Hypertensive Disorders of Pregnancy

Cardiovascular adverse events in pregnancy: A global perspective

Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.

Improved prediction of gestational hypertension by inclusion of placental growth factor and pregnancy associated plasma protein-a in a sample of Ghanaian women

BACKGROUND

We assessed whether adding the biomarkers Pregnancy Associated Plasma Protein-A (PAPP-A) and Placental Growth Factor (PlGF) to maternal clinical characteristics improved the prediction of a previously developed model for gestational hypertension in a cohort of Ghanaian pregnant women.

METHODS

This study was nested in a prospective cohort of 1010 pregnant women attending antenatal clinics in two public hospitals in Accra, Ghana. Pregnant women who were normotensive, at a gestational age at recruitment of between 8 and 13 weeks and provided a blood sample for biomarker analysis were eligible for inclusion. From serum, biomarkers PAPP-A and PlGF concentrations were measured by the AutoDELFIA immunoassay method and multiple of the median (MoM) values corrected for gestational age (PAPP-A and PlGF) and maternal weight (PAPP-A) were calculated. To obtain prediction models, these biomarkers were included with clinical predictors maternal weight, height, diastolic blood pressure, a previous history of gestational hypertension, history of hypertension in parents and parity in a logistic regression to obtain prediction models. The Area Under the Receiver Operating Characteristic Curve (AUC) was used to assess the predictive ability of the models.

RESULTS

Three hundred and seventy three women participated in this study. The area under the curve (AUC) of the model with only maternal clinical characteristics was 0.75 (0.64-0.86) and 0.89(0.73-1.00) for multiparous and primigravid women respectively. The AUCs after inclusion of both PAPP-A and PlGF were 0.82 (0.74-0.89) and 0.95 (0.87-1.00) for multiparous and primigravid women respectively.

CONCLUSION

Adding the biomarkers PAPP-A and PlGF to maternal characteristics to a prediction model for gestational hypertension in a cohort of Ghanaian pregnant women improved predictive ability. Further research using larger sample sizes in similar settings to validate these findings is recommended.

The role of vitamin D in pre-eclampsia: a systematic review

BACKGROUND

The etiology of pre-eclampsia (PE) is not yet fully understood, though current literature indicates an upregulation of inflammatory mediators produced by the placenta as a potential causal mechanism. Vitamin D is known to have anti-inflammatory properties and there is evidence of an inverse relationship between dietary calcium intake and the incidence of PE. Evidence of the role of vitamin D status and supplementation in the etiology and prevention of PE is reviewed in this article along with identification of research gaps to inform future studies.

METHODS

We conducted a structured literature search using MEDLINE electronic databases to identify published studies until February 2015. These sources were retrieved, collected, indexed, and assessed for availability of pregnancy-related data on PE and vitamin D.

RESULTS

Several case-control studies and cross-sectional studies have shown an association between vitamin D status and PE, although evidence has been inconsistent. Clinical trials to date have been unable to show an independent effect of vitamin D supplementation in preventing PE.

CONCLUSIONS

The included clinical trials do not show an independent effect of vitamin D supplementation in preventing PE; however, issues with dose, timing, and duration of supplementation have not been completely addressed.

Childhood Risk Factors and Pregnancy-Induced Hypertension: The Bogalusa Heart Study

BACKGROUND

Pregnancy-induced hypertension (PIH) causes increased risk of maternal, fetal, and neonatal morbidity and mortality. Identification of risk factors for PIH in early life is central to the development of prevention strategies.

METHODS

A cohort of 703 women aged 25.5-51.3 years from the Bogalusa Heart Study were included. PIH were defined as self-reported hypertension during pregnancy and a blood pressure level <140/90mm Hg without antihypertensive medication (n = 131) at the subsequent examinations. Body mass index (BMI), systolic and diastolic blood pressure, high- and low-density lipoprotein cholesterol, and triglycerides measured during childhood (4-17 years) were considered. General linear models were used to examine differences in childhood between those who did and those who did not develop PIH. Logistic regression models were used to estimate odds ratios for PIH associated with childhood risk factors.

RESULTS

Compared to women who did not develop PIH, those who developed PIH had higher BMI (20.2 vs. 19.2kg/m(2), P = 0.0002) and systolic blood pressure (104.1 vs. 103.3mm Hg, P = 0.008) in childhood. After adjustment for other variables, childhood BMI was the only risk factor associated with PIH, with each standard deviation increase in childhood BMI being associated with an odds ratio of 1.35 (95% confidence interval: 1.08-1.68) for PIH. The odds of PIH increased significantly as childhood BMI increased from the bottom quartile to the top quartile (P for trend = 0.006).

CONCLUSIONS

Elevated childhood BMI is a significant risk factor for PIH in adulthood, which underscores the importance of body weight control in childhood for prevention of PIH.

Nursing care for women with pre-eclampsia and/or eclampsia: integrative review

OBJECTIVE

To analyze the available evidence in the literature on nursing care for women with pre-eclampsia and/or eclampsia.

METHODS

Integrative review searching for primary studies in the databases PubMed, CINAHL, LILACS and SciELO.

RESULTS

The sample size consisted of 17 primary studies published between January 2000 and December 2014, grouped into four categories: standardizing blood pressure measurement technique; training with simulation; instruments for standardization of care and quality of care The main nursing actions were: physical examination, early detection of signs of pre-eclampsia/eclampsia, monitoring of laboratory tests, fetal assessment, qualification and training of professionals. We identified the need for standardization of care from instruments, protocols and blood pressure measurement technique, early identification and treatment of hypertensive crisis through institutional protocols and review of cases and work processes.

CONCLUSION

Women with pre-eclampsia and/or eclampsia require specific nursing care, which must be guided by care protocols based on scientific evidence.

OBJETIVO

Analisar as evidências disponíveis na literatura sobre assistência de enfermagem às mulheres com pré-eclâmpsia e/ou eclâmpsia.

MÉTODO

Revisão integrativa cuja busca dos estudos primários foi realizada nas bases de dados PubMed, CINAHL, LILACS e SciELO.

RESULTADOS

Amostra foi composta por 17 estudos primários, publicados entre janeiro de 2000 e dezembro de 2014, agrupados em quatro categorias: padronização da técnica de mensuração da pressão arterial; treinamentos com simulação; instrumentos para padronização da assistência e qualidade da assistência As principais ações de enfermagem foram: exame físico, identificação precoce de sinais de pré-eclâmpsia/eclâmpsia, acompanhamento de exames laboratoriais, avaliação fetal, capacitação e treinamento dos profissionais. Identificou-se a necessidade de padronização do atendimento a partir de instrumentos e protocolos e da técnica de aferição da pressão arterial, identificação e tratamento precoces da crise hipertensiva mediante protocolos institucionais e revisão de casos e processos de trabalho.

CONCLUSÃO

Mulheres com pré-eclâmpsia e/ou eclâmpsia exigem cuidados de enfermagem específicos, os quais devem ser pautados em protocolos de cuidados baseados em evidências científicas.

Diet quality before or during pregnancy and the relationship with pregnancy and birth outcomes: the Australian Longitudinal Study on Women's Health

OBJECTIVE

To assess whether diet quality before or during pregnancy predicts adverse pregnancy and birth outcomes in a sample of Australian women.

DESIGN

The Dietary Questionnaire for Epidemiological Studies was used to calculate diet quality using the Australian Recommended Food Score (ARFS) methodology modified for pregnancy.

SETTING

A population-based cohort participating in the Australian Longitudinal Study on Women's Health (ALSWH).

SUBJECTS

A national sample of Australian women, aged 20-25 and 31-36 years, who were classified as preconception or pregnant when completing Survey 3 or Survey 5 of the ALSWH, respectively. The 1907 women with biologically plausible energy intake estimates were included in regression analyses of associations between preconception and pregnancy ARFS and subsequent pregnancy outcomes.

RESULTS

Preconception and pregnancy groups were combined as no significant differences were detected for total and component ARFS. Women with gestational hypertension, compared with those without, had lower scores for total ARFS, vegetable, fruit, grain and nuts/bean/soya components. Women with gestational diabetes had a higher score for the vegetable component only, and women who had a low-birth-weight infant had lower scores for total ARFS and the grain component, compared with those who did not report these outcomes. Women with the highest ARFS had the lowest odds of developing gestational hypertension (OR=0·4; 95 % CI 0·2, 0·7) or delivering a child of low birth weight (OR=0·4; 95 % CI 0·2, 0·9), which remained significant for gestational hypertension after adjustment for potential confounders.

CONCLUSIONS

A high-quality diet before and during pregnancy may reduce the risk of gestational hypertension for the mother.

Effects of dietary interventions on pregnancy outcomes: a systematic review and meta-analysis

Dietary intake during pregnancy influences maternal health. Poor dietary practices during pregnancy have been linked to maternal complications. The objective was to determine the effect of dietary intervention before or during pregnancy on pregnancy outcomes. A systematic review was conducted without date restrictions. Randomised controlled trials (RCTs) evaluating whole diet or dietary components and pregnancy outcomes were included. Two authors independently identified papers for inclusion and assessed methodological quality. Meta-analysis was conducted separately for each outcome using random effects models. Results were reported by type of dietary intervention: (1) counselling; (2) food and fortified food products; or (3) combination (counseling + food); and collectively for all dietary interventions. Results were further grouped by trimester when the intervention commenced, nutrient of interest, country income and body mass index. Of 2326 screened abstracts, a total of 28 RCTs were included in this review. Dietary counselling during pregnancy was effective in reducing systolic [standardised mean difference (SMD) -0.26, 95% confidence interval (CI) -0.45 to -0.07; P < 0.001] and diastolic blood pressure (SMD -0.57, 95% CI -0.75 to -0.38; P < 0.001). Macronutrient dietary interventions were effective in reducing the incidence of preterm delivery (SMD -0.19, 95% CI -0.34 to -0.04; P = 0.01). No effects were seen for other outcomes. Dietary interventions showed some small, but significant differences in pregnancy outcomes including a reduction in the incidence of preterm birth. Further high-quality RCTs, investigating micronutrient provision from food, and combination dietary intervention, are required to identify maternal diet intakes that optimise pregnancy outcomes.

Management of cardiovascular diseases during pregnancy

The prevalence of cardiovascular diseases (CVDs) in women of childbearing age is rising. The successes in medical and surgical treatment of congenital heart disease have led to an increasing number of women at childbearing age presenting with problems of treated congenital heart disease. Furthermore, in developing countries and in immigrants from these countries, rheumatic valvular heart disease still plays a significant role in young women. Increasing age of pregnant women and increasing prevalence of atherosclerotic risk factors have led to an increase in women with coronary artery disease at pregnancy. Successful management of pregnancy in women with CVDs requires early diagnosis, a thorough risk stratification, and appropriate management by a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, and primary care physicians. The following review is based on the recent European guidelines on the management of CVDs during pregnancy, which aim at providing concise and simple recommendations for these challenging problems.

Effect of age, parity, and race on the incidence of pregnancy associated hypertension and eclampsia in the United States

PURPOSE

To describe the incidence of pregnancy associated hypertension and eclampsia from adolescence through the fifth decade of life, including the effect of parity and race, in the United States.

METHODS

Data were evaluated from the National Center for Health Statistics (vital statistics section). The data were stratified by maternal age group, parity (G1, first pregnancy; G2+, second or higher pregnancy), and racial group.

RESULTS

The incidence of pregnancy associated hypertension (PAH) decreased with increased age in late adolescence in the G2+ group but not the G1 group (total and all racial groups). The incidence of PAH was significantly greater for non-Hispanic black or non-Hispanic white than Hispanic groups for all age groups (P⩽.02) except age ⩽15years (G2+ group) and 45-54years (both G1 and G2+ groups). The incidence of eclampsia decreased with increased age in late adolescence in the G2+ group (total and all racial groups) and the G1 group (total and non-Hispanic black groups). The incidence of eclampsia was significantly greater for non-Hispanic black than non-Hispanic white and for non-Hispanic white than Hispanic groups for all age groups except age ⩽15years in the G2+ group. The incidence of PAH and eclampsia increased substantially in both G1 and G2+ groups in the fifth decade of life (total and all racial groups).

CONCLUSIONS

The incidence of PAH (G2+ group) and eclampsia (G1 and G2+ groups) decreased with increased age during adolescence and increased in the fifth decade (G1 and G2+ groups).

Studies on angiotensin-converting enzyme insertion/deletion polymorphism and genotype distributions in Turkish preeclampsia patients

Placental, immune and genetic factors are thought to play an important role in preeclampia (PE)'s pathophysiology. Angiotensin-Converting Enzyme (ACE) plays a vital role in the renin-angiotensin-system (RAS) which regulates blood pressure by converting angiotensin I into a powerfull vasoconstrictor angiotensin II. A deletion polymorphism (D allele) has been reported to be associated with elevated ACE activity. The aim of the this study was to investigate whether there is an association between angiotensin converting enzyme (ACE) insertion/deletion (I/D) polymorphism and PE. In this study, 120 preeclamptic and 116 normotensive Turkish pregnant women were genotyped for ACE I/D polymorphism and the distribution of genotype and allele frequencies of this polymorphism in preeclampsia and controls were evaluated. Codominant, dominant and recessive models were appplied in ACE gene I/D polymorphism. In the codominant model, DD genotype was found significantly more frequent in preeclampsia than controls (P = 0.016). Moreover, in dominant model (DD frequency versus DI+II frequency) there was a significant relation between DD genotype and preeclampsia (P = 0.006). D allele frequency was 64.6% in preeclampsia while it was 56.1% in controls (P = 0.062). In conclusion, there was significant difference in genotype distribution between preeclampsia and controls.

Atrial Remodeling in Pregnant Hypertensive Women: Comparison between Chronic and Gestational Hypertension

OBJECTIVES

Left atrial (LA) enlargement is a common finding in hypertensive patients (pts), however little information is available on LA changes during pregnancy. The present study evaluated LA size and function in pregnant women with hypertension.

METHODS

Patients population included 30 women with chronic hypertension and 30 patients with gestational hypertension. A control group of 16 normotensive pregnant women was selected. Serial echocardiography was performed at 12 and 24 week of gestation in chronic hypertension and at 24 week in gestational hypertension and after delivery. LA diameters and volumes were measured and compared. LA conduit volume, passive and active emptying volumes were calculated. Patients were divided in 2 groups according to max LAV Index > 32 ml/m(2) at 24 week of gestation.

RESULTS

Patients with chronic hypertension showed higher LA diameters (42 ± 2.0 vs. 36.5 ± 1.8; p<0.001) and LA volumes (maximal volume 45.5 ± 4.0 vs. 38.1 ± 7.3; p<0.001) compared with patients with gestational hypertension. The median value of max LAVI was 32 + 6.2 ml/m(2) in chronic and 26 + 5 ml/m(2) in gestational hypertension (p<0.01). During follow-up patients with max LAVI > 32 ml/m(2) had more clinical complications evaluated as increase of therapy, fluid retention that need diuretic and hospitalization.

CONCLUSION

Patients with chronic hypertension showed a more marked increased of LA volumes compared to gestational hypertension due to a remodeling of atrial shape as effect of chronic overload. Patients with more dilated LA volumes developed a greater number of clinical complications suggesting that a dilated LA could be a parameter of hemodynamic instability.

Preeclampsia: pathophysiology and implications for care

Nurses are increasingly encountering pregnant/postpartum women with hypertensive disorders of pregnancy, of which preeclampsia is one of the most common. The Joint Commission published a Sentinel Event Alert in 2010 on prevention of maternal death. This report notes that one of the 5 leading causes of pregnancy-related mortality between 1991 and 1997 was "hypertensive disorder." Preeclampsia presents significant risk to the health of the mother and the fetus. Clearly, nurses must understand the pathophysiology, assessment, management, recurrence risk, and long-term implications of preeclampsia to participate fully in a management plan that promotes safe patient care.

Stress, symptoms, self-monitoring confidence, well-being, and social support in the progression of preeclampsia/gestational hypertension

OBJECTIVE

To investigate the relationships of psychological stress, preeclampsia/gestational hypertension symptoms, confidence in self-monitoring, well-being, and perceived social support with preeclampsia/gestational hypertension disease progression in outpatient women. Women with mild and severe preeclampsia/gestational hypertension were compared for differences in these variables.

DESIGN

A retrospective, correlational, and comparative design.

SETTING

Postpartum units of three urban hospitals in Philadelphia, Pennsylvania.

PARTICIPANTS

One hundred postpartum women with preeclampsia/gestational hypertension.

MAIN OUTCOME MEASURES

Psychological stress measured by the Perceived Stress Scale, preeclampsia/gestational hypertension symptoms by the Preeclampsia/Gestational Hypertension Checklist, confidence in self-monitoring by the Self-Confidence in Self-Monitoring Scale, well-being by the Index of Well-Being, and social support by the Interpersonal Support Evaluation List.

RESULTS

Women with worsening/severe preeclampsia/gestational hypertension reported a significantly higher number of symptoms than women with mild preeclampsia/gestational hypertension (p= .02). Psychological stress was significantly higher (p= .04) in women with worsening/severe preeclampsia/gestational hypertension. There were no differences in well-being, self-confidence in self-monitoring, or perceived social support between women with mild preeclampsia/gestational hypertension and those with worsening preeclampsia/gestational hypertension.

CONCLUSION

Worsening/severe preeclampsia/gestational hypertension was associated with increasing psychological stress and a higher number of preeclampsia/gestational hypertension symptoms.

Racial disparity in hypertensive disorders of pregnancy in New York State: a 10-year longitudinal population-based study

OBJECTIVES

We studied trends of hypertensive disorders of pregnancy by residential socioeconomic status (SES) and racial/ethnic subgroups in New York State over a 10-year period.

METHODS

We merged New York State discharge data for 2.5 million women hospitalized with delivery from 1993 through 2002 with 2000 US Census data.

RESULTS

Rates of diagnoses for all hypertensive disorders combined and for preeclampsia individually were highest among Black women across all regions and neighborhood poverty levels. Although hospitalization rates for preeclampsia decreased over time for most groups, differences in rates between White and Black women increased over the 10-year period. The proportion of women living in poor areas remained relatively constant over the same period. Black and Hispanic women were more likely than White women to have a form of diabetes and were at higher risk of preeclampsia; preeclampsia rates were higher in these groups both with and without diabetes than in corresponding groups of White women.

CONCLUSIONS

An increasing trend of racial/ethnic disparity in maternal hypertension rates occurred in New York State during the past decade. This trend was persistent after stratification according to SES and other risk factors. Additional research is needed to understand the factors contributing to this growing disparity.

Doppler sonography of the uterine and the cubital arteries in normal pregnancies, preeclampsia and intrauterine growth restriction: evidence for a systemic vessel involvement

AIMS

The decrease in uterine resistance during normal pregnancy is known to be related to invading trophoblast cells which derive from placental tissue. Uterine and peripheral resistance is elevated in preeclampsia. The aim of the present study was to prospectively examine uterine and peripheral resistance in pregnancies complicated by preeclampsia (PE), fetal intrauterine growth restriction (IUGR) and pregnancy induced hypertension (PIH).

METHODS

Sixty-seven women with normal pregnancies, 17 with PE, 12 with IUGR underwent Doppler sonographic investigation of the uterine and the cubital arteries. The Pulsatility Index (PI) was calculated for each vessel. Statistical analysis was performed and a P-value <0.05 was considered significant.

RESULTS

Patients with preeclampsia and IUGR showed a significant higher resistance at the placental (mean PI 1.267 and 1.063), nonplacental (mean PI 1.631 and 1.124) and cubital artery (mean PI 3,777 and 3.995) compared to the normal pregnancy group (mean PI 0.678; 0.859 and 2.95 respectively). Mean birth weight in the PE group was 1409 g, in the IUGR group 1649 g and 3419 g in the normal pregnancy group.

CONCLUSIONS

Pregnancies with IUGR are associated with elevated peripheral resistance in the maternal arterial system as seen in pregnancies with preeclampsia. Our findings encourage to further investigate the maternal vascular system in high risk pregnancies.

Effects of Oral L-Arginine on the Foetal Condition and Neonatal Outcome in Preeclampsia: A Preliminary Report

Estimation of the influence of oral supplementation with low dose of L-arginine on biophysical profile, foeto-placental circulation and neonatal outcome in preeclampsia. Randomized, placebo-controlled, double-blind, clinical trial. Oral therapy with 3 g of L-arginine daily or placebo as a supplement to standard therapy. Eighty-three preeclamptic women, randomly assigned to the L-arginine (n=42) or placebo (n=41) groups; [n=30 (L-arginine) and n=31 (placebo) ended the study, respectively]. Foetal gain chances due to ultrasound biometry, biophysical profile, Doppler velocimetry of pulsatility indices of umbilical and middle cerebral arteries, cerebro-placental ratio, as well as differences in duration of pregnancy and clinical data of newborn. L-arginine treatment transitory accelerated foetal gain and improved biophysical profile. Starting from 3rd week of therapy, the umbilical artery pulsatility indices values were significantly lower in L-arginine than in placebo group. Moreover, treatment with L-arginine caused significant increase of middle cerebral artery pulsatility indices and cerebro-placental ratio values. Latency was longer in L-arginine group. Neonates delivered in the L-arginine group revealed higher Apgar score. Supplementary treatment with oral L-arginine seems to be promising in improving foetal well-being and neonatal outcome as well as in prolonging pregnancy complicated with preeclampsia. However, these benefits require confirmation in more-powered, larger studies.

Childbirth education for multiple pregnancy: part 1: prenatal considerations

Women with a multiple pregnancy have unique learning needs in preparing for birth. This paper explores the issues relevant to women with a multiple pregnancy to support a positive birth experience. One of the foundations of childbirth education and nursing care is to provide the individual woman and her family with knowledge regarding the birth process, what to expect, and how to cope with labor and birth. Education also focuses on caring for the newborns after birth and how to manage in the early days at home. However, traditional childbirth education classes, which meet in a series of evenings or Saturdays, may not meet the needs of women with a multiple pregnancy. In addition, because of the differences in care that exist for women with a multiple pregnancy, new paradigms for childbirth education are needed to meet the learning needs of these families. The purpose of this paper is to provide information to the childbirth educator on the differences in care women with a multiple pregnancy can expect and to suggest strategies to meet the childbirth education needs of these families.