New Evidence in the Management of Chronic Hypertension in Pregnancy

Nutricional intake, maternal outcomes and knowledge on preeclampsia prevention: Was there impact during the COVID-19 pandemic among women with hypertension?

AIM

Compare nutritional intake, weight gain, frequency of superimposed pre-eclampsia (SPE) and adequate use/knowledge on preventive interventions for PE, before and during the COVID-19 pandemic among pregnant women with chronic hypertension (CH) METHODS: Prospective cohort of pregnant women with CH. Inclusion between 13 and 25 weeks, with sociodemographic characterization, food frequency questionnaire and 24-hour recall (R24h). Indirect adherence test MEDTAKE was employed to investigate adequate use/understanding of calcium and aspirin. Frequency of SPE, weight gain, food intake, maternal and perinatal outcomes were compared between periods.

RESULTS

58 women were included and 116 R24h considered. Over 80 % used aspirin and calcium for PE prophylaxis. However, less than half understood the meaning of such interventions. There were no differences in sociodemographic characteristics, majority white, 20 to 34 years-old, and multiparous. There were 31 women included before and 27 during the pandemic. Frequency of SPE was respectively 40 % and 44.4 % before and during the pandemic (p = 0.746) and weight gain 8.7Kg before and 7.4Kg during the pandemic. There was no difference in macronutrient intake, average calcium consumption was 444.8 mg before and 402.6 mg during the pandemic; with inadequate use/understanding of preventive interventions for PE.

CONCLUSION

The pandemic period did not significantly increase the risk of SPE, without significant increase in weight gain or worsening food quality intake and knowledge on preventive interventions.

Pregnancy in end-stage kidney disease: Great news that needs to be handled carefully

Compared to women with normal kidney function, women with end-stage kidney disease (ESKD) are much less likely to become pregnant, but more likely to have a complicated pregnancy. While renal transplantation remains the best option for women who desire to have a child, pregnancy on dialysis should be considered an option for those who may not receive a transplant during their reproductive years. Many physicians do not encounter a pregnant patient with ESKD during their nephrology training, and may not feel prepared to provide care for such patients in a busy practice. In this paper, we briefly provide an overview of the most significant practical points related to management of a pregnant patient with ESKD through a real-life case with twin pregnancy. The two key elements in management of these patients would be an intensified hemodialysis regimen and a multidisciplinary team that can provide frequent, regular, and multifaceted assessments.

A retrospective review of pregnancy outcomes in women with uncomplicated mild to moderate chronic hypertension

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.

Pro-BNP Levels and Its Prognostic Role in Chronic Hypertensive Pregnancies: A Prospective Case-Control Study From A Tertiary Care Hospital

BACKGROUND

This study aimed to investigate the prognostic value of N-terminal B-type natriuretic peptide (NT-proBNP) in pregnancies with isolated chronic hypertension (HT).

METHOD

34 pregnant women with chronic HT and 40normotensive controls were enrolled. The association between plasma NT-proBNP levels obtained in the first trimester and perinatal complications were evaluated.

RESULTS

NT-proBNP levelsstrongly predicted low birth weight (AUC=0.842, p<0.001). NT-proBNP and birth weight were negatively correlated (r= -0.323, p=0.005). NT-proBNP was found to be an individual determinant of low birth weight in univariate analysis (OR:1.03; 95%CI:1.01-1.04).

CONCLUSION

NT-proBNP levels can be useful to predict low birth weight in pregnancies with chronic HT.

CNN-Based LCD Transcription of Blood Pressure From a Mobile Phone Camera

Routine blood pressure (BP) measurement in pregnancy is commonly performed using automated oscillometric devices. Since no wireless oscillometric BP device has been validated in preeclamptic populations, a simple approach for capturing readings from such devices is needed, especially in low-resource settings where transmission of BP data from the field to central locations is an important mechanism for triage. To this end, a total of 8192 BP readings were captured from the Liquid Crystal Display (LCD) screen of a standard Omron M7 self-inflating BP cuff using a cellphone camera. A cohort of 49 lay midwives captured these data from 1697 pregnant women carrying singletons between 6 weeks and 40 weeks gestational age in rural Guatemala during routine screening. Images exhibited a wide variability in their appearance due to variations in orientation and parallax; environmental factors such as lighting, shadows; and image acquisition factors such as motion blur and problems with focus. Images were independently labeled for readability and quality by three annotators (BP range: 34-203 mm Hg) and disagreements were resolved. Methods to preprocess and automatically segment the LCD images into diastolic BP, systolic BP and heart rate using a contour-based technique were developed. A deep convolutional neural network was then trained to convert the LCD images into numerical values using a multi-digit recognition approach. On readable low- and high-quality images, this proposed approach achieved a 91% classification accuracy and mean absolute error of 3.19 mm Hg for systolic BP and 91% accuracy and mean absolute error of 0.94 mm Hg for diastolic BP. These error values are within the FDA guidelines for BP monitoring when poor quality images are excluded. The performance of the proposed approach was shown to be greatly superior to state-of-the-art open-source tools (Tesseract and the Google Vision API). The algorithm was developed such that it could be deployed on a phone and work without connectivity to a network.

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

OBJECTIVE DATA

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

STUDY

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

STUDY APPRAISAL AND SYNTHESIS METHODS

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

RESULTS

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

CONCLUSION

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

A mushroom diet reduced the risk of pregnancy-induced hypertension and macrosomia: a randomized clinical trial

Background

Pregnancy-induced hypertension (PIH) is a disease characterized by high blood pressure detected after 20 weeks of pregnancy, affecting approximately 10% of pregnant women worldwide. Effective strategies are imperatively needed to prevent and treat PIH.

Methods

Subjects were required to consume 100 g mushroom daily from pre-pregnancy to the 20th week of gestation. The gestational hypertension and related primary and secondary outcomes of the mushroom diet (MD) group and placebo group were investigated to compare the intervention of a MD on the PIH and preeclampsia-associated maternal and child health conditions.

Results

A total of 582 and 580 subjects belonging to the MD group and placebo group were included for the analysis, respectively. Compared to the placebo, the MD significantly reduced the incidence of gestational hypertension (P = 0.023), preeclampsia (P = 0.014), gestational weight gain (P = 0.017), excessive gestational weight gain (P = 0.032) and gestational diabetes (P = 0.047). Stratified analysis showed that the MD lowered the risk of PIH for overweighed women (P = 0.036), along with the percentage of macrosomia (P = 0.007).

Conclusion

An MD could serve as a preventative strategy for lowering the risk of PIH and could control newborn birthweight while reducing comorbidities including gestational weight gain, diabetes etc.

Methyldopa versus nifedipine or no medication for treatment of chronic hypertension during pregnancy: A multicenter randomized clinical trial

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.

Increases in placental nitric oxide, but not nitric oxide-mediated relaxation, underlie the improvement in placental efficiency and antihypertensive effects of hydrogen sulphide donor in hypertensive pregnancy

Dysregulation of hydrogen sulphide (H₂ S) producing enzymes has been related to hypertensive pregnancy, and H₂ S donor, sodium hydrosulphide (NaHS) exerts antihypertensive effects, modulates angiogenic factors production and acts as an antioxidant. Moreover, reduction in nitric oxide (NO) bioavailability is related to hypertensive pregnancy and H₂ S may interact with NO, modulating its production. We aimed to investigate the NaHS effects in hypertension-in-pregnancy and also in feto-placental parameters. Female Wistar rats (200-250 g) were mated and desoxycorticosterone acetate injections followed by replacement of water by 0.9% saline solution were used to induce hypertensive pregnancy. Rats were divided into four groups: normal pregnant (Norm-Preg), pregnant + NaHS (Preg+NaHS), hypertensive pregnant (HTN-Preg) and HTN-Preg+NaHS. Systolic blood pressure was increased in HTN-Preg and this increase was blunted in HTN-Preg+NaHS. Fetal and placental weights were decreased in HTN-Preg animals, while fetal growth restriction was improved in HTN-Preg+NaHS. Placental weight was lower in HTN-Preg+NaHS than in HTN-Preg; however, placental efficiency was re-established in HTN-Preg+NaHS rats. We observed that a partial contribution of placental NO, but not changes in anti-angiogenic factors may mediate the increases in placental efficiency in HTN-Preg+NaHS. HTN-Preg presented thoracic aorta hyperreactivity to phenylephrine while NaHS treatment blunted this hyperreactivity, which seems not to be related to NO-mediated relaxation induced by acetylcholine. Therefore, changes in vascular responsiveness promoted by NaHS treatment may underlie the beneficial effects in systolic blood pressure and feto-placental parameters in our study.

Resistant Hypertension in Pregnancy: How to Manage?

PURPOSE OF REVIEW

The concept of resistant hypertension may be changed during pregnancy by the physiological hemodynamic changes and the particularities of therapy choices in this period. This review discusses the management of pregnant patients with preexisting resistant hypertension and also of those who develop severe hypertension in gestation and puerperium.

RECENT FINDINGS

The main cause of severe hypertension in pregnancy is preeclampsia, and differential diagnosis must be done with secondary or primary hypertension. Women with preexisting resistant hypertension may need pharmacological therapy adjustment. Several drugs can be used to treat severe hypertension, with exception of angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists. The most used drugs are methyldopa, beta-blockers, and calcium channel antagonists. There is a general agreement that severe hypertension must be treated, but there are still debates over the goals of the treatment. Delivery is indicated in viable pregnancies in which blood pressure control is not achieved with three drugs in full doses. Resistant hypertension may arise in postpartum. The management of resistant hypertension in pregnancy must regard the possible etiology, the fetal well-being, and the mother's risk. Good care is mandatory to reduce maternal mortality risk.