BackgroundWomen with a history of hypertensive disorders, including pre‐eclampsia, during pregnancy have a two‐ to‐five‐fold increased risk of cardiovascular disease (CVD). In 15% of women, pre‐eclampsia recurs in the following pregnancy.ObjectivesTo evaluate all evidence on the future risk of developing hypertension and CVD after multiple pregnancies complicated by pre‐eclampsia compared with pre‐eclampsia in a single pregnancy followed by normal subsequent pregnancy.Search strategyEmbase and Medline were searched until June 2017.Selection criteriaAll relevant studies on the risk of developing hypertension, atherosclerosis, ischaemic heart disease, cerebrovascular accident (CVA), thromboembolism, heart failure or overall hospitalisation and mortality due to CVD after having had recurrent pre‐eclampsia.Data collection and analysisTwenty‐two studies were included in the review. When possible, we calculated pooled risk ratios (RR) with 95% CI through random‐effect analysis.Main resultsRecurrent pre‐eclampsia was consistently associated with an increased pooled risk ratio of hypertension (RR 2.3; 95% CI 1.9–2.9), ischaemic heart disease (RR 2.4; 95% CI 2.2–2.7), heart failure (RR 2.9; 95% CI 2.3–3.7), CVA (RR 1.7; 95% CI 1.2–2.6) and hospitalisation due to CVD (RR 1.6; 95% CI 1.3–1.9) when compared with women with subsequent uncomplicated pregnancies. Other studies on thromboembolism, atherosclerosis and cardiovascular mortality found a positive effect, but data could not be pooled.ConclusionsThis systematic review and meta‐analysis support consistent higher risk for future development of hypertension and CVD in women with recurring pre‐eclampsia as opposed to women with a single episode of pre‐eclampsia.Tweetable abstractThe risk of future cardiovascular disease increases when women have recurrence of pre‐eclampsia compared with a single episode.

Background Women with a history of hypertensive disorders, including pre-eclampsia, during pregnancy have a two-to-fivefold increased risk of cardiovascular disease (CVD). In 15% of women, pre-eclampsia recurs in the following pregnancy.Objectives To evaluate all evidence on the future risk of developing hypertension and CVD after multiple pregnancies complicated by pre-eclampsia compared with pre-eclampsia in a single pregnancy followed by normal subsequent pregnancy.Search strategy Embase and Medline were searched until June 2017.Selection criteria All relevant studies on the risk of developing hypertension, atherosclerosis, ischaemic heart disease, cerebrovascular accident (CVA), thromboembolism, heart failure or overall hospitalisation and mortality due to CVD after having had recurrent pre-eclampsia.Data collection and analysis Twenty-two studies were included in the review. When possible, we calculated pooled risk ratios (RR) with 95% CI through random-effect analysis.Main results Recurrent pre-eclampsia was consistently associated with an increased pooled risk ratio of hypertension (RR 2.3; 95% CI 1.9-2.9), ischaemic heart disease (RR 2.4; 95% CI 2.2-2.7), heart failure (RR 2.9; 95% CI 2.3-3.7), CVA (RR 1.7; 95% CI 1.2-2.6) and hospitalisation due to CVD (RR 1.6; 95% CI 1.3-1.9) when compared with women with subsequent uncomplicated pregnancies. Other studies on thromboembolism, atherosclerosis and cardiovascular mortality found a positive effect, but data could not be pooled.Conclusions This systematic review and meta-analysis support consistent higher risk for future development of hypertension and CVD in women with recurring pre-eclampsia as opposed to women with a single episode of pre-eclampsia.

Background Patients still receive non-beneficial treatments when nearing the end of life. Advance care planning (ACP) interventions have shown to positively influence compliance with end of life wishes. Hospital physicians seem to miss opportunities to engage in ACP, whereas patients visiting the outpatient clinic usually have one or more chronic conditions and are at risk for medical emergencies. So far, implemented ACP interventions have had limited impact. Structural implementation of ACP may be beneficial. We hypothesize that having ACP conversations more towards the end of life and involving the treating physician in the ACP conversation may help patient wishes and goals to become more concrete and more often documented, thus facilitating goal-concordant care. Aim To facilitate timely shared decision making and increase patient autonomy we aim to develop an ACP intervention at the outpatient clinic for frail patients and determine the feasibility of the intervention. Methods The United Kingdom’s Medical Research Council framework was used to structure the development of the ACP intervention. Key elements of the ACP intervention were determined by reviewing existing literature and an iterative process with stakeholders. The feasibility of the developed intervention was evaluated by a feasibility study of 20 ACP conversations at the geriatrics and pulmonology department of a non-academic hospital. Feasibility was assessed by analysing evaluation forms by patients, nurses and physicians and by evaluating with stakeholders. A general inductive approach was used for analysing comments. The developed intervention was described using the template for intervention description and replication (TIDieR). Results We developed a multidisciplinary timely undertaken ACP intervention at the outpatient clinic. Key components of the developed intervention consist of 1) timely patient selection 2) preparation of patient and healthcare professional 3) a scripted ACP conversation in a multidisciplinary setting and 4) documentation. 94.7% of the patients, 60.0% of the nurses and 68.8% of the physicians agreed that the benefits of the ACP conversation outweighed the potential burdens. Conclusion This study showed that the developed ACP intervention is feasible and considered valuable by patients and healthcare professionals.

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