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

Abstract

BACKGROUND

Eclampsia and pre-eclampsia are hypertensive disorders of pregnancy (HDPs) that may pose significant long-term risk to maternal patients during the post-partum period. Acute neurological complications of these conditions include recurrent seizures, cerebral edema, intracerebral hemorrhage, stroke, and altered mental status. The long-term neurological sequelae of each condition, and how they differ, remain understudied.

AIM

To systematically review and compare long-term neurological outcomes including cognitive impairment, and cerebrovascular events in individuals who experience eclampsia and pre-eclampsia.

METHODS

A systematic review was conducted via PubMed including studies published from 2005 to 2025. Eligible studies included human participants with a history of HDP, and results of neurological outcomes assessed at least three months postpartum. Outcomes of interest included cognitive impairment, structural brain changes, and stroke/stroke risk factors.

RESULTS

A total of 49 studies met inclusion criteria for final synthesis. The findings of our literature review suggest individuals with a history of HDP have an elevated long-term risk of stroke, with greatest hazard ratios present in hemorrhagic stroke. Eclampsia was linked to higher stroke risk compared to preeclampsia. In terms of structural outcomes found on imaging, all HDPs were strongly associated with white matter lesions, atrophy, blood-brain barrier (BBB) leakage, and carotid atherosclerosis, supporting a pathway of persistent cerebrovascular and neurovascular injury. Cognitive impairment in patient-reported data showed deficits; however, objective testing showed non-significant differences.

CONCLUSION

These findings suggest that stroke and structural brain abnormalities are well-supported sequelae of long-term HDP complications, particularly in eclampsia, while cognitive outcomes remain heterogeneous. Thus, differentiated postpartum care and neurologic evaluation may be warranted in at-risk mothers. Further studies are needed to confirm these findings, investigate possible external contributing factors, and inform evidence-based risk assessment and surveillance guidelines.

Keywords: Hypertensive disorders of pregnancy; Preeclampsia; Stroke risk; Cognitive impairment; Neurovascular outcomes

Core Tip: This review of literature examines the neurological consequences for women who have previously experienced gestational hypertension, eclampsia, or preeclampsia. A total of 49 studies were included. After 90 days or greater postpartum, these factors were consistently linked to higher rates of stroke, white matter hyperintensities, structural brain atrophy, and remodeling across studies. The results of this review suggest that pregnancy-related hypertensive disorders may not be isolated obstetrical diseases, but rather long-term risk factors for the development of neurological conditions. Early intervention and surveillance in multidisciplinary treatment, including neurology, vascular medicine, and neurosurgery, may help mitigate negative consequences of disease progression.