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Women who developed hypertension during pregnancy were more likely to show cognitive impairment 15 years later, a prospective study suggested.

Compared with those who had normal blood pressure during pregnancy, women who developed gestational hypertension or preeclampsia performed worse on immediate and delayed recall testing a median of 14.7 years later, reported Maria Adank, MD, of Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues, in .

Impairment was driven mainly by women with gestational hypertension and was independent of ethnicity, educational level, and pre-pregnancy BMI.

"That hypertension during pregnancy, even in the absence of preeclampsia, is associated with such detrimental long term effects should serve as a call to action for prevention," noted Lisa Leffert, MD, of Massachusetts General Hospital and colleagues, in an .

"Gestational hypertension differs from preeclampsia with severe features by the absence of proteinuria or evidence of other end-organ damage," they wrote. "One might surmise that women with gestational hypertension are less impaired than those with preeclampsia and are therefore less likely to develop future related disease. Instead, the Adank et al. study and those of others have demonstrated long-term cognitive, cerebrovascular, and cardiac sequelae in women with gestational hypertension."

Preeclampsia has been linked with in earlier research, but showed no clear evidence of impairment on standard neurocognitive tests. Gestational hypertension has been tied to higher rates of chronic high blood pressure and other comorbidities, while gestational hypertension and preeclampsia have been associated with maternal atherosclerotic cardiovascular disease, independent of traditional risk factors.

Adank and colleagues looked at a cohort of pregnant women in the substudy with a delivery date between April 2002 and January 2006 who were part of the population-based prospective study in Rotterdam. The cohort included 481 women with a normotensive pregnancy and 115 women with hypertensive disorders of pregnancy (80 with gestational hypertension and 35 with preeclampsia).

Cognitive assessments a median 14.7 years later included executive function, processing speed, verbal learning and memory, fine motor, and visuospatial tests, which were combined into a composite global cognition factor. Mean age at cognitive testing was 46. Twenty percent of women with hypertensive disorders of pregnancy had depression at the time of cognitive testing.

About 6 months before cognitive testing, 68 women were classified as hypertensive. Women with a history of hypertensive disorders of pregnancy had a higher proportion of hypertension (30.4%) than those previously normotensive during pregnancy (6.9%).

Women with gestational hypertensive disorders of pregnancy had worse immediate recall and delayed recall scores -- measured by the number of correct answers in three trials of a 15-word learning test -- compared with women who had a normotensive pregnancy. These associations remained significant after adjusting for confounders (immediate recall -0.25, 95% CI -0.44 to -0.06; delayed recall -0.30, 95% CI -0.50 to -0.10).

Sensitivity analysis excluding women with preeclampsia showed that women with gestational hypertension performed worse than women with a normotensive pregnancy on all parts of the 15-word learning test, even after accounting for confounders.

Hypertensive disorders of pregnancy were negatively associated with other cognitive assessments and the composite global factor, but these relationships were nonsignificant after adjustment.

How gestational hypertension or preeclampsia are linked with subsequent dysfunction is unclear. "What is clear is that once a woman has been diagnosed with one of the hypertensive disorders of pregnancy, it is of paramount importance that she be educated about her future vascular disease risk as well as the potential cognitive implications and receive close and comprehensive follow-up care," the editorialists observed. "Increasing awareness among healthcare providers to the existence of a delayed cognitive component in women with hypertensive disorders of pregnancy may help identify those at risk for future decline."

The study had several limitations, the researchers noted. No cognitive tests were performed before or during pregnancy, and effects within one woman could not be investigated. Selection bias may have occurred and unknown confounders may have influenced results.

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