relationship between depression and hypertension in pregnancy. Only two of these did not find a significant association. Of the ten studies that concentrated on antidepressant medications, all except one found an association with hypertension in pregnancy to varying degrees. Conclusion: Review of the literature suggests a possible association between depression and antihypertensive medications with pregnancy-related hypertension, but further studies are needed.

Download Full-text

Abstract MP63: Established Cardiovascular Disease Risk Factors Mediate The Relationship Between Hypertensive Disorders In First Pregnancy And Maternal Cardiovascular Disease

Circulation ◽

10.1161/circ.141.suppl_1.mp63 ◽

2020 ◽

Vol 141 (Suppl_1) ◽

Cited By ~ 1

Author(s):

Jennifer J Stuart ◽

Lauren J Tanz ◽

Eric B Rimm ◽

Donna Spiegelman ◽

Stacey A Missmer ◽

...

Keyword(s):

Risk Factors ◽

Cardiovascular Disease ◽

Chronic Hypertension ◽

Cvd Risk Factors ◽

First Birth ◽

Cvd Risk ◽

Hypertensive Disorders ◽

Increased Risk ◽

History Of ◽

The Relationship

Introduction: Women with a history of hypertensive disorders in pregnancy (HDP; gestational hypertension [GHTN] or preeclampsia) have an increased risk of CVD risk factors and events compared to women with normotensive pregnancies. However, the extent to which the relationship between HDP and CVD events is mediated by established CVD risk factors is less clear. Hypothesis: We hypothesized that a large proportion of the HDP-CVD relationship would be mediated by subsequent CVD risk factors — chronic hypertension (CHTN), type 2 diabetes (T2D), hypercholesterolemia, and BMI. Methods: Parous women free of prior CVD events, CHTN, T2D, and hypercholesterolemia at first birth in the Nurses’ Health Study II comprised the analytic sample (n=57,974). Pregnancy history was retrospectively reported in 2009. Women were followed for confirmed CVD events (coronary heart disease [non-fatal or fatal MI, fatal CHD] or stroke [non-fatal or fatal]) from first birth through 2015. Potential mediators were self-reported on biennial questionnaires. We used Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the relationship between HDP in first pregnancy (preeclampsia or GHTN vs. normotension [ref]) and CVD, adjusting for age, race/ethnicity, parental education, family history of CVD before age 60, and pre-pregnancy risk factors (e.g., smoking, diet, and BMI). To evaluate the proportion of the HDP-CVD association that was jointly mediated by the CVD risk factors we used the difference method, comparing a model including these four factors to a model without them. Results: Nine percent of women (n=5,306) had a history of HDP in first pregnancy (preeclampsia: 6.3%; GHTN: 2.9%). CVD events occurred in 650 women with normotension in first pregnancy, 30 with GHTN, and 81 with preeclampsia. Adjusting for pre-pregnancy confounders, women with HDP in first pregnancy had a 63% higher rate of incident CVD (CI: 1.33-2.00) compared to women with normotension in first pregnancy; in particular, the strongest association was observed between preeclampsia and CHD (HR=2.18, CI: 1.62-2.93). The overall HDP-CVD association was largely mediated by the group of four CVD risk factors (HDP: proportion mediation [PM]=65%, CI: 35-87; preeclampsia: PM=57%, CI: 21-87; GHTN: PM=99%, CI: inestimable). All CVD risk factors contributed to mediation, but chronic hypertension accounted for the largest proportion. Conclusions: While approximately 40% of the association between preeclampsia and CVD remained unexplained, almost all the increased risk of CVD conferred by a history of GHTN was jointly accounted for by the development of established risk factors postpartum. Screening for CHTN, T2D, hypercholesterolemia, and overweight/obesity after pregnancy may be especially helpful in CVD prevention among women with a history of HDP.

Download Full-text

The Risk Factors That Predict Chronic Hypertension After Delivery in Women With a History of Hypertensive Disorders of Pregnancy

Medicine ◽

10.1097/md.0000000000001747 ◽

2015 ◽

Vol 94 (42) ◽

pp. e1747 ◽

Cited By ~ 9

Author(s):

Ji-won Hwang ◽

Sung-Ji Park ◽

Soo-young Oh ◽

Sung-A. Chang ◽

Sang-Chol Lee ◽

...

Keyword(s):

Risk Factors ◽

Chronic Hypertension ◽

Hypertensive Disorders Of Pregnancy ◽

Hypertensive Disorders ◽

History Of

Download Full-text

Frequent Placental SARS-CoV-2 in Patients with COVID-19-Associated Hypertensive Disorders of Pregnancy

Fetal Diagnosis and Therapy ◽

10.1159/000520179 ◽

2021 ◽

pp. 1-11

Author(s):

Marta Fabre ◽

Pilar Calvo ◽

Sara Ruiz-Martinez ◽

Maria Peran ◽

Daniel Oros ◽

...

Keyword(s):

Viral Load ◽

Gestational Hypertension ◽

Group Versus ◽

Control Group ◽

Hypertensive Disorders Of Pregnancy ◽

Rt Pcr ◽

Third Trimester ◽

Hypertensive Disorders ◽

The Moment ◽

The Relationship

Introduction: Studies described an increased frequency of hypertensive disorders of pregnancy (HDP) after a COVID-19 episode. There is limited evidence about SARS-CoV-2 viral load in placenta. This study aimed to investigate the relationship between SARS-CoV-2 viral load in the placenta and clinical development of HDP after COVID-19 throughout different periods of gestation. Methods: This is a case-control study in women with and without gestational hypertensive disorders after SARS-CoV-2 infection diagnosed by RT-PCR during pregnancy. Patients were matched by gestational age at the moment of COVID-19 diagnosis. We performed an analysis of SARS-CoV-2 RNA levels in placenta. Results: A total of 28 women were enrolled. Sixteen patients were diagnosed with COVID-19 during the third trimester and the remaining 12 patients in the other trimesters. Ten placentas (35.7%) were positive for SARS-CoV-2, 9 of them (9/14, 64.3%) belonged to the HDP group versus 1 (1/14, 7.2%) in the control group (p = 0.009). Those cases with the highest loads of viral RNA developed severe preeclampsia (PE). Conclusion: Among women diagnosed with COVID-19 during pregnancy, the presence of SARS-CoV-2 in the placenta was more frequent among women suffering from PE or gestational hypertension. Furthermore, the most severe cases of HDP were associated with high placental viral load, not necessarily associated with a positive nasopharyngeal RT-PCR at delivery. Our data suggest that SARS-CoV-2 infection during pregnancy could trigger gestational hypertensive disorders through persistent placental infection and resulting placental damage.

Download Full-text

Association between hypertensive disorders of pregnancy and cardiovascular disease in a population of Cameroonian women at two hospitals of yaounde : a case control study

10.31730/osf.io/t7y64 ◽

2018 ◽

Author(s):

Benedict Taa Nguimbis Esseme ◽

Mbondji Ebongué

Keyword(s):

Cardiovascular Disease ◽

Cardiovascular Diseases ◽

Gestational Hypertension ◽

Case Control ◽

Sub Saharan Africa ◽

Pediatric Care ◽

Hypertensive Disorders Of Pregnancy ◽

Hypertensive Disorders ◽

Increased Risk ◽

History Of

AbstractBackground: Positive associations have been found between Hypertensive Disorders of Pregnancy gestational hypertension, preeclampsia and cardiovascular diseases within non-black African populations, but no data exist from sub-Saharan Africa. We aimed to assess this association in Cameroonian mothers.Methods: We used a case-control design. Cases were women diagnosed with arteriosclerotic cardiovascular disease between 2012 and 2017 at the General and the Gyneco-obstetric hospital of Yaoundé. Controls were mothers of children who seeked pediatric care at the Gyneco-obstetric hospital of Yaoundé, with no diagnosis of cardiovascular disease. We abstracted data from patient files to assess cardiovascular disease, and used phone-based questionnaires to assess prior history of Hypertensive Disorders of Pregnancy. We used logistic regression and propensity scores for adjustment. Results: Out of 1228 individuals selected, 173 cases and 339 controls participated in the study. We found no increased risk of cardiovascular diseases for women with a history of Hypertensive Disorders of Pregnancy (OR = 0.83, 95% CI, 0.51 to 1.34). Women with gestational hypertension had 2.33 (95% CI, 0.99 to 5.50) times the risk of women with no history of Hypertensive Disorders of Pregnancy, an inverse association was observed between preeclampsia and cardiovascular diseases (OR = 0.28, 95% CI, 0.10 to 0.72). Conclusions: Cameroonian women with a history of gestational hypertension may have an increased risk of cardiovascular diseases. However, population-based studies with more accurate data on the exposure are needed.

Download Full-text