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Physical Well-Being in Women With a History of Severe Preeclampsia

Posted on: Tuesday, 20 September 2005, 03:00 CDT

Abstract

Objective. To evaluate the physical and mental health of women with a history of severe preeclampsia.

Methods. In a historical cohort study 131 former patients with a history of severe preeclampsia and 127 control patients received questionnaires about experienced physical and mental complaints after delivery. At a follow-up visit blood pressure, body mass index, and proteinuria were measured and venous blood was drawn.

Results. Former patients experienced significantly (p < 0.001) more frequent problems of headache (31% vs. 2%), right upper quadrant pain (16% vs. 1%), visual disturbances (21% vs. 1%), tiredness (66% vs. 27%), subjective loss of concentration (37% vs. 16%), and mental health (37% vs. 6%) compared with controls. When present, these health problems, except for tiredness, lasted significantly more often beyond six months postpartum compared to controls. Admittance to the intensive care unit was associated with headache, and subjective loss of memory and concentration over a longer period of time. The risk of recurrence of severe preeclampsia was a subject of concern in 20% of former patients. At follow-up, systolic and diastolic blood pressures were significantly higher (p < 0.001) among former patients.

Conclusion. Patients with a history of severe preeclampsia more frequently reported physical and mental complaints, also during a longer period of time.

Keywords: Preeclampsia, physical health, mental health

Introduction

Severe preeclampsia has a significant impact on maternal morbidity [1,2]. One of the most typical hallmarks of this disease is the spontaneous resolution after delivery. In general, recovery, such as normalization of blood pressure and platelet counts, takes place within one or two months postpartum, though this depends on the severity of disease and any other underlying diseases [3-6]. Nevertheless, with respect to other health aspects, such as tiredness, headache, and mental problems, recovery may be different when compared to uncomplicated pregnancies. In general, with regard to the obstetric history unselected, the population's physical and emotional health problems up to 18 months postpartum were reported to occur in 75-94% of the interviewed women and only some of those women sought professional help for this [7,8].

Postpartum maternal morbidity after preeclamptic pregnancy may be directly related to the multi-organ involvement of the disease [9,10]. Moreover, the psychosocial impact of the disease and the state of health of the new-born child may also affect the woman's mental health [11,12]. Women with severe preeclampsia are often admitted to the intensive care unit, which in itself may also influence psychological outcome [13].

A better knowledge of the physical and mental well-being and experienced complaints might be helpful in providing care for women with a history of severe preeclampsia. Therefore, we investigated the presence of complaints and measured several haematological, biochemical, and clinical parameters among women with a history of severe preeclampsia, compared with women with a history of uncomplicated pregnancies only.

Methods

Between January 2000 and March 2001 a follow-up study among women with a history of severe preeclampsia was conducted. The study protocol was approved by the ethics committee of the University Medical Centre Nijmegen and informed consent was obtained from all participants. Severe preeclampsia was defined as a diastolic blood pressure of 110 mm Hg or higher, measured two times or more with an interval of at least 4 h, and a proteinuria of at least 0.3 g/l or the occurrence of HELLP syndrome, defined as lactatedehydrogenase concentration ≥ 600 IU/l, aminotransferases ≥ 70 IU/l, and a thrombocytopenia < 100 x 10^sup 9^/l, in combination with gestational hypertension or preeclampsia.

We invited 241 women with a history of severe preeclampsia, admitted to our hospital in the time period 1995-1999, to participate in this study. At the time of disease in the past they had also been included in a study on some pathophysiologic features of preeclampsia and HELLP syndrome [14,15]. Forty-nine women (20%) did not want to participate for various reasons such as no interest, distance, and emotional distress, and 31 women (13%) could not be traced. The remaining 161 women (67%) received additional information by mail, in which the purpose and content of the follow- up study was explained.

For various reasons another 27 women were not included as they appeared to have had either mild preeclampsia, pre-existing chronic hypertension, or suffered from type I diabetes or lupus erythematosus. Control women (n=135) with an uncomplicated obstetrical history, were recruited from the outpatient clinic, midwife practices, and by advertising in local newspapers. Since these women were randomly selected, this was a non-matched cohort group. Five control women appeared to have had a complicated obstetric history for some form of chronic or gestational hypertension, recurrent early pregnancy loss, or premature delivery and were therefore excluded. Three women with a history of severe preeclampsia and three control women did not complete the questionnaire appropriately and were not taken into analysis.

Finally, 131 women with a history of severe preeclampsia and 127 controls remained for further analysis of questionnaires. One- hundred-and-twenty-three former patients and 97 controls visited the out-patient clinic for taking blood and a confined physical examination. In short, the study consisted of a questionnaire, measurement of body mass index, blood pressure, heart rate, proteinuria, and a venous blood draw for the determination of concentrations of hemoglobin, hematocrit, platelet count, creatinine, uric acid, aminotransferases, lactatedehydrogenase, gammaglutamyltransferase, and bilirubin. Blood pressure was measured in a sitting position with a sphygmomanometer; the diastole was recorded at phase V Korotkoff sound.

In the questionnaire, the below mentioned health complaints, were listed and women were asked if they had experienced these health complaints following the index pregnancy (former patients) or their first pregnancy (controls). The following health complaints or disorders were asked for: hypertension, renal disease, headache, right upper quadrant pain, visual disturbances, tiredness, subjective loss of memory or concentration and mental or other problems. Renal disease was not further defined in the questionnaire; mental problems were not specified in detail. Furthermore it was noted whether the complaints lasted more than six months.

All participating women received the questionnaire some weeks before their visit to our outpatient clinic. During their visit the reported answers were verbally verified in the groups of former patients and controls and additional information was obtained on whether they had been admitted to the Intensive Care Unit and their desire to become pregnant again after their index or first pregnancy, respectively.

Information on the obstetric history, blood pressure, and body mass index before the index pregnancy as well as on age, race, parity, educational levels, and the time interval between the index pregnancy and this study was also obtained from the questionnaires. Educational levels may be regarded as indicators of socio-economic status [16]. They were categorized as low (primary education, lower and intermediate vocational education, or intermediate secondary education) or high (higher secondary and vocational education, or university education).

Statistics

The prevalence of experienced health complaints and the period of time they lasted were compared between former patients and controls, using odds ratios and the corresponding 95% confidence intervals (CI) and were tested using Chi-square analysis.

Haematological, biochemical, and clinical parameters were compared using Students t-test or Mann-Whitney U test, as appropriate. The number of women, whose biochemical parameters exceeded the reference values of our local laboratory were compared between both groups using Chi-square analysis. Epi-info 6.0 and SPSS 6.0 were applied for analyses.

Results

In Table I the characteristics of the two groups are presented. Maternal age, race, and primiparity were not different between the groups though patients had significantly (p < 0.01) lower educational levels than controls. As expected gestational age and birth weight of the index pregnancy were significantly lower among patients (p < 0.01).

The women with a history of severe preeclampsia (n = 80) who had chosen not to participate in this study had a median age of 34 years (27-41) and 94% of them were Caucasians. This was not different from the patient cohort, though other characteristics were not known since we had not been able to interview them.

The interval between the index pregnancy and completion of the questionnaire was significantly (p < 0.01) longer in former patients as compared with controls.

Eighty-five percent of the patients reported at least one health complaint sometime after their index pregnancy, which is significantly (p < 0.001) higher compared to 45% of the controls. Headache (31% vs. 2%), right upper quadrant pain (16% vs. 1%), visual disturbances (21% vs. 1%), tiredness (66% vs. 27%),and some loss of concentration (37% vs. 16%) were reported significantly (p < 0.001) more often by the former patients compared to controls, as well as mental problems (37% vs. 6%, p < 0.01). Moreover, they reported significantly (p < 0.001) more often that these health problems were still present six months postpartum compared to controls (Table II). Under the heading 'other problems' six patients reported some form of numb feeling, weakness, and tingling of their limbs compared to one woman of the control group.

Table I. Clinical and demographic data of former patients and controls.

Table II. Reported health complaints lasting more than 6 months among former patients and controls.

There was no difference in prevalence of health or mental problems reported, between patients who experienced perinatal mortality and those who did not. The overall perinatal mortality rate among patients in our study was 10%, whereas it was nought in the control group.

Overall, patients who had been admitted to the intensive care unit (ICU) did not report more frequent health complaints. However, persistence of problems of headache, and subjective loss of concentration and memory beyond 6 months postpartum were significantly (p < 0.01) more frequent in patients who had been admitted to the ICU (Table III).

Seventy-eight former patients had become pregnant again (47%). Fifty-one percent of the control women became pregnant again after their first pregnancy. Twenty former patients were still aiming for another pregnancy (15%) whereas 31 women (25%) had chosen not to become pregnant again after the index pregnancy.

Forty-one former patients (31%) feared preeclampsia to recur. In this group, 14 women (11%) did not want another pregnancy because of this fear, while 11 women said to aim for another pregnancy despite their fear to develop preeclampsia again, and 16 of them had already been pregnant. None of the control women reported any fear for a new pregnancy. The overall recurrence rate of some kind of hypertensive complications in a subsequent pregnancy was 58%.

Table III. Experienced health complaints (> 6 months) among former patients in relation to admittance to ICU.

Table IV. Biochemical and clinical parameters in former patients and controls at follow-up.

Haematological and biochemical parameters of former patients and controls are depicted in Table IV. Uric acid and gamma- glutamyltransferase (gamma-GT) were both significantly (p < 0.01) higher in former patients compared to controls. However, the number of women in whom concentrations fell outside the laboratory reference value was very small and not significantly different between the groups.

Systolic and diastolic blood pressures at follow-up were significantly higher among women with a history of severe preeclampsia (Table IV). Twelve former patients (9%) were shown to be hypertensive, six of them using antihypertensive medication.

Discussion

This is the first study exclusively reporting on physical well- being of women after severe preeclampsia. Our findings demonstrate that women with a history of severe preeclampsia experienced more often, and for a longer period of time, health complaints than women who had uncomplicated pregnancies only. ICU admittance prolonged the time of duration of headache and subjective loss of concentration and memory.

One third of our patient group had complaints of headache, lasting for more than six months in 61% of this group. Vasospasms of the cerebral vasculature appear up to 3 months postpartum in women after preeclampsia [17]. This may be related to the complaints of headache, as during disease headache is associated with abnormal cerebral perfusion pressure [18]. A direct relationship between chronic hypertension and headache will not explain its high frequency, since the prevalence of chronic hypertension after the index pregnancy was 9% in our study. The frequency of headache is only 2% in our control group, which is much lower than the reported 15% in Glazener's study, which, however, consisted of an unselected group of women with regard to obstetrical history [7]. The diagnosis headache is complex due to its different manners of presentation. In order to achieve a better understanding of a possible relationship between preeclampsia and HELLP syndrome and ongoing postpartum complaints of headache it would be interesting to know the exact type of headache, frequency of attacks and use of analgesics. This should be investigated in a prospective study design.

Active episodes of the HELLP syndrome are characterized by right upper quadrant pain or epigastric pain [19]. Sixteen percent of the former patients still experienced such a pain once in a while. Involvement of liver injury is characterized by an initial rise of aminotransferases and a second one of alkaline phosphatase and gamma- GT concentrations, which is suggestive of cholestasis. Eight weeks after delivery liver enzymes are normalized [20]. In our study gamma- GT levels were slightly higher among former patients, though within normal ranges. Since liver enzyme concentrations in the former patients were within normal ranges, the aetiology of this pain postpartum may not be the same as during HELLP syndrome, especially as the median interval between the complaints and blood sampling was four years.

Visual loss is a symptom of preeclampsia which has been associated with increased blood pressure, cerebral oedema, as well as with generalized vascular dysfunction [21]. In our study, complaints of visual loss varied from permanent impairment of vision to temporary cortical blindness, and were not directly associated with chronic hypertension. Tiredness is a common problem in women who recently have given birth and is unrelated to parity or method of delivery [7,8]. Severe preeclampsia and especially HELLP syndrome are associated with general malaise and fatigue as well [19], which may be related to the higher incidence of tiredness we found among former patients. In both study groups subjective memory loss was reported equally frequent, although former patients who were admitted to the intensive care unit more often had subjective memory problems beyond 6 months than women who were not admitted. Possibly, the more severely ill patients, being admitted more often to the ICU, need a longer recovery period. Both the incidence and duration of subjective loss of concentration were significantly higher and longer among former patients. The effect of pregnancy on cognitive functions has been the subject of many studies, though the conclusions are contradictory [22,23]. Several important endocrinological changes are associated with changes in cognition and mood, during as well as after pregnancy [24]. A direct relationship between preeclampsia and concentration problems has not been reported, though might be suspected since the central nervous system is involved in the pathophysiology of preeclampsia [9]. Up to 37% of the former patients reported some kind of mental problems compared to 6% of the controls. Studies on the psychosocial sequel of severe preeclampsia, however, are scarce [11]. Psychosocial health of former ICU patients has been more related to the level of perceived physical health rather than whether or not the patient had been admitted to the ICU [13,25].

In a recent publication, preeclampsia was not identified as a predictor for post-traumatic stress disorder [26]. There is no information on the association between preeclampsia and the occurrence of postpartum depression [27]. The care and concern for the preterm born infant, who is often admitted to the neonatal intensive care unit, put a substantial psychosocial stress on women and their partners, as demonstrated in previous reports [12,28]. A direct effect of preeclampsia on postpartum tiredness, loss of concentration, and mental problems will therefore be difficult to identify. A control group of parents of prematurely born children after normotensive pregnancy was not at our disposal.

The postpartum recovery of clinically recognizable disease and especially of the platelet count and liver function tests takes place in the first weeks after delivery [3,4,6]. During preeclampsia increased uric acid concentrations are associated with decreased renal clearance but also with increased oxidative stress [29,30]. Slightly higher uric acid in former patients might suggest both an ongoing or an underlying renal problem or some pre-existing activated detoxification system [31]. Nisell et al. reported a higher incidence of chronic hypertension among women seven years after they experienced gestational hypertension or preeclampsia [32]. Our findings of higher systolic and diastolic blood pressures among former patients compared to controls, confirm the results of that study [32]. Blood pressure was only measured once in our study. However, measured elevated blood pressures have been shown to be associated with future development of hypertension and cardiovascular disease [33].

For 11% of the former patients their fear for recurrence was reason to refrain from a new pregnancy, which is lower than the rate of 34% as reported by Van Pampus et al. [34]. In our study 31% of the former patients feared recurrence, though the percentage of women who definitely refrained from a new pregnancy was much lower. Since control women did not experience complicated pregnancies, we could not make a clear comparison between these groups. There are no data on fear for a new pregnancy of women with prematurely born infants.

In our study, differences between the groups in time-interval between the time of study and the index pregnancy may have influenced the results. However, recall of pregnancy related events in women 30 years or more after delivery has shown to be reproducible and reasonably accurate [35]. Other reports on maternal recall demonstrated no substantial deterioration over time either [36,37]. One may \argue that women with a history of severe preeclampsia might be more focussed to recall some kind of symptoms than control women do. However, as all questionnaires were verbally verified with former patients as well as control women, such an effect is probably limited.

In conclusion, physical and mental well-being of women with a history of severe preeclampsia seems to be impaired and sufficient support for this group of women is needed.

Acknowledgement

This study was supported by grant no. 28-2801.1 from Zorg Onderzoek Nederland, The Hague, the Netherlands.

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EVA MARIA ROES1, MAARTEN T. M. RAIJMAKERS2, MARIEKE SCHOONENBERG1, NATASHA WANNER1, WILBERT H. M. PETERS2, & ERIC A. P. STEEGERS1,3

1 Department of Obstetrics & Gynecology, University Medical Centre, Nijmegen, 2 Department of Gastroenterology, University Medical Centre, Nijmegen, and 3 Department of Obstetrics & Gynaecology, Erasmus University Medical Centre Rotterdam, The Netherlands

Correspondence: Eric A. P. Steegers, Professor and Head Subdivision Obstetrics and Prenatal Medicine, Department Obstetrics & Gynaecology, Erasmus MC - University Medical Centre, Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands. Tel: +31 104633632. Fax: +31 104635826. E-mail: e.a.p.steegers@erasmusmc.nl

Copyright CRC Press Jul 2005

Source: Journal of Maternal - Fetal & Neonatal Medicine

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