Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy

doi:10.1016/j.bpobgyn.2011.01.006

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 25, Issue 4, August 2011, Pages 391-403

https://doi.org/10.1016/j.bpobgyn.2011.01.006 Get rights and content

Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, pre-eclampsia and chronic hypertension with superimposed pre-eclampsia. Pre-eclampsia complicates about 3% of pregnancies, and all hypertensive disorders affect about five to 10% of pregnancies. Secular increases in chronic hypertension, gestational hypertension and pre-eclampsia have occurred as a result of changes in maternal characteristics (such as maternal age and pre-pregnancy weight), whereas declines in eclampsia have followed widespread antenatal care and use of prophylactic treatments (such as magnesium sulphate). Determinants of pre-eclampsia rates include a bewildering array of risk and protective factors, including familial factors, sperm exposure, maternal smoking, pre-existing medical conditions (such as hypertension, diabetes mellitus and anti-phospholipid syndrome), and miscellaneous ones such as plurality, older maternal age and obesity. Hypertensive disorders are associated with higher rates of maternal, fetal and infant mortality, and severe morbidity, especially in cases of severe pre-eclampsia, eclampsia and haemolysis, elevated liver enzymes and low platelets syndrome.

Introduction

Hypertensive disorders of pregnancy constitute an enigmatic and clinically challenging group of pregnancy complications that are responsible for a substantial burden of illness in both industrialised and less industrialised countries. This review outlines the disease definitions, global burden of disease, natural history, and unresolved epidemiologic questions of the hypertensive disorders of pregnancy.

Section snippets

Definitions and classification of hypertensive disorders of pregnancy

The primary clinical entities that comprise the hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, pre-eclampsia and chronic hypertension with superimposed pre-eclampsia. A major challenge in the study of hypertension in pregnancy has been the development of precise definitions for each of these entities, but universal agreement on disease definitions remains elusive.

Global burden of illness

Hypertensive disorders of pregnancy complicate roughly 5–10% of pregnancies.¹³ A World Health Organization review identified hypertension as the single leading cause of maternal mortality in industrialised countries, accounting for 16% of deaths.¹⁴ In Africa and Asia, hypertensive disorders accounted for 9% of maternal deaths, whereas, in Latin America and the Caribbean, the figure was over 25%.¹⁴ Hypertensive disorders of pregnancy are annually responsible for about 25,000 maternal deaths in

Incidence and temporal trends

Accurate estimates of the incidence of pre-eclampsia are difficult to obtain because of a lack of standardisation of diagnostic criteria in population databases.15, 16 Pre-eclampsia complicates about 3% of pregnancies in the USA.*17, *18 Reports from other industrialised countries have also yielded estimates between 3 and 5%, including prospective studies from Wellington, New Zealand (3.3%)¹⁹ and studies based on the Swedish, Danish and Norwegian Medical Birth Registers (3.0%, 4.5%, and 3.0%,

Heterogeneity of pre-eclampsia

Considerable heterogeneity in pregnancy outcomes is evident depending on gestational age at onset of pre-eclampsia. For example, maternal mortality rates are 24 times higher when pre-eclampsia onset occurs at less than 28 weeks compared with onset at term gestation.⁸³ Infants of mothers with pre-eclampsia at preterm gestation are significantly smaller than their non-pre-eclampsia peers of similar gestation, whereas infants of mothers with pre-eclampsia at term gestation are at increased risk of

Intersecting perinatal mortality curves

A paradoxical relationship between hypertension in pregnancy and gestational age-specific (and birth-weight-specific) perinatal mortality has been reported in several studies.89, 90 At term gestation, neonatal mortality rates are higher among infants of women with hypertension in pregnancy compared with infants of women without hypertension. The opposite is true at preterm gestation (Fig. 1). This phenomenon is also observed with stillbirth (Fig. 1). Such paradoxical effects are not unique to

Conclusion

Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, pre-eclampsia and chronic hypertension with superimposed pre-eclampsia. Pre-eclampsia, the hallmarks of which include poor placental perfusion and systemic involvement, is a heterogeneous disease, with a distinct and more severe clinical profile when gestation at disease onset is less than 34 weeks. Pre-eclamspia complicates about 3% of pregnancies, and all hypertensive disorders affect about five to 10

Conflict of interest

None declared.

Acknowledgements

JAH was supported by post-doctoral fellowship awards from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research (MSFHR). SL was supported by a post-doctoral fellowship award from MSFHR. KSJ holds a career scientist award from the Child and Family Research Institute, Vancouver, Canada.

References (98)

B.M. Sibai et al.
Diagnosis and management of atypical pre-eclampsia-eclampsia
Am J Obstet Gynecol
(2009)
P. Von Dadelszen et al.
Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the the fullPIERS model
Lancet
(2011)
K.S. Khan et al.
WHO analysis of causes of maternal death: a systematic review
Lancet
(2006)
M.T. Lydon-Rochelle et al.
The reporting of pre-existing maternal medical conditions and complications of pregnancy on birth certificates and in hospital discharge data
Am J Obstet Gynecol
(2005)
A.K. Klemmensen et al.
Diagnostic criteria and reporting procedures for pre-eclampsia: a national survey among obstetrical departments in Denmark
Eur J Obstet Gynecol Reprod Biol
(2005)
P.Y. Robillard et al.
Paternity patterns and risk of pre-eclampsia in the last pregnancy in multiparae
J Reprod Immunol
(1993)
G. Dekker et al.
The birth interval hypothesis-does it really indicate the end of the primipaternity hypothesis
J Reprod Immunol
(2003)
J.X. Wang et al.
Surgically obtained sperm, and risk of gestational hypertension and pre-eclampsia
Lancet
(2002)
M. Yasuda et al.
Prospective studies of the association between anticardiolipin antibody and outcome of pregnancy
Obstet Gynecol
(1995)
M.G. van Pampus et al.
High prevalence of hemostatic abnormalities in women with a history of severe pre-eclampsia
Am J Obstet Gynecol
(1999)

P.L. Yudkin et al.

Risk of unexplained stillbirth at different gestational ages

Lancet

(1987)

Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy

Am J Obstet Gynecol

(2000)

J.M. Roberts et al.

Pre-eclampsia: recent insights

Hypertension

(2005)

J.M. Roberts et al.

The two stage model of pre-eclampsia: variations on the theme

Placenta

(2009)

S.A. Lowe et al.

Guidelines for the management of hypertensive disorders of pregnancy 2008

Aust N Z J Obstet Gynaecol

(2009)

C.V. Ananth et al.

Pre-eclampsia and preterm birth subtypes in Nova Scotia, 1986 to 1992

Am J Perinatol

(1997)

S. Hernandez-Diaz et al.

Risk of pre-eclampsia in first and subsequent pregnancies: prospective cohort study

BMJ

(2009)

S.D. McDonald et al.

The recurrence risk of severe de novo pre-eclampsia in singleton pregnancies: a population-based cohort

BJOG

(2009)

ACOG Practice Bulletin. Diagnosis and management of pre-eclampsia and eclampsia

Int J Gynecol Obstet

(2002)

L.A. Magee et al.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

J Obstet Gynecol Canada

(2008)

J. Menzies et al.

Current CHS and NHBPEP criteria for severe preeclampsia do not uniformly predict adverse maternal or perinatal outcomes

Hypertens Pregnancy

(2007)

F.G. Cunningham et al.

Williams obstetrics

(2010)

A.B. Wallis et al.

Secular trends in the rates of pre-eclampsia, eclampsia, and gestational hypertension, United States, 1987–2004

Am J Hypertens

(2008)

E.V. Kuklina et al.

Hypertensive disorders and severe obstetric morbidity in the United States

Obstet Gynecol

(2009)

P. Stone et al.

Measurements of blood pressure, oedema and proteinuria in a pregnant population of New Zealand

Aust N Z J Obstet Gynaecol

(1995)

B.L. Dahlstrom et al.

Changes in the prevalence of pre-eclampsia in Akershus County and the rest of Norway during the past 35 years

Acta Obstet Gynecol Scand

(2006)

C.B. Rudra et al.

Monthly variation in pre-eclampsia prevalence: Washington State, 1987–2001

J Matern Fetal Neonatal Med

(2005)

J.K. Phillips et al.

Seasonal variation in pre-eclampsia based on timing of conception

Obstet Gynecol

(2004)

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To identify classes of psychosocial stressors among women who developed preeclampsia and to evaluate the associations between these classes and correlates of psychosocial wellbeing.
We performed a secondary analysis of women who developed preeclampsia (n = 727) from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort (2010–2013). Latent class analysis was used to identify classes of social stressors based on seven psychological and sociocultural indicators. Associations between latent classes and correlates (demographics, health behavior, and health-systems level) were estimated using multinomial logistic regression.
Classes of psychosocial wellbeing.
Among women who developed preeclampsia, three classes reflective of psychosocial wellbeing were identified: Class 1: Intermediate Psychosocial Wellbeing (53 %), Class 2: Positive Psychosocial Wellbeing (31 %), Class 3: Negative Psychosocial Wellbeing (16 %). Women in the Negative Psychosocial Wellbeing Class were more likely to have poor sleep and a sedentary lifestyle compared with the Positive and Intermediate Psychosocial Wellbeing Classes. Both the Negative and Intermediate Psychosocial Wellbeing Classes reported concern about their quality of medical care compared with the Positive Psychosocial Wellbeing Class (adjusted odds ratio [aOR]: 6.19, 95 % confidence interval [CI]: 3.37, 11.36 and aOR: 2.19, 95 % CI: 1.31, 3.65, respectively).
Women who develop preeclampsia are heterogenous and experience different intensities of internal and external stressors. Understanding the linkages between psychosocial wellbeing during pregnancy and modifiable behavioral and structural factors may inform future tailored management strategies for preeclampsia and the optimization of maternal postpartum health.
Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries
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Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.
Hypertensive states of pregnancy
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Hypertensive disorders in pregnancy (HDP) remain a leading cause of pregnancy-related maternal and foetal morbidity and mortality worldwide, including chronic hypertension, gestational hypertension, and pre-eclampsia.
Affected women and newborns also have an increased risk of cardiovascular disease later in life, independent of traditional cardiovascular disease risks. Despite these risks, recommendations for optimal diagnosis and treatment have changed little in recent decades, probably due to fear of the foetal repercussions of decreased blood pressure and possible drug toxicity.
In this document we review the diagnostic criteria and classification of (HDP), as well as important aspects regarding pathophysiology and early detection that allows early identification of women at risk, with the aim of preventing both immediate and long-term consequences. Prophylactic treatment with aspirin is also reviewed early and a therapeutic approach is carried out that involves close maternal and foetal monitoring, and if necessary, the use of safe drugs in each situation.
This review aims to provide an updated vision for the prevention, diagnosis, and treatment of HDP that is useful in our usual clinical practice.
Los estados hipertensivos del embarazo (EHE) siguen siendo una de las principales causas de morbilidad y mortalidad materna y fetal relacionada con el embarazo en todo el mundo, incluyen la hipertensión crónica, la hipertensión gestacional y la preeclampsia.
Las mujeres afectadas y los recién nacidos también tienen un mayor riesgo de sufrir enfermedades cardiovasculares en el futuro, independientemente de los riesgos tradicionales de la enfermedad cardiovascular. A pesar de estos riesgos, las recomendaciones para un diagnóstico y un tratamiento óptimo han cambiado poco en las últimas décadas, probablemente por el miedo a las repercusiones fetales de la disminución de la presión arterial y la posible toxicidad farmacológica.
En ese documento revisamos los criterios diagnósticos y la clasificación de los EHE, así como aspectos importantes en cuanto a fisiopatología y la detección temprana que permita la identificación precoz de las mujeres en riesgo, con el objetivo de prevenir tanto las secuelas inmediatas como a largo plazo. También se revisa el tratamiento profiláctico con aspirina de forma precoz y se realiza una aproximación terapéutica que implica una estrecha vigilancia materna y fetal, y si es necesario, el uso de fármacos seguros en cada situación.
Esta revisión pretende dar una visión actualizada para la prevención, diagnóstico y tratamiento de los EHE que sea de utilidad en nuestra práctica clínica habitual.
Improved neonatal outcomes in pregnancies with coexisting gestational diabetes and preeclampsia in normal birthweight neonates- insights from a retrospective cohort study
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We aimed to assess neonatal and maternal outcomes in appropriate-for-gestational-weight (AGA) neonates of mothers with both gestational diabetes mellitus (GDM) and preeclampsia (PET).
Medical records of women diagnosed with GDM or PET were reviewed. Women with AGA neonates were divided into three groups- GDM, PET, and GDM + PET and maternal neonatal and placental outcomes were compared. The primary outcome was a composite of adverse neonatal outcomes, including intensive care unit admission (NICU), neurological morbidity, hypoglycemia, ventilation, respiratory distress syndrome (RDS), phototherapy, sepsis, blood transfusion, and neonatal death. Post-hoc analysis was performed to determine between-group significance.
Composite adverse neonatal outcomes are significantly lower in women with multiple morbidities compared to women with confined PET (p = 0.015), and a similar trend is observed when comparing neonatal outcomes between women with GDM to those with GDM + PET, yet these results are underpowered (18.9 % vs. 12.8 % respectively, p = 0.243). Placentas of women with GDM + PET were larger, with a lower rate of placentas below the 10th percentile as compared to placentas of women with isolated PET (p < 0.001), but with similar rates of MVM lesions.
While maternal and placental outcomes in patients of the GDM + PET group resemble the characteristics of the PET group, surprisingly, the neonatal outcomes in this group are significantly better compared to isolated morbidities. The paradoxical benefit attributed to the coexistence of GDM + PET may be explained by a balance of the opposing trends characterizing these morbidities-the reduced blood and nutrient supply characterizing PET vs. chronic overflow and abundance typical of GDM.
approval of local ethics committee WOMC-19-0152.
The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia
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Preeclampsia remains the leading cause of maternal morbidity and mortality and is associated with abnormal body fluid homeostasis and cardiovascular dysfunction. Moreover, 2 distinct hemodynamic phenotypes have been described in preeclampsia, which might require different therapeutic approaches. Fluid restriction is mandatory in women at risk of pulmonary edema, whereas additional fluid administration may be required to correct tissue hypoperfusion in women with intravascular volume depletion. As clinical examination alone cannot discriminate among different hemodynamic patterns, optimal management of women with preeclampsia remains challenging. Noninvasive bedside ultrasound has become an important diagnostic and monitoring tool in critically ill patients, and it has been demonstrated that it can also be used in the monitoring of women with preeclampsia. Echocardiography in combination with lung ultrasound provides information on hemodynamic status, cardiac function, lung congestion, and fluid responsiveness and, therefore, could help clinicians identify women at higher risk of life-threatening complications. This review describes the cardiovascular changes in preeclampsia and provides an overview of the ultrasound methodologies that could be efficiently used for better hemodynamic assessment and management of women with preeclampsia.
Association between body mass index and chronic hypertension in patients with hypertension disorders of pregnancy one-year postpartum
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To determine the association between body mass index (BMI) and chronic hypertension (CHTN) one-year postpartum following pregnancies complicated by hypertensive disorders of pregnancy (HDP).
A retrospective cohort study of patients with HDP (gestational hypertension or preeclampsia) in a single Midwestern academic center from 2014 to 2018. The primary outcome was CHTN at one-year postpartum, defined as systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg or taking antihypertensive medication at one-year postpartum. The primary exposure variable was BMI at one-year postpartum, categorized as underweight (<18.5 kg/m²), normal (18.5–24.9 kg/m²), overweight (25-<30 kg/m²), and obese (≥30 kg/m²) and as continuous BMI variable. Descriptive statistics and adjusted logistic regression analysis were performed.
Out of 596 patients with HDP included in this analysis, 275 (46.1 %) had CHTN one-year postpartum. Mean one-year postpartum BMI was 27.9 ± 5.2 kg/m². Prevalence of CHTN at one-year postpartum was higher in obese (38.1 %) and overweight (30.0 %) groups compared to the normal weight group (29.9 %), p < 0.001. In multivariate logistic regression, obesity at one-year postpartum, compared to normal, was associated with 73 % higher likelihood of CHTN following HDP (adjusted OR 1.73, 95 % CI 1.06–2.84). With BMI as a continuous variable, each unit increase in BMI one-year postpartum was associated with 6 % higher likelihood of CHTN (adjusted OR 1.06, 95 % CI 1.02–1.15).
Obesity at one-year postpartum following HDP was associated with a higher risk of CHTN compared with normal BMI. Weight is a modifiable risk factor that should be targeted in postpartum interventions to reduce cardiovascular disease following HDP.

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1Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy

Introduction

Section snippets

Definitions and classification of hypertensive disorders of pregnancy

Global burden of illness

Incidence and temporal trends

Heterogeneity of pre-eclampsia

Intersecting perinatal mortality curves

Conclusion

Conflict of interest

Acknowledgements

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Eur J Obstet Gynecol Reprod Biol

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Am J Obstet Gynecol

Lancet

Lancet

Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy

Am J Obstet Gynecol

Pre-eclampsia: recent insights

Hypertension

The two stage model of pre-eclampsia: variations on the theme

Placenta

Guidelines for the management of hypertensive disorders of pregnancy 2008

Aust N Z J Obstet Gynaecol

Pre-eclampsia and preterm birth subtypes in Nova Scotia, 1986 to 1992

Am J Perinatol

Risk of pre-eclampsia in first and subsequent pregnancies: prospective cohort study

BMJ

The recurrence risk of severe de novo pre-eclampsia in singleton pregnancies: a population-based cohort

BJOG

ACOG Practice Bulletin. Diagnosis and management of pre-eclampsia and eclampsia

Int J Gynecol Obstet

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

J Obstet Gynecol Canada

Current CHS and NHBPEP criteria for severe preeclampsia do not uniformly predict adverse maternal or perinatal outcomes

Hypertens Pregnancy

Williams obstetrics

Secular trends in the rates of pre-eclampsia, eclampsia, and gestational hypertension, United States, 1987–2004

Am J Hypertens

Hypertensive disorders and severe obstetric morbidity in the United States

Obstet Gynecol

Measurements of blood pressure, oedema and proteinuria in a pregnant population of New Zealand

Aust N Z J Obstet Gynaecol

Changes in the prevalence of pre-eclampsia in Akershus County and the rest of Norway during the past 35 years

Acta Obstet Gynecol Scand

Monthly variation in pre-eclampsia prevalence: Washington State, 1987–2001

J Matern Fetal Neonatal Med

Seasonal variation in pre-eclampsia based on timing of conception

Obstet Gynecol

1
Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy