US Athlete’s Death Highlights Risk of Hypertensive Disorders of Pregnancy

Tori Bowie, a highly decorated American track and field star, died from pregnancy-related complications that may have included eclampsia, according to an autopsy report released this week from the Orange Country, FL, medical examiner’s office.

The 32-year-old Bowie, who won gold, silver, and bronze medals at the 2016 Olympic Games, was 8 months pregnant at the time of her death on May 2, 2023. Her death shocked the sports world, but cardiologists say her tragic case highlights the risk of hypertensive disorders in pregnancy.

Michael Honigberg, MD (Massachusetts General Hospital, Boston), a physician at the Corrigan Women’s Heart Health Program, said that while many risk factors for preeclampsia are well documented, such as obesity, they don’t fully capture everybody who may be at risk for developing the hypertensive disorder. Moreover, the risk of preeclampsia doesn’t affect everybody equally, with African-American women, like Bowie, at a higher risk of pregnancy-related complications than white women.

“There are misconceptions about the sort of person in whom preeclampsia occurs,” he told TCTMD. “It’s one of the things that can be scary and challenging about it.”

Her record-breaking times on the track are part of what made Bowie’s death so startling. Born in Sand Hill, MS, Bowie was once the fastest woman in the world, a title she claimed after winning the 100m in 10.85 seconds at the 2017 world championships in London, England. She was also a highly decorated Olympic athletic, winning a silver medal in the 100m and a bronze medal in the 200m at the 2016 games in Rio de Janeiro, Brazil. At those Olympics, she also ran the anchor leg on the gold medal-winning 4 x 100m relay team. 

“Very similar to cardiovascular disease, hypertensive disorders of pregnancy and preeclampsia tend to be more common in individuals who already have high blood pressure and in individuals who are obese or who have a higher body mass index than what we think is optimal,” Natalie Bello, MD (Cedars-Sinai Medical Center, Los Angeles, CA), chair of the American College of Cardiology’s Reproductive Health & Cardio-Obstetrics Council, told TCTMD. “We know that we have an obesity crisis in the country right now and around the world so a lot of this we think is probably attributable to people having suboptimal cardiometabolic health.”

Unfortunately, preeclampsia and hypertensive disorders of pregnancy are on the rise in the United States. Natalie Bello

Honigberg, whose research involves the study of novel maternal genetic variants linked with preeclampsia, pointed out that while obstetrician-gynecologists screen for overt risk factors, these risk factors can miss a substantial proportion of women who could develop the disorder. There is a strong genetic component to preeclampsia, he said, which can put someone with even ideal cardiometabolic health at risk.

“We think that probably about a third of it reflects maternal genetic predisposition and another 20% reflects fetal genes,” he said. “A lot of the causal biomarkers that drive at least the late stages of this condition come from the placenta, which is a different set of genes from mom. It’s partly mom’s genes and partly dad’s genes. So it’s really complex biology and genetics.”

In a JAMA Cardiology study last week, Finnish researchers identified genes related to blood pressure that were associated with preeclampsia in a genome-wide association study, but showed that many of the cardiovascular disease-related genes influenced other processes as well, including cardiometabolic, endothelial, and placental function.

Eclampsia “Exceedingly Rare”

Hypertensive disorders in pregnancy include chronic hypertension, gestational hypertension (high blood pressure that develops during pregnancy, particularly the latter half), and preeclampsia or eclampsia. Data from the US Centers for Disease Control and Prevention (CDC) showed that hypertensive disorders affect roughly 1 in 7 women delivering in the hospital, with large disparities seen across racial and ethnic lines.  

Preeclampsia is a condition in which a woman with normal blood pressure develops hypertension (≥ 140 mm Hg systolic or ≥ 90 mm Hg diastolic), along with protein in the urine and other symptoms, including neurologic changes, such as headaches and visual disturbances, in the second half of pregnancy or soon after giving birth. Untreated, it can progress rapidly to eclampsia, which can lead to seizures, stroke, and death.

The progression to eclampsia is preventable if detected early, said Bello, noting the main approaches are antihypertensive medications to get blood pressure under control and the use intravenous magnesium sulfate to prevent seizures.

There are misconceptions about the sort of person in whom preeclampsia occurs. Michael Honigberg

In one recent study that used National Inpatient Sample (NIS) data from the Agency for Healthcare Research and Quality (AHRQ), the incidence of preeclampsia was 5.2%. In other studies, the incidence ranges from 3% to 6% of all pregnancies, depending on the region. Preeclampsia, along with other hypertensive disorders of pregnancy, increase a woman’s long-term risk of cardiovascular disease.

Many physicians, including cardiologists, may not have kept pace with this research since their medical school training and may be unaware that the landscape has shifted.

“Unfortunately, preeclampsia and hypertensive disorders of pregnancy are on the rise in the United States,” said Bello. “Eclampsia, thankfully, is quite rare. That’s why with having an awareness of the signs of symptoms that are indicative of preeclampsia or impending preeclampsia, and getting medical attention quickly, our hope is that we can treat people with magnesium, lower their blood pressure, and prevent that progression.”

Other risk factors for preeclampsia include a history of autoimmune disorders, advanced maternal age, a history of chronic kidney disease, and first pregnancy (not including miscarriages or abortions). Multiple studies have shown that Black women have the highest risk of the disorder compared with other racial/ethnic groups, with estimates showing the prevalence of preeclampsia is approximately 60% higher compared with white women.

To TCTMD, Honigberg said it’s not entirely clear why Black women are more likely to develop preeclampsia, although there is a strong suspicion that the various social determinants of health drive the racial disparity.

“Exactly how that translates to the extremely complex biology of this condition, we still don't really understand all of those steps,” he said. “We know that Black women in the US are more likely to have overt cardiometabolic risk factors strongly linked to preeclampsia. Things like pre-pregnancy chronic hypertension, pre-pregnancy prediabetes or diabetes, pre-pregnancy overweight or obesity—that’s part of it, but I don’t think it explains all of it. We don't have the sort of high-quality, robust data that clearly explains the reason [for higher rates among Black women].”

In 2021, the CDC reported that 1,205 women died while pregnant, or within 42 days of terminating the pregnancy, which was up from 861 deaths in 2020 and 754 deaths in 2019. The maternal mortality rate for Black women was 2.5 times higher than that for white women in 2021.

Maternal Mortality Higher in Black Americans

Bello said the unfortunate death of Tori Bowie emphasizes the importance of patient/physician discussions about pregnancy, particularly if they may be at risk for preeclampsia or other hypertensive disorders. “I like to educate my patients about what are the warning signs of preeclampsia and eclampsia,” she said. “It’s a little tricky because there can be some overlap with the physiologic changes of pregnancy and the signs of preeclampsia.”

Swelling, particularly over a short period of time, nausea, headaches, or visual changes should all be considered as potential signs of preeclampsia, said Bello. “I would say always in pregnancy, err on the side of caution and check with your doctor,” she said. High blood pressure, she added, is a silent killer, so it’s important for women to have their blood pressure checked at every prenatal visit, which is a US Preventive Services Task Force recommendation. For women at high risk for preeclampsia, the American College of Obstetricians and Gynecologists (ACOG) recommends low-dose aspirin started after 12 weeks gestation and continued until pregnancy.   

In 2022, the Chronic Hypertension and Pregnancy (CHAP) trial, which was funded by the National Heart, Lung, and Blood Institute, showed that treating pregnant women with mild, chronic hypertension to a target of less than 140/90 mm Hg was associated with significantly better pregnancy outcomes and no signal of harm to the mother or baby.

Honigberg said there is more-uniform practice around controlling blood pressure since the CHAP trial was published, noting there had been some initial concerns about the effects of lower blood pressure on fetal growth. Many of the other recommendations to prevent or treat preeclampsia include typical heart-healthy recommendations, such as eating a healthy diet (preferably a Mediterranean one) and exercising, as well as maintaining a body mass index as normal as possible.

“And for those with chronic hypertension, making sure it’s adequately treated,” he said.