COMMENTARY

Preventing Fatal Maternal Stroke and Other CV Events

JoAnn E. Manson, MD, DrPH

Disclosures

July 25, 2019

This transcript has been edited for clarity.

Hello. I am Dr JoAnn Manson, professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts. I'd like to talk with you about two recent reports, one in JAMA Cardiology[1] and one in Obstetrics & Gynecology,[2] that highlight the sobering relationship between preeclampsia or hypertensive disorders of pregnancy (HDP) and maternal cardiovascular events, as well as provide strong support for the preventability of these complications.

The first study[1] was a prospective, population-based cohort study from Norway, where they followed about 24,000 pregnant women, among whom 9% (about 2200) had an HDP. They documented that the subsequent risk for a cardiovascular event was increased 60% in these women—about a doubling in the risk for myocardial infarction in women with a HDP. They were interested in looking at the percentage of excess risk attributable to conventional risk factors and they documented that close to 80% of the excess risk was related to elevated blood pressure measured during follow-up or to elevated body mass index (BMI), either overweight or obese, suggesting at least two very important targets for reducing the risk for these cardiovascular complications.

The second study[2] was from California, a statewide study looking at pregnancy-related maternal death. During a period of about 5 years, between 2002 and 2007, they documented 333 maternal deaths, one sixth of which were due to preeclampsia or HDP. About 60% of the preeclampsia or HDP-related deaths were due to stroke. They had some very alarming findings. The median blood pressure measured prior to stroke, in women who died from stroke, was a systolic pressure of 196 mm Hg and a diastolic pressure of 113 mm Hg. Nearly all of the women who sustained a stroke had a systolic blood pressure preceding stroke that was > 160 mm Hg. They also found that a little less than 50% of the women had received any antihypertensive treatment for these elevated blood pressures.

This study was done prior to the release of updated guidelines from the American College of Obstetricians and Gynecologists (ACOG Practice Bulletin #202, "Gestational Hypertension and Preeclampsia" and Practice Bulletin #203, "Chronic Hypertension in Pregnancy") and other professional organizations that target systolic and diastolic blood pressure elevations and urge treatment within 30-60 minutes of significantly elevated blood pressure during pregnancy. Hopefully these updated guidelines will help to make a dent in reducing complications such as stroke and other cardiovascular events. It's very clear that it's important to place high priority on management of hypertension and urgent treatment of significant elevations of blood pressure to reduce these tragic complications.

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