Long-term neurological consequences of hypertensive disorders of pregnancy: Implications for postpartum monitoring and intervention

Table 2 Summary of representative studies reporting long-term stroke and vascular outcomes in women with a history of hypertensive disorders of pregnancy

Ref.	Design/setting	Exposure/comparison	Sample (exposed/ref)	Follow-up (years)	Stroke outcome(s)	Effect (95%CI)	Notes
Verburgt et al[19], 2025	Case-control, young women with ischemic stroke vs population controls	Any APO; HDP (PE/PIH) vs none	358 stroke/714 ref	Up to prior pregnancies	Ischemic stroke	PE OR: 4.0 (2.4-6.8); HDP OR: 2.0 (1.4-2.7); SGA OR: 2.8 (2.0-3.9); Preterm OR: 2.7 (1.9-4.0)	HDP strongest with large-artery disease; suggests atherosclerotic mechanism in some cryptogenic strokes
Crump et al[20], 2025	Nationwide cohort, Sweden	APOs (PTB, SGA, PE, other HTN, GDM) vs none	35824 stroke/2201393 total	Up to 46	All stroke	PE aHR: 1.36 (1.31-1.41); other HTN 1.82 (1.67-1.98); GDM 1.86 (1.69-2.04); PTB 1.40 (1.36-1.45); SGA 1.26 (1.22-1.29)	Risks persisted 30-46 years; partly explained by shared familial factors
Hung et al[21], 2022	Nationwide cohort, Taiwan	HDP subtypes vs non-HDP	13617 HDP/54468 ref	≤ 17	Any, ischemic, hemorrhagic	Any aHR: 1.71 (1.46-2.00); Isch aHR: 1.60 (1.35-1.89); Hem aHR: 2.98 (2.13-4.18)	Isch peak 1-3 years (aHR: 2.14); Hem peak 10-15 years (aHR: 4.64); highest with CH superimposed PE (aHR: 3.86)
Auger et al[36], 2020	Provincial cohort, Canada	Very/moderate PTB vs term; mediation by maternal vascular disorders (including PE)	1199364	Approximately 10-20	Ischemic stroke hospitalization	Incidence higher with PTB. For 95%CI PE explained 8.3% (very PTB) and 11.0% (moderate PTB) of PTB-stroke association	Specific stroke HRs by PTB reported; PE key mediator of PTB → stroke/CVD
Garovic et al[23], 2020	Historical cohort, Olmsted County (United States)	Prior HDP vs matched referents	571 HDP/1142 ref	Median 36	Any stroke	HR: 2.27 (1.37-3.76)	HDP also increase CAD, CKD, arrhythmia; robust to adjustments
Arnott et al[24], 2020	National registry, Australia	HDP (early-onset < 34 weeks) × smoking vs no HDP	528106 (first births)	10 (risk estimate)	Composite CVD (including ischemic stroke)	EO-HDP, non-smokers HR: 4.90 (3.00-7.80); EO-HDP + smoking HR: 23.5 (13.5-40.5)	Stroke included in composite; strong interaction with smoking
Gastrich et al[25], 2020	Matched cohort, United States	History of PE vs matched controls	6360 PE/325347 ref	Up to several years	Hospitalized stroke	HR: 1.81 (0.75-4.37) (NS)	MI and CV death increase; stroke directionally increase but underpowered
Kuo et al[26], 2018	Nationwide cohort, Taiwan	PE/eclampsia vs age-matched controls	1295 cases/5180 ref	Approximately 10	Cerebrovascular disease (stroke)	Eclampsia HR: 10.71 (3.45-33.24); PE HR: 3.47 (1.46-8.23)	Hemorrhagic stroke: Eclampsia HR: 19.74; PE NS
Lobitz et al[27], 2024	National admin cohort, Australia	Caesarean vs vaginal; adjusted including HDP/DM	14179299	≤ 365 days PP	Stroke readmission	HR: 1.40 (1.26-1.56)	Increase 180-365 days (HR: 1.94)
Lin et al[29], 2016	Nationwide cohort, Taiwan	PIH vs non-PIH	28346 PIH/113384 ref	Approximately 10	Intracranial hemorrhage	aHR: 2.81 (1.58-4.99)	Hemorrhagic risk increasing strongly
Nelander et al[30], 2016	Cohort, Sweden (≥ 65 years)	Any HDP vs none	3232	To late life	Any stroke	HR: 1.36 (borderline)	Attenuated at oldest ages
Akhter et al[35], 2014	Vascular imaging cohort, Norway	Severe PE vs normotensive	42 PE/44 ref	9 years (range 1-13)	Vascular surrogate (carotid IMT/plaques)	Intima 013 ± 0.02 mm vs 0.08 ± 0.01 mm (+63%); I/M ratio 0.27 ± 0.07 vs 0.15 ± 0.03 (+80%); IMT 063 ± 0.12 mm vs 0.61 ± 0.12 mm (+3%); media -7%	Increased carotid intimal thickening and arterial remodeling consistent with early subclinical atherosclerosis after severe PE

Of 23 included studies, 12 with detailed effect estimates, or national cohort data are shown here. CI: Confidence interval; APO: Adverse pregnancy outcome; HDP: Hypertensive disorder of pregnancy; PE: Preeclampsia; PIH: Pregnancy-induced hypertension; Ref: Reference/control group; OR: Odds ratio; SGA: Small for gestational age; HTN: Hypertension; GDM: Gestational diabetes mellitus; PTB: Preterm birth; aHR: Adjusted hazard ratio; CH: Chronic hypertension; HR: Hazard ratio; Isch: Ischemic stroke; Hem: Hemorrhagic stroke; PTB → stroke/CVD: Pathway from preterm birth to stroke or cardiovascular disease; CAD: Coronary artery disease; CKD: Chronic kidney disease; EO-HDP: Early-onset hypertensive disorder of pregnancy; NS: Not significant; MI: Myocardial infarction; CV: Cardiovascular; DM: Diabetes mellitus; I/M: Intima/media ratio; IMT: Intima-media thickness.