Any type of hypertension in pregnancy incurs high future risk of cardiovascular disease

courtesy: indiatimes.com

Women presenting with any subtype of hypertensive disorders of pregnancy (HDP) are at increased risk of developing future hypertension, Ischemic Heart Disease (IHD), stroke and renal disease reports the results of a large retrospective cohort study epub ahead of print in journal Hypertension.

The results demonstrate that women with any type of hypertension during pregnancy are 2.78 times the risk of future hypertension, nearly twice the risk of IHD and stroke and 2.76 times the risk of renal disease as compared to women who were normotensive during pregnancy.

Contrary to popular belief, the highest risk is faced by women with gestational hypertension (OR, 4.08; CI,3.23–5.10) and not by women with preeclampsia during pregnancy (OR,3.06; CI,2.18–4.29).

Women with preeclampsia in pregnancy are nearly 5 times at risk of developing renal disease as compared to their normotensive counterparts during pregnancy (OR, 4.74; CI, 2.19 –10.20).

This retrospective study was conducted at a metropolitan tertiary hospital in Sydney, Australia, across a period of nine years. Data was extracted from medical records. A total of 31 656 deliveries took place during the study period out of which HDP was diagnosed in 4387 (13.8%) women, whereas 27262 (86.2%) of the women remained normotensive in their pregnancy.

The time to develop CVD from index pregnancy varied between 3 to 29 years, the median being 20 years. Future risk of developing CVD also increased proportionately as the severity of HDP increases. Women with preeclampsia also had more severe hypertension as compared to women with gestational hypertension. Women with severe HDP were older, deliver early in pregnancy and have babies that are small for gestational age.

Women who delivered ≤34 weeks gestation also are at increased and early risk of future CVD and as compared to women who delivered >34 weeks gestation. Receiving anti-hypertensive medication during pregnancy did not alter the future risk of developing CVD, although it benefited maternal and fetal outcome.

Under-reporting of chronic hypertension in young women might have limited some aspects of data analysis.

Hence, these women who have history of HDP should be explained in detail about their future risk of CVD and renal diseases. They should be advised a lifelong close monitoring for B.P and other modifiable risk factors for the development of CVD.

Cardiovascular risk assessment should also include obstetric history of women.

Further research is warranted to look into prevention of CVD after the risk is identified early in disease course.

 Abstract, Full Text

USPSTF final recommendation statement favor screening for preeclampsia throughout pregnancy.

The US Preventive Services Task Force (USPSTF) today issued its final recommendations for preeclampsia screening by monitoring the blood pressure throughout pregnancy with grade B, meaning there exists substantial net benefit for the mother and infant because of screening.

The recommendations, accompanying editorial and systematic review evidence was published online 25 April 2017 in JAMA.

USPSTF has earlier released a draft recommendation on September 27, 2016 which was open to public comments till October 2017.

The task force last full review of this topic was in 1996. The topic was again reviewed recently in light of new evidence and change in definition of preeclampsia.

The current recommendation states that Blood Pressure measurement should be done at each antenatal visit. No timing interval is mentioned.

The screening applies to all pregnant women without a known diagnosis of preeclampsia or being at high risk for the disease.

Conditions associated with increased risks are previous history of eclampsia or preeclampsia (particularly early-onset preeclampsia), medical morbidities associated includes DM 1 or 2, GDM, chronic hypertension, renal disease, and autoimmune diseases), previous history of adverse pregnancy outcome and multifetal gestation.

Other risk factors include nulliparity, obesity, African American race, low socioeconomic status, and advanced maternal age.

Evidence did not suggest point of care urine testing when screening for preeclampsia because it alone could not predict the health outcome.

Recently revised criteria for the diagnosis of preeclampsia include:

• elevated blood pressure (≥140/90 mm Hg on 2 occasions 4 hours apart, after 20 weeks of gestation)
• and either proteinuria (≥300 mg/dL on a 24-hour urine protein test, protein to creatinine ratio of ≥0.3 mg/mmol, or urine protein dipstick reading >1 if quantitative analysis is not available)
• or, in the absence of proteinuria, thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms.

The USPSTF further recommends low dose aspirin (81 mg/d) after 12 weeks of gestation for all women at high risk for preeclampsia.

Other Obstetrics and Gynecology societies like The Society of Obstetricians and Gynecologists of Canada, The National Institute for Health(NIH) and Care Excellence recommends urinalysis for proteinuria at each antenatal visit.

The ACOG only recommends B.P. measurements at every visit with detailed history to evaluate the risk.

“Preeclampsia and CVDs including hypertension are bound not only by common pathophysiology but also epidemiology” said Nisha I. Parikh, MD, and Juan Gonzalez, MD, PhD, from the University of California, San Francisco, in an accompanying editorial published simultaneously in JAMA Internal Medicine.

"Pregnancy is essentially a cardiovascular stress test, and the development of preeclampsia among other pregnancy complications is the earliest marker of patients at risk for future [cardiovascular disease].” They further added.

The full text of recommendation statement in JAMA can be assessed here.

The accompanying editorial in JAMA can be accessed here.

The accompanying editorial in JAMA cardiology can be accessed here.

The accompanying editorial in JAMA Internal Medicine can be accessed here.