Hypertensive Disorders in Pregnancy and Mortality at Delivery Hospitalization - United States, 2017-2019

Trimester and severity of SARS-CoV-2 infection during pregnancy and risk of hypertensive disorders in pregnancy

OBJECTIVE

SARS-CoV-2 infection during pregnancy has been linked with an increased risk of hypertensive disorders of pregnancy (HDP). The aim of this study was to examine how both trimester and severity of SARS-CoV-2 infection impact HDP.

METHODS

We conducted a cohort study of SARS-CoV-2-infected individuals during pregnancy (n = 205) and examined the association between trimester and severity of infection with incidence of HDP using modified Poisson regression models to calculate risk ratios (RR) and 95% confidence intervals (CI). We stratified the analysis of trimester by severity to understand the role of timing of infection among those with similar symptomatology and also examined timing of infection as a continuous variable.

RESULTS

Compared to a reference cohort from 2018, SARS-CoV-2 infection did not largely increase the risk of HDP (RR: 1.17; CI:0.90, 1.51), but a non-statistically significant higher risk of preeclampsia was observed (RR: 1.33; CI:0.89, 1.98), in our small sample. Among the SARS-CoV-2 cohort, severity was linked with risk of HDP, with infections requiring hospitalization increasing the risk of HDP compared to asymptomatic/mild infections. Trimester of infection was not associated with risk of HDP, but a slight decline in the risk of HDP was observed with later gestational week of infection. Among patients with asymptomatic or mild symptoms, SARS-CoV-2 in the first trimester conferred a higher risk of HDP compared to the third trimester (RR: 1.70; CI:0.77, 3.77), although estimates were imprecise.

CONCLUSION

SARS-CoV-2 infection in early pregnancy may increase the risk of HDP compared to infection later in pregnancy.

Reach and effectiveness of a non-university cardio-obstetrics program

BACKGROUND

Current guidelines recommend multidisciplinary cardiovascular obstetric programs (CVOB) to manage complex pregnant patients with cardiovascular disease. Minimal evaluation of these programs exists, with most of these programs offered at university-based centers.

METHODS

A cohort of 113 patients managed by a CVOB team at a non-university health system (2018-2019) were compared to 338 patients seen by cardiology prior to the program (2016-2017). CVOB patients were matched with comparison patients (controls) on modified World Health Organization (mWHO) category classification, yielding a cohort of 102 CVOB and 102 controls.

RESULTS

CVOB patients were more ethnically diverse and cardiovascular risk was higher compared to controls based on mWHO ≥ II-III (57% vs 17%) and. After matching, CVOB patients had more cardiology tests during pregnancy (median of 8 tests vs 5, p < .001) and were more likely to receive telemetry care (32% vs 19%, p = .025). The median number of perinatology visits was significantly higher in the CVOB group (8 vs 2, p < .001). Length of stay was a half day longer for vaginal delivery patients in the CVOB group (median 2.66 vs 2.13, p = .006).

CONCLUSION

Implementation of a CVOB program resulted in a more diverse patient population than previously referred to cardiology. The CVOB program participants also experienced a higher level of care in terms of increased cardiovascular testing, monitoring, care from specialists, and appropriate use of medications during pregnancy.

Hypertensive Disorders in Pregnancy: Differences by Hispanic Ethnicity and Black Race

OBJECTIVE

Black individuals carry the greatest burden of maternal mortality, with hypertensive disorders during pregnancy being a significant driving force to this disparity. However, research on maternal health disparities predominantly groups Hispanic Black individuals with all other individuals of Hispanic ethnicity. We hypothesized that this aggregation might obscure the risk patterns of hypertensive disorders in pregnancy for Hispanic-Black and non-Hispanic Black individuals.

METHODS

We analyzed a California statewide dataset of vital records linked to hospitalization discharge data for births from 2007 to 2018. Using multivariable logistic regression models adjusted for age, pre-pregnancy BMI, parity, smoking status, diabetes, and chronic renal disease, we compared the odds of hypertensive disorders in pregnancy between Hispanic Black, non-Hispanic Black, and non-Black Hispanic racial-ethnic groups. Hypertensive disorders were categorized into two groups: (1) any hypertensive disorder and (2) chronic hypertension alone, non-severe hypertensive disorders, and severe hypertensive disorders in pregnancy.

RESULTS

Non-Hispanic Black people had 75% increased odds of developing a hypertensive disorder during pregnancy (adjusted odds ratio (aOR); 95% confidence interval (CI): 1.74, 1.78) and Hispanic-Black individuals had a 31% increased odds (95% CI: 1.24, 1.38) as compared with non-Black Hispanic individuals. When considering hypertensive disorders separately, the race-associated differences were largest for chronic hypertension alone, with non-Hispanic Black individuals showing an aOR of 2.35 (95% CI: 2.32, 2.38) and Hispanic-Black individuals an aOR of 1.80 (95% CI: 1.66, 1.95).

CONCLUSION

Compared with non-Black Hispanic individuals, the prevalence of hypertensive disorders in pregnancy was higher in Black-Hispanic individuals and highest in non-Hispanic Black individuals. Racial/ethnic differences were larger for chronic hypertension alone than for preeclampsia.

Association of Prepregnancy Cardiometabolic Health With Hypertensive Disorders of Pregnancy Among Historically Underrepresented Groups in the United States

BACKGROUND

Prepregnancy diabetes and obesity are associated with hypertensive disorders of pregnancy (HDPs). However, the proportion of cases of HDP in the population explained by diabetes and obesity (population attributable fraction), especially among American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander, is not well characterized.

METHODS AND RESULTS

We conducted a cross-sectional analysis of data on individuals with a live singleton birth from the US National Vital Statistics System between 2016 and 2019. We used adjusted logistic regression to estimate the prevalence odds ratios of HDPs and tested interaction for race and ethnicity. We calculated the population attributable fraction for the effect of obesity and diabetes on HDPs. Among 13 201 338 birthing individuals, (mean age, 29±6 years), 7% had HDP. The prevalence of HDP was highest among American Indian and Alaska Native individuals (9.1%). Prepregnancy diabetes (prevalence odds ratio, 2.63 [95% CI, 2.59-2.67]) and obesity (prevalence odds ratio, 2.95 [95% CI, 2.93-2.97]) were associated with HDPs. Compared with non-Hispanic White individuals, the association of diabetes with HDPs was strongest among Native Hawaiian and Other Pacific Islander (prevalence odds ratio, 3.05 [95% CI, 2.48-3.77]), and the association of obesity with HDP was strongest among Asian individuals (prevalence odds ratio, 3.44 [95% CI, 3.35-3.54]; all P for interaction <0.05). Population attributable fractions for diabetes and obesity were highest among Native Hawaiian and Other Pacific Islander individuals (diabetes, 3.7% [95% CI, 3.3%-4.0%]; and obesity, 45% [95% CI, 41.9%-47.8%]).

CONCLUSIONS

Prepregnancy diabetes and obesity are associated with HDP across all racial and ethnic groups. Diabetes and obesity have highest population attributable fractions among Native Hawaiian and Other Pacific Islander individuals and should be aggressively targeted during childhood, adolescence, and young adulthood to reduce risk of HDPs.

Trends in sensor-based health metrics during and after pregnancy: descriptive data from the apple women's health study

Background

While it is known that vital signs and behaviors change during pregnancy, there is limited data on timing and scale of changes for sensor-derived health metrics across pregnancy and postpartum. Wearable technology provides an opportunity to understand physiologic and behavioral changes across pregnancy with greater detail, more frequent measurements, and improved accuracy. The aim of this study is to describe changes in physiologic and behavioral sensor-based health metrics during pregnancy and postpartum in the Apple Women's Health Study (AWHS) and their relationship to demographic factors.

Methods

The Apple Women's Health Study is a digital, longitudinal, observational study that includes U.S. residents with an iPhone and Apple Watch. We evaluated changes from pre-pregnancy through delivery and postpartum for sensor-derived health metrics. Minimum required data samples per day, week and overall were data element specific, and included 12 weeks prior to pregnancy start, and 12 weeks postpartum for pregnancies lasting between 24 and 43 weeks.

Findings

A total of 757 pregnancies from 733 participants were included. Resting heart rate (RHR) increased across pregnancy, peaking in the third trimester (pre-pregnancy median RHR 65.0 beats per minute [BPM], interquartile range [IQR] 60.0-70.2 B.M. third trimester median RHR 75.5 B.M. IQR 69.0-82.0 B.M., with a decrease prior to delivery and nadir postpartum (postpartum median RHR 62.0 B.M. IQR 57.0-66.0 B.M.. Heart rate variability (HRV) decreased from pre-pregnancy (39.9 milliseconds, IQR 32.6-48.3 milliseconds), reaching a nadir in the third trimester (29.9 milliseconds, IQR 25.2-36.4 milliseconds), before rebounding in the last weeks of pregnancy. Measures of activity, such as exercise minutes, stand minutes, step count and Cardio Fitness were all decreased in each trimester compared to pre-pregnancy, with their nadirs postpartum. Total sleep duration increased slightly in early pregnancy (pre-pregnancy 7.2 hours, IQR 6.7-7.7 hours; 1st trimester 7.4 hours, IQR 6.8-7.9 hours), with the lowest sleep duration postpartum (6.2 hours, IQR 5.4-6.8 hours).

Interpretation

Resting heart rate increased during pregnancy, with a decrease prior to delivery, while heart rate variability decreased across pregnancy, with an upward trend before delivery. Behavioral metrics, such as exercise and sleep, showed decreasing trends during and after pregnancy. These data provide a foundation for understanding normal pregnancy physiology and can facilitate hypothesis generation related to physiology, behavior, pregnancy outcomes and disease.

The simultaneous occurrence of gestational diabetes and hypertensive disorders of pregnancy affects fetal growth and neonatal morbidity

BACKGROUND

Gestational diabetes is associated with increased risk of hypertensive disorders of pregnancy, but there are limited data on fetal growth and neonatal outcomes when both conditions are present.

OBJECTIVE

We evaluated the risk of abnormal fetal growth and neonatal morbidity in pregnancies with co-occurrence of gestational diabetes and hypertensive disorders of pregnancy.

STUDY DESIGN

In a retrospective study of 47,093 singleton pregnancies, we compared the incidence of appropriate for gestational age birthweight in pregnancies affected by gestational diabetes alone, hypertensive disorders of pregnancy alone, or both gestational diabetes and hypertensive disorders of pregnancy with that in pregnancies affected by neither disorder using generalized estimating equations (covariates: maternal age, nulliparity, body mass index, insurance type, race, marital status, and prenatal care site). Secondary outcomes were large for gestational age birthweight, small for gestational age birthweight, and a neonatal morbidity composite outcome (stillbirth, hypoglycemia, hyperbilirubinemia, respiratory distress, encephalopathy, preterm delivery, neonatal death, and neonatal intensive care unit admission).

RESULTS

The median (interquartile range) birthweight percentile in pregnancies with both gestational diabetes and hypertensive disorders of pregnancy (50 [24.0-78.0]; N=179) was similar to that of unaffected pregnancies (50 [27.0-73.0]; N=35,833). However, the absolute rate of appropriate for gestational age birthweight was lower for gestational diabetes/hypertensive disorders of pregnancy co-occurrence (78.2% vs 84.9% for unaffected pregnancies). Adjusted analyses showed decreased odds of appropriate for gestational age birthweight in pregnancies with both gestational diabetes and hypertensive disorders of pregnancy compared with unaffected pregnancies (adjusted odds ratio, 0.72 [95% confidence interval, 0.52-1.00]; P=.049), and in pregnancies complicated by gestational diabetes alone (adjusted odds ratio, 0.78 [0.68-0.89]; P<.001) or hypertensive disorders of pregnancy alone (adjusted odds ratio, 0.73 [0.66-0.81]; P<.001). The absolute risk of large for gestational age birthweight was greater in pregnancies with both gestational diabetes and hypertensive disorders of pregnancy (14.5%) than in unaffected pregnancies (8.2%), without apparent difference in the risk of small for gestational age birthweight (7.3% vs 6.9%). However, in adjusted models comparing pregnancies with gestational diabetes/hypertensive disorders of pregnancy co-occurrence with unaffected pregnancies, neither an association with large for gestational age birthweight (adjusted odds ratio, 1.33 [0.88-2.00]; P=.171) nor small for gestational age birthweight (adjusted odds ratio, 1.32 [0.80-2.19]; P=.293) reached statistical significance. Gestational diabetes/hypertensive disorders of pregnancy co-occurrence carried an increased risk of neonatal morbidity that was greater than that observed with either condition alone (gestational diabetes/hypertensive disorders of pregnancy: adjusted odds ratio, 3.13 [2.35-4.17]; P<.001; gestational diabetes alone: adjusted odds ratio, 2.01 [1.78-2.27]; P<.001; hypertensive disorders of pregnancy alone: adjusted odds ratio, 1.38 [1.26-1.50]; P<.001).

CONCLUSION

Although pregnancies with both gestational diabetes and hypertensive disorders of pregnancy have a similar median birthweight percentile to those affected by neither condition, pregnancies concurrently affected by both conditions have a higher risk of abnormal fetal growth and neonatal morbidity.

Intermanufacturer assessment of diagnostic performance of angiogenic ratio vs glycosylated fibronectin in women with suspected pre-eclampsia

OBJECTIVE

To compare the diagnostic performance of different manufacturers' immunoassays for the soluble fms-like tyrosine kinase-1 (sFlt-1)-to-placental growth factor (PlGF) ratio with that of a point-of-care (PoC) test for glycosylated fibronectin (GlyFn) in women with suspected pre-eclampsia (PE).

METHODS

This was a prospective, single-center, double-blinded, non-interventional study of East Asian women with a singleton pregnancy who presented with hypertension with or without clinical features of PE after 20 weeks' gestation between January 2020 and March 2022. Maternal serum samples were collected at the time of presentation, and subsequent management followed the departmental protocol, based on gestational age, severity of hypertension, fetal condition and presence of severe PE features. Women diagnosed with PE at presentation were excluded. PE was diagnosed according to the 2018 International Society for the Study of Hypertension in Pregnancy classification. Levels of sFlt-1 and PlGF were measured using the Cobas e411 (Roche Diagnostics), BRAHMS KRYPTOR (ThermoFisher Scientific) and iMAGIN 1800 (Ningbo Aucheer) platforms. GlyFn levels were measured using the Lumella™ GlyFn PoC test (DiabetOmics Inc.). The predictive performance of each test to rule out PE within 7 days and rule in PE within 28 days from the date of presentation was assessed. Based on the PROGNOSIS study, a sFlt-1/PlGF ratio of ≤ 38 on the Roche platform was used to predict the absence of PE within 7 days. The sFlt-1/PlGF ratio was classified as high or low using platform-specific thresholds equivalent to a Roche sFlt-1/PlGF ratio of 38, which were derived using Passing-Bablok regression. GlyFn was categorized as high or low using two reported clinical management thresholds (263 μg/mL and 510 μg/mL).

RESULTS

Overall, 236 women with suspected PE were included, of whom 70 (29.7%) were diagnosed with PE; 36 (51.4%) and 70 (100%) developed PE within 7 days and 28 days, respectively. Eighty-eight (37.3%) women had a sFlt-1/PlGF ratio of > 38 on the Roche platform, 79 (33.5%) women had a sFlt-1/PlGF ratio of > 55 on the KRYPTOR platform and 96 (40.7%) women had a sFlt-1/PlGF ratio of > 40 on the iMAGIN 1800 platform. Furthermore, 62 (26.3%) and four (1.7%) women had a GlyFn level of > 263 μg/mL and > 510 μg/mL, respectively. The negative predictive value (NPV) of the sFlt-1/PlGF ratio measured on the Roche, KRYPTOR and iMAGIN 1800 platforms to rule out PE within 7 days after presentation was 83.3%, 82.0% and 82.9%, respectively, while that for GlyFn > 263 μg/mL and > 510 μg/mL was 82.6% and 70.4%, respectively. The corresponding positive predictive values (PPV) to rule in PE within 28 days after presentation were 50.5%, 52.3% and 46.7%, respectively, for the sFlt-1/PlGF ratio, and 35.4% and 50.0%, respectively, for GlyFn > 263 μg/mL and > 510 μg/mL.

CONCLUSIONS

The predictive performance of different manufacturers' assays for the sFlt-1/PlGF ratio to rule in and rule out PE were similar once standardized to a common threshold. Our findings suggest that the sFlt-1/PlGF ratio and GlyFn using a cut-off of 263 μg/mL can both be utilized to rule out PE within 7 days after assessment, with a moderate NPV. The PPV for ruling in PE within 28 days remains poor. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy Outcomes in Women Who Developed Elevated Blood Pressure and Stage I Hypertension after 20 Weeks, Gestation

OBJECTIVE

 The American College of Obstetrics threshold for hypertension (≥140/90 mm Hg) differs from those of the American College of Cardiology (ACC) and the American Heart Association (AHA). It is unknown if ACC/AHA hypertension levels are associated with adverse pregnancy outcomes (APOs) after 20 weeks gestation. The purpose of this study is to analyze APOs in women with blood pressure (BP) in the elevated or stage 1 range after 20 weeks gestation.

STUDY DESIGN

 This was a secondary analysis of the nuMoM2b prospective cohort study of 10,038 nulliparous, singleton pregnancies between 2010 and 2014. BP was measured at three visits during the pregnancy using a standard protocol. Women without medical comorbidities, with normal BP by ACC/AHA guidelines (systolic BP [SBP] < 120 and diastolic BP [DBP] < 80 mm Hg) up to 22 weeks, were included. Exposure was BP between 22 and 29 weeks gestation: normal (SBP < 120 and DBP < 80 mm Hg), elevated (SBP: 120-129 and DBP < 80 mm Hg), and stage 1 (SBP: 130-139 or DBP: 80-89 mm Hg). The primary outcome was hypertensive disorder of pregnancy (HDP) at delivery. Secondary outcomes included fetal growth restriction (FGR), placental abruption, preterm delivery, and cesarean delivery. Multivariable-adjusted odds ratio (aORs) and 95% confidence intervals (CIs) were estimated using logistic regression models.

RESULTS

 Of 4,460 patients that met inclusion criteria, 3,832 (85.9%) had BP in the normal range, 408 (9.1%) in elevated, and 220 (4.9%) in stage 1 range between 22 and 29 weeks. The likelihood of HDP was significantly higher in women with elevated BP (aOR: 1.71, 95%CI: 1.18,2.48), and stage 1 BP (aOR: 2.79, 95%CI: 1.84,4.23) compared to normal BP (p < 0.001). Stage 1 BP had twice odds of FGR (aOR: 2.33, 95%CI: 1.22,4.47) and elevated BP had three times odds of placental abruption (aOR: 3.03; 95%CI: 1.24,7.39).

CONCLUSION

 Elevated or stage 1 BP >20 weeks of pregnancy are associated with HDP, FGR, and placental abruption.

KEY POINTS

· Elevated and stage 1 BP increases risk for HDP.. · Elevated BP increases risk for placental abruption.. · Stage 1 BP increases risk for FGR..

Risk of Postpartum Hemorrhage in Hypertensive Disorders of Pregnancy: Stratified by Severity

OBJECTIVE

 We aimed to determine the composite maternal hemorrhagic outcome (CMHO) among individuals with and without hypertensive disorders of pregnancy (HDP), stratified by disease severity. Additionally, we investigated the composite neonatal adverse outcome (CNAO) among individuals with HDP who had postpartum hemorrhage (PPH) versus did not have PPH.

STUDY DESIGN

 Our retrospective cohort study included all singletons who delivered at a Level IV center over two consecutive years. The primary outcome was the rate of CMHO, defined as blood loss ≥1,000 mL, use of uterotonics, mechanical tamponade, surgical techniques for atony, transfusion, venous thromboembolism, intensive care unit admission, hysterectomy, or maternal death. A subgroup analysis was performed to investigate the primary outcome stratified by (1) chronic hypertension, (2) gestational hypertension and preeclampsia without severe features, and (3) preeclampsia with severe features. A multivariable regression analysis was performed to investigate the association of HDP with and without PPH on a CNAO which included APGAR <7 at 5 minutes, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, seizures, neonatal sepsis, meconium aspiration syndrome, ventilation >6 hours, hypoxic-ischemic encephalopathy, or neonatal death.

RESULTS

 Of 8,357 singletons, 2,827 (34%) had HDP. Preterm delivery <37 weeks, induction of labor, prolonged oxytocin use, and magnesium sulfate usage were more common in those with versus without HDP (p < 0.001). CMHO was higher among individuals with HDP than those without HDP (26 vs. 19%; adjusted relative risk [aRR] = 1.11, 95% CI: 1.01-1.22). In the subgroup analysis, only individuals with preeclampsia with severe features were associated with higher CMHO (n = 802; aRR = 1.52, 95% CI: 1.32-1.75). There was a higher likelihood of CNAO in individuals with both HDP and PPH compared to those with HDP without PPH (aRR = 1.49, 95% CI: 1.06-2.09).

CONCLUSION

 CMHO was higher among those with HDP. After stratification, only those with preeclampsia with severe features had an increased risk of CMHO. Among individuals with HDP, those who also had a PPH had worse neonatal outcomes than those without hemorrhage.

KEY POINTS

· Individuals with HDP had an 11% higher likelihood of CMHO.. · After stratification, increased CMHO was limited to those with preeclampsia with severe features.. · There was a higher likelihood of CNAO in those with both HDP and PPH compared to HDP without PPH..

Investigation of usage of antenatal care services by Syrian immigrant pregnant women and the frequency of anaemia and hypertension during the pandemic

During the pandemic period, the use of health services by disadvantaged groups such as immigrants has deteriorated. The study aims to evaluate the use of antenatal care services by Syrian pregnant women during the pandemic. It is a cross-sectional type of study. The population consisted of 495 pregnant women who applied to the Extended Migrant Health Center (EMHC) between August 2020 and December 2022. Demographic data and pregnancy-related health records were examined through the system records, without any contact with the pregnant women. The percentage of pregnant women who had timely follow-up for each antenatal visit were 11.5% (n=56), 17.2% (n=80), 20.0% (n=88), and 17.4% (n=73), respectively. Only 17.7% (n=87) of the pregnant women made the recommended number of visits during their pregnancy period. The recommended number of follow-ups was statistically significantly higher in women with high-risk pregnancies (p=0.045). Of the pregnant women, 27.4% had anaemia and 2.4% had hypertension. The use of antenatal care in immigrant pregnant women is very low. Interventions are needed in this regard. Increasing the utilization of antenatal care services by immigrant pregnant women is extremely important for both the health of the pregnant woman and the health of the baby.

H2S donor GYY4137 mitigates sFlt-1-induced hypertension and vascular dysfunction in pregnant rats†

Gestational hypertension, often associated with elevated soluble Fms-related receptor tyrosine kinase 1 (sFlt-1), poses significant risks to both maternal and fetal health. Hydrogen sulfide (H2S), a gasotransmitter, has demonstrated blood pressure-lowering effects in hypertensive animals and humans. However, its role in pregnancy-induced hypertension remains unclear. This study investigated the impact of GYY4137, a slow-release H2S donor, on sFlt-1-induced hypertension in pregnant rats . Pregnant rats were administered sFlt-1 (6 μg/kg/day, intravenously) or vehicle from gestation day (GD) 12-20. A subset of these groups received GYY4137 ( 50 mg/kg/day, intraperitoneal) from GD 16-20. Serum H2S levels, mean arterial blood pressure, uterine artery blood flow, and vascular reactivity were assessed. Elevated sFlt-1 reduced both maternal weight gain and serum H2S levels. GYY4137 treatment restored both weight gain and H2S levels in sFlt-1 dams. sFlt-1 increased mean arterial pressure and decreased uterine artery blood flow in pregnant rats. However, treatment with GYY4137 normalized blood pressure and restored uterine blood flow in sFlt-1 dams. sFlt-1 dams exhibited heightened vasoconstriction to phenylephrine and GYY4137 significantly mitigated the exaggerated vascular contraction. Notably, sFlt-1 impaired endothelium-dependent relaxation, while GYY4137 attenuated this impairment by upregulating eNOS protein levels and enhancing vasorelaxation in uterine arteries. GYY4137 mitigated sFlt-1-induced fetal growth restriction. In conclusion, sFlt-1 mediated hypertension is associated with decreased H2S levels. Replenishing H2S with the donor GYY4137 mitigates hypertension and improves vascular function and fetal growth outcomes. This suggests modulation of H2S could offer a novel therapeutic strategy for managing gestational hypertension and adverse fetal effects.

Does Timing of Diagnosis of Hypertensive Disorders of Pregnancy Impact Blood Pressure Resolution?

OBJECTIVE

 Hypertensive disorders of pregnancy (HDP) can be diagnosed prior to labor, during labor, or postpartum. We evaluated whether the timing of HDP diagnosis impacts postpartum blood pressure (BP) outcomes.

STUDY DESIGN

 Secondary analysis of 384 patients with HDP from a trial evaluating furosemide use on BP outcomes. The timing of HDP diagnosis was categorized into diagnosis in the antepartum period, prior to labor versus diagnosis peripartum (during labor or first day of postpartum). Outcomes included time to resolution of hypertension and persistent hypertension 7 days' postpartum. Logistic and Cox regression models were used.

RESULTS

 Patients diagnosed in the peripartum period had a shorter median time to postpartum BP resolution after adjusting for severity of HDP, mode of delivery, and furosemide use (5.5 vs. 6.5 days, adjusted hazard ratio: 1.18, 95% confidence interval [1.11-1.25]).

CONCLUSION

 Patients diagnosed with HDP in the peripartum period experience a faster BP resolution than those diagnosed in the antepartum period.

KEY POINTS

· HDP can be diagnosed before and during labor and postpartum.. · The timing of HDP diagnosis may have different implications for postpartum BP outcomes.. · Patients diagnosed with HDP in the peripartum period experienced a 24-hour shorter time to BP resolution.. · Timing of HDP diagnosis may provide an added window of opportunity to augment existing modalities of managing postpartum hypertension and related cardiovascular disease complications..

Protocol for a randomized controlled trial comparing phone-based prenatal mindfulness training to usual care for pregnant people at risk for hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are the most common medical conditions in pregnancy and a leading cause of maternal morbidity and mortality in the United States. There are few interventions available to prevent HDP, and those currently available do not target underlying mechanisms of disease. Mindfulness training (MT) is effective at reducing blood pressure in non-pregnant patients with pre-hypertension and hypertension and has proven more effective at blood pressure reduction than other stress management interventions. MT thus holds great promise as a mind-body intervention to prevent HDP. This randomized trial will harness subjective and objective ecological momentary assessment methodology combined with wearable biosensor technology to capture psychological, physiological, and interpersonal processes through which MT may lead to improved maternal cardiovascular parameters. Pregnant women at risk for HDP will be randomized to an 8-week phone-delivered MT intervention or usual care. Through these methods, we will evaluate psychological, physiological, and interpersonal responses to daily experiences linking MT to cardiovascular parameters among women at risk for HDP.

Public health and system approach in eliminating disparities in hypertensive disorders and cardiovascular outcomes in non-Hispanic Black women across the pregnancy life course

Hypertension is one of the leading risk factors for cardiovascular disease. The ACC/AHA/Multisociety hypertension guideline covered all aspects of the recommendations for optimal blood pressure diagnosis and management to improve cardiovascular outcomes. Despite this, there remains a growing prevalence of hypertension within the United States, largely in non-Hispanic Black women at earlier stages of their life course. This highlights the evident racial disparities, but offers a targeted opportunity for improved outcomes. With hypertension increasingly seen in the antenatal and immediate postpartum period, and obstetrics societies weighing in on the need to alter pharmacotherapy initiation goals, national initiatives have purposefully targeted pregnant and postpartum women in an effort to improve outcomes. This same energy must also re-focus health care efforts across the entire health continuum. Public health and system strategies are in place to do so, with the strongest enforcing initiatives as early as childhood with a greater focus on primordial prevention.

Automated image transcription for perinatal blood pressure monitoring using mobile health technology

This paper introduces a novel approach to address the challenges associated with transferring blood pressure (BP) data obtained from oscillometric devices used in self-measured BP monitoring systems to integrate this data into medical health records or a proxy database accessible by clinicians, particularly in low literacy populations. To this end, we developed an automated image transcription technique to effectively transcribe readings from BP devices, ultimately enhancing the accessibility and usability of BP data for monitoring and managing BP during pregnancy and the postpartum period, particularly in low-resource settings and low-literate populations. In the designed study, the photos of the BP devices were captured as part of perinatal mobile health (mHealth) monitoring programs, conducted in four studies across two countries. The Guatemala Set 1 and Guatemala Set 2 datasets include the data captured by a cohort of 49 lay midwives from 1697 and 584 pregnant women carrying singletons in the second and third trimesters in rural Guatemala during routine screening. Additionally, we designed an mHealth system in Georgia for postpartum women to monitor and report their BP at home with 23 and 49 African American participants contributing to the Georgia I3 and Georgia IMPROVE projects, respectively. We developed a deep learning-based model which operates in two steps: LCD localization using the You Only Look Once (YOLO) object detection model and digit recognition using a convolutional neural network-based model capable of recognizing multiple digits. We applied color correction and thresholding techniques to minimize the impact of reflection and artifacts. Three experiments were conducted based on the devices used for training the digit recognition model. Overall, our results demonstrate that the device-specific model with transfer learning and the device independent model outperformed the device-specific model without transfer learning. The mean absolute error (MAE) of image transcription on held-out test datasets using the device-independent digit recognition were 1.2 and 0.8 mmHg for systolic and diastolic BP in the Georgia IMPROVE and 0.9 and 0.5 mmHg in Guatemala Set 2 datasets. The MAE, far below the FDA recommendation of 5 mmHg, makes the proposed automatic image transcription model suitable for general use when used with appropriate low-error BP devices.

Types and timing of trauma exposure across the life course and maternal hypertension

BACKGROUND

Exposure to trauma across the life course may be associated with cardio-metabolic dysfunction during pregnancy; however, previous research has been inconsistent, particularly in highly exposed populations.

OBJECTIVES

To estimate associations between types and timing (first occurrence) of trauma exposure and hypertension experienced during pregnancy in a safety-net hospital in Atlanta, Georgia, 2011-2022.

METHODS

Participants completed a 14-item trauma screener. We linked that information to data from the medical record on hypertension (including chronic hypertension, gestational hypertension or preeclampsia). We fit logistic regression models and used the estimates to calculate risk ratios for each trauma type and each critical window (0-9 years, 10-19 and 20+). We fit unadjusted models and adjusted for age, parity and education.

RESULTS

We included 704 individuals with a delivery within 12 months following screening. The majority (94%, 661) reported at least one traumatic event, most commonly witnessing violence (79.4%). Overall, 18% experienced gestational hypertension, 10.8% chronic hypertension and 11.9% preeclampsia. Among individuals who reported trauma, 31.5% screened positive for probable posttraumatic stress disorder and 30.9% for probable depression, compared to 0 and 2.3% among those without reported trauma. No trauma type (violence, witnessing violence, non-interpersonal or sexual assault) was associated with increased hypertensive risk, regardless of timing.

CONCLUSIONS

In this sample with a high trauma and hypertension burden, trauma was not associated with an elevated risk of hypertension during pregnancy, despite a high burden of PTSD and depressive symptoms among people with trauma exposure.

Hypertensive Disorders of Pregnancy: A Window into Breastfeeding Outcomes in Varied Healthcare Systems

Varied hospital systems demonstrate diverse and often very different approaches to patient care. This may best be analyzed by looking at specific disorders and outcomes in a population with these disorders. As one such lens, hypertensive disorders of pregnancy (HDPs) continue to pose a severe health risk for mothers and infants, and breastfeeding outcomes play a crucial role in determining long-term maternal and fetal health. This pilot study investigated breastfeeding outcomes in two hospitals, as representatives for differing healthcare systems, among patients diagnosed with HDPs. Data were collected for 12 months at two hospitals, one private and one military, on 729 patients diagnosed with HDPs. Data were analyzed for infant maturity at birth and breastfeeding outcomes. Most participants (83.2%) stated their intention to breastfeed for the first six months of life. By hospital discharge, only 56% (p = 0.0001) of the private hospital participants were breastfeeding compared to 65% of the military hospital participants. In addition, while 69% of infants were born before term, more infants were born before term at the private hospital (71%) than at the military hospital (65%), with 37% (private) and 42% (military) of preterm infants breastfeeding at hospital discharge. Significant differences existed between these two hospital systems in the number of those initiating breastfeeding and breastfeeding at hospital discharge. The military hospital was more successful in assisting these high-risk women in meeting their breastfeeding intentions. Changes in hospital practices, such as metrics and incentivization, focusing on breastfeeding support, could improve the rate of breastfeeding at hospital discharge and impact long-term health outcomes.

Impact of Patient Safety Bundle and Team-Based Training on Obstetric Hypertensive Emergencies

OBJECTIVE

 Hypertensive disorders of pregnancy, defined as chronic (<20 weeks) or gestational (>20 weeks), are a leading cause of pregnancy-related mortality in the United States. Hypertensive disorders of pregnancy had increased prevalence from 13.3 to 15.9% among delivery hospitalizations between 2017 and 2019. The objective of this project was to increase the percentage of obstetric patients with hypertensive emergency who received evidence-based treatment within 60 minutes at a single academic center.

STUDY DESIGN

 Data were collected before and after the implementation of a hypertension patient safety bundle. Each occurrence of hypertensive emergency was assessed to determine if evidence-based intervention occurred within 60 minutes, and if the intervention steps were successfully followed. Bundle implementation included creation of a standardized order set and interdisciplinary team-based simulations. Baseline data compared 250 preimplementation to 250 postimplementation interventions. The quality improvement interdisciplinary team reevaluated data monthly and incorporated process improvements through Plan-Do-Study-Act (PDSA) cycles to achieve a goal of 80% of patients receiving evidence-based treatment within 60 minutes.

RESULTS

 A total of 1,025 hypertensive emergencies were identified in 543 patients. Prior to the protocol on average 64% of patients received evidence-based, timely treatment. After implementation of this bundle and several PDSA cycles, we sustained >80% of patients receiving target treatment for the final 6 months of data collection. The leading deviations were "no medication given" and "incorrect medication." Improvements in order set accessibility and repeated team-based trainings led to improvement in these identified protocol deviations.

CONCLUSION

 Implementation of a patient safety bundle led to a sustained 6-month improvement in the percentage of patients receiving appropriate treatment of obstetric hypertensive emergency within 60 minutes of the first severe hypertension measurement. Processes that may have helped achieve this outcome included standardized order sets, team awareness of institutional data, and team-based simulations.

KEY POINTS

· Hypertensive emergency treatment improved with patient safety bundle.. · Training and order sets improved adherence to hypertensive emergency patient safety bundle.. · Regular data review necessary for sustainability of hypertensive emergency patient safety bundle..

Lived experience of hypertensive disorders of pregnancy: a systematic review and meta-synthesis

BACKGROUND

Hypertensive disorders are major causes of maternal and neonatal morbidity and mortality, affecting ∼10% pregnancies worldwide.

OBJECTIVE

Understanding the lived experience of women with hypertensive disorders during pregnancy is important to inform best practice and provide holistic care.

STUDY DESIGN

This is a systematic review and meta-synthesis of studies containing qualitative components relating to direct lived experience of hypertensive disorders of pregnancy. Medline via Ovid, Embase via Ovid, CINAHL via Ebsco, PsycINFO via Ebsco, Scopus, Web of Science Core Collection, and ASSIA via ProQuest were searched between database inception and June 2024. Quality assessment was performed using the Critical Appraisal Skills Programme checklist for qualitative research. Themes were labeled and organized into a framework using NVivo software.

RESULTS

Eighteen studies were included in the meta-synthesis. Anxiety, stress, fear and panic emerged as the most common emotional experiences during hypertensive disorders of pregnancy. Loss of control was also mentioned frequently and consistently across studies (frequency effect size 38.9% and intensity effect size 15.3%). Emotional responses to physical symptoms or lack thereof, and feelings about the impact of the complicated pregnancy on family and community also emerged as central themes associated with hypertensive disorders of pregnancy.

CONCLUSION

A range of emotional experiences was captured across the studies included in our meta-synthesis, some of which were observed across global settings whereas others were context-dependent. Interventions and care pathways for pregnancies affected by hypertensive disorders should aim to support women through complex emotional experiences as well as reducing morbidity and mortality.

Trends in the Incidence of Hypertensive Disorders of Pregnancy Among the Medicaid Population before and During COVID-19

Importance

Hypertensive disorders of pregnancy (HDP) are a group of high blood pressure disorders during pregnancy that are a leading cause of maternal and infant morbidity and mortality. Data on the trend in the incidence of HDP among the Medicaid population during coronavirus disease of 2019 (COVID-19) are lacking.

Objective

To determine the trends in the annual incidence of HDP among pregnant Medicaid-insured women in Louisiana before and during the COVID-19 pandemic (2016-2021).

Methods

A total of 113,776 pregnant women aged 15-50 years were included in this study. For multiparous individuals, only the first pregnancy was used in the analyses. Women with a diagnosis of each type-specific HDP were identified by using the International Classification of Diseases, 10th revision (ICD-10) codes. The annual incidence of HDP was calculated for each race and age subgroup. For each type-specific HDP, the annual age-specific incidence was calculated.

Results

The incidence of HDP increased from 10.5% in 2016 to 17.7% in 2021. The highest race/ethnicity-specific incidence of HDP was seen in African American women (19.2%), then White women (13.1%), followed by other women (10.7%).

Conclusion and Relevance

HDP remains a very prevalent and significant global health issue, especially in African American women and during the COVID-19 pandemic. Severe HDP substantially increases the risk of mortality in offspring and poses long-term issues for both mother and infant. HDP prevention holds particular relevance for the Medicaid population, given the health care disparities and barriers that impact quality of care, leading to an increased risk for HDP.

Update on Preeclampsia and Hypertensive Disorders of Pregnancy

There have been recent advances in the prevention, diagnosis, and management of hypertensive disorders of pregnancy which complicate approximately 16% of pregnancies in the United States. Initiation of low-dose aspirin by 16 weeks' gestation reduces preeclampsia in high-risk women. The Food and Drug Administration approved the use of the soluble fms-like tyrosine kinase 1/placental growth factor ratio for the short-term prediction of preeclampsia. Pregnancy outcomes are improved in women with chronic hypertension when antihypertensives are initiated at a threshold blood pressure of 140/90 mm Hg. Women with prior preeclampsia have increased cardiovascular disease risk and should receive risk reduction counseling.

Remote blood pressure management for postpartum hypertension: a cost-effectiveness analysis

BACKGROUND

Recognizing the importance of close follow-up after hypertensive disorders of pregnancy, many centers have initiated programs to support postpartum remote blood pressure management.

OBJECTIVE

This study aimed to evaluate the cost-effectiveness of remote blood pressure management to determine the scalability of these programmatic interventions.

STUDY DESIGN

This was a cost-effectiveness analysis of using remote blood pressure management vs usual care to manage postpartum hypertension. The modeled remote blood pressure management included provision of a home blood pressure monitor, guidance on warning symptoms, instructions on blood pressure self-monitoring twice daily, and clinical staff to manage population-level blood pressures as appropriate. Usual care was defined as guidance on warning symptoms and recommendations for 1 outpatient visit for blood pressure monitoring within a week after discharge. This study designed a Markov model that ran over fourteen 1-day cycles to reflect the initial 2 weeks after delivery when most emergency department visits and readmissions occur and remote blood pressure management is clinically anticipated to be most impactful. Parameter values for the base-case scenario were derived from both internal data and literature review. Quality-adjusted life-years were calculated over the first year after delivery and reflected the short-term morbidities associated with hypertensive disorders of pregnancy that, for most birthing people, resolve by 2 weeks after delivery. Sensitivity analyses were performed to assess the strength and validity of the model. The primary outcome was the incremental cost-effectiveness ratio, which was defined as the cost needed to gain 1 quality-adjusted life-year. The secondary outcome was incremental cost per readmission averted. Analyses were performed from a societal perspective.

RESULTS

In the base-case scenario, remote blood pressure management was the dominant strategy (ie, cost less, higher quality-adjusted life-years). In univariate sensitivity analyses, the most cost-effective strategy shifted to usual care when the cost of readmission fell below $2987.92 and the rate of reported severe range blood pressure with a response in remote blood pressure management was <1%. Assuming a willingness to pay of $100,000 per quality-adjusted life-year, using remote blood pressure management was cost-effective in 99.28% of simulations in a Monte Carlo analysis. Using readmissions averted as a secondary effectiveness outcome, the incremental cost per readmission averted was $145.00.

CONCLUSION

Remote blood pressure management for postpartum hypertension is cost saving and has better outcomes than usual care. Our data can be used to inform future dissemination of and support funding for remote blood pressure management programs.

Bone development in fetuses with intrauterine growth restriction caused by maternal endocrine-metabolic dysfunctions

Intrauterine growth restriction (IUGR) affects a large proportion of infants, particularly in underdeveloped countries. Among the main causes of IUGR, maternal endocrine-metabolic dysfunction is highlighted, either due to its high incidence or due to the severity of the immediate and mediated changes that these dysfunctions cause in the fetus and the mother. Although the effects of endocrine and metabolic disorders have been widely researched, there are still no reviews that bring together and summarize the effects of these conditions on bone development in cases of IUGR. Therefore, the present literature review was conducted with the aim of discussing bone changes observed in fetuses with IUGR caused by maternal endocrine-metabolic dysfunction. The main endocrine dysfunctions that occur with IUGR include maternal hyperthyroidism, hypothyroidism, and hypoparathyroidism. Diabetes mellitus, hypertensive disorders, and obesity are the most important maternal metabolic dysfunctions that compromise fetal growth. The bone changes reported in the fetus are, for the most part, due to damage to cell proliferation and differentiation, as well as failures in the synthesis and mineralization of the extracellular matrix, which results in shortening and fragility of the bones. Some maternal dysfunctions, such as hyperthyroidism, have been widely studied, whereas conditions such as hypoparathyroidism and gestational hypertensive disorders require further study regarding the mechanisms underlying the development of bone changes. Similarly, there is a gap in the literature regarding changes related to intramembranous ossification, as most published articles only describe changes in endochondral bone formation associated with IUGR. Furthermore, there is a need for more research aimed at elucidating the late postnatal changes that occur in the skeletons of individuals affected by IUGR and their possible relationships with adult diseases, such as osteoarthritis and osteoporosis.

Per- and polyfluoroalkyl substances (PFAS) and hypertensive disorders of Pregnancy- integration of epidemiological and mechanistic evidence

BACKGROUND

Hypertensive disorders of pregnancy (HDP) remain a significant global health burden despite medical advancements. HDP prevalence appears to be rising, leading to increased maternal and fetal complications, mortality, and substantial healthcare costs. The etiology of HDP are complex and multifaceted, influenced by factors like nutrition, obesity, stress, metabolic disorders, and genetics. Emerging evidence suggests environmental pollutants, particularly Per- and polyfluoroalkyl substances (PFAS), may contribute to HDP development.

OBJECTIVE

This review integrates epidemiological and mechanistic data to explore the intricate relationship between PFAS exposure and HDP.

EPIDEMIOLOGICAL EVIDENCE

Studies show varying degrees of association between PFAS exposure and HDP, with some demonstrating positive correlations, particularly with preeclampsia. Meta-analyses suggest potential fetal sex-specific differences in these associations.

MECHANISTIC INSIGHTS

Mechanistically, PFAS exposure appears to disrupt vascular hemodynamics, placental development, and critical processes like angiogenesis and sex steroid regulation. Experimental studies reveal alterations in the renin-angiotensin system, trophoblast invasion, oxidative stress, inflammation, and hormonal dysregulation - all of which contribute to HDP pathogenesis. Elucidating these mechanisms is crucial for developing preventive strategies.

THERAPEUTIC POTENTIAL

Targeted interventions such as AT2R agonists, caspase inhibitors, and modulation of specific microRNAs show promise in mitigating adverse outcomes associated with PFAS exposure during pregnancy.

KNOWLEDGE GAPS AND FUTURE DIRECTIONS

Further research is needed to comprehensively understand the full spectrum of PFAS-induced placental alterations and their long-term implications for maternal and fetal health. This knowledge will be instrumental in developing effective preventive and therapeutic strategies for HDP in a changing environmental landscape.

Severe Hypertension in Pregnancy: Progress Made and Future Directions for Patient Safety, Quality Improvement, and Implementation of a Patient Safety Bundle

Hypertensive disorders of pregnancy account for approximately 5% of pregnancy-related deaths in the United States and are one of the leading causes of maternal morbidity. Focus on improving patient outcomes in the setting of hypertensive disorders of pregnancy has increased in recent years, and quality improvement initiatives have been implemented across the United States. This paper discusses patient safety and quality initiatives for hypertensive disorders of pregnancy, with an emphasis on progress made and a patient safety tool: the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Future patient safety and quality directions for the treatment of hypertensive disorders of pregnancy will be reviewed.

Diagnosis and Treatment of Eclampsia

Hypertensive disorders of pregnancy affect approximately 5% to 10% of pregnant women. Eclampsia is a serious hypertensive disorder that is primarily characterized by the onset of grand mal seizure activity in the absence of other causative conditions. While eclampsia is diagnosed clinically, laboratory tests are recommended to assess for complications. Treatment strategies for eclampsia focus on controlling seizures and managing hypertension. Acute care during a seizure is critical because of the need for immediate medical interventions, including the management of the airway, breathing, and circulation, as well as ensuring the safety of the patient during convulsions. Magnesium sulfate is the preferred anticonvulsant drug. Care must be taken during administration to prevent magnesium toxicity. Antihypertensive drugs used in eclampsia include labetalol, hydralazine and nifedipine. The definitive treatment of eclampsia is delivery. Close monitoring of both mother and fetus is important to identify any indications for delivery. The timing and mode of delivery depend on obstetric indications, the severity of eclampsia, the gestational age of the fetus, and the overall clinical status of the patient. Neuraxial anesthesia is the anesthesia of choice for conscious, seizure-free, and with stable vital signs women undergoing cesarean section.

Antihypertensive medication prescription dispensation among pregnant women in the United States: A cohort study

IMPORTANCE

Hypertension is increasingly common in pregnancy capable individuals, yet there is limited data on antihypertensive medication dispensation in peripartum individuals.

OBJECTIVE

To describe antihypertensive medication dispensation from preconception through the first year postpartum.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Truven Health Market Scan administrative data from 2008 to 2014 to identify women in the United States with commercial or government health insurance, aged 15-54, free from heart disease, who experienced a pregnancy and filled at least 1 prescription for an antihypertensive medication between 3 months prior to conception and 12 months after the end of the pregnancy.

MAIN OUTCOMES AND MEASURES

We describe antihypertensive dispensation patterns (continuation, initiation, and discontinuation) by medication class during 5 time periods: preconception, first, second, and third trimesters, and the first year postpartum.

RESULTS

Of 1,058,521 pregnancies, 108,614 (10.3%) were exposed to at least 1 antihypertensive medication dispensation. The most commonly dispensed medications across all periods combined were adrenergic blockers, calcium channel blockers (CCBs), and diuretics. Renin-angiotensin-aldosterone system (RAAS) inhibitors were the third most dispensed medication class in the preconception period (26.4%), and fills decreased to 5.7% and 1.7% in the second and third trimesters, respectively. Of the women with chronic hypertension who filled at least 1 prescription prior to conception, 8.4% were not dispensed an antihypertensive medication during the first year after delivery.

CONCLUSIONS AND RELEVANCE

Antihypertensive prescription dispensation of both preferred and potentially harmful agents is common in pregnancy capable individuals. Patterns of dispensation suggest room for improvement in the treatment of chronic hypertension after a pregnancy.

Association of Race and Ethnicity and Social Factors With Postpartum Primary Care or Cardiology Follow-Up Visits Among Individuals With Preeclampsia

BACKGROUND

Preeclampsia is associated with increased cardiovascular morbidity and death. Primary care or cardiology follow-up, in complement to routine postpartum obstetric care, provides an essential opportunity to address cardiovascular risk. Prior studies investigating racial differences in the recommended postpartum follow-up have incompletely assessed the influence of social factors. We hypothesized that racial and ethnic differences in follow-up with a primary care provider or cardiologist would be modified by income and education.

METHODS AND RESULTS

We identified adult individuals with preeclampsia (September 2014 to September 2019) in a national administrative database. We compared occurrence of a postpartum visit with a primary care provider or cardiologist within 1 year after delivery by race and ethnicity using multivariable logistic regression models. We examined whether education or income modified the association between race and ethnicity and the likelihood of follow-up. Of 18 050 individuals with preeclampsia (aged 31.8±5.7 years), Black individuals (11.7%) had lower odds of primary care provider or cardiology follow-up within 1 year after delivery compared with White individuals (adjusted odds ratio, 0.77 [95% CI, 0.70-0.85]) as did Hispanic individuals (14.8%; adjusted odds ratio, 0.79 [95% CI, 0.73-0.87]). Black and Hispanic individuals with higher educational attainment were more likely to have follow-up than those with lower educational attainment (P for interaction=0.033) as did those in higher income brackets (P for interaction=0.006).

CONCLUSIONS

We identified racial and ethnic differences in primary care or cardiology follow-up in the year postpartum among individuals diagnosed with preeclampsia, a disparity that may be modified by social factors. Enhanced system-level interventions are needed to reduce barriers to follow-up care.

Approach to Altered Mental Status in Pregnancy and Postpartum

The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.

Cardiometabolic Risk Factors Associated with Magnesium and Vitamin D Nutrients during Pregnancy-A Narrative Review

This narrative review comprehensively explores the cardiometabolic implications of two vital nutrients, magnesium and vitamin D, during gestation. Magnesium, a key regulator of vascular tone, glucose metabolism, and insulin sensitivity, plays a crucial role in mitigating gestational hypertension and diabetes, a point this review underscores. Conversely, vitamin D, critical for immune response and calcium level maintenance, is linked to gestational diabetes and hypertensive disorders of pregnancy. The authors aim to enhance comprehension of the complex interaction between these nutrients and cardiometabolic function in pregnancy, knowledge that is pivotal for optimizing maternal-fetal outcomes. The mother's health during pregnancy significantly influences the long-term development of the fetus. Recognizing the impact of these nutrient deficiencies on the physiology of cardiometabolic cycles underscores the importance of adequate nutritional support during pregnancy. It also emphasizes the pressing need for future research and targeted interventions to alleviate the burden of pregnancy complications, highlighting the crucial role of healthcare professionals, researchers, and policy makers in obstetrics and gynecology in this endeavor.

Elevated Cardiovascular Biomarkers Following Hypertensive Disorder of Pregnancy

Hypertensive disorder of pregnancy (HDP) is associated with an increased risk for later-life cardiovascular disease (CVD). Whether the HDP pregnancy itself confers risk towards CVD later in life is suggested in several epidemiologic studies. Given this connection and that the HDP exposure itself may play a role, understanding whether markers associated with cardiovascular risk vary based on HDP history in the years following pregnancy may assist with risk stratification and development of targeted interventions. We measured 77 proteins (CVD-associated and inflammatory markers) in n=22 individuals with a history of HDP and n=43 matched controls with no HDP history at a median of 4 years after pregnancy. Several CVD-associated proteins (fibrinogen, fetuin-A, L-selectin, and alpha-1-acid glycoprotein) were significantly elevated, by orders of magnitude, in individuals with a history of HDP compared to normotensive pregnancies (all p<0.0001). In multivariable linear regression models controlling for age, body mass index, chronic hypertension, and diabetes, a history of HDP remained associated with higher levels of CVD-associated proteins (all p<0.0001). We clustered samples based on global patterns of CVD protein expression and found a significant difference in CVD protein expression patterns between post-Normal and post-HDP samples. Conversely, differences in circulating inflammatory markers were largely insignificant or more subtle than that observed with the CVD-associated proteins. Identification of biomarkers associated with CVD in the intervening years after HDP but before evident CVD is critical to understanding post-HDP cardiovascular risk to provide insight for the development of therapeutic interventions that mitigate CVD event risk in this high-risk population.

Maternal Smoking and Risk of Hypertensive Disorders of Pregnancy: Effect Modification by Body Mass Index and Gestational Weight Gain

BACKGROUND

Although smoking cigarettes has been shown to have a protective effect on preeclampsia, quitting smoking also results in weight gain. Weight gain leading to an obese body mass index is a risk factor for hypertensive disorders of pregnancy (HDP).

METHODS

The objective of this study was to explore the relationship between smoking status, body mass index, and gestational weight gain on the risk of HDP. A cross-sectional analysis was performed utilizing US birth certificate data. We examined HDP risks in relation to maternal smoking, body mass index, and gestational weight gain. Associations were expressed as rate ratios with 95% CIs and adjusted for potential confounders. Clinically important outcomes of smoking throughout pregnancy were also evaluated.

RESULTS

Of the 22 191 568 women studied, HDP rates among nonsmokers, those who quit smoking, and persistent smokers were 6.8%, 8.6%, and 7.0%, respectively. The rate ratio of HDP was higher for women who quit smoking, especially evident among those with excessive gestational weight gain. Corrections for exposure misclassification and unmeasured confounding strengthened the associations among women who quit smoking. There was an almost 6-fold increase in the rate of stillbirth for persistent smokers (2.3%) compared with those who quit smoking (0.4%) and nonsmokers (0.4%).

CONCLUSIONS

Women who quit smoking during pregnancy were more likely to gain excessive weight and develop HDP. Although quitting smoking during pregnancy may be associated with an increase in the risk of HDP, it is also associated with a reduced risk of stillbirth. Pregnant women counseled to quit smoking should also receive counseling on nutrition and exercise to prevent excessive gestational weight gain.

First trimester prenatal metal mixtures, vitamins, and hypertensive disorders of pregnancy in the project viva cohort

BACKGROUND

Hypertensive disorders of pregnancy (HDP) such as preeclampsia and gestational hypertension are major contributors to maternal and child morbidity and mortality. Previous studies have reported associations with selected metals and vitamins but are limited in sample size and non-prospective study designs. We evaluated prospective associations of metal mixtures with HDP and tested interactions by vitamins.

STUDY DESIGN

We measured first trimester (median = 10.1 weeks) concentrations of essential (copper, magnesium, manganese, selenium, zinc) and nonessential (arsenic, barium, cadmium, cesium, mercury, lead) metals in red blood cells (n = 1,386) and vitamins (B12 and folate) in plasma (n = 924) in Project Viva, a pre-birth US cohort. We collected diagnosis of HDP by reviewing medical records. We used multinomial logistic regression and Bayesian Kernel Machine Regression to estimate individual and joint associations of metals with HDP and interactions by vitamins, after adjusting for key covariates.

RESULTS

The majority of participants were non-Hispanic white (72.5 %), never smokers (68.5 %) with a mean (SD) age of 32.3 (4.6) years. Fifty-two (3.8 %) developed preeclampsia and 94 (6.8 %) gestational hypertension. A doubling in first trimester erythrocyte copper was associated with 78 % lower odds of preeclampsia (OR=0.22, 95 % confidence interval: 0.08, 0.60). We also observed significant associations between higher erythrocyte total arsenic and lower odds of preeclampsia (OR=0.80, 95 % CI: 0.66, 0.97) and higher vitamin B12 and increased odds of gestational hypertension (OR=1.79, 95 % CI: 1.09, 2.96), but associations were attenuated after adjustment for dietary factors. Lower levels of the overall metal mixture and essential metal mixture were associated with higher odds of preeclampsia. We found no evidence of interactions by prenatal vitamins or between metals.

CONCLUSION

Lower levels of a first-trimester essential metal mixture were associated with an increased risk of preeclampsia, primarily driven by copper. No associations were observed between other metals and HDP after adjustment for confounders and diet.

PARCCS: A Machine Learning Risk-Prediction Model for Acute Peripartum Cardiovascular Complications During Delivery Admissions

Background

Maternal mortality in the United States remains high, with cardiovascular (CV) complications being a leading cause.

Objectives

The purpose of this paper was to develop the PARCCS (Prediction of Acute Risk for Cardiovascular Complications in the Peripartum Period Score) for acute CV complications during delivery.

Methods

Data from the National Inpatient Sample (2016-2020) and International Classification of Diseases, Tenth Revision codes to identify delivery admissions were used. Acute CV/renal complications were defined as a composite of pre-eclampsia/eclampsia, peripartum cardiomyopathy, renal complications, venous thromboembolism, arrhythmias, and pulmonary edema. A risk prediction model, PARCCS, was developed using machine learning consisting of 14 variables and scored out of 100 points.

Results

Of the 2,371,661 pregnant patients analyzed, 7.0% had acute CV complications during delivery hospitalization. Patients with CV complications had a higher prevalence of comorbidities and were more likely to be of Black race and lower income. The PARCCS variables included electrolyte imbalances (13 points [p]), age (3p for age <20 years), cesarean delivery (4p), obesity (5p), pre-existing heart failure (28p), multiple gestations (4p), Black race (2p), gestational hypertension (3p), low income (1p), gestational diabetes (2p), chronic diabetes (6p), prior stroke (22p), coagulopathy (5p), and nonelective admission (2p). Using the validation set, the performance of the model was evaluated with an area under the receiver-operating characteristic curve of 0.68 and a 95% CI of 0.67 to 0.68.

Conclusions

PARCCS has the potential to be an important tool for identifying pregnant individuals at risk of acute peripartum CV complications at the time of delivery. Future studies should further validate this score and determine whether it can improve patient outcomes.

Preeclampsia: Short- and Long-Term Effects

Does our time inside the womb predict our future? Evidence suggests that the environment in the womb plays a powerful role in predicting specific adult diseases. The fetus is constantly responding and adapting to the intrauterine environment by a process called programming. Toxic exposures, such as nutritional deficits and hypoxia, can affect fetal development and increase the risk for specific diseases that manifest later in our adult life. Preeclampsia (PE) is one disorder that results in a less-than-optimal environment for the growing fetus. It is pregnancy-specific and defined as new-onset hypertension after 20 weeks' gestation in the presence of maternal multiorgan dysfunction. To the best of our understanding, the pathogenesis is multifactorial and involves dysfunction of the placenta and the vascular, renal, and immunological systems. Treatment options are limited and may result in adverse outcomes for the fetus and newborn. Preeclampsia is a major contributor to perinatal and maternal morbidity and mortality worldwide, thus generating a significant healthcare burden. Research continues to demonstrate that mothers and infants affected by PE are at increased susceptibility to chronic conditions such as cardiovascular, renal, metabolic, and neurological diseases. More efforts are needed to further understand this disease. Efforts to increase awareness will help improve clinical outcomes for both mothers and infants.

Aspirin 162 mg vs 81 mg for preeclampsia prophylaxis in high-risk obese individuals: a comparative effectiveness open-label randomized trial (ASPREO)

BACKGROUND

In the United States, leading medical societies recommend 81 mg of aspirin daily for the prevention of preeclampsia in women at risk, whereas the NICE guidelines in the United Kingdom recommend a dose as high as 150 mg of aspirin. Recent data also suggest that in the obese population, inadequate dosing or aspirin resistance may impact the efficacy of aspirin at the currently recommended doses.

OBJECTIVE

We evaluated whether daily administration of 162 mg aspirin would be more effective compared with 81 mg in decreasing the rate of preeclampsia with severe features in high-risk obese pregnant individuals.

STUDY DESIGN

We performed a randomized trial between May 2019 and November 2022. Individuals at 12-20 weeks of gestational age with a body mass index ≥30 kg/m2 at the time of enrollment and at least 1 of 3 high-risk factors: history of preeclampsia in a prior pregnancy, at least stage I hypertension documented in the index pregnancy, pregestational diabetes or gestational diabetes diagnosed before 20 weeks of gestational age were randomized to either 162 mg or 81 mg of aspirin daily till delivery, participants were not blinded to treatment allocation. Exclusion criteria were multifetal gestation, known major fetal anomalies, seizure disorder, baseline proteinuria, on aspirin because of other indications, or contraindication to aspirin. The primary outcome was preeclampsia with severe features (preeclampsia or superimposed preeclampsia with severe features; eclampsia; or hemolysis, elevated liver enzymes, low platelet count syndrome). Secondary outcomes included rates of preterm birth because of preeclampsia, small for gestational age, postpartum hemorrhage, abruption, and medication side effects. A sample size of 220 was needed using a preplanned Bayesian analysis of the primary outcome to estimate the posterior probability of benefit or harm with a neutral informative prior.

RESULTS

Approximately 220/343 (64.1%) individuals were randomized. The primary outcome was available for 209/220 (95%) individuals. Baseline characteristics were similar between groups, with the median gestational age at enrollment being 15.9 weeks in the 162 mg aspirin group and 15.6 weeks in the 81 mg aspirin group. Enrollment before 16 weeks occurred in 55 of 110 of those assigned to 162 mg and 58 of 110 of those assigned to 81 mg of aspirin. The primary outcome occurred in n of d individuals (35%) in the 162 mg aspirin group and n of d individuals (40%) in the 81 mg aspirin group (posterior relative risk, 0.88; 95% credible interval, 0.64-1.22). Bayesian analysis indicated a 78% probability of a reduction in the primary outcome with 162 mg aspirin compared with 81 mg aspirin dose. Rates of indicated preterm birth because of preeclampsia (21% vs 21%), small for gestational age (6.5% vs 2.9%), abruption (2.8% vs 3.0%), and postpartum hemorrhage (10.0% vs 8.8%) were similar between groups. Medication adverse effects were also similar.

CONCLUSION

Among high-risk obese individuals, there was a 78% probability of benefit that 162 mg aspirin compared with 81 mg will decrease the rate of preeclampsia with severe features. With the best estimate of a 12% reduction when using 162 mg of aspirin compared with 81 mg of aspirin in this population. This trial supports doing a larger multicenter trial.

Systematic review and meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome

Screening for polycystic ovary syndrome (PCOS) in antenatal care is inadequate, largely owing to the lack of clarity around whether PCOS is an independent risk factor for pregnancy complications. This systematic review and meta-analysis include 104 studies and 106,690 pregnancies in women with and without PCOS from inception until 13th July 2022. We report that women with PCOS are younger and have higher body mass index (BMI) around conception and have greater gestational weight gain. The odds of miscarriage, gestational diabetes mellitus, gestational hypertension, pre-eclampsia and cesarean section are higher in women with PCOS. The increased odds of adverse outcomes in PCOS remain significant when age and BMI are matched and when analyses are restricted to high-quality studies. This work informed the recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome, emphasizing that PCOS status should be captured in all women who are planning to, or have recently become pregnant to facilitate prevention of adverse outcomes and improve pregnancy outcomes.

Low-dose aspirin prophylaxis to prevent hypertensive disorders of pregnancy after in vitro fertilisation: a scoping review protocol

INTRODUCTION

Pregnancies resulting from in vitro fertilisation are associated with an increased risk of developing hypertensive disorders of pregnancy, such as preeclampsia, when compared with naturally conceived pregnancies.

OBJECTIVE

The efficacy of aspirin prophylaxis to reduce the incidence of preeclampsia is well established in naturally conceived pregnancies identified as high risk for developing preeclampsia. However, the efficacy of aspirin to reduce the rate of preeclampsia for all pregnancies resulting from in vitro fertilisation remains uncertain, although in vitro fertilisation conception is a well-known risk factor for preeclampsia. Therefore, the purpose of this scoping review is to provide a comprehensive overview of the current literature regarding the use of low-dose aspirin to prevent hypertensive disorders of pregnancy after in vitro fertilisation.

INCLUSION CRITERIA

This review will identify all peer-reviewed published articles including pregnant women who underwent embryo transfer after in vitro fertilisation and were prescribed low-dose aspirin to reduce the risk of hypertensive disorders of pregnancy.

METHODS

We have devised a comprehensive search strategy to systematically identify pertinent studies published from January 2000 until May 2024, within the Medline (PubMed interface), Embase and Scopus databases. The search strategy is based on the keywords 'aspirin,' 'pregnancy-induced hypertension,' and ('in vitro fertilization' OR 'oocyte donation' OR 'embryo transfer' OR 'donor conception'). Two reviewers will independently screen the titles, abstracts and full-text articles to select the relevant articles, using the Covidence software.

ETHICS AND DISSEMINATION

No patients are involved in this study. This study aims to be published in a peer-reviewed journal and could be presented at a conference.

Antihypertensive utilization patterns among pregnant persons with pre-existing hypertension in the US: A population-based study

BACKGROUND

Hypertension among persons with childbearing potential is on the rise. Maintaining proper blood pressure during pregnancy is vital to prevent maternal and neonatal complications. Yet, limited evidence on the risk-benefit of various antihypertensives presents challenges for informed decision-making during this critical period. This study aimed to examine the utilization patterns of different classes of antihypertensives among persons with pre-existing hypertension before, during, and after pregnancy.

METHODS

We used MarketScan® Commercial Database 2011-2020 to analyze antihypertensive utilization among pregnant persons aged 12 to 55 identified via a validated algorithm. Pre-existing hypertension was defined as ≥1 inpatient or ≥2 outpatient encounters for hypertension within the 180 days preceding the LMP. Antihypertensive utilization was described during target periods: 0-3 months (0-3M) before pregnancy, 1st/2nd/3rd trimester (T1/2/3), 0-3M, and 4-6M after pregnancy.

RESULTS

We identified 1,950,292 pregnancies, of which 20,576 (12,978 live and 7,598 non-live) had pre-existing hypertension. Both groups had similar antihypertensive use (80.1% and 81.0%, respectively) during the 6 months before pregnancy (baseline). For live-birth pregnancies, 13.9% of baseline users discontinued treatment during pregnancy, while 28.9% of non-users initiated antihypertensives during pregnancy, and 17.2% started postpartum. Before pregnancy, the predominant antihypertensives included thiazide diuretics (21.9%), combined α- and β-blockers (18.4%), and dihydropyridines (16.2%). During pregnancy, thiazide diuretics, cardioselective β-blockers, and ACE inhibitors declined (T3: 3.0%, 4.2%, and 0.8%). Dihydropyridine use was steady during pregnancy, but preference shifted from amlodipine to nifedipine in T3 (2.2.% vs.10.8%). Central α2-agonists increased during pregnancy (up to 15.2% in T3) compared to both pre- (9.8%) and post-pregnancy (5.7%). ARBs mirrored ACE inhibitors, with less than 1% utilization in later trimesters. Combination agents dropped from 10.8% pre-pregnancy to 0.8% in T3, then rebounded to 7.3% post-pregnancy.

CONCLUSION

Research is warranted to evaluate the choice of antihypertensives and optimal timing to switch to safer alternatives, considering maternal and fetal outcomes.

Short and long-term complications of hypertensive disorders of pregnancy: lifelong cardiovascular risks we cannot ignore

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy (HDP) pose a significant threat to maternal cardiovascular health, with emerging research shedding light on the enduring risks beyond the gestational period. This review highlights updates regarding cardiovascular risks associated with HDP and their implications for long-term health.

RECENT FINDINGS

Patients with a history of HDP are at an elevated risk of developing chronic hypertension, ischemic heart disease, stroke, valvular heart disease, and heart failure.Not surprisingly, patients with HDP experience higher rates of maternal and fetal adverse events in the antepartum and immediate postpartum periods, with high readmission rates for cardiovascular complications. The high risk of chronic hypertension after a HDP then leads to the development of subclinical disease over 5-10 years with overt cardiovascular disease becoming most prevalent in the decades following pregnancy. Early hypertension management in the antepartum and postpartum periods has lifelong health benefits and highlights the need for seamless postpartum transitions with close blood pressure monitoring and cardiovascular risk mitigation.

SUMMARY

HDP significantly increases the risk of short and long-term adverse cardiovascular events. Integrated healthcare models that assess and address postpartum cardiovascular risk are necessary to improve the cardiovascular health and longevity of those effected by HDP.

Black Father's Influence on Adverse Pregnancy Outcomes in the United States: A Narrative Synthesis of Literature

Few studies have investigated paternal characteristics in relationship with adverse pregnancy outcomes, and results are inconsistent. The purpose of this study was to review studies examining associations between characteristics of Black fathers and adverse pregnancy outcomes in the United States. A systematic narrative synthesis was conducted of research studies examining paternal characteristics of Black fathers in association with adverse pregnancy outcomes: preterm birth, hypertensive disorders of pregnancy, gestational diabetes, spontaneous abortion, and maternal mortality. Seven databases (Academic Search Premier, CINHAL, CENTRAL, ClinicalTrials.gov, Embase, PubMed, and Web of Science) were searched for original research articles from inception to February 2023. Articles were excluded if they (a) were in a language other than English, (b) did not describe original research, (c) included a geographic region outside of the United States, (d) did not include adverse maternal outcomes as a study outcome, (e) did not describe race of fathers in the study sample, and (f) did not describe a paternal characteristic of Black fathers. The search resulted in 210 articles. Six studies were included in the final review; five studies examined associations between paternal characteristics of Black fathers and preterm birth, finding significantly increased odds of preterm birth among births with Black fathers. Among births with non-Hispanic Black paternity, the odds of hypertensive disorders of pregnancy were reduced or not significantly associated. Researchers should continue to explore paternal factors that influence pregnancy outcomes in racial/ethnic-specific models to identify optimal intervention strategies to improve disparities in maternal and child health outcomes.

Postpartum Remote Blood Pressure Monitoring Using a Mobile App in Women with a Hypertensive Disorder of Pregnancy

BACKGROUND

Hypertensive disorders of pregnancy affect approximately 15% of pregnancies in the United States and are a leading cause of postpartum readmissions. Morbidity due to hypertension may be higher in the first several weeks postpartum. The ability to monitor blood pressure and intervene in the postpartum period is critical to reducing morbidity and mortality.

LOCAL PROBLEM

At WellSpan Health, hypertensive disorders were increasing and a leading cause of severe maternal morbidity and readmission.

INTERVENTIONS

A remote blood pressure monitoring app called BabyScripts™ myBloodPressure was implemented in September 2020. Prior to discharge postpartum, all patients with a diagnosis of a hypertensive disorder of pregnancy were given an automatic blood pressure cuff and instructions on how to monitor and track their blood pressure daily in the app.

RESULTS

A total of 1,260 patients were enrolled in the BabyScripts™ myBloodPressure module between September 2020 and July 2022 across five maternity hospitals. Of those enrolled 74% ( n = 938) entered seven or more blood pressures, and of those who entered at least one blood pressure 9% ( n = 107) entered at least one critical range blood pressure ( ≥ 150 mmHg systolic and or ≥ 100 mmHg diastolic).

CONCLUSION

Most women enrolled in the app were highly engaged and entered seven or more readings. Patients with critical blood pressures were identified; thus, the program has the potential to identify those at risk of severe complications. Barriers should be removed, and remote patient monitoring considered as a solution to improve postpartum assessment in patients with hypertensive disorders of pregnancy.

Longitudinal Management of Cardiovascular Risk Factors Among Postpartum Women

Background: Pregnancy-related cardiovascular (CV) conditions, including hypertensive disorders of pregnancy (HDP) and gestational diabetes (GDM), are associated with increased long-term CV risk. Methods: This retrospective cohort study defined the prevalence of HDP and GDM within a large, academic health system in the southeast United States between 2012 and 2015 and described health care utilization and routine CV screening up to 1-year following delivery among those with pregnancy-related CV conditions. Rates of follow-up visits and blood pressure, hemoglobin A1c (HbA1c), and lipid screening in the first postpartum year were compared by provider type and pregnancy-related CV condition. Results: Of the 6027 deliveries included, 20% were complicated by HDP and/or GDM. Rates of pre-pregnancy CV risk factors were high, with a significantly higher proportion of pre-pregnancy obesity among women with HDP than in normal pregnancies. Those with both HDP/GDM had the highest rates of follow-up by 1-year postpartum, yet only half of those with any pregnancy-related CV condition had any follow-up visit after 12 weeks. Although most (70%) of those with HDP had postpartum blood pressure screening, less than one-third of those with GDM had a repeat HbA1c by 12 months. Overall, postpartum lipid screening was rare (<20%). Conclusion: There is a high burden of pregnancy-related CV conditions in a large U.S. academic health system. Although overall rates of follow-up in the early postpartum period were high, gaps in longitudinal follow-up exist. Low rates of CV risk factor follow-up at 1 year indicate a missed opportunity for early CV prevention.

Centering Equity and Fostering Stakeholder Collaboration and Trust-Pillars of the Maternal Health Innovation Program in Maryland

Objective

To describe two main pillars of the Maryland Maternal Health Innovation Program (MDMOM): (1) centering equity and (2) fostering broad stakeholder collaboration and trust.

Methods

We summarized MDMOM's key activities and used severe maternal morbidity (SMM) surveillance and program monitoring data to quantify MDMOM's work on the two pillars. We developed measures of hospital engagement with MDMOM (participation in quality improvement [QI] activities, participation in check-in meetings, staff involvement) and with other partners (participation in QI activities, representation in state-level groups). We examined Bonferroni-adjusted correlations between these hospital engagement measures and with key hospital characteristics: level of maternity care, annual delivery volume, and SMM rate.

Results

Over 100 national and state organizations and individual stakeholders contributed to our building the MDMOM program and implementing key activities centering equity: hospital-based SMM surveillance in 20 of Maryland's 32 hospitals; almost 5,000 trainings offered to perinatal health care providers; two telemedicine/telehealth interventions; training of home visitors and community-based organization staff. Birthing hospitals represent MDMOM's main implementation partners. The strength of their participation in MDMOM QI activities is positively correlated to their participation in check-in meetings and with the degree of involvement by physicians in such activities. Higher engagement in MDMOM QI activities is also positively correlated to hospitals' participation in other state-level maternal health initiatives or groups.

Conclusion

Our experience with the MDMOM program demonstrates that an equity focus and broad stakeholder collaboration building strong relationships and providing implementation support can lead to high levels of engagement in innovative maternal health interventions.

Factors Associated with Refractory Severe Hypertension in Patients with Preeclampsia

OBJECTIVE

 This study aimed to identify factors associated with refractory severe hypertension that does not resolve after an initial dose of antihypertensive medication in patients with preeclampsia.

STUDY DESIGN

 This was a retrospective study of all pregnant and postpartum individuals with a diagnosis of preeclampsia, superimposed preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome, or eclampsia who delivered at 22 weeks or greater at a single academic institution from 2010 to 2020. Inclusion criteria were patients with preeclampsia who developed severe hypertension (systolic pressure ≥160 mm Hg or diastolic pressure ≥110 mm Hg) and received antihypertensive medications for acute severe hypertension. We defined refractory severe hypertension as a systolic blood pressure of ≥160 mm Hg or a diastolic blood pressure of ≥110 mm Hg that did not improve after receiving the initial treatment. To evaluate for factors associated with refractory severe hypertension, we developed multivariable modified Poisson regression using all variables with p-value <0.1 on bivariable analysis and calculated adjusted relative risks (aRRs) with 95% confidence intervals (95% CIs).

RESULTS

 Of 850, 386 (45.4%) had refractory severe hypertension and 464 (54.6%) responded to the initial antihypertensive medications. Factors associated with refractory severe hypertension included higher body mass index (BMI), chronic hypertension, and higher systolic pressure. Every 5 kg/m2 increase in BMI was associated with a 7% increased risk of refractory severe hypertension (aRR = 1.07; 95% CI: 1.02-1.12). Every 10 mm Hg increase in systolic blood pressure was associated with a 10% increased risk of refractory severe hypertension (aRR = 1.10; 95% CI: 1.04-1.17). Chronic hypertension was associated with a 25% increased risk of refractory severe hypertension (aRR = 1.25; 95% CI: 1.01-1.56) in the diastolic pressure model.

CONCLUSION

 Refractory severe hypertension was associated with elevated BMI, chronic hypertension, and higher systolic blood pressure.

KEY POINTS

· Risk factors for refractory severe hypertension are not well-known.. · Almost half of the patients had refractory severe hypertension.. · Higher BMI, chronic hypertension, and higher systolic pressure were the risk factors.. · These patients would require closer follow-up and prompt response to vital signs..

Prevalence of Hypertensive Disorders of Pregnancy and Gestational Diabetes Mellitus by Race and Ethnicity in Illinois, 2018 to 2020

PURPOSE

Use administrative discharge data from 2018 to 2020 to determine if there are differences in the prevalence of hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) by race and ethnicity in Illinois.

STUDY DESIGN AND METHODS

This retrospective cross-sectional study used administrative discharge records from all patients who had live births in Illinois over a 3-year period; 2018, 2019, 2020. Multivariate analyses were performed to control for covariates and determine if associations vary by race and ethnicity for HDP and GDM.

RESULTS

A total of 287,250 discharge records were included. Multivariate analyses showed that after adjusting for covariates, non-Hispanic Black women had 1.60 increased odds of HDP compared to non-Hispanic White women (OR, 1.60; 95% CI, 1.55-1.65). Hispanic women (OR, 1.45; 95% CI, 1.40-1.50), Asian/Pacific Islander women (OR, 2.07; 95% CI, 1.97-2.17), and American Indian/Alaska Native women (OR, 1.43; 95% CI, 1.17-1.74) had an increased odds of GDM compared to non-Hispanic White women.

CLINICAL IMPLICATIONS

Women of color were at increased odds for HDP and GDM in Illinois. To eliminate poor maternal outcomes in women of color at risk for HDP and GDM, more culturally congruent health equity practices, policies, and comprehensive care interventions must be adopted.

Increased Risk of Gestational Hypertension by Periconceptional Exposure to Ambient Air Pollution and Effect Modification by Prenatal Depression

BACKGROUND

Air pollution has been associated with gestational hypertension (GH) and preeclampsia, but susceptible windows of exposure and potential vulnerability by comorbidities, such as prenatal depression, remain unclear.

METHODS

We ascertained GH and preeclampsia cases in a prospective pregnancy cohort in Los Angeles, CA. Daily levels of ambient particulate matters (with a diameter of ≤10 μm [PM10] or ≤2.5 μm [PM2.5]), nitrogen dioxide, and ozone were averaged for each week from 12 weeks preconception to 20 gestational weeks. We used distributed lag models to identify susceptible exposure windows, adjusting for potential confounders. Analyses were additionally stratified by probable prenatal depression to explore population vulnerability.

RESULTS

Among 619 participants, 60 developed preeclampsia and 42 developed GH. We identified a susceptible window for exposure to PM2.5 from 1 week preconception to 11 weeks postconception: higher exposure (5 µg/m3) within this window was associated with an average of 8% (95% CI, 1%-15%) higher risk of GH. Among participants with probable prenatal depression (n=179; 32%), overlapping sensitive windows were observed for all pollutants from 8 weeks before to 10 weeks postconception with increased risk of GH (PM2.5, 16% [95% CI, 3%-31%]; PM10, 39% [95% CI, 13%-72%]; nitrogen dioxide, 65% [95% CI, 17%-134%]; and ozone, 45% [95% CI, 9%-93%]), while the associations were close to null among those without prenatal depression. Air pollutants were not associated with preeclampsia in any analyses.

CONCLUSIONS

We identified periconception through early pregnancy as a susceptible window of air pollution exposure with an increased risk of GH. Prenatal depression increases vulnerability to air pollution exposure and GH.

Preeclampsia epidemiology(ies) and pathophysiology(ies)

Preeclampsia/eclampsia was first described 2000 years ago. Concepts guiding diagnosis have changed over time making longitudinal studies challenging. Similarly, concepts of pathophysiology have evolved from eclampsia as a pregnancy seizure disorder to preeclampsia as a hypertensive and renal disorder to our current concept of a preeclampsia as a pregnancy specific, multisystemic inflammatory disorder. Although preeclampsia is pregnancy specific and many pathophysiologic findings begin to resolve with delivery, its impact extends beyond pregnancy. The risk of cardiovascular and neurological disease is increased after pregnancy in women who have had preeclampsia. The disorder is not a disease, but a syndrome and emerging data indicate multiple pathways to the syndrome. It is likely that our failure to have a major impact on prediction and prevention despite a large increase in understanding is due to the existence of multiple subtypes of preeclampsia. This concept should guide future research.