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Nisar MI, Kabole I, Khanam R, Shahid S, Bakari BA, Chowdhury NH, Qazi MF, Dutta A, Rahman S, Khalid J, Dhingra U, Hasan T, Ansari N, Deb S, Mitra DK, Mehmood U, Aftab F, Ahmed S, Khan S, Ali SM, Ahmed S, Manu A, Yoshida S, Bahl R, Baqui AH, Sazawal S, Jehan F. Does the implementation of revised American College of Cardiology and American Heart Association (ACC/AHA) guidelines improve the identification of stillbirths and preterm births in hypertensive pregnancies: a population-based cohort study from South Asia and sub-Saharan Africa. BMC Pregnancy Childbirth 2024; 24:451. [PMID: 38951766 PMCID: PMC11218258 DOI: 10.1186/s12884-024-06637-2] [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: 02/16/2024] [Accepted: 06/12/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are a significant cause of maternal mortality worldwide. The classification and treatment of hypertension in pregnancy remain debated. We aim to compare the effectiveness of the revised 2017 ACC/AHA blood pressure threshold in predicting adverse pregnancy outcomes. METHODS We conducted a secondary data analysis of the Alliance for Maternal and Newborn Health Improvement (AMANHI) biorepository study, including 10,001 pregnant women from Bangladesh, Pakistan, and Tanzania. Blood pressure was measured using validated devices at different antenatal care visits. The blood pressure readings were categorized as: normal blood pressure (systolic blood pressure (sBP) < 120 mm Hg and diastolic blood pressure (dBP) < 80 mm Hg), elevated blood pressure (sBP 120-129 and dBP < 80), stage 1 hypertension (sBP 130-139 or dBP 80-89, or both), and stage 2 hypertension (sBP ≥ 140 or dBP ≥ 90, or both). We estimated risk ratios for stillbirths and preterm births, as well as diagnostic test properties of both the pre-existing JNC7 (≥ 140/90) and revised ACC/AHA (≥ 130/80) thresholds using normal blood pressure as reference group. RESULTS From May 2014 to June 2018, blood pressure readings were available for 9,448 women (2,894 in Bangladesh, 2,303 in Pakistan, and 4,251 in Tanzania). We observed normal blood pressure in 70%, elevated blood pressure in 12.4%, stage 1 hypertension in 15.2%, and stage 2 hypertension in 2.5% of the pregnant women respectively. Out of these, 310 stillbirths and 9,109 live births were recorded, with 887 preterm births. Using the ACC/AHA criteria, the stage 1 hypertension cut-off revealed 15.3% additional hypertension diagnoses as compared to JNC7 criteria. ACC/AHA defined hypertension was significantly associated with stillbirths (RR 1.8, 95% CI 1.4, 2.3). The JNC 7 hypertension cut-off of ≥ 140/90 was significantly associated with a higher risk of preterm births (RR 1.6, 95% CI 1.2, 2.2) and stillbirths (RR 3.6, 95% CI 2.5, 5.3). Both criteria demonstrated low sensitivities (8.4 for JNC-7 and 28.1 for ACC/AHA) and positive predictive values (11.0 for JNC7 and 5.2 for ACC/AHA) in predicting adverse outcomes. CONCLUSION The ACC/AHA criteria (≥ 130/80) identified additional cases of hypertension but had limited predictive accuracy for stillbirths and preterm births, highlighting the ongoing need for improved criteria in managing pregnancy-related hypertension.
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Affiliation(s)
- Muhammad Imran Nisar
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | | | - Rasheda Khanam
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shahira Shahid
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | | | | | - Muhammad Farrukh Qazi
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | - Arup Dutta
- Center for Public Health Kinetics, New Delhi, India
| | - Sayedur Rahman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Javairia Khalid
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | - Usha Dhingra
- Center for Public Health Kinetics, New Delhi, India
| | - Tarik Hasan
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | - Nadia Ansari
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | - Saikat Deb
- Center for Public Health Kinetics, New Delhi, India
| | - Dipak K Mitra
- Department of Public Health, School of Health and Life Sciences, North South University, Dhaka, Bangladesh
| | - Usma Mehmood
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | - Fahad Aftab
- Center for Public Health Kinetics, New Delhi, India
| | | | - Shahiryar Khan
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan
| | | | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alexander Manu
- London School of Hygiene & Tropical Medicine, Faculty of Epidemiology and Public Health, London, UK
| | - Sachiyo Yoshida
- Department for Maternal, Child, Adolescents and Ageing Health, World Health Organization, Avenue Appia 20, Geneva, 1211, Switzerland.
| | - Rajiv Bahl
- Department for Maternal, Child, Adolescents and Ageing Health, World Health Organization, Avenue Appia 20, Geneva, 1211, Switzerland
| | - Abdullah H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Fyezah Jehan
- Department of Pediatrics and Child Health, Aga Khan University, Stadium Road, Karachi, 74800, Karachi, Pakistan.
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Slade LJ, Mistry HD, Bone JN, Wilson M, Blackman M, Syeda N, von Dadelszen P, Magee LA. American College of Cardiology and American Heart Association blood pressure categories-a systematic review of the relationship with adverse pregnancy outcomes in the first half of pregnancy. Am J Obstet Gynecol 2022; 228:418-429.e34. [PMID: 36241079 DOI: 10.1016/j.ajog.2022.10.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/02/2022] [Accepted: 10/04/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE A relationship between the 2017 American College of Cardiology and American Heart Association blood pressure thresholds and adverse pregnancy outcomes has been reported, but few studies have explored the diagnostic test properties of these cutoffs. DATA SOURCES We systematically searched electronic databases (from 2017 to 2021) for reports of blood pressure measurements in pregnancy, classified according to 2017 American College of Cardiology and American Heart Association criteria, and their relationship with pregnancy outcomes. STUDY ELIGIBILITY CRITERIA Studies recording blood pressure at <20 weeks gestation were included. METHODS Meta-analyses were used to investigate the strength of the association between blood pressure cutoffs and adverse outcomes, and the diagnostic test properties were calculated. RESULTS Of 23 studies included, there was a stepwise relationship between the American College of Cardiology and American Heart Association blood pressure category (when compared with normal blood pressure of <120/80 mmHg) and the strength of the association with preeclampsia. The category of elevated blood pressure had a risk ratio of 2.0 (95% prediction interval, 0.8-4.8), the stage 1 hypertension category had a risk ratio of 3.0 (95% prediction interval, 1.1-8.5), and the stage 2 hypertension category had a risk ratio of 7.9 (95% prediction interval, 1.8-35.1). Between-study variability was related to the magnitude of the association with stronger relationships in larger studies at low risk of bias and with unselected populations with multiple routine blood pressure measurements. None of the systolic blood pressure measurements of <120 mmHg, <130/80 mmHg, or <140/90 mmHg were useful to rule out the development of preeclampsia (all negative likelihood ratios >0.2). Only a blood pressure measurement of ≥140/90 mmHg was a good predictor for the development of preeclampsia (positive likelihood ratio, 5.95). The findings were similar for other outcomes. CONCLUSION Although a blood pressure of 120 to 140 over 80 to 90 mmHg at <20 weeks gestation is associated with a heightened risk for preeclampsia and adverse pregnancy outcomes and may assist in risk prediction in multivariable modelling, lowering the diagnostic threshold for chronic hypertension would not assist clinicians in identifying women at heightened risk.
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Affiliation(s)
- Laura J Slade
- Department of Obstetrics and Gynaecology, Women's and Children's Hospital, Adelaide, Australia.
| | - Hiten D Mistry
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Jeffrey N Bone
- British Columbia Children's Hospital Research Institute, The University of British Columbia, Vancouver, Canada; Department of Obstetrics and Gynecology, The University of British Columbia, Vancouver, Canada
| | - Milly Wilson
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Maya Blackman
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Nuhaat Syeda
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course and Population Health Sciences, Faculty of Medicine, King's College London, London, United Kingdom
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Gunderson EP, Greenberg M, Nguyen-Huynh MN, Tierney C, Roberts JM, Go AS, Tao W, Alexeeff SE. Early Pregnancy Blood Pressure Patterns Identify Risk of Hypertensive Disorders of Pregnancy Among Racial and Ethnic Groups. Hypertension 2022; 79:599-613. [PMID: 34963295 PMCID: PMC9004135 DOI: 10.1161/hypertensionaha.121.18568] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality and confer 4-fold higher perinatal mortality in Black women. Early pregnancy blood pressure patterns may differentiate risk of hypertensive disorders of pregnancy. METHODS This study identified distinct blood pressure trajectories from 0 to 20 weeks' gestation to evaluate subsequent pregnancy-related hypertension in a retrospective cohort of 174 925 women with no prior hypertension or history of preeclampsia, prenatal care entry ≤14 weeks, and a stillborn or live singleton birth delivered at Kaiser Permanente Northern California hospitals in 2009 to 2019. We used electronic health records to obtain clinical outcomes, covariables, and longitudinal outpatient blood pressure measurements ≤20 weeks' gestation (mean 4.1 measurements). Latent class trajectory modeling identified 6 blood pressure groups: ultra-low-declining(referent), low-declining, moderate-fast-decline, low-increasing, moderate-stable, and elevated-stable. Multivariable logistic regression evaluated trajectory group-associations with the odds of preeclampsia/eclampsia and gestational hypertension' and effect modification by race-ethnicity and prepregnancy body size. RESULTS Compared with ultra-low-declining, adjusted odds ratios (95% confidence intervals [CIs]) for low-increasing, moderate-stable, and elevated-stable groups were 3.25 (2.7-3.9), 5.3 (4.5-6.3), and 9.2 (7.7-11.1) for preeclampsia/eclampsia' and 6.4 (4.9-8.3), 13.6 (10.5-17.7), and 30.2 (23.2-39.4) for gestational hypertension. Race/ethnicity, and prepregnancy obesity modified the trajectory-group associations with preeclampsia/eclampsia (interaction P<0.01), with highest risks for Black, then Hispanic and Asian women for all blood pressure trajectories, and with increasing obesity class. CONCLUSIONS Early pregnancy blood pressure patterns revealed racial and ethnic differences in associations with preeclampsia/eclampsia risk within equivalent levels and patterns. These blood pressure patterns may improve individual risk stratification permitting targeted surveillance and early mitigation strategies.
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Affiliation(s)
- Erica P. Gunderson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Mara Greenberg
- Department of Obstetrics and Gynecology, Kaiser Permanente, Oakland Medical Center, CA
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA,Department of Neurology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA
| | - Cassidy Tierney
- Department of Obstetrics and Gynecology, Kaiser Permanente, Oakland Medical Center, CA
| | - James M. Roberts
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, Epidemiology and Clinical and Translational Research, University of Pittsburgh, PA
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA,Departments of Epidemiology, Biostatistics and Medicine, University of California
| | - Wei Tao
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Stacey E. Alexeeff
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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