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Countouris ME, Shapero KS, Swabe G, Hauspurg A, Davis EM, Magnani JW. Association of Race and Ethnicity and Social Factors With Postpartum Primary Care or Cardiology Follow-Up Visits Among Individuals With Preeclampsia. J Am Heart Assoc 2024; 13:e033188. [PMID: 39109511 DOI: 10.1161/jaha.123.033188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 07/02/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Preeclampsia is associated with increased cardiovascular morbidity and death. Primary care or cardiology follow-up, in complement to routine postpartum obstetric care, provides an essential opportunity to address cardiovascular risk. Prior studies investigating racial differences in the recommended postpartum follow-up have incompletely assessed the influence of social factors. We hypothesized that racial and ethnic differences in follow-up with a primary care provider or cardiologist would be modified by income and education. METHODS AND RESULTS We identified adult individuals with preeclampsia (September 2014 to September 2019) in a national administrative database. We compared occurrence of a postpartum visit with a primary care provider or cardiologist within 1 year after delivery by race and ethnicity using multivariable logistic regression models. We examined whether education or income modified the association between race and ethnicity and the likelihood of follow-up. Of 18 050 individuals with preeclampsia (aged 31.8±5.7 years), Black individuals (11.7%) had lower odds of primary care provider or cardiology follow-up within 1 year after delivery compared with White individuals (adjusted odds ratio, 0.77 [95% CI, 0.70-0.85]) as did Hispanic individuals (14.8%; adjusted odds ratio, 0.79 [95% CI, 0.73-0.87]). Black and Hispanic individuals with higher educational attainment were more likely to have follow-up than those with lower educational attainment (P for interaction=0.033) as did those in higher income brackets (P for interaction=0.006). CONCLUSIONS We identified racial and ethnic differences in primary care or cardiology follow-up in the year postpartum among individuals diagnosed with preeclampsia, a disparity that may be modified by social factors. Enhanced system-level interventions are needed to reduce barriers to follow-up care.
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Affiliation(s)
- Malamo E Countouris
- Division of Cardiology, Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Kayle S Shapero
- Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University Providence RI USA
| | - Gretchen Swabe
- Division of Cardiology, Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology, and Reproductive Sciences University of Pittsburgh Pittsburgh PA USA
| | - Esa M Davis
- Department of Family and Community Medicine University of Maryland Baltimore MD USA
| | - Jared W Magnani
- Division of Cardiology, Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
- Center for Research on Health Care University of Pittsburgh School of Medicine Pittsburgh PA USA
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Cochrane E, Doctor T, Tavella N, Dubois B, McCarthy L, Stratis C, Stoffels G, Bianco A, DeBolt C. Examining the predictive value of fetal fraction on hypertensive disorders of pregnancy. Eur J Obstet Gynecol Reprod Biol 2024; 301:77-81. [PMID: 39106618 DOI: 10.1016/j.ejogrb.2024.08.001] [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: 04/03/2024] [Revised: 07/17/2024] [Accepted: 08/01/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Cell-free fetal DNA (cffDNA) screening is routinely performed in pregnancy. Abnormal fetal fraction has been associated with adverse pregnancy outcomes, including hypertensive disorders of pregnancy, which are associated with severe maternal and neonatal morbidity and mortality. OBJECTIVE This study examined whether abnormal fetal fraction, defined in this study as fetal fraction either <6 or >15 on the basis of restricted-cubic-spline-plot within our study population, was associated with HDP in a retrospective sample, as well as whether fetal fraction improves the prediction of hypertensive disorders of pregnancy (HDP). We hypothesized that abnormal fetal fraction would be associated with HDP and that adding fetal fraction to a model would significantly improve its strength to predict HDP. STUDY DESIGN This was a retrospective cohort study of 729 patients delivering singleton, non-anomalous pregnancies with conclusive cffDNA screening. The primary outcome was HDP. Logistic regression models tested associations between fetal fraction and HDP. We evaluated the impact of including fetal fraction on the prediction of hypertensive disorders of pregnancy (HDP) by comparing the area under the receiver operating characteristic (ROC) curve (AUC) between predictive models with and without fetal fraction. RESULTS Among the study sample, there was an HDP rate of 11.5 %. Abnormal fetal fraction was defined as <6 % percentile and >15 %, HDP incidence was significantly higher in patients with fetal fraction <6 % compared to patients with fetal fraction in normal range (fetal fraction 6-15 %) (19.5 % vs 10.7 %, p = 0.006 on post hoc comparison). Model 1 had one predictor (fetal fraction) with an AUC of 0.59, Model 2 had three predictors (BMI, nulliparity, history of HDP) with an AUC of 0.71, and Model 3 had four predictors (BMI, nulliparity, history of HDP, and fetal fraction) with an AUC of 0.73. Models 2 and 3 were not significantly different (p = 0.18). CONCLUSIONS More patients who developed HDP had low fetal fraction and fewer patients who developed HDP had high fetal fraction compared to those patients who did not develop HDP. Based on results from multivariable regression models, we cannot conclude that fetal fraction improves HDP prediction. However, developing standardized values for abnormal fetal fraction may be clinically useful.
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Affiliation(s)
| | - Tahera Doctor
- Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | | | | | - Lily McCarthy
- Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | | | | | - Angela Bianco
- Icahn School of Medicine at Mount Sinai, NY, NY, USA
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Broussard LL, Mejia-Greene KX, Devane-Johnson SM, Lister RL. Collaborative Training as a Conduit to Build Knowledge in Black Birth Workers. J Racial Ethn Health Disparities 2024; 11:2037-2043. [PMID: 37365426 DOI: 10.1007/s40615-023-01671-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/31/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Black women have worse birthing outcomes in part due to perceived racism. Therefore, mistrust between Black birthing people and their obstetric providers is profound. Black birthing people may use doulas to support and advocate throughout their pregnancy. OBJECTIVE The objective of this study was to create a structured didactic training between community doulas and institutional obstetric providers to address common pregnancy complications that disproportionately affect Black women. STUDY DESIGN The collaborative training session was a 2-h-long session jointly developed by a community doula, Maternal/Fetal Medicine physician, and a nurse midwife. The doulas (n = 12) took a pre- and post-test assessment before and after collaborative training. The scores were averaged, and we calculated student t tests between the pre- and post-assessment. A p-value of < 0 .05 was significant. RESULTS All twelve participants who completed this training session identified as Black cisgender women. The mean score correct of the pretest results was 55.25%. The initial percent correct for post-birth warning signs, hypertension in pregnancy, and gestational diabetes mellitus/ breastfeeding sections were 37.5%, 72.9%, and 75%, respectively. Following training, the percent correct per section increased to 92.7%, 81.3%, and 100% respectively. The mean score of correct answers on the post-test increased to 91.92% (p < 0.01). CONCLUSION An educational framework that leverages community and institutional partnerships between doulas and institutional obstetric providers can bridge the gap to improve knowledge of community partners and increase trust of Black birth workers.
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Affiliation(s)
| | | | | | - Rolanda L Lister
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, B1100 Medical Center North, Nashville, TN, 37232, USA.
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Chapman RR, Mohamed SB, Rage H, Abdulahi A, Jimenez J, Gavin AR, Zetell J, Chatterjee KN, Valderrábano S, Sundar S, Madey H, Pfeiffer JT. Preventing Health Disparities during COVID through Perinatal Home Screening as Black Authoritative Knowledge. J Racial Ethn Health Disparities 2024; 11:1286-1300. [PMID: 37191769 PMCID: PMC10187511 DOI: 10.1007/s40615-023-01608-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
During COVID-19 epidemic, health protocols limited face-to-face perinatal visits and increased reliance on telehealth. To prevent increased health disparities among BIPOC pregnant patients in health-underserved areas, we used a pre-post survey design to pilot a study assessing (1) feasibility of transferring technology including a blood pressure (BP) cuff (BPC) and a home screening tool, (2) providers' and patients' acceptance and use of technology, and (3) benefits and challenges of using the technology. Specific objectives included (1) increasing contact points between patients and perinatal providers; (2) decreasing barriers to reporting and treating maternal hypertension, stress/depression, and intimate partner violence (IPV)/domestic violence (DV); and (3) bundling to normalize and facilitate mental, emotional, and social health monitoring alongside BP screening. Findings confirm this model is feasible. Patients and providers used this bundling model to improve antenatal screening under COVID quarantine restrictions. More broadly, home-monitoring improved antenatal telehealth communication, provider diagnostics, referral and treatment, and bolstered patient autonomy through authoritative knowledge. Implementation challenges included provider resistance, disagreement with lower than ACOG BP values to initiate clinical contact and fear of service over-utilization, and patient and provider confusion about tool symbols due to limited training. We hypothesize that routinized pathologization and projection of crisis onto BIPOC people, bodies, and communities, especially around reproduction and continuity, may contribute to persistent racial/ethnic health disparities. Further research is needed to examine whether authoritative knowledge increases use of critical and timely perinatal services by strengthening embodied knowledge of marginalized patients and, thus, their autonomy and self-efficacy to enact self-care and self-advocacy.
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Affiliation(s)
- Rachel R Chapman
- Department of Anthropology, University of Washington, Seattle, WA, USA.
| | - Sumaya B Mohamed
- Department of Anthropology, University of Washington, Seattle, WA, USA
| | | | | | - Jan Jimenez
- College of Osteopathic Medicine, Yakima, WA, USA
| | - Amelia R Gavin
- School of Social Work, University of Washington, Seattle, WA, USA
| | - Jasmine Zetell
- Department of Anthropology, University of Washington, Seattle, WA, USA
| | | | | | | | | | - James T Pfeiffer
- Department of Global Health, University of Washington, Seattle, WA, USA
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Rajendran A, Liu Y, Boyer TM, Vaught AJ, Hays AG, Coresh J, Vaidya D, Michos ED, Minhas AS. Regional Differences in the US in Outcomes with Preeclampsia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.20.24307230. [PMID: 38826281 PMCID: PMC11142255 DOI: 10.1101/2024.05.20.24307230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
This study explores preeclampsia outcomes across US regions and examines regional differences in specific preeclampsia-associated pregnancy complications and disease management. Patient-reported measures were obtained from The Preeclampsia Registry, an open-access database composed of women with at least one pregnancy diagnosed with a hypertensive disorder of pregnancy. Pregnancies and associated outcomes were stratified by US region (Northeast, Midwest, South and West). Among 2,667 pregnancies of which 92% were in White women, maximum systolic blood pressure at any time in pregnancy was highest among women in the South and Midwest (p=0.039). Furthermore, more women in the South received pre-pregnancy antihypertensives (p=0.026) and antenatal steroids (p=0.025) and delivered at an earlier gestational age (p=0.014) compared to women in other regions. Pregnancy complications such as elevated liver enzymes were higher in women in the South (p=0.019), and women in the South and West had additional end-organ damage such as renal complications (p<0.001) and hemolysis (p=0.008) as compared to women in other regions. Further investigation is needed to assess whether healthcare access or policy could be contributing to these regional discrepancies.
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Affiliation(s)
- Aardra Rajendran
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yisi Liu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Theresa M. Boyer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Arthur J. Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
- Division of Acute Care and Adult Trauma Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Allison G. Hays
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dhananjay Vaidya
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Erin D. Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anum S. Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Xu XR, Cheng L, Wang YP. Prediction of severe preeclampsia and intrauterine growth restriction based on serum placental exosome miR-520a-5p levels during the first-trimester. Medicine (Baltimore) 2024; 103:e38188. [PMID: 38758859 PMCID: PMC11098175 DOI: 10.1097/md.0000000000038188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/18/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND To assess the predictive capabilities of serum exosomal levels of micro-RNA-520a-5p (miR-520a-5p) concerning the occurrence of severe preeclampsia (sPE) and fetal growth restriction (FGR) during the first trimester of pregnancy. METHODS During the period spanning from October 2020 to October 2021, serum samples were procured from the first trimester and subsequently preserved by freezing at -80 ℃. These samples were obtained from 105 pregnant women in a nested case-control study. This cohort consisted of individuals who later developed sPE (sPE group, n = 35) and FGR (FGR group, n = 35) during the third trimester. Additionally, 35 women with normal blood pressure were denoted as normal pregnancy group. Serum samples from the first trimester were retrieved from all groups for further analysis after thawing. Exosomes were extracted from the serum samples collected during the first trimester and examined using transmission electron microscopy, western blot, and nanoparticle tracking analysis. Additionally, the determination of their placental origin was also established during the course of the study. Exosome miR-520a-5p levels were measured using real-time quantitative polymerase chain reaction assays, primarily involving quantitative reverse transcription polymerase chain reactions. Fetal placental tissues from the 3 groups were collected shortly after birth, and miR-520a-5p expression was measured using real-time quantitative polymerase chain reaction. Serum placental exosomes and fetal placental tissues were compared for miR-520a-5p levels. Placental trophoblasts were identified as the source of serum exosomes in all 3 groups. RESULTS It was found that serum placental exosomes exhibited lower levels of miR-520a-5p in both the sPE and FGR groups when compared to the normal pregnancy group. This finding was consistent with observations made in postpartum placental tissues. The predictive accuracy for sPE using miR-520a-5p levels in serum placental exosomes during the first trimester was notably higher (area under the receiver operating characteristic curve = 0.806, P <.05) compared to the prediction of FGR (area under the receiver operating characteristic curve = 0.628, P <.05). CONCLUSION Placenta-derived exosomes can be extracted from maternal serum during the first trimester of pregnancy and miR-520a-5p detected from the exosomes. The downregulation of miR-520a-5p serves as a more predictive indicator for the subsequent development of sPE compared to predicting FGR.
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Affiliation(s)
- Xin-Ran Xu
- Obstetrics Department of Tianjin Central Hospital of Obstetrics and Gynecology, Tianjin, China
- NanKai University Affiliated Maternity Hospital, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Lan Cheng
- Obstetrics Department of Tianjin Central Hospital of Obstetrics and Gynecology, Tianjin, China
- NanKai University Affiliated Maternity Hospital, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
| | - Yan-Ping Wang
- Obstetrics Department of Tianjin Central Hospital of Obstetrics and Gynecology, Tianjin, China
- NanKai University Affiliated Maternity Hospital, Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin, China
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Conklin MB, Wells BM, Doe EM, Strother AM, Tarasiewicz MEB, Via ER, Conrad LB, Farias-Eisner R. Understanding Health Disparities in Preeclampsia: A Literature Review. Am J Perinatol 2024; 41:e1291-e1300. [PMID: 36603833 DOI: 10.1055/a-2008-7167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Preeclampsia is a multifactorial pathology with negative outcomes in affected patients in both the peripartum and postpartum period. Black patients in the United States, when compared to their White and Hispanic counterparts, have higher rates of preeclampsia. This article aims to review the current literature to investigate how race, social determinants of health, and genetic profiles influence the prevalence and outcomes of patients with preeclampsia. Published studies utilized in this review were identified through PubMed using authors' topic knowledge and a focused search through a Medline search strategy. These articles were thoroughly reviewed to explore the contributing biosocial factors, genes/biomarkers, as well as negative outcomes associated with disparate rates of preeclampsia. Increased rates of contributing comorbidities, including hypertension and obesity, which are largely associated with low access to care in Black patient populations lead to disparate rates of preeclampsia in this population. Limited research shows an association between increased rate of preeclampsia in Black patients and specific APOL1, HLA-G, and PP13 gene polymorphisms as well as factor V Leiden mutations. Further research is required to understand the use of certain biomarkers in predicting preeclampsia within racial populations. Understanding contributing biosocial factors and identifying genes that may predispose high-risk populations may help to address the disparate rates of preeclampsia in Black patients as described in this review. Further research is required to understand if serum, placental, or urine biomarkers may be used to predict individuals at risk of developing preeclampsia in pregnancy. KEY POINTS: · Prevalence of preeclampsia in the U.S. is higher in Black patients compared to other racial groups.. · Patients with preeclampsia are at risk for poorer health outcomes both during and after delivery.. · Limited research suggests specific biomarkers or gene polymorphisms contribute to this difference; however, explanations for this disparity are multifactorial and further investigation is necessary..
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Affiliation(s)
- Mary B Conklin
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Emily M Doe
- School of Medicine, Creighton University, Omaha, Nebraska
| | | | | | - Emily R Via
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Lesley B Conrad
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, School of Medicine, Creighton University, Omaha, Nebraska
- Lynch Comprehensive Cancer Research Center, School of Medicine, Creighton University, Omaha, Nebraska
| | - Robin Farias-Eisner
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, School of Medicine, Creighton University, Omaha, Nebraska
- Lynch Comprehensive Cancer Research Center, School of Medicine, Creighton University, Omaha, Nebraska
- College of Osteopathic Medicine of the Pacific Northwest, Western University of Health Sciences, Pomona, California
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, the University of California at Los Angeles, Los Angeles, California
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Woolcock H, Parra N, Zhang Y, Reddy UM, Bello NA, Miller E, Booker WA. Pregnancy Outcomes in Women Who Developed Elevated Blood Pressure and Stage I Hypertension after 20 Weeks Gestation. Am J Perinatol 2024. [PMID: 38569509 DOI: 10.1055/a-2298-5347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The American College of Obstetrics threshold for hypertension (≥140/90 mm Hg) differs from those of the American College of Cardiology (ACC) and the American Heart Association (AHA). It is unknown if ACC/AHA hypertension levels are associated with adverse pregnancy outcomes (APOs) after 20 weeks gestation. The purpose of this study is to analyze APOs in women with blood pressure (BP) in the elevated or stage 1 range after 20 weeks gestation. STUDY DESIGN This was a secondary analysis of the nuMoM2b prospective cohort study of 10,038 nulliparous, singleton pregnancies between 2010 and 2014. BP was measured at three visits during the pregnancy using a standard protocol. Women without medical comorbidities, with normal BP by ACC/AHA guidelines (systolic BP [SBP] < 120 and diastolic BP [DBP] < 80 mm Hg) up to 22 weeks, were included. Exposure was BP between 22 and 29 weeks gestation: normal (SBP < 120 and DBP < 80 mm Hg), elevated (SBP: 120-129 and DBP < 80 mm Hg), and stage 1 (SBP: 130-139 or DBP: 80-89 mm Hg). The primary outcome was hypertensive disorder of pregnancy (HDP) at delivery. Secondary outcomes included fetal growth restriction (FGR), placental abruption, preterm delivery, and cesarean delivery. Multivariable-adjusted odds ratio (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. RESULTS Of 4,460 patients that met inclusion criteria, 3,832 (85.9%) had BP in the normal range, 408 (9.1%) in elevated, and 220 (4.9%) in stage 1 range between 22 and 29 weeks. The likelihood of HDP was significantly higher in women with elevated BP (aOR 1.71, 95%CI: 1.18,2.48), and stage 1 BP (aOR: 2.79, 95%CI: 1.84,4.23) compared to normal BP (p < 0.001). Stage 1 BP had twice odds of FGR (aOR: 2.33, 95%CI: 1.22,4.47) and elevated BP had three times odds of placental abruption (aOR: 3.03; 95%CI: 1.24,7.39). CONCLUSION Elevated or stage 1 BP >20 weeks of pregnancy are associated with HDP, FGR, and placental abruption. KEY POINTS · Elevated and stage 1 BP increases risk for HDP.. · Elevated BP increases risk for placental abruption.. · Stage 1 BP increases risk for FGR..
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Affiliation(s)
- Helen Woolcock
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York
| | - Natalia Parra
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York
| | - Yijia Zhang
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York
| | - Natalie A Bello
- Department of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Eliza Miller
- Department of Neurology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York
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Ragunanthan NW, Lamb J, Hauspurg A, Beck S. Assessment of Racial Disparities in Aspirin Prophylaxis for Preeclampsia Prevention. Am J Perinatol 2024; 41:635-640. [PMID: 35189651 PMCID: PMC9900494 DOI: 10.1055/s-0042-1743142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Low-dose aspirin is recommended for preeclampsia prevention among women with high-risk conditions, including chronic hypertension. Black women have higher rates of hypertensive disorders of pregnancy, and whether this is related to disparities in aspirin prophylaxis is unknown. We investigated the relationship between race and counseling/prescription and uptake of aspirin among a cohort of women with chronic hypertension. STUDY DESIGN This is a single-institution, retrospective cohort study of women with chronic hypertension who delivered between 2016 and 2018. Medical record review was performed to assess counseling/prescription of aspirin prophylaxis and self-reported uptake. Self-reported uptake was determined by mention in the provider's notes or by inclusion in the medication reconciliation system. Demographic and obstetric outcome data were compared by self-reported race (Black vs. all other races) in univariate analysis. Multivariable logistic regression analysis was performed to evaluate the association between race and aspirin adherence. RESULTS We included 872 women: 361 (41.4%) Black women and 511 (58.6%) white or other race women. Overall, 567 (65.0%) women were counseled and/or given a prescription for aspirin, and 411 (72.4%) of those women reported uptake. Black women were equally likely to be counseled and/or prescribed aspirin compared with all other races (67.3 vs. 63.4%; p = 0.7). However, Black women were less likely to report uptake of aspirin (63.8 vs. 79.0%; p < 0.001). After adjustment for total prenatal visits and tobacco use, Black race was associated with an adjusted odds ratio of 0.53 (95% confidence interval: 0.36-0.78) for uptake of aspirin. CONCLUSION In our cohort, recommendation for aspirin prophylaxis was suboptimal in all groups, reaching only 65% of eligible women. Black women were equally likely as women of other races to receive counseling about aspirin, but rates of uptake were lower. Our findings suggest that counseling and prescription of aspirin alone in high-risk Black women are not sufficient for utilization of this intervention. KEY POINTS · Rates of counseling about aspirin prophylaxis for preeclampsia did not vary by race.. · Black women had lower rates of uptake of aspirin compared with women of other races.. · Counseling about aspirin was inadequate in general, reaching only 65% of eligible women..
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Affiliation(s)
- Nina W. Ragunanthan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jordan Lamb
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stacy Beck
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Johnson JD. Black Pregnancy-Related Mortality in the United States. Obstet Gynecol Clin North Am 2024; 51:1-16. [PMID: 38267121 DOI: 10.1016/j.ogc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
The maternal mortality rate for non-Hispanic Black birthing people is 69.9 deaths per 100,000 live births compared with 26.6 deaths per 100,000 live births for non-Hispanic White birthing people. Black pregnancy-related mortality has been underrepresented in research and the media; however, there is growing literature on the role of racism in health disparities. Those who provide care to Black patients should increase their understanding of racism's impact and take steps to center the experiences and needs of Black birthing people.
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Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, 550 North University Bloulevard, Suite 2440, Indianapolis, IN 46202, USA.
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Daskalopoulou SS, Labos C, Kuate Defo A, Cooke AB, Kalra B, Kumar A, Mantzoros CS. Analysis of Predictive Information From Biomarkers Added to Clinical Models of Preeclampsia: Consideration of PAPP-A2, Activin A, and sFlt-1:PlGF Ratio. Can J Cardiol 2024; 40:422-430. [PMID: 38787345 DOI: 10.1016/j.cjca.2023.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/22/2023] [Accepted: 10/23/2023] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Preeclampsia remains a major cause of maternal and fetal adverse outcomes in pregnancy; however, accurate and universally acceptable predictive tools remain elusive. We investigated whether a panel of biomarkers could improve risk prediction for preeclampsia when measured at various pregnancy time points. METHODS In this prospective cohort study, 192 women with first-trimester high-risk singleton pregnancies were consecutively recruited from tertiary obstetrics clinics in Montréal, Canada. Clinical information (height, pre-pregnancy weight, personal and family medical history, medication use) was collected at baseline. Blood pressure was measured and blood samples collected at each trimester to quantify soluble Fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF), pregnancy-associated plasma protein A2 (PAPP-A2), PAPP-A, activin A, inhibin A, follistatin, and glycosylated fibronectin. A random-effects hierarchic logistic regression model was used to relate change in biomarker levels to incidence of preeclampsia. RESULTS When added to a clinical model composed of maternal age, pre-pregnancy body mass index, race, and mean arterial pressure, a positive third-trimester result for both PAPP-A2 and activin A had a better positive predictive value than the sFlt-1:PlGF ratio added to the clinical model (91.67% [95% confidence interval (CI) 78.57%-100%] vs 66.67% [57.14%-100%]), while maintaining a comparable high negative predictive value (97.69% [95% CI 95.34%-100%] vs 96.00% [92.19%-99.21%]). CONCLUSIONS Whereas the third-trimester sFlt-1:PlGF ratio can predict short-term absence of preeclampsia, PAPP-A2 and activin A had both high positive and negative predictive values and therefore could serve as biomarkers to predict the occurrence (and absence) of preeclampsia; these findings will be validated in future studies.
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Affiliation(s)
- Stella S Daskalopoulou
- Vascular Health Unit, Research Institute of the McGill University Health Centre, Department of Medicine, McGill University, Montréal, Québec, Canada; Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada; Division of Internal Medicine, Department of Medicine, McGill University Health Centre, McGill University, Montréal, Québec, Canada.
| | - Christopher Labos
- Vascular Health Unit, Research Institute of the McGill University Health Centre, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Alvin Kuate Defo
- Vascular Health Unit, Research Institute of the McGill University Health Centre, Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Alexandra B Cooke
- Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada
| | | | | | - Christos S Mantzoros
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA; Section of Endocrinology, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts, USA
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Adams EK, Kramer MR, Joski PJ, Coloske M, Dunlop AL. Examination of the Black-White racial disparity in severe maternal morbidity among Georgia deliveries, 2016 to 2020. AJOG GLOBAL REPORTS 2024; 4:100303. [PMID: 38283324 PMCID: PMC10811457 DOI: 10.1016/j.xagr.2023.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Studies find that delivery hospital explains a significant portion of the Black-White gap in severe maternal morbidity. No such studies have focused on the US Southeast, where racial disparities are widest, and few have examined the relative contribution of hospital, residential, and maternal factors. OBJECTIVE This study aimed to estimate the portion of Georgia's Black-White gap in severe maternal morbidity during delivery through 42 days postpartum explained by hospital, residential, and maternal factors. STUDY DESIGN Using linked Georgia hospital discharge, birth, and fetal death records for 2016 through 2020, we identified 413,124 deliveries to non-Hispanic White (229,357; 56%) or Black (183,767; 44%) individuals. We linked hospital data from the American Hospital Association and Center for Medicare and Medicaid Services, and area data from the Area Resource File and American Community Survey. We identified severe maternal morbidity indicator conditions during delivery or subsequent hospitalizations through 42 days postpartum. Using race-specific logistic models followed by a decomposition technique, we estimated the portion of the Black-White severe maternal morbidity gap explained by the following: (1) sociodemographic factors (age, education, marital status, and nativity), (2) medical conditions (diabetes mellitus, gestational diabetes, chronic hypertension, gestational hypertension or preeclampsia, and smoking), (3) obstetrical factors (singleton or multiple, and birth order); (4) access to care (no or third trimester care, and payer), (5) hospital factors that are time-varying (delivery volume, deliveries per full-time equivalent nurse, doctor communication, patient safety, and adverse event composite score) or measured time-invariant characteristics (ownership, profit status, religious affiliation, teaching status, and perinatal level), and (6) residential factors (county urban/rural classification, percent uninsured women of reproductive age, obstetrician-gynecologists per women of reproductive age, number of federally-qualified and community health centers, medically-underserved area [yes/no], and census tract neighborhood deprivation index). We estimated models with and without hospital fixed-effects, which account for unobserved time-invariant hospital characteristics such as within-hospital care processes or unmeasured hospital-specific factors. RESULTS There was 1.8 times the rate of severe maternal morbidity per 100 discharges among non-Hispanic Black (3.15) than among White (1.73) individuals, with an explained proportion of 30.4% in models without and 49.8% in models with hospital fixed-effects. In the latter, hospital fixed-effects explained the largest portion of the Black-White severe maternal morbidity gap (15.1%) followed by access to care (14.9%) and sociodemographic factors (14.4%), with residential factors being protective for Black individuals (-7.5%). Smaller proportions were explained by medical (5.6%), obstetrical (4.0%), and time-varying hospital factors (3.2%). Within each category, the largest explanatory portion was payer type (13.3%) for access to care, marital status (10.3%) for sociodemographic, gestational hypertension (3.3%) for medical, birth order (3.6%) for obstetrical, and patient safety indicator (3.1%) for time-varying hospital factors. CONCLUSION Models with hospital fixed-effects explain a greater proportion of Georgia's Black-White severe maternal morbidity gap than models without them, thereby supporting the point that differences in care processes or other unmeasured factors within the same hospital translate into racial differences in severe maternal morbidity during delivery through 42 days postpartum. Research is needed to discern and ameliorate sources of within-hospital differences in care. The substantial proportion of the gap attributable to racial differences in access to care and sociodemographic factors points to other needed policy interventions.
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Affiliation(s)
- E. Kathleen Adams
- Department of Health Policy and Management, Rollins School of Public Health Emory University, Atlanta, GA (Dr Adams, Mr Joski, and Ms Coloske)
| | - Michael R. Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University Atlanta, GA (Dr Kramer)
| | - Peter J. Joski
- Department of Health Policy and Management, Rollins School of Public Health Emory University, Atlanta, GA (Dr Adams, Mr Joski, and Ms Coloske)
| | - Marissa Coloske
- Department of Health Policy and Management, Rollins School of Public Health Emory University, Atlanta, GA (Dr Adams, Mr Joski, and Ms Coloske)
| | - Anne L. Dunlop
- Department of Gynecology and Obstetrics, School of Medicine, Emory University Atlanta, GA (Dr Dunlop)
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Howard E, Gillispie-Bell V, Olet S, Glenn B, Ammar N, Price-Haywood EG. Evaluating Racial Disparities in Implementation and Monitoring of a Remote Blood Pressure Program in a Pregnant Population-A Retrospective Cohort Study. Ochsner J 2024; 24:22-30. [PMID: 38510223 PMCID: PMC10949055 DOI: 10.31486/toj.23.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background: Whether remote blood pressure (BP) monitoring can decrease racial disparities in BP measurement during pregnancy and the postpartum period remains unclear. This study evaluated whether Black and White patients enrolled in the Connected Maternity Online Monitoring (CMOM) program showed improvements in BP ascertainment and interval. Methods: A retrospective cohort of 3,976 pregnant patients enrolled in CMOM were compared to matched usual care patients between January 2016 and September 2022 using electronic health record data. The primary outcomes were BP ascertainment (number of BP measurements) and BP interval (time between BP measurements) during pregnancy and the postpartum period. The proportion of patients with a hypertensive disorder of pregnancy who checked their BP within 7 days of discharge following delivery was also assessed. Results: Enrollment in CMOM was lower among Black patients than White patients (42.1% vs 54.7%, P<0.0001). Patients in the CMOM group had more BP measurements than patients in the usual care group during pregnancy (rate ratio=1.78, 95% CI 1.74-1.82) and the postpartum period (rate ratio=1.30, 95% CI 1.23-1.37), with significant improvements for both Black and White patients enrolled in CMOM compared to patients in usual care. The CMOM intervention did not result in an improvement in 7-day postpartum adherence to checking BP for Black patients (risk ratio=1.03, 95% CI 0.94-1.11) as it did for White patients (risk ratio=1.09, 95% CI 1.01-1.17). Conclusion: Remote BP monitoring programs are a helpful tool to improve the frequency of BP measurements and shorten intervals between measurements during the prenatal and postpartum periods for all patients. Future evaluation is needed to determine the barriers to offering the program to and enrolling Black patients.
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Affiliation(s)
- Elizabeth Howard
- Ochsner-Xavier Institute for Health Equity and Research, Ochsner Clinic Foundation, New Orleans, LA
| | - Veronica Gillispie-Bell
- Ochsner-Xavier Institute for Health Equity and Research, Ochsner Clinic Foundation, New Orleans, LA
- Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
| | - Susan Olet
- Ochsner-Xavier Institute for Health Equity and Research, Ochsner Clinic Foundation, New Orleans, LA
| | - Beth Glenn
- Ochsner-Xavier Institute for Health Equity and Research, Ochsner Clinic Foundation, New Orleans, LA
| | - Nariman Ammar
- Ochsner-Xavier Institute for Health Equity and Research, Ochsner Clinic Foundation, New Orleans, LA
| | - Eboni G. Price-Haywood
- Ochsner-Xavier Institute for Health Equity and Research, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
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14
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Aisagbonhi O, Bui T, Nasamran CA, St Louis H, Pizzo D, Meads M, Mulholland M, Magallanes C, Lamale-Smith L, Laurent LC, Morey R, Jacobs MB, Fisch KM, Horii M. High placental expression of FLT1, LEP, PHYHIP and IL3RA - In persons of African ancestry with severe preeclampsia. Placenta 2023; 144:13-22. [PMID: 37949031 PMCID: PMC10843761 DOI: 10.1016/j.placenta.2023.10.008] [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] [Received: 07/05/2023] [Revised: 10/13/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION Mortality from preeclampsia (PE) and PE-associated morbidities are 3-to 5-fold higher in persons of African ancestry than in those of Asian and European ancestries. METHODS To elucidate placental contribution to worse PE outcomes in African ancestry pregnancies, we performed bulk RNA sequencing on 50 placentas from persons with severe PE (sPE) of African (n = 9), Asian (n = 18) and European (n = 23) ancestries and 73 normotensive controls of African (n = 10), Asian (n = 15) and European (n = 48) ancestries. RESULTS Previously described canonical preeclampsia genes, involved in metabolism and hypoxia/angiogenesis including: LEP, HK2, FSTL3, FLT1, ENG, TMEM45A, ARHGEF4 and HTRA1 were upregulated sPE versus normotensive placentas across ancestries. LTF, NPR3 and PHYHIP were higher in African vs. Asian ancestry sPE placentas. Allograft rejection/adaptive immune response genes were upregulated in placentas from African but not in Asian or European ancestry sPE patients; IL3RA was of particular interest because the patient with the highest placental IL3RA expression, a person of African ancestry with sPE, developed postpartum cardiomyopathy, and was the only patient out of 123, that developed this condition. Interestingly, the sPE patients with the highest IL3RA expression among persons of Asian and European ancestries developed unexplained tachycardia peripartum, necessitating echocardiography in the European ancestry patient. The association between elevated placental IL3RA levels and unexplained tachycardia or peripartum cardiomyopathy was found to be significant in the 50 sPE patients (p = .0005). DISCUSSION High placental upregulation of both canonical preeclampsia and allograft rejection/adaptive immune response genes may contribute to worse PE outcomes in African ancestry sPE patients.
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Affiliation(s)
- Omonigho Aisagbonhi
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA; Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA.
| | - Tony Bui
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA; Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA; Sanford Consortium for Regenerative Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Chanond A Nasamran
- Center for Computational Biology and Bioinformatics, University of California, San Diego, La Jolla, CA, USA
| | - Hailee St Louis
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA
| | - Donald Pizzo
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA
| | - Morgan Meads
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA; Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA; Sanford Consortium for Regenerative Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Megan Mulholland
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA; Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA; Sanford Consortium for Regenerative Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Celestine Magallanes
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Leah Lamale-Smith
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Louise C Laurent
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Robert Morey
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA; Sanford Consortium for Regenerative Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Marni B Jacobs
- Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Kathleen M Fisch
- Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA; Sanford Consortium for Regenerative Medicine, University of California, San Diego, La Jolla, CA, USA; Center for Computational Biology and Bioinformatics, University of California, San Diego, La Jolla, CA, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Mariko Horii
- Department of Pathology, University of California, San Diego, La Jolla, CA, USA; Center for Perinatal Discovery, University of California, San Diego, La Jolla, CA, USA; Sanford Consortium for Regenerative Medicine, University of California, San Diego, La Jolla, CA, USA
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15
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Bisson C, Dautel S, Mueller A, Britt R, Patel E, Suresh S, Tsigas E, Rana S. Patient and provider perception of home blood pressure monitoring kits. Pregnancy Hypertens 2023; 34:33-38. [PMID: 37783091 DOI: 10.1016/j.preghy.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/20/2023] [Accepted: 09/22/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Pregnant patients of racial/ethnic minorities have higher preeclampsia rates. Home blood pressure monitoring (HBPM) has been investigated for disparity reduction. Smaller studies showed patients find HBPM to be a helpful intervention postpartum. Further investigation is needed to define the role of HPBM in an at-risk and diverse population antepartum. OBJECTIVE To assess patient perception of HBPM among diverse patients at high risk of disease development. STUDY DESIGN Prospective study conducted from April 2020-September 2021. HBPM kits were advertised and interested parties across the United States responded. Cuff Kits were then distributed to participating providers. Providers distributed the kits to patients meeting high-risk criteria for disease development, prioritizing those of racial/ethnic minorities. Surveys were distributed quarterly to providers and patients to assess HBPM perception. RESULTS 2910 Cuff Kits were distributed to patients at 179 sites in 14 states. Of those, 1160 were distributed to Black patients, 1045 to White patients, and 500 to Hispanic patients. 117 patients completed surveys, with most patients finding Cuff Kits "very valuable" or "valuable" (68.4% and 19.7%, respectively). Most providers (73.4%) felt the Cuff Kits influenced patient care. CONCLUSIONS Most patients receiving Cuff Kits reported a beneficial impact on disease understanding and most belonged to racial/ethnic groups at higher risk of adverse outcomes. Providers found HBPM had a beneficial impact on care. Though more research is needed to illustrate the impact of HBPM on outcomes, this study suggests that among racial/ethnic minorities and those at the high risk, HBPM is a well-received intervention.
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Affiliation(s)
- Courtney Bisson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Sydney Dautel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Rebecca Britt
- Preeclampsia Foundation, Melbourne, FL, United States
| | - Easha Patel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States
| | - Sunitha Suresh
- Department of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, NorthShore University Health System, Evanston, IL, United States
| | - Eleni Tsigas
- Preeclampsia Foundation, Melbourne, FL, United States
| | - Sarosh Rana
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago Medicine, Chicago, IL, United States.
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Salahshurian E, Moore TA. Integrative Review of Black Birthing People's Interactions With Clinicians During the Perinatal Period. West J Nurs Res 2023; 45:1063-1071. [PMID: 37772363 DOI: 10.1177/01939459231202493] [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: 09/30/2023]
Abstract
Maternal morbidity and mortality disproportionately affect Black birthing people. Multiple factors contribute to these disparities, including variations in quality health care, structural racism, and implicit bias. Interactions between Black patients and perinatal clinicians could further affect perinatal care use and subsequent perinatal outcomes. This integrative review aims to synthesize quantitative and qualitative literature published in peer-reviewed journals in English within the past 10 years that address patient-clinician interactions during the perinatal period for Black birthing people in the United States. A systematic search of CINAHL, PubMed, PsycINFO, MEDLINE, and Embase recovered 24 articles that met the eligibility criteria for inclusion in this review. The following themes emerged from synthesizing Black patients' interactions with perinatal clinicians: Care Quality, Communication, Power Dynamic, and Established Relationships. Mutual respect, effective communication, and shared decision-making may be key modifiable factors to address through clinician education to improve perinatal care for many Black persons.
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Affiliation(s)
- Erin Salahshurian
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Tiffany A Moore
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
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17
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DiBiase RM, Gottesman RF, Tom SE, Walker KA, Mosley T, Lutsey PL, Miller EC. Parity and Risk of Dementia in Women: The Atherosclerosis Risk in Communities Study. J Womens Health (Larchmt) 2023; 32:1031-1040. [PMID: 37615600 PMCID: PMC10541925 DOI: 10.1089/jwh.2023.0030] [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: 08/25/2023] Open
Abstract
Objective: Reproductive factors, including parity, may contribute to dementia risk, due to hormonal, physiological, social, and demographic factors. We hypothesized that higher parity would be associated with increased dementia risk. Materials and Methods: We utilized data from the Atherosclerosis Risk in Communities (ARIC) community-based cohort study. Participants were recruited in 1987-1989 and followed through 2017. Participants, all born between 1921 and 1945, were from four U.S. communities in Forsyth County, NC; Jackson, MS; Minneapolis, MN; and Washington County, MD. We included all female participants seen at ARIC visit three or five for whom parity and dementia outcomes were available (N = 7,921). The primary exposure was self-reported number of live births. Our primary outcome was dementia, diagnosed via neurocognitive assessments, informant interviews, and expert adjudication. We created Cox proportional hazards models to evaluate the association between parity and incident dementia, adjusting for demographic factors, education level, apolipoprotein E allele status, and vascular risk factors. We tested for interactions by race and birth cohort. Results: The adjusted hazard ratio was 0.82 (95% confidence intervals [CI] 0.69-0.99) for dementia in women with 0-1 births and 0.85 (95% CI 0.72-0.99) for women with 5+ births, compared to women with 2 births (reference group). This association was present in women born from 1924 to 1934, but not in women born in 1935 or later (p-interaction <0.001). Conclusion: We found an inverted U-shaped association of parity with dementia risk. This effect was modified by birth cohort, suggesting that the association may depend on demographic and sociocultural factors.
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Affiliation(s)
- Rebecca M. DiBiase
- Department of Neurology, McGaw Medical Center of Northwestern University, Chicago, Illinois, USA
| | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland, USA
| | - Sarah E. Tom
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
| | - Keenan A. Walker
- Laboratory of Behavioral Neuroscience, National Institute on Aging, Baltimore, Maryland, USA
| | - Thomas Mosley
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Eliza C. Miller
- Department of Neurology, Columbia University Irving Medical Center, New York, New York, USA
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Arkerson BJ, Finneran MM, Harris SR, Schnorr J, McElwee ER, Demosthenes L, Sawyer R. Remote Monitoring Compared With In-Office Surveillance of Blood Pressure in Patients With Pregnancy-Related Hypertension: A Randomized Controlled Trial. Obstet Gynecol 2023; 142:855-861. [PMID: 37734091 PMCID: PMC10510790 DOI: 10.1097/aog.0000000000005327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/30/2023] [Accepted: 04/06/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To compare the rate of blood pressure ascertainment within 10 days of postpartum discharge among individuals with hypertensive disorders of pregnancy randomized either to in-office blood pressure assessment or at-home monitoring. METHODS This was a multisite randomized controlled trial of postpartum patients diagnosed with a hypertensive disorder of pregnancy before discharge between April 2021 and September 2021 and was performed at two academic training institutions. Patients were randomized to either an in-office blood pressure check or remote monitoring through a web-enabled smartphone platform. The primary outcome was the rate of any blood pressure ascertainment within 10 days of discharge. Secondary outcomes include rates of initiation of antihypertensive medication, readmission, and additional office or triage visits for hypertension. Assuming a 10-day postdischarge blood pressure ascertainment rate of 50% in the in-office arm, we estimated that 186 participants would provide 80% power to detect a 20% difference in the primary outcome between groups. RESULTS One hundred ninety-seven patients were randomized (96 remote, 101 in-office). Patients with remote monitoring had higher rates of postpartum blood pressure ascertainment compared with in-office surveillance (91.7% [n=88] vs 58.4% [n=59]; P<.001). There were 11 (11.5%) patients in the intervention arm whose only qualifying blood pressure was a postdischarge in-person ascertainment, yielding a true remote monitoring uptake rate of 80.2%. In those with remote blood pressure uptake (n=77), the median number of blood pressure checks was 15 (interquartile range 6-26) and the median duration of remote monitoring use was 14 days (interquartile range 9-16). There were no differences in rates of readmission for hypertension (5.0% [n=5] vs 4.2% [n=4], P=.792) or initiation of antihypertensive medications after discharge (9.4% [n=9] vs 6.9% [n=7], P=.530). Rates of unscheduled visits were increased in the remote monitoring arm, but this did not reach statistical significance (5.0% [n=5] vs 12.5% [n=12], P=.059). When stratifying the primary outcome by race and randomization group, Black patients had lower rates of blood pressure ascertainment than White patients when assigned to in-office surveillance (41.2% [n=14] vs 69.5% [n=41], P=.007), but there was no difference in the remote management group (92.9% [n=26] vs 92.9% [n=52], P>.99). CONCLUSION Remote monitoring can increase postpartum blood pressure ascertainment within 10 days of discharge for women with hypertensive disorders of pregnancy and has the potential to promote health equity. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT04823949.
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Affiliation(s)
- Brittany J Arkerson
- Departments of Obstetrics and Gynecology, Prisma Health-Upstate, Greenville, South Carolina, and the Medical University of South Carolina, Charleston, South Carolina
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Henderson JT, Webber EM, Thomas RG, Vesco KK. Screening for Hypertensive Disorders of Pregnancy: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2023; 330:1083-1091. [PMID: 37721606 DOI: 10.1001/jama.2023.4934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Importance Hypertensive disorders of pregnancy are a leading cause of pregnancy-related morbidity and mortality in the US. Objective To conduct a targeted systematic review to update the evidence on the effectiveness of screening for hypertensive disorders of pregnancy to inform the US Preventive Services Task Force. Data Sources MEDLINE and the Cochrane Central Register of Controlled Trials for relevant studies published between January 1, 2014, and January 4, 2022; surveillance through February 21, 2023. Study Selection English-language comparative effectiveness studies comparing screening strategies in pregnant or postpartum individuals. Data Extraction and Synthesis Two reviewers independently appraised articles and extracted relevant data from fair-or good-quality studies; no quantitative synthesis was conducted. Main outcomes and measures Morbidity or mortality, measures of health-related quality of life. Results The review included 6 fair-quality studies (5 trials and 1 nonrandomized study; N = 10 165) comparing changes in prenatal screening practices with usual care, which was routine screening at in-person office visits. No studies addressed screening for new-onset hypertensive disorders of pregnancy in the postpartum period. One trial (n = 2521) evaluated home blood pressure measurement as a supplement to usual care; 3 trials (total n = 5203) evaluated reduced prenatal visit schedules. One study (n = 2441) evaluated proteinuria screening conducted only for specific clinical indications, compared with a historical control group that received routine proteinuria screening. One additional trial (n = 80) only addressed the comparative harms of home blood pressure measurement. The studies did not report statistically significant differences in maternal and infant complications with alternate strategies compared with usual care; however, estimates were imprecise for serious, rare health outcomes. Home blood pressure measurement added to prenatal care visits was not associated with earlier diagnosis of a hypertensive disorder of pregnancy (104.3 vs 106.2 days), and incidence was not different between groups in 3 trials of reduced prenatal visit schedules. No harms of the different screening strategies were identified. Conclusions and Relevance This review did not identify evidence that any alternative screening strategies for hypertensive disorders of pregnancy were more effective than routine blood pressure measurement at in-person prenatal visits. Morbidity and mortality from hypertensive disorders of pregnancy can be prevented, yet American Indian/Alaska Native persons and Black persons experience inequitable rates of adverse outcomes. Further research is needed to identify screening approaches that may lead to improved disease detection and health outcomes.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Elizabeth M Webber
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
- CareOregon, Portland
| | - Kimberly K Vesco
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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20
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Barry MJ, Nicholson WK, Silverstein M, Cabana MD, Chelmow D, Coker TR, Davis EM, Donahue KE, Jaén CR, Li L, Ogedegbe G, Rao G, Ruiz JM, Stevermer J, Tsevat J, Underwood SM, Wong JB. Screening for Hypertensive Disorders of Pregnancy: US Preventive Services Task Force Final Recommendation Statement. JAMA 2023; 330:1074-1082. [PMID: 37721605 DOI: 10.1001/jama.2023.16991] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Importance Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017. Objective The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy. Population Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension. Evidence Assessment The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit. Recommendation The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).
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Affiliation(s)
| | | | | | | | | | | | - Esa M Davis
- University of Maryland School of Medicine, Baltimore
| | | | | | - Li Li
- University of Virginia, Charlottesville
| | | | - Goutham Rao
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Joel Tsevat
- University of Texas Health Science Center, San Antonio
| | | | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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21
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Docheva N, Woelkers D, Yao W, Jin Y, Espinoza J, Kunz L, Amegashie C, Gencay M, Harris J, Rana S. Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study. Pregnancy Hypertens 2023; 33:8-16. [PMID: 37245376 DOI: 10.1016/j.preghy.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/21/2023] [Accepted: 05/16/2023] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms. STUDY DESIGN This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control). MAIN OUTCOME MEASURES Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms). RESULTS Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%). CONCLUSIONS Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.
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Affiliation(s)
- N Docheva
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA
| | - D Woelkers
- Department of Reproductive Medicine, University of California, San Diego, CA, USA
| | - W Yao
- Roche Diagnostics, Indianapolis, IN, USA
| | - Y Jin
- Roche Diagnostics, Indianapolis, IN, USA
| | - J Espinoza
- The Fetal Center at Children's Memorial Hermann Hospital and McGovern Medical School at the University of Texas, Houston, TX, USA
| | - L Kunz
- Roche Diagnostics, Indianapolis, IN, USA
| | - C Amegashie
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA
| | - M Gencay
- Roche Diagnostics, Indianapolis, IN, USA
| | - J Harris
- Roche Diagnostics, Indianapolis, IN, USA
| | - S Rana
- Department of Obstetrics and Gynecology/Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA.
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22
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Ibarra AJ, Butters MA, Lim G, Jeyabalan A, Li R, Balasubramani GK, Catov JM. Longitudinal cognitive evaluation before and after delivery among people with preeclampsia. Am J Obstet Gynecol MFM 2023; 5:100966. [PMID: 37084869 PMCID: PMC10876122 DOI: 10.1016/j.ajogmf.2023.100966] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND Cognitive impairments related to preeclampsia after pregnancy have been reported; however, it is not known if weaknesses in cognition occur before and shortly after delivery. OBJECTIVE This study aimed to assess the feasibility of longitudinal cognitive testing before and after delivery, and to investigate whether those with preeclampsia have cognitive weaknesses during the third trimester of pregnancy and at 1 and 3 months postpartum. We hypothesized that people with preeclampsia would have lower cognition scores across all time points compared with normotensive people. STUDY DESIGN This longitudinal, prospective, observational study in a single institution enrolled people (N=30) at ≥28 weeks of gestation with preeclampsia (N=16) or normotension (N=14). People with chronic hypertension, neurologic or developmental disabilities, moderate or severe depression or anxiety, or current substance use were excluded. Subjective (Everyday Cognition Scale) and objective assessment of executive function (Stroop Color-Word Interference Test, Trail-Making Test), attention and working memory (Digit Span subtest), and information processing speed (Digit Symbol Substitution Test) was conducted, and Z-scores were calculated. Baseline characteristics (eg, prepregnancy body mass index) were collected from the medical record. Generalized linear models were used to estimate associations. RESULTS We enrolled 37% (30/81) of eligible people and retained 80% (24/30) and 53% (16/30) at 1 and 3 months postpartum, respectively. People with preeclampsia reported more memory problems (ß=0.87; 95% confidence interval, 0.44-1.31), and scored worse on attention and working memory (ß=-0.94; 95% confidence interval, -1.42 to -0.45) and executive function (Stroop test ß=-0.86; 95% confidence interval, -1.53 to -0.19) domains compared with normotensive people after adjusting for time, age, education, and prepregnancy body mass index. CONCLUSION Longitudinal assessment of cognition in pregnant preeclamptic and normotensive people is feasible. People with preeclampsia reported worse subjective memory and had lower scores in attention, working memory, and executive function.
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Affiliation(s)
- Andrea J Ibarra
- Departments of Anesthesiology and Perioperative Medicine (Drs Ibarra and Lim).
| | | | - Grace Lim
- Departments of Anesthesiology and Perioperative Medicine (Drs Ibarra and Lim)
| | - Arun Jeyabalan
- Obstetrics, Gynecology and Reproductive Sciences (Drs Jeyabalan and Catov), University of Pittsburgh, Pittsburgh, PA
| | - Runjia Li
- Departments of Epidemiology (Ms Li and Dr Catov)
| | | | - Janet M Catov
- Obstetrics, Gynecology and Reproductive Sciences (Drs Jeyabalan and Catov), University of Pittsburgh, Pittsburgh, PA; Departments of Epidemiology (Ms Li and Dr Catov); Magee-Womens Research Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA (Dr Catov)
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23
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Jasthi DL, Lappen JR, Garber S, Kennedy S, McCarther N, Nagle-Yang S, Moore T, Frank S, Huth-Bocks A. Associations between adverse childhood experiences and obstetrical outcomes in a predominantly Black-identifying and low-income pregnant population. Am J Obstet Gynecol MFM 2023; 5:101008. [PMID: 37156467 DOI: 10.1016/j.ajogmf.2023.101008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Recent literature indicates that adverse childhood experiences have been associated with poor obstetrical outcomes, including pregnancy loss, preterm birth, and low birthweight. Several studies have been conducted in primarily self-identified White individuals who report middle to high income levels. Less is known about the impact of adverse childhood experiences on obstetrical outcomes in minority-identifying and low-income populations, who are known to experience a greater number of adverse childhood experiences and are at higher risk of maternal morbidity. OBJECTIVE This study aimed to examine associations between adverse childhood experiences and a broad range of obstetrical outcomes among predominantly Black-identifying pregnant persons who have low income and live in an urban area. STUDY DESIGN This is a single-center retrospective cohort study of pregnant persons referred to a mental healthcare manager because of elevated psychosocial risks identified by screening tools or provider concerns during the study period from April 2018 to May 2021. Pregnant persons aged <18 years and those who did not speak English were excluded. Patients completed validated mental and behavioral health screening tools including the Adverse Childhood Experiences Questionnaire. Medical charts were reviewed for obstetrical outcomes, including preterm birth, low birthweight, hypertensive disorders of pregnancy, gestational diabetes mellitus, chorioamnionitis, sexually transmitted infection, maternal group B streptococcus carrier status, type of delivery, and attendance of a postpartum visit. Associations between high (≥4) and very high (≥6) of 10 adverse childhood experience score and obstetrical outcomes were analyzed using bivariate analysis and multivariate logistic regression, adjusting for confounding factors (significant at P<.05 in bivariate analysis). RESULTS Our cohort included 192 pregnant persons, of whom 176 (91.7%) self-identified as Black or African American and 181 (94.8%) had public insurance (used as a proxy for low income). Adverse childhood experience score ≥4 was reported by 91 (47.4%) individuals and score ≥6 by 50 (26%). On univariate analysis, adverse childhood experience score ≥4 was associated with preterm birth (odds ratio, 2.17; 95% confidence interval, 1.02-4.61). Adverse childhood experience score ≥6 was associated with hypertensive disorders of pregnancy (odds ratio, 2.09; 95% confidence interval, 1.05-4.15) and preterm birth (odds ratio, 2.29; 95% confidence interval, 1.05-4.96). After accounting for chronic hypertension, associations between adverse childhood experience score and obstetrical outcomes were no longer significant. CONCLUSION Approximately half of the pregnant persons referred to a mental healthcare manager had a high adverse childhood experience score, underscoring the high burden of childhood trauma on populations facing long-standing systemic racism and barriers to healthcare access. High and very high adverse childhood experience score may be associated with chronic health conditions that predate pregnancy and can alter obstetrical outcomes. Obstetrical care providers have a unique opportunity to mitigate risk of associated poor health outcomes during preconception and prenatal care by screening for adverse childhood experiences.
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Affiliation(s)
- Divya L Jasthi
- Case Western Reserve University School of Medicine, Cleveland, OH (Ms Jasthi and Drs Frank and Huth-Bocks)
| | - Justin R Lappen
- Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH (Dr Lappen)
| | - Sarah Garber
- Department of Obstetrics and Gynecology, University Hospitals, Cleveland, OH (Drs Garber, Kennedy, McCarther, and Ms Moore)
| | - Sarah Kennedy
- Department of Obstetrics and Gynecology, University Hospitals, Cleveland, OH (Drs Garber, Kennedy, McCarther, and Ms Moore)
| | - Noria McCarther
- Department of Obstetrics and Gynecology, University Hospitals, Cleveland, OH (Drs Garber, Kennedy, McCarther, and Ms Moore)
| | - Sarah Nagle-Yang
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Denver, CO (Dr Nagle-Yang)
| | - Tamika Moore
- Department of Obstetrics and Gynecology, University Hospitals, Cleveland, OH (Drs Garber, Kennedy, McCarther, and Ms Moore)
| | - Scott Frank
- Case Western Reserve University School of Medicine, Cleveland, OH (Ms Jasthi and Drs Frank and Huth-Bocks)
| | - Alissa Huth-Bocks
- Case Western Reserve University School of Medicine, Cleveland, OH (Ms Jasthi and Drs Frank and Huth-Bocks); Merrill Palmer Skillman Institute, Wayne State University, Detroit, MI (Dr Huth-Bocks).
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24
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Palatnik A, McGee P, Bailit JL, Wapner RJ, Varner MW, Thorp JM, Caritis SN, Prasad M, Tita ATN, Saade GR, Rouse DJ, Blackwell SC. The Association of Race and Ethnicity with Severe Maternal Morbidity among Individuals Diagnosed with Hypertensive Disorders of Pregnancy. Am J Perinatol 2023; 40:453-460. [PMID: 35764308 PMCID: PMC9794629 DOI: 10.1055/a-1886-5404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE This study aimed to examine whether there are racial disparities in severe maternal morbidity (SMM) in patients with hypertensive disorders of pregnancy (HDP). STUDY DESIGN Secondary analysis of an observational study of 115,502 patients who had a live birth at ≥20 weeks in 25 hospitals in the United States from 2008 to 2011. Only patients with HDP were included in this analysis. Race and ethnicity were categorized as non-Hispanic White, non-Hispanic Black (NHB), and Hispanic and were abstracted from the medical charts. Patients of other races and ethnicities were excluded. Associations were estimated between race and ethnicity, and the primary outcome of SMM, defined as any of the following, was estimated by unadjusted logistic and multivariable backward logistic regressions: blood transfusion ≥4 units, unexpected surgical procedure, need for a ventilator ≥12 hours, intensive care unit (ICU) admission, or failure of ≥1 organ system. Multivariable models were run classifying HDP into three levels as follows: (1) gestational hypertension; (2) preeclampsia (mild, severe, or superimposed); and (3) eclampsia or HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. RESULTS A total of 9,612 individuals with HDP met inclusion criteria. No maternal deaths occurred in this cohort. In univariable analysis, non-Hispanic White patients were more likely to present with gestational hypertension whereas NHB and Hispanic patients were more likely to present with preeclampsia. The frequency of the primary outcome, composite SMM, was higher in NHB patients compared with that in non-Hispanic White or Hispanic patients (11.8 vs. 4.5% in non-Hispanic White and 4.8% in Hispanic, p < 0.001). This difference was driven by a higher frequency of blood transfusions and ICU admissions among NHB individuals. Prior to adjusting the analysis for confounding factors, the odds ratio (OR) of primary composite outcomes in NHB individuals was 2.85 (95% confidence interval [CI]: 2.38, 3.42) compared with non-Hispanic White. After adjusting for sociodemographic and clinical factors, hospital site, and the severity of HDP, the OR of composite SMM did not differ between the groups (adjusted OR [aOR] = 1.26, 95% CI: 0.95, 1.67 for NHB, and aOR = 1.29, 95% CI: 0.94, 1.77 for Hispanic, compared with non-Hispanic White patients). Sensitivity analysis was done to exclude one single site that was an outliner with the highest ICU admissions and demonstrated no difference in ICU admission by maternal race and ethnicity. CONCLUSION NHB patients with HDP had higher rates of the composite SMM compared with non-Hispanic White patients, driven mainly by a higher frequency of blood transfusions and ICU admissions. However, once severity and other confounding factors were taken into account, the differences did not persist. KEY POINTS · Black patients with HDP had higher frequency of SMM compared with non-Hispanic White patients.. · The SMM disparities were driven by blood transfusions and ICU admissions.. · After adjustment for confounders, including HDP severity, the significant difference in SMM did not persist..
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Affiliation(s)
- Anna Palatnik
- Division of maternal fetal medicine, Department of obstetrics and gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paula McGee
- George Washington University Biostatistics Center, Washington, District of Columbia
| | - Jennifer L Bailit
- Division of maternal fetal medicine, Department of obstetrics and gynecology, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio
| | - Ronald J Wapner
- Division of maternal fetal medicine, Department of obstetrics and gynecology, Columbia University, New York, New York
| | - Michael W Varner
- Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Utah Health Sciences Center, Salt Lake City, Utah
| | - John M Thorp
- Division of maternal fetal medicine, Department of obstetrics and gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Steve N Caritis
- Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mona Prasad
- Division of maternal fetal medicine, Department of obstetrics and gynecology, The Ohio State University, Columbus, Ohio
| | - Alan T N Tita
- Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - George R Saade
- Division of maternal fetal medicine, Department of obstetrics and gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Dwight J Rouse
- Division of maternal fetal medicine, Department of obstetrics and gynecology, Brown University, Providence, Rhode Island
| | - Sean C Blackwell
- Division of maternal fetal medicine, Department of obstetrics and gynecology, McGovern Medical School-Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
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25
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Lemon LS, Hauspurg A, Garrard W, Quinn B, Simhan HN. Neighborhood disadvantage and the racial disparity in postpartum hypertension. Am J Obstet Gynecol MFM 2023; 5:100773. [PMID: 36244624 PMCID: PMC10784748 DOI: 10.1016/j.ajogmf.2022.100773] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/21/2022] [Accepted: 10/08/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Postpartum hypertension is the leading cause of postpartum readmission and has long-lasting cardiovascular effects. Black patients have higher incidence rates of hypertensive disorders after delivery and subsequent severe maternal morbidity. Neighborhood advantage, a marker of social determinants of health, has not been studied concerning postpartum hypertension. Moreover, the interplay between race and neighborhood advantage and their effect on postpartum hypertension have not been previously explored. OBJECTIVE This study aimed to evaluate the association between neighborhood-level social determinants of health and postpartum hypertension and explore whether these factors explain previously documented racial disparities. STUDY DESIGN This study included a retrospective cohort of people enrolled in a remote monitoring program of postpartum hypertension at the time of delivery within 1 health network from March 2019 to September 2021. Patients were eligible for enrollment after a diagnosis of hypertensive disorder during pregnancy or delivery. We further limited the cohort to self-reported Black and White patients with blood pressures recorded at 3 weeks and 6 weeks postpartum. The neighborhood advantage for each person at the time of delivery was classified using the area deprivation index, an accepted surrogate of social determinants of health and our primary exposure. The secondary exposure was self-reported race. Study outcomes of interest were hypertensive status (stage 1 hypertension: ≥130 to 139/80 to 89 mm Hg; stage 2 hypertension: ≥140/90 mm Hg) at 3 and 6 weeks after delivery. In addition, hypertensive status by neighborhood area deprivation index using logistic regression was molded. In secondary analyses, a case-control cohort matched on the area deprivation index was created, and conditional logistic regression was used to evaluate race. Finally, mixed-effects models modeling hypertension by race and clustering within the area deprivation index were used. RESULTS Of 4193 people enrolled, 2722 were Black or White and had blood pressure data recorded at 3 weeks after delivery, and 1126 had blood pressure data recorded at 6 weeks after delivery. After accounting for prenatal body mass index, smoking status, type of hypertension, and antihypertensives prescribed at discharge, persons living in the most disadvantaged neighborhoods were twice as likely (adjusted odds ratio, 2.03; 95% confidence interval, 1.53-2.69) to develop stage 2 hypertension at 21 days after delivery and 1.67 times more likely (95% confidence interval, 1.06-2.64) to develop stage 2 hypertension at 6 weeks after delivery than persons living in the most advantaged neighborhoods. Both associations were attenuated after adjusting for race. When people with stage 2 hypertension were matched on area deprivation index with normotensive counterparts, Black patients were still 3 to 4 times more likely to develop stage 2 hypertension at 3 (adjusted odds ratio, 3.00; 95% confidence interval, 1.95-4.63) and 6 (adjusted odds ratio, 4.61; 95% confidence interval, 2.05-10.36) weeks after delivery. This association remained after clustering within a neighborhood at 3 (adjusted odds ratio, 3.12; 95% confidence interval, 2.41-4.06) and 6 (adjusted odds ratio, 2.99; 95% confidence interval, 1.96-4.54) weeks after delivery. There was no significant difference in stage 1 hypertension. CONCLUSION Neighborhood advantage was associated with the development of persistent hypertension at 3 and 6 weeks after delivery. This association did not explain the racial disparity in sustained high blood pressure.
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Affiliation(s)
- Lara S Lemon
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Lemon and Hauspurg, Ms Quinn, and Dr Simhan); Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA (Drs Lemon and Garrard).
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Lemon and Hauspurg, Ms Quinn, and Dr Simhan); Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Hauspurg and Simhan)
| | - William Garrard
- Department of Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA (Drs Lemon and Garrard)
| | - Beth Quinn
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Lemon and Hauspurg, Ms Quinn, and Dr Simhan)
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Lemon and Hauspurg, Ms Quinn, and Dr Simhan); Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA (Drs Hauspurg and Simhan)
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26
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Burns A, DeAtley T, Short SE. The maternal health of American Indian and Alaska Native people: A scoping review. Soc Sci Med 2023; 317:115584. [PMID: 36521232 PMCID: PMC9875554 DOI: 10.1016/j.socscimed.2022.115584] [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: 07/22/2021] [Revised: 11/21/2022] [Accepted: 11/26/2022] [Indexed: 11/30/2022]
Abstract
Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.
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Affiliation(s)
- Ailish Burns
- Department of Sociology, Brown University, 108 George St Box 1916, Providence RI, 02912, USA; Population Studies and Training Center, Brown University, 68 Waterman St Box 1836, Providence RI, 02912, USA.
| | - Teresa DeAtley
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA
| | - Susan E Short
- Department of Sociology, Brown University, 108 George St Box 1916, Providence RI, 02912, USA; Population Studies and Training Center, Brown University, 68 Waterman St Box 1836, Providence RI, 02912, USA
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27
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Thadhani R, Lemoine E, Rana S, Costantine MM, Calsavara VF, Boggess K, Wylie BJ, Moore Simas TA, Louis JM, Espinoza J, Gaw SL, Murtha A, Wiegand S, Gollin Y, Singh D, Silver RM, Durie DE, Panda B, Norwitz ER, Burd I, Plunkett B, Scott RK, Gaden A, Bautista M, Chang Y, Diniz MA, Karumanchi SA, Kilpatrick S. Circulating Angiogenic Factor Levels in Hypertensive Disorders of Pregnancy. NEJM EVIDENCE 2022; 1:EVIDoa2200161. [PMID: 38319832 DOI: 10.1056/evidoa2200161] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Among women with hypertensive disorders of pregnancy, biomarkers may stratify risk for developing preeclampsia with severe features (sPE). METHODS: Across 18 U.S. centers, we prospectively measured the ratio of serum soluble fms-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF) in pregnant women hospitalized between 23 and 35 weeks of gestation. The primary outcome was predicting sPE, and secondary outcomes included predicting adverse outcomes within 2 weeks. The prognostic performance of the sFlt-1:PlGF ratio was assessed by using a derivation/validation design. RESULTS: A total of 1014 pregnant women were evaluated; 299 were included in the derivation cohort and 715 in the validation cohort. In the derivation cohort, the median sFlt-1:PlGF ratio was 200 (interquartile range, 53 to 458) among women who developed sPE compared with 6 (interquartile range, 3 to 26) in those who did not (P<0.001). The discriminatory ratio of ≥40 was then tested in the validation cohort and yielded a 65% positive (95% confidence interval [CI], 59 to 71) and a 96% negative (95% CI, 93 to 98) predictive value for the primary outcome. The ratio performed better than standard clinical measures (area under the receiver-operating characteristic curve, 0.92 versus <0.75 for standard-of-care tests). Compared with women with a ratio <40, women with a ratio ≥40 were at higher risk for adverse maternal outcomes (16.1% versus 2.8%; relative risk, 5.8; 95% CI, 2.8 to 12.2). CONCLUSIONS: In women with a hypertensive disorder of pregnancy presenting between 23 and 35 weeks of gestation, measurement of serum sFlt-1:PlGF provided stratification of the risk of progressing to sPE within the coming fortnight. (Funded by Cedars-Sinai Medical Center and Thermo Fisher Scientific; ClinicalTrials.gov NCT03815110.)
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Affiliation(s)
- Ravi Thadhani
- Cedars-Sinai Medical Center, Los Angeles
- Massachusetts General Hospital, Boston
| | - Elizabeth Lemoine
- Cedars-Sinai Medical Center, Los Angeles
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Sarosh Rana
- University of Chicago Medical Center, Chicago
| | | | | | - Kim Boggess
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | | | | | - Jimmy Espinoza
- Baylor College of Medicine and Texas Children's Hospital, Houston
| | | | - Amy Murtha
- University of California at San Francisco, San Francisco
| | | | - Yvonne Gollin
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | | | | | | | | | - Errol R Norwitz
- Tufts Medical Center, Boston
- Newton-Wellesley Hospital, Newton, MA
| | | | | | | | - Anna Gaden
- Cedars-Sinai Medical Center, Los Angeles
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Ukah UV, Li X, Wei SQ, Healy-Profitós J, Dayan N, Auger N. Black-White disparity in severe cardiovascular maternal morbidity: A systematic review and meta-analysis. Am Heart J 2022; 254:35-47. [PMID: 35944667 DOI: 10.1016/j.ahj.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 07/14/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND To synthesize existing evidence on Black-White disparities in the prevalence of severe cardiovascular maternal morbidity. METHODS We searched MEDLINE, EMBASE, and CINAHL for observational studies published before July 31, 2021 that compared the risk of severe cardiovascular maternal morbidity between Black and White women. The outcome was severe cardiovascular maternal morbidity, including acute myocardial infarction, peripartum cardiomyopathy, and stroke during pregnancy, delivery, or postpartum. We extracted relevant information including adjusted and unadjusted effect estimates. We used random-effects models to estimate the pooled association between race and severe cardiovascular maternal morbidity, presented as odds ratios with 95% confidence intervals for the comparison of Black women relative to White women. RESULTS We included 18 studies that met the eligibility criteria for systematic review and meta-analysis. All studies were conducted in the United States and included a total of 7,656,876 Black women and 26,412,600 White women. Compared with White women, Black women had an increased risk of any severe cardiovascular maternal morbidity (adjusted odds ratio, 1.90; 95% confidence interval, 1.54-2.33). Black women were at risk of acute myocardial infarction (adjusted odds ratio, 1.38; 95% confidence interval, 1.14-1.68), peripartum cardiomyopathy (adjusted odds ratio, 1.71; 95% confidence interval, 1.51-1.94), and stroke (adjusted odds ratio, 2.13; 95% confidence interval, 1.39-3.26). CONCLUSIONS Black women have a considerably higher risk of severe cardiovascular maternal morbidity than White women, including acute myocardial infarction, peripartum cardiomyopathy, and stroke. Reducing inequality in adverse cardiovascular outcomes of pregnancy between Black and White women should be prioritized.
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Affiliation(s)
- Ugochinyere Vivian Ukah
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Xinting Li
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada
| | - Shu Qin Wei
- Institut national de santé publique du Québec, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
| | - Jessica Healy-Profitós
- Institut national de santé publique du Québec, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada
| | - Natalie Dayan
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Departments of Medicine and Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nathalie Auger
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Institut national de santé publique du Québec, Montreal, Quebec, Canada; University of Montreal Hospital Research Centre, Montreal, Quebec, Canada; Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Montreal, Quebec, Canada.
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Abstract
PURPOSE OF THE REVIEW Despite marked progress in cardiovascular disease management in the last several decades, there remain significant, persistent disparities in cardiovascular health in historically marginalized racial and ethnic groups. Here, we outline current state of health disparities in cardiovascular disease, discuss the interplay between social determinants of health, structural racism, and cardiovascular outcomes, and highlight strategies to address these issues. RECENT FINDINGS Across the continuum of atherosclerotic cardiovascular disease (ASCVD) prevention, there remain significant disparities in outcomes including morbidity and mortality by race, ethnicity, and socioeconomic status (SES). These disparities begin early in childhood (primordial prevention) and continue with a higher prevalence of cardiovascular risk factors (primary prevention), and in the uptake of evidence-based therapies (secondary prevention). These disparities are driven by social determinants of health and structural racism that disproportionately disadvantage historically marginalized populations. Structural racism and social determinants of health contribute to significant disparities in cardiovascular morbidity and mortality.
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Affiliation(s)
- Ankita Devareddy
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ashish Sarraju
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.
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Zahid S, Tanveer ud Din M, Minhas AS, Rai D, Kaur G, Carfagnini C, Khan MZ, Ullah W, Van Spall HGC, Hays AG, Michos ED. Racial and Socioeconomic Disparities in Cardiovascular Outcomes of Preeclampsia Hospitalizations in the United States 2004-2019. JACC. ADVANCES 2022; 1:100062. [PMID: 38938395 PMCID: PMC11198579 DOI: 10.1016/j.jacadv.2022.100062] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 06/29/2024]
Abstract
Background Preeclampsia is associated with higher in-hospital cardiovascular events and mortality with known disparities by race/ethnicity, but data on the interaction between income and these outcomes remain limited. Objectives This study investigated racial and socioeconomic disparities in cardiovascular outcomes of preeclampsia at delivery hospitalizations. Methods We analyzed National Inpatient Sample data using International Classification of Diseases-9th Revision/-10th Revision codes between 2004 and 2019. We identified a total of 2,436,991 delivery hospitalizations with preeclampsia/eclampsia as a primary diagnosis representing White (43.1%), Black (18.4%), Hispanic (18.7%), and Asian or Pacific Islander (A/PI; 3.3%) women. We stratified the population based on median household income (low income, medium income, and high income). Logistic regression and propensity-matched analysis were used for reporting outcomes adjusted for age, hospital region, and baseline comorbidities. Results Black Hispanic, and A/PI women with preeclampsia had higher in-hospital mortality compared with White women across all groups of income. Hispanic women had lower odds of peripartum cardiomyopathy (PPCM) compared with White women. A significant interaction effect was observed with race/ethnicity and median household income for in-hospital mortality and PPCM with preeclampsia. Furthermore, high-income Black women had higher odds of PPCM, stroke, acute kidney injury, heart failure, cardiac arrhythmia, and venous thromboembolism compared with low-income White women. Conclusions Women with preeclampsia experience significant racial/ethnic and socioeconomic disparities in inpatient mortality and cardiovascular outcomes at delivery. Across all income groups, Black, Hispanic, and A/PI women experience higher odds of in-hospital mortality compared with White women. Furthermore, high-income Black women had greater odds of many CV complications compared with low-income White women.
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Affiliation(s)
- Salman Zahid
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, New York, USA
| | - Mian Tanveer ud Din
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Anum S. Minhas
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Devesh Rai
- Sands-Constellation Heart Institute, Rochester General Hospital, Rochester, New York, USA
| | - Gurleen Kaur
- Division of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | | | - Muhammad Zia Khan
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, West Virginia, USA
| | - Waqas Ullah
- Department of Cardiovascular Medicine, Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Harriette Gillian Christine Van Spall
- Department of Medicine (Cardiology) and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Research Institute of St. Joseph’s, Hamilton, Ontario, Canada
| | - Allison G. Hays
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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31
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Burger RJ, Delagrange H, van Valkengoed IGM, de Groot CJM, van den Born BJH, Gordijn SJ, Ganzevoort W. Hypertensive Disorders of Pregnancy and Cardiovascular Disease Risk Across Races and Ethnicities: A Review. Front Cardiovasc Med 2022; 9:933822. [PMID: 35837605 PMCID: PMC9273843 DOI: 10.3389/fcvm.2022.933822] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/06/2022] [Indexed: 12/30/2022] Open
Abstract
Pregnancy is often considered to be a "cardiometabolic stress-test" and pregnancy complications including hypertensive disorders of pregnancy can be the first indicator of increased risk of future cardiovascular disease. Over the last two decades, more evidence on the association between hypertensive disorders of pregnancy and cardiovascular disease has become available. However, despite the importance of addressing existing racial and ethnic differences in the incidence of cardiovascular disease, most research on the role of hypertensive disorders of pregnancy is conducted in white majority populations. The fragmented knowledge prohibits evidence-based targeted prevention and intervention strategies in multi-ethnic populations and maintains the gap in health outcomes. In this review, we present an overview of the evidence on racial and ethnic differences in the occurrence of hypertensive disorders of pregnancy, as well as evidence on the association of hypertensive disorders of pregnancy with cardiovascular risk factors and cardiovascular disease across different non-White populations, aiming to advance equity in medicine.
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Affiliation(s)
- Renée J Burger
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Pregnancy and Birth, Amsterdam, Netherlands
| | - Hannelore Delagrange
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Irene G M van Valkengoed
- Department of Public and Occupational Health, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, Netherlands
| | - Christianne J M de Groot
- Amsterdam Reproduction and Development, Pregnancy and Birth, Amsterdam, Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Atherosclerosis and Ischemic Syndromes, Amsterdam, Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Pregnancy and Birth, Amsterdam, Netherlands
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Jeganathan S, Wetcher CS, White V, Hemphill J, Carryl L, Gulersen M, Shan W, Lewis D, Rochelson B, Blitz MJ. Nonadherence to treatment protocol for severe hypertension in pregnancy. Am J Obstet Gynecol MFM 2022; 4:100688. [PMID: 35817395 DOI: 10.1016/j.ajogmf.2022.100688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/11/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are one of the leading causes of maternal mortality and severe morbidity. The American College of Obstetricians and Gynecologists recommends treatment of persistent severe hypertension because this has been shown to improve overall outcomes. Treatment remains inconsistent and may be influenced by patient-level sociodemographic and clinical characteristics. OBJECTIVE This study aimed to identify which factors are associated with nonadherence to an institutional protocol for the treatment of severe hypertension in pregnancy. STUDY DESIGN Retrospective cohort study of patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg and/or diastolic blood pressures >110 mm Hg between 15 and 60 minutes apart) during their delivery hospitalization in 3 hospitals within an integrated health system from February 1, 2018 to March 1, 2020. Adherence to an institutional protocol was defined as receiving antihypertensive medication within 1 hour of a second severe blood pressure measurement. Demographic information, medical comorbidities, and delivery hospitalization characteristics were compared between women who received treatment based on institutional protocol and those who did not. Patient zone improvement plan codes were linked to neighborhood-level data from the US Census Bureau's American Community Survey to extract socioeconomic characteristics. A multivariable logistic regression was performed to evaluate factors associated with delayed treatment while adjusting for potential confounders. RESULTS Of the 996 patients included, 449 (45%) received treatment within 60 minutes and 547 (55%) did not. Having an elevated, nonsevere range blood pressure (adjusted odds ratio, 0.55; 95% confidence interval, 0.38-0.79) or a severe range blood pressure (adjusted odds ratio, 0.25; 95% confidence interval, 0.16-0.38) on admission, persistent severe hypertension ≥1 hour before or after delivery (adjusted odds ratio, 0.27; 95% confidence interval, 0.27-0.45), and chronic hypertension (adjusted odds ratio, 0.58; 95% confidence interval, 0.37-0.93) were associated with timely treatment. Hospital site (adjusted odds ratio, 1.97; 95% confidence interval, 1.18-3.28) and increasing gestational age (adjusted odds ratio, 1.14; 95% confidence interval, 1.07-1.21) were associated with nonadherence to treatment protocol. A subanalysis evaluating treatment in 344 (35%) patients who had a nonelevated blood pressure on admission showed that White race, persistent severe hypertension within 1 hour of delivery, increasing gestational age, body mass index, twin gestation, preferred language other than English or Spanish, and a higher neighborhood unemployment rate were associated with nonadherence to treatment protocol. CONCLUSION Several factors were associated with nonadherence to an institutional protocol for treatment of persistent severe hypertension. Provider bias may impact whether treatment is executed or not. Awareness of these risk factors may improve timely administration of antihypertensive medication in pregnant and postpartum patients.
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Affiliation(s)
- Sumithra Jeganathan
- Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Manhasset, NY (Drs Jeganathan, Wetcher, White, Gulersen, Lewis, and Rochelson).
| | - Cara S Wetcher
- Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Manhasset, NY (Drs Jeganathan, Wetcher, White, Gulersen, Lewis, and Rochelson)
| | - Virginia White
- Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Manhasset, NY (Drs Jeganathan, Wetcher, White, Gulersen, Lewis, and Rochelson)
| | - Julie Hemphill
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY (Mses Hemphill and Carryl)
| | - Leigha Carryl
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY (Mses Hemphill and Carryl)
| | - Moti Gulersen
- Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Manhasset, NY (Drs Jeganathan, Wetcher, White, Gulersen, Lewis, and Rochelson)
| | - Weiwei Shan
- Biostatistics Unit, Feinstein Institutes for Medical Research, Manhasset, NY (Dr Shan)
| | - Dawnette Lewis
- Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Manhasset, NY (Drs Jeganathan, Wetcher, White, Gulersen, Lewis, and Rochelson)
| | - Burton Rochelson
- Department of Obstetrics and Gynecology, North Shore University Hospital, Northwell Health, Manhasset, NY (Drs Jeganathan, Wetcher, White, Gulersen, Lewis, and Rochelson)
| | - Matthew J Blitz
- Department of Obstetrics and Gynecology, Southside Hospital, Northwell Health, Bay Shore, NY (Blitz)
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Differences in disease severity and delivery gestational age between black and white patients with hypertensive disorders of pregnancy. Pregnancy Hypertens 2022; 28:88-93. [DOI: 10.1016/j.preghy.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 11/23/2022]
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McNew KL, Abraham A, Sack DE, Smart CD, Pettway YD, Falk AC, Lister RL, Faucon AB, Bejan CA, Capra JA, Aronoff DM, Boyd KL, Moore DJ. Vascular alterations impede fragile tolerance to pregnancy in type 1 diabetes. F&S SCIENCE 2022; 3:148-158. [PMID: 35560012 PMCID: PMC9850286 DOI: 10.1016/j.xfss.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine the impact of autoimmunity in the absence of glycemic alterations on pregnancy in type 1 diabetes (T1D). DESIGN Because nonobese diabetic (NOD) mice experience autoimmunity before the onset of hyperglycemia, we studied pregnancy outcomes in prediabetic NOD mice using flow cytometry and enzyme-linked immunosorbent assays. Once we determined that adverse events in pregnancy occurred in euglycemic mice, we performed an exploratory study using electronic health records to better understand pregnancy complications in humans with T1D and normal hemoglobin A1c levels. SETTING University Medical Center. PATIENT(S)/ANIMAL(S) Nonobese diabetic mice and electronic health records from Vanderbilt University Medical Center. INTERVENTION(S) Nonobese diabetic mice were administered 200 μg of an anti-interleukin 6 (IL-6) antibody every other day starting on day 5 of gestation. MAIN OUTCOME MEASURE(S) Changes in the number of abnormal and reabsorbed pups in NOD mice and odds of vascular complications in pregnancy in T1D in relation to A1c. RESULT(S) Prediabetic NOD mice had increased adverse pregnancy outcomes compared with nonautoimmune mice; blockade of IL-6, which was secreted by endothelial cells, decreased the number of reabsorbed and abnormal fetuses. Similarly, vascular complications were increased in pregnant patients with T1D across all A1c values. CONCLUSION(S) The vascular secretion of IL-6 drives adverse pregnancy outcomes in prediabetic NOD mice. Pregnant patients with T1D have increased vascular complications even with normal hemoglobin A1cs, indicating a potential effect of autoimmunity on the placental vasculature.
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Affiliation(s)
- Kelsey L. McNew
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt University Medical Scientist Training Program, Nashville, Tennessee
| | - Abin Abraham
- Vanderbilt University Medical Scientist Training Program, Nashville, Tennessee,Vanderbilt University School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Daniel E. Sack
- Vanderbilt University Medical Scientist Training Program, Nashville, Tennessee,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Charles Duncan Smart
- Vanderbilt University Medical Scientist Training Program, Nashville, Tennessee,Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Yasminye D. Pettway
- Vanderbilt University Medical Scientist Training Program, Nashville, Tennessee,Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Alexander C. Falk
- Division of Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rolanda L. Lister
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Annika B. Faucon
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Genetics Institute, Vanderbilt University, Nashville, Tennessee
| | - Cosmin A. Bejan
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A. Capra
- Bakar Computational Health Sciences Institute and Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - David M. Aronoff
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelli L. Boyd
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Gilead Science, Inc., Foster, California
| | - Daniel J. Moore
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,Division of Pediatric Endocrinology, Vanderbilt University Medical Center, Nashville, Tennessee
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Suresh S, Amegashie C, Patel E, Nieman KM, Rana S. Racial Disparities in Diagnosis, Management, and Outcomes in Preeclampsia. Curr Hypertens Rep 2022; 24:87-93. [PMID: 35254590 DOI: 10.1007/s11906-022-01172-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE OF THE REVIEW Racial disparities are prevalent in many aspects of obstetric care in the USA. Non-Hispanic black women have a higher prevalence of the diagnosis of hypertensive disorders of pregnancy in addition to associated morbidity and mortality. The purpose of this review is to review current data regarding racial disparities in the diagnosis and management of hypertensive disorders of pregnancy. RECENT FINDINGS Diagnosis of hypertensive disorders of pregnancy is more common among non-Hispanic black women even after adjustment for comorbidities. Furthermore, prevalence of severe morbidity among those with hypertensive disorders of pregnancy is increased in non-Hispanic black women, including cardiovascular events related. Proposed management solutions include quality improvement initiatives, telehealth, and strategies to reduce both structural racism and implicit bias. Racial disparities exist in both diagnosis and management of hypertensive disorders of pregnancy; further innovative work is needed to reduce these disparities.
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Affiliation(s)
- Sunitha Suresh
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | | | - Easha Patel
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Kristin M Nieman
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA
| | - Sarosh Rana
- Division of Maternal Fetal Medicine/Department of Obstetrics and Gynecology, University of Chicago Medicine, 5841 S. Maryland Ave, MC 2050, Chicago, IL, 60637, USA.
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Abstract
Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.
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Affiliation(s)
- Kathryn M. Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence RI
| | - Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cheryl Carcel
- Neurology Program, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Eliza C. Miller
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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37
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Johnson JD, Louis JM. Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature. Am J Obstet Gynecol 2022; 226:S876-S885. [PMID: 32717255 DOI: 10.1016/j.ajog.2020.07.038] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022]
Abstract
The burden of preeclampsia, a substantial contributor to perinatal morbidity and mortality, is not born equally across the population. Although the prevalence of preeclampsia has been reported to be 3% to 5%, racial and ethnic minority groups such as non-Hispanic Black women and American Indian or Alaskan Native women are widely reported to be disproportionately affected by preeclampsia. However, studies that add clarity to the causes of the racial and ethnic differences in preeclampsia are limited. Race is a social construct, is often self-assigned, is variable across settings, and fails to account for subgroups. Studies of the genetic structure of human populations continue to find more variations within racial groups than among them. Efforts to examine the role of race and ethnicity in biomedical research should consider these limitations and not use it as a biological construct. Furthermore, the use of race in decision making in clinical settings may worsen the disparity in health outcomes. Most of the existing data on disparities examine the differences between White and non-Hispanic Black women. Fewer studies have enough sample size to evaluate the outcomes in the Asian, American Indian or Alaskan Native, or mixed-race women. Racial differences are noted in the occurrence, presentation, and short-term and long-term outcomes of preeclampsia. Well-established clinical risk factors for preeclampsia such as obesity, diabetes, and chronic hypertension disproportionately affect non-Hispanic Black, American Indian or Alaskan Native, and Hispanic populations. However, with comparable clinical risk factors for preeclampsia among women of different race or ethnic groups, addressing modifiable risk factors has not been found to have the same protective effect for all women. Abnormalities of placental formation and development, immunologic factors, vascular changes, and inflammation have all been identified as contributing to the pathophysiology of preeclampsia. Few studies have examined race and the pathophysiology of preeclampsia. Despite attempts, a genetic basis for the disease has not been identified. A number of genetic variants, including apolipoprotein L1, have been identified as possible risk modifiers. Few studies have examined race and prevention of preeclampsia. Although low-dose aspirin for the prevention of preeclampsia is recommended by the US Preventive Service Task Force, a population-based study found racial and ethnic differences in preeclampsia recurrence after the implementation of low-dose aspirin supplementation. After implementation, recurrent preeclampsia reduced among Hispanic women (76.4% vs 49.6%; P<.001), but there was no difference in the recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252). Future research incorporating the National Institute on Minority Health and Health Disparities multilevel framework, specifically examining the role of racism on the burden of the disease, may help in the quest for effective strategies to reduce the disproportionate burden of preeclampsia on a minority population. In this model, a multilevel framework provides a more comprehensive approach and takes into account the influence of behavioral factors, environmental factors, and healthcare systems, not just on the individual.
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Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Judette M Louis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL.
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38
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Garovic VD, Dechend R, Easterling T, Karumanchi SA, McMurtry Baird S, Magee LA, Rana S, Vermunt JV, August P. Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e21-e41. [PMID: 34905954 PMCID: PMC9031058 DOI: 10.1161/hyp.0000000000000208] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.
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Henderson JT, Vesco KK, Senger CA, Thomas RG, Redmond N. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 326:1192-1206. [PMID: 34581730 DOI: 10.1001/jama.2021.8551] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Preeclampsia is a hypertensive disorder of pregnancy that poses serious maternal and infant health risks. Previous systematic reviews have established benefits of low-dose aspirin taken during pregnancy to prevent preeclampsia and its sequelae. OBJECTIVE To update evidence for the US Preventive Services Task Force (USPSTF) on effectiveness of aspirin use in preventing preeclampsia in individuals at increased risk based on clinical risk factors or measurements associated with higher disease incidence than in the general population. DATA SOURCES Studies from previous USPSTF review (2014), literature published January 2013 through May 15, 2020, in MEDLINE, PubMed (for publisher-supplied records only), EMBASE, and Cochrane Central Register of Controlled Trials. Ongoing surveillance through January 22, 2021. STUDY SELECTION Good- and fair-quality randomized clinical trials (RCTs) of low-dose aspirin use during pregnancy to prevent preeclampsia among individuals at increased risk; studies conducted in general populations to evaluate potential harms. DATA EXTRACTION AND SYNTHESIS Dual article screening and risk-of-bias assessment. Study data abstracted into prespecified forms, checked for accuracy. Random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Diagnosis of preeclampsia; adverse pregnancy health outcomes and complications including eclampsia, perinatal mortality, preterm birth, small for gestational age, and potential bleeding harms or infant/child harms from aspirin exposure. RESULTS A total of 23 randomized clinical trials (RCTs) (N = 26 952) were included; 18 were conducted among participants at increased preeclampsia risk. Aspirin dosages ranged from 50 mg/d to 150 mg/d. Most trials enrolled majority White populations selected based on a range of risk factors. The incidence of preeclampsia among the trials of participants at increased risk ranged from 4% to 30%. Aspirin use was significantly associated with lower risk of preeclampsia (pooled relative risk [RR], 0.85 [95% CI, 0.75-0.95]; 16 RCTs [n = 14 093]; I2 = 0%), perinatal mortality (pooled RR, 0.79 [95% CI, 0.66-0.96]; 11 RCTs [n = 13 860]; I2 = 0%), preterm birth (pooled RR, 0.80 [95% CI, 0.67-0.95]; 13 RCTs [n = 13 619]; I2 = 49%), and intrauterine growth restriction (pooled RR, 0.82 [95% CI, 0.68-0.99]; 16 RCTs [n = 14 385]; I2 = 41%). There were no significant associations of aspirin use with risk of postpartum hemorrhage (pooled RR, 1.03 [95% CI, 0.94-1.12]; 9 RCTs [n = 23 133]; I2 = 0%) and other bleeding-related harms, or with rare perinatal or longer-term harms. Absolute risk reductions for preeclampsia associated with aspirin use ranged from -1% to -6% across larger trials (n >300) and were greater in smaller trials. For perinatal mortality, absolute risk reductions ranged from 0.5% to 1.1% in the 3 largest trials. CONCLUSIONS AND RELEVANCE Daily low-dose aspirin during pregnancy was associated with lower risks of serious perinatal outcomes for individuals at increased risk for preeclampsia, without evident harms.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Kimberly K Vesco
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nadia Redmond
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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Minhas AS, Michelle Ogunwole S, Vaught A(J, Wu P, Mamas MA, Gulati M, Zhao D, Hays AG, Michos ED. Racial Disparities in Cardiovascular Complications With Pregnancy-Induced Hypertension in the United States. Hypertension 2021; 78:480-488. [PMID: 34098730 PMCID: PMC8266726 DOI: 10.1161/hypertensionaha.121.17104] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Anum S. Minhas
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - S. Michelle Ogunwole
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arthur (Jason) Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine
| | - Pensee Wu
- Department of Maternal Fetal Medicine, Keele University, Stoke-on-Trent, United Kingdom
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Martha Gulati
- Division of Cardiology, University of Arizona College of Medicine, Phoenix, AZ
| | - Di Zhao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allison G. Hays
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Roset Bahmanyar E, Out HJ, van Duin M. Women and babies are dying from inertia: a collaborative framework for obstetrical drug development is urgently needed. Am J Obstet Gynecol 2021; 225:43-50. [PMID: 34215353 DOI: 10.1016/j.ajog.2021.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/10/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022]
Abstract
Obstetrical complications, often referred to as the "great obstetrical syndromes," are among the most common global causes of mortality and morbidity in young women and their infants. However, treatments for these syndromes are underdeveloped compared with other fields of medicine and are urgently needed. This current paucity of treatments for obstetrical complications is a reflection of the challenges of drug development in pregnancy. The appetite of pharmaceutical companies to invest in research for obstetrical syndromes is generally reduced by concerns for maternal, fetal, and infant safety, poor definition, and high-risk regulatory paths toward product approval. Notably, drug candidates require large investments for development with an unguaranteed return on investment. Furthermore, the discovery of promising drug candidates is hampered by a poor understanding of the pathophysiology of obstetrical syndromes and their uniqueness to human pregnancies. This limits translational extrapolation and de-risking strategies in preclinical studies, as available for other medical areas, compounded with limited fetal safety monitoring to capture early prenatal adverse reactions. In addition, the ethical review committees are reluctant to approve the inclusion of pregnant women in trials, and in the absence of regulatory guidance in obstetrics, clinical development programs are subject to unpredictable regulatory paths. To develop effective and safe drugs for pregnancy complications, substantial commitment, and investment in research for innovative therapies are needed in parallel with the creation of an enabling ethical, legislative, and guidance framework. Solutions are proposed to enable stakeholders to work with a common set of expectations to facilitate progress in this medical discipline. Addressing this significant unmet need to advance maternal and possibly perinatal health requires the involvement of all stakeholders and specifically patients, couples, and clinicians facing pregnancy complications in the dearth of appropriate therapies. This paper focused on the key pharmaceutical research and development challenges to achieve effective and safe treatments for obstetrical syndromes.
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Racial Discrimination and Stress Across the Life Course: Associations With Prenatal Inflammation, Perceived Stress, and Depressive Symptoms. Nurs Res 2021; 70:S21-S30. [PMID: 34173372 DOI: 10.1097/nnr.0000000000000525] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Among Black Americans, interpersonal racial discrimination is common. Stress, including following discrimination, contributes to pregnancy complications. In this secondary analysis, we provide data on associations among discrimination, stress, and their interaction across the life course and inflammation, perceived stress, and depressive symptoms during pregnancy. METHODS During the early third trimester, Black American women (n = 93) completed the Experiences of Discrimination Scale, the Stress and Adversity Inventory, the Perceived Stress Scale, and the Center for Epidemiological Studies Depression Inventory. Plasma interleukin-6 (IL-6), IL-8, tumor necrosis factor-α (TNF-α), and IL-β levels were quantified. Associations were examined by linear regression, controlling for demographic, behavioral, and clinical covariates. RESULTS Associations among racial discrimination and plasma IL-8, TNF-α, and IL-β levels depended upon average ratings of life course stress. When stress was low, discrimination in the mid tertile was associated with the highest levels of IL-8, TNF-α, and IL-β. Subscale analyses suggested that findings related to IL-8 were driven by chronic stress whereas findings related to TNF-α and IL-β were driven by acute stress. When examined together, greater discrimination but not greater life course stress was associated with higher prenatal perceived stress. In subscale analyses, the association between discrimination and prenatal perceived stress depended upon average ratings of life course acute stress. When acute stress was low, discrimination in the midtertile was associated with the highest levels of prenatal perceived stress. When acute stress was high, discrimination in the high tertile was associated with the highest levels of prenatal perceived stress. There were also direct associations among greater life course chronic stress, prenatal perceived stress, and prenatal depressive symptoms. Associations were attenuated when discrimination was included as a covariate. CONCLUSIONS The current analyses suggest that, among Black Americans, prenatal inflammation, perceived stress, and depressive symptoms may be shaped by racial discrimination and stress across the life course. In many cases, associations among discrimination and prenatal parameters depended upon how stressful exposures to life course stressors had been rated. The data suggest the potential for adaptive plasticity under some stress and highlight the deleterious nature of compounding stress.
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Kern-Goldberger A, Hirshberg A. Reducing Disparities Using Telehealth Approaches for Postdelivery Preeclampsia Care. Clin Obstet Gynecol 2021; 64:375-383. [PMID: 33904843 DOI: 10.1097/grf.0000000000000605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The management of hypertensive disease of pregnancy presents an ongoing challenge after patients are discharged from delivery hospitalizations. Preeclampsia and other forms of postpartum hypertension increase the risk for severe maternal morbidity and mortality in the postpartum period, and both hypertension and its associated adverse events disproportionately affect black women. With its ability to transcend barriers to health care access, telemedicine can facilitate high-quality postpartum care delivery for preeclampsia management and thereby reduce racial disparities in obstetric care and outcomes. Here we discuss racial disparities in preeclampsia and the challenge of providing equitable postpartum preeclampsia care. We then describe the utility of novel telemedicine platforms and their application to combat these disparities in preeclampsia care.
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Affiliation(s)
- Adina Kern-Goldberger
- Department of Obstetrics & Gynecology, Maternal Child Health Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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44
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Reducing Maternal Morbidity and Racial Disparities in Hypertension Care Using an Automated Care Pathway. Obstet Gynecol 2021; 137:209-210. [PMID: 33416282 DOI: 10.1097/aog.0000000000004265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Ames BN, Grant WB, Willett WC. Does the High Prevalence of Vitamin D Deficiency in African Americans Contribute to Health Disparities? Nutrients 2021; 13:499. [PMID: 33546262 PMCID: PMC7913332 DOI: 10.3390/nu13020499] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/24/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
African Americans have higher incidence of, and mortality from, many health-related problems than European Americans. They also have a 15 to 20-fold higher prevalence of severe vitamin D deficiency. Here we summarize evidence that: (i) this health disparity is partly due to insufficient vitamin D production, caused by melanin in the skin blocking the UVB solar radiation necessary for its synthesis; (ii) the vitamin D insufficiency is exacerbated at high latitudes because of the combination of dark skin color with lower UVB radiation levels; and (iii) the health of individuals with dark skin can be markedly improved by correcting deficiency and achieving an optimal vitamin D status, as could be obtained by supplementation and/or fortification. Moderate-to-strong evidence exists that high 25-hydroxyvitamin D levels and/or vitamin D supplementation reduces risk for many adverse health outcomes including all-cause mortality rate, adverse pregnancy and birth outcomes, cancer, diabetes mellitus, Alzheimer's disease and dementia, multiple sclerosis, acute respiratory tract infections, COVID-19, asthma exacerbations, rickets, and osteomalacia. We suggest that people with low vitamin D status, which would include most people with dark skin living at high latitudes, along with their health care provider, consider taking vitamin D3 supplements to raise serum 25-hydroxyvitamin D levels to 30 ng/mL (75 nmol/L) or possibly higher.
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Affiliation(s)
- Bruce N. Ames
- Molecular and Cell Biology, Emeritus, University of California, Berkeley, CA 94720, USA;
| | - William B. Grant
- Sunlight, Nutrition and Health Research Center, San Francisco, CA 94164-1603, USA
| | - Walter C. Willett
- Departments of Nutrition and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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46
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Friedman A. Clinical Implications of Maternal Disparities Administrative Data Research. Clin Perinatol 2020; 47:759-767. [PMID: 33153660 DOI: 10.1016/j.clp.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Administrative data research on maternal racial disparities supports 2 broad clinical inferences. First, failure to rescue in terms of both death and severe maternal morbidity likely accounts for a significant proportion of maternal disparities. Second, risk for adverse outcomes by race is generally differential with risk for cardiovascular complications particularly high for non-Hispanic black women. These differentials suggest that underlying health conditions may represent an important contributor to overall disparities, and optimal longitudinal care utilization with nonobstetric specialists is required to mitigate risk.
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Affiliation(s)
- Alexander Friedman
- Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, PH 16-66, New York, NY 10032, USA.
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47
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Fasanya HO, Hsiao CJ, Armstrong-Sylvester KR, Beal SG. A Critical Review on the Use of Race in Understanding Racial Disparities in Preeclampsia. J Appl Lab Med 2020; 6:247-256. [PMID: 33227139 DOI: 10.1093/jalm/jfaa149] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/11/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Preeclampsia is a significant cause of maternal morbidity and mortality, affecting up to 8% of pregnancies globally. Although the precise etiology is still under study, the literature suggests that vascular changes reduce placental perfusion and affect the remodeling of spiral arteries to create the hallmark feature of preeclampsia: elevated blood pressure. Screening for preeclampsia is currently recommended for all pregnant women, particularly if risk factors exist. A noted risk factor codified in guidelines is "African-American race." CONTENT We summarize the racial disparities in preeclampsia incidence, morbidity, and mortality. We consider the limitations of using race to understand disparities by also examining multiethnic, immigration, and international studies. We then critically evaluate laboratory analytes associated with racial disparities of preeclampsia and explore other mechanisms of action, such as socioeconomic status, stress, and access to care. SUMMARY Black and African-American women are consistently at higher risk of preeclampsia incidence, morbidity, and mortality than their white counterparts. Asian women are consistently at lower risk of preeclampsia, whereas the association for Hispanic women remains unclear. When these broad racial categories are subdivided by geographic or cultural origin, preeclampsia disparities within racial groups are identified. The limited literature suggests that sub-Saharan African immigrants tend to have a higher risk of preeclampsia than US-born white populations but a lower risk than US-born Black women. Existing studies seeking to identify racial differences in analytes have limited research designs and tend to operationalize race as a proxy for biologically inherent (i.e., genetic) differences between races despite a plethora of other possible explanatory mechanisms.
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Affiliation(s)
- Henrietta O Fasanya
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL.,Genetics Institute, University of Florida, Gainesville, FL.,MD-PhD Program, University of Florida College of Medicine, Gainesville, FL.,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL
| | - Chu J Hsiao
- Genetics Institute, University of Florida, Gainesville, FL.,MD-PhD Program, University of Florida College of Medicine, Gainesville, FL.,Department of Anthropology, University of Florida College of Liberal Arts and Sciences, Gainesville, FL
| | - Kendra R Armstrong-Sylvester
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
| | - Stacy G Beal
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL
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Nuckols VR, Holwerda SW, Luehrs RE, DuBose LE, Stroud AK, Brandt D, Betz AM, Fiedorowicz JG, Scroggins SM, Santillan DA, Grobe JL, Sigmund CD, Santillan MK, Pierce GL. Beat-to-Beat Blood Pressure Variability in the First Trimester Is Associated With the Development of Preeclampsia in a Prospective Cohort: Relation With Aortic Stiffness. Hypertension 2020; 76:1800-1807. [PMID: 32951467 DOI: 10.1161/hypertensionaha.120.15019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Women with preeclampsia, a hypertensive disorder of pregnancy, exhibit greater beat-to-beat blood pressure variability (BPV) in the third trimester after clinical onset of the disorder. However, it remains unknown whether elevated BPV precedes the development of preeclampsia. A prospective study cohort of 139 women (age 30.2±4.0 years) were enrolled in early pregnancy (<14 weeks gestation). BPV was quantified by time domain analyses of 10-minute continuous beat-to-beat blood pressure recordings via finger photoplethysmography in the first, second, and third trimesters. Aortic stiffness (carotid-femoral pulse wave velocity) and spontaneous cardiovagal baroreflex sensitivity were also measured each trimester. Eighteen women (13%) developed preeclampsia. Systolic BPV was higher in all trimesters among women who developed versus did not develop preeclampsia (first: 4.8±1.3 versus 3.7±1.2, P=0.001; second: 5.1±1.8 versus 3.8±1.1, P=0.02; third: 5.2±0.8 versus 4.0±1.1 mm Hg, P=0.002). Elevated first trimester systolic BPV was associated with preeclampsia (odds ratio, 1.94 [95% CI, 1.27-2.99]), even after adjusting for risk factors (age, body mass index, systolic blood pressure, history of preeclampsia, and diabetes mellitus) and was a significant predictor of preeclampsia (area under the receiver operator characteristic curve=0.75±0.07; P=0.002). Carotid-femoral pulse wave velocity was elevated in the first trimester among women who developed preeclampsia (5.9±0.8 versus 5.2±0.8 m/s; P=0.002) and was associated with BPV after adjustment for mean blood pressure (r=0.26; P=0.005). First trimester baroreflex sensitivity did not differ between groups (P=0.23) and was not related to BPV (P=0.36). Elevated systolic BPV is independently associated with the development of preeclampsia as early as the first trimester, possibly mediated in part by higher aortic stiffness.
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Affiliation(s)
- Virginia R Nuckols
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Seth W Holwerda
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA.,the Abboud Cardiovascular Research Center (S.W.H., M.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Rachel E Luehrs
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Lyndsey E DuBose
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Amy K Stroud
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Debra Brandt
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Alexandria M Betz
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Jess G Fiedorowicz
- Psychiatry (J.G.F.), University of Iowa, Iowa City, IA.,Epidemiology (J.G.F.), University of Iowa, Iowa City, IA.,Internal Medicine (J.G.F.), University of Iowa, Iowa City, IA
| | - Sabrina M Scroggins
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Donna A Santillan
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA
| | - Justin L Grobe
- Departments of Physiology (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI.,Biomedical Engineering (J.L.G.), Medical College of Wisconsin, Milwaukee, WI.,Cardiovascular Research Center (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | - Curt D Sigmund
- Departments of Physiology (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI.,Cardiovascular Research Center (J.L.G., C.D.S.), Medical College of Wisconsin, Milwaukee, WI
| | - Mark K Santillan
- Obstetrics and Gynecology (D.B., A.M.B., S.M.S., D.A.S., M.K.S.), University of Iowa, Iowa City, IA.,the Abboud Cardiovascular Research Center (S.W.H., M.K.S., G.L.P.), University of Iowa, Iowa City, IA
| | - Gary L Pierce
- From the Departments of Health and Human Physiology (V.R.N., S.W.H., R.E.L., L.E.D., A.K.S., G.L.P.), University of Iowa, Iowa City, IA.,the Abboud Cardiovascular Research Center (S.W.H., M.K.S., G.L.P.), University of Iowa, Iowa City, IA.,Fraternal Order of Eagles Diabetes Research Center (G.L.P.), University of Iowa, Iowa City, IA
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Xu Y, Xia X, Jiang Y, Wu D, Wang S, Fu S, Yang N, Zhang Y, Sun L. Down-regulated lncRNA AGAP2-AS1 contributes to pre-eclampsia as a competing endogenous RNA for JDP2 by impairing trophoblastic phenotype. J Cell Mol Med 2020; 24:4557-4568. [PMID: 32150333 PMCID: PMC7176850 DOI: 10.1111/jcmm.15113] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/06/2020] [Accepted: 02/15/2020] [Indexed: 01/17/2023] Open
Abstract
Recently, growing evidence has shown that aberrant long non‐coding RNA (lncRNA) expression in conjunction with an impaired trophoblastic phenotype could implicate the pathological process of pre‐eclampsia (PE). However, only a small portion of lncRNAs has been characterized with regard to the function and molecular mechanisms involved in PE. There are still gaps in the available knowledge; as a result, there are currently only a few applicable treatments for PE in the context of lncRNA. Here, we found that lncRNA AGAP2‐AS1 is abnormally down‐regulated in severe PE placenta tissues. Using human trophoblasts, we established that AGAP2‐AS1 knockdown could inhibit trophoblasts proliferation and invasion and promote cell apoptosis. Further, we showed that overexpression of AGAP2‐AS1 substantially stimulated the development of the trophoblastic phenotype. Through high‐throughput sequencing analysis, we demonstrated that silencing of AGAP2‐AS1 favourably regulated various genes which are relevant to trophoblastic growth and invasion. Mechanistically, AGAP2‐AS1 promoted the suppressor protein, Jun dimerization protein 2 (JDP2), by sponging miR‐574‐5p. Resultantly, further impairment of the trophoblastic phenotype was achieved by way of inhibiting cell growth, apoptosis and invasion. We also determined that the expression of AGAP2‐AS1 could be mediated by FOXP1. Our results showed that the down‐regulated expression of lncRNA AGAP2‐AS1 might serve as a key suppressor in PE via inhibition of JDP2 at the post‐transcriptional level by competing for miR‐574; thus, this presents a novel therapeutic strategy for PE.
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Affiliation(s)
- Yetao Xu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xi Xia
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Shenzhen Hospital, Shenzhen, China
| | - Ying Jiang
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan Wu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Sailan Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shilong Fu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Nana Yang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yuanyuan Zhang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lizhou Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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50
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Miller EC, Zambrano Espinoza MD, Huang Y, Friedman AM, Boehme AK, Bello NA, Cleary KL, Wright JD, D'Alton ME. Maternal Race/Ethnicity, Hypertension, and Risk for Stroke During Delivery Admission. J Am Heart Assoc 2020; 9:e014775. [PMID: 31973601 PMCID: PMC7033883 DOI: 10.1161/jaha.119.014775] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Racial disparities contribute to maternal morbidity in the United States. Hypertension is associated with poor maternal outcomes, including stroke. Disparities in hypertension might contribute to maternal strokes. Methods and Results Using billing data from the Healthcare Cost and Utilization Project's National Inpatient Sample, we analyzed the effect of race/ethnicity on stroke during delivery admission in women aged 18 to 54 years delivering in US hospitals from January 1, 1998, through December 31, 2014. We categorized hypertension as normotensive, chronic hypertension, or pregnancy‐induced hypertension. Adjusted risk ratios (aRRs) and 95% CIs were calculated using log‐linear Poisson regression models, testing for interactions between race/ethnicity and hypertensive status. A total of 65 286 425 women were admitted for delivery during the study period, of whom 7764 were diagnosed with a stroke (11.9 per 100 000 deliveries). Hypertension modified the effect of race/ethnicity (P<0.0001 for interaction). Among women with pregnancy‐induced hypertension, black and Hispanic women had higher stroke risk compared with non‐Hispanic whites (blacks: aRR, 2.07; 95% CI, 1.86–2.30; Hispanics: aRR, 2.19; 95% CI, 1.98–2.43). Among women with chronic hypertension, all minority women had higher stroke risk (blacks: aRR, 1.71; 95% CI, 1.30–2.26; Hispanics: aRR, 1.75; 95% CI, 2.32–5.63; Asian/Pacific Islanders: aRR, 3.62; 95% CI, 2.32–5.63). Among normotensive women, only blacks had increased stroke risk (aRR, 1.17; 95% CI, 1.07–1.28). Conclusions Pregnant US women from minority groups had higher stroke risk during delivery admissions, compared with non‐Hispanic whites. The effect of race/ethnicity was larger in women with chronic hypertension or pregnancy‐induced hypertension. Targeting blood pressure management in pregnancy may help reduce maternal stroke risk in minority populations.
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Affiliation(s)
- Eliza C Miller
- Department of Neurology Vagelos College of Physicians and Surgeons Columbia University New York NY
| | | | - Yongmei Huang
- Department of Obstetrics and Gynecology Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Amelia K Boehme
- Department of Neurology Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Natalie A Bello
- Department of Medicine Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Kirsten L Cleary
- Department of Obstetrics and Gynecology Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology Vagelos College of Physicians and Surgeons Columbia University New York NY
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology Vagelos College of Physicians and Surgeons Columbia University New York NY
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