Book Review

Hypertension in Pregnancy

N Engl J Med 2000; 343:1660November 30, 2000

Article

Hypertension in Pregnancy
(Handbook of Hypertension. Vol. 21.) Edited by Peter C. Rubin. 374 pp., illustrated. Amsterdam, Elsevier, 2000. $235. ISBN: 0-444-50416-8

This second edition of Hypertension in Pregnancy will inevitably be compared with the second edition of Chesley's Hypertensive Disorders in Pregnancy, which appeared last year (M.D. Lindheimer, J.M. Roberts, and F.G. Cunningham, eds. Stamford, Conn.: Appleton & Lange, 1999). Although, as the titles suggest, there is unavoidable overlap, the two books do have different flavors. Perhaps this is because the editor of this volume of the Handbook of Hypertension is a physician with a long-standing interest in obstetrical medicine, whereas two of the three editors of Chesley are obstetricians. The “feel” of each book is different as well. Hypertension in Pregnancy, with its considerably shorter and less detailed chapters, is probably more suitable as an introduction to research related to the hypertensive diseases of pregnancy, whereas Chesley covers topics in greater depth and is suitable for the specialist. Only one of the topics common to both books, the genetics of hypertension during pregnancy, is covered by the same author in both books, and it is interesting to compare the books' approaches to the other topics.

Some of the differences in emphasis reflect Rubin's interest in obstetrical medicine. Thus, there is an entire chapter devoted to the measurement of the blood pressure during pregnancy, which discusses the pitfalls, the problems, and the use of automated monitoring of the blood pressure. Such monitoring has led to the interesting observation that the normal nighttime fall in systemic blood pressure ceases to occur some weeks before the onset of clinically definable disease, although the predictive value of the observation is weak. A more detailed discussion of the various ways of handling the large volumes of data generated by such monitoring would have been helpful. The authors rightly warn of the inaccuracies of some automated systems in women with severe hypertension during pregnancy.

An entire chapter is appropriately devoted to the use of magnesium sulfate in the prevention of eclampsia. The chapter was written by Leila Duley, the highly experienced coordinator of the largest multicenter trial comparing magnesium sulfate with other commonly used treatments. This trial convincingly supported the use of magnesium sulfate, which has long been advocated in the United States but has been criticized as not being an evidence-based therapy. Another departure from Chesley is the incorporation of a useful chapter on the clinical trials of treatments (not prophylaxis) for hypertension in pregnancy, whether chronic or apparently induced by or associated with pregnancy. A common methodologic approach has been applied to all trials that used specified entry criteria. This unified approach will be helpful to those seeking to assess the effects of different treatments on differing presentations of hypertension, although it leaves many questions unanswered.

I approached the chapter on the children of women whose pregnancies were complicated by hypertension with particular interest, since this topic tends to be studied only rarely. There are good reasons for this apparent neglect. There are substantial difficulties in unraveling the effects of being born prematurely to a hypertensive mother, who may have been treated with powerful antihypertensive agents, from those of being born prematurely for other reasons. Premature birth is, by definition, not the norm. The authors make this clear, and although they provide a highly relevant discussion of the problems associated with prematurity per se, it is evident that the effects of superimposed hypertension cannot readily be identified — perhaps suggesting that, if there are any adverse effects, they are not serious. Indeed, there has long been a suspicion that premature infants born to mothers with preeclampsia may actually fare better than other premature infants. A recent report from the National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units tends to support this impression (S.F. Bottoms, et al., “Obstetric Determinants of Neonatal Survival,” American Journal of Obstetrics and Gynecology 1999;180:665–669).

It is slightly surprising that, with a physician as its editor, this book only touches on the long-term outcome for the mother herself. The long-term studies described in Chesley suggested a difference between the outcome in women who had preeclampsia only in a first pregnancy and the outcome in those who also had it in a second or subsequent pregnancy; the risk of hypertension outside of pregnancy was greater among the latter. This observation is now well established. Differences are now also being demonstrated between women who had first occurrences of hypertension alone during pregnancy and those who had marked proteinuria as well, the former being at greater risk for hypertension in later life. There are also associations between hypertension during pregnancy and both heart disease and cerebrovascular accidents. It is to be hoped that a future edition will give some consideration to these issues.

Overall, Hypertension in Pregnancy is a useful overview, without as much detail as the second edition of Chesley. It is thus perhaps more likely than that book to be used by physicians with an interest in the subject and those beginning research on preeclampsia, rather than by those with an established commitment to the field. It certainly has a place in the postgraduate library.

Fiona Broughton Pipkin, D.Phil., F.R.C.O.G.
University of Nottingham Medical School, Nottingham NG7 2UH, United Kingdom