The pressures of pregnancyBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2789 (Published 16 April 2014) Cite this as: BMJ 2014;348:g2789
In most developed countries except, notably, the United States, women are delaying parenthood for longer and longer. In England and Wales the latest data show that the mean age of a mother giving birth was at an all time high of 29.8 years in 2012 and that women aged 40 or over had the fastest rising fertility rate. Against this backdrop Kate Bramham and colleagues have explored a surprisingly under-researched area: the risks of pregnancy for women with chronic hypertension (doi:10.1136/bmj.g2301).
Their systematic review found that women who were hypertensive before or at the start of pregnancy had high pooled average incidences of all adverse outcomes of pregnancy. The findings withstood subgroup analyses by factors such as gross national income per capita and prevalence of multiple pregnancy and congenital abnormality. The study yielded as many questions as answers: why exactly does hypertension put mothers and babies at higher risk? It’s not all down to a greater propensity to pre-eclampsia, and analysis of the results by parity, maternal age, and ethnicity did not identify an underlying cause either.
In a linked editorial Tine D Clausen and Thomas Bergholt note that the risks of chronic hypertension in pregnancy are on a par with those in women with type 1 diabetes (doi:10.1136/bmj.g2655). “What can we do to prevent the adverse outcomes related to chronic hypertension during pregnancy?” they ask. “Even now, the simple and depressing answer is ‘not much.’” More research really is needed, not least to define a standard international definition of chronic hypertension in pregnancy: at what blood pressure level should women and their doctors be worried, and is it OK to relax if there’s no proteinuria? We don’t know, but we should definitely care.
On the other hand, are medics paying too much attention to the risks of gestational diabetes? Kenneth K Hodson and colleagues don’t think so. Responding to last month’s Too Much Medicine article, they argue that the overall decline in perinatal mortality makes reducing morbidity increasingly important and justifies the identification and treatment of more women for relatively less benefit (doi:10.1136/bmj.g2690). Women should be given the choice, they assert, rather than the medical profession, “which takes a global, rather than individual, view of worthiness.”
In reply, Edmond A Ryan and colleagues defend their argument that newly proposed international diagnostic criteria will double or triple its prevalence in the absence of evidence of clinical or cost benefit (doi:10.1136/bmj.g2692). Of course, women should be given a choice about intervention in gestational diabetes, they say, but it’s unhelpful to use terms that are “fraught with emotion such as ‘risk of her baby dying’” when the risk is so low, and a more rational and less emotional approach seems desirable.
And so to the fraught topic of teenage pregnancy. The good news, says Sophie Arie (doi:10.1136/bmj.g2561), is that Britain’s notoriously high rates have suddenly dropped, and it looks like the Labour government’s well funded and extensive 10 year strategy to halve the rate of teenage conceptions from 2000-10 has paid off. The number of 15-17 year olds getting pregnant in England and Wales started to fall significantly in 2008. By 2010 it had dropped to the lowest level since records began in 1969, and by 2012 it was down to 27.9 in 1000. But Alison Hadley, who headed up that national strategy, is worried that progress may stall—and not just because the current government has dismantled or disinvested in many of the necessary services: “We have extreme sexualisation of things, but young people would still say they’d feel embarrassed about asking about contraception.” Politicians and educators: more rationality and less emotion, please.
Cite this as: BMJ 2014;348:g2789
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