1
|
Nyakio O, Cakwira H, Masimango G, Kena L, Narayan G, Naaz F, Mugenyi N, Cyubahiro VK, Amani T, Balagizi F, Suvvari TK, Oduoye MO, Akilimali A. The silent threat: investigating the incidence and clinical characteristics of pre-eclampsia and eclampsia in women from tertiary care hospitals of the Democratic Republic of Congo. Ann Med Surg (Lond) 2024; 86:3267-3272. [PMID: 38846848 PMCID: PMC11152814 DOI: 10.1097/ms9.0000000000002087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/22/2024] [Indexed: 06/09/2024] Open
Abstract
Background Pre-eclampsia and eclampsia are medical conditions that can cause severe complications, such as maternal and foetal morbidity and mortality. This study aimed to assess the incidence and characteristics of pre-eclampsia and eclampsia. Methods From July 2021 to July 2022, the authors conducted a retrospective, cross-sectional, descriptive study in the Department of Obstetrics and Gynaecology of a tertiary care hospital in the Democratic Republic of the Congo (DR Congo). Out of 1236 total deliveries, 40 patients aged 18-35 years with pre-eclampsia and/or eclampsia with complete data in medical records were studied. Results In the studied group, 3.23% of women (40 cases) experienced pre-eclampsia or eclampsia, with the majority (75%, 30 cases) occurring before childbirth. Among these, 62.5% (25 cases) were first-time mothers. The main complications observed in the mothers included HELLP syndrome and placental abruption, whereas their newborns frequently exhibited delayed in-utero growth. Caesarean delivery was the prevalent birthing method, and the treatments most often used for effective management were magnesium sulfate and nicardipine. Conclusion The research highlights the common occurrence of eclampsia among patients in the DRC and stresses the critical need for prompt detection of hypertensive complications during pregnancy, aiming to reduce negative health impacts on both mothers and their children.
Collapse
Affiliation(s)
- Olivier Nyakio
- Faculty of Medicine, Evangelic University in Africa
- Faculty of Medicine, Official University of Bukavu
| | - Hugues Cakwira
- Faculty of Medicine, Catholic University of Bukavu
- Department of research, Medical Research Circle (MedReC), Bukavu
| | - Gaston Masimango
- Faculty of Medicine, Official University of Bukavu
- Department of research, Medical Research Circle (MedReC), Bukavu
| | - Louison Kena
- Department of research, Medical Research Circle (MedReC), Bukavu
- Faculty of Medicine, Université Libre des Pays des Grands Lacs, Goma, DR Congo
| | - Gaurang Narayan
- Department of Obstetrics and Gynecology, Indira Gandhi Government Medical College, Nagpur
| | - Farheen Naaz
- Medical college, Deccan College of Medical Sciences, Hyderabad
| | - Nathan Mugenyi
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Toussaint Amani
- Department of research, Medical Research Circle (MedReC), Bukavu
- Faculty of Medicine, Université Libre des Pays des Grands Lacs, Goma, DR Congo
| | - Fabien Balagizi
- Department of research, Medical Research Circle (MedReC), Bukavu
| | - Tarun Kumar Suvvari
- Department of Surgery, Rangaraya Medical College, Kakinada, Andhra Pradesh, India
| | | | - Aymar Akilimali
- Department of research, Medical Research Circle (MedReC), Bukavu
- Society for Maternal-Fetal Medicine (SMFM), SW, Washington, DC
- Department of research, East Africa Medical Students Association, Nairobi, Kenya
| |
Collapse
|
2
|
Cozzi GD, Battarbee AN, Sanjanwala AR, Casey BM, Subramaniam A. Association of Maternal Medical Comorbidities with Duration of Expectant Management in Patients with Severe Preeclampsia. Am J Perinatol 2024; 41:e1521-e1530. [PMID: 37072011 PMCID: PMC10582202 DOI: 10.1055/s-0043-1768232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE This study aimed to estimate the association between number of maternal comorbidities and duration of expectant management and perinatal outcomes in patients with preeclampsia with severe features. STUDY DESIGN Retrospective cohort of patients with preeclampsia with severe features delivering live, nonanomalous singletons at 23 to 342/7 weeks' gestation at a single center from 2016 to 2018. Patients delivered for an indication other than severe preeclampsia were excluded. Patients were categorized based on the number (0, 1, or ≥2) of comorbidities present: chronic hypertension, pregestational diabetes, chronic kidney disease, and systemic lupus erythematosus. The primary outcome was proportion of potential expectant management time achieved, that is, days of expectant management achieved divided by total potential expectant management time (days from severe preeclampsia diagnosis to 340/7 weeks). Secondary outcomes included delivery gestational age, days of expectant management, and perinatal outcomes. Outcomes were compared in bivariable and multivariable analyses. RESULTS Of 337 patients included, 167 (50%) had 0, 151 (45%) had 1, and 19 (5%) had ≥2 comorbidities. Groups differed with respect to age, body mass index, race/ethnicity, insurance, and parity. The median proportion of potential expectant management achieved in this cohort was 1.8% (interquartile range: 0-15.4), and did not differ by number of comorbidities (adjusted β: 5.3 [95% confidence interval [CI]: -2.1 to 12.9] for 1 comorbidity vs. 0 and adjusted β: -2.9 [95% CI: -18.0 to 12.2] for ≥2 comorbidities vs. 0). There was no difference in delivery gestational age or duration of expectant management in days. Patients with ≥2 (vs. 0) comorbidities had higher odds of composite maternal morbidity (adjusted odds ratio: 3.0 [95% CI: 1.1-8.2]). There was no association between number of comorbidities and composite neonatal morbidity. CONCLUSION Among patients with preeclampsia with severe features, the number of comorbidities was not associated with duration of expectant management; however, patients with ≥2 comorbidities had higher odds of adverse maternal outcomes. KEY POINTS · Greater number of medical comorbidities were not associated with expectant management duration.. · Two or more medical comorbidities were associated with higher odds of adverse maternal outcomes.. · Expectant management should be undertaken cautiously in medically complicated patients..
Collapse
Affiliation(s)
- Gabriella D. Cozzi
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Ashley N. Battarbee
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Aalok R. Sanjanwala
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Brian M. Casey
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| | - Akila Subramaniam
- Division of Maternal Fetal Medicine Center for Women’s Reproductive Health, University of Alabama at Birmingham, Alabama
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Alabama
| |
Collapse
|
3
|
Harding CC, Goldstein KM, Goldstein SA, Wheeler SM, Mitchell NS, Copeland LA. Maternal chronic hypertension in women veterans. Health Serv Res 2024; 59:e14277. [PMID: 38234056 PMCID: PMC10915474 DOI: 10.1111/1475-6773.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVE To describe the prevalence of maternal chronic hypertension (MCH), assess how frequently blood pressure is controlled before pregnancy among those with MCH, and explore management practices for antihypertensive medications (AHM) during the pre-pregnancy and pregnancy periods. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN We conducted a descriptive observational study using data abstracted from the Veterans Health Administration (VA) inclusive of approximately 11 million Veterans utilizing the VA in fiscal years 2010-2019. DATA COLLECTION/EXTRACTION METHODS Veterans aged 18-50 were included if they had a diagnosis of chronic hypertension before a documented pregnancy in the VA EMR. We identified chronic hypertension and pregnancy with diagnosis codes and defined uncontrolled blood pressure as ≥140/90 mm Hg on at least one measurement in the year before pregnancy. Sensitivity models were conducted for individuals with at least two blood pressure measurements in the year prior to pregnancy. Multivariable logistic regression explored the association of covariates with recommended and non-recommended AHMs received 0-6 months before pregnancy and during pregnancy. PRINCIPAL FINDINGS In total, 8% (3767/46,178) of Veterans with a documented pregnancy in VA data had MCH. Among 2750 with MCH meeting inclusion criteria, 60% (n = 1626) had uncontrolled blood pressure on at least one BP reading and 31% (n = 846) had uncontrolled blood pressure on at least two BP readings in the year before pregnancy. For medications, 16% (n = 437) received a non-recommended AHM during pregnancy. Chronic kidney disease (OR = 3.2; 1.6-6.4) and diabetes (OR = 2.3; 1.7-3.0) were most strongly associated with use of a non-recommended AHM during pregnancy. CONCLUSIONS Interventions are needed to decrease the prevalence of MCH, improve preconception blood pressure control, and ensure optimal pharmacologic antihypertensive management among Veterans of childbearing potential.
Collapse
Affiliation(s)
- Ceshae C. Harding
- Department of Medicine, Division of General Internal MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Karen M. Goldstein
- Department of Medicine, Division of General Internal MedicineDuke UniversityDurhamNorth CarolinaUSA
- Durham VA Health Care SystemDurhamNorth CarolinaUSA
| | - Sarah A. Goldstein
- Department of Medicine, Division of Cardiovascular MedicineYale New Haven Health SystemNew HavenConnecticutUSA
| | - Sarahn M. Wheeler
- Department of Obstetrics and Gynecology, Division of Maternal‐Fetal MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Nia S. Mitchell
- Department of Medicine, Division of General Internal MedicineDuke UniversityDurhamNorth CarolinaUSA
| | | |
Collapse
|
4
|
Karpova NS, Dmitrenko OP, Budykina TS. Literature Review: The sFlt1/PlGF Ratio and Pregestational Maternal Comorbidities: New Risk Factors to Predict Pre-Eclampsia. Int J Mol Sci 2023; 24:ijms24076744. [PMID: 37047717 PMCID: PMC10095124 DOI: 10.3390/ijms24076744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023] Open
Abstract
One of the main causes of maternal and neonatal morbidity and mortality is pre-eclampsia. It is characterized by a high sFlt1/PlGF ratio, according to prior research. Pregestational diseases in mothers may increase the risk of developing pre-eclampsia. Only a few studies have looked at the connection between maternal comorbidities before conception and the sFlt1/PlGF ratio. The most recent information regarding the association between maternal pregestational diseases and the ratio of sFlt1/PlGF is described in this review. The paper also examines current research suggesting that changes in pregnancy hormones and metabolites are related to a high sFlt1/PlGF ratio. Certain maternal disorders have been found to dramatically raise sFlt-1 and sFlt1/PlGF levels, according to an analysis of the literature. There is still debate about the data on the association between the sFlt1/PlGF ratio and maternal disorders such as HIV, acute coronary syndromes, cardiovascular function in the mother between 19 and 23 weeks of pregnancy, thyroid hormones, diabetes, and cancer. Additional research is needed to confirm these findings.
Collapse
Affiliation(s)
- Nataliia Sergeevna Karpova
- Federal State Budgetary Institution “Research Institute of Pathology and Pathophysiology”, St. Baltiyskaya, House 8, Moscow 125315, Russia
| | - Olga Pavlovna Dmitrenko
- Federal State Budgetary Institution “Research Institute of Pathology and Pathophysiology”, St. Baltiyskaya, House 8, Moscow 125315, Russia
| | - Tatyana Sergeevna Budykina
- State Budgetary Health Institution of the Moscow Region “Moscow Regional Research Institute of Obstetrics and Gynecology”, St. Pokrovka, d.22a, Moscow 101000, Russia
| |
Collapse
|
5
|
Ling HZ, Guy G, Nicolaides KH, Kametas NA. Longitudinal maternal cardiac function in hypertensive disorders of pregnancy. Am J Obstet Gynecol MFM 2023; 5:100824. [PMID: 36464241 DOI: 10.1016/j.ajogmf.2022.100824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Compared with gestational hypertension, preeclampsia has traditionally been considered the worse end of the spectrum of hypertensive disorders of pregnancy. It is associated with worse pregnancy outcomes and future cardiovascular morbidities. Both hypertensive disorders may be associated with cardiac maladaptation in pregnancy. However, previous studies were limited by small numbers and a paucity of longitudinal data and unaccounted for the contribution of maternal characteristics that can affect hemodynamics. OBJECTIVE This study aimed to assess, in an unselected population, the maternal cardiac adaptation in normotensive and hypertensive pregnancies after controlling for important maternal characteristics that affect maternal cardiac function and the interaction among these covariates. STUDY DESIGN This was a prospective, multicenter longitudinal study of maternal hemodynamics, assessed by a noninvasive bioreactance technology, measured at 11 0/7 to 13 6/7, 19 0/7 to 24 0/7, 30 0/7 to 34 0/7, and 35 0/7 to 37 0/7 weeks of gestation in 3 groups of women. Group 1 was composed of women with preeclampsia (n=45), group 2 was composed of women with gestational hypertension (n=61), and group 3 was composed of normotensive women (n=1643). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal age, height, weight, weight gain, race, previous obstetrical history, and birthweight. RESULTS After adjusting for confounders that significantly affect maternal hemodynamics, both group 1 and group 2, compared with group 3, had pathologic cardiac adaptation. Group 1, compared with group 3, demonstrated hyperdynamic circulation with significantly higher cardiac output driven by greater stroke volume in the first trimester of pregnancy. As the pregnancies progressed to after 20 0/7 weeks of gestation, this hyperdynamic state transitioned to hypodynamic state with low cardiac output and high peripheral vascular resistance. Group 2, compared with group 3, had no significant differences in cardiac output, stroke volume, and heart rate before 20 0/7 weeks of gestation but thereafter demonstrated a continuous decline in cardiac output and stroke volume, similar to group 1. Both groups 1 and 2, compared with group 3, had persistently elevated mean arterial pressure and uterine artery pulsatility index throughout pregnancy. CONCLUSION After adjusting for confounders that affect maternal hemodynamics in an unselected pregnant population, women with preeclampsia and gestational hypertension, compared with normotensive women, demonstrated similar cardiac maladaptation. This pathologic profile was evident after 20 0/7 weeks of gestation and at least 10 weeks before the clinical manifestation of the disease.
Collapse
Affiliation(s)
- Hua Zen Ling
- Fetal Medicine Research Institute, King's College London, Denmark Hill, London
| | - Gavin Guy
- Fetal Medicine Research Institute, King's College London, Denmark Hill, London
| | - Kypros H Nicolaides
- Fetal Medicine Research Institute, King's College London, Denmark Hill, London
| | - Nikos A Kametas
- Fetal Medicine Research Institute, King's College London, Denmark Hill, London.
| |
Collapse
|
6
|
Okwor CJ, Adedapo KS, Bello OO, Meka IA, Okwor CV, Uche CZ, Nwajiobi CE, Nto-Ezimah UA, Uchechukwu CE, Arum EJ. Assessment of brain natriuretic peptide and copeptin as correlates of blood pressure in chronic hypertensive pregnant women. Clin Hypertens 2022; 28:37. [PMID: 36517833 PMCID: PMC9753280 DOI: 10.1186/s40885-022-00221-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/01/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy including preexisting (or chronic) hypertension are the most common complication encountered during pregnancy that contribute significantly to maternal and perinatal morbidity and mortality. Brain natriuretic peptide (BNP) and copeptin have been investigated as biomarkers in various hypertensive disorders, but studies of their clinical value in chronic hypertensive pregnant women are sparce. This study aimed to assess the levels of BNP and copeptin in chronic hypertensive pregnant women and investigate their correlation with blood pressure (BP) in chronic hypertensive pregnant women in South Western Nigeria. METHODS One hundred and sixty consenting pregnant women in their third trimester of pregnancy, grouped into those with chronic hypertension (n = 80) and normotensive (n = 80), were recruited for this cross-sectional study. Age and clinical characteristics were obtained, and blood was aseptically drawn for BNP and copeptin measurement using enzyme-linked immunosorbent assay. Data was analyzed with IBM SPSS ver. 20.0. Data was analyzed using Student t-test, chi-square, and Pearson correlation test as appropriate. Statistical significance was set at P < 0.05. RESULTS The mean systolic BP (SBP) and diastolic BP (DBP) were significantly higher in pregnant women with chronic hypertension (158.30 ± 3.51 and 105.08 ± 2.47 mmHg, respectively) compared with normotensive pregnant women (100.72 ± 3.02 and 70.29 ± 1.96 mmHg, respectively). The mean levels of BNP and copeptin were higher in pregnant women with chronic hypertension (57.26 ± 3.65 pg/mL and 12.44 ± 1.02 pmol/L, respectively) compared with normotensive pregnant women (49.85 ± 2.44 pg/mL and 10.25 ± 1.50 pmol/L, respectively) though not statistically significant. Correlations observed between SBP and DBP with levels of BNP (r = 0.204, P = 0.200; r = 0.142, P = 0.478) and copeptin (r = - 0.058, P = 0.288; r = 0.045, P = 0.907) were not statistically significant. CONCLUSIONS There was no association between BP and the levels of BNP and copeptin in pregnant women with chronic hypertension who were already on antihypertensive treatment, with the implication that antihypertensive treatment may modulate BNP and copeptin release despite significantly elevated BP levels.
Collapse
Affiliation(s)
- Chika J. Okwor
- grid.412438.80000 0004 1764 5403Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
| | - Kayode S. Adedapo
- grid.412438.80000 0004 1764 5403Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
| | - Oluwasomidoyin O. Bello
- grid.412438.80000 0004 1764 5403Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Nigeria
| | - Ijeoma A. Meka
- grid.413131.50000 0000 9161 1296Department of Chemical Pathology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chukwuemeka V. Okwor
- grid.413131.50000 0000 9161 1296Department of Radiation Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chukwuemelie Z. Uche
- grid.10757.340000 0001 2108 8257Department of Medical Biochemistry & Molecular Biology, University of Nigeria, Enugu, Nigeria
| | - Chiebonam E. Nwajiobi
- grid.413131.50000 0000 9161 1296Department of Chemical Pathology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Uloaku A. Nto-Ezimah
- grid.413131.50000 0000 9161 1296Department of Chemical Pathology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Chisom E. Uchechukwu
- grid.413131.50000 0000 9161 1296Department of Chemical Pathology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Ekene J. Arum
- grid.413131.50000 0000 9161 1296Department of Chemical Pathology, University of Nigeria Teaching Hospital, Enugu, Nigeria
| |
Collapse
|
7
|
Blue NR, Allshouse AA, Grobman WA, Day RC, Haas DM, Simhan HN, Parry S, Saade GR, Silver RM. Developing a predictive model for perinatal morbidity among small for gestational age infants. J Matern Fetal Neonatal Med 2022; 35:8462-8471. [PMID: 34582307 PMCID: PMC8958182 DOI: 10.1080/14767058.2021.1980533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND While neonates with birth weight <10th percentile are at increased risk of morbidity and mortality, most of these are constitutionally small and not at increased risk. There are no current strategies that reliably distinguish constitutionally small neonates from small neonates at the highest risk of morbidity, so additional tools for risk stratification are needed. OBJECTIVE Our objectives were to identify factors that are independently associated with perinatal morbidity among neonates with birth weight <10th percentile (small for gestational age, SGA) and to create predictive models of perinatal morbidity among SGA neonates based on the timing of information availability. STUDY DESIGN This secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, was a nested case-control study. Participants were prospectively enrolled at eight U.S. centers, with data collection occurring at three standard time points during pregnancy and again after delivery. Our analysis included neonates with birth weights <10th percentile and excluded those with major congenital malformations or suspected or confirmed aneuploidy. The primary outcome was a composite of perinatal morbidity, defined as NICU admission >48 h, NEC, sepsis, RDS, mechanical ventilation, retinopathy of prematurity, seizures, grade 3 or 4 IVH, stillbirth, or death before discharge. Cases were SGA neonates that experienced the primary outcome, and controls were SGA neonates that did not. Maternal factors for potential inclusion in predictive modeling were drawn from a broad list of variables collected as part of the NuMoM2B study, including demographic, anthropometric, clinical, ultrasound, social/behavioral, dietary, and psychological variables. Characteristics that were different in bivariate analysis between cases and controls then underwent further evaluation and refinement. Continuous and multi-category variables were assessed using multiple approaches, including as continuous variables, using standard categories (such as for BMI) as well as empirically-derived cut-points identified by receiver-operating characteristics methodology. The approach for each variable that resulted in the best performance was selected for use in modeling. After variable optimization, multivariable analysis was used to derive prediction models using factors known at mid-pregnancy (Model 1) and delivery (Model 2). RESULTS Of the original cohort, 865 were eligible and analyzed, with 134 (15.5%) experiencing the primary outcome. After bivariable and multivariable analysis, these variables were included in Model 1: BMI, stress level, diastolic blood pressure, narcotic use (all in 1st trimester), and uterine artery pulsatility index at 16-21 weeks. Model 2 added the following variables to Model 1: preterm delivery, preeclampsia, and suspected fetal growth restriction. When models 1 and 2 were empirically tested and compared to predicted performance to demonstrate calibration, observed morbidity rates approximately followed expected rates within deciles. Models 1 and 2 had respective areas under the receiver-operating characteristic curve of 0.72 (95% CI 0.67-0.76) and 0.84 (0.80-0.88), to predict the composite morbidity. CONCLUSION Using a deeply phenotyped cohort of nulliparous women, we created two models with the moderate-good prediction of perinatal morbidity among SGA neonates. TRIAL REGISTRATION clinicaltrials.gov ID: NCT01322529.
Collapse
Affiliation(s)
- Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert C Day
- Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, CA, USA
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, USA
| |
Collapse
|
8
|
Sepúlveda-Martínez A, Conrads T, Guiñez R, Guiñez J, Llancaqueo M, Parra-Cordero M. Perinatal outcomes of pregestational hypertension according to blood pressure range at 11-14 week scan: Impact of the 2017 ACC/AHA guidelines. Front Med (Lausanne) 2022; 9:994386. [PMID: 36313988 PMCID: PMC9613962 DOI: 10.3389/fmed.2022.994386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/21/2022] [Indexed: 11/20/2022] Open
Abstract
Objective The aim of this study was to evaluate the impact on perinatal outcomes related to placental insufficiency with the application of the new 2017 ACC/AHA guidelines to a group of chronic hypertensive pregnancies during their first-trimester assessment. Study design This retrospective cohort study included pregnancies with preconceptional hypertension and known perinatal outcomes. In the first trimester, a combined screening for preterm preeclampsia (p-PE) was performed, including blood pressure (BP), mean uterine artery Doppler, and maternal characteristics. Patients were divided, according to the 2017 ACC/AHA consensus, into the following groups: elevated or less, Stage 1, and Stage 2. For adverse perinatal outcome assessment, univariate and multivariate regression analyses were performed, considering the “elevated or less” group as a reference. Odds ratios (OR) were compared with linear trend analysis. The main outcomes measured were preterm PE and FGR < 3rd percentile. Results Of the 130 included patients, 59 (45.4%) were classified as elevated or less, 47 (36.2%) as Stage 1, and 24 (18.4%) as Stage 2. p-PE showed a significant increase according to BP range [7% (OR = 1.0), 19.6% (OR = 3.2), and 21.7% (OR = 3.7)]; trend p = 0.02, for elevated or less, Stage 1, and Stage 2, respectively. There was a non-significant increased trend of FGR < 3rd percentile according to the BP stage. The best multivariate predictive model for p-PE included a previous PE background (OR = 15) and mean arterial pressure in mmHg (OR = 1.1). Conclusion The use of the 2017 ACC/AHA consensus in pregnancies with chronic hypertension identifies an intermediate risk group for placental-mediated diseases.
Collapse
Affiliation(s)
- Alvaro Sepúlveda-Martínez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile,Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico San Borja Arriarán, Santiago, Chile,Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Universidad del Desarrollo y Clínica Alemana de Santiago, Santiago, Chile,*Correspondence: Alvaro Sepúlveda-Martínez,
| | - Tomas Conrads
- Critical Care Unit, Department of Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Rodolfo Guiñez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Javiera Guiñez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Marcelo Llancaqueo
- Cardiology Unit, Department of Internal Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Mauro Parra-Cordero
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile,Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico San Borja Arriarán, Santiago, Chile
| |
Collapse
|
9
|
Feig DS, Zinman B, Asztalos E, Donovan LE, Shah PS, Sanchez JJ, Tomlinson G, Murphy KE. Determinants of Small for Gestational Age in Women With Type 2 Diabetes in Pregnancy: Who Should Receive Metformin? Diabetes Care 2022; 45:1532-1539. [PMID: 35671033 DOI: 10.2337/dc22-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In the MiTy (Metformin in Women With Type 2 Diabetes in Pregnancy) randomized trial of metformin versus placebo added to insulin, we found numerous benefits with metformin but identified an increased proportion of infants who were small for gestational age (SGA). We aimed to determine the predictors of SGA in order to individualize care. RESEARCH DESIGN AND METHODS Using logistic regression, we assessed baseline maternal characteristics as predictors of SGA. We compared maternal/neonatal outcomes in SGA metformin and placebo groups using the t, χ2, or Fisher exact test, as appropriate. RESULTS Among the 502 mothers, 460 infants were eligible for this study. There were 30 infants with SGA in the metformin group (12.9%) and 15 in the placebo group (6.6%) (P = 0.026). Among SGA infants, those in the metformin group were delivered significantly later than those in the placebo group (37.2 vs. 35.3 weeks; P = 0.038). In adjusted analyses, presence of a comorbidity (chronic hypertension and/or nephropathy) (odds ratio [OR] 3.05; 95% CI 1.58-5.81) and metformin use (OR 2.26; 95% CI 1.19-4.74) were predictive of SGA. The absolute risk of SGA was much higher in women receiving metformin with comorbidity compared with women receiving metformin without comorbidity (25.0% vs. 9.8%). CONCLUSIONS In this study, we observed a high percentage of SGA births among women with type 2 diabetes and chronic hypertension and/or nephropathy who were treated with metformin. Therefore, with the aim of reducing SGA, it is reasonable to be cautious in our use of metformin in those with type 2 diabetes and chronic hypertension or nephropathy in pregnancy.
Collapse
Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada.,Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Bernard Zinman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada.,Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Lois E Donovan
- Departments of Medicine and Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Prakesh S Shah
- Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - J Johanna Sanchez
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Kellie E Murphy
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada.,Sinai Health System, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Al Khalaf S, Khashan AS, Chappell LC, O'Reilly ÉJ, McCarthy FP. Role of Antihypertensive Treatment and Blood Pressure Control in the Occurrence of Adverse Pregnancy Outcomes: a Population-Based Study of Linked Electronic Health Records. Hypertension 2022; 79:1548-1558. [PMID: 35502665 DOI: 10.1161/hypertensionaha.122.18920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Chronic hypertension (CH) adversely impacts pregnancy. It remains unclear whether antihypertensive treatment alters these risks. We examined the role of antihypertensive treatment in the association between CH and adverse pregnancy outcomes. METHODS Electronic health records from the UK Caliber and Clinical Practice Research Datalink were used to define a cohort of women delivering between 1997 and 2016. Primary outcomes were preeclampsia, preterm birth (PTB), and fetal growth restriction (FGR). We used multivariable logistic regression to compare outcomes in women with CH to women without CH and propensity score matching to compare antihypertensive agents. RESULTS The study cohort consisted of 1 304 679 women and 1 894 184 births. 14 595 (0.77%) had CH, and 6786 (0.36%) were prescribed antihypertensive medications in pregnancy. Overall, women with CH (versus no CH), had higher odds of preeclampsia (adjusted odds ratio [aOR], 5.74 [95% CI, 5.44-6.07]); PTB (aOR, 2.53 [2.39-2.67]); and FGR (aOR, 2.51 [2.31-2.72]). Women with CH prescribed treatment (versus untreated women) had higher odds of preeclampsia (aOR, 1.17 [1.05-1.30]), PTB (1.25 [1.12-1.39]), and FGR (1.80 [1.51-2.14]). Women prescribed methyldopa (versus β-blockers) had higher odds of preeclampsia (aOR, 1.43 [1.19-1.73]); PTB (1.59 [1.30-1.93]), but lower odds of FGR (aOR, 0.66 [0.48-0.90]). Odds of adverse outcomes were similar in relation to calcium channel blockers (versus β-blockers) except for PTB (aOR, 1.94 [1.15-3.27]). Among women prescribed treatment, lower average blood pressure (<135/85 mm Hg) was associated with better pregnancy outcomes. CONCLUSIONS Treatment with antihypertensive agents and control of hypertension ameliorates some effects but higher risks of adverse outcomes persist. β-Blockers versus methyldopa may be associated with better pregnancy outcomes except for FGR. Powered trials are needed to inform optimal treatment of CH during pregnancy.
Collapse
Affiliation(s)
- Sukainah Al Khalaf
- School of Public Health (S.A.K., A.S.K., E.J.O.), University College Cork, Ireland.,INFANT Research Centre (S.A.K., A.S.K., F.P.M.), University College Cork, Ireland
| | - Ali S Khashan
- School of Public Health (S.A.K., A.S.K., E.J.O.), University College Cork, Ireland.,INFANT Research Centre (S.A.K., A.S.K., F.P.M.), University College Cork, Ireland
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London (L.C.C.)
| | - Éilis J O'Reilly
- School of Public Health (S.A.K., A.S.K., E.J.O.), University College Cork, Ireland.,Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA (E.J.O.).,Environmental Research Institute, University College Cork, Ireland (E.J.O.).,Environmental Research Institute, University College Cork, Ireland (E.J.O.)
| | - Fergus P McCarthy
- INFANT Research Centre (S.A.K., A.S.K., F.P.M.), University College Cork, Ireland.,Department of Obstetrics and Gynaecology, Cork University Hospital, Ireland (F.P.M.)
| |
Collapse
|
11
|
Hypertensive disorders of pregnancy: definition, management, and out-of-office blood pressure measurement. Hypertens Res 2022; 45:1298-1309. [PMID: 35726086 PMCID: PMC9207424 DOI: 10.1038/s41440-022-00965-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/11/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022]
Abstract
Hypertensive disorders of pregnancy increase the risk of adverse maternal and fetal outcomes. In 2018, the Japanese classification of hypertensive disorders of pregnancy was standardized with those of other countries, and a hypertensive disorder of pregnancy was considered to be present if hypertension existed during pregnancy and up to 12 weeks after delivery. Strategies for the prevention of hypertensive disorders of pregnancy have become much clearer, but further research is needed on appropriate subjects and methods of administration, and these have not been clarified in Japan. Although guidelines for the use of antihypertensive drugs are also being studied and standardized with those of other countries, the use of calcium antagonists before 20 weeks of gestation is still contraindicated in Japan because of the safety concerns that were raised regarding possible fetal anomalies associated with their use at the time of their market launch. Chronic hypertension is now included in the definition of hypertensive disorders of pregnancy, and blood pressure measurement is a fundamental component of the diagnosis of hypertensive disorders of pregnancy. Out-of-office blood pressure measurements, including ambulatory and home blood pressure measurements, are important for pregnant and nonpregnant women. Although conditions such as white-coat hypertension and masked hypertension have been reported, determining their occurrence in pregnancy is complicated by the gestational week. This narrative review focused on recent reports on hypertensive disorders of pregnancy, including those related to blood pressure measurement and classification. ![]()
Collapse
|
12
|
Jung YM, Oh GC, Noh E, Lee HY, Oh MJ, Park JS, Jun JK, Lee SM, Cho GJ. Pre-pregnancy blood pressure and pregnancy outcomes: a nationwide population-based study. BMC Pregnancy Childbirth 2022; 22:226. [PMID: 35305601 PMCID: PMC8934452 DOI: 10.1186/s12884-022-04573-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 03/02/2022] [Indexed: 01/21/2023] Open
Abstract
Background Hypertension has been known to increase the risk of obstetric complications. Recently, the American College of Cardiology endorsed lower thresholds for hypertension as systolic blood pressure of 130-139 mmHg or diastolic blood pressure 80-89 mmHg. However, there is a paucity of information regarding the impact of pre-pregnancy blood pressure on pregnancy outcomes. We aimed to evaluate the effect of pre-pregnancy blood pressure on maternal and neonatal complications. Methods In this nationwide, population based study, pregnant women without history of hypertension and pre-pregnancy blood pressure < 140/90 mmHg were enrolled. The primary outcome of composite morbidity was defined as any of the followings: preeclampsia, placental abruption, stillbirth, preterm birth, or low birth weight. Results A total of 375,305 pregnant women were included. After adjusting for covariates, the risk of composite morbidity was greater in those with stage I hypertension in comparison with the normotensive group (systolic blood pressure, odds ratio = 1.68, 95% CI: 1.59 – 1.78; diastolic blood pressure, odds ratio = 1.56, 95% CI: 1.42 – 1.72). There was a linear association between pre-pregnancy blood pressure and the primary outcome, with risk maximizing at newly defined stage I hypertension and with risk decreasing at lower blood pressure ranges. Conclusions ‘The lower, the better’ phenomenon was still valid for both maternal and neonatal outcomes. Our results suggest that the recent changes in diagnostic thresholds for hypertension may also apply to pregnant women. Therefore, women with stage I hypertension prior to pregnancy should be carefully observed for adverse outcomes.
Collapse
|
13
|
Binder J, Kalafat E, Palmrich P, Pateisky P, Khalil A. Should angiogenic markers be included in diagnostic criteria of superimposed pre-eclampsia in women with chronic hypertension? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:192-201. [PMID: 34165863 DOI: 10.1002/uog.23711] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Although the most recent guidance from the International Society for the Study of Hypertension in Pregnancy (ISSHP) has highlighted the role of angiogenic marker assessment in the diagnosis of pre-eclampsia (PE) in women with chronic hypertension, the ISSHP has withheld recommending its implementation due to the limited available evidence in this group of women. Therefore, we aimed to investigate the value of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) assessment in women with chronic hypertension and suspected superimposed PE. METHODS This was a retrospective analysis of prospectively collected data recorded in an electronic database between January 2013 and October 2019. Women with chronic hypertension and singleton pregnancy who had suspected superimposed PE were included. Superimposed PE was suspected in women presenting with worsening hypertension, epigastric pain, new-onset edema, dyspnea or neurological symptoms. The exclusion criteria were delivery within 1 week after assessment for reasons other than PE, chronic kidney disease, history of cardiac disease, fetal aneuploidy, genetic syndrome or major structural anomaly and missing pregnancy outcome. Maternal serum angiogenic markers (sFlt-1, PlGF and sFlt-1/PlGF ratio) were measured. The primary outcome was the utility of angiogenic markers in the prediction of superimposed PE. Predictive accuracy was assessed for superimposed PE diagnosed at different timepoints, including within 1 week after assessment and any time before birth. The secondary outcome was comparison of adverse maternal and perinatal outcomes between women with superimposed PE diagnosed according to the traditional ISSHP criteria and those diagnosed according to extended criteria including angiogenic markers. The predictive accuracy of each angiogenic marker was assessed using receiver-operating-characteristics-curve analysis. Area under the curve (AUC) values were compared using De Long's test. A sensitivity analysis was planned for gestational age at assessment. The association of various variables with composite adverse maternal and perinatal outcomes was assessed using binomial regression. RESULTS The study included 142 pregnant women with chronic hypertension and suspected superimposed PE, of whom 25 (17.6%) developed PE within 1 week after assessment, 52 (36.6%) developed PE at any timepoint before birth and 90 (63.4%) delivered without PE. Maternal serum angiogenic imbalance was associated significantly with superimposed PE diagnosed according to the ISSHP criteria within 1 week or at any time after assessment (P < 0.001 for both). The predictive accuracy of maternal serum sFlt-1/PlGF ratio for superimposed PE diagnosed within 1 week after assessment was superior to that of maternal serum PlGF level (AUC, 0.91 vs 0.86; P = 0.032). The addition of angiogenic imbalance to the traditional ISSHP diagnostic criteria was associated with an increase in the detection rate (35.1% increase; 95% credible interval (CrI), 16.6-53.6%) and positive (9.6% increase; 95% CrI, 0.0-20.6%) and negative (3.1% increase; 95% CrI, 1.3-4.9%) predictive values for composite adverse maternal outcome, with high posterior probabilities of an increase in each predictive accuracy parameter (> 99.9%, 95.6% and > 99.9%, respectively), without a meaningful decrease in specificity. The addition of angiogenic imbalance improved the detection rate for composite adverse perinatal outcome (20.6% increase; 95% CrI, 0.0-42.2%), with a high posterior probability (96.9%). There was a corresponding drop in specificity (5.7% decrease; 95% CrI, -2.3% to 13.6%), with a posterior probability of 91.8%. CONCLUSIONS In women with chronic hypertension and suspected superimposed PE, addition of maternal serum angiogenic markers to the traditional diagnostic criteria for superimposed PE improved significantly the sensitivity for the prediction of both maternal and perinatal adverse outcomes. Implementation of angiogenic marker assessment in the evaluation of pregnant women with chronic hypertension should therefore be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- J Binder
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Statistics, Faculty of Arts and Sciences, Middle East Technical University, Ankara, Turkey
- Department of Obstetrics and Gynecology, Faculty of Medicine, Koc University, Istanbul, Turkey
| | - P Palmrich
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - P Pateisky
- Department of Obstetrics and Fetomaternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| |
Collapse
|
14
|
Kametas NA, Nzelu D, Nicolaides KH. Chronic hypertension and superimposed preeclampsia: screening and diagnosis. Am J Obstet Gynecol 2022; 226:S1182-S1195. [PMID: 35177217 DOI: 10.1016/j.ajog.2020.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 01/23/2023]
Abstract
Superimposed preeclampsia complicates about 20% of pregnancies in women with chronic hypertension and is associated with increased maternal and perinatal morbidity compared with preeclampsia alone. Distinguishing superimposed preeclampsia from chronic hypertension can be challenging because, in chronic hypertension, the traditional criteria for the diagnosis of preeclampsia, hypertension, and significant proteinuria can often predate the pregnancy. Furthermore, the prevalence of superimposed preeclampsia is unlikely to be uniformly distributed across this high-risk group but is related to the severity of preexisting endothelial dysfunction. This has led to interest in identifying biomarkers that could help in screening and diagnosis of superimposed preeclampsia and in the stratification of risk in women with chronic hypertension. Elevated levels of uric acid and suppression of other renal biomarkers, such as the renin-angiotensin aldosterone system, have been demonstrated in women with superimposed preeclampsia but perform only modestly in its prediction. In addition, central to the pathogenesis of preeclampsia is a tendency toward an antiangiogenic state thought to be triggered by an impaired placenta and, ultimately, contributing to the endothelial dysfunction pathognomonic of the disease. In the general obstetrical population, angiogenic factors, such as soluble fms-like tyrosine kinase-1 and placental growth factor, have shown promise in the prediction of preeclampsia. However, soluble fms-like tyrosine kinase-1 and placental growth factor are impaired in women with chronic hypertension irrespective of whether they develop superimposed preeclampsia. Therefore, the differences in levels are less discriminatory in the prediction of superimposed preeclampsia compared with the general obstetrical population. Alternative biomarkers to the angiogenic and renal factors include those of endothelial dysfunction. A characteristic of both preeclampsia and chronic hypertension is an exaggerated systemic inflammatory response causing or augmenting endothelial dysfunction. Thus, proinflammatory mediators, such as tumor necrosis factor-α, interleukin-6, cell adhesion molecules, and endothelin, have been investigated for their role in the screening and diagnosis of superimposed preeclampsia in women with chronic hypertension. To date, the existing limited evidence suggests that the differences between those who develop superimposed preeclampsia and those who do not are, as with angiogenic factors, also modest and not clinically useful for the stratification of women with chronic hypertension. Finally, pro-B-type natriuretic peptide is regarded as a sensitive marker of early cardiac dysfunction that, in women with chronic hypertension, may predate the pregnancy. Thus, it has been proposed that pro-B-type natriuretic peptide could give insight as to the ability of women with chronic hypertension to adapt to the hemodynamic requirements of pregnancy and, subsequently, their risk of developing superimposed preeclampsia. Although higher levels of pro-B-type natriuretic peptide have been demonstrated in women with superimposed preeclampsia compared with those without, current evidence suggests that pro-B-type natriuretic peptide is not a predictor for the disease. The objectives of this review are to, first, discuss the current criteria for the diagnosis of superimposed preeclampsia and, second, to summarize the evidence for these potential biomarkers that may assist in the diagnosis of superimposed preeclampsia.
Collapse
Affiliation(s)
- Nikos A Kametas
- Antenatal Hypertension Clinic, Division of Women's Health, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom; Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom.
| | - Diane Nzelu
- Antenatal Hypertension Clinic, Division of Women's Health, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Kypros H Nicolaides
- Antenatal Hypertension Clinic, Division of Women's Health, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom; Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| |
Collapse
|
15
|
Suzuki H, Takagi K, Matsubara K, Mito A, Kawasaki K, Nanjo S, Mimura K, Bokuda K, Makino S, Nakamoto O, Ichihara A, Seki H. Maternal and perinatal outcomes according to blood pressure levels for prehypertension: A review and meta-analysis. HYPERTENSION RESEARCH IN PREGNANCY 2022. [DOI: 10.14390/jsshp.hrp2021-018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hirotada Suzuki
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine
| | - Kenjiro Takagi
- Perinatal Center, Division of Maternal and Fetal Medicine, Jichi Medical University, Saitama Medical Center
| | - Keiichi Matsubara
- Department of Obstetrics and Gynecology, Ehime University School of Medicine
| | - Asako Mito
- Department of Obstetric Medicine, Center for Maternal-Fetal and Reproductive Medicine, National Center for Child Health and Development
| | - Kaoru Kawasaki
- Department of Obstetrics and Gynecology, Kyoto University
| | - Sakiko Nanjo
- Department of Obstetrics and Gynecology, Wakayama Medicine University
| | - Kazuya Mimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine
| | - Kanako Bokuda
- Department of Endocrinology and Hypertension, Tokyo Women’s Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Osamu Nakamoto
- Department of Obstetrics and Gynecology, Osaka City General Hospital
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women’s Medical University
| | - Hiroyuki Seki
- Center for Maternal, Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University
| | | |
Collapse
|
16
|
Angras K, Sullivan M, Young AJ, Paglia MJ, Mackeen AD. A retrospective review of pregnancy outcomes in women with uncomplicated mild to moderate chronic hypertension. J Matern Fetal Neonatal Med 2021; 35:9071-9077. [PMID: 34903131 DOI: 10.1080/14767058.2021.2014451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine pregnancy complications in women with uncomplicated mild-moderate chronic hypertension (CHTN) treated with antihypertensives prior to 20 weeks compared to those not on antihypertensives. STUDY DESIGN This retrospective cohort study examined singleton pregnancies of women with mild-moderate CHTN who delivered from 01/2014-3/2019. Pregnancies complicated by hypertension at ≥ 20 weeks, end organ damage, preexisting diabetes mellitus, early-onset gestational diabetes, multifetal gestation, and fetal anomalies were excluded. Adjusted logistic regression analyses were performed for each of the outcomes. Adjusted odds ratios (aOR) were reported along with associated 95% confidence intervals (CI) and p-values. MAIN OUTCOME MEASURES Primary outcome was superimposed preeclampsia with severe features. Additional maternal outcomes were superimposed preeclampsia without severe features, severe hypertension, indicated preterm delivery, placental abruption, and mode of delivery. Neonatal outcomes included composite perinatal outcomes (fetal growth restriction, intrauterine fetal demise, and small for gestational age neonate), low birth weight, very low birth weight, admission to the neonatal intensive care unit, and Apgar score <7 at 5-minutes. RESULTS 345 women were identified: 232 (67.2%) were not taking antihypertensives and 113 (32.8%) were taking ≥1 antihypertensive. There was no significant difference in the primary outcome (p = 0.65; aOR = 0.88; 95% CI 0.51-1.52) among the group taking antihypertensive therapy as compared to those not taking antihypertensives. No statistically significant differences were seen for any of the other secondary maternal or neonatal outcomes. CONCLUSIONS Our data supports that the use of antihypertensive therapy in women with mild-moderate CHTN does not reduce the risk of developing superimposed preeclampsia.
Collapse
Affiliation(s)
- Kajal Angras
- Division of Maternal-Fetal Medicine, Women's Health Service Line, Danville, PA, USA
| | - Maranda Sullivan
- Division of Maternal-Fetal Medicine, Women's Health Service Line, Danville, PA, USA
| | - Amanda J Young
- Biomedical and Translational Informatics Institute, Danville, PA, USA
| | - Michael J Paglia
- Division of Maternal-Fetal Medicine, Women's Health Service Line, Danville, PA, USA
| | - A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Women's Health Service Line, Danville, PA, USA
| |
Collapse
|
17
|
Medjedovic E, Kurjak A. The Importance of Doppler Analysis of Uterine Circulation in Pregnancy for a Better Understanding of Preeclampsia. Med Arch 2021; 75:424-430. [PMID: 35169369 PMCID: PMC8802687 DOI: 10.5455/medarh.2021.75.424-430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The etiology of preeclampsia has still not been completely explained. Early identification of women with the risk of developing preeclampsia is a key goal of antenatal care. OBJECTIVE To investigate risk factors for preeclampsia from the history, laboratory and ultrasound findings (Doppler). METHODS Pregnant women with normal Doppler sonography in the second trimester of pregnancy were classified as a control group, while pregnant women with impaired Doppler in the second trimester were considered as the investigated group with presumably increased risk for preeclampsia. A total number of 80 patients was included in the study (40 patients in each group). RESULTS The difference of urea, uric acid and lactate dehydrogenase (LDH) in the serum of the control and investigated group was statistically significant, while the differences were not statistically significant for creatinine, aspartate aminotransferase (AST) and alanine aminotransferase (ALT). The presence of a notch sign during assessment of blood flow in uterine arteries in subjects in the investigated group with the diagnosis of preeclampsia had the specificity of 47.62%, and sensitivity of 88.89%. The positive predictive value of a notch sign during assessment of blood flow in uterine arteries as a marker for diagnosis of preeclampsia in the second trimester of pregnancy was 90.91%, and its negative. Systolic and diastolic blood pressure are dependent variables which are predicting preeclampsia, whilst a notch sign in uterine arteries was designated as an independent variable predicting preeclampsia. CONCLUSION From the laboratory tests the following parameters were considered as the risk factors for preeclampsia: increasing levels of urea, uric acid, and LDH. Notch sign was considered to be a very strong predictor of preeclampsia, especially if present bilaterally. Doppler sonography in the second trimester of pregnancy is a good predictor for early diagnosis of preeclampsia.
Collapse
Affiliation(s)
- Edin Medjedovic
- Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
- Department of Gynecology, Obstetrics and Reproductive medicine, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
| | - Asim Kurjak
- Department of Gynecology, Obstetrics and Reproductive medicine, School of Medicine, Sarajevo School of Science and Technology, Sarajevo, Bosnia and Herzegovina
- Department of Obstetrics and Gynecology, Medical School University of Zagreb, Zagreb, Croatia
| |
Collapse
|
18
|
Lower systolic blood pressure levels in early pregnancy are associated with a decreased risk of early-onset superimposed preeclampsia in women with chronic hypertension: a multicenter retrospective study. Hypertens Res 2021; 45:135-145. [PMID: 34635810 DOI: 10.1038/s41440-021-00763-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 08/10/2021] [Accepted: 08/25/2021] [Indexed: 11/08/2022]
Abstract
To clarify the impact of blood pressure (BP) management ranges on pregnancy outcomes, we conducted a multicenter retrospective analysis of 215 women with singleton pregnancies diagnosed with essential hypertension either before or within 14 weeks of gestation. Patients were classified according to systolic BP (sBP; <130, 130-139, 140-159, and ≥160 mmHg) or diastolic BP (dBP; <80, 80-89, 90-109, and ≥110 mmHg) at 8-11, 12-15, and 16-19 weeks of gestation. The risk of early-onset superimposed preeclampsia and small-for-gestational-age neonates was assessed in each BP group. Moreover, a subgroup analysis was performed in 144 eligible patients whose BP was measured at both 12-13 and 14-15 weeks of gestation. At 16-19 weeks of gestation, higher sBP significantly increased the incidence of early-onset superimposed preeclampsia (13.3%, 24.6%, 32.2% and 75.0%, respectively) and small-for-gestational-age neonates (6.0%, 13.1%, 16.9% and 50.0%, respectively). Multivariate logistic regression analyses showed that women with sBP < 130 mmHg at 16-19 weeks of gestation had a significantly lower risk of early-onset superimposed preeclampsia than women with sBP of 140-159 mmHg. Subgroup analyses also showed that even at 14-15 weeks of gestation, sBP < 130 mmHg was associated with a significantly lower risk of early-onset superimposed preeclampsia than an sBP of 140-159 mmHg. In conclusion, sBP < 130 mmHg within 14 weeks of gestation reduced the risk of developing early-onset superimposed preeclampsia in women with chronic hypertension.
Collapse
|
19
|
Binder J, Palmrich P, Kalafat E, Pateisky P, Öztürk E, Mittelberger J, Khalil A. Prognostic Value of Angiogenic Markers in Pregnant Women With Chronic Hypertension. J Am Heart Assoc 2021; 10:e020631. [PMID: 34459247 PMCID: PMC8649241 DOI: 10.1161/jaha.120.020631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Women with chronic hypertension face a 5‐ to 6‐fold increased risk of developing preeclampsia compared with normotensive women. Angiogenic markers, especially soluble fms‐like kinase 1 (sFlt‐1) and placental growth factor (PlGF), were identified as clinically useful markers predicting the development of preeclampsia, but data on the prediction of superimposed preeclampsia are scarce. Therefore, we aimed to evaluate the predictive value of the sFlt‐1/PlGF ratio for delivery because of superimposed preeclampsia in women with chronic hypertension. Methods and Results This retrospective study included 142 women with chronic hypertension and suspected superimposed preeclampsia. Twenty‐seven women (19.0%) delivered because of maternal indications only, 17 women (12.0%) because of fetal indications primarily, and 98 women (69.0%) for other reasons. Women who both delivered because of maternal indications and for fetal indications had a significantly higher sFlt‐1/PlGF ratio (median 99.9 and 120.2 versus 7.3, respectively, P<0.001 for both) and lower PlGF levels (median 73.6 and 53.3 versus 320.0 pg/mL, respectively, P<0.001 for both) compared with women who delivered for other reasons. SFlt‐1/PlGF ratio and PlGF were strong predictors for delivery because of superimposed preeclampsia, whether for maternal or fetal indications (P<0.05). Half of women with angiogenic imbalance (sFlt‐1/PlGF ratio ≥85 or PlGF levels <100 pg/mL) delivered because of maternal or fetal indications within 1.6 weeks (95% CI, 1.0–2.4 weeks). Conclusions Angiogenic marker imbalance in women with suspected superimposed preeclampsia can predict delivery because of maternal and fetal indications related to superimposed preeclampsia and is associated with a significantly shorter time to delivery interval.
Collapse
Affiliation(s)
- Julia Binder
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Pilar Palmrich
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Erkan Kalafat
- Department of Statistics Faculty of Arts and Sciences Middle East Technical University Ankara Turkey.,Department of Obstetrics and Gynecology Faculty of Medicine Koc University Istanbul Turkey
| | - Petra Pateisky
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Ebru Öztürk
- Department of Biostatistics Faculty of Medicine Hacettepe University Ankara Turkey
| | - Johanna Mittelberger
- Department of Obstetrics and Feto-Maternal Medicine Medical University of Vienna Austria
| | - Asma Khalil
- Fetal Medicine Unit St George's Hospital St George's University of London London United Kingdom.,Vascular Biology Research Centre Molecular and Clinical Sciences Research Institute St George's University of London London United Kingdom
| |
Collapse
|
20
|
Braveman P, Dominguez TP, Burke W, Dolan SM, Stevenson DK, Jackson FM, Collins JW, Driscoll DA, Haley T, Acker J, Shaw GM, McCabe ERB, Hay WW, Thornburg K, Acevedo-Garcia D, Cordero JF, Wise PH, Legaz G, Rashied-Henry K, Frost J, Verbiest S, Waddell L. Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:684207. [PMID: 36303973 PMCID: PMC9580804 DOI: 10.3389/frph.2021.684207] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022] Open
Abstract
In 2017–2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.
Collapse
Affiliation(s)
- Paula Braveman
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Paula Braveman
| | - Tyan Parker Dominguez
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, United States
| | - Wylie Burke
- University of Washington School of Medicine, Seattle, WA, United States
| | - Siobhan M. Dolan
- Albert Einstein College of Medicine, New York, NY, United States
| | | | | | - James W. Collins
- Northwestern University School of Medicine, Chicago, IL, United States
| | - Deborah A. Driscoll
- University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Terinney Haley
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Julia Acker
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Gary M. Shaw
- Stanford University School of Medicine, Stanford, CA, United States
| | - Edward R. B. McCabe
- David Geffen School of Medicine at University of California, Los Angeles, CA, United States
| | | | - Kent Thornburg
- School of Medicine, Oregon State University, Portland, OR, United States
| | | | - José F. Cordero
- University of Georgia College of Public Health, Athens, GA, United States
| | - Paul H. Wise
- Stanford University School of Medicine, Stanford, CA, United States
| | - Gina Legaz
- March of Dimes, White Plains, NY, United States
| | | | | | - Sarah Verbiest
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | |
Collapse
|
21
|
Nzelu D, Nicolaides KH, Kametas NA. First trimester angiogenic and inflammatory factors in women with chronic hypertension and impact of blood pressure control: a case-control study. BJOG 2021; 128:2171-2179. [PMID: 34245653 DOI: 10.1111/1471-0528.16835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess first trimester serum placental growth factor (PLGF), soluble fms-like tyrosine kinase-1 (sFLT-1), interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α), endothelin and vascular cell adhesion molecule (VCAM) in women with chronic hypertension (CH) stratified according to blood pressure (BP) control. DESIGN Case-control. SETTING Tertiary referral centre. POPULATION 650 women with CH, 142 normotensive controls. METHODS In the first trimester, patients with CH were subdivided into four groups. Group 1 included women without pre-pregnancy CH presenting with BP ≥140/90 mmHg. Groups 2-4 had pre-pregnancy CH; in group 2 the BP was <140/90 mmHg without antihypertensive medication, in group 3 the BP was <140/90 mmHg with antihypertensive medication, and in group 4 the BP was ≥140/90 mmHg despite antihypertensive medication. PLGF, sFLT-1, IL-6, TNF-α, endothelin and VCAM were measured at 11+0 -13+6 weeks' gestation and converted into multiples of the expected median (MoM) using multivariate regression analysis in the controls. MAIN OUTCOME MEASURE Comparisons of MoM values of PLGF, sFLT-1, endothelin, IL-6, TNF-α and VCAM between the entire cohort of women with CH and the control group were made using Student's t-test or Mann-Whitney U-test. Comparisons between the four CH groups were made using analysis of variance or Kruskal-Wallis tests. RESULTS Compared with the control group, women with CH had significantly lower MoM of PLGF, sFLT-1 and IL-6 and a significantly higher MoM of endothelin. Between the four groups of women with CH, there were no significant differences in the MoM of sFLT-1, PLGF, sFLT-1/PLGF ratio, endothelin, IL-6 or VCAM, or in the levels of TNF- α. CONCLUSION In women with CH, differences exist in first trimester angiogenic and inflammatory profiles when compared with normotensive pregnancies. However, these differences do not assist in the stratification of women with CH to identify those with more severe underlying disease and worse pregnancy outcomes. TWEETABLE ABSTRACT First trimester blood pressure control impacts on serum PLGF, sFLT-1, endothelin and IL-6 in women with chronic hypertension.
Collapse
Affiliation(s)
- D Nzelu
- Fetal Medicine Research Institute, King's College Hospital, London, UK.,King's College London, London, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - N A Kametas
- Fetal Medicine Research Institute, King's College Hospital, London, UK.,King's College London, London, UK
| |
Collapse
|
22
|
Al Khalaf SY, O'Reilly ÉJ, Barrett PM, B Leite DF, Pawley LC, McCarthy FP, Khashan AS. Impact of Chronic Hypertension and Antihypertensive Treatment on Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e018494. [PMID: 33870708 PMCID: PMC8200761 DOI: 10.1161/jaha.120.018494] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Maternal chronic hypertension is associated with adverse pregnancy outcomes. Previous studies examined the association between either chronic hypertension or antihypertensive treatment and adverse pregnancy outcomes. We aimed to synthesize the evidence on the effect of chronic hypertension/antihypertensive treatment on adverse pregnancy outcomes. Methods and Results Medline/PubMed, EMBASE, and Web of Science were searched; we included observational studies and assessed the effect of race/ethnicity, where possible, following a registered protocol (CRD42019120088). Random-effects meta-analyses were used. A total of 81 studies were identified on chronic hypertension, and a total of 16 studies were identified on antihypertensive treatment. Chronic hypertension was associated with higher odds of preeclampsia (adjusted odd ratio [aOR], 5.43; 95% CI, 3.85-7.65); cesarean section (aOR, 1.87; 95% CI, 1.6-2.16); maternal mortality (aOR, 4.80; 95% CI, 3.04-7.58); preterm birth (aOR, 2.23; 95% CI, 1.96-2.53); stillbirth (aOR, 2.32; 95% CI, 2.22-2.42); and small for gestational age (SGA) (aOR, 1.96; 95% CI, 1.6-2.40). Subgroup analyses indicated that maternal race/ethnicity does not influence the observed associations. Women with chronic hypertension on antihypertensive treatment (versus untreated) had higher odds of SGA (aOR, 1.86; 95% CI, 1.38-2.50). Conclusions Chronic hypertension is associated with adverse pregnancy outcomes, and these associations appear to be independent of maternal race/ethnicity. In women with chronic hypertension, those on treatment had a higher risk of SGA, although the number of studies was limited. This could result from a direct effect of the treatment or because severe hypertension during pregnancy is a risk factor for SGA and women with severe hypertension are more likely to be treated. The effect of antihypertensive treatment on SGA needs to be further tested with large randomized controlled trials.
Collapse
Affiliation(s)
- Sukainah Y Al Khalaf
- School of Public Health University College Cork Cork Ireland.,INFANT Research Centre University College Cork Ireland
| | - Éilis J O'Reilly
- School of Public Health University College Cork Cork Ireland.,Department of Nutrition Harvard T.H. Chan School of Public Health Boston MA
| | - Peter M Barrett
- School of Public Health University College Cork Cork Ireland.,INFANT Research Centre University College Cork Ireland
| | | | - Lauren C Pawley
- Department of Anatomy and Neuroscience University College Cork Cork Ireland
| | - Fergus P McCarthy
- INFANT Research Centre University College Cork Ireland.,Department of Obstetrics and Gynaecology University College Cork Cork Ireland
| | - Ali S Khashan
- School of Public Health University College Cork Cork Ireland.,INFANT Research Centre University College Cork Ireland
| |
Collapse
|
23
|
Dumitrascu-Biris D, Nzelu D, Dassios T, Nicolaides K, Kametas NA. Chronic hypertension in pregnancy stratified by first-trimester blood pressure control and adverse perinatal outcomes: A prospective observational study. Acta Obstet Gynecol Scand 2021; 100:1297-1304. [PMID: 33609284 DOI: 10.1111/aogs.14132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The aim of this study was to assess perinatal outcomes in women with chronic hypertension (CH) stratified into four groups according to their blood pressure (BP) control in the first trimester of pregnancy. MATERIAL AND METHODS This was a prospective cohort study between January 2011 and June 2017, based in a university hospital in London, UK. The population consisted of four groups: group 1 included women without history of CH, presenting in the first trimester with BP >140/90 mmHg (n = 100). Groups 2-4 had prepregnancy CH; group 2 had BP <140/90 mmHg without antihypertensives (n = 234), group 3 had BP <140/90 mmHg with antihypertensives (n = 272), and group 4 had BP ≥140/90 mmHg despite antihypertensives (n = 194). The main outcome measures were: fetal growth restriction, admission to neonatal (NNU) or neonatal intensive care unit (NICU) for ≥2 days, composite neonatal morbidity, and composite serious adverse neonatal outcome. Outcomes were collected from the hospital databases and for up to 6 weeks postnatally. Differences between groups were assessed using chi-squared test and multivariate logistic regression was used to assess the independent contribution of the four groups to the prediction of pertinent outcomes, after controlling for maternal characteristics. RESULTS There was a higher incidence of fetal growth restriction in groups 3 (17.6%) and 4 (18.2%), compared with groups 1 (10.0%) and 2 (11.1%) (P = .04). There were more admissions to the NNU for ≥2 days in groups 3 (23.2%) and 4 (25.0%), compared with groups 1 (17.0%) and 2 (13.2%) (P = .008); and more admissions to NICU for ≥2 days in groups 3 (9.2%) and 4 (9.4%), compared with groups 1 (3.0%) and 2 (3.4%) (P = .01). Composite neonatal morbidity was higher in groups 3 (22.4%) and 4 (21.4%), compared with groups 1 (17.0%) and 2 (11.5%) (P = .009). Composite serious adverse postnatal outcome was higher in groups 3 (3.3%) and 4 (4.2%), compared with groups 1 (1.0%) and 2 (0.9%) but the difference did not reach statistical significance (P = .09). These results were also observed when values were adjusted for maternal characteristics. CONCLUSIONS In CH adverse perinatal outcomes are worse in women who are known to have CH and need antihypertensives in the first trimester of pregnancy. Women with newly diagnosed CH in the first trimester have similar outcomes to those with known CH who have antihypertensive treatment discontinued.
Collapse
Affiliation(s)
- Dan Dumitrascu-Biris
- Antenatal Hypertension Clinic, Fetal Medicine Research Institution, King's College Hospital, London, UK
| | - Diane Nzelu
- Antenatal Hypertension Clinic, Fetal Medicine Research Institution, King's College Hospital, London, UK
| | - Theodore Dassios
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Kypros Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institution, King's College Hospital, London, UK
| | - Nikos A Kametas
- Antenatal Hypertension Clinic, Fetal Medicine Research Institution, King's College Hospital, London, UK.,Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institution, King's College Hospital, London, UK
| |
Collapse
|
24
|
Rotem R, Rottenstreich M, Prado E, Baumfeld Y, Yohay D, Pariente G, Weintraub AY. Trends of change in the individual contribution of risk factors for small for gestational age over more than 2 decades. Arch Gynecol Obstet 2020; 302:1159-1166. [PMID: 32748052 DOI: 10.1007/s00404-020-05725-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 07/28/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Over the past years, the prevalence of various risk factors for small for gestational age (SGA) neonates has changed. Little is known if there was also a change in the specific contribution of these risk factors to the prevalence of SGA. We aim to identify trends in the specific contribution of various risk factors for SGA by observing their odds ratios (ORs) throughout different time periods. METHODS A nested case-control study was conducted. The ORs for selected known risk factors for SGA occurring in three consecutive 8-year intervals between 1988 and 2014 (T1 - 1988-1996; T2 - 1997-2005; T3 - 2006-2014) were compared. Data were retrieved from the medical centre's computerized perinatal database. Multivariable logistic regression models were constructed and ORs were compared to identify the specific contribution of independent risk factors for SGA along the study period. RESULTS During the study period, 285,992 pregnancies met the study's inclusion criteria, of which 15,013 (5.25%) were SGA. Between 1988 and 2014, the incidence of SGA increased from 2.6% in 1988 to 2.9% in 2014. Using logistic regression models, nulliparity, maternal age, gestational age, hypertensive disorders of pregnancy, oligohydramnios and pre-gestational diabetes mellitus were found to be independently associated with SGA. While the adjusted ORs (aOR) of hypertensive disorders of pregnancy and pre-gestational diabetes mellitus had increased, aORs for nulliparity, maternal age and gestational age had remained stable over time. Oligohydramnios had demonstrated a mixed trend of change over the time. CONCLUSION In our study, the specific contribution of factors associated with SGA had changed over time. Having a better understating of the changes in the specific contribution of different risk factors for SGA may enable obstetricians to provide consultations.
Collapse
Affiliation(s)
- Reut Rotem
- Department of Obstetrics and Gynaecology, Shaare Zedek Medical Centre, Jerusalem, Affiliated with the Hebrew University Medical School of Jerusalem, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynaecology, Shaare Zedek Medical Centre, Jerusalem, Affiliated with the Hebrew University Medical School of Jerusalem, Jerusalem, Israel.
| | - Ella Prado
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Soroka University Medical Centre, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yael Baumfeld
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Soroka University Medical Centre, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - David Yohay
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Soroka University Medical Centre, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gali Pariente
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Soroka University Medical Centre, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, Soroka University Medical Centre, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| |
Collapse
|
25
|
Nzelu D, Biris D, Karampitsakos T, Nicolaides KK, Kametas NA. First trimester serum angiogenic and anti-angiogenic factors in women with chronic hypertension for the prediction of preeclampsia. Am J Obstet Gynecol 2020; 222:374.e1-374.e9. [PMID: 31705883 DOI: 10.1016/j.ajog.2019.10.101] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/10/2019] [Accepted: 10/30/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND An imbalance between angiogenic and antiangiogenic factors is thought to be a central pathogenetic mechanism in preeclampsia. In pregnancies that subsequently experience preeclampsia, the maternal serum concentration of the angiogenic placental growth factor is decreased from as early as the first trimester of pregnancy, and the concentration of the antiangiogenic soluble fms-like tyrosine kinase-1 is increased in the last few weeks before the clinical presentation of the disease. Chronic hypertension, which complicates 1-2% of pregnancies, is the highest risk factor for the development of preeclampsia among all other factors in maternal demographic characteristics and medical history. Two previous studies in women with chronic hypertension reported that first-trimester serum placental growth factor and soluble fms-like tyrosine kinase-1 levels were not significantly different between those who experienced superimposed preeclampsia and those who did not, whereas a third study reported that concentrations of placental growth factor were decreased. OBJECTIVE The purpose of this study was to investigate whether, in women with chronic hypertension, serum concentrations of placental growth factor and soluble fms-like tyrosine kinase-1 and soluble fms-like tyrosine kinase-1/placental growth factor ratio at 11+0-13+6 weeks gestation are different between those women who experienced superimposed preeclampsia and those who did not and to compare these values with those in normotensive control subjects. STUDY DESIGN The study population comprised 650 women with chronic hypertension, which included 202 women who experienced superimposed preeclampsia and 448 women who did not experience preeclampsia, and 142 normotensive control subjects. Maternal serum concentration of placental growth factor and soluble fms-like tyrosine kinase-1 were measured by an automated biochemical analyzer and converted into multiples of the expected median with the use of multivariate regression analysis in the control group. Comparisons of placental growth factor and soluble fms-like tyrosine kinase-1 levels and soluble fms-like tyrosine kinase-1/placental growth factor ratio in multiples of the expected median values between the 2 groups of chronic hypertension and the control subjects were made with the analysis of variance or the Kruskal-Wallis test. RESULTS In the group of women with chronic hypertension who experienced preeclampsia compared with those women who did not experience preeclampsia, there were significantly lower median concentrations of serum placental growth factor multiples of the expected median (0.904 [interquartile range, 0.771-1.052] vs 0.948 [interquartile range, 0.814-1.093]; P=.014) and soluble fms-like tyrosine kinase-1 multiples of the expected median (0.895 [interquartile range, 0.760-1.033] vs 0.938 [interquartile range, 0.807-1.095]; P=.013); they were both lower than in the normotensive control subjects (1.009 [interquartile range, 0.901-1.111] and 0.991 [interquartile range, 0.861-1.159], respectively; P<.01 for both). There were no significant differences among the 3 groups in soluble fms-like tyrosine kinase-1/placental growth factor ratios. In women with chronic hypertension, serum placental growth factor and soluble fms-like tyrosine kinase-1 levels provided poor prediction of superimposed preeclampsia (area under the curve, 0.567 [95% confidence interval, 0.537-0.615] and 0.546 [95% confidence interval, 0.507-0.585], respectively). CONCLUSION Women with chronic hypertension, and particularly those who subsequently experienced preeclampsia, have reduced first-trimester concentrations of both placental growth factor and soluble fms-like tyrosine kinase-1.
Collapse
|
26
|
Heimberger S, Perdigao JL, Mueller A, Shahul S, Naseem H, Minhas R, Chintala S, Rana S. Effect of blood pressure control in early pregnancy and clinical outcomes in African American women with chronic hypertension. Pregnancy Hypertens 2020; 20:102-107. [PMID: 32229425 DOI: 10.1016/j.preghy.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/05/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Chronic hypertension (cHTN) affects 3-5% of all pregnancies and is twice as prevalent in African American (AA) women. AA women develop more severe HTN at an earlier onset and have higher rates of adverse pregnancy outcomes. Blood pressure control during pregnancy is controversial. STUDY DESIGN This retrospective cohort included AA women with cHTN and singleton pregnancies delivering between January 2013 and December 2016. Patients were classified as not receiving antihypertensives in the first 20 weeks (Group A), on antihypertensives in the first 20 weeks but with an average BP <140/90 during pregnancy (Group B) and on antihypertensives in the first 20 weeks but with average BP during pregnancy ≥140/90 (Group C). Adverse outcomes including severe HTN and preterm delivery <35 weeks was compared between groups. RESULTS Of the 198 patients included, 68 received at least one AHT before 20 weeks including 45 patients with average BP <140/90 and 23 with average BP ≥140/90 during pregnancy. The incidence of superimposed PE and preterm birth was significantly higher among women with elevated BPs on AHT (39.1% vs 8.9% vs 17.7%, p = 0.01; preterm birth 52.2%, 8.9% and 9.2%, p < 0.001 for Groups C, B and A, respectively). A significantly higher proportion of adverse neonatal outcomes were observed in Group C (78.3%) as opposed to those in Group B (53.3%) or Group A (50.0%; p = 0.04). CONCLUSIONS Among AA women with cHTN, use of antihypertensives prior to 20 weeks and lower antenatal BP was associated with a decreased risk of adverse maternal and neonatal outcomes.
Collapse
Affiliation(s)
- Sarah Heimberger
- University of Chicago Pritzker School of Medicine, Chicago, IL, United States
| | - Joana Lopes Perdigao
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Pennsylvania, PA, United States
| | - Ariel Mueller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, IL, United States; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sana Shahul
- University of Chicago, Chicago, IL, United States
| | - Heba Naseem
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, IL, United States
| | - Ruby Minhas
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, IL, United States
| | - Sireesha Chintala
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, IL, United States
| | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, IL, United States.
| |
Collapse
|
27
|
Wu DD, Gao L, Huang O, Ullah K, Guo MX, Liu Y, Zhang J, Chen L, Fan JX, Sheng JZ, Lin XH, Huang HF. Increased Adverse Pregnancy Outcomes Associated With Stage 1 Hypertension in a Low-Risk Cohort: Evidence From 47 874 Cases. Hypertension 2020; 75:772-780. [PMID: 32008433 DOI: 10.1161/hypertensionaha.119.14252] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The recommendations for the diagnosis of stage 1 hypertension were recently revised by the American Heart Association primarily based on its impact on cardiovascular disease risks. Whether the newly diagnosed stage 1 hypertension impacts pregnancy complications remain poorly defined. We designed a retrospective cohort study to investigate the associations of stage 1 hypertension detected in early gestation (<20 weeks) with risks of adverse pregnancy outcomes stratified by prepregnancy body mass index. A total of 47 874 women with singleton live births and blood pressure (BP) <140/90 mm Hg were included, with 5781 identified as stage 1a (systolic BP, 130-134 mm Hg; diastolic BP, 80-84 mm Hg; or both) and 3267 as stage 1b hypertension (systolic BP, 135-139 mm Hg; diastolic BP, 85-90 mm Hg; or both). Slightly higher, yet significant, rates and risks of gestational diabetes mellitus, preterm delivery, and low birth weight (<2500 g) were observed in both groups compared with normotensive controls. Importantly, women with stage 1a and stage 1b hypertension had significantly increased incidences of hypertensive disorders in pregnancy compared with normotensive women (adjusted odds ratio, 2.34 [95% CI, 2.16-2.53]; 3.05 [2.78-3.34], respectively). After stratifying by body mass index, stage 1a and 1b hypertension were associated with increased hypertensive disorders in pregnancy risks in both normal weight (body mass index, 18.5-24.9; adjusted odds ratio, 2.44 [2.23-2.67]; 3.26 [2.93-3.63]) and the overweight/obese (body mass index, ≥25; adjusted odds ratio, 1.90 [1.56-2.31]; 2.36 [1.92-2.90]). Current findings suggested significantly increased adverse pregnancy outcomes associated with stage 1 hypertension based on the revised American Heart Association guidelines, especially in women with prepregnancy normal weight.
Collapse
Affiliation(s)
- Dan-Dan Wu
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - Ling Gao
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - Ou Huang
- Department of Surgery, Ruijin Hospital, Medical School of Shanghai Jiaotong University, China (O.H.)
| | - Kamran Ullah
- Department of Zoology, University of Swabi, Khyber Pakhtunkhwa, Pakistan (K.U.)
| | - Meng-Xi Guo
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - Ye Liu
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - Jian Zhang
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - Lei Chen
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.)
| | - Jian-Xia Fan
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - Jian-Zhong Sheng
- The Key Laboratory of Reproductive Genetics, Ministry of Education (Zhejiang University), Hangzhou, China (J.-Z.S.).,Department of Pathology and Pathophysiology, School of Medicine, Zhejiang University, Hangzhou, China (J.-Z.S.)
| | - Xian-Hua Lin
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| | - He-Feng Huang
- From the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China (D.-D.W., L.G., M.-X.G., Y.L., J.Z., L.C., J.-X.F., X.-H.L., H.-F.H.).,Shanghai Key Laboratory of Embryo Original Diseases, China (D.D.W., L.G., M.-X.G., Y.L., J.Z., J.-X.F., X.-H.L., H.-F.H.)
| |
Collapse
|
28
|
Li H, Liu J, Tan D, Huang G, Zheng J, Xiao J, Wang H, Huang Q, Feng N, Zhang G. Maternal HIV infection and risk of adverse pregnancy outcomes in Hunan province, China: A prospective cohort study. Medicine (Baltimore) 2020; 99:e19213. [PMID: 32080112 PMCID: PMC7034691 DOI: 10.1097/md.0000000000019213] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study described the prevalence of adverse pregnancy outcomes (APOs) in Chinese HIV-infected pregnant women, and examined the relationship between maternal HIV infection /HIV-related factors and APOs.This prospective cohort study was carried out among 483 HIV-infected pregnant women and 966 HIV-uninfected pregnant women. The HIV-infected and HIV-uninfected women were enrolled from midwifery hospitals in Hunan province between October 2014 and September 2017. All data were extracted in a standard structured form, including maternal characteristics, HIV infection status, HIV-related factors and their pregnancy outcomes. APOs were assessed by maternal HIV infection status and HIV-related factors using logistic regression analysis.The incidences of stillbirth (3.9% vs 1.1%), preterm birth (PTB) (8.9% vs 3.7%), low birth weight (LBW) (12.2% vs 3.1%) and small for gestational age (SGA) (21.3% vs 7.0%) were higher in HIV-infected women than HIV-uninfected women, with adjusted ORs of 2.77 (95%CI: 1.24-6.17), 2.37 (95%CI: 1.44-3.89), 4.20 (95%CI: 2.59-6.82) and 3.26 (95%CI: 3.26-4.64), respectively. No differences were found in neonatal asphyxia or birth defects between HIV-infected and HIV-uninfected groups, with adjusted ORs of 1.12 (95%CI: 0.37-3.43) and 1.10 (95%CI: 0.51-2.39), respectively. Among HIV-infected pregnant women, different antiretroviral (ARV) regimens were significantly associated with stillbirths, but not PTB, LBW or SGA. Compared with untreated HIV infection (10.1%), both mono/dual therapy and HAART were associated with a reduced risk of stillbirths (2.0% and 3.2%, respectively), with an AOR of 0.19 (95%CI: 0.04-0.92) and 0.31 (95%CI: 0.11-0.85), respectively. Initial time of ARV drugs use and HIV infection status of the sexual partner were not associated with maternal APOs.The findings of this study indicated that maternal HIV infection was associated with significantly increased risks of stillbirth, PTB, LBW and SGA, but not neonatal asphyxia or birth defects. On the condition that most HIV-infected pregnant women started ARV therapy in or after the second trimester, both mono/dual therapy and HAART had a protective effect on stillbirth compared with untreated HIV infection. As some important confounders were not effectively controlled and the specific regimens of HAART were not analyzed, the above findings may have certain bias.
Collapse
Affiliation(s)
- Huixia Li
- Department of Child Health Care
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital
| | | | | | | | - Jianfei Zheng
- Department of Emergency Medicine, Second Xiangya Hospital, Central South University
| | | | - Hua Wang
- NHC Key Laboratory of Birth Defects Research, Prevention and Treatment, Hunan Provincial Maternal and Child Health Care Hospital
- Department of Maternal Health Care, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan Province
| | | | - Na Feng
- Department of Health Care, Shenzhen Nanshan Maternal and Child Health Care Hospital, Shenzhen, Guangdong Province
| | - Guoqiang Zhang
- Department of AIDS Prevention and Control, Hunan Provincial Center for Disease Control and Prevention, Changsha, Hunan Province, China
| |
Collapse
|
29
|
Vézina-Im LA, Nicklas TA, Baranowski T. Intergenerational Effects of Health Issues Among Women of Childbearing Age: a Review of the Recent Literature. Curr Nutr Rep 2019; 7:274-285. [PMID: 30259413 DOI: 10.1007/s13668-018-0246-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the latest scientific evidence, primarily from systematic reviews/meta-analyses and large cohort studies, on the impact of health issues among women of childbearing age and their effect on their offspring during pregnancy and from birth to adulthood. RECENT FINDINGS Women of childbearing age with overweight/obesity, diabetes, and hypertension prior to pregnancy are at increased risk for adverse outcomes during pregnancy, such as excessive gestational weight gain, gestational diabetes mellitus, and hypertensive disorders of pregnancy. These adverse outcomes could complicate delivery and put their offspring at risk of developing overweight/obesity, diabetes, and hypertension (i.e., intergenerational transmission of health issues). Interventions should target women of childbearing age, especially those who wish to conceive, in order to possibly stop the transmission of women's health issues to the offspring and favor a healthy pregnancy from the start. This could be one of the best strategies to promote both maternal and child health.
Collapse
Affiliation(s)
- Lydi-Anne Vézina-Im
- Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX, 77030, USA.
| | - Theresa A Nicklas
- Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX, 77030, USA
| | - Tom Baranowski
- Children's Nutrition Research Center, Baylor College of Medicine, 1100 Bates Street, Houston, TX, 77030, USA
| |
Collapse
|
30
|
Preeclampsia: The Relationship between Uterine Artery Blood Flow and Trophoblast Function. Int J Mol Sci 2019; 20:ijms20133263. [PMID: 31269775 PMCID: PMC6651116 DOI: 10.3390/ijms20133263] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 12/29/2022] Open
Abstract
Maternal uterine artery blood flow is critical to maintaining the intrauterine environment, permitting normal placental function, and supporting fetal growth. It has long been believed that inadequate transformation of the maternal uterine vasculature is a consequence of primary defective trophoblast invasion and leads to the development of preeclampsia. That early pregnancy maternal uterine artery perfusion is strongly associated with placental cellular function and behaviour has always been interpreted in this context. Consistently observed changes in pre-conceptual maternal and uterine artery blood flow, abdominal pregnancy implantation, and late pregnancy have been challenging this concept, and suggest that abnormal placental perfusion may result in trophoblast impairment, rather than the other way round. This review focuses on evidence that maternal cardiovascular function plays a significant role in the pathophysiology of preeclampsia.
Collapse
|
31
|
Lackner HK, Papousek I, Schmid-Zalaudek K, Cervar-Zivkovic M, Kolovetsiou-Kreiner V, Nonn O, Lucovnik M, Pfniß I, Moertl MG. Disturbed Cardiorespiratory Adaptation in Preeclampsia: Return to Normal Stress Regulation Shortly after Delivery? Int J Mol Sci 2019; 20:ijms20133149. [PMID: 31252672 PMCID: PMC6651868 DOI: 10.3390/ijms20133149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/21/2019] [Accepted: 06/24/2019] [Indexed: 12/30/2022] Open
Abstract
Women with pregnancies complicated by preeclampsia appear to be at increased risk of metabolic and vascular diseases in later life. Previous research has also indicated disturbed cardiorespiratory adaptation during pregnancy. The aim of this study was to follow up on the physiological stress response in preeclampsia several weeks postpartum. A standardized laboratory test was used to illustrate potential deviations in the physiological stress responding to mildly stressful events of the kind and intensity in which they regularly occur in further everyday life after pregnancy. Fifteen to seventeen weeks postpartum, 35 women previously affected by preeclampsia (19 mild, 16 severe preeclampsia), 38 women after uncomplicated pregnancies, and 51 age-matched healthy controls were exposed to a self-relevant stressor in a standardized stress-reactivity protocol. Reactivity of blood pressure, heart rate, stroke index, and systemic vascular resistance index as well as baroreceptor sensitivity were analyzed. In addition, the mutual adjustment of blood pressure, heart rate, and respiration, partitioned for influences of the sympathetic and the parasympathetic branches of the autonomic nervous system, were quantified by determining their phase synchronization. Findings indicated moderately elevated blood pressure levels in the nonpathological range, reduced stroke volume, and elevated systemic vascular resistance in women previously affected by preeclampsia. Despite these moderate abnormalities, at the time of testing, women with previous preeclampsia did not differ from the other groups in their physiological response patterns to acute stress. Furthermore, no differences between early, preterm, and term preeclampsia or mild and severe preeclampsia were observed at the time of testing. The findings suggest that the overall cardiovascular responses to moderate stressors return to normal in women who experience a pregnancy with preeclampsia a few weeks after delivery, while the operating point of the arterial baroreflex is readjusted to a higher pressure. Yet, their regulation mechanisms may remain different.
Collapse
Affiliation(s)
- Helmut K Lackner
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 8010 Graz, Austria.
| | - Ilona Papousek
- Department of Psychology, Biological Psychology Unit, University of Graz, 8010 Graz, Austria.
| | - Karin Schmid-Zalaudek
- Division of Physiology, Otto Loewi Research Center, Medical University of Graz, 8010 Graz, Austria.
| | - Mila Cervar-Zivkovic
- Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria.
| | | | - Olivia Nonn
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, 8010 Graz, Austria.
| | - Miha Lucovnik
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia.
| | - Isabella Pfniß
- Department of Obstetrics and Gynecology, Medical University of Graz, 8036 Graz, Austria.
| | - Manfred G Moertl
- Department of Obstetrics and Gynecology, Clinical Center, 9020 Klagenfurt, Austria.
| |
Collapse
|
32
|
Salama M, Rezk M, Gaber W, Hamza H, Marawan H, Gamal A, Abdallah S. Methyldopa versus nifedipine or no medication for treatment of chronic hypertension during pregnancy: A multicenter randomized clinical trial. Pregnancy Hypertens 2019; 17:54-58. [PMID: 31487657 DOI: 10.1016/j.preghy.2019.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/27/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the maternal and fetal outcome in women with mild to moderate chronic hypertension on antihypertensive drug (methyldopa or nifedipine) therapy compared to no medication. METHODS This multicenter randomized clinical trial was conducted at Menoufia University hospital, Shibin El-kom Teaching hospital and 11 Central hospitals at Menoufia governorate, Egypt.490 pregnant women with mild to moderate chronic hypertension were randomized into three groups; methyldopa group (n = 166), nifedipine group (n = 160) and control or no medication group (n = 164) who were followed from the beginning of pregnancy till the end of puerperium to record maternal and fetal outcome. RESULTS Mothers in the control (no medication) group were more prone for the development of severe hypertension, preeclampsia, renal impairment, ECG changes, placental abruption and repeated hospital admissions (p < 0.001) when compared to mothers in both treatment groups (methyldopa and nifedipine). Neonates in the control (no medication) group were more prone for prematurity and admission to neonatal ICU (p < 0.001). CONCLUSION Antihypertensive drug therapy is advisable in mild to moderate chronic hypertension during pregnancy to decrease maternal and fetal morbidity. When considering which agents to use for treatment, oral methyldopa and nifedipine are valid options.
Collapse
Affiliation(s)
- Mohamed Salama
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Egypt
| | - Mohamed Rezk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Egypt.
| | - Wael Gaber
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Egypt
| | - Haitham Hamza
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Egypt
| | - Hala Marawan
- Department of Community Medicine and Public Health, Faculty of Medicine, Menoufia University, Egypt
| | - Awni Gamal
- Department of Cardiology, Faculty of Medicine, Menoufia University, Egypt
| | - Sameh Abdallah
- Department of Pediatrics, Faculty of Medicine, Menoufia University, Egypt
| |
Collapse
|
33
|
Kadji C, Cannie MM, Resta S, Guez D, Abi-Khalil F, De Angelis R, Jani JC. Magnetic resonance imaging for prenatal estimation of birthweight in pregnancy: review of available data, techniques, and future perspectives. Am J Obstet Gynecol 2019; 220:428-439. [PMID: 30582928 DOI: 10.1016/j.ajog.2018.12.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/20/2022]
Abstract
Fetuses at the extremes of growth abnormalities carry a risk of perinatal morbidity and death. Their identification traditionally is done by 2-dimensional ultrasound imaging, the performance of which is not always optimal. Magnetic resonance imaging superbly depicts fetal anatomy and anomalies and has contributed largely to the evaluation of high-risk pregnancies. In 1994, magnetic resonance imaging was introduced for the estimation of fetal weight, which is done by measuring the fetal body volume and converting it through a formula to fetal weight. Approximately 10 studies have shown that magnetic resonance imaging is more accurate than 2-dimensional ultrasound imaging in the estimation of fetal weight. Yet, despite its promise, the magnetic resonance imaging technique currently is not implemented clinically. Over the last 5 years, this technique has evolved quite rapidly. Here, we review the literature data, provide details of the various measurement techniques and formulas, consider the application of the magnetic resonance imaging technique in specific populations such as patients with diabetes mellitus and twin pregnancies, and conclude with what we believe could be the future perspectives and clinical application of this challenging technique. The estimation of fetal weight by ultrasound imaging is based mainly on an algorithm that takes into account the measurement of biparietal diameter, head circumference, abdominal circumference, and femur length. The estimation of fetal weight by magnetic resonance imaging is based on one of the 2 formulas: (1) magnetic resonance imaging-the estimation of fetal weight (in kilograms)=1.031×fetal body volume (in liters)+0.12 or (2) magnetic resonance imaging-the estimation of fetal weight (in grams)=1.2083×fetal body volume (in milliliters)ˆ0.9815. Comparison of these 2 formulas for the detection of large-for-gestational age neonates showed similar performance for preterm (P=.479) and for term fetuses (P=1.000). Literature data show that the estimation of fetal weight with magnetic resonance imaging carries a mean or median relative error of 2.6 up to 3.7% when measurements were performed at <1 week from delivery; whereas for the same fetuses, the relative error at 2-dimensional ultrasound imaging varied between 6.3% and 11.4%. Further, in a series of 270 fetuses who were evaluated within 48 hours from birth and for a fixed false-positive rate of 10%, magnetic resonance imaging detected 98% of large-for-gestational age neonates (≥95th percentile for gestation) compared with 67% with ultrasound imaging estimates. For the same series, magnetic resonance imaging applied to the detection of small-for-gestational age neonates ≤10th percentile for gestation, for a fixed 10% false-positive rate, reached a detection rate of 100%, compared with only 78% for ultrasound imaging. Planimetric measurement has been 1 of the main limitations of magnetic resonance imaging for the estimation of fetal weight. Software programs that allow semiautomatic segmentation of the fetus are available from imaging manufacturers or are self-developed. We have shown that all of them perform equally well for the prediction of large-for-gestational age neonates, with the advantage of the semiautomatic methods being less time-consuming. Although many challenges remain for this technique to be generalized, a 2-step strategy after the selection of a group who are at high risk of the extremes of growth abnormalities is the most likely scenario. Results of ongoing studies are awaited (ClinicalTrials.gov Identifier # NCT02713568).
Collapse
Affiliation(s)
- Caroline Kadji
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Serena Resta
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - David Guez
- Advanced Technology Center, Sheba Tel Hashomer Hospital, Ramat Gan, Israel
| | - Fouad Abi-Khalil
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium.
| |
Collapse
|
34
|
Akbar MIA, Adibrata MA, Aditiawarman, Aryananda RA, Angsar MD, Dekker G. Maternal and perinatal outcome related to severity of chronic hypertension in pregnancy. Pregnancy Hypertens 2019; 16:154-160. [PMID: 31056152 DOI: 10.1016/j.preghy.2019.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/03/2019] [Accepted: 04/21/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Chronic hypertension in pregnancy is an important cause of maternal and neonatal morbidity and mortality. The aim of this study was to determine the effect of severity of chronic hypertension in pregnancy on maternal and perinatal outcome in an Indonesian population. STUDY DESIGN This study was performed in Dr Soetomo General Hospital, a tertiary center in East - Java, Indonesia over the period of 2013-2017. Chronic hypertension (CH) was divided using JNC VII criteria, as stage 1 (Blood pressure ≥140/90 mmHg) and Stage 2 (BP > 160/110 mmHg) hypertension. MAIN OUTCOME MEASURES The primary outcomes were maternal and perinatal outcome. Data was statistically analyzed using Chi-square, Fischer exact test, and Mann-Whitney test (program: SPSS ®23). RESULTS Over these 5 years, 352 patients were diagnosed with CH. The stage 2 of CH was associated with worse maternal outcome: maternal death (5.6% vs 0.8%; p = 0.016), laboratory values of urinary protein +3 (67% vs 21,5%, p = 0.001) and +4 (12.3% vs 0.4%, p = 0.001), LDH > 600 IU/L (11.3% vs 5.3%, p = 0.04), ALT > 70 IU/L (11.3% vs 4.1%, p = 0.01), AST > 70 IU/L (12.3% vs 5.3%, p = 0.02), BUN > 25 mg/dL (27.4% vs 8.1%, p = 0.001), SK > 1.1 mg/dL (29.2% vs 6.5%, p = 0.001) and Albumin <3 g/dL (65.1% vs 10.2%, p = 0.001), need for ICU admission (76.4% vs 36.6%, p = 0.001), mechanical ventilation (48.1% vs 21.1%, p = 0.001), and occurrence of complications (72.6% vs 57.7%, p = 0.006). Stage 2 CH in pregnancy was associated with an increased risk of maternal death (OR: 7.22; 95% CI: 1.43-36.36; p = 0,016). Stage 2 CH was also associated with worse perinatal outcome, in terms of lower birth weight (1635 ± 863.27 vs 2063.74 ± 935.43, p = 0.001), lower Apgar score (p = 0.001), and number of intra uterine complications such as: IUGR, stillbirth, and placental abruption (27.4% vs 11.8%, p = 0.001). CONCLUSIONS Stage 2 CH in pregnancy is associated with worse maternal and perinatal outcomes compared with stage 1. Intervention to prevent disease progression to stage 2 before pregnancy may improve maternal and perinatal outcomes during pregnancy.
Collapse
Affiliation(s)
- Muhammad Ilham Aldika Akbar
- Department of Obstetrics & Gynecology, Soetomo Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Obstetrics & Gynecology, Universitas Airlangga Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.
| | - Muhammad Arief Adibrata
- Department of Obstetrics & Gynecology, Soetomo Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Aditiawarman
- Department of Obstetrics & Gynecology, Soetomo Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Rozi Aditya Aryananda
- Department of Obstetrics & Gynecology, Soetomo Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Muhammad Dikman Angsar
- Department of Obstetrics & Gynecology, Soetomo Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Gustaaf Dekker
- Department of Obstetrics & Gynecology, Soetomo Hospital, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Obstetrics & Gynecology, Lyell-McEwin Hospital, The University of Adelaide, Australia
| |
Collapse
|
35
|
Groenhof T, Ganzevoort W, Lely A. Chronic hypertension in pregnancy: an unique opportunity. Am J Obstet Gynecol 2018; 219:509-510. [PMID: 29885307 DOI: 10.1016/j.ajog.2018.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/31/2018] [Indexed: 10/14/2022]
|
36
|
Quinn M. Uterine arteriolar injuries in chronic hypertension. Am J Obstet Gynecol 2018; 219:508-509. [PMID: 29885302 DOI: 10.1016/j.ajog.2018.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 05/31/2018] [Indexed: 11/26/2022]
|