Long term health complications following hypertension in pregnancy

Prof Pensée Wu of Keele University has worked with APEC to create a new comprehensive summary for women and healthcare professionals on the long term health issues that can arise following pre-eclampsia and hypertension in pregnancy. 

Hypertensive disorders of pregnancy (HDP) are complications of pregnancy affecting around 2 – 8% of pregnancies. It is classified into: pre-eclampsia, gestational hypertension, chronic hypertension, white coat hypertension and masked hypertension. Although most HDP resolve after pregnancy, they have been linked with increased chances of developing heart disease in later life.

Women who have had pre-eclampsia have double the risk of developing high blood pressure, stroke and heart disease, as well as quadruple the risk of heart failure in the future, compared to women who did not have pre-eclampsia. Women who had pre-eclampsia more than once also have a higher risk of developing long term health issues. Although the increase in relative risk is the highest within the first year after delivery, these risks persist decades after the pregnancy (when the absolute risks for older women are greater than for women immediately after delivery.)

Women who had pre-eclampsia have a 6-fold increased risk of renal disease and double the risk of diabetes and venous thromboembolism (VT). VT is when a blood clot forms in a deep vein (deep vein thrombosis, DVT) breaks free and travels in the circulation to the lungs (pulmonary embolism) in later life. Women who had gestational hypertension have a 1.4-fold increased risk for future stroke and coronary heart disease, which is lower than that for women who had preeclampsia

The association between HDP and future Cardio Vascular Disease (CVD) are now well established, however, many women with HDP miss out on appropriate postnatal cardiovascular screening due to either lack of awareness in healthcare professionals or among the women themselves. There are several international guidelines that advocate the incorporation of HDP in the cardiovascular risk assessment of women to prevent future disease. The American Heart Association (AHA) CVD prevention guidelines (2011) consider women with a history of HDP as ‘at
2 risk’ and recommend lifestyle modifications, such as giving up smoking, increasing regular physical activity, eating healthily and monitoring of blood pressure.

If cholesterol levels are found to be high, women are advised to take medication to lower them. The AHA/American Stroke Association (ASA) stroke prevention guidelines (2014) recommend considering the evaluation and treatment of women with a history of pre-eclampsia/eclampsia for cardiovascular risk factors including high blood pressure, obesity, smoking, and high cholesterol, starting from 6 months to 1 year after delivery. Pre-eclampsia has been included as a risk-enhancing factor for consideration of treatment in the American College of Cardiology (ACC)/AHA guideline on the management of blood cholesterol (2018) and the ACC/AHA CVD guideline on the primary prevention of CVD (2019). The European Society of Cardiology (ESC) CVD prevention guidelines (2021) suggest that in women with a history of HDP, screening for high blood pressure and diabetes might be useful.

There has been increasing recognition that a collaborative multidisciplinary approach is needed from pre-conception, through pregnancy and postpartum and at-risk women are monitored closely by obstetricians in the immediate postpartum period. This monitoring would then be followed up in primary care with referral to long term cardiology if monitoring is needed. In addition to high blood pressure and cholesterol management, lifestyle modification may help to reduce the risk of developing Cardio Vascular Disease in later life.