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Kitt J, Krasner S, Barr L, Frost A, Tucker K, Bateman PA, Suriano K, Kenworthy Y, Lapidaire W, Lacharie M, Mills R, Roman C, Mackillop L, Cairns A, Aye C, Ferreira V, Piechnik S, Lukaschuk E, Thilaganathan B, Chappell LC, Lewandowski AJ, McManus RJ, Leeson P. Cardiac Remodeling After Hypertensive Pregnancy Following Physician-Optimized Blood Pressure Self-Management: The POP-HT Randomized Clinical Trial Imaging Substudy. Circulation 2024; 149:529-541. [PMID: 37950907 DOI: 10.1161/circulationaha.123.067597] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 11/09/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Hypertensive pregnancy disorders are associated with adverse cardiac remodeling, which can fail to reverse in the postpartum period in some women. The Physician-Optimized Postpartum Hypertension Treatment trial demonstrated that improved blood pressure control while the cardiovascular system recovers postpartum associates with persistently reduced blood pressure. We now report the effect on cardiac remodeling. METHODS In this prospective, randomized, open-label, blinded end point trial, in a single UK hospital, 220 women were randomly assigned 1:1 to self-monitoring with research physician-optimized antihypertensive titration or usual postnatal care from a primary care physician and midwife. Participants were 18 years of age or older, with preeclampsia or gestational hypertension, requiring antihypertensives on hospital discharge postnatally. Prespecified secondary cardiac imaging outcomes were recorded by echocardiography around delivery, and again at blood pressure primary outcome assessment, around 9 months postpartum, when cardiovascular magnetic resonance was also performed. RESULTS A total of 187 women (101 intervention; 86 usual care) underwent echocardiography at baseline and follow-up, at a mean 258±14.6 days postpartum, of which 174 (93 intervention; 81 usual care) also had cardiovascular magnetic resonance at follow-up. Relative wall thickness by echocardiography was 0.06 (95% CI, 0.07-0.05; P<0.001) lower in the intervention group between baseline and follow-up, and cardiovascular magnetic resonance at follow-up demonstrated a lower left ventricular mass (-6.37 g/m2; 95% CI, -7.99 to -4.74; P<0.001), end-diastolic volume (-3.87 mL/m2; 95% CI, -6.77 to -0.98; P=0.009), and end-systolic volume (-3.25 mL/m2; 95% CI, 4.87 to -1.63; P<0.001) and higher left and right ventricular ejection fraction by 2.6% (95% CI, 1.3-3.9; P<0.001) and 2.8% (95% CI, 1.4-4.1; P<0.001), respectively. Echocardiography-assessed left ventricular diastolic function demonstrated a mean difference in average E/E' of 0.52 (95% CI, -0.97 to -0.07; P=0.024) and a reduction in left atrial volumes of -4.33 mL/m2 (95% CI, -5.52 to -3.21; P<0.001) between baseline and follow-up when adjusted for baseline differences in measures. CONCLUSIONS Short-term postnatal optimization of blood pressure control after hypertensive pregnancy, through self-monitoring and physician-guided antihypertensive titration, associates with long-term changes in cardiovascular structure and function, in a pattern associated with more favorable cardiovascular outcomes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04273854.
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Affiliation(s)
- Jamie Kitt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Samuel Krasner
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Logan Barr
- Queen's University School of Medicine, Kingston, Canada (L.B.)
| | - Annabelle Frost
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Katherine Tucker
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Paul A Bateman
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Katie Suriano
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Yvonne Kenworthy
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Winok Lapidaire
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Miriam Lacharie
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Rebecca Mills
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Cristian Roman
- Institute of Biomedical Engineering, Department of Engineering Science (C.R.), University of Oxford, United Kingdom
| | - Lucy Mackillop
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Alexandra Cairns
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
| | - Christina Aye
- Nuffield Department of Women's and Reproductive Health (A.F., L.M., A.C., C.A.), University of Oxford, United Kingdom
- Fetal Medicine Unit, Oxford University Hospitals National Health Service Foundation Trust, United Kingdom (C.A.)
| | - Vanessa Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (V.F., E.L.), University of Oxford, United Kingdom
| | - Stefan Piechnik
- Oxford Centre for Clinical Magnetic Resonance Research, Division of Cardiovascular Medicine, Radcliffe Department of Medicine (M.L., R.M., S.P.), University of Oxford, United Kingdom
| | - Elena Lukaschuk
- Oxford Centre for Clinical Magnetic Resonance Research (V.F., E.L.), University of Oxford, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals National Health Service Foundation Trust, London, United Kingdom (B.T.)
- Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Lucy C Chappell
- King's College London and Guy's and St Thomas' National Health Service Foundation Trust, United Kingdom (L.C.C.)
| | - Adam J Lewandowski
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences (J.K., K.T., P.A.B., R.J.M.), University of Oxford, United Kingdom
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine (J.K., S.K., A.F., K.S., Y.K., W.L., A.J.L., P.L.), University of Oxford, United Kingdom
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Reding KW, Jordan JH. Multimodal Imaging Evidence for Optimized Blood Pressure Control Following Hypertensive Pregnancy: Mechanistic Insights Into Beneficial Cardiac Remodeling From the POP-HT Trial. Circulation 2024; 149:542-544. [PMID: 38346108 DOI: 10.1161/circulationaha.124.068282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
- Kerryn W Reding
- Department of Biobehavioral Nursing and Health Informatics, University of Washington School of Nursing, Seattle (K.W.R.)
- Division of Public Health Sciences, Fred Hutch Cancer Center, Seattle, WA (K.W.R.)
| | - Jennifer H Jordan
- Department of Biomedical Engineering, College of Engineering (J.H.J.), Pauley Heart Center, Virginia Commonwealth University School of Medicine, Richmond
- Department of Internal Medicine, Division of Cardiology (J.H.J.), Pauley Heart Center, Virginia Commonwealth University School of Medicine, Richmond
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Cutler HR, Barr L, Sattwika PD, Frost A, Alkhodari M, Kitt J, Lapidaire W, Lewandowski AJ, Leeson P. Temporal patterns of pre- and post-natal target organ damage associated with hypertensive pregnancy: a systematic review. Eur J Prev Cardiol 2024; 31:77-99. [PMID: 37607255 PMCID: PMC10767256 DOI: 10.1093/eurjpc/zwad275] [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] [Received: 07/02/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 08/24/2023]
Abstract
AIMS Hypertensive pregnancy is associated with increased risks of developing a range of vascular disorders in later life. Understanding when hypertensive target organ damage first emerges could guide optimal timing of preventive interventions. This review identifies evidence of hypertensive target organ damage across cardiac, vascular, cerebral, and renal systems at different time points from pregnancy to postpartum. METHODS AND RESULTS Systematic review of Ovid/MEDLINE, EMBASE, and ClinicalTrials.gov up to and including February 2023 including review of reference lists. Identified articles underwent evaluation via a synthesis without meta-analysis using a vote-counting approach based on direction of effect, regardless of statistical significance. Risk of bias was assessed for each outcome domain, and only higher quality studies were used for final analysis. From 7644 articles, 76 studies, including data from 1 742 698 pregnancies, were identified of high quality that reported either blood pressure trajectories or target organ damage during or after a hypertensive pregnancy. Left ventricular hypertrophy, white matter lesions, proteinuria, and retinal microvasculature changes were first evident in women during a hypertensive pregnancy. Cardiac, cerebral, and retinal changes were also reported in studies performed during the early and late post-partum period despite reduction in blood pressure early postpartum. Cognitive dysfunction was first reported late postpartum. CONCLUSION The majority of target organ damage reported during a hypertensive pregnancy remains evident throughout the early and late post-partum period despite variation in blood pressure. Early peri-partum strategies may be required to prevent or reverse target organ damage in women who have had a hypertensive pregnancy.
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Affiliation(s)
- Hannah Rebecca Cutler
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Logan Barr
- Department of Biomedical and Molecular Sciences, Queens University, Barrie St, Kingston, Canada
| | - Prenali Dwisthi Sattwika
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
- Department of Internal Medicine, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Bulaksumur, Caturtunggal, Kec, Kabupaten Sleman, Indonesia
| | - Annabelle Frost
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Mohanad Alkhodari
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
- Healthcare Engineering Innovation Center, Department of Biomedical Engineering, Khalifa University, Abu Dhabi, Shakhbout Bin Sultan St, Hadbat Al Za'faranah, United Arab Emirates
| | - Jamie Kitt
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Winok Lapidaire
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Adam James Lewandowski
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK
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Kitt J, Fox R, Frost A, Shanyinde M, Tucker K, Bateman PA, Suriano K, Kenworthy Y, McCourt A, Woodward W, Lapidaire W, Lacharie M, Santos M, Roman C, Mackillop L, Delles C, Thilaganathan B, Chappell LC, Lewandowski AJ, McManus RJ, Leeson P. Long-Term Blood Pressure Control After Hypertensive Pregnancy Following Physician-Optimized Self-Management: The POP-HT Randomized Clinical Trial. JAMA 2023; 330:1991-1999. [PMID: 37950919 PMCID: PMC10640702 DOI: 10.1001/jama.2023.21523] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/02/2023] [Indexed: 11/13/2023]
Abstract
Importance Pregnancy hypertension results in adverse cardiac remodeling and higher incidence of hypertension and cardiovascular diseases in later life. Objective To evaluate whether an intervention designed to achieve better blood pressure control in the postnatal period is associated with lower blood pressure than usual outpatient care during the first 9 months postpartum. Design, Setting, and Participants Randomized, open-label, blinded, end point trial set in a single hospital in the UK. Eligible participants were aged 18 years or older, following pregnancy complicated by preeclampsia or gestational hypertension, requiring antihypertensive medication postnatally when discharged. The first enrollment occurred on February 21, 2020, and the last follow-up, November 2, 2021. The follow-up period was approximately 9 months. Interventions Participants were randomly assigned 1:1 to self-monitoring along with physician-optimized antihypertensive titration or usual postnatal care. Main Outcomes and Measures The primary outcome was 24-hour mean diastolic blood pressure at 9 months postpartum, adjusted for baseline postnatal blood pressure. Results Two hundred twenty participants were randomly assigned to either the intervention group (n = 112) or the control group (n = 108). The mean (SD) age of participants was 32.6 (5.0) years, 40% had gestational hypertension, and 60% had preeclampsia. Two hundred participants (91%) were included in the primary analysis. The 24-hour mean (SD) diastolic blood pressure, measured at 249 (16) days postpartum, was 5.8 mm Hg lower in the intervention group (71.2 [5.6] mm Hg) than in the control group (76.6 [5.7] mm Hg). The between-group difference was -5.80 mm Hg (95% CI, -7.40 to -4.20; P < .001). Similarly, the 24-hour mean (SD) systolic blood pressure was 6.5 mm Hg lower in the intervention group (114.0 [7.7] mm Hg) than in the control group (120.3 [9.1] mm Hg). The between-group difference was -6.51 mm Hg (95% CI, -8.80 to -4.22; P < .001). Conclusions and Relevance In this single-center trial, self-monitoring and physician-guided titration of antihypertensive medications was associated with lower blood pressure during the first 9 months postpartum than usual postnatal outpatient care in the UK. Trial Registration ClinicalTrials.gov Identifier: NCT04273854.
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Affiliation(s)
- Jamie Kitt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Rachael Fox
- Mercy Hospital for Women, Department of Obstetrics and Gynecology, Heidelberg, Australia
| | - Annabelle Frost
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Katherine Tucker
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul A. Bateman
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Katie Suriano
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Yvonne Kenworthy
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Annabelle McCourt
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - William Woodward
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Winok Lapidaire
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Miriam Lacharie
- Oxford Centre for Clinical Magnetic Resonance Research, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
| | - Mauro Santos
- Institute for Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Cristian Roman
- Institute for Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Lucy Mackillop
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Basky Thilaganathan
- Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Molecular Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom
| | - Lucy C. Chappell
- King’s College London, London, United Kingdom
- Guy’s St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Adam J. Lewandowski
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Richard J. McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Paul Leeson
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
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Silverio SA, Bye A, Hildersley R, Chingara O, Chang YS, Bick D. A longitudinal qualitative study of women's experiences of postnatal care following hypertensive disorders of pregnancy. Women Birth 2023; 36:460-468. [PMID: 36925402 DOI: 10.1016/j.wombi.2023.03.004] [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: 06/27/2022] [Revised: 03/06/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023]
Abstract
PROBLEM There has been little focus on women's views of care and recovery following pregnancy complicated by hypertensive disorders of pregnancy [HDP] despite long-term implications for maternal health. BACKGROUND Increasingly in clinical research, areas of interest include the extent to which women are involved in postnatal care planning, perceived value of routine postnatal contacts, lifestyle behaviour advice, and extent to which ongoing concerns about HDP could be discussed with healthcare professionals. AIM This study explored women's experiences of birth-recovery up to 12 months following HDP. METHODS A longitudinal qualitative study using semi-structured interviews at four and 12 months postpartum. Twenty-four women who each had a form of HDP, were recruited using a maximum variation, purposive sampling strategy from four National Health Service maternity units in London, 21 of whom were interviewed at both time points. Data were collected and analysed by timepoint following a recurrent, cross-sectional cohort approach using template analysis methodology. FINDINGS Four main themes and ten sub-themes were identified. Main themes included: assumptions about blood pressure; perinatal experiences; postnatal care pathways; and managing complex health conditions. DISCUSSION Postnatal care needs to be tailored to women's individual needs following HDP, with ongoing review by relevant clinicians during and beyond the first six weeks. Many women with HDP have ongoing information needs about hypertensive status, treatment and prognoses, and future birth planning. CONCLUSION Policy makers, health providers and funders cannot continue to ignore the need to ensure postnatal services meet the needs of women who have experienced medically complex pregnancies.
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Affiliation(s)
- Sergio A Silverio
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Amanda Bye
- Department of Psychological Medicine, Division of Academic Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Rosanna Hildersley
- Section of Women's Mental Health, Department of Health Service & Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Olivia Chingara
- Department of Women & Children's Health, School of Life Course Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Yan-Shing Chang
- Department of Child & Family Health, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, United Kingdom
| | - Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, Faculty of Science, Engineering and Medicine, University of Warwick, Coventry, United Kingdom.
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Fraser A, Catov JM. Placental syndromes and long-term risk of hypertension. J Hum Hypertens 2023; 37:671-674. [PMID: 36702879 PMCID: PMC10403351 DOI: 10.1038/s41371-023-00802-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/28/2022] [Accepted: 01/11/2023] [Indexed: 01/27/2023]
Abstract
Higher blood pressure prior to pregnancy is associated with increased risk of placental abruption, hypertension and preeclampsia, preterm delivery and fetal growth restriction. These conditions are jointly termed placental syndromes as they are characterised by impaired placentation and early placental vascularization. Placental syndromes are associated with an increased maternal risk of progression to hypertension and cardiovascular disease (CVD) in later life. Women affected by both a clinical placental syndrome and with evidence of placental maternal vascular malperfusion (MVM) have a particularly high risk of hypertension and CVD. Yet whether placental impairment and clinical syndromes are causes or consequences of higher blood pressure in women remains unclear. In this review, we address the relationship between blood pressure and maternal health in pregnancy. We conclude that there is a pressing need for studies with a range of detailed measures of cardiac and vascular structure and function taken before, during and after pregnancy to solve the 'chicken and egg' puzzle of women's blood pressure and pregnancy health, and to inform effective precision medicine prevention and treatment of both placental syndromes and chronic hypertension in women.
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Affiliation(s)
- Abigail Fraser
- Population Health Sciences, Bristol Medical School and the MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.
| | - Janet M Catov
- Department of Obstetrics, Gynaecology and Reproductive Sciences and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
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Wu P, Green M, Myers JE. Hypertensive disorders of pregnancy. BMJ 2023; 381:e071653. [PMID: 37391211 DOI: 10.1136/bmj-2022-071653] [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] [Indexed: 07/02/2023]
Abstract
Hypertensive disorders of pregnancy (HDP) are one of the most commonly occurring complications of pregnancy and include chronic hypertension, gestational hypertension, and pre-eclampsia. New developments in early pregnancy screening to identify women at high risk for pre-eclampsia combined with targeted aspirin prophylaxis could greatly reduce the number of affected pregnancies. Furthermore, recent advances in the diagnosis of pre-eclampsia, such as placental growth factor based testing, have been shown to improve the identification of those pregnancies at highest risk of severe complications. Evidence from trials has refined the target blood pressure and timing of delivery to manage chronic hypertension and pre-eclampsia with non-severe features, respectively. Importantly, a wealth of epidemiological data now links HDP to future cardiovascular disease and diabetes decades after an affected pregnancy. This review discusses the current guidelines and research data on the prevention, diagnosis, management, and postnatal follow-up of HDP. It also discusses the gap in knowledge regarding the long term risks for cardiovascular disease following HDP and illustrates the importance of improving adherence to postnatal guidelines to monitor hypertension and the need for more research focused on primary prevention of future cardiovascular disease in women identified as being at high risk because of HDP.
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Affiliation(s)
- Pensée Wu
- School of Medicine, Keele University, Newcastle-under-Lyme, UK
- Academic Department of Obstetrics and Gynaecology, University Hospital of North Midlands, Stoke-on-Trent, UK
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Jenny E Myers
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK
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Steele DW, Adam GP, Saldanha IJ, Kanaan G, Zahradnik ML, Danilack-Fekete VA, Stuebe AM, Peahl AF, Chen KK, Balk EM. Postpartum Home Blood Pressure Monitoring: A Systematic Review. Obstet Gynecol 2023; Publish Ahead of Print:00006250-990000000-00798. [PMID: 37311173 DOI: 10.1097/aog.0000000000005270] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/11/2023] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To assess the effectiveness of postpartum home blood pressure (BP) monitoring compared with clinic-based follow-up and the comparative effectiveness of alternative home BP-monitoring regimens. DATA SOURCES Search of Medline, Cochrane, EMBASE, CINAHL, and ClinicalTrials.gov from inception to December 1, 2022, searching for home BP monitoring in postpartum individuals. METHODS OF STUDY SELECTION We included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm studies that evaluated the effects of postpartum home BP monitoring (up to 1 year), with or without telemonitoring, on postpartum maternal and infant outcomes, health care utilization, and harm outcomes. After double screening, we extracted demographics and outcomes to SRDR+. TABULATION, INTEGRATION, AND RESULTS Thirteen studies (three RCTs, two nonrandomized comparative studies, and eight single-arm studies) met eligibility criteria. All comparative studies enrolled participants with a diagnosis of hypertensive disorders of pregnancy. One RCT compared home BP monitoring with bidirectional text messaging with scheduled clinic-based BP visits, finding an increased likelihood that at least one BP measurement was ascertained during the first 10 days postpartum for participants in the home BP-monitoring arm (relative risk 2.11, 95% CI 1.68-2.65). One nonrandomized comparative study reported a similar effect (adjusted relative risk [aRR] 1.59, 95% CI 1.36-1.77). Home BP monitoring was not associated with the rate of BP treatment initiation (aRR 1.03, 95% CI 0.74-1.44) but was associated with reduced unplanned hypertension-related hospital admissions (aRR 0.12, 95% CI 0.01-0.96). Most patients (83.3-87.0%) were satisfied with management related to home BP monitoring. Home BP monitoring, compared with office-based follow-up, was associated with reduced racial disparities in BP ascertainment by approximately 50%. CONCLUSION Home BP monitoring likely improves ascertainment of BP, which is necessary for early recognition of hypertension in postpartum individuals, and may compensate for racial disparities in office-based follow-up. There is insufficient evidence to conclude that home BP monitoring reduces severe maternal morbidity or mortality or reduces racial disparities in clinical outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022313075.
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Affiliation(s)
- Dale W Steele
- Center for Evidence Synthesis in Health, Department of Health Services, Policy, and Practice, and the Department of Epidemiology, Brown University School of Public Health, and the Department of Emergency Medicine, the Department of Pediatrics, and Department of Medicine, and the Department of Obstetrics and Gynecology, Brown University Warren Alpert Medical School, Providence, Rhode Island; the Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; the Center for Outcomes Research and Evaluation, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and the Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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9
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Cífková R. Hypertension in Pregnancy: A Diagnostic and Therapeutic Overview. High Blood Press Cardiovasc Prev 2023:10.1007/s40292-023-00582-5. [PMID: 37308715 PMCID: PMC10403432 DOI: 10.1007/s40292-023-00582-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/16/2023] [Indexed: 06/14/2023] Open
Abstract
Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality. It is important to distinguish between pre-existing (chronic) hypertension and gestational hypertension, developing after 20 weeks of gestation and usually resolving within 6 weeks postpartum. There is a consensus that systolic blood pressure ≥ 170 or diastolic blood pressure ≥ 110 mmHg is an emergency and hospitalization is indicated. The selection of the antihypertensive drug and its route of administration depend on the expected time of delivery. The current European guidelines recommend initiating drug treatment in pregnant women with persistent elevation of blood pressure ≥ 150/95 mmHg and at values > 140/90 mmHg in women with gestational hypertension (with or without proteinuria), with pre-existing hypertension with the superimposition of gestational hypertension, and with hypertension with subclinical organ damage or symptoms at any time during pregnancy. Methyldopa, labetalol, and calcium antagonists (the most data are available for nifedipine) are the drugs of choice. The results of the CHIPS and CHAP studies are likely to reduce the threshold for initiating treatment. Women with a history of hypertensive disorders in pregnancy, particularly those with pre-eclampsia, are at high risk of developing cardiovascular disease later in life. Obstetric history should become a part of the cardiovascular risk assessment in women.
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Affiliation(s)
- Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital, Prague, Czech Republic.
- Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czech Republic.
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Self-management system for postpartum women with hypertension disorders: an eHealth application intervention study. BMC Pregnancy Childbirth 2023; 23:184. [PMID: 36927463 PMCID: PMC10018986 DOI: 10.1186/s12884-023-05483-y] [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: 09/08/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Hypertension disorders are relatively common in pregnant women and often persist in the postpartum period. Few studies are available regarding the self-management of postpartum hypertension via the eHealth system. This study aimed to develop a self-management eHealth system for women with postpartum hypertension during the postpartum period. METHODS We adopted a multi-platform system for this research, not only for use on the web interface but also on smartphones. The proposed system possessed three features: (1) the population was limited to postnatal women with hypertension; (2) a self-care record, which allowed postnatal women to keep track of their blood pressure, pulse, weight, medication record, exercise record, and risk factor assessment; and (3) through this system, nurse-midwives could keep track of postnatal women's health status maintaining the complete record and could communicate directly with the users if their health monitor values reach beyond normal range. RESULTS Thirty-nine postnatal women with postpartum hypertension were recruited to the study. A survey to evaluate the usability and satisfaction of the proposed e-health application system was completed by these women. The usability rate of the system reached 92.4% (46.2% satisfied and 46.2% strongly satisfied), which suggested that the system was helpful to the users. The satisfaction rate of the system reached 94.9% (43.6% satisfied and 51.3% strongly satisfied), which suggested that the system was acceptable to the users. CONCLUSION This proposed system has been developed completely with user experience and professional advice from experts. Postnatal women could gain important postpartum-related knowledge and access their related health records and other information easily via their smartphones or computers. During the postpartum period, an eHealth application system can effectively assist women with hypertension to manage their blood pressure and related postnatal healthcare issues.
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Giorgione V, Jansen G, Kitt J, Ghossein-Doha C, Leeson P, Thilaganathan B. Peripartum and Long-Term Maternal Cardiovascular Health After Preeclampsia. Hypertension 2023; 80:231-241. [PMID: 35904012 DOI: 10.1161/hypertensionaha.122.18730] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
There is widespread acceptance of the increased prevalence of cardiovascular diseases occurring within 1 to 2 decades in women following a preeclamptic pregnancy. More recent evidence suggests that the deranged biochemical and echocardiographic findings in women do not resolve in the majority of preeclamptic women following giving birth. Many women continue to be hypertensive in the immediate postnatal period with some exhibiting occult signs of cardiac dysfunction. There is now promising evidence that with close monitoring and effective control of blood pressure control in the immediate postnatal period, women may have persistently lower blood pressures many years after stopping their medication. This review highlights the evidence that delivering effective medical care in the fourth trimester of pregnancy can improve the long-term cardiovascular health after a preeclamptic birth.
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Affiliation(s)
- Veronica Giorgione
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom (V.G., B.T.)
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom (V.G., B.T.)
| | - Gwyneth Jansen
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands (G.J., C.G.-D.)
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands (G.J.)
| | - Jamie Kitt
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford' United Kingdom (J.K., P.L.)
| | - Chahinda Ghossein-Doha
- GROW School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands (G.J., C.G.-D.)
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht' the Netherlands (C.G.-D.)
| | - Paul Leeson
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford' United Kingdom (J.K., P.L.)
| | - Basky Thilaganathan
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, United Kingdom (V.G., B.T.)
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, United Kingdom (V.G., B.T.)
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