The gestational period serves as a natural stress test that can be used to predict future cardiovascular health risks of female patients. Recent evidence confirms that mothers with hypertensive pregnancies have higher cardiovascular disease (CVD) risks compared to other women of similar age. In women with preeclampsia, those delivering before 37 weeks of gestation and mothers with recurring preeclampsia in subsequent pregnancies carry the greater risks. These sex-specific risks are of similar magnitude to traditional CVD risk factors, such as smoking and obesity. Unfortunately, none of the commonly used CVD risk stratification models make use of these sex-specific markers, which can powerfully predict future CVD outcomes. Because women have historically posed a greater diagnostic challenge than men in assessing CVD risks, better models for risk stratification in this sex group are needed. A history of hypertension in pregnancy should be included as a variable in cardiovascular risk stratification. In addition, screening women for a history of preeclampsia should become routine practice, with greater emphasis placed on therapies to modify adverse outcomes for these higher-risk women.
Get full access to this article
View all access options for this article.
References
1.
ChesleyLC, SomersWH, GorenberHRet al.An analysis of some factors associated with posttoxemic hypertension. Am J Obstet Gynecol, 1941; 41:751–764.
2.
AdamsEM, MacGillivrayI. Long-term effect of preeclampsia on blood-pressure. Lancet, 1961; 2:1373–1375.
3.
EpsteinFH. Late vascular effects of toxemia of pregnancy. N Engl J Med, 1964; 271:391–395.
4.
SibaiBM, el-NazerA, Gonzalez-RuizA. Severe preeclampsia-eclampsia in young primigravid women: Subsequent pregnancy outcome and remote prognosis. Am J Obstet Gynecol, 1986; 155:1011–1016.
5.
NisellH, LintuH, LunellNOet al.Blood pressure and renal function seven years after pregnancy complicated by hypertension. Br J Obstet Gynaecol, 1995; 101:876–881.
6.
NorthRA, SimmonsD, BarnfatherDet al.What happens to women with preeclampsia? Microalbuminuria and hypertension following preeclampsia. Aust NZ J Obstet Gynaecol, 1996; 36:233–238.
7.
MarinR, GorostidiM, PortalCGet al.Long-term prognosis of hypertension in pregnancy. Hypertens Pregnancy, 2000; 19:199–209.
8.
ShammasAG, MaayahJF. Hypertension and its relation to renal function 10 years after pregnancy complicated by preeclampsia and pregnancy induced hypertension. Saudi Med J, 2000; 21:190–202.
9.
SattarN, RamsayJ, CrawfordLet al.Classic and novel risk factor parameters in women with a history of preeclampsia. Hypertension, 2003; 42:39–42.
10.
GarovicVD, BaileyKR, BoerwinkleEet al.Hypertension in pregnancy as a risk factor for cardiovascular disease later in life. J Hypertens, 2010; 28:826–833.
11.
CraiciIM, WagnerSJ, HaymanSRet al.Pre-eclamptic pregnancies: An opportunity to identify women at risk for future cardiovascular disease. Womens Health (Lond), 2008; 4:133–135.
12.
PoutaA, HartikainenAL, SovioUet al.Manifestations of metabolic syndrome after hypertensive pregnancy. Hypertension, 2004; 43:825–831.
13.
RayJG, VermeulenMJ, SchullMJet al.Cardiovascular health after maternal placental syndromes (CHAMPS): Population-based retrospective cohort study. Lancet, 2005; 366:1797–1803.
14.
HaukkamaaL, SalminenM, LaivuoriHet al.Risk for subsequent coronary artery disease after preeclampsia. Am J Cardiol, 2004; 93:805–808.
15.
HannafordP, FerryS, HirschS. Cardiovascular sequelae of toxaemia of pregnancy. Heart, 1997; 77:154–158.
ArainFA, KuniyoshiFH, AbdalrhimADet al.Sex/gender medicine: The biological basis for personalized care in cardiovascular medicine. Circ J, 2009; 73:1774–1782.
18.
BergJ, BjorckL, DudasKet al.Symptoms of a first acute myocardial infarction in women and men. Gend Med, 2009; 6:454–462.
19.
ShawLJ, BugiardiniR, MerzCN. Women and ischemic heart disease: Evolving knowledge. J Am Coll Cardiol, 2009; 54:1561–1575.
20.
TowfighiA, ZhengL, OvbiageleB. Sex-specific trends in midlife coronary heart disease risk and prevalence. Arch Intern Med, 2009; 169:1762–1766.
21.
AbufulA, GidronY, HenkinY. Physicians' attitudes toward prevention therapy for coronary artery disease: Is there a gender bias?Clin Cardiol, 2005; 28:389–393.
22.
DalyC, ClemensF, Lopez SendonJLet al.Gender differences in the management and clinical outcome of stable angina. Circ J, 2006; 113:490–498.
23.
NijdamME, TimmermanMR, FranxAet al.Cardiovascular risk factor assessment after preeclampsia in primary care. BMC Fam Pract, 2009; 10:77.
24.
MercuroG, DeiddaM, PirasAet al.Gender determinants of cardiovascular risk factors and diseases. J Cardiovasc Med (Hagerstown), 2010; 11:207–220.
25.
YoderSR, ThornburgLL, BisognanoJD. Hypertension in pregnancy and women of childbearing years. Am J Med, 2009; 122:890–895.
26.
ChhabraS, KakaniA. Maternal mortality due to eclamptic and non-eclamptic hypertensive disorders: A challenge. J Obstet Gynecol, 2007; 27:25–29.
27.
KuklinaEV, AyalaC, CallaghanWM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol, 2009; 113:1299–1306.
28.
WallisAB, SaftlasAF, HsiaJ, AtrashHK. Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987–2004. Am J Hypertens, 2008; 21:521–526.
29.
RobertsC, AlgertC, MorrisJ, Henderson-SmartD. Hypertensive disorders in pregnancy: A population-based study. Med J Aust, 2005; 182:332–335.
30.
GarovicVD, HaymanSR. Hypertension in pregnancy: An emerging risk factor for cardiovascular disease. Nat Clin Pract Nephrol, 2007; 3:613–622.
31.
RamsayJE, StewartF, GreerISet al.Microvascular dysfunction: A link between preeclampsia and maternal coronary hart disease. Br J Obstet Gynaecol, 2003; 110:1029–1031.
32.
ZhangJ, MeikleS, TrumbleA. Severe maternal morbidity associated with hypertensive disorders in pregnancy in the United States. Hypertens Pregnancy, 2003; 22:203–212.
33.
CraiciI, WagnerS, GarovicVD. Preeclampsia and future cardiovascular risk: Formal risk factor or failed stress test?Ther Adv Cardiovasc Dis, 2008; 2:249–259.
34.
DuckittK, HarringtonD. Risk factors for pre-eclampsia at antenatal booking: Systematic review of controlled studies. BMJ, 2005; 330:565. [Epub March 2, 2005]
35.
ChenXK, WenSW, BottomleyJet al.In vitro fertilization is associated with an increased risk for preeclampsia. Hypertens Pregnancy, 2009; 28:1–12.
36.
O'BrienTE, RayJG, ChanWS. Maternal body mass index and the risk of preeclampsia: A systematic review. Epidemiology, 2003; 14:368–374.
37.
BardenA, SinghR, WaltersBNet al.Factors predisposing to pre-eclampsia in women with gestational diabetes. J Hypertens, 2004; 22:2371–2378.
38.
CooperR, AthertonK, PowerC. Gestational age and risk factors for cardiovascular disease: Evidence from the 1958 British cohort followed to mid-life. Int J Epidemiol, 2009; 38:235–244.
39.
PulverLS, Guest-WarnickG, StoddardGJet al.Weight for gestational age affects the mortality of late preterm infants. Pediatrics, 2009; 123:e1072–e1077.
40.
ReinehrT, KleberM, ToschkeAM. Small for gestational age status is associated with metabolic syndrome in overweight children. Eur J Endocrinol, 2009; 160:579–584.
41.
WuCS, NohrEA, BechBHet al.Health of children born to mothers who had preeclampsia: A population-based cohort study. Am J Obstet Gynecol, 2009; 201:269.e1–269.e10.
42.
KajantieE, ErikssonJG, OsmondCet al.Pre-eclampsia is associated with increased risk of stroke in the adult offspring: The Helsinki Birth Cohort Study. Stroke, 2009; 40:1176–1180.
43.
McDonaldSD, MalinowskiA, XouQet al.Cardiovascular sequelae of preeclampsia/eclampsia: A systematic review and meta-analysis. Am H J, 2008; 156:918–930.
44.
BellamyL, CasasJP, HingoraniADet al.Pre-eclampsia and risk of cardiovascular disease and cancer in later life: Systematic review and meta-analysis. BMJ, 2007; 335:974–986.
45.
LykkeJA, Langhoff-RoosJ, SibaiBJet al.Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother. Hypertension, 2009; 53:944–951.
VikseBE, IrgensLM, LeivestadTet al.Preeclampsia and the risk of end-stage renal disease. N Engl J Med, 2008; 359:800–809.
48.
PadwalR, StrausSE, McAlisterFA. Cardiovascular risk factors and their effects on the decision to treat hypertension: Evidence based review. BMJ, 2001; 322:977–980.
49.
AntmanEM, CohenM, BerninkPJet al.The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA, 2000; 284:835–842.
50.
BoersmaE, PieperKS, SteyerbergEWet al.Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circ J, 2000; 101:2557–2567.
51.
EagleKA, LimMJ, DabbousOHet al.A validated prediction model for all forms of acute coronary syndrome: Estimating the risk of 6-month postdischarge death in an international registry. JAMA, 2004; 291:2727–2733.
52.
SleightPM. The Systematic Coronary Risk Evaluation (SCORE)2002. Medscape Public Health & Prevention. www.medscape.com/viewarticle/438575
53.
AssmannG, SchulteH. The Prospective Cardiovascular Munster Study: Prevalence and prognostic significance of hyperlipidemia in men with systemic hypertension. Am J Cardiol, 1987; 59:9G–17G.
54.
World Health Organization. WHO/ISH cardiovascular risk prediction charts. www.who.int/cardiovascular_diseases/guidelines/Chart_predictions/en/index.html
55.
HelfandM, BuckleyDI, FreemanMet al.Emerging risk factors for coronary heart disease: A summary of systematic reviews conducted for the U.S. Preventive Services Task Force. Ann Intern Med, 2009; 151:496–507.
56.
JonsdottirLS, ArngrimssonR, GeirssonRTet al.Death rates from ischemic heart disease in women with a history of hyptertension in pregnancy. Acta Obstet Gynecol Scand, 1995; 74:772–776.
57.
IrgensHU, ReisaeterL, IrgensLMet al.Long-term mortality of mothers and fathers after preeclampsia: Population-based cohort study. BMJ, 2001; 323:1213–1217.
58.
SmithGC, PellJP, WalshD. Pregnancy complications and maternal risk of ischaemic heart disease: A retrospective cohort study of 129,290 births. Lancet, 2001; 357:2002–2006.
59.
WilsonBJ, WatsonMS, PrescottGJet al.Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: Results from cohort study. BMJ, 2003; 326:845.
60.
KestenbaumB, SeligerSL, EasterlingTRet al.Cardiovascular and thromboembolic event following hypertensive pregnancy. Am J Kidney Dis, 2003; 42:982–989.
61.
FunaiEF, FriedlanderY, PaltielOet al.Long-term after preeclampsia. Epidemiology, 2005; 16:206–215.
62.
KaajaR, KinnunenT, LuotoR. Regional differences in the prevalence of preeclampsia in relation to risk fators for coronary artery disease in women in Finland. Eur Heart J, 2005; 26:44–50.
63.
WikstromAK, HaglundB, OlovssonMet al.The risk of maternal ischaemic heart disease after gestational hypertensive disease. Br J Obstet Gynaecol, 2005; 112:1486–1491.
64.
MoscaL, BankaCL, BenjaminEJet al.Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. Circ J, 2007; 115:1481–1501.
65.
Society of Obstetric Medicine of Australia and New Zealand. Guidelines for the management of hypertensive disorders of pregnancy, 2008. www.somanz.org/pdfs/somanz_guidelines_2008.pdf
66.
National Institute for Health and Clinical Excellence, 2010. www.nice.org.uk/nicemedia/live/11827/47351.pdf
