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

Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave, Boston, MA 02115, USA.
BMJ (online) (Impact Factor: 17.45). 02/2009; 338(jun18 1):b2255. DOI: 10.1136/bmj.b2255
Source: PubMed


To investigate whether pre-eclampsia is more common in first pregnancies solely because fewer affected women, who presumably have a higher risk of recurrence, go on to have subsequent pregnancies.
Prospective cohort study.
Swedish Medical Birth Register.
763 795 primiparous mothers who had their first births in Sweden, 1987-2004.
The risk of pre-eclampsia was 4.1% in the first pregnancy and 1.7% in later pregnancies overall. However, the risk was 14.7% in the second pregnancy for women who had had pre-eclampsia in their first pregnancy and 31.9% for women who had had pre-eclampsia in the previous two pregnancies. The risk for multiparous women without a history of pre-eclampsia was around 1%. The incidence of pre-eclampsia associated with delivery before 34 weeks' gestation was 0.42% in primiparous women, 0.11% in multiparous women without a history of pre-eclampsia, and 6.8% and 12.5% in women who had had one or two previous pregnancies affected, respectively. The proportion of women who went on to have a further pregnancy was 4-5% lower after having a pregnancy with any pre-eclampsia but over 10% lower if pre-eclampsia was associated with very preterm delivery. The estimated risk of pre-eclampsia in parous women did not change with standardisation for pregnancy rates.
Having pre-eclampsia in one pregnancy is a poor predictor of subsequent pregnancy but a strong predictor for recurrence of pre-eclampsia in future gestations. The lower overall risk of pre-eclampsia among parous women was not explained by fewer conceptions among women who had had pre-eclampsia in a previous gestation. Early onset pre-eclampsia might be associated with a reduced likelihood of a future pregnancy and with more recurrences than late onset pre-eclampsia when there are further pregnancies. Findings are consistent with the existence of two distinct conditions: a severe recurrent early onset type affected by chronic factors, genetic or environmental, and a milder sporadic form affected by transient factors.

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    • "Therefore, gynecologists often provide extensive follow-up and counseling to these women, both postpartum and during their next pregnancy. However, only 7% of these former patients will actually develop a recurrent early-onset PE in their next pregnancy [2]. Therefore, current clinical management may be excessive in most former patients [4] [5] [6]. "
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    ABSTRACT: Objective To explore hospital costs by pregnant women with a history of early-onset preeclampsia or HELLP syndrome, managed according to customary, but non-standardized prenatal care, by relating maternal and child outcome to maternal health care expenditure. Study design This was a cohort study, in women of 18 years or older who suffered from early-onset preeclampsia or HELLP syndrome in their previous pregnancy (n = 104). We retrieved data retrospectively from hospital information systems and medical records of patients who had received customary, non-standardized prenatal care between 1996 and 2012. Our analyses focused on the costs generated between the first antenatal visit at the outpatient clinic and postpartum hospital discharge. Outcome measures were hospital resource use, costs, maternal and child outcome (recurrence of preeclampsia or HELLP syndrome, incidence of eclampsia, gestational age at delivery, intrauterine fetal demise, small-for-gestational-age birth and low 5 minutes’ Apgar score). We used linear regression analyses to evaluate whether maternal and child outcome and baseline characteristics correlated with hospital costs. Results Maternal hospital costs per patient averaged € 8047. Main cost drivers were maternal admissions and outpatient visits, together accounting for 80% of total costs. Primary cost drivers were preterm birth and recurrent preeclampsia or HELLP syndrome. Conclusion Hospital costs in the next pregnancy of formerly preeclamptic women varied widely with over 70% being medically unexplainable. The results of this study support the view that care standardization in these women can be expected to improve costs and efficacy of care without compromising outcome.
    Full-text · Article · Aug 2014 · European Journal of Obstetrics & Gynecology and Reproductive Biology
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    • "The number of women included in this study was chosen on basis on an earlier study in this field [13], but post hoc power analysis show that almost the double sample size is needed for achieving a statistical power of 80% when investigating e.g. preeclampsia, that affects only about 3-4% of all pregnant women [41]. "
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    Full-text · Article · Jan 2014 · BMC Pregnancy and Childbirth
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    • "Preeclampsia is defined as the association of pregnancy-induced hypertension and proteinuria of ≥300 mg/24 h after 20 weeks’ gestation [1] [2]. Preeclampsia is a common disease complicating 3% of pregnancies (4.1% in the first pregnancy and 1.7% in later ones) [3] and causing significant maternal and perinatal morbidity. A systematic review [4] highlighted that 10% to 15% of maternal deaths that occur every year worldwide are related to hypertensive complications of pregnancy. "
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    ABSTRACT: Nulliparity is a major risk factor of preeclampsia investigated in numerous trials of its prevention. We aimed to assess whether these trials considered nulliparity in subject selection or analysis of results. 01 April 2013 search of MEDLINE via PubMed, EMBASE and the Cochrane Library. 01 April 2013 search of trials registered in Randomised controlled trials and metaanalyses of preeclampsia prevention with no restriction to period of publication or language. Metaanalyses were selected to fully identify relevant trials. One reader appraised each selected article/registered protocol using a pretested, standardized data abstraction form developed in a pilot test. For each article, he recorded whether both nulliparous and multiparous were included and, in case of mixed populations, whether randomisation was stratified, and whether subgroup analyses had been reported. For registered protocols, he only assessed whether it was planned to include mixed populations. 88 randomised controlled trials were identified, representing 83,396 included women. In 58 of the 88 articles identified (65.9%), preeclampsia was the primary outcome. In 31 of these (53.4%), the investigation combined nulliparous and multiparous women; only two reports in 31 (6.5%) stated that randomisation was stratified on parity and only four (12.9%) described a subgroup analysis by parity. Of the 30 registered trials, 20 (66.6%) planned to include both nulliparous and multiparous women. Parity is largely ignored in randomised controlled trials of preeclampsia prevention, which raises difficulties in interpreting the results.
    Full-text · Article · Jun 2013 · PLoS ONE
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