Cardiovascular death in women who had hypertension in pregnancy: a case-control study

Pre-eclampsia and long-term maternal health

Pre-eclampsia is a syndrome of pregnancy, defined by the gestational-onset of hypertension and proteinuria, which resolves postpartum. This definition does not consider the variable multiorgan involvement of a syndrome that can include seizures, fulminating hepatic necrosis and a consumptive coagulopathy. These disparate clinical features are a consequence of an accelerated but transient metabolic syndrome with widespread maternal endothelial dysfunction and inflammation. A trigger to this maternal state is the relatively ischaemic placenta. As pregnancy progresses, the concentration of vaso-toxic factors released by the relatively ischaemic placenta gradually builds up in the maternal circulation. Those predisposed to endothelial dysfunction, e.g. women with risk factors for cardiovascular disease, are more sensitive to these placental derived factors and will develop pre-eclampsia before natural onset of labour. A woman's vulnerability to pre-eclampsia is therefore composed of a unique balance between her pre-existing maternal endothelial and metabolic health and the concentration of placental derived factors toxic to maternal endothelium. Delivery of the placenta remains the only cure. Years later, women who had pre-eclampsia are at increased risk of chronic hypertension, ischaemic heart disease, cerebrovascular disease, kidney disease, diabetes mellitus, thromboembolism, hypothyroidism and even impaired memory. This article describes how a brief, usually single episode of this acute pregnancy syndrome might both identify those vulnerable to chronic disease in later life and in some cases initiate chronic disease.

Hypertension in pregnancy: is it time for a new approach to treatment?

Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. The current definition and treatment recommendations for elevated blood pressure (BP) during pregnancy in the United States have remained unchanged for many years, unlike the recommendations for hypertension treatment in the general population. Clinical studies have provided convincing evidence that women with hypertensive pregnancy disorders are at both immediate and long-term risk for cardiovascular complications; these findings suggest that consideration be given to lowering the presently recommended BP thresholds, both for the initiation of therapy and for therapeutic targets, and to simplifying the approach to the management of elevated BP in pregnancy. This review focuses on the current treatment strategies for hypertensive pregnancy disorders, new developments in the field of hypertension, in general, and in pregnant patients, in particular, and their potential impact on contemporary BP goals and the use of specific antihypertensive medications in pregnancy.

Hypertension complicating diabetic pregnancies: pathophysiology, management, and controversies

Hypertensive disorders of pregnancy (HDP), including pre-existing hypertension, gestational hypertension, and preeclampsia, further complicate already high-risk pregnancies in women with diabetes mellitus (DM). Women with both pre-existing and gestational diabetes are at increased risk for HDP, leading to higher maternal and fetal morbidity. Further, particularly in diabetic women and women with a history of gestational diabetes, HDP significantly increases the risk for future cardiovascular events. For clinicians, women with hypertension and diabetes during pregnancy pose a management challenge. Specifically, preconception management should stress strict control of glycemia, blood pressure, and prevention of diabetic complications, specifically nephropathy, which specifically increases the risk for preeclampsia. During gestation, clinicians must be aware of potential maternal and fetal complications associated with various anti-hypertensive therapies, including known fetotoxicity of ACE inhibitors and ARBs when given in the 2nd or 3rd trimester, and the risks and benefits of expectant management versus delivery in cases of severe gestational hypertension or preeclampsia. Indeed, diabetic women must be followed closely prior to conception and throughout gestation to minimize the risk of HDP and its associated complications.

Hypertension in pregnancy as a risk factor for cardiovascular disease later in life

OBJECTIVE

The association between hypertension in pregnancy and future cardiovascular disease (CVD) increasingly is recognized. We aimed to assess the role of hypertension in pregnancy as an independent risk factor for hypertension, coronary heart disease (CHD), and stroke later in life.

METHODS

Women who participated in the Phase 2 (2000-2004) Family Blood Pressure Program study (n = 4782) were categorized into women with no history of pregnancy lasting more than 6 months (n = 718), women with no history of hypertension in pregnancy (n = 3421), and women with a history of hypertension in at least one pregnancy (n = 643). We used Kaplan-Meier and Cox proportional hazard models to estimate and contrast the risks of subsequent diagnoses of hypertension, CHD, and stroke among the groups.

RESULTS

Women with a history of hypertension in pregnancy, compared with those without such a history, were at increased risks for the subsequent diagnoses of hypertension (50% hypertensive at the age 53 vs. 60, P < 0.001), CHD (14% estimated event rate vs. 11%, P = 0.009), and stroke (12% estimated event rate vs. 5%, P < 0.001). The increased risk for subsequent hypertension remained significant after controlling for race, family history of CVD, smoking, dyslipidemia, and diabetes mellitus, with an adjusted hazard ratio of 1.88 [95% confidence interval (CI) 1.49-2.39, P < 0.001]. After controlling for traditional risk factors, including subsequent hypertension, the increased risk for stroke remained statistically significant (hazard ratio 2.10, 95% CI 1.19-3.71, P = 0.01), but not for CHD.

CONCLUSION

Hypertension in pregnancy may be an independent risk factor for subsequent diagnoses of hypertension and stroke.

Pregnancy outcomes in women with moderate-to-severe psoriasis

BACKGROUND

The association between psoriasis and pregnancy outcomes has not been adequately examined, although psoriasis onset is common in the reproductive period.

OBJECTIVE

To evaluate the association between moderate-to-severe psoriasis and pregnancy complications.

METHODS

A retrospective, matched cohort study of 68 deliveries in 35 women with moderate-to-severe psoriasis compared to 237 deliveries in 236 women without psoriasis randomly selected after matching for age, parity and gestational age.

RESULTS

The psoriasis patients had higher mean of past spontaneous (0.42±0.58 vs. 0.26±0.63, P=0.002) and induced (0.32±0.60 vs. 0.06±0.25, P=0.001) abortions than controls. They had a higher percentage of pregnancy-induced hypertensive diseases (7.4% vs. 2.1%, P<0.05) and premature rupture of membranes (16% vs. 5.5%, P<0.008). Newborns to women with psoriasis had higher birth weight (3375±543 g vs. 3247±460 g, P=0.03), increased percentage of large-for-gestational age (24% vs. 12%, P=0.02), and macrosomia (13% vs. 4.2%P=0.02). In multivariate analysis, moderate-to-severe psoriasis was an independent risk factor for previous spontaneous abortions, induced abortions, premature rupture of membranes (PROM), and newborn macrosomia.

CONCLUSION

Moderate-to-severe psoriasis is associated with spontaneous and induced abortions, pregnancy-induced hypertensive diseases, premature rupture of membranes, large-for-gestational age newborns, and macrosomia.

Mortality of mothers from cardiovascular and non-cardiovascular causes following pregnancy complications in first delivery

The combined effects of preterm delivery, small-for-gestational-age offspring, hypertensive disorders of pregnancy, placental abruption and stillbirth on early maternal death from cardiovascular causes have not previously been described in a large cohort. We investigated the effects of pregnancy complications on early maternal death in a registry-based retrospective cohort study of 782 287 women with a first singleton delivery in Denmark 1978-2007, followed for a median of 14.8 years (range 0.25-30.2) accruing 11.6 million person-years. We employed Cox proportional hazard models of early death from cardiovascular and non-cardiovascular causes following preterm delivery, small-for-gestational-age offspring and hypertensive disorders of pregnancy. We found that preterm delivery and small-for-gestational-age were both associated with subsequent death of mothers from cardiovascular and non-cardiovascular causes. Severe pre-eclampsia was associated with death from cardiovascular causes only. There was a less than additive effect on cardiovascular mortality hazard ratios with increasing number of pregnancy complications: preterm delivery 1.90 [95% confidence intervals 1.49, 2.43]; preterm delivery and small-for-gestational-age offspring 3.30 [2.25, 4.84]; preterm delivery, small-for-gestational-age offspring and pre-eclampsia 3.85 [2.07, 7.19]. Thus, we conclude that, separately and combined, preterm delivery and small-for-gestational-age are strong markers of early maternal death from both cardiovascular and non-cardiovascular causes, while hypertensive disorders of pregnancy are markers of early death of mothers from cardiovascular causes.

Diagnosis and treatment of hypertensive disorders during pregnancy

Pregnancy is a cardiovascular and metabolic challenge to the human female body. This review summarizes current knowledge on the regulation of blood pressure and plasma volume in normal and hypertensive pregnant women. During pregnancy, systemic vascular resistance and blood pressure decrease, whereas cardiac output and blood volume increase to safeguard an adequate circulation in the utero-placental arterial bed. Hypertension affects 10% of all pregnancies and is accompanied by an increase in foetal and maternal morbidity and mortality. Hypertension in pregnancy includes a wide spectrum of conditions, including pre-eclampsia and eclampsia, pre-eclampsia superimposed on chronic hypertension, chronic hypertension, and gestational hypertension. Endothelial dysfunction, oxidative stress and an exaggerated inflammatory response are features related to hypertensive disorders. Microangiopathic disorders can easily mimic hypertensive disorders during pregnancy. Although they have some symptoms in common, they require another type of management. To reduce the risk of maternal and foetal complications due to haemodynamic maladaptations, the current management includes rest at home or in the hospital, close monitoring of maternal and foetal signs and symptoms, early start of antihypertensive therapy, and timely delivery regarding maternal and foetal survival chances. Thresholds to initiate blood pressure lowering treatment during pregnancy are 160 mmHg systole or 110 mmHg diastole. Below these thresholds, treatment must be individualized because current evidence does not support aggressive medical interventions. Alpha-methyldopa and dihydropyridinic calcium channel blockers are among the recommended antihypertensives.

Toxaemia of pregnancy and risk of mortality in later life: evidence from the Royal College of General Practitioners' Oral Contraception Study

OBJECTIVE

To examine whether toxaemia of pregnancy is associated with an increased risk of mortality, in particular premature death.

METHODS

A cohort nested within the Royal College of General Practitioners' Oral Contraception Study focusing on women who never used oral contraceptives. A total of 2865 parous women with a history of toxaemia of pregnancy were compared with 11,460 parous women without such a history. Adjusted hazards ratios and 95% confidence intervals were calculated for death from all causes, vascular disease and cancer. Risk of premature death before the age of 65 years was compared between the two groups.

RESULTS

Women with a history of toxaemia had a significant increased risk of death from any cause (adjusted HR 1.20, 95% CI 1.04-1.39) and from vascular disease (adjusted HR 1.38, 95% CI 1.05-1.82). Women with a history of toxaemia who did not subsequently develop hypertension or vascular disease had significantly increased risks of all-cause and vascular mortality. These risks were not found among women who developed these conditions. Toxaemia of pregnancy was not associated with premature death.

CONCLUSION

Toxaemia of pregnancy was associated with increased mortality but not premature death.

Miscarriage and risk of cardiovascular disease

In a nationally representative sample (the Health 2000 Survey) comprising 3,937 Finnish women aged 30-99 years, we examined the association of miscarriage (assessed by questionnaire) with risk of cardiovascular disease (assessed by physician's examination and linkages to hospital discharge and drug reimbursement registers). We considered age, smoking, body mass index, waist/hip ratio, physical activity, education, number of previous pregnancies, blood pressure, and fasting blood glucose and cholesterol as potentially confounding factors in the analysis. In women 50-74 years of age who had experienced pregnancy, history of miscarriage tended to be associated with a higher risk of myocardial infarction (age-adjusted odds ratio (OR): 2.1, 95% confidence interval (CI): 1.0-4.3), and the risk increased significantly with the number of miscarriages (age-adjusted OR per miscarriage: 1.4, 95% CI: 1.1-1.8). These results suggest that women who experience repeated miscarriages may be at an increased risk of cardiovascular disease later in life.

Long-term maternal cardiovascular function in a mouse model of sFlt-1-induced preeclampsia

Our aim was to evaluate the long-term effects of preeclampsia on vascular function in a mouse model induced by sFlt-1 overexpression. CD-1 mice at day 8 of gestation were injected via the tail vein with adenovirus carrying sFlt1 (AdsFlt1), adenovirus carrying the murine IgG2alpha Fc fragment as the adenovirus control (AdmFc), or saline. Vascular function in the mothers was investigated 6-8 mo after delivery by recording blood pressure (BP) by telemetry (AdsFlt1 n = 8, AdmFc n = 6, saline n = 4) and exploring carotid artery reactivity in a wire myograph (AdsFlt1 n = 6, AdmFc n = 8, saline n = 4). sFlt-1 blood levels at 6-8 mo postpartum had returned to low levels and were comparable between the three groups (P = 0.808). There was no statistically significant difference in BP (P = 0.067) or vascular reactivity between the three groups of postpartum mice (phenylephrine P = 0.079, thromboxane P = 0.979, serotonin P = 0.659, acetylcholine P = 0.795, sodium nitroprusside P = 0.728, isoproterenol P = 0.370). Our results indicate that in a mouse model overexpression of sFlt-1 does not lead to increased in BP and altered vascular function in the absence of the pregnancy and has no long-term effect on BP and vascular function in the postpartum mothers. Our findings favor the hypothesis that increased cardiovascular diseases in women with history of preeclampsia are likely the result of preexisting risk factors common to preeclampsia and cardiovascular diseases.

Latin American guidelines on hypertension. Latin American Expert Group

Hypertension is a highly prevalent cardiovascular risk factor in the world and particularly overwhelming in low and middle-income countries. Recent reports from the WHO and the World Bank highlight the importance of chronic diseases such as hypertension as an obstacle to the achievement of good health status. It must be added that for most low and middle-income countries, deficient strategies of primary healthcare are the major obstacles for blood pressure control. Furthermore, the epidemiology of hypertension and related diseases, healthcare resources and priorities, the socioeconomic status of the population vary considerably in different countries and in different regions of individual countries. Considering the low rates of blood pressure control achieved in Latin America and the benefits that can be expected from an improved control, it was decided to invite specialists from different Latin American countries to analyze the regional situation and to provide a consensus document on detection, evaluation and treatment of hypertension that may prove to be cost-utility adequate. The recommendations here included are the result of preparatory documents by invited experts and a subsequent very active debate by different discussion panels, held during a 2-day sessions in Asuncion, Paraguay, in May 2008. Finally, in order to improve clinical practice, the publication of the guidelines should be followed by implementation of effective interventions capable of overcoming barriers (cognitive, behavioral and affective) preventing attitude changes in both physicians and patients.

Association of Remote Hypertension in Pregnancy With Coronary Artery Disease

Because hypertensive pregnancies have been associated with increased cardiovascular disease, we aimed to identify whether angiographically characterized coronary artery disease differed in women with previous normotensive pregnancies or hypertensive pregnancies (HPs). The study group included 217 parous women, aged 60.9±9.2 (SD) years, who required coronary angiography between January 2006 and December 2007, 36.8±9.9 and 28.8±10.5 years after their first and last pregnancy, respectively; 146 had normotensive pregnancies and 71 had ≥1 HP, according to a questionnaire including reproductive history and cardiovascular risks. Body mass index, smoking, and frequency of diabetes were similar in both groups. Chronic hypertension (93% versus 78%; P =0.007), hyperlipidemia (82% versus 69%; P =0.049), and premature familial cardiovascular disease (42% versus 20%; P =0.001) prevailed in HPs. Participants with HPs were younger (58.9±8.3 versus 61.9±9.6 years; P =0.025) than participants with normotensive pregnancies. Although 49% of all participants had hemodynamically significant coronary artery disease (≥70% stenosis), no differences were observed between groups in the number of stenotic arteries; however, their number increased by 28% and 22% over a 10-year period in HPs and normotensive pregnancies, respectively ( P =0.034). Multivariate analysis showed that HPs had a nonsignificant risk of having coronary artery disease (odds ratio: 1.21; 95% CI: 0.64 to 2.28), and being a current smoker (odds ratio: 4.13; 95% CI: 1.85 to 9.25), a diabetic (odds ratio: 2.29; 95% CI: 1.85 to 9.25), or having a family history of premature cardiovascular disease (odds ratio: 2.34; 95% CI: 1.17 to 2.39) significantly increased the risk of coronary artery disease. This study demonstrates that women with HPs have earlier coronary disease, probably related to intermediate cardiovascular risks that have a gestational expression.

The visually-evoked cerebral blood flow response in women with a recent history of preeclampsia and/or eclampsia

Several studies provide evidence for altered cerebral hemodynamics during (pre)eclampsia. Whether (pre)eclampsia has a persistent negative impact on cerebral hemodynamics, possibly contributing to an elevated risk of premature stroke, is unknown. The aims of this study were (i) to refine and apply a control system-based method previously introduced by Rosengarten to quantify the visually-evoked blood flow response of the posterior cerebral artery (PCA); and (ii) to test the hypothesis with this method that cerebral hemodynamics in women with a recent history of (pre)eclampsia is abnormal relative to that in parous controls. Hereto, we recorded cerebral blood flow velocity (CBFV) in the PCA by transcranial Doppler (TCD) sonography during cyclic visual stimulation in 15 former preeclamptics, 13 former eclamptics and 13 controls. The typical CBFV response was fitted with the step response of a second-order-linear model enabling quantification by parameters K (gain), zeta (damping), omega (natural frequency), T(v) (rate time) and T(d) (time delay). The method refinement introduced here consisted of response filtering before quantification and of considering the individual instead of group-averaged response patterns. Application of this refinement reduced the fitting errors (1.4 +/- 1.2 vs. 3.2 +/- 1.8, p < 0.01). Intergroup differences in model parameters were not found. Although statistically not significant, a trend was observed that critical damping (zeta>1) occurred more frequently in the combined group of former patients than in the controls (7 of 28 vs.1 of 13, p = 0.16). Critical damping (zeta>1) reflects an abnormal response, which is either compensated for by a rise in rate time ("intermediate"; zeta>1; T(v) > 20) or remains uncompensated ("sluggish"; zeta>1; T(v) < 20). Critical damping increased significantly (p = 0.039) with (pre-)eclampsia-to-test-interval in the PE+E patients with abnormal responses (zeta>1), suggesting that (pre)eclampsia might induce diminishing cerebral hemodynamic function over time. Based on a system-analytical classification approach, the data of this study provide evidence for individual CBFV responses to be abnormal in former (pre)eclamptics compared with controls. Further study is needed to reveal how the abnormal CBFV response classification reflects cerebrovascular dysfunction.

Preeclampsia and future cardiovascular risk: formal risk factor or failed stress test?

It is estimated that 10% of pregnancies are affected by hypertension worldwide. Approximately one-half of all hypertensive pregnancy disorders are due to preeclampsia, a pregnancy-specific disorder, its distinctive feature being either sudden onset, or worsening of pre-existing proteinuria. It has become increasingly recognized that women with a history of preeclampsia are at increased risk for future cardiovascular disease (CVD), but the mechanisms of this increase in risk are unclear. One possible explanation is that these two conditions share several common metabolic abnormalities as risk factors, including obesity, insulin resistance, and lipid abnormalities that may lead to preeclampsia and CVD at different times of a woman's life. Recent studies have revealed that, similar to CVD, several mediators of endothelial cell dysfunction are up-regulated in preeclampsia. Free radical derived oxidative stress, various inflammatory markers, including neutrophil response, C-reactive protein, and leukocyte adhesion, may contribute to endothelial dysfunction in both preeclampsia and coronary atherosclerosis. Alternatively, preeclampsia itself may induce metabolic and vascular changes that may increase the overall future risk for CVD in affected women. Therefore, at present, it remains unclear whether preeclampsia is a formal risk factor for CVD, or identifies women at increased risk for CVD later in life. Pending large-scale studies aiming to examine the causality of this association, women with a history of preeclampsia should be counseled regarding their increased risks for hypertension and other cardiovascular sequelae later in life, followed closely and treated aggressively for modifiable CVD risk factors.

Risk factors for cardiovascular disease in women: relationship to lipid peroxidation and oxidative stress

Many risk factors that promote cardiovascular disease (CVD) have been identified. These include hypertension, hypercholesterolemia, diabetes, decreased estrogen in post-menopausal women, increased homocysteine, and cigarette smoking. It has recently become clear that a mechanism common to these risk factors is oxidative stress. CVD risk factors specific to women are parity, oophorectomy, pre-eclampsia, and menopause. There are several proposed mechanisms to explain these women-specific associations, such as reduced lifetime exposure to estrogen and insulin resistance, but the underlying mechanism is still unclear. One fact that did not receive much attention is the role of the oxidation hypothesis in these reproductive factors-CVD associations. In fact, pregnant, oophorectomized, and post-menopausal women exhibit higher levels of lipid peroxidation than non-pregnant, non-oophorectomized and pre-menopausal women, respectively. We propose that the increased levels of lipid peroxidation during these states are responsible, at least in part, for their increased risk of CVD. This review extends the concept of the oxidation hypothesis of CVD to reproductive risk factors in women. It also addresses the potential role of oxidative stress in the hyperthyroidism-CVD relationship, as hyperthyroidism is a common disorder that most frequently occurs in women. We also discuss how screening human populations for reactive oxygen species (ROS) levels could help identify groups with a high level of ROS that may be at risk of developing CVD.

Prepregnancy body mass index, hypertensive disorders of pregnancy, and long-term maternal mortality

OBJECTIVE

Recent studies have shown increased maternal mortality rates after hypertensive disorders of pregnancy (HDP), but the reasons for this increase remain unclear. This study examines the relationship between elevated prepregnancy body mass index (BMI), HDP, and postpregnancy mortality.

STUDY DESIGN

Data came from a 1975-1976 subset (n = 13,722 women) of a population-based cohort. Multiple logistic regression was used to examine the risk of HDP by BMI; age-adjusted Cox proportional hazards models were used to examine survival rates.

RESULTS

Overweight (BMI, 25-29.9 kg/m2) and obesity (BMI, > or = 30 kg/m2) were associated with increased HDP (odds ratio [OR], 2.82; 95% confidence interval [CI], 2.40-3.31 and OR, 5.51; 95% CI, 4.15-7.31]) and decreased survival (hazard ratio [HR], 1.42; 95% CI, 1.10-1.83 and HR, 2.43; 95% CI, 1.61-3.68), compared with normal weight (BMI, 18.5-24.9 kg/m2). HDP was significantly associated with increased mortality rates for women who survived > 15 years (HR, 1.94; 95% CI, 1.42-2.67]; HR adjusted for BMI, 1.65; 95% CI, 1.19-2.79]). A greater increase in risk of death after HDP was seen in the overweight women (HR, 1.86; 95% CI, 1.07-3.20) and obese women (HR, 2.90; 95% CI, 1.28-6.58), compared with normal weight women (HR, 1.26; 95% CI, 0.74-2.14).

CONCLUSION

Elevated prepregnancy BMI is associated with increased risk of HDP, which are in turn is associated with increased long-term maternal mortality rates. This association between HDP and mortality rates increases with elevated prepregnancy BMI.

Troponin I levels in patients with preeclampsia

INTRODUCTION

Preeclampsia involves a diffuse inflammatory state and elevated levels of troponins in patients with preeclampsia have been anecdotally reported. It is, however, unknown whether it is attributable to the preeclampsia.

OBJECTIVE

We sought to determine the troponin I levels at the time of delivery in pregnant women with and without preeclampsia.

METHODS

Plasma samples were obtained at the time of delivery and serum troponin I was measured by ELISA method.

RESULTS

Thirty-nine women were included (20 with preeclampsia and 19 without). Mean troponin I level was 0.008 ng/mL in patients with preeclampsia and 0.01 ng/mL in controls (P =.59). The highest troponin I level was 0.04 ng/mL for both patients with and without preeclampsia.

CONCLUSIONS

Preeclampsia was not associated with a rise in troponin I levels in our study. Patients with preeclampsia and elevated troponin levels should have further cardiac investigations.

Pregnancy-related factors and the risk of isolated systolic hypertension

BACKGROUND

Isolated systolic hypertension (ISH) is known to be a strong predictor of cerebrovascular and cardiac events, especially in women. Metabolic and hormonal changes associated with reproductive history may contribute to the development of cardiovascular diseases. The aim of this study was to identify associations between pregnancy-related factors and ISH.

METHODS

A cross-sectional study based on a random sample of 3937 Finnish women aged 30-99 was carried out. Associations between pregnancy-related factors and ISH were analyzed using multivariate analyses.

RESULTS

Of 3470 subjects, 26% had ISH. Younger age at first delivery predicted a higher risk of ISH (odds ratio after adjustment for age, education, smoking, height and weight = 1.31, 95% CI 1.07-1.61). Age at first and last delivery was significantly associated with age, education, marital status and use at any time of hormone replacement therapy (HRT); age at first delivery was also associated with toxemia in any pregnancy, weight and body mass index (BMI). In the univariate analyses, ISH was significantly associated with age, height, weight, BMI, education, marital status, oral contraceptive pills use at any time and HRT use at any time.

CONCLUSION

This population-based study showed that early age at first delivery increased the risk of ISH, which may in turn increase cerebrovascular and cardiac events after menopause. Age at first delivery is heavily dependent on education, which may be linked to the risk of developing of cardiovascular disease throughout adulthood. The other plausible mechanism may be adiposity due to pregnancy.

Endothelial dysfunction: a link among preeclampsia, recurrent pregnancy loss, and future cardiovascular events?

We tested the hypothesis that endothelial dysfunction could cause placentation-related defects, persist after the complicated pregnancy, and probably cause cardiovascular disease later in life. Brachial arterial reactivity and factors related to endothelial dysfunction, such as circulating cholesterol, uric acid, nitrites, l-arginine, asymmetrical dimethylarginine, vascular endothelial growth factor, and soluble vascular endothelial growth factor receptor-1, in women with previous healthy pregnancies (n=22), patients with severe preeclampsia (n=25), or patients with recurrent pregnancy loss (n=29), at day 10 of the luteal phase of an ovulatory cycle an average of 11 to 27 months after pregnancy were evaluated. Both groups with placentation defects had a significant decrease in endothelium-dependent dilatation, a higher rate of endothelial dysfunction, lower serum nitrites, and higher cholesterol as compared with control subjects; subjects with previous preeclampsia additionally had higher normal blood pressures and a greater parental prevalence of cardiovascular disease. Patients with recurrent pregnancy loss also demonstrated a significantly lower endothelium-independent vasodilatation. A trend to an inverse correlation was found between serum cholesterol serum and endothelial-mediated vasodilatation in the whole study population. Uric acid, l-arginine, asymmetrical dimethylarginine, vascular endothelial growth factor, and soluble vascular endothelial growth factor receptor-1 were similar in all of the groups. We postulate that endothelial dysfunction may represent a link between preeclampsia and increased cardiovascular disease latter in life and propose that women with unexplained recurrent miscarriages are also at increased cardiovascular risk. The identification and correction of endothelial dysfunction detected during the reproductive stage on obstetric outcome and on cardiovascular diseases needs to be elucidated.

Preterm delivery of a first child and subsequent mothers' risk of ischaemic heart disease: a nested case-control study

Several studies have suggested that preterm delivery is related to a risk of subsequent ischaemic heart disease (IHD) in the mother. We conducted a nested case-control study in the E3N cohort to assess the association between preterm delivery of a first child and IHD, and the effect of major cardiovascular risk factors on this association. The study included 109 cases and 395 controls. Mothers who had preterm delivery were at an increased risk of IHD [multivariate hazard ratio 2.09 (95% confidence interval 1.07-4.09)]. This association was independent of major cardiovascular risk factors.

Family stability during childhood and the risk to develop hypertensive diseases in pregnancy

BACKGROUND

Parental care giving, divorce and death are associated with physical health as an adult.

AIM

To investigate whether the structure of the nuclear family during childhood shows any correlation with the development of hypertensive diseases in pregnancy as an adult.

STUDY DESIGN

Self-administered questionnaires were sent to 2600 women with hypertensive diseases in pregnancy and to 1484 controls.

SUBJECTS

After confirmation of the diagnosis data from 842 patients and 623 control women were evaluated.

OUTCOME MEASURES

Type, number and involvement of different caregivers, parental separation, parental death.

RESULTS

In both groups parental separation and parental death were found equally often. In all age groups during childhood fathers were involved significantly less often in care giving when women with hypertensive disorders in pregnancy were compared to control women (1st-3rd year 23.4%/17%, <0.0001; 4th-10th year 25.7%/19.3%, <0.0001; 11th-18th year 30.1%/23.9%, <0.0001). The total number of caregivers involved was significantly higher in patients.

CONCLUSIONS

The quality of parental care giving, i.e. the involvement of fathers and the total number of caregivers correlate with the risk to develop HDP. Further research is needed to specify underlying mechanisms and the relevant factors of the parent-child relationship.

Family history of early-onset cardiovascular disorders is associated with a higher risk of severe preeclampsia

AIM

The aim was to evaluate familial early-onset cardiovascular disorders as potential risk factors for severe preeclampsia.

STUDY DESIGN

A case-control study was carried out by interviewing 162 primiparous severely preeclamptic women and 521 primiparous healthy control patients after delivery to determine the frequency of cardiovascular disorders (chronic hypertension, myocardial infarction, stroke) developed before the age of 50 among their parents. The chi2-test was utilized to estimate odds ratios (OR) and 95% confidence intervals (95% CI). The association was adjusted for pre-pregnancy body mass index, maternal age, and smoking habits before pregnancy using logistic regression analysis.

RESULTS

Maternal and paternal early-onset chronic hypertension (adjusted OR: 3.84, 95% CI: 2.25-6.54; and adjusted OR: 3.26, 95% CI: 1.76-6.05) as well as paternal early-onset myocardial infarction (adjusted OR: 3.33; 95% CI: 1.51-7.32) were independent risk factors for severe preeclampsia. Early-onset stroke affected only the fathers of severely preeclamptic patients. Among the severely preeclamptic patients a positive family history of cardiovascular disorders developed before the age of 50 increased the risk of early-onset preeclampsia (developing before the 32nd gestational week) by 5.05-fold (95% CI: 3.08-8.31) compared with the control group.

CONCLUSION

Our results suggest that the presence of familial early-onset cardiovascular disorders is a predisposing factor for severe preeclampsia.

Migraine Headaches and Preeclampsia: An Epidemiologic Review

OBJECTIVE

To summarize and evaluate available empirical research on the relationship between migraines and gestational hypertension or preeclampsia and to provide direction for future research in this area.

BACKGROUND

Migraines affect a substantial proportion of reproductive-aged women and have been associated with cardiovascular risk factors and ischemic disease in this population. Preeclampsia is a vascular disorder of pregnancy, also linked to adverse cardiovascular outcomes.

METHODS

Publications were identified by a MEDLINE search using keywords "migraine,""preeclampsia," and "gestational hypertension," and by examination of the reference lists of identified articles.

RESULTS

The literature review yielded 10 studies addressing the association between migraines and preeclampsia or gestational hypertension. Of the 10 studies, 8 reported a positive association between the syndromes.

CONCLUSIONS

Available evidence suggests that migraines and preeclampsia may reflect an underlying predisposition toward ischemic injury. More rigorous epidemiologic research is warranted, after consideration of several important methodologic issues.

Relationship between high consumption of marine fatty acids in early pregnancy and hypertensive disorders in pregnancy

OBJECTIVE

To investigate whether there is a relationship between maternal intake of cod-liver oil in early and late pregnancy and hypertensive disorders in pregnancy.

DESIGN

An observational prospective study.

SETTING

Free-living conditions in a community with traditional fish and cod-liver oil consumption.

POPULATION

Four hundred and eighty-eight low-risk pregnant Icelandic women.

METHODS

Maternal use of cod-liver oil, foods and other supplements was estimated with a semiquantitative food frequency questionnaire covering food intake together with lifestyle factors for the previous 3 months. Questionnaires were filled out twice, between 11 and 15 weeks of gestation and between 34 and 37 weeks of gestation. Supplements related to hypertensive disorders in pregnancy, i.e. gestational hypertension and pre-eclampsia, were presented, with logistic regression controlling for potential confounding.

MAIN OUTCOME MEASURES

Gestational hypertension, pre-eclampsia, cod-liver oil and multivitamins.

RESULTS

The odds ratio for developing hypertensive disorders in pregnancy for women consuming liquid cod-liver oil was 4.7 (95% CI 1.8-12.6, P= 0.002), after adjusting for confounding factors. By dividing the amount of n-3 long-chain polyunsaturated fatty acids (n-3 LCPUFA) into centiles, the odds ratio for hypertensive disorders across groups for n-3 LCPUFA suggested a u-shaped curve (P = 0.008). Similar results were found for gestational hypertension alone. Further, the use of multivitamin supplements without vitamins A and D in late pregnancy doubled the odds of hypertensive disorders (OR 2.4, 95% CI 1.0-5.4, P= 0.044).

CONCLUSIONS

Consumption of high doses of n-3 LCPUFA in early pregnancy, or other nutrients found in liquid cod-liver oil, may increase the risk of developing hypertensive disorders in pregnancy.

The risk of maternal ischaemic heart disease after gestational hypertensive disease

OBJECTIVE

The aim of this study was to investigate whether the risk of developing ischaemic heart disease (IHD) later in life increases with severity and recurrence of gestational hypertensive disease.

DESIGN

Cross-sectional population-based study.

SETTING

Sweden.

POPULATION

Women (403,550) giving birth to their first child in Sweden, 1973-1982. Of this cohort, 207,054 women who also gave birth to a second child during the same period were analysed separately.

METHODS

All women were followed up for 15 years, starting 4-14 years after the index pregnancy. Women who suffered from hypertensive disease during pregnancy were compared with women with normal pregnancies with regard to hospitalisation for, or death from, IHD during the follow up period.

MAIN OUTCOME MEASURES

Fatal or non-fatal IHD.

RESULTS

The adjusted incidence rate ratio (IRR) for later development of IHD was 1.6 (95% CI 1.3-2.0) when the first pregnancy was complicated by gestational hypertension without proteinuria, 1.9 (95% CI 1.6-2.2) for mild pre-eclampsia and 2.8 (95% CI 2.2-3.7) for severe pre-eclampsia. Women with gestational hypertension in their first pregnancy but not in their second had an adjusted IRR of 1.9 (95% CI 1.5-2.4) for development of IHD. Women with hypertensive disease in both pregnancies had an IRR of 2.8 (95% CI 2.0-3.9) compared with women with two normal pregnancies.

CONCLUSION

Severe hypertensive disease in pregnancy has a stronger association with later development of IHD than has mild hypertensive disease. Recurrent hypertensive disease is more strongly associated with IHD than is non-recurrent disease.