Chronic Hypertension in Pregnancy:

Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States

BACKGROUND

Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth.

METHODS

Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods.

RESULTS

Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines.

CONCLUSIONS

Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.

Impact of Chronic Hypertension and Antihypertensive Treatment on Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis

Background Maternal chronic hypertension is associated with adverse pregnancy outcomes. Previous studies examined the association between either chronic hypertension or antihypertensive treatment and adverse pregnancy outcomes. We aimed to synthesize the evidence on the effect of chronic hypertension/antihypertensive treatment on adverse pregnancy outcomes. Methods and Results Medline/PubMed, EMBASE, and Web of Science were searched; we included observational studies and assessed the effect of race/ethnicity, where possible, following a registered protocol (CRD42019120088). Random-effects meta-analyses were used. A total of 81 studies were identified on chronic hypertension, and a total of 16 studies were identified on antihypertensive treatment. Chronic hypertension was associated with higher odds of preeclampsia (adjusted odd ratio [aOR], 5.43; 95% CI, 3.85-7.65); cesarean section (aOR, 1.87; 95% CI, 1.6-2.16); maternal mortality (aOR, 4.80; 95% CI, 3.04-7.58); preterm birth (aOR, 2.23; 95% CI, 1.96-2.53); stillbirth (aOR, 2.32; 95% CI, 2.22-2.42); and small for gestational age (SGA) (aOR, 1.96; 95% CI, 1.6-2.40). Subgroup analyses indicated that maternal race/ethnicity does not influence the observed associations. Women with chronic hypertension on antihypertensive treatment (versus untreated) had higher odds of SGA (aOR, 1.86; 95% CI, 1.38-2.50). Conclusions Chronic hypertension is associated with adverse pregnancy outcomes, and these associations appear to be independent of maternal race/ethnicity. In women with chronic hypertension, those on treatment had a higher risk of SGA, although the number of studies was limited. This could result from a direct effect of the treatment or because severe hypertension during pregnancy is a risk factor for SGA and women with severe hypertension are more likely to be treated. The effect of antihypertensive treatment on SGA needs to be further tested with large randomized controlled trials.

Neonatal effects of intrauterine metoprolol/bisoprolol exposure during the second and third trimester: a cohort study with two comparison groups

OBJECTIVES

Our aim was to evaluate the effects of beta-blockers during the second and third trimester on fetal growth, length of gestation and postnatal symptoms in exposed infants.

METHODS

The current prospective observational cohort study compares 294 neonates of hypertensive mothers on metoprolol or bisoprolol during the second and/or third trimester with 225 methyldopa-exposed infants and 588 infants of nonhypertensive mothers. The risks for reduced birth weight, prematurity, neonatal bradycardia, hypoglycaemia and respiratory disorders were analysed.

RESULTS

The rate of small-for-gestational-age children was significantly higher in long-term beta-blocker exposed infants (24.1%) compared with the methyldopa cohort [10.2%, odds ratio (OR)adj 2.5, 95% confidence interval (CI) 1.2-5.2] and the nonhypertensive cohort (9.9%, ORadj 4.3, 95% CI 2.6-7.1). The risk for preterm birth was significantly increased compared with nonhypertensive pregnancies (ORadj 2.2, 95% CI 1.3-3.8) but not compared with the methyldopa cohort. Neonatal adverse outcomes occurred more frequently in the study cohort (11.5%) compared with the nonhypertensive comparison group (6.5%) and the methyldopa cohort (8.4%), but without statistical significance (ORadj 1.5, 95% CI 0.7-3.0 and ORadj 1.5, 95% CI 0.7-3.3, respectively).

CONCLUSION

Long-term intrauterine exposure to metoprolol or bisoprolol may increase the risk of being born small-for-gestational-age. It is still a matter of debate to which extent maternal hypertension contributes to the lower birth weight. Serious neonatal symptoms are rare. Altogether, metoprolol and bisoprolol are well tolerated treatment options, but a case-by-case decision on close neonatal monitoring is recommended.

Hypertension and reproductive dysfunction: a possible role of inflammation and inflammation-associated lymphangiogenesis in gonads

Hypertension is one of the most prevalent diseases that leads to end organ damage especially affecting the heart, kidney, brain, and eyes. Numerous studies have evaluated the association between hypertension and impaired sexual health, in both men and women. The detrimental effects of hypertension in men includes erectile dysfunction, decrease in semen volume, sperm count and motility, and abnormal sperm morphology. Similarly, hypertensive females exhibit decreased vaginal lubrication, reduced orgasm, and several complications in pregnancy leading to fetal and maternal morbidity and mortality. The adverse effect of hypertension on male and female fertility is attributed to hormonal imbalance and changes in the gonadal vasculature. However, mechanistic studies investigating the impact of hypertension on gonads in more detail on a molecular basis remain scarce. Hence, the aim of the current review is to address and summarize the effects of hypertension on reproductive health, and highlight the importance of research on the effects of hypertension on gonadal inflammation and lymphatics.

Timing of Delivery in Women With Chronic Hypertension

OBJECTIVE

To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery.

METHODS

We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801).

RESULTS

Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57-0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69-1.17]).

CONCLUSION

Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.

Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy are common and contribute inordinately to maternal and fetal morbidity and mortality. Although not completely understood, recent clinical trials have provided important insights into pathogenesis of preeclampsia. Preeclampsia is considered a systemic disease with generalized endothelial dysfunction and risk of future cardiovascular disease. This review revisits the definitions and classifications of hypertensive disorders of pregnancy; discusses updates on pathophysiology, prevention, and early prediction of preeclampsia; reviews current management guidelines; and discusses potential risks and benefits associated with treatment. Improvement in management and outcomes of women with hypertensive disorders of pregnancy seems in sight in the near future.

Pharmacotherapy for hypertension in pregnant patients: special considerations

INTRODUCTION

Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated.

AREAS COVERED

This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP.

EXPERT OPINION

Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.

Aspirin Effect on Adverse Pregnancy Outcomes Associated With Stage 1 Hypertension in a High-Risk Cohort

Recently, the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines revised the recommendations for diagnosis of chronic hypertension. The new classification system includes a diagnosis of stage 1 hypertension in adults with blood pressures 130 to 139/80 to 89 mm Hg. We sought to compare outcomes among women at high risk for preeclampsia with stage 1 hypertension and assessed whether women with stage 1 hypertension had benefit from aspirin treatment compared with high-risk normotensive women. We performed a secondary analysis of the high-risk aspirin trial and included women with prior preeclampsia or diabetes mellitus. Among these women, 827 (81%) were classified as normotensive, whereas 193 (19%) were classified as stage 1 hypertensive. Among women receiving placebo, preeclampsia occurred significantly more often in women with stage 1 hypertension compared with normotensive high-risk women after adjustment for maternal age and body mass index (39.1% versus 15.1%; risk ratio, 2.49; 95% confidence interval, 1.74-3.55). Further, women with stage 1 hypertension had a significant risk reduction related to aspirin prophylaxis (risk ratio, 0.61; 95% confidence interval, 0.39-0.94) that was not seen in normotensive high-risk women (risk ratio, 0.97; 95% confidence interval, 0.70-1.34). Application of the American College of Cardiology/American Heart Association guidelines in a high-risk population demonstrates that in the setting of other risk factors, the presence of stage 1 hypertension is associated with a significantly increased risk of preeclampsia when compared with high-risk normotensive women. These findings emphasize the importance of recognition of stage 1 hypertension as an additive risk factor in women at high risk for preeclampsia and the benefit of aspirin.

Modeling Superimposed Preeclampsia Using Ang II (Angiotensin II) Infusion in Pregnant Stroke-Prone Spontaneously Hypertensive Rats

Hypertensive disorders of pregnancy are the second leading cause of maternal deaths worldwide. Superimposed preeclampsia is an increasingly common problem and often associated with impaired placental perfusion. Understanding the underlying mechanisms and developing treatment options are crucial. The pregnant stroke-prone spontaneously hypertensive rat has impaired uteroplacental blood flow and abnormal uterine artery remodeling. We used Ang II (angiotensin II) infusion in pregnant stroke-prone spontaneously hypertensive rats to mimic the increased cardiovascular stress associated with superimposed preeclampsia and examine the impact on the maternal cardiovascular system and fetal development. Continuous infusion of Ang II at 500 or 1000 ng/kg per minute was administered from gestational day 10.5 until term. Radiotelemetry and echocardiography were used to monitor hemodynamic and cardiovascular changes, and urine was collected prepregnancy and throughout gestation. Uterine artery myography assessed uteroplacental vascular function and structure. Fetal measurements were made at gestational day 18.5, and placentas were collected for histological and gene expression analyses. The 1000 ng/kg per minute Ang II treatment significantly increased blood pressure (P<0.01), reduced cardiac output (P<0.05), and reduced diameter and increased stiffness of the uterine arteries (P<0.01) during pregnancy. The albumin:creatinine ratio was increased in both Ang II treatment groups (P<0.05; P<0.0001). The 1000 ng/kg per minute-treated fetuses were significantly smaller than vehicle treatment (P<0.001). Placental expression of Ang II receptors was increased in the junctional zone in 1000 ng/kg per minute Ang II-treated groups (P<0.05), with this zone showing depletion of glycogen content and structural abnormalities. Ang II infusion in pregnant stroke-prone spontaneously hypertensive rats mirrors hemodynamic, cardiac, and urinary profiles observed in preeclamptic women, with evidence of impaired fetal growth.

Perinatal outcomes associated with abnormal cardiac remodeling in women with treated chronic hypertension

BACKGROUND

Adverse maternal outcomes associated with chronic hypertension include accelerated hypertension and resultant target organ damage. One example is long-standing hypertension leading to maternal cardiac dysfunction. Our group has previously identified that features of such injury manifest as cardiac remodeling with left ventricular hypertrophy. Moreover, these features of cardiac remodeling identified in women with chronic hypertension during pregnancy were associated with adverse perinatal outcomes. Recent definitions of maternal cardiac remodeling using echocardiography have been expanded to include measurements of wall thickness. We hypothesized that these new features characterizing cardiac remodeling in women with chronic hypertension may also be associated with adverse perinatal outcomes.

OBJECTIVE

There were 3 aims in this study of women with treated chronic hypertension during pregnancy: to (1) apply the updated definitions of maternal cardiac remodeling; (2) elucidate whether these features of cardiac remodeling were associated with adverse perinatal outcomes; and (3) determine which, if any, of the newly defined cardiac remodeling strata were most damaging when compared to women with normal cardiac geometry.

STUDY DESIGN

This was a retrospective study of women with treated chronic hypertension during pregnancy delivered from January 2009 through January 2016. Cardiac remodeling was categorized by left ventricular mass index and relative wall thickness into 4 groups determined using the 2015 American Society of Echocardiography guidelines: normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Perinatal outcomes were analyzed according to each category of cardiac remodeling compared with outcomes in women with normal geometry.

RESULTS

A total of 314 women with treated chronic hypertension underwent echocardiography at a mean gestational age of 17.9 weeks. There were no differences between maternal age (P = .896), habitus (P = .36), or duration of chronic hypertension (P = .212) among the 4 groups. Abnormal cardiac remodeling was found in 51% and was significantly associated with increased rates of superimposed preeclampsia (P = .015), preterm birth (P < .001), and neonatal intensive care admission (P = .003). These outcomes reached the greatest significance when comparisons were made between eccentric hypertrophy and normal geometry.

CONCLUSION

Using current American Society of Echocardiography guidelines, 51% of women with treated chronic hypertension during pregnancy have some degree of abnormal cardiac remodeling. Any suggestion of maternal cardiac remodeling, regardless of subtype, was associated with increased risks for superimposed preeclampsia and preterm birth with its resultant perinatal sequelae. Eccentric ventricular hypertrophy, previously thought to mimic exercise physiology, appears to be the most associated with adverse perinatal outcomes. Despite evidence of cardiac remodeling, ejection fraction was preserved.

Chronic hypertension in pregnancy: impact of ethnicity and superimposed preeclampsia on placental, endothelial, and renal biomarkers

Black ethnicity is associated with worse pregnancy outcomes in women with chronic hypertension. Preexisting endothelial and renal dysfunction and poor placentation may contribute, but pathophysiological mechanisms underpinning increased risk are poorly understood. This cohort study aimed to investigate the relationship between ethnicity, superimposed preeclampsia, and longitudinal changes in markers of endothelial, renal, and placental dysfunction in women with chronic hypertension. Plasma concentrations of placental growth factor (PlGF), syndecan-1, renin, and aldosterone and urinary angiotensinogen-to-creatinine ratio (AGTCR), protein-to-creatinine ratio (PCR), and albumin-to-creatinine ratio (ACR) were quantified during pregnancy and postpartum in women with chronic hypertension. Comparisons of longitudinal biomarker concentrations were made using log-transformation and random effects logistic regression allowing for gestation. Of 117 women, superimposed preeclampsia was diagnosed in 21% ( n = 25), with 24% ( n = 6) having an additional diagnosis of diabetes. The cohort included 63 (54%) women who self-identified as being of black ethnicity. PlGF concentrations were 67% lower [95% confidence interval (CI) -79 to -48%] and AGTCR, PCR, and ACR were higher over gestation, in women with subsequent superimposed preeclampsia (compared with those without superimposed preeclampsia). PlGF <100 pg/ml at 20-23.9 wk of gestation predicted subsequent birth weight <3rd percentile with 88% sensitivity (95% CI 47-100%) and 83% specificity (95% CI 70-92%). Black women had 43% lower renin (95% CI -58 to -23%) and 41% lower aldosterone (95%CI -45 to -15%) concentrations over gestation. Changes in placental (PlGF) and renal (AGTCR/PCR/ACR) biomarkers predated adverse pregnancy outcome. Ethnic variation in the renin-angiotensin-aldosterone system exists in women with chronic hypertension in pregnancy and may be important in treatment selection.

Chronic hypertension: first-trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational age

BACKGROUND

There is extensive evidence that prepregnancy chronic hypertension is associated with a high risk of development of severe hypertension and preeclampsia and birth of small-for-gestational-age neonates. However, previous studies have not reported whether antihypertensive use, blood pressure control, or normalization of blood pressure during early pregnancy influences the rates of these pregnancy complications.

OBJECTIVE

The purpose of this study was to stratify women with prepregnancy chronic hypertension according to the use of antihypertensive medications and level of blood pressure control at the first hospital visit during the first trimester of pregnancy and to examine the rates of severe hypertension, preeclampsia, and birth of small-for-gestational-age neonates according to such stratification.

STUDY DESIGN

We conducted a prospective study of 586 women with prepregnancy chronic hypertension, in the absence of renal or liver disease, that was booked at a dedicated clinic for the management of hypertension in pregnancy. The patients had singleton pregnancies and were subdivided according to findings in their first visit: group 1 (n=199), blood pressure <140/90 mm Hg without antihypertensive medication; group 2 (n=220), blood pressure <140/90 mm Hg with antihypertensive medication; and group 3 (n=167), systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg, despite antihypertensive medication. In the subsequent management of these pregnancies, our policy was to maintain the blood pressure at 130-140/80-90 mm Hg with the use of antihypertensive medication; antihypertensive drugs were stopped if the blood pressure was persistently <130/80 mm Hg. The outcome measures were severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg), preterm and term preeclampsia (in addition to hypertension at least 1 of renal involvement, liver impairment, neurologic complications, or thrombocytopenia), and birth of small-for-gestational-age neonates (birthweight <5th percentile for gestational age). The incidence of these complications was compared in the 3 strata.

RESULTS

The median gestational age at presentation was 10.0 weeks (interquartile range, 9.1-11.0 weeks). In groups 2 and 3, compared with group 1, there was a significantly higher body mass index, incidence of black racial origin, and history of preeclampsia in a previous pregnancy. There was a significant increase from group 1 to group 3 in the incidence of severe hypertension (10.6%, 22.2%, and 52.1%), preterm preeclampsia with onset at <37 weeks of gestation (7.0%, 15.9%, and 20.4%), and small for gestational age (13.1%, 17.7%, and 21.1%), but not term preeclampsia with onset at ≥37 weeks of gestation (9.5%, 9.1%, and 6.6%).

CONCLUSIONS

In women with prepregnancy chronic hypertension, the rates of development of severe hypertension, preterm preeclampsia, and small for gestational age are related to the use of antihypertensive medications and the level of blood pressure control at the first hospital visit during the first trimester of pregnancy.

The effect of labetalol and nifedipine MR on blood pressure in women with chronic hypertension in pregnancy

AIM

To compare the blood pressure (BP) lowering effects of labetalol and nifedipine modified release (MR) in hypertensive pregnant women. We also investigated the effect on the heart rate (HR) and determined the proportion of time spent in target.

METHODS

This was an exploratory study. Women with chronic hypertension taking either labetalol or nifedipine were offered 24-h ambulatory blood pressure monitoring (ABPM). Sleep, wake and drug ingestion times were self-reported. An indirect response model was used to analyse the systolic BP (SBP), diastolic BP (DBP) and HR time-series; the effect of gestation and type of drug was evaluated.

RESULTS

Forty-eight women were recruited: 24 in each group. There was no difference in clinical characteristics. In women taking nifedipine there was a positive association between the dose of nifedipine and pre-dose BP p = .002, this was not present in the labetalol group. There was a difference between the drug effects on both the SBP and DBP time-series (p = .014). In comparison to labetalol, there was less variation in day time BP in those women prescribed nifedipine. Women on labetalol spent a larger proportion of time with their DBP below target (<80 mmHg). The HR dynamics were qualitatively different, a stimulatory effect was found with nifedipine compared to an inhibitory effect with labetalol.

CONCLUSION

There are significant and important differences between the BP lowering effects of nifedipine and labetalol. A large randomised control trial is required to investigate the relationship between BP variability and time in target on pregnancy outcomes.

Frequency and consequences of ventricular hypertrophy in pregnant women with treated chronic hypertension

BACKGROUND

Ventricular hypertrophy is a known sequela of long-standing chronic hypertension with associated morbidity and mortality.

OBJECTIVE

We sought to assess the frequency and importance of left ventricular hypertrophy in gravidas treated for chronic hypertension during pregnancy.

STUDY DESIGN

This was a retrospective study of pregnant women with chronic hypertension who were delivered at our hospital from January 2009 through February 2015. All women who were given antihypertensive therapy underwent maternal echocardiography and were managed in a dedicated, high-risk prenatal clinic. Left ventricular hypertrophy was defined using the criteria of the American Society of Echocardiography as left ventricular mass indexed to maternal body surface area with a value of >95 g/m². Maternal and infant outcomes were then analyzed according to the presence or absence of left ventricular hypertrophy.

RESULTS

Of 253 women who underwent echocardiography, 48 (19%) met criteria for left ventricular hypertrophy. Women in this latter cohort were significantly more likely to be African American (P = .031), but there were no other demographic differences. More than 85% of the entire cohort had a body mass index >30 kg/m² and a third of all women had class III obesity with a body mass index of >40 kg/m². Importantly, duration of chronic hypertension (P = .248) and gestational age at time of echocardiography (P = .316) did not differ significantly between the groups. Left ventricular function was preserved in both groups as measured by left ventricular ejection fraction (P = .303). Those with ventricular hypertrophy were at greater risk to be delivered preterm (P = .001), to develop superimposed preeclampsia (P = .028), and to have an infant requiring intensive care (P = .023) when compared with women without ventricular hypertrophy. These findings persisted after adjustment for age, race, and parity. The gestational age at delivery according to measured left ventricular size was also examined and with increasing ventricular mass there was a significant association with the severity of preterm birth (P < .001).

CONCLUSION

Left ventricular hypertrophy was identified in 1 in 5 women given antepartum treatment for chronic hypertension. Further analysis showed that these women were at significantly greater risk for superimposed preeclampsia and its attendant perinatal sequelae of preterm birth.

Signs of eclampsia during singleton deliveries and early neonatal mortality in low- and middle-income countries from three WHO regions

OBJECTIVE

To determine the prevalence of eclampsia symptoms and to explore associations between eclampsia and early neonatal mortality.

METHODS

The present secondary analysis included Demographic and Health Surveys data from 2005 to 2012; details of signs related to severe obstetric adverse events of singleton deliveries during interviewees' most recent delivery in the preceding 5 years were included. Data and delivery history were merged for pooled analyses. Convulsions-used as an indicator for having experienced eclampsia-and early neonatal mortality rates were compared, and a generalized random effect model, adjusted for heterogeneity between and within countries, was used to investigate the impact of presumed eclampsia on early neonatal mortality.

RESULTS

The merged dataset included data from six surveys and 55 384 live deliveries that occurred in Colombia, Bangladesh, Indonesia, Mali, Niger, and Peru. Indications of eclampsia were recorded for 1.2% (95% confidence interval [CI] 1.0-1.3), 1.7% (95% CI 1.5-2.1), and 1.7% (95% CI 1.5-2.1) of deliveries reported from the American, South East Asian, and African regions, respectively. Pooled analyses demonstrated that eclampsia was associated with increased risk of early neonatal mortality (adjusted risk ratio 2.1 95% CI 1.4-3.2).

CONCLUSION

Increased risk of early neonatal mortality indicates a need for strategies targeting the early detection of eclampsia and early interventions.

Enoxaparin and Aspirin Compared With Aspirin Alone to Prevent Placenta-Mediated Pregnancy Complications: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether daily enoxaparin, added to low-dose aspirin, started before 14 weeks of gestation reduces placenta-mediated complications in pregnant women with previous severe preeclampsia diagnosed before 34 weeks of gestation.

METHODS

In this open-label multicenter randomized trial, we enrolled consenting pregnant women with previous severe preeclampsia diagnosed before 34 weeks of gestation, gestational age at randomization of 7-13 weeks, singleton pregnancy, and no plan for anticoagulation. Eligible patients were randomly assigned to a one-to-one ratio to receive daily either 4,000 international units enoxaparin plus 100 mg aspirin or 100 mg aspirin alone. Randomization was done by a web-based randomization system. The primary composite outcome comprised maternal death, perinatal death, preeclampsia, small for gestational age (less than the 10th percentile), and placental abruption. A sample size of 232 women equally divided into two groups was needed to detect a significant reduction in primary outcome from 55% in the aspirin group to 36.7% in the enoxaparin-aspirin group (α: 0.05, β: 0.8, two-sided).

RESULTS

Between November 14, 2009, and February 21, 2015, 257 participants were enrolled. Baseline demographic and clinical factors were similar between groups. Eight women were excluded after randomization (six in the enoxaparin-aspirin group and two in the aspirin group), leaving 124 participants assigned to enoxaparin-aspirin and 125 to aspirin. Five participants were lost to follow-up (two in the enoxaparin-aspirin group and three in the aspirin group). There was no significant difference between the groups in the primary outcome: enoxaparin-aspirin 42 of 122 (34.4%) compared with aspirin alone 50 of 122 (41%) (relative risk 0.84, 95% confidence interval 0.61-1.16, P=.29). The occurrence of complications did not differ between the two groups.

CONCLUSION

Antepartum prophylactic enoxaparin does not significantly reduce placenta-mediated complications in women receiving low-dose aspirin for previous severe preeclampsia diagnosed before 34 weeks of gestation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT00986765.

Baseline Renal Function Tests and Adverse Outcomes in Pregnant Patients With Chronic Hypertension

OBJECTIVE

To examine the relationship between baseline renal function tests in pregnant patients with chronic hypertension and adverse pregnancy outcomes.

METHODS

This was a retrospective cohort study of women with a singleton pregnancy and chronic hypertension with assessment of renal function (urine protein-to-creatinine ratio and serum creatinine) before 20 weeks of gestation. The primary outcome was severe preeclampsia at less than 34 weeks of gestation. Secondary outcomes were severe preeclampsia at any gestational age, any preeclampsia, preterm birth at less than 35 weeks of gestation, composite perinatal outcome (perinatal death, assisted ventilation, cord pH less than 7, 5-minute Apgar score 3 or less, or neonatal seizures), and small for gestational age. The association between baseline renal function and the primary outcome was assessed with receiver operating characteristic (ROC) curves and objective cutoffs determined. Outcomes were compared between those with values above and below the cutoffs using univariable and multivariable analyses.

RESULTS

Seven hundred fifty-five pregnant women with chronic hypertension had baseline renal function assessment. The urine protein-to-creatinine ratio and creatinine cutoffs for severe preeclampsia at less than 34 weeks of gestation were 0.12 or greater and 0.75 mg/dL or greater, respectively. The area under the ROC curves for severe preeclampsia at less than 34 weeks of gestation was 0.74 (95% confidence interval [CI] 0.7-0.8) for urine protein-to-creatinine ratio and 0.67 (95% CI 0.6-0.8) for creatinine. A urine protein-to-creatinine ratio 0.12 or greater was associated with an increased risk of developing severe preeclampsia at less than 34 weeks of gestation (16.4% compared with 2.6%, adjusted odds ratio [OR] 7.5, 95% CI 3.9-14.6) as was a creatinine 0.75 mg/dL or greater (15.7% compared with 4.6%, adjusted OR 3.5, 95% CI 1.9-6.3). Severe preeclampsia at less than 34 weeks of gestation occurred in only 1.6% of patients if their baseline tests were below both cutoffs.

CONCLUSION

Baseline assessment of renal function can be used as a risk stratification tool in pregnant patients with chronic hypertension.

Pregnancy Outcome After First Trimester Use of Methyldopa: A Prospective Cohort Study

Published experience on first trimester exposure to methyldopa is still limited, although it is recommended as first-line treatment for hypertensive disorders in pregnancy in most countries. The primary aim of this prospective observational cohort study was to analyze the rate of major birth defects and spontaneous abortions in women with methyldopa therapy for chronic hypertension. Outcomes of 261 pregnancies with first trimester exposure to methyldopa and 526 comparison pregnancies without chronic hypertension reported to the German Embryotox pharmacovigilance institute were evaluated. The rate of major birth defects in the exposed cohort was not significantly increased compared with the comparison cohort (3.7% versus 2.5%; adjusted odds ratio, 1.24; 95% confidence interval, 0.4-4.0). There was a tendency toward a higher rate of spontaneous abortions in exposed women. The risk of preterm birth was significantly higher, and adjusted birth weight scores were significantly lower in the methyldopa group. Head circumferences were significantly reduced in exposed boys only. There was neither evidence for an increased risk for birth defects or increase in early pregnancy loss nor evidence for growth restriction or a reduced head circumference in a sensitivity analysis comparing monotherapies with methyldopa to metoprolol. However, the significantly increased risk of preterm birth in methyldopa-treated pregnancies was confirmed. In conclusion, our study does not indicate a teratogenic risk of methyldopa. Further studies are needed to confirm its safety in the first trimester and clarify the influence of hypertension and methyldopa on preterm birth and intrauterine growth.

CLINICAL TRIAL REGISTRATION

URL: https://drks-neu.uniklinik-freiburg.de/drks_web/. Unique identifier: DRKS00010502.

Is use of multiple antihypertensive agents to achieve blood pressure control associated with adverse pregnancy outcomes?

OBJECTIVE

We assessed whether requiring >1 medication for blood pressure control is associated with adverse pregnancy outcomes.

STUDY DESIGN

Retrospective cohort of 974 singletons with chronic hypertension at a tertiary care center. Subjects on >1 antihypertensive agent were compared with those on one agent <20 weeks gestational age with results stratified by average blood pressure (<140/90 and ⩾140/90 mm Hg) from prenatal visits. The primary maternal outcome was preeclampsia; the primary neonatal outcome was small for gestational age (<10th percentile).

RESULT

Among women with blood pressure ⩾140/90 mm Hg, women on multiple agents had the greatest risk of preeclampsia, severe preeclampsia, antenatal admissions to rule out preeclampsia, preterm birth <35 weeks and composite neonatal adverse outcomes.

CONCLUSION

Compared with use of a single agent when blood pressure is ⩾140/90 mm Hg, use of multiple agents increases adverse risks, while no such finding exists when blood pressure is controlled below 140/90 mm Hg.

Early-onset preeclampsia is associated with perinatal mortality and severe neonatal morbidity

OBJECTIVE

To evaluate neonatal outcomes of pregnancies complicated by early-onset preeclampsia (PE) and compare these outcomes to those of gestational age matched neonates born to mothers whose pregnancy was not complicated by early-onset PE.

METHODS

We analyzed the outcome in 97 neonates born to mothers with early-onset PE (24-32 weeks amenorrhea at diagnosis) and compared it to that of 680 gestational age-matched neonates born between 25-36 weeks due to other etiologies and admitted to the Neonatal Intensive Care Unit (NICU) of a tertiary referral hospital in the Netherlands. We used Chi-square test, Wilcoxon test, and logistic regression analyses.

RESULTS

Neonates born to PE mothers had a higher perinatal mortality (13% vs. 7%, p = 0.03) and infant mortality (16% vs. 9%, p= 0.03), a 20% lower birth weight (1150 vs. 1430 g, p<0.001), were more often SGA (22% vs. 9%, p < 0.001) and had more neonatal complications as compared to neonates born to mothers without PE.

CONCLUSIONS

Overall adverse perinatal outcome is significantly worse in neonates born to mothers with early-onset PE. The effect of early-onset PE on perinatal mortality seems partially due to SGA. Whether these differences are due to uteroplacental factors or intrinsic neonatal factors remains to be elucidated.

Pregnancy as a critical window for blood pressure regulation in mother and child: programming and reprogramming

Pregnancy is a critical time for long-term blood pressure regulation in both mother and child. Pregnancies complicated by placental insufficiency, resulting in pre-eclampsia and intrauterine growth restriction, are associated with a threefold increased risk of the mother to develop hypertension later in life. In addition, these complications create an adverse intrauterine environment, which programmes the foetus and the second generation to develop hypertension in adult life. Female offspring born to a pregnancy complicated by placental insufficiency are at risk for pregnancy complications during their own pregnancies as well, resulting in a vicious circle with programmed risk for hypertension passing from generation to generation. Here, we review the epidemiology and mechanisms leading to the altered programming of blood pressure trajectories after pregnancies complicated by placental insufficiency. Although the underlying mechanisms leading to hypertension remain the subject of investigation, several abnormalities in angiotensin sensitivity, sodium handling, sympathetic activity, endothelial function and metabolic pathways are found in the mother after exposure to placental insufficiency. In the child, epigenetic modifications and disrupted organ development play a crucial role in programming of hypertension. We emphasize that pregnancy can be viewed as a window of opportunity to improve long-term cardiovascular health of both mother and child, and outline potential gains expected of improved preconceptional, perinatal and post-natal care to reduce the development of hypertension and the burden of cardiovascular disease later in life. Perinatal therapies aimed at reprogramming hypertension are a promising strategy to break the vicious circle of intergenerational programming of hypertension.

Awaiting blood pressure stabilization in ambulatory pregnant women: is 5 minutes sufficient?

OBJECTIVE

Current recommendations for timing of blood pressure measurement in ambulatory pregnant women vary and are based on studies in the nonpregnant population. The objective of this study was to determine if there is a difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) between minute-5 and minute-10.

METHODS

A prospective study was conducted at our prenatal care clinics. Participants had their blood pressure measured upon sitting and every 5 minutes for 15 minutes. Initial SBP and DBP were compared to measurements at each time point. Additionally, the SBP and DBP at minute-5 were compared to minute-10. All statistical tests were two-sided.

RESULTS

Data from 400 patients were analyzed. Of these, 34.0% were in the first, 30.7% were in the second trimester, and 35.2% were in the third trimester. In each trimester, there was a significant difference in the SBP and DBP at minute-5 compared to minute-0. At minute-10 compared to minute-5, there was no further drop for all trimesters, except for a small drop in DBP in the second trimester (-1.3 ± 6.0, p = 0.012).

CONCLUSION

In an ambulatory setting, 5 minutes after sitting appears to be an appropriate time point to measure blood pressure in pregnancy.

[Hypertension during pregnancy: Epidemiology, definition]

Hypertension in pregnancy has several forms that differ by their mechanisms and their consequences for mothers and fetus. Chronic hypertension is defined by SBP≥140mm Hg or DBP≥90mm Hg before pregnancy or before the 20th week of amenorrhea. Gestational hypertension is defined by SBP≥140mm Hg or DBP≥90mm Hg during or after the 20th week of amenorrhea. Preeclampsia is the occurrence of hypertension and proteinuria after 20weeks of amenorrhea. Severe preeclampsia is accompanied by clinical signs and symptoms indicating visceral pain. The HELLP syndrome is a severe preeclampsia accompanied by intravascular hemolysis and hepatic cytolysis. Eclampsia is characterized by seizures of the tonic-clonic type. A chronic hypertension is observed in 1-5% of pregnancies. Gestational hypertension without proteinuria appears in 5-6% of pregnancies. A preeclampsia develops in 1-2% of pregnancies, but much more frequently (up 34%) in the presence of risk factors. High blood pressure during pregnancy remains, by its complications, the leading cause of maternal morbidity and mortality.

Management of pregnancies complicated by hypertensive disorders of pregnancy: Could we do better?

BACKGROUND

Hypertensive disorders are among the most common medical problems in pregnancy. Compliance with clinical practice guidelines has potential to translate to significant maternal and perinatal health benefits.

AIMS

To evaluate compliance with Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) clinical guidelines for management of hypertension during pregnancy.

METHODS

Inclusion criteria: women with hypertension in pregnancy who gave birth at a tertiary obstetric centre in 2010. Compliance with SOMANZ guidelines was assessed, as well as uptake of findings from the 'Induction of labour versus expectant monitoring for mild gestational hypertension/pre-eclampsia after 36 weeks' gestation' (HYPITAT) trial.

RESULTS

Of 5624 women, 516 (9.2%) were identified with hypertension (49 chronic hypertension (CH); 457 gestational hypertension (GH) or pre-eclampsia (PE)). Thresholds to diagnose hypertension and initiate anti-hypertensive treatment were consistent with SOMANZ recommendations. Among women with CH, only 12.2% were prescribed aspirin prior to 16 weeks as PE prophylaxis. Of women with PE, 37 (18.6%) had known risk factors for development of PE at the initial visit yet only nine (24.3%) received aspirin. Of the 244 women who met HYPITAT inclusion criteria at 36 weeks, 174 (77.7%) were managed expectantly; nine (5.2%) developed severe adverse outcomes.

CONCLUSION

Current management guidelines for hypertension treatment were generally followed, although aspirin prophylaxis was frequently overlooked, resulting in up to 19 excess PE cases. Uptake of recommendations from the HYPITAT trial was low; however, severe complications were fewer than expected. Overall, this suggests that clinicians appropriately weigh up the likely maternal risk compared to infant benefits of deferred delivery in each case, a key recommendation of HYPITAT-II.

Identifying immune mechanisms mediating the hypertension during preeclampsia

Preeclampsia (PE) is a pregnancy-associated disorder that affects 5-8% of pregnancies and is a major cause of maternal, fetal, and neonatal morbidity and mortality. Hallmark characteristics of PE are new onset hypertension after 20 wk gestation with or without proteinuria, chronic immune activation, fetal growth restriction, and maternal endothelial dysfunction. However, the pathophysiological mechanisms that lead to the development of PE are poorly understood. Recent data from studies of both clinical and animal models demonstrate an imbalance in the subpopulations of CD4+ T cells and a role for these cells as mediators of inflammation and hypertension during pregnancy. Specifically, it has been proposed that the imbalance between two CD4+ T cell subtypes, regulatory T cells (Tregs) and T-helper 17 cells (Th17s), is involved in the pathophysiology of PE. Studies from our laboratory highlighting how this imbalance contributes to vasoactive factors, endothelial dysfunction, and hypertension during pregnancy will be discussed in this review. Therefore, the purpose of this review is to highlight hypertensive mechanisms stimulated by inflammatory factors in response to placental ischemia, thereby elucidating a role.

Hypertension in pregnancy: An unresectable mediastinal pheochromocytoma

Hypertension is a relatively common occurrence during pregnancy, which usually has a benign course with an excellent prognosis. However, physicians caring for pregnant women should have a high index of suspicion for underlying medical conditions that could lead to a more perilous outcome. Herein, we present the case of a pregnant woman who was found to have uncontrollable hypertension late in her pregnancy, secondary to a mediastinal pheochromocytoma, which was deemed unresectable at the time of exploration after her delivery.

Risk factors for serious morbidity in term nonanomalous neonates

OBJECTIVE

The purpose of this study was to identify ante- and intrapartum risk factors for serious morbidity in term nonanomalous neonates.

STUDY DESIGN

We analyzed the first 5000 subjects within an ongoing prospective cohort study of consecutive term births from 2010-2012. The primary outcome was a composite of serious neonatal morbidity defined as ≥1 cases of hypoxic ischemic encephalopathy, meconium aspiration with pulmonary hypertension, requirement of hypothermia therapy, respiratory distress syndrome, seizures, sepsis or suspected sepsis, or death. We calculated odds ratios for the composite morbidity that is associated with ante- and intrapartum factors. Multivariable logistic regression was used to estimate adjusted odds ratios.

RESULTS

Of 5000 term nonanomalous births, 393 had the composite morbidity. Significant risk factors for morbidity were nulliparity, presence of meconium, first stage of labor >95th percentile, second stage of labor >95th percentile, pregestational diabetes mellitus, chronic hypertension, obesity, maternal intrapartum fever, and cesarean delivery. In contrast, induction of labor and gestational age ≥41 weeks were not associated with significant morbidity.

CONCLUSION

We identified several significant risk factors for serious morbidity in term nonanomalous neonates. Clinicians may use these risk factors to help anticipate the potential need for additional neonatal support at delivery.

Major risk factors for stillbirth in different trimesters of pregnancy--a systematic review

Stillbirth remains an event that has an important impact on global health issues. Different levels of health care between countries suggest that the stillbirth rate may be one of the indicators of the quality of a country's medical system. In this review, major risk factors for stillbirth will be discussed, especially in different trimesters of pregnancy. Early identification of risk factors for stillbirth and appropriate antenatal management may reduce preventable stillbirths and improve general outcomes of pregnancy.

[Analysis of the causes for increases in the length of stay in the Recovery Unit of La Paz Maternity Hospital in 2008]

OBJECTIVE

To establish the spectrum of diseases in the obstetric patient that involves an increase in the length of stay in the Recovery Unit of a specialist Maternity Hospital. To analyse the severity of these conditions as regards the means required for their resolu-tion, as well as to identify the factors that influence on post-operative morbidity in the obstetric patient.

MATERIAL AND METHODS

All the case histories of all the patients admitted to the Maternity Hospital Recovery Unit during the year 2008 were reviewed. Those who required a lon-ger stay than usual were selected, which included, those with more than 6hours after a caesarean, and all admissions made during pregnancy, or after dilation and curettage or partum.

RESULTS

Out of a total of 10419 births delivered in 2008, 3000 obstetric patients were ad-mitted to the Maternity Hospital Recovery Unit, of which 285 (9.5%) required critical care. The most frequent cause of increased length of stay was obstetric haemorrhage, followed by hypertensive states of pregnancy. No patients died in this Unit in the year 2008.

CONCLUSIONS

The number of patients who had an increased length of stay in the Mater-nity Hospital Recovery Unit is similar to the percentage of patients who are admitted to Intensive Care Units in countries such as Canada or the United Kingdom, but our Unit had a lower death rate in the year evaluated. The main causes are obstetric haemorrhage and hypertensive states of pregnancy, thus patients with risk factors for developing these complications must be observed closely and monitored.

Chronic hypertension in pregnancy and the risk of congenital malformations: a cohort study

OBJECTIVE

Chronic hypertension is a common medical condition in pregnancy. The purpose of the study was to examine the association between maternal chronic hypertension and the risk of congenital malformations in the offspring.

STUDY DESIGN

We defined a cohort of 878,126 completed pregnancies linked to infant medical records using the Medicaid Analytic Extract. The risk of congenital malformations was compared between normotensive controls and those with treated and untreated chronic hypertension. Confounding was addressed using propensity score matching.

RESULTS

After matching, compared with normotensive controls, pregnancies complicated by treated chronic hypertension were at increased risk of congenital malformations (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.5), as were pregnancies with untreated chronic hypertension (OR 1.2; 95% CI, 1.1-1.3). In our analysis of organ-specific malformations, both treated and untreated chronic hypertension was associated with a significant increase in the risk of cardiac malformations (OR, 1.6; 95% CI, 1.4-1.9 and OR, 1.5; 95% CI, 1.3-1.7, respectively). These associations persisted across a range of sensitivity analyses.

CONCLUSION

There is a similar increase in the risk of congenital malformations (particularly cardiac malformations) associated with treated and untreated chronic hypertension that is independent of measured confounders. Studies evaluating the teratogenic potential of antihypertensive medications must control for confounding by indication. Fetuses and neonates of mothers with chronic hypertension should be carefully evaluated for potential malformations, particularly cardiac defects.

Medically complex pregnancies and early breastfeeding behaviors: a retrospective analysis

BACKGROUND

Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices.

METHODS

We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status.

RESULTS

More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52-0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with >30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47-0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81-8.94; and AOR = 2.68; 95% CI, 1.70-4.23, respectively).

CONCLUSIONS

Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants.

Management of Hypertensive Disorders in Pregnancy

Hypertensive disorders are the most common medical complication of pregnancy, with an incidence of 5-10%, and a common cause of maternal mortality in the USA. Incidence of pre-eclampsia has increased by 25% in the past two decades. In addition to being among the lethal triad, there are likely up to 100 other women who experience ‘near miss’ significant maternal morbidity that stops short of death for every pre-eclampsia-related mortality. The purpose of this review is to present the new task force statement and novel definitions, as well as management approaches to each of the hypertensive disorders in pregnancy. The increased understanding of the pathophysiology of hypertension in pregnancy, as well as advances in medical therapy to minimize risks of fetal toxicity and teratogenicity, will improve our ability to prevent and treat hypertension in pregnancy. Fetal programming and fetal origins of adult disease theories extrapolate the benefit of such therapy to future generations.

Associations of blood pressure change in pregnancy with fetal growth and gestational age at delivery: findings from a prospective cohort

Hypertensive disorders of pregnancy are associated with intrauterine growth restriction and preterm birth. However, the associations of patterns of blood pressure change during pregnancy with these outcomes have not been studied in detail. We studied repeat antenatal blood pressure measurements of 9697 women in the Avon Longitudinal Study of Parents and Children (median [interquartile range], 10 [9-11] measurements per woman). Bivariate linear spline models were used to relate blood pressure changes to perinatal outcomes. Higher systolic, but not diastolic, blood pressure at baseline (8 weeks of gestation) and a greater increase in systolic and diastolic blood pressure between 18 and 36 weeks of gestation were associated with lower offspring birth weight and being smaller for gestational age in confounder-adjusted models. For example, the mean difference (95% confidence interval) in birth weight per 1 mm Hg/wk greater increase in systolic blood pressure between 18 and 30 weeks was -71 g (-134 to -14) and between 30 and 36 weeks was -175 g (-208 to -145). A smaller decrease in systolic and diastolic blood pressure before 18 weeks and a greater increase between 18 and 36 weeks were associated with a shorter gestation (percentage difference in gestational duration per 1 mm Hg/wk greater increase in systolic blood pressure between 18 and 30 weeks was -0.60% [-1.01 to -0.18] and between 30 and 36 weeks was -1.01% [-1.36 to -0.74]). Associations remained strong when restricting to normotensive women. We conclude that greater increases in blood pressure, from the 18-week nadir, are related to reduced fetal growth and shorter gestation even in women whose blood pressure does not cross the threshold for hypertensive disorders of pregnancy.

Prescription of antihypertensive medications during pregnancy in the UK

PURPOSE

This study aimed to describe the management of antihypertensive medications in pregnancy by general practitioners in the UK and compare it with current guidelines.

METHODS

We used electronic medical records from The Health Improvement Network database from 1996 to 2010 to identify completed pregnancies. The study cohort included the first pregnancy identified during the study period in women aged 13-49 years. Information on both hypertension diagnoses and prescription of specific antihypertensive medications within the 90 days before the last menstrual period (LMP) and during pregnancy was ascertained from electronic medical records.

RESULTS

Among 148,544 eligible pregnancies, we identified 1995 (1.3%) during which the women had pre-existing hypertension diagnosed by the LMP date. Overall, the prevalence of antihypertensive medications during the first trimester was 1.5%; beta-blockers were the most commonly prescribed antihypertensive. Among women with pre-existing hypertension, 36% were prescribed an antihypertensive medication during the 90 days before the LMP. Among those, 9.6% and 22.2% had discontinued their medication by the first and second trimesters, respectively. For contraindicated drugs such as angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers, the corresponding discontinuation rates were around 25% and 70%. Women who switched therapy received preferably either methyldopa or an alpha/beta-blocker.

CONCLUSIONS

In this population of UK pregnant women, prescription patterns of antihypertensive medications were dominated by recommended treatments, although some patients continued on contraindicated drugs throughout pregnancy or switched to preferred agents in a delayed fashion.