Understanding Preeclampsia

How to Reduce Risk in Pregnancy and Prevent Future Cardiovascular Disease

By Alexsia Priolo

Introduction

Pregnancy places significant physiologic stress on the cardiovascular system, prompting structural and hemodynamic changes to manage increased blood volume and cardiac output. Preeclampsia, a hypertensive disorder of pregnancy, primarily affects healthy nulliparous women with no apparent risk factors. It is characterized by gestational hypertension accompanied by new-onset proteinuria or other adverse conditions. Between 2012 and 2021, the prevalence of preeclampsia in Canada rose from 1.6% to 2.6%, and globally, it occurs in 3-5% of pregnancies. The condition is believed to stem from the failure of spiral artery remodeling in the placenta, leading to hypoperfusion, hypoxia, oxidative stress, systemic inflammation, endothelial dysfunction, and ultimately, systemic hypertension and organ hypoperfusion.¹

Signs and Symptoms

The primary indicator of preeclampsia is elevated blood pressure. Additional symptoms include headaches, abdominal pain, shortness of breath, burning behind the sternum, nausea, vomiting, confusion, heightened anxiety, and visual disturbances such as sensitivity to light, blurred vision, or seeing flashing spots or auras.^{2, 3}

Diagnosis

Preeclampsia is diagnosed after 20 weeks of gestation when systolic blood pressure reaches ≥140 mmHg or diastolic blood pressure reaches ≥90 mmHg on at least two occasions, 15 minutes apart, in someone with previously normal blood pressure. This diagnosis must include either new-onset proteinuria or one or more adverse conditions, such as renal, liver, neurological, or hematological complications or uteroplacental dysfunction.⁴

Feature	Description
Gestational Hypertension	≥140 mmHg systolic or ≥90 mmHg diastolic on at least two occasions four hours apart after 20 weeks of gestation
Proteinuria	Protein:Creatinine ratio ≥30 mg/mmol or Albumin:Creatinine ratio ≥8 mg/mmol
Renal Complications	Acute kidney injury (creatinine ≥90 µmol/L)
Liver Complications	Elevated transaminases, with or without right upper quadrant or epigastric abdominal pain
Neurological Complications	Eclampsia, altered mental status, blindness, stroke, clonus, severe and persistent visual scotomata
Hematological Complications	Thrombocytopenia (platelet count <150,000/µL), disseminated intravascular coagulation, hemolysis
Uteroplacental Dysfunction	Fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, stillbirth

Table 1: Diagnostic Criteria of Preeclampsia 

The International Society for the Study of Hypertension in Pregnancy also recommends laboratory tests to evaluate maternal organ dysfunction, including hemoglobin, platelet count, serum creatinine, liver enzymes, and serum uric acid.⁵

Management Options

Management often involves antihypertensive therapy tailored to patient characteristics, contraindications, and preferences. Early and accurate diagnosis is critical to effective management and reducing potential complications.⁶

Risk Factors and Reducing Risk

Identifying risk factors early in pregnancy allows for timely intervention and prevention of chronic illnesses. High-risk factors include prior preeclampsia, chronic hypertension, diabetes mellitus, chronic kidney disease, and autoimmune disorders. Moderate-risk factors include obesity, nulliparity, multifetal pregnancy, and advanced maternal age. Black women are at increased risk of preeclampsia, regardless of socioeconomic status. Other factors include raised mean arterial blood pressure, polycystic ovary syndrome, sleep-disordered breathing, infections, and extended vaginal bleeding during pregnancy.^{7, 8}

Table 2: Clinical Risk Factors for Preeclampsia

High Risk Factors	Moderate Risk Factors
Prior preeclampsia	Obesity (BMI >30 kg/m²)
Chronic hypertension	Nulliparity
Diabetes mellitus (Type I or II)	Multifetal pregnancy
Chronic kidney disease	Advanced maternal age (>35 years)
Autoimmune disorders	Personal or family history of preeclampsia
Assisted reproductive therapy	Socioeconomic factors

Strategies for Current Pregnancies

• Aspirin: Antiplatelet agents such as aspirin can significantly reduce preeclampsia risk when started at 12-16 weeks of gestation for high-risk individuals. A dose of 81-162 mg/day is recommended until 36 weeks of gestation.⁹
• Calcium: Supplementation of at least 500 mg/day is suggested for women with low dietary calcium intake, and when combined with aspirin, it further reduces the risk.¹⁰
• Vitamin D: While not universally recommended, supplementation may benefit women with pre-existing deficiencies.¹¹
• Exercise: Regular physical activity, starting in the first trimester, can reduce the risk of gestational hypertensive disorders.^{12, 13}
• Diet: Adhering to a Mediterranean-style diet rich in vegetables, fruits, legumes, whole grains, low-fat dairy, and seafood may lower the odds of developing preeclampsia, particularly in Black women.¹⁴

Strategies for Future Pregnancies

For women with a history of preeclampsia, reducing interpregnancy intervals (avoiding both very short and very long intervals) and achieving interpregnancy weight loss are key to lowering risk. Postpartum blood pressure monitoring and lactation also contribute to better cardiovascular health.^{15, 16}

Short and Long-Term Complications

Preeclampsia poses significant risks to maternal and fetal health, including high maternal morbidity, intrauterine growth restriction, placental abruption, preterm birth, and stillbirth. Long-term, it increases the risk of hypertension, ischemic heart disease, stroke, diabetes, and hyperlipidemia. The American Heart Association recognizes pregnancy complications, including preeclampsia, as major risk factors for cardiovascular disease, comparable to smoking. ^{16, 17}

A study by Cho has demonstrated that around 10-15 years postpartum, there is a 3.7-fold risk of developing hypertension, a 2.2-fold risk of developing ischemic heart disease, a 1.8-fold risk of stroke, and a 1.5-fold risk of overall mortality. In general, there is also an increased risk of developing diabetes and hyperlipidemia.¹⁸

When compared to women without, women with gestational hypertension and preeclampsia had higher BMI, lower levels of high-density lipoprotein, higher levels of triglycerides, low-density lipoprotein (LDL), and total cholesterol.¹⁹

According to the 2019 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, adults between 40 and 75 should undergo a 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation.²⁰

In addition, all adults should consume a healthy diet emphasizing the intake of vegetables, fruits, nuts, whole grains, lean animal protein, and fish, and minimize the intake of trans-fats, red and processed meats, refined carbohydrates, and sweetened beverages. In addition, salt intake should be less than 1500mg daily.

Other recommendations include:

• Counseling and caloric restriction are recommended to achieve and maintain weight loss (for overweight/obese adults)
  
• Attain and maintain ideal body weight (ex. BMI between 18.5-24.9 kg/m2)
  
• Attain and maintain a waist circumference of <88cm
  
• A minimum of 150 minutes per week of accumulated moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity
  
• Tobacco cessation
  
• Reduction of alcohol consumption of less than 1 drink per day for women.

Conclusion

Pregnancy serves as a stress test for the cardiovascular system, and a diagnosis of preeclampsia signals a failed test with implications for future vascular and metabolic health. Naturopathic doctors are uniquely positioned to support patients with preeclampsia by addressing both immediate concerns and long-term health risks tailored to their reproductive journey. ^{19, 20}

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References

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2. Croke L. Gestational Hypertension and Preeclampsia: A Practice Bulletin from ACOG. Am Fam physician. 2019;100(10):649-650.
3. Fox R, Kitt J, Leeson P, Aye CYL, Lewandowski AJ. Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. J Clin Med. 2019;8(10):1625. doi:10.3390/jcm8101625
4. Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, et al. Preeclampsia and Future Cardiovascular Health. Circ: Cardiovasc Qual Outcomes. 2017;10(2):e003497. doi:10.1161/circoutcomes.116.003497
5. Magee LA, Smith GN, Bloch C, Côté AM, Jain V, Nerenberg K, et al. Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management. J Obstet Gynaecol Can. 2022;44(5):547-571.e1. doi:10.1016/j.jogc.2022.03.002
6. Ross KM, Schetter CD, McLemore MR, Chambers BD, Paynter RA, Baer R, et al. Socioeconomic Status, Preeclampsia Risk and Gestational Length in Black and White Women. J Racial Ethn Heal Disparities. 2019;6(6):1182-1191. doi:10.1007/s40615-019-00619-3
7. Bartsch E, Medcalf KE, Park AL, Ray JG, Group HR of P eclampsia I. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ. 2016;353:i1753. doi:10.1136/bmj.i1753
8. Chen WY, Sun SF. Clinical efficacy of low-dose aspirin combined with calcium in preventing preeclampsia: A systematic review and meta-analysis. Medicine. 2023;102(34):e34620. doi:10.1097/md.0000000000034620
9. AlSubai A, Baqai MH, Agha H, Shankarlal N, Javaid SS, Jesrani EK, et al. Vitamin D and preeclampsia: A systematic review and meta-analysis. SAGE Open Med. 2023;11:20503121231212092. doi:10.1177/20503121231212093
10. World Health Organization. (2012). Guideline: Vitamin D Supplementation in Pregnant Women. Retrieved from http://www.who.int/publications/i/item/9789241500275
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13. Minhas AS, Hong X, Wang G, Rhee DK, Liu T, Zhang M, et al. Mediterranean‐Style Diet and Risk of Preeclampsia by Race in the Boston Birth Cohort. J Am Hear Assoc: Cardiovasc Cerebrovasc Dis. 2021;11(9):e022589. doi:10.1161/jaha.121.022589
14. Ni W, Gao X, Su X, Cai J, Zhang S, Zheng L, et al. Birth spacing and risk of adverse pregnancy and birth outcomes: A systematic review and dose–response meta‐analysis. Acta Obstet Gynecol Scand. 2023;102(12):1618-1633. doi:10.1111/aogs.14648
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17. Davenport MH, Ruchat SM, Poitras VJ, Garcia AJ, Gray CE, Barrowman N, et al. Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1367. doi:10.1136/bjsports-2018-099355
18. Cho L, Davis M, Elgendy I, Epps K, Lindley KJ, Mehta PK, et al. Summary of Updated Recommendations for Primary Prevention of Cardiovascular Disease in Women JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(20):2602-2618. doi:10.1016/j.jacc.2020.03.060
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20. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;74(10):1376-1414. doi:10.1016/j.jacc.2019.03.009