Best Practice & Research Clinical Obstetrics & Gynaecology
1Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy
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.
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