New-onset hypertension in pregnancy: a review of the long-term maternal effects

2012;14:99–105DOI: 10.1111/j.1744-4667.2012.00095.x

The Obstetrician & Gynaecologist

http://onlinetog.org

Review

New-onset hypertension in pregnancy: a review of thelong-term maternal effectsAmanda Green MRCOG,a,∗ Pamela Loughna MRCGP MD FRCOG,b Fiona Broughton Pipkin BA Hons MA DPhil FRCOG

ad eundemc

aClinical Research Fellow, Academic Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, City Hospital Campus,Hucknall Road, Nottingham NG5 1PB, UKbSenior Lecturer/Consultant Obstetrician, Academic Division of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust,Nottingham, UKcProfessor of Perinatal Physiology, Academic Division of Obstetrics and Gynaecology, University of Nottingham, City Hospital Campus,Nottingham, UK∗Correspondence: Amanda Green. Email: [email protected]

Key content� Women with a history of new-onset hypertension in pregnancyhave an increased risk of future hypertension and cardiovasculardisease; women who deliver preterm (before 34 weeks of gestation)are at even higher risk.

� In this group of women, cardiovascular disease often occurs at amuch earlier age.

� Follow-up after pregnancy is vital to ensure that ongoing disease isappropriately investigated and managed.

� Simple lifestyle changes may help reduce these risks.

Learning objectives� To have increased awareness of the future risks of hypertensivepregnancy.

� To be able to quantify the risk of future disease from currentevidence in the literature.

� To be able to counsel women and discuss lifestylechanges.

Ethical issues� Do we counsel women adequately about the long-term risk ofdisease after hypertensive pregnancy?

� Are we missing opportunities for diseaseprevention?

Keywords cardiovascular disease / gestational hypertension /pre-eclampsia / renal disease / stroke / venous thromboembolism

Please cite this paper as: Green A, Loughna P, Broughton Pipkin F. New-onset hypertension in pregnancy: a review of the long-term maternal effects. TheObstetrician & Gynaecologist 2012;14:99–105.

Introduction

Gestational hypertension and pre-eclampsia are commondisorders of pregnancy. Obstetricians and gynaecologists areexperts at acute diagnosis and management of these conditionsbut they do not commonly debrief women about their long-term risks. The National Institute for Health and ClinicalExcellence (NICE) Hypertension in Pregnancy1 guidelinerecommends that all women with these conditions are seenpostnatally and that the future risk of hypertension and itscomplications, including renal disease, are explained. It is vitalthat we have up-to-date, evidence-based knowledge about therisks so that we can counsel women accurately. Simple lifestylechanges can prevent disease in this group of young mothers.This would benefit not only their own health and their qualityand length of life, but also that of their offspring.

This article explores the current understanding of the futurerisks of hypertension and cardiovascular, cerebrovascular,arterial, renal and metabolic disease. It provides information

from both the literature and early results from our specialistpostnatal clinic to help clinicians counsel women and discusslifestyle changes.

Hypertension in pregnancy

This is diagnosed when there are two or more episodes, morethan 4 hours apart, of blood pressure >140/90 mmHg at≥20 weeks of gestation.2 Proteinuria is significant if there is≥0.3 g urinary protein/24 hours, a spot protein:creatinine ratio≥30, or ≥++ protein on urine dipstick, with no evidence ofurinary tract infection. See Table 1 for further details.

Both gestational and essential hypertension can progressto pre-eclampsia, which is mainly a disease of primigravidae(occurring in 4.1% of first versus 1.7% of subsequentpregnancies), although it can recur or occur for the firsttime in subsequent pregnancies. The lower overall risk ofpre-eclampsia among parous women cannot be explained by

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New-onset hypertension in pregnancy

Table 1. Definitions and incidence of hypertensive diseases in pregnancy

Disease Pre-eclampsia Gestational hypertension Essential (chronic) hypertension

Definition Hypertension and significantproteinuria at ≥20 weeks ofgestation

Hypertension at ≥20 weeks ofgestation in the absence ofsignificant proteinuria

Hypertension at ≤20 weeks of gestation orin women already taking antihypertensivemedication at booking

Incidence (%) 2–834,35 4.2–7.936 236

there being fewer pregnancies among women who have hadpre-eclampsia in a previous pregnancy.3 There is no effect ofparity on women with gestational hypertension and they havea 16–50% chance of developing the disease again.1

In this article we review new-onset hypertension inpregnancy and not chronic hypertension.

The long-term effects of hypertension inpregnancy

Developments in health care, such as progress in informationtechnology and increasing demands for accountability, have ledto an increase in the number of medical registries over recentyears. These can provide data on large numbers of patients;however, they do have their pitfalls. The quality of a registry isonly as good as the data entered into it and, in practice, patientsare often registered incorrectly and data items inaccuratelyrecorded or not recorded at all. Strict frameworks are neededfor data entry to minimise errors. Some of the studies describedbelow are based on data from registries.

HypertensionA number of studies have shown an increased risk of futurehypertension after pregnancy complicated by hypertensivedisease. Bellamy et al.4 carried out a systematic reviewand meta-analysis looking at the long-term risks: 21 030

women from 13 studies were included. The risk of chronichypertension after a pre-eclamptic pregnancy was fourtimes higher than in controls (95% confidence interval[CI] 2.70–5.05) with a mean follow-up of 14 years;after pregnancy complicated by gestational hypertensionit increased three-fold (relative risk [RR] 3.39, 95%CI 0.82–13.92).

Subsequently, data were analysed from the Danish NationalRegistries, which included 782 287 women with a medianfollow-up of 14.6 years.5 In this study severe pre-eclampsiawas identified when data were entered in the patient registry;the exact criteria used to diagnose disease severity were notgiven. The results are shown in Table 2. In the UK, Wilsonet al.6 examined the long-term outcome of women deliveringin Aberdeen from1951–1970. Results were obtained from bothquestionnaire data and physical examination of respondentsin the cohort. Although this study is subject to recall bias,the authors sought to minimise this by linking findings tohospital discharge databases. Hannaford et al.7 used data fromthe Royal College of General Practitioners oral contraceptivestudy.7 Prospective data provided by 1400 general practitionerson pregnancy outcomes and occurrence of further diseases wereanalysed: 214 356 woman-years of observations were included.

The studies described strongly suggest that there is a higherrisk of long-term hypertension after pregnancy complicated byhypertension alone or by pre-eclampsia. The long-term risk

Table 2. The risk of long-term hypertension following hypertensive pregnancy

Lykke et al. (Denmark)5 Hannaford et al. (UK)7 Wilson et al. (Aberdeen, UK)6

Pregnancy complication Hazard ratio (95% CI) Relative risk (95% CI) Adjusted odds ratio (95% CI)

Gestational hypertension 5.94 (5.55–6.36) 2.47 (1.74–3.51)Pre-eclampsia

Mild 3.87 (3.70–4.05) 2.35 (2.08–2.65) 3.98 (2.82–5.61)Severe 7.58 (7.05–8.14)Preterm delivery 8.72 (7.77–9.77)SGA baby 4.17 (3.63–4.79)Preterm delivery + SGA 7.68 (6.80–8.67)Pre-eclampsia in two pregnancies 6 (5.4–6.67)

SGA = small for gestational age

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Green et al.

appears to vary according to the severity of disease and thegestation at onset.

Cardiovascular diseaseLong-term hypertension predisposes to cardiovascular disease.A number of large population-based studies have attempted toidentify whether hypertensive pregnancy increases the long-term risk of cardiovascular disease.

The systematic review by Bellamy et al.4 showed that,compared with women with uncomplicated pregnancies,women with a history of pre-eclampsia were twice as likelyto develop ischaemic heart disease (RR 2.16, 95% CI 1.86–2.52) and that the cardiac event was more likely to be fatal(RR 2.60, 95% CI 1.94–3.49). Two studies8, 9 included inthe meta-analysis showed that those delivering early (before37 weeks of gestation) had an eight-fold increased risk ofischaemic heart disease (RR 7.7, 95% CI 4.40–13.52).

A systematic review by McDonald et al.10 included 15 studiesof 116 175 women with previous pre-eclampsia and 2 259 576without. Those with previous pre-eclampsia had an increasedrisk of cardiovascular disease (case control studies oddsratio [OR] 2.47, 95% CI 1.22–5.01; cohort studies RR 2.33,95% CI 1.95–2.78) and were more likely to die from theircardiac event (RR 2.29, 95% CI 1.73–3.04). Women withmore severe pre-eclampsia had a higher risk (mild: RR 2.00,95% CI 1.83–2.19; moderate: RR 2.99, 95% CI 2.51–3.58;severe: RR 5.36, 95% CI 3.96–7.27, P = 0.0001) as did thosedelivering preterm. A number of the studies included in thismeta-analysis showed that women who develop cardiovasculardisease following hypertensive pregnancy develop the diseaseat a younger age than the general population. Worryingly, inone large study,11 which included over 1 million women, theaverage age of first cardiovascular events was 38 years in thestudy group, compared with 60.2 years in the control group.

There is less evidence in the literature considering the riskof cardiovascular disease following pregnancy complicated bygestational hypertension. In a study from Iceland,12 death ratesfrom ischaemic heart disease were significantly higher amongwomen with eclampsia or pre-eclampsia than among thosewho had only hypertension at the time of the index pregnancy(χ2 = 5.3, P<0.05).

These studies all confirm that there is a long-term risk ofcardiovascular disease following hypertensive pregnancy and,again, the risk appears to depend on the severity and gestationof onset. Many of the studies included large numbers of women;however, they are subject to bias because they are based on birthand death registries.

Cerebrovascular diseaseHypertension during pregnancy increases the risk of stroke(4.3 per 100 000 deliveries, 95% CI 2.4–7.1).13 The studiesdescribed below show that there is also an increased risk offuture cerebrovascular disease.

Wilson et al.6 carried out a large study with well-defineddata for the diagnosis of hypertensive disease. These data,from Aberdeen, of women with pre-eclampsia and gestationalhypertension, showed a higher mortality from stroke up to30 years after the pregnancy. However, this was only statisticallysignificant for pre-eclampsia (adjusted incident ratio 3.59,P = 0.044).6 The meta-analysis by Bellamy4 also showed thatthe risk of fatal and non-fatal stroke was increased 1.81 timesin women with pre-eclampsia compared with controls (95%CI 1.45–2.27) and that these women were more likely to die(fatal stroke RR 2.98, 95% CI 1.11–7.96, non-fatal strokeRR 1.76, 95% CI 1.40–2.22). Preterm delivery increased therisk (preterm RR 5.08, 95% CI 2.09–12.35, term RR 0.98, 95%CI 0.50–1.92).

This evidence suggests that the risk of stroke persists beyondthe postpartum period. Chronic hypertension is a well-knownrisk factor for cerebrovascular disease. However, it is unclearwhether a history of hypertension in pregnancy conveys anadditional risk.

Venous thromboembolismThis is a well-known complication of pregnancy which resultsfrom changes in the concentrations of clotting factors in normalpregnancy. The studies described below show that there isa small but significantly increased long-term risk of venousthromboembolism following pre-eclampsia but not gestationalhypertension.

The Danish birth registry study5 showed that the risk ofsubsequent thromboembolism was increased 1.03-fold (95%CI 0.73–1.45) after gestational hypertension, 1.53-fold (95%CI 1.32–1.77) after mild pre-eclampsia and 1.91-fold (95%CI 1.35–2.70) after severe pre-eclampsia, with a mean follow-up of 14.6 years. The meta-analysis by Bellamy4 found a1.79-fold increased risk of venous thromboembolism inwomen with a history of pre-eclampsia compared with controls(95% CI 1.37–2.33). Some studies linked pre-eclampsia toinherited or acquired thrombophilias but others have foundconflicting results.14, 15

Renal diseaseA number of studies have also looked at the association ofhypertension during pregnancy with long-term renal disease.

Data from the Medical Birth Registry of Norway wascompared with the Norwegian Renal Registry, which containsdata on all patients with end-stage renal disease.16 Womenwith pre-eclampsia during their first pregnancy had a 3-foldhigher risk of end-stage kidney disease (95% CI 2.2–4.9).Pre-eclampsia during two or three pregnancies was associatedwith a relative risk of 15.5 (95% CI 7.8–30.8). Preterm deliveryor a low birthweight baby was associated with a higher risk.

McDonald et al.17 carried out a systematic review andmeta-analysis of 7 cohort studies, which included 273 patientsand 33 controls, looking at the risk of ongoing proteinuria.17



Thirty-one percent of women with pre-eclampsia hadmicroalbuminuria at follow-up (mean 7.1 years postpartum)compared with 7% of controls. Severe pre-eclampsia carried an8-fold risk (95% CI 1.19–44.93). Gestational hypertension wascompared in 3 studies (n = 135). Women with gestationalhypertension had a higher risk of microalbuminuria thancontrols (RR 2.2, 95% CI 1.17–4.12) but this was lower thanfor the pre-eclampsia group.

These two publications both confirm that there is an ongoingrisk of renal disease following hypertensive pregnancy, despiteusing different primary endpoints to diagnose renal disease.It is possible that pre-eclampsia causes kidney damage or thatit exacerbates subclinical disease. Hypertension in pregnancyand renal disease also share a number of risk factors, includinghypertension, obesity, diabetes and endothelial dysfunction,and women at risk of one disease may simply be more at riskof the other.

Metabolic diseaseDiabetes doubles the risk of developing pre-eclampsia orgestational hypertension.18 However, there is much lessevidence about the long-term risks of developing diabetesfollowing hypertensive pregnancy. Lykke5 and Callaway19

have both shown an increased risk of type II diabetes afterhypertensive pregnancy: for a mixed group of women withprevious hypertension, OR 2.03, 95% CI 1.42–2.91; forgestational hypertension, RR 3.12, 95% CI 2.63–3.70; and forsevere pre-eclampsia, RR 3.68, 95% CI 3.04–4.46.

There is insufficient evidence to draw conclusions aboutthe association between pre-eclampsia and the future risk ofdiabetes; however, both conditions have a higher incidence inthe obese population and share similar risk factors.

The postnatal visit

The blood pressure of most women with a history ofpre-eclampsia or gestational hypertension returns to normalin the postnatal period; however, the time scale of this isnot well known.20 Podymow et al.21 studied 62 women afterhypertensive pregnancy: 81% had normal blood pressure by3 months, with a mean time of 5.4 ± 3.7 weeks. Resultsfrom a study in the Netherlands,22 which included 205women, showed that 61% were normotensive 3 months afterpre-eclamptic pregnancy and 82% at 2 years. There was nocorrelation between the gestation at onset of pre-eclampsiaand the time to resolution of hypertension.

Studies of continuing proteinuria following pregnancycomplicated by pre-eclampsia have varying results. Berkset al.22 showed that 14% still had proteinuria at 3 monthspostpartum, with only 2% at 2 years. The time to resolutionof proteinuria increased by 16% for every 1 g/day increase inmaximal proteinuria (P = 0.001). In a study from the UK,23

however, only 1.8% still had dipstick-positive proteinuria at amedian postnatal age of 11 weeks.

Results from the first 200 women attending our specialistpostnatal clinic show that 11% of women with pre-eclampsiaand 20% of women with gestational hypertension continueto have hypertension requiring antihypertensive medication at6 weeks postpartum (women are reviewed once at 6 weeks).Women with continuing hypertension and no significantfamily history of hypertension are referred to a physician forfurther investigation: 6% of pre-eclamptic women and 10%of those with gestational hypertension fit these criteria. Sevenpercent of women who have had pre-eclampsia continue tohave significant proteinuria (protein–creatinine ratio >30).These women have been referred to the renal physicians andone is awaiting a renal biopsy.

We are encountering continuing hypertension in 11% offormerly pre-eclamptic women at 6 weeks, in comparison withthe 9% reported by Samwiil et al.24 in a directly comparableUK sample studied at 11 weeks postnatal age. The numberof women with continuing proteinuria in our populationis significantly lower than the group described by Berkset al.,22 but higher than in the study from the UK,23 althoughproteinuria was measured a median of 5 weeks later in thisstudy.

Women with mildly impaired renal function (estimatedglomerular filtration rate 60–89 ml/minute/1.73 m2) shouldbe monitored due to a higher risk of future renal disease. Wehave found this in 5% and 9% of women with pre-eclampsiaand gestational hypertension, respectively.

Our specialist clinic has a relatively low rate of non-attendance (13%). Studies have shown that follow-up of thesewomen is poor24 and we still see women at 6 weeks who have nothad their blood pressure checked since discharge home. Moreworryingly, a number of women stop their antihypertensivetreatment when their supply of tablets from the hospital runsout, without seeking medical advice first. Many of the womenwho attend appreciate the opportunity to discuss their recentpregnancy and plans for the future; this is an ideal time todiscuss their future risk of disease and give lifestyle advice tohelp reduce their risk. All women who attend our clinic areadvised to have yearly blood pressure checks in the future, asadvised by the Pre-eclampsia Foundation.25

National Institute for Health and Clinical Excellenceguidance1 suggests that all women are seen at 6–8 weeksfollowing hypertensive pregnancy. The review should includemeasurement of blood pressure, urine testing and a review ofantihypertensive drugs. Our clinic is run by a clinical researchfellow, but in the future it may be possible for these women tobe seen by a specially trained midwife.

Predicting future disease

A number of mechanisms linking hypertension in pregnancyand cardiovascular disease have been suggested. The theory thathypertension in pregnancy may induce irreversible changesthat increase the overall risk for cardiovascular disease is


Green et al.

Table 3. The risk of future disease following hypertensive pregnancy

Reference Type of study n RR (95% CI)

Pre-eclampsiaDisease

Cardiovascular Bellamy4 Systematic review and meta-analysis 348 8160 3.7 (2.70–5.05)Cerebrovascular Bellamy4 Systematic review and meta-analysis 348 8160 2.16 (1.86–2.52)Venous thromboembolism Bellamy4 Systematic review and meta-analysis 348 8160 1.81 (1.45–2.27)Renal Bellamy4 Systematic review and meta-analysis 348 8160 1.79 (1.37–2.33)Diabetes (mild pre-eclampsia) Lykke5 Registry-based cohort 96 5475 3.45 (3.2–3.73)Diabetes (severe pre-eclampsia) Lykke5 Registry-based cohort 96 5475 4.09 (3.52–4.76)

Gestational hypertensionDisease

Cardiovascular Bellamy4 Systematic review and meta-analysis 348 8160 3.39 (0.82–13.9)Cerebrovascular Jonsdottir12 Population-based longitudinal 7543 1.47 (1.05–2)Venous thromboembolism Wilson6 Cohort 3593 2.87 (0.81–10.2)Renal Lykke5 Registry-based cohort 96 5475 1.01 (0.72–1.4)Diabetes Lykke5 Registry-based cohort 96 5475 3.41 (2.96–3.93)

probably too simplistic. It is more likely that the linkbetween the two conditions is a complex interplay of geneticfactors, endothelial dysfunction, oxidative stress, systemicinflammation and metabolic abnormalities.

Many women seen 6 weeks after hypertensive pregnancyare considered to be at low risk of future cardiovasculardisease if traditional risk factors are used (age, gender, bloodpressure, cholesterol levels, diabetes, cigarette smoking andsocial deprivation). However, the studies described all highlightthat cardiovascular disease in this group of women occurs atan earlier age and is associated with higher mortality than inwomen who have not had high blood pressure in pregnancy.11

Epidemiologically, the increased risk can be identified as earlyas 10 years after the index pregnancy. Looking at the risk ofcardiovascular disease in women who have recently deliveredis fraught with difficulties. This is a group of young womenwho are often outside the validated age limit for cardiovascularrisk scores,26 but assessing the risk of cardiovascular disease inthis group is vital to allow prevention of disease.

There are a number of risk scores available forestimating future cardiovascular risk. Until recently, NICEhas recommended the modified Framingham Risk Score tobe used in the UK.27, 28 However, the data used are basedon an American population and do not take into accountsocioeconomic factors, family history or ethnicity and theyare less accurate in Europeans.29 Risk scores based on datafrom UK populations are available: these include QRISK(English data) and ASSIGN (Scottish data), which do takeinto account ethnicity and social deprivation.26, 30 Thesescores are being assessed by NICE. A current study in theNetherlands, HyRAS,31 looking specifically at women who havehad a hypertensive pregnancy, will give us more evidence inthe future.

Advice about reducing disease

Many of the parameters that increase an individual’s riskof hypertension in pregnancy also increase the risk of anindividual developing cardiovascular disease. Our postnatalpopulation has high levels of obesity (43%), hyperlipidaemia(18%) and smoking (10%). These factors are potentiallyamenable to lifestyle changes. The following interventions areknown to reduce the risk of future cardiovascular disease inthe general female population32, 33 and should be discussed atthe postnatal visit: stopping smoking, lifestyle modification(physical activity, diet, alcohol consumption and weight),blood pressure control (to below 140/85 mmHg) and strictdiabetic control (meticulous control of blood pressure andglucose).

Treating hyperlipidaemia reduces the risk of cardiovasculardisease. Measuring lipids in the postpartum period is difficultdue to the effects of recent pregnancy and lactation andobtaining a fasting sample. Women with raised lipids at thepostnatal visit may be at particularly high risk of cardiovasculardisease and should be referred back to their general practitionerfor future lipid assessment following the postnatal and lactationperiod. There is no evidence for primary prevention of futurecardiovascular disease with aspirin or statins in this group ofwomen and further research is needed.

Following the postnatal visit it is important to communicatewith the general practitioner. A large UK study24 has shownthat community follow-up of women with pre-eclampsia ispoor, with many women never having their blood pressure orurine checked postnatally. The elevated risk of future diseasein this group in unlikely to be commonly known across thewider medical community and a programme of education forgeneral practitioners may be necessary.



Conclusions

A summary of the risks of long-term disease followinghypertensive pregnancy is given in Table 3. Although it is notyet known whether risk factors presenting prepregnancy causeor exacerbate the risk, the studies highlighted have shown anassociation between hypertension in pregnancy and chronichypertension and cardiovascular, cerebrovascular, metabolicand renal disease. In this population of women the diseasestend to occur at an earlier age and are more likely to befatal. Preterm delivery, a small-for-gestational-age baby anddisease in more than one pregnancy appear to increase therisk further. Our postnatal clinic has shown that reviewingwomen at 6 weeks postnatally ensures review of hypertension,medication and proteinuria. It also provides an opportunityto discuss the pregnancy and to plan management of futurepregnancies. Predicting which women are at the highest riskof future disease is difficult. There are, however, a number ofcommon risk factors, including chronic hypertension, obesity,renal disease and diabetes. The postnatal visit provides the idealopportunity to consider an individual’s future risk and offeradvice on lifestyle changes that could provide risk reduction.

References1 National Institute for Health and Clinical Excellence. Hypertension in

Pregnancy: The Management of Hypertensive Disorders DuringPregnancy. Clinical Guideline 107. London: NICE; 2010[http://guidance.nice.org.uk/CG107].

2 Brown MA, Lindheimer MD, de Swiet M, Van Assche A, MoutquinJM. The classification and diagnosis of the hypertensive disorders ofpregnancy: statement from the International Society for the Study ofHypertension in Pregnancy (ISSHP). Hypertens Pregnancy2001;20:ix–xiv.

3 Hernandez-Diaz S, Toh S, Cnattingius S. Risk of pre-eclampsia in firstand subsequent pregnancies: prospective cohort study. BMJ2009;338:b2255 [http://dx.doi.org/10.1136/bmj.b2255].

4 Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia andrisk of cardiovascular disease and cancer in later life: systematicreview and meta-analysis. BMJ 2007;335:974 [http://dx.doi.org/10.1136/bmj.39335.385301.BE].

5 Lykke JA, Langhoff-Roos J, Sibai BM, Funai EF, Triche EW, Paidas MJ.Hypertensive pregnancy disorders and subsequent cardiovascularmorbidity and type 2 diabetes mellitus in the mother. Hypertension2009;53:944–51 [http://dx.doi.org/10.1161/HYPERTENSIONAHA.109.130765].

6 Wilson BJ, Watson MS, Prescott GJ, Sunderland S, Campbell DM,Hannaford P, et al. Hypertensive diseases of pregnancy and risk ofhypertension and stroke in later life: results from cohort study. BMJ2003;326:845 [http://dx.doi.org/10.1136/bmj.326.7394.845].

7 Hannaford P, Ferry S, Hirsch S. Cardiovascular sequelae of toxaemiaof pregnancy. Heart 1997;77:154–8.

8 Irgens HU, Reisaeter L, Irgens LM, Lie RT. Long term mortality ofmothers and fathers after pre-eclampsia: population based cohortstudy. BMJ 2001;323:1213–7 [http://dx.doi.org/10.1136/bmj.323.7323.1213].

9 Smith GCS, Pell JP, Walsh D. Pregnancy complications and maternalrisk of ischaemic heart disease: a retrospective cohort study of 129290 births. Lancet 2001;357:2002–6 [http://dx.doi.org/10.1016/S0140-6736(00)05112-6].

10 McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ.Cardiovascular sequelae of preeclampsia/eclampsia: A systematicreview and meta-analyses. Am Heart J 2008;156:918–30 [http://dx.doi.org/10.1016/j.ahj.2008.06.042].

11 Ray JG, Vermeulen MJ, Schull MJ, Redelmeier DA. Cardiovascularhealth after maternal placental syndromes (CHAMPS):population-based retrospective cohort study. Lancet2005;366:1797–803 [http://dx.doi.org/10.1016/S0140-6736(05)67726-4].

12 Jonsdottir LS, Arngrımsson R, Geirsson RT, Sigvaldason H, SigfussonN. Death rates from ischemic heart disease in women with a historyof hypertension in pregnancy. Acta Obstet Gynecol Scand1995;74:772–6 [http://dx.doi.org/10.3109/00016349509021195].

13 Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartumstroke and Intracranial venous thrombosis. Stroke 2000;31:1274–82[http://dx.doi.org/10.1161/01.STR.31.6.1274].

14 Kahn SR, Platt R, McNamara H, Rozen R, Chen MF, Genest J Jr, et al.Inherited thrombophilia and preeclampsia within a multicentercohort: the Montreal Preeclampsia Study. Am J Obstet Gynecol2009;200:151.e1–9.

15 van Pampus MlG, Aarnoudse JG. Long-term outcomes afterpreeclampsia. Clin Obstet Gynecol 2005;48:489–94 [http://dx.doi.org/10.1097/01.grf.0000160316.67359.3d].

16 Vikse BE, Irgens LM, Leivestad T, Skjaerven R, Iversen BM.Preeclampsia and the risk of end-stage renal disease. N Engl J Med2008;359:800–9 [http://dx.doi.org/10.1056/NEJMoa0706790].

17 McDonald SD, Han Z, Walsh MW, Gerstein HC, Devereaux PJ. Kidneydisease after preeclampsia: a systematic review and meta-analysis.Am J Kidney Dis 2010;55:1026–39[http://dx.doi.org/10.1053/j.ajkd.2009.12.036].

18 Dunne F, Brydon P, Smith K, Gee H. Pregnancy in women with Type2 diabetes: 12 years outcome data 1990–2002. Diabet Med2003;20:734–8[http://dx.doi.org/10.1046/j.1464-5491.2003.01017.x].

19 Callaway LK, Lawlor DA, O’Callaghan M, Williams GM, Najman JM,McIntyre HD. Diabetes mellitus in the 21 years after a pregnancy thatwas complicated by hypertension: findings from a prospective cohortstudy. Am J Obstet Gynecol 2007;197:492.e1–7.

20 Magee L, Sadeghi S, von Dadelszen P. Prevention and treatment ofpostpartum hypertension. Cochrane Database Syst Rev2005;(1):CD004351.

21 Podymow T, August P. Postpartum course of gestationalhypertension and preeclampsia. Hypertens Pregnancy2010;29:294–300 [http://dx.doi.org/10.3109/10641950902777747].

22 Berks D, Steegers EA, Molas M, Visser W. Resolution of hypertensionand proteinuria after preeclampsia. Obstet Gynecol2009;114:1307–14 [http://dx.doi.org/10.1097/AOG.0b013e3181c14e3e].

23 Genetics of Pre-eclampsia (GOPEC) consortium, babies, pre-eclampticmothers and grandparents: a three-generation phenotyping study. JHypertens 2007;25:849–54[http://dx.doi.org/10.1097/HJH.0b013e32803fb634].

24 Samwiil L, Mercer C, Jarrett P, O’Malley S; Genetics of Pre-EclampsiaCollaborative Study (GOPEC) Research Midwives. Blood pressure andurinalysis are often omitted in women who have sufferedpre-eclampsia at their six-week postnatal check. BJOG2004;111:623–5 [http://dx.doi.org/10.1111/j.1471-0528.2004.00136.x].

25 Preeclampsia Foundation. Preeclampsia & Heart Disease[www.preeclampsia.org/images/pdf/heartdiseasebrochure.pdf].

26 Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, May M,Brindle P. Derivation and validation of QRISK, a new cardiovasculardisease risk score for the United Kingdom: prospective open cohortstudy. BMJ 2007;335:136 [http://dx.doi.org/10.1136/bmj.39261.471806.55].


Green et al.

27 Cooper A, Nherera L, Calvert N, O’Flynn N, Turnbull N, Robson J,et al. Clinical Guidelines and Evidence Review for Lipid Modification:Cardiovascular Risk Assessment and the Primary and SecondaryPrevention of Cardiovascular Disease. London: National CollaboratingCentre for Primary Care and Royal College of General Practitioners;2008: [www.nice.org.uk/nicemedia/live/11982/40742/40742.pdf].

28 Anderson KM, Odell PM, Wilson PW, Kannel WB. Cardiovasculardisease risk profiles. Am Heart J 1991;121:293–8[http://dx.doi.org/10.1016/0002-8703(91)90861-B].

29 Marrugat J, D’Agostino R, Sullivan L, Elosua R, Wilson P, Ordovas J,et al. An adaptation of the Framingham coronary heart disease riskfunction to European Mediterranean areas. J Epidemiol CommunityHealth 2003;57:634–8 [http://dx.doi.org/10.1136/jech.57.8.634].

30 Woodward M, Brindle P, Tunstall-Pedoe H; SIGN group on riskestimation. Adding social deprivation and family history tocardiovascular risk assessment: the ASSIGN score from the ScottishHeart Health Extended Cohort (SHHEC). Heart 2007;93:172–6[http://dx.doi.org/10.1136/hrt.2006.108167].

31 Hermes W, Franx A, van Pampus MG, Bloemenkamp KW, van derPost JA, Porath M, et al. 10-Year cardiovascular event risks forwomen who experienced hypertensive disorders in late pregnancy:

the HyRAS study. BMC Pregnancy Childbirth 2010;10:28[http://dx.doi.org/10.1186/1471-2393-10-28].

32 Department of Health. National Service Framework for CoronaryHeart Disease. Modern Standards & Service Models. London: DoH;2000 [www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4057526.pdf].

33 Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primaryprevention of coronary heart disease in women through diet andlifestyle. N Engl J Med 2000;343:16–22 [http://dx.doi.org/10.1056/NEJM200007063430103].

34 Roberts CL, Ford JB, Algert CS, Antonsen S, Chalmers J, CnattingiusS, Gokhale M, et al. Population-based trends in pregnancyhypertension and pre-eclampsia: an international comparative study.BMJ Open 2011;1:e000101 [http://dx.doi.org/10.1136/bmjopen-2011-000101].

35 Duley L. The global impact of pre-eclampsia and eclampsia. SemiPerinatol 2009;33:130–7 [http://dx.doi.org/10.1053/j.semperi.2009.02.010].

36 Roberts CL, Bell JC, Ford JB, Hadfield RM, Algert CS, Morris JM. Theaccuracy of reporting of the hypertensive disorders of pregnancy inpopulation health data. Hypertens Pregnancy 2008;27:285–97[http://dx.doi.org/10.1080/10641950701826695].


New-onset hypertension in pregnancy: a review of the long-term maternal effects

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