Recurrence of Preeclampsia in Northern Tanzania: A Registry-Based Cohort Study

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Abstract

Objective

Preeclampsia occurs in about 4 per cent of pregnancies worldwide, and may have particularly serious consequences for women in Africa. Studies in western countries have shown that women with preeclampsia in one pregnancy have a substantially increased risk of preeclampsia in subsequent pregnancies. We estimate the recurrence risks of preeclampsia in data from Northern Tanzania.

Methods

A prospective cohort study was designed using 19,811 women who delivered singleton infants at a hospital in Northern Tanzania between 2000and2008. A total of 3,909 women were recorded with subsequent deliveries in the hospital with follow up through 2010. Adjusted recurrence risks of preeclampsia were computed using regression models.

Results

The absolute recurrence risk of preeclampsia was25%, which was 9.2-fold (95% CI: 6.4 - 13.2) compared with the risk for women without prior preeclampsia. When there were signs that the preeclampsia in a previous pregnancy had been serious either because the baby was delivered preterm or had died in the perinatal period, the recurrence risk of preeclampsia was even higher. Women who had preeclampsia had increased risk of a series of adverse pregnancy outcomes in future pregnancies. These include perinatal death (RR= 4.3), a baby with low birth weight (RR= 3.5), or a preterm birth (RR= 2.5). These risks were only partly explained by recurrence of preeclampsia.

Conclusions

Preeclampsia in one pregnancy is a strong predictor for preeclampsia and other adverse pregnancy outcomes in subsequent pregnancies in Tanzania. Women with previous preeclampsia may benefit from close follow-up during their pregnancies.

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Most cited references 17

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

Sonia Hernandez-Diaz, Sengwee Toh, Sven Cnattingius (2009)

Objective 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. Design Prospective cohort study. Setting Swedish Medical Birth Register. Participants 763 795 primiparous mothers who had their first births in Sweden, 1987-2004. Main outcome measures Pre-eclampsia. Results 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. Conclusions 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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Fetal and maternal contributions to risk of pre-eclampsia: population based study.

Lars S Rasmussen, R H Lie, H Brunborg … (1998)

To use familial patterns of recurrence of pre-eclampsia to investigate whether paternal genes expressed in the fetus contribute to the mother's risk of pre-eclampsia and whether mother's susceptibility to pre-eclampsia is related to maternal inheritance by mitochondrial DNA. Linked data on pregnancies of different women who had children with the same father, and subsequently linked data on pregnancies of half sisters who either had same mother and different fathers or had same father and different mothers. Population based data from the Medical Birth Registry of Norway covering all births since 1967 (about 1.7 million) and the Norwegian Central Population Register. Relative risk of pre-eclampsia after a previous pre-eclamptic pregnancy in the family. Relative risks approximated by odds ratios. If a woman becomes pregnant by a man who has already fathered a pre-eclamptic pregnancy in a different woman her risk of developing pre-eclampsia is 1.8 (95% confidence interval 1.2 to 2.6). If the woman has a half sister who had pre-eclampsia and with whom she shares the same mother but different fathers the risk of pre-eclampsia is 1.6 (0.9 to 2.6). If the two sisters have the same father but different mothers the risk is 1.8 (1.01 to 2.9). Both the mother and the fetus contribute to the risk of pre-eclampsia, the contribution of the fetus being affected by paternal genes. Mitochondrial genes, which are transmitted by mothers, do not seem to contribute to the risk.

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Prediction and prevention of recurrent preeclampsia.

B Sibai, Paul Barton (2008)

Women with a history of previous preeclampsia are at increased risk of preeclampsia and other adverse pregnancy outcomes in subsequent pregnancies. The magnitude of this risk is dependent on gestational age at time of disease onset, severity of disease, and presence or absence of preexisting medical disorders. The objective in the management of these patients is to reduce risk factors by optimizing maternal health before conception and to detect obstetric complications as early as possible. This objective can be achieved by formulating a rational approach that includes preconception evaluation and counseling, early antenatal care, frequent monitoring of maternal and fetal well-being, and timely delivery. First-trimester ultrasound examination is essential for accurate dating and establishing fetal number. Laboratory studies are obtained to assess the function of different organ systems that are likely to be affected by preeclampsia and to establish a baseline for future assessment. Recent studies have confirmed that there is no single biomarker that can be clinically useful for the prediction of recurrent preeclampsia. Combinations of biomarkers and biophysical parameters appear promising, but more data are needed to confirm their use in clinical practice. Supplementation with fish oil, calcium, or vitamin C and E and the use of antihypertensives have been shown to be ineffective in the prevention of recurrent preeclampsia and are not recommended. Supplementation with low-dose aspirin may be offered on an individualized basis. Because women with previous preeclampsia are at increased risk for adverse pregnancy outcomes (preterm delivery, fetal growth restriction, abruptio placentae, and fetal death) in subsequent pregnancies, we recommend more frequent monitoring for signs and symptoms of severe hypertension or preeclampsia than that recommended for normal pregnancy. This monitoring may include more frequent prenatal visits, home blood pressure monitoring, or nursing contacts. For patients with a prior pregnancy complicated by preeclampsia with fetal growth restriction, we recommend serial ultrasound evaluation of fetal growth and amniotic fluid volume. The development of severe gestational hypertension, fetal growth restriction, or recurrent preeclampsia requires maternal hospitalization.

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Author and article information

Contributors

Andrew Dewan: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, USA )

ISSN (Electronic): 1932-6203

Publication date Collection: 2013

Publication date (Electronic): 1 November 2013

Volume: 8

Issue: 11

Electronic Location Identifier: e79116

Affiliations

[1 ]Kilimanjaro Christian Medical University College, Moshi, Tanzania

[2 ]Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway

[3 ]Centre for International Health, University of Bergen, Bergen, Norway

[4 ]Norwegian Institute of Public Health, Oslo, Norway

[5 ]Department of Obstetrics and Gynaecology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

[6 ]Department of Pediatrics, Kilimanjaro Christian Medical Centre, Moshi, Tanzania

Yale School of Public Health, United States of America

Author notes

* E-mail: jmmahande@ 123456yahoo.com

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: MJM RTL. Performed the experiments: MJM RTL. Analyzed the data: MJM RTL. Contributed reagents/materials/analysis tools: MJM RTL. Wrote the manuscript: MJM AKD GM BTM JO RM RTL. Manuscript preparation and subsequent revisions: MJM Advice in designing the study and revision of the manuscript for important intellectual content: RTL. Reviewed the manuscript: AKD BTM JO RM. Responsible for the KCMC registry: GM.

Article

Publisher ID: PONE-D-13-21986

DOI: 10.1371/journal.pone.0079116

PMC ID: 3815128

PubMed ID: 24223889

SO-VID: a5064afc-d0fe-4948-a8de-34fe7a3b7ca0

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 28 May 2013

Date accepted : 18 September 2013

Funding

The birth registry was supported by the Norwegian Council for Higher Education’s Program for Development Research or Nasjonalt program for Utvikling, Forskning og Utdanning (NUFU) and Quota scholarship scheme as part of MJM PhD training. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Recurrence of Preeclampsia in Northern Tanzania: A Registry-Based Cohort Study

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Abstract

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Conclusions

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PLOS Climate

Most cited references 17

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

Fetal and maternal contributions to risk of pre-eclampsia: population based study.

Prediction and prevention of recurrent preeclampsia.

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