Less-tight versus tight control of hypertension in pregnancy

Cardiometabolic health during early adulthood and risk of miscarriage: a prospective study

Background: Several studies have found that women who are overweight or obese have an increased risk of miscarriage. There is also some evidence of associations of other aspects of cardiometabolic health, including blood pressure and lipids, with miscarriage risk, although these have not been examined to the same extent as body-mass index (BMI). Methods: Our objective was to investigate the risk of miscarriage according to pre-pregnancy cardiometabolic health. We examined pre-pregnancy levels of BMI, blood pressure, fasting insulin and metabolites profile at age 18 and risk of miscarriage by age 24. The study included adult female offspring in the Avon Longitudinal Study of Parents and Children with a pregnancy between 18 and 24 years of age (n=434 for BMI and blood pressure; n=265 for metabolites). We used log-binomial regression to calculate adjusted associations between cardiometabolic health measures and miscarriage. Results: The overall risk of miscarriage was 22%.  The adjusted relative risks for miscarriage were 0.96 (95% CI: 0.92-1.00) for BMI (per unit increase), 0.98 (0.96-1.00) for systolic blood pressure, and 1.00 (0.97-1.04) for diastolic blood pressure (per 1 mmHg increase).  Total cholesterol, total lipids and phospholipids in HDL-cholesterol were associated with increased likelihood of miscarriage, but none of the p-values for the metabolites were below the corrected threshold for multiple testing (p-value ≤0.003). Conclusions: Our findings indicate no strong evidence to support a relationship between pre-pregnancy cardiometabolic health and risk of miscarriage in young, healthy women who became pregnant before age 24. Future studies are necessary that are able to evaluate this question in samples with a wider age range.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Blood pressure targets in adults with hypertension

BACKGROUND

This is the first update of this review first published in 2009. When treating elevated blood pressure, doctors usually try to achieve a blood pressure target. That target is the blood pressure value below which the optimal clinical benefit is supposedly obtained. "The lower the better" approach that guided the treatment of elevated blood pressure for many years was challenged during the last decade due to lack of evidence from randomised trials supporting that strategy. For that reason, the standard blood pressure target in clinical practice during the last years has been less than 140/90 mm Hg for the general population of patients with elevated blood pressure. However, new trials published in recent years have reintroduced the idea of trying to achieve lower blood pressure targets. Therefore, it is important to know whether the benefits outweigh harms when attempting to achieve targets lower than the standard target.

OBJECTIVES

The primary objective was to determine if lower blood pressure targets (any target less than or equal to 135/85 mm Hg) are associated with reduction in mortality and morbidity as compared with standard blood pressure targets (less than or equal to 140/ 90 mm Hg) for the treatment of patients with chronic arterial hypertension. The secondary objectives were: to determine if there is a change in mean achieved systolic blood pressure (SBP) and diastolic blood pressure (DBP associated with "lower targets" as compared with "standard targets" in patients with chronic arterial hypertension; and to determine if there is a change in withdrawals due to adverse events with "lower targets" as compared with "standard targets", in patients with elevated blood pressure.

SEARCH METHODS

The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials up to May 2019: the Cochrane Hypertension Specialised Register, CENTRAL (2019, Issue 4), Ovid MEDLINE, Ovid Embase, the WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing patients allocated to lower or to standard blood pressure targets (see above).

DATA COLLECTION AND ANALYSIS

Two review authors (JAA, VL) independently assessed the included trials and extracted data. Primary outcomes were total mortality; total serious adverse events; myocardial infarction, stroke, congestive heart failure, end stage renal disease, and other serious adverse events. Secondary outcomes were achieved mean SBP and DBP, withdrawals due to adverse effects, and mean number of antihypertensive drugs used. We assessed the risk of bias of each trial using the Cochrane risk of bias tool and the certainty of the evidence using the GRADE approach.  MAIN RESULTS: This update includes 11 RCTs involving 38,688 participants with a mean follow-up of 3.7 years. This represents 7 new RCTs compared with the original version. At baseline the mean weighted age was 63.1 years and the mean weighted blood pressure was 155/91 mm Hg. Lower targets do not reduce total mortality (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.86 to 1.05; 11 trials, 38,688 participants; high-certainty evidence) and do not reduce total serious adverse events (RR 1.04, 95% CI 0.99 to 1.08; 6 trials, 18,165 participants; moderate-certainty evidence). This means that the benefits of lower targets do not outweigh the harms as compared to standard blood pressure targets. Lower targets may reduce myocardial infarction (RR 0.84, 95% CI 0.73 to 0.96; 6 trials, 18,938 participants, absolute risk reduction (ARR) 0.4%, number needed to treat to benefit (NNTB) 250 over 3.7 years) and congestive heart failure (RR 0.75, 95% CI 0.60 to 0.92; 5 trials, 15,859 participants, ARR 0.6%, NNTB  167 over 3.7 years) (low-certainty for both outcomes). Reduction in myocardial infarction and congestive heart failure was not reflected in total serious adverse events. This may be due to an increase in other serious adverse events (RR 1.44, 95% CI 1.32 to 1.59; 6 trials. 18,938 participants, absolute risk increase (ARI) 3%,  number needed to treat to harm (NNTH) 33 over four years) (low-certainty evidence). Participants assigned to a "lower" target received one additional antihypertensive medication and achieved a significantly lower mean SBP (122.8 mm Hg versus 135.0 mm Hg, and a lower mean DBP (82.0 mm Hg versus 85.2 mm Hg, than those assigned to "standard target".

AUTHORS' CONCLUSIONS

For the general population of persons with elevated blood pressure, the benefits of trying to achieve a lower blood pressure target rather than a standard target (≤ 140/90 mm Hg) do not outweigh the harms associated with that intervention. Further research is needed to see if some groups of patients would benefit or be harmed by lower targets. The results of this review are primarily applicable to older people with moderate to high cardiovascular risk. They may not be applicable to other populations.

Optimizing Care Preconception for Women With Diabetes and Obesity

The prevalence of diabetes in reproductive age women has been reported to be as high as 6.8%, with pregestational diabetes affecting 2% of all pregnancies. As cases of diabetes in children and adolescents rise, more patients will be entering reproductive age and pregnancy with diagnoses of obesity, prediabetes, type 2 diabetes. Early interventions of diet modification and exercise to maintain healthy weights can delay or even prevent these complications. It is critical for health care providers to emphasize the importance of preconception counseling in this high-risk patient population to reduce the morbidities associated with obesity and diabetes in pregnancy.

Hypertensive Disorders of Pregnancy, Cesarean Delivery, and Severe Maternal Morbidity in an Urban Safety-Net Population

Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016-2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.

ADIPS 2020 guideline for pre-existing diabetes and pregnancy

This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.

Hypertensive Disorders of Pregnancy

Hypertension is the most common medical disorder occurring during pregnancy and a leading cause of maternal and perinatal morbidity and mortality. Accurate blood pressure measurement and the diagnosis and treatment of hypertensive disorders during pregnancy and in the postpartum period are pivotal to improve outcomes. This article details hemodynamic adaptations to pregnancy and provides an approach to the prevention, diagnosis, and management of hypertensive disorders of pregnancy (HDP) and hypertensive emergencies. In addition, it reviews optimal strategies for the care of women with hypertension during the fourth trimester and beyond to minimize future cardiovascular risk.

Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy are increasing in incidence and are major causes of maternal morbidity and mortality both in the United States and worldwide. An understanding of these diseases is essential for the practicing nephrologist, as preexisting kidney disease is an important risk factor. In addition, the development of hypertensive disorders of pregnancy has important implications for long-term risk of kidney disease and cardiovascular disease. The definition and diagnostic criteria has changed in recent years as our understanding of the disease entity has progressed. Currently, proteinuria is no longer a necessary diagnostic feature of preeclampsia. Preeclampsia and gestational hypertension may develop through multiple different mechanisms. Current research suggests contributions of both placental factors and maternal factors contribute to the disease and represent different phenotypic presentations of preeclampsia.

End-Stage Kidney Disease and Dialysis in Pregnancy

End-stage kidney disease is associated with low fertility, with rates of conception in women on dialysis estimated at 1/100th of the general population. However, live birth rates are increasing over time in women on hemodialysis, whereas they remain lower and static in women on peritoneal dialysis. Intensification of hemodialysis, targeting a serum blood urea nitrogen <35 mg/dL or 36 hours of dialysis per week in women with no residual kidney function, is associated with improved live birth rates and longer gestational age. Even in intensively dialyzed cohorts, rates of prematurity and need for neonatal intensive care are high, upwards of 50%. Although women on peritoneal dialysis in pregnancy do not appear to be at increased risk of delivering preterm compared with those on hemodialysis, their infants are more likely to be small for gestational age. As such, hemodialysis has emerged as the preferred dialysis modality in pregnancy. Provision of specialized nephrology, obstetric, and neonatal care is necessary to manage these complex pregnancies and family planning counseling should be offered to all women with end-stage kidney disease.

Methyldopa versus labetalol or no medication for treatment of mild and moderate chronic hypertension during pregnancy: a randomized clinical trial

OBJECTIVE

to assess the maternal and fetal outcome in women with mild to moderate chronic hypertension on antihypertensive drug (methyldopa or labetalol) therapy compared to no medication.

METHODS

This multicenter randomized clinical study was conducted at Menoufia University hospital, Shibin El-kom Teaching hospital at Menoufia governorate, Egypt.486 pregnant women with mild to moderate chronic hypertension were randomized into three groups; methyldopa group (n = 164), labetalol group (n = 160), and control or no medication group (n = 162) who were followed from the beginning of pregnancy till the end of puerperium to record maternal and fetal outcome.

RESULTS

There was a highly significant difference between treatment groups (methyldopa and labetalol) and control group regarding the development of maternal severe hypertension, development of preeclampsia, renal impairment, presence of ECG changes, placental abruption, and repeated admission to hospital for blood pressure control (p < 0.001) with higher occurrence in the control (no treatment) group. Neonates in the labetalol group were more prone for the development of small for gestational age (SGA), neonatal hypotension, neonatal hyperbilirubinemia, and admission to NICU than their counterparts in the methyldopa and control groups (p < 0.001). The rate of prematurity was significantly higher in the control group than the treatment groups (p < 0.05).

CONCLUSION

Treatment of mild to moderate chronic hypertension during pregnancy is beneficial in decreasing both maternal and fetal morbidity. The use of labetalol was associated with higher rates of SGA, neonatal hypotension, and neonatal hyperbilirubinemia compared to methyldopa or no medication.

Chronic Kidney Disease and Pregnancy

Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such as obesity and advanced maternal age are increasing; thus, more pregnancies are likely to be affected by CKD. Strategies that involve coordinated multidisciplinary care to optimize preconception health, perform meticulous antenatal monitoring, and provide continued care in the postpartum "fourth trimester" appear to be most beneficial for both the mother and baby. Discussions surrounding preconception risk stratification should be individualized based on CKD stage/serum creatinine level, degree of hypertension and proteinuria, and comorbid conditions. Preparation for pregnancy should include optimization of comorbidities and medication adjustments to those compatible with pregnancy. Unless contraindicated, all women with CKD should be prescribed low-dose aspirin in pregnancy to reduce risk of preeclampsia. After delivery, women with CKD may benefit from an early postpartum visit (within 7-10 days) for blood pressure check and may require serial monitoring of serum creatinine and proteinuria as appropriate. Breastfeeding is safe and can be recommended for most women with CKD. A contraceptive plan that includes patients' preferences, feasibility, medical eligibility, duration, and effectiveness of the contraceptive method should be implemented.

Development and Validation of a Nomogram for Predicting the Risk of Pregnancy-Induced Hypertension: A Retrospective Cohort Study

Objective: To develop and validate a prediction model for identifying pregnant women at risk of developing pregnancy-induced hypertension (PIH) to guide treatment decision and classification of management. Methods: This study retrospectively enrolled 907 consecutive pregnant women with de novo hypertension from the Antenatal Care Center of Henan Provincial People's Hospital between June 1, 2018 and May 31, 2019. The cohort was randomly divided into two subgroups: the development cohort (n = 635) and validation cohort (n = 272). Univariate analysis and backward elimination of multivariate logistic regression analyses were utilized to identify predictive factors, and a nomogram was established. The performance was assessed using the area under the curve (AUC), the mean AUC of k-fold cross-validation, and calibration plots. Based on the classification and regression tree model, risk classification was performed. Results: The score included five commonly available predictors: body mass index, proteinuria, age, uric acid, and mean arterial pressure (BPAUM score). When applied to internal validation, the score revealed good discrimination with stratified fivefold cross-validation in the development cohort (AUC = 0.91) and validation cohort (AUC: 0.89) at fixed 10% false-positive rates, and the calibration plots showed good calibration. The total score point was divided into three risk classifications: low risk (0 - 179 points), medium risk (179 - 204 points), and high risk (>204 points). Conclusions: This study established a prediction model for predicting PIH, which could be used in clinical decision-making to improve maternal health and birth outcomes.

Implementation of national antenatal hypertension guidelines: a multicentre multiple methods study

OBJECTIVE

To evaluate the implementation of National Institute for Health and Care Excellence antenatal hypertension guidelines, to identify strategies to reduce incidences of severe hypertension and associated maternal and perinatal morbidity and mortality in pregnant women with chronic hypertension.

METHODS

We used a multiple method multisite approach to establish implementation of guidelines and the associated barriers and facilitators. We used a national survey of healthcare professionals (n=97), case notes review (n=55) and structured observations (n=42) to assess implementation. The barriers and facilitators to implementation were identified from semistructured qualitative interviews with healthcare professionals (n=13) and pregnant women (n=18) using inductive thematic analysis. The findings were integrated and evaluated using the Consolidated Framework for Implementation Research.

SETTING AND PARTICIPANTS

Pregnant women with chronic hypertension and their principal carers (obstetricians, midwives and physicians), at three National Health Service hospital trusts with different models of care.

RESULTS

We found severe hypertension to be prevalent (46% of case notes reviewed) and target blood pressure practices to be suboptimal (56% of women had an antenatal blood pressure target documented). Women were infrequently given information (52%) or offered choice (19%) regarding antihypertensives. Women (14/18) reported internal conflict in taking antihypertensives and non-adherence was prevalent (8/18). Women who were concordant with treatment recommendations described having mutual trust with professionals mediated through appropriate information, side effect management and involvement in decision making. Professionals reported needing updates and tools for target blood pressure setting and shared decision making underpinned by antihypertensive safety and effectiveness research.

CONCLUSIONS

Women's non-adherence to antihypertensives is higher than anticipated. Suboptimal information provision around treatment, choice of antihypertensives and target setting practices by healthcare professionals may be contributory. Understanding the reasons for non-adherence will inform education and decision-making strategies needed to address both clinician and women's behaviour. Further research into the effectiveness and long-term safety of common antihypertensives is also required.

Comparative efficacy and safety of oral antihypertensive agents in pregnant women with chronic hypertension: a network metaanalysis

OBJECTIVE DATA

Chronic hypertension is associated with adverse perinatal outcomes, although the optimal treatment is unclear. The aim of this network metaanalysis was to simultaneously compare the efficacy and safety of antihypertensive agents in pregnant women with chronic hypertension.

STUDY

Medline, Scopus, CENTRAL, Web of Science, Clinicaltrials.gov, and Google Scholar databases were searched systematically from inception to December 15, 2019. Both randomized controlled trials and cohort studies were held eligible if they reported the effects of antihypertensive agents on perinatal outcomes among women with chronic hypertension.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcomes were preeclampsia and small-for-gestational-age risk. A frequentist network metaanalytic random-effects model was fitted. The main analysis was based on randomized controlled trials. The credibility of evidence was assessed by taking into account within-study bias, across-studies bias, indirectness, imprecision, heterogeneity, and incoherence.

RESULTS

Twenty-two studies (14 randomized controlled trials and 8 cohorts) were included, comprising 4464 women. Pooling of randomized controlled trials indicated that no agent significantly affected the incidence of preeclampsia. Atenolol was associated with significantly higher risk of small-for-gestational age compared with placebo (odds ratio, 26.00; 95% confidence interval, 2.61-259.29) and is ranked as the worst treatment (P-score=.98). The incidence of severe hypertension was significantly lower when nifedipine (odds ratio, 0.27; 95% confidence interval, 0.14-0.55), methyldopa (odds ratio, 0.31; 95% confidence interval, 0.17-0.56), ketanserin (odds ratio, 0.29; 95% confidence interval, 0.09-0.90), and pindolol (odds ratio, 0.17; 95% confidence interval, 0.05-0.55) were administered compared with no drug intake. The highest probability scores were calculated for furosemide (P-score=.86), amlodipine (P-score=.82), and placebo (P-score=.82). The use of nifedipine and methyldopa were associated with significantly lower placental abruption rates (odds ratio, 0.29 [95% confidence interval, 0.15-0.58] and 0.23 [95% confidence interval, 0.11-0.46], respectively). No significant differences were estimated for cesarean delivery, perinatal death, preterm birth, and gestational age at delivery.

CONCLUSION

Atenolol was associated with a significantly increased risk for small-for-gestational-age infants. The incidence of severe hypertension was significantly lower when nifedipine and methyldopa were administered, although preeclampsia risk was similar among antihypertensive agents. Future large-scale trials should provide guidance about the choice of antihypertensive treatment and the goal blood pressure during pregnancy.

Management of hypertension in pregnancy

Hypertensive diseases of pregnancy remain a leading cause of maternal and neonatal morbidity and mortality. Therefore, we sought to review the management of these conditions in pregnancy. In this review we discuss the most updated definitions, different antihypertensives, delivery recommendations and overall goals of management, including their effects on uteroplacental perfusion. We also highlight different medical situations where one antihypertensive may be preferable over others.

Cardiometabolic health during early adulthood and risk of miscarriage: a prospective study

Background: Several studies have found that women who are overweight or obese have an increased risk of miscarriage. There is also some evidence of associations of other aspects of cardiometabolic health, including blood pressure and lipids, with miscarriage risk, although these have not been examined to the same extent as body-mass index (BMI). Methods: Our objective was to investigate the risk of miscarriage according to pre-pregnancy cardiometabolic health. We examined pre-pregnancy levels of BMI, blood pressure, fasting insulin and metabolites profile at age 18 and risk of miscarriage by age 24. The study included adult female offspring in the Avon Longitudinal Study of Parents and Children with a pregnancy between 18 and 24 years of age (n=434 for BMI and blood pressure; n=265 for metabolites). We used log-binomial regression to calculate adjusted associations between cardiometabolic health measures and miscarriage. Results: The overall risk of miscarriage was 22%.  The adjusted relative risks for miscarriage were 0.96 (95% CI: 0.92-1.00) for BMI (per unit increase), 0.98 (0.96-1.00) for systolic blood pressure, and 1.00 (0.97-1.04) for diastolic blood pressure (per 1 mmHg increase).  Total cholesterol, total lipids and phospholipids in HDL-cholesterol were associated with increased likelihood of miscarriage, but none of the p-values for the metabolites were below the corrected threshold for multiple testing (p-value ≤0.003). Conclusions: Pre-pregnancy cardiometabolic health in late adolescence was not associated with miscarriage risk in young, healthy women who became pregnant before age 24.

Hemodynamic Complications in Pregnancy: Preeclampsia and Beyond

Normal pregnancy is a complex and dynamic process that requires significant adaptation from the maternal system. Failure of this adaptive process in pregnancy contributes to many pregnancy related disorders, including the hypertensive disorders of pregnancy. This article discusses placental development and how abnormalities in the process of vascular remodeling contribute to the multisystem maternal and fetal disease that is preeclampsia and fetal growth restriction. We review some of the consequences of this condition on the mother and fetus, aspects of the clinical management of preeclampsia and how it can influence both mother and infant in the postnatal period and beyond.

Prevention, Diagnosis, and Management of Hypertensive Disorders of Pregnancy: a Comparison of International Guidelines

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy (HDP)-gestational hypertension, preeclampsia, and eclampsia-are a leading cause of adverse maternal and perinatal outcomes internationally. Prevention, timely diagnosis, and prompt management can reduce associated morbidity. The purpose of this review is to compare international guidelines pertaining to HDP.

RECENT FINDINGS

Fourteen HDP guidelines were compared relative to guidelines for the United States (US) where the authors practice. Aspirin is universally recommended for high-risk women to reduce preeclampsia risk. Recommended dose and gestational age at initiation vary. Diagnoses of chronic hypertension, gestational hypertension, and preeclampsia in pregnant women are similar, although blood pressure (BP) thresholds for antihypertensive medication initiation and treatment targets vary due to the limitations in high-quality evidence. There are differences among international HDP guidelines related to dose and timing of aspirin initiation, thresholds for antihypertensive medication initiation, and BP targets. However, all guidelines acknowledge the significant morbidity associated with HDP and advocate for timely diagnosis and management to reduce associated morbidity and mortality. More research is needed to understand optimal BP thresholds at which to initiate antihypertensive medication regimens and BP targets in pregnancy.

Hypertension During Pregnancy

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy affect about 5-10% of pregnancies impacting maternal, fetal, and neonatal outcomes. We review the recent studies in this field and discuss the pathophysiology, diagnosis, and management of hypertension during pregnancy, as well as the short- and long-term consequences on the cardiovascular health of women.

RECENT FINDINGS

Although the American College of Cardiology/American Heart Association revised their guidelines for hypertension in the general population in 2017, hypertension during pregnancy continues to be defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg, measured on two separate occasions. The addition of stage 1 hypertension will increase the prevalence of hypertension during pregnancy, identifying more women at risk of preeclampsia; however, more research is needed before changing the BP goal because a lower target BP has a risk of poor placental perfusion. Women with chronic hypertension have a higher incidence of superimposed preeclampsia, cesarean section, preterm delivery before 37 weeks' gestation, birth weight less than 2500 g, neonatal unit admission, and perinatal death. They also have a higher risk of developing cardiovascular disease later in life. The guidelines recommend low-dose aspirin for women with moderate and high risk of preeclampsia. While treating pregnant women with hypertension, the effectiveness of the antihypertensive agent must be balanced with risks to the fetus. Hypertensive disorders of pregnancy should be appropriately and promptly recognized and treated during pregnancy. They should further be co-managed by the obstetrician and cardiologist to decrease the long-term negative impact on the cardiovascular health of women.

The Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials in Mozambique, Pakistan, and India: an individual participant-level meta-analysis

BACKGROUND

To overcome the three delays in triage, transport and treatment that underlie adverse pregnancy outcomes, we aimed to reduce all-cause adverse outcomes with community-level interventions targeting women with pregnancy hypertension in three low-income countries.

METHODS

In this individual participant-level meta-analysis, we de-identified and pooled data from the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trials in Mozambique, Pakistan, and India, which were run in 2014-17. Consenting pregnant women, aged 12-49 years, were recruited in their homes. Clusters, defined by local administrative units, were randomly assigned (1:1) to intervention or control groups. The control groups continued local standard of care. The intervention comprised community engagement and existing community health worker-led mobile health-supported early detection, initial treatment, and hospital referral of women with hypertension. For this meta-analysis, as for the original studies, the primary outcome was a composite of maternal or perinatal outcome (either maternal, fetal, or neonatal death, or severe morbidity for the mother or baby), assessed by unmasked trial surveillance personnel. For this analysis, we included all consenting participants who were followed up with completed pregnancies at trial end. We analysed the outcome data with multilevel modelling and present data with the summary statistic of adjusted odds ratios (ORs) with 95% CIs (fixed effects for maternal age, parity, maternal education, and random effects for country and cluster). This meta-analysis is registered with PROSPERO, CRD42018102564.

FINDINGS

Overall, 44 clusters (69 330 pregnant women) were randomly assigned to intervention (22 clusters [36 008 pregnancies]) or control (22 clusters [33 322 pregnancies]) groups. 32 290 (89·7%) pregnancies in the intervention group and 29 698 (89·1%) in the control group were followed up successfully. Median maternal age of included women was 26 years (IQR 22-30). In the intervention clusters, 6990 group and 16 691 home-based community engagement sessions and 138 347 community health worker-led visits to 20 819 (57·8%) of 36 008 women (of whom 11 095 [53·3%] had a visit every 4 weeks) occurred. Blood pressure and dipstick proteinuria were assessed per protocol. Few women were eligible for methyldopa for severe hypertension (181 [1%] of 20 819) or intramuscular magnesium sulfate for pre-eclampsia (198 [1%]), of whom most accepted treatment (162 [89·5%] of 181 for severe hypertension and 133 [67·2%] of 198 for pre-eclampsia). 1255 (6%) were referred to a comprehensive emergency obstetric care facility, of whom 864 (82%) accepted the referral. The primary outcome was similar in the intervention (7871 [24%] of 32 290 pregnancies) and control clusters (6516 [22%] of 29 698; adjusted OR 1·17, 95% CI 0·90-1·51; p=0·24). No intervention-related serious adverse events occurred, and few adverse effects occurred after in-community treatment with methyldopa (one [2%] of 51; India only) and none occurred after in-community treatment with magnesium sulfate or during transport to facility.

INTERPRETATION

The CLIP intervention did not reduce adverse pregnancy outcomes. Future community-level interventions should expand the community health worker workforce, assess general (rather than condition-specific) messaging, and include health system strengthening.

FUNDING

University of British Columbia, a grantee of the Bill & Melinda Gates Foundation.

Future Directions: Analyzing Health Disparities Related to Maternal Hypertensive Disorders

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide, constituting one of the most significant causes of maternal morbidity and mortality. Hypertensive disorders, specifically gestational hypertension, chronic hypertension, and preeclampsia, throughout pregnancy are contributors to the top causes of maternal mortality in the United States. Diagnosis of hypertensive disorders throughout pregnancy is challenging, with many disorders often remaining unrecognized or poorly managed during and after pregnancy. Moreover, the research has identified a strong link between the prevalence of maternal hypertensive disorders and racial and ethnic disparities. Factors that influence the prevalence of maternal hypertensive disorders among racially and ethnically diverse women include maternal age, level of education, United States-born status, nonmetropolitan residence, prepregnancy obesity, excess weight gain during pregnancy, and gestational diabetes. Examination of the factors that increase the risk for maternal hypertensive disorders along with the current interventions utilized to manage hypertensive disorders will assist in the identification of gaps in prevention and treatment strategies and implications for future practice. Specific focus will be placed on disparities among racially and ethnically diverse women that increase the risk for maternal hypertensive disorders. This review will serve to promote the development of interventions and strategies that better address and prevent hypertensive disorders throughout a pregnant woman's continuum of care.

Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period

Introduction

there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa.

Methods

fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04: 00, 08: 00, 14: 00 and 22: 00 hours.

Results

nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3.

Conclusion

a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely.

Aspirin for the prevention of placenta-mediated complications in pregnant women with chronic hypertension

Chronic hypertension affects 1-5% of women of childbearing age. During pregnancy, chronic hypertension is associated with an increased risk of vascular disease such as superimposed preeclampsia (PE), intrauterine growth retardation (IUGR), placental abruption, and preterm delivery. These serious and frequent pathologies, specific to pregnancy, carry a particularly high risk of maternal complications (HELLP syndrome, eclampsia, maternal death) and perinatal complications (perinatal death, neurological disorders). To date, there is no curative treatment of vascular complications of chronic hypertension during pregnancy. The only effective treatment, once the complications are established, is usually stopping the pregnancy and delivering the placenta. Some recommendations suggest the use of low dose aspirin in the prevention of these complications. Although the efficacy of low-dose aspirin is assumed in patients with previous preeclampsia, few studies have evaluated its efficacy in patients with chronic hypertension. Controlled prospective studies using very low doses of aspirin (less than 100 mg) and started after 15 weeks of gestation do not seem conclusive. The objective of this work is first to detail the complications of chronic hypertension during pregnancy, then to analyze the studies which evaluated the interest of low dose aspirin in prevention of the placental vascular complications of the pregnancy in patients with chronic hypertension. We also propose an update on the European and North American national recommendations for the prevention of preeclampsia by low dose aspirin in the high-risk population of patients with chronic hypertension. Finally we present the CHASAP (Chronic Hypertension and Acetyl Salicylic Acid in Pregnancy) trial (NCT04356326), a multicentric prospective randomized double-blind superiority trial, which will compare, in pregnant women with chronic hypertension, the efficacy of low dose aspirin (150 mg/day) with a placebo, in the prevention of maternal-fetal morbidity and mortality (preeclampsia, placental abruption, IUGR, perinatal death, maternal death, and preterm delivery).

Blood Pressure and Angiogenic Markers in Pregnancy: Contributors to Pregnancy-Induced Hypertension and Offspring Cardiovascular Risk

Pregnancy-induced hypertension is a severe pregnancy complication, increasing risk of long-term cardiovascular disease in mothers and offspring. We hypothesized that maternal blood pressure in pregnancy associated with offspring blood pressure; that the associations were sex-specific; and that maternal circulating placental angiogenic markers (PlGF [placental growth factor] and sFlt-1 [soluble fms-like tyrosine kinase-1]) mediated this relationship. We analyzed data from 2434 women and 2217 children from the Odense Child Cohort, a prospective Danish cohort study. Offspring blood pressure trajectory from 4 months to 5 years was highly associated to maternal first, second, and third trimester blood pressure, and mean blood pressure in pregnancy, independent of maternal and offspring covariates. There were offspring sex-specific associations: Girls from mothers in the highest quartile of first and third trimester blood pressure had significantly higher systolic blood pressure at 5 years than the rest of the cohort (mean difference±SEM: 1.81±0.59 and 2.11±0.59 mm Hg, respectively, all P<0.01); whereas boys had significantly higher diastolic blood pressure at 5 years (mean difference±SEM: 1.11±0.45 and 1.03±0.45, respectively, all P<0.05). Concentrations of PlGF at gestational week 28 correlated inversely to maternal gestational blood pressure trajectory, independent of the diagnosis of pregnancy-induced hypertension, adjusted β coefficients (95% CI) for predicting systolic blood pressure (SBP): -3.18 (-4.66 to -1.70) mm Hg, for predicting diastolic blood pressure (DBP): -2.48 (-3.57 to -1.40) mm Hg. In conclusion, maternal gestational blood pressure predicted offspring blood pressure trajectory until 5 years in a sex-differential manner. Furthermore, subtle alterations in blood pressure in early pregnancy preceded hypertension or preeclampsia, and PlGF was a mediator of cardiovascular health in pregnancy.

Chronic hypertension in pregnancy

Chronic hypertension and associated cardiovascular disease are among the leading causes of maternal and perinatal morbidity and death in the United States. Chronic hypertension in pregnancy is associated with a host of adverse outcomes that include preeclampsia, cesarean delivery, cerebrovascular accidents, fetal growth restriction, preterm birth, and maternal and perinatal death. There are several key issues related to the diagnosis and management of chronic hypertension in pregnancy where data are limited and further research is needed. These challenges and recent guidelines for the management of chronic hypertension are reviewed. Well-timed pregnancies are of utmost importance to reduce the risks of chronic hypertension; long-acting reversible contraceptive options are preferred. Research to determine optimal blood pressure thresholds for diagnosis and treatment to optimize short- and long-term maternal and perinatal outcomes should be prioritized along with interventions to reduce extant racial and ethnic disparities.

Management of Autosomal Dominant Polycystic Kidney Disease (ADPKD) During Pregnancy: Risks and Challenges

Autosomal dominant polycystic kidney disease (ADPKD) affects up to 1 in 1000 people. The disease is characterized by the progressive development of cysts throughout the renal parenchyma due to inherited pathogenic variants in genes including PKD1 or PKD2 and eventually leads to gradual loss of renal function, along with manifestations in other organ systems such as hepatic cysts and intracranial aneurysms. ADPKD management has advanced considerably in recent years due to genetic testing availability, pre-implantation genetic diagnosis technology and new therapeutic agents. Renal disease in pregnancy is recognised as an important risk factor for adverse maternal and fetal outcome. Women with ADPKD and health professionals face multiple challenges in optimising outcomes during the pre-pregnancy, pregnancy and post-partum periods.

Stroke in Pregnancy: A Focused Update

Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Updates in Diagnosis and Management of Preeclampsia in Women with CKD

It is estimated that women with CKD are ten times more likely to develop preeclampsia than women without CKD, with preeclampsia affecting up to 40% of pregnancies in women with CKD. However, the shared phenotype of hypertension, proteinuria, and impaired excretory kidney function complicates the diagnosis of superimposed preeclampsia in women with CKD who have hypertension and/or proteinuria that predates pregnancy. This article outlines the diagnoses of preeclampsia and superimposed preeclampsia. It discusses the pathogenesis of preeclampsia, including abnormal placentation and angiogenic dysfunction. The clinical use of angiogenic markers as diagnostic adjuncts for women with suspected preeclampsia is described, and the limited data on the use of these markers in women with CKD are presented. The role of kidney biopsy in pregnancy is examined. The management of preeclampsia is outlined, including important advances and controversies in aspirin prophylaxis, BP treatment targets, and the timing of delivery.

Hypertension and Reproduction

PURPOSE OF REVIEW

Many aspects of reproduction have been associated with increased blood pressure and impaired glucose metabolism that reveals a subsequent increased risk of cardiovascular disease. The aim of this review is to assess reproductive life factors associated with an increased risk of hypertension and cardiovascular disease, e.g., early life programming, sexual, and reproductive health in men and women.

RECENT FINDINGS

Impaired fetal growth, with low birth weight adjusted for gestational age, has been found associated with hypertension in adulthood. Erectile dysfunction, currently considered an early diagnostic marker of cardiovascular disease preceding the manifestation of coronary artery disease by several years, frequently coexisting with hypertension, could also be exacerbated by some antihypertensive drugs. Male hypogonadism or subfertility are associated with increased cardiovascular risk. Hypertensive disorders in pregnancy including preeclampsia represent a major cause of maternal, fetal and neonatal morbidity, and mortality. The risk of developing preeclampsia can be substantially reduced in women at its high or moderate risk with a low dose of acetylsalicylic acid initiated from 12 weeks of gestation. An increased risk of hypertension in women following invasive-assisted reproductive technologies has been newly observed. Blood pressure elevation has been noticed following contraceptive pill use, around the menopause and in postmenopausal age. Furthermore, drug treatment of hypertension has to be considered as a factor with a potential impact on reproduction (e.g., due to teratogenic drug effects). In summary, a deeper understanding of reproductive life effects on hypertension and metabolic abnormalities may improve prediction of future cardiovascular disease.

Patient Preferences and Decisional Needs When Choosing a Treatment Approach for Pregnancy Hypertension: A Stated Preference Study

The Hypertension Canada 2018 clinical guidance for pregnancy hypertension recommends antihypertensive therapy for raised blood pressure in pregnancy to a target diastolic blood pressure (BP) of 85 mm Hg (ie, "tight" control). Although evidence shows this approach reduces the incidence of severe maternal hypertension without increasing risk to the baby, we do not know how pregnant women feel about this approach, particularly as they are generally medication averse. An online survey assessed pregnant women's preferences for management of pregnancy hypertension and explored decisional needs. The survey included information provision and knowledge assessment, a preference elicitation task, and a decisional needs assessment. Survey responses were analysed descriptively, by latent class analysis to identify treatment priority subgroups, and by logistic regression to assess predictors of treatment preference. For the 183 pregnant respondents, 3 treatment priority subgroups were identified, with most respondents expressing equal prioritization of treatment outcomes and components (eg, taking medication). Participants who preferred tight control (49%) were more often white (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.18-4.55), with a university education/professional qualification (OR 1.95; 95% CI: 1.02-3.7), and had greater knowledge about pregnancy hypertension and pregnancy complications (OR 1.37; 95% CI: 1.15-1.65). Participants reported diverse decisional needs, but most preferred to make final treatment decisions themselves (70%), with (48%) or without (22%) physician input. The diversity of priorities, preferences, and decisional needs for management of pregnancy hypertension identified in this study emphasises the importance of an individualized approach to treatment recommendations.

Chronic Kidney Disease and Pregnancy

Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.

Blood Pressure Variability in Pregnancy: an Opportunity to Develop Improved Prognostic and Risk Assessment Tools

PURPOSE OF REVIEW

This review discusses the mortality and morbidity of hypertensive disorders of pregnancy (HDP) and the current diagnostic thresholds. It then explores measurement of variability in blood pressure (BP) during pregnancy as an opportunity to identify women at high risk of cardiovascular disease (CVD) later in life.

RECENT FINDINGS

HDP is known to be associated with increased risk of long-term CVD. Current CVD prognostic tools do not incorporate a history of HDP given a lack of improved risk discrimination. However, HDP diagnostic criteria are currently based on a binary threshold, and there is some evidence for the use of variability in BP throughout gestation as a marker of CVD risk. HDP increases long-term risk of CVD. Future studies investigating changes in diagnostic criteria, including the use of BP variability, may improve long-term CVD risk prediction and be incorporated into future risk assessment tools.

Are blood pressure level and variability related to pregnancy outcome? Analysis of control of hypertension in pregnancy study data

OBJECTIVE

To examine the relationship between pregnancy outcomes and BP level and variability.

DESIGN

Secondary analysis of CHIPS trial data (Control of Hypertension In Pregnancy Study, NCT01192412).

SETTING

International.

POPULATION OR SAMPLE

Women with chronic or gestational hypertension.

METHODS

BP measurement was standardised in outpatient clinics. Adjusted (including for allocated group) mixed effects logistic regression was used to assess relationships between major CHIPS outcomes and both BP level (mean of clinic readings) and visit-to-visit within-participant BP variability (standard deviation and average real variability of absolute successive difference of BP values). BP values 7-28 days prior to outcomes (or birth for perinatal outcomes) were excluded in sensitivity analyses.

MAIN OUTCOME MEASURES

Major CHIPS outcomes.

RESULTS

Among 961 (97.4%) women, higher BP level was associated with more adverse maternal and perinatal outcomes (usually at p < 0.001) except for serious maternal complications. Among 913 (92.5%) women with at least two post-randomisation outpatient visits, higher BP variability was associated with increased odds of severe hypertension and pre-eclampsia (usually at p < 0.01). Sensitivity analyses suggested reverse causality for these maternal outcomes, but greater diastolic BP variability may have been associated with fewer adverse perinatal outcomes.

CONCLUSIONS

Higher BP is an adverse prognostic marker, regardless of target BP. While the association between higher BP variability and severe hypertension and pre-eclampsia may be related to higher BP at diagnosis, our results suggest a possible advantage of BP variability for the fetus, through undefined mechanisms.

TWEETABLE ABSTRACT

Higher blood pressure (BP) is associated with more adverse pregnancy outcomes, but higher BP variability may be good for the baby.

14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Treatment of severe hypertension during pregnancy: we still do not know what the best option is

Intracranial hemorrhage and stroke are primary causes of maternal mortality in pregnancies affected by hypertensive disorders. As such antihypertensive therapy plays a crucial role in the management of severe hypertension. However, the target level to achieve the best outcome for both - mother and fetus - is still unclear. Moreover, given the lack of well-designed randomized controlled trials with standardized key outcomes, the current choice of antihypertensive medications depends rather on clinicians' preference. Furthermore, data on long-term outcomes of offspring is not available. Therefore, there is an urgent need for randomized trials comparing different anti-hypertensive options to address efficacy and safety questions.

Severe antepartum hypertension and associated peripartum morbidity among pregnant women in an urban tertiary care medical center

OBJECTIVES

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Although acute severe hypertension carries with it a poor prognosis, treatment is often delayed and not universal.

STUDY DESIGN

A total of 654 patients were assessed for the impact of hypertensive disorders of pregnancies on maternal and fetal morbidity and divided into three groups: normotensive (Group I, N = 306), non-severe hypertension (Group II, N = 248) and severe-range hypertension with blood pressure (BP) episodes ≥160 systolic or ≥105 diastolic (Group III, N = 100). Retrospective demographic and medical information was abstracted from patients' medical records to collect study data.

MAIN OUTCOME MEASURES

The main outcomes assessed were composite maternal adverse events,fetal adverse events, and time to treatment.

RESULTS

Patients in Group III had higher systolic (182 vs 155 vs 133) and diastolic (106 vs 95 vs 81) BPs compared to patients in Groups II and I. Patients in Group III had a significantly higher incidence of maternal adverse events (26.0% vs 6.5% vs 2.0%, respectively; p < 0.001) and higher neonatal composite adverse events (52.0% vs 17.7% vs 26.1%, respectively; p < 0.001) as compared to patients in Groups II and I. Only 52.2% of patients in Group III were treated within recommended 60 minutes or less.

CONCLUSIONS

Patients with severe hypertension antepartum have higher associated maternal and fetal adverse events while treatment is often delayed. Further studies should evaluate the effects of adequate time to treatment for severe hypertension. Steps should also be taken to standardize identification and reporting of severe maternal morbidity.

Österreichischer Blutdruckkonsens 2019

Erhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.

Home blood pressure in pregnancy-the upper reference limit

OBJECTIVES

To investigate whether the upper home blood pressure reference limit in healthy pregnant women correspond to 135/85 mmHg as used when diagnosing white coat hypertension outside pregnancy.

METHODS

In this prospective observational study 103 healthy, singleton pregnant women with a mean age of 32 ± 4 (±SD) years and with a median pre-pregnancy body mass index of 21 (interquartile range 20-24) kg/m were included. Home blood pressure was measured with the device Microlife® BP 3A Plus twice daily for three days (18 measurements in total) in addition to routine office blood pressure measurements in early (median 12 (weeks)), mid (20) and late pregnancy (35). Upper blood pressure reference limits were calculated as mean +2 SD.

RESULTS

Office blood pressure versus home blood pressure were 115 ± 11/72 ± 7 versus 103 ± 7/64 ± 5 mmHg in early pregnancy, 112 ± 11/74 ± 7 versus 102 ± 7/63 ± 5 mmHg in mid pregnancy and 118 ± 11/75 ± 8 versus 107 ± 8/66 ± 6 mmHg in late pregnancy. The mean difference between office blood pressure and home blood pressure was 10 mmHg. In late pregnancy, the upper reference limit was 140/91 mmHg for office blood pressure and 123/78 mmHg for home blood pressure with slightly lower values in early and mid pregnancy, respectively.

CONCLUSION

In late pregnancy, the upper home blood pressure reference limit in a population of healthy women was 123/78 mmHg. This value questions the generally proposed level of 135/85 mmHg to define white coat hypertension in pregnancy.