Prevalence of persistent hypertension following pregnancy complicated by hypertensive disorders in low- and middle-income countries: a systematic review

Background

Hypertensive disorders of pregnancy can lead to persistent hypertension (pHTN) in the months and even years following delivery. However, its prevalence in low- and middle-income countries (LMICs) is not well characterized.

Objective

To synthesize available evidence on the pHTN prevalence following a pregnancy complicated by hypertensive disorders of pregnancy in LMICs.

Search strategy

PubMed, CINAHL Plus, Global Health (EBSCOhost), and Scopus from inception through a search date of July 12, 2022, and updated on January 2, 2024.

Selection criteria

Cross-sectional studies and cohort studies reporting pHTN prevalence were eligible.

Data collection and analysis

We conducted a narrative synthesis of data and categorized reported prevalence time points into several broader categories. We used the Newcastle-Ottawa checklist to assess the risk of bias. The protocol is registered in PROSPERO (CRD42022345739).

Results

We reviewed 1,584 abstracts and identified 22 studies that reported pHTN between 2000 and 2023 from 14 LMICs. The overall prevalence of pHTN ranged between 6.9% and 62.2%, with the highest prevalence noted within African studies and the lowest in South American studies. Estimates at different follow-up periods postpartum were 6.9%-42.9% at six weeks, 34.0%-62.2% at three months, 14.8%-62.2% at six months, 12.7%-61.2% at 12 months, and 7.5%-31.8% at more than 12 months. The quality score of the selected studies ranged from 50% to 100%.

Conclusions

The extant literature reports a high prevalence of pHTN in LMICs following a pregnancy complicated by hypertensive disorders. To reduce long-term complications of pHTN, programs should emphasize early screening and linkages to long-term care for at-risk women.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=345739, PROSPERO (CRD42022345739).

The Risk of Persistent Hypertension and Chronic Kidney Disease in Early- and Late-Onset Preeclampsia: A Report From Developing Country

BACKGROUND AND OBJECTIVE

Preeclampsia (PE) has been disproportionately prevalent in developing countries and constitutes a leading cause of maternal mortality, and also has long-term impacts, including renal consequences. This study aimed to explore the risk of persistent hypertension and kidney failure in early-onset PE (EOP) and late-onset PE (LOP) in the five years after delivery.

METHODS

This retrospective cohort study included women with a prior history of severe PE or normotensive pregnancy admitted to tertiary hospitals in Indonesia. The blood pressure, body mass index (BMI), urea, creatinine serum, and protein urine were analyzed, and the risk of chronic kidney disease (CKD) after five years was performed using the Kidney Disease Improvement Global Outcomes (KDIGO) classification.

RESULTS

Twenty-seven EOP, 35 LOP, and 30 normotensive cases were included. Mean blood pressure after five years was recorded as 115.6 ± 14.25 mmHg in the normotensive group, 131.82 ± 19.34 mmHg in the LOP group, and 154.96 ± 23.48 mmHg in the EOP group. According to the KDIGO classification, the normotensive group had an average 10% risk of CKD, but severe PE had a risk of CKD greater than 90%. In the severe PE group, the risk of CKD was 20.94 times higher compared to normotensive women (OR 20.94; 95% CI 2.67-163.72, p = 0.004). The risk of CKD in the EOP group was 6.75 times higher than in the LOP group (OR 6.75; 95% CI 2.19-20.76, p = 0.001), whereas persistent hypertension in the EOP group was 5.78 times higher than in the LOP group (OR 5.78; 95% CI 1.91-17.395, p = 0.002).

CONCLUSIONS

PE women have a higher risk of CKD than normotensive women. Women with a history of EOP are more likely to develop persistent hypertension and CKD than women with a prior LOP history.

Immune Markers, Blood Pressure Severity, and Cardiac Remodeling 1 to 2 Years After Hypertensive Disorders of Pregnancy

Background Cardiovascular dysfunction and hypertension can persist postpartum following hypertensive disorders of pregnancy (HDPs). This study hypothesized that activin A, proinflammatory markers and concentric remodeling by echo would be higher 1-2 years postpartum following HDP with persistent hypertension compared to HDP with normalized blood pressure (BP). We further hypothesized correlations between biomarkers with BP and echocardiographic indices. Methods and Results This study enrolled participants with HDPs but no prepregnancy hypertension followed 1 to 2 years after delivery. Activin A and inflammatory cytokines, BP, and echocardiograms were obtained. Biomarker concentrations and echocardiographic parameters were compared between HDP with and without persistent hypertension. Individuals with persistent hypertension at a mean of 1.6 years postpartum had significantly higher activin A concentrations (median[interquartile range 25-75] 230.6 [196.0-260.9] versus 175.3 pg/mL [164.3-188.4]; P<0.01), more concentric left ventricular concentric remodeling (relative wall thickness >0.42, 48% versus 7%; P<0.01), and worse peak left atrial strain (33.4% versus 39.3%; P<0.05) as compared with those whose BP normalized. Higher activin A and interleukin-6 concentrations correlated with higher systolic (activin A: r=0.43, P=0.01) and diastolic BP (activin A: r=0.58, P<0.01; interleukin-6: r=0.36; P<0.05), as well as greater left ventricular thickness (activin A and interventricular septal thickness: r=0.41, interleukin-6 and interventricular septal thickness: r=0.36; both P<0.05). Conclusions Individuals with HDPs and persistent hypertension had significantly higher activin A and greater concentric remodeling compared with those with HDPs and normalized BP at 1 to 2 years postpartum. Activin A was positively correlated with both BP and echocardiographic indices (left ventricular thickness), suggesting overlapping processes between persistent hypertension and cardiac remodeling.

Developing an Actionable Taxonomy of Persistent Hypertension Using Electronic Health Records

BACKGROUND

The digital transformation of medical data presents opportunities for novel approaches to manage patients with persistent hypertension. We sought to develop an actionable taxonomy of patients with persistent hypertension (defined as 5 or more consecutive measurements of blood pressure ≥160/100 mmHg over time) based on data from the electronic health records.

METHODS

This qualitative study was a content analysis of clinician notes in the electronic health records of patients in the Yale New Haven Health System. Eligible patients were 18 to 85 years and had blood pressure ≥160/100 mmHg at 5 or more consecutive outpatient visits between January 1, 2013 and October 31, 2018. A total of 1664 patients met criteria, of which 200 records were randomly selected for chart review. Through a systematic, inductive approach, we developed a rubric to abstract data from the electronic health records and then analyzed the abstracted data qualitatively using conventional content analysis until saturation was reached.

RESULTS

We reached saturation with 115 patients, who had a mean age of 66.0 (SD, 11.6) years; 54.8% were female; 52.2%, 30.4%, and 13.9% were White, Black, and Hispanic patients. We identified 3 content domains related to persistence of hypertension: (1) non-intensification of pharmacological treatment, defined as absence of antihypertensive treatment intensification in response to persistent severely elevated blood pressure; (2) non-implementation of prescribed treatment, defined as a documentation of provider recommending a specified treatment plan to address hypertension but treatment plan not being implemented; and (3) non-response to prescribed treatment, defined as clinician-acknowledged persistent hypertension despite documented effort to escalate existing pharmacologic agents and addition of additional pharmacologic agents with presumption of adherence.

CONCLUSIONS

This study presents a novel actionable taxonomy for classifying patients with persistent hypertension by their contributing causes based on electronic health record data. These categories can be automated and linked to specific types of actions to address them.

Persistent hypertension at 3 months postpartum among women with hypertensive disorders of pregnancy at a tertiary hospital in Southwestern Uganda

BACKGROUND

Hypertension is a key contributor to the global epidemic of cardiovascular disease and is responsible for more deaths worldwide than any other cardiovascular risk factor. Hypertensive disorders of pregnancy, of which preeclampsia and eclampsia are the most common forms, have been shown to be a female-specific risk factor for chronic hypertension.

OBJECTIVE

This study aimed to determine the proportion and risk factors for persistent hypertension at 3 months after delivery among women with hypertensive disorders of pregnancy in Southwestern Uganda.

STUDY DESIGN

This was a prospective cohort study of pregnant women with hypertensive disorders of pregnancy admitted for delivery at Mbarara Regional Referral Hospital in Southwestern Uganda from January 2019 to December 2019; however, women with chronic hypertension were excluded from the study. The participants were followed up for 3 months after delivery. Participants with a systolic blood pressure of ≥140 mm Hg or a diastolic blood pressure of ≥90 mm Hg or receiving antihypertension therapy at 3 months after delivery were considered to have persistent hypertension. Multivariable logistic regression was used to determine independent risk factors associated with persistent hypertension.

RESULTS

A total of 111 participants with hypertensive disorders of pregnancy diagnosed at hospital admission were enrolled with a follow-up rate of 49% (54/111) at 3 months after delivery. Of these women, 21 of 54 (39%) had persistent hypertension 3 months after delivery. In the adjusted analyses, an elevated serum creatinine level (>106.08 µmol/L [≤1.2 mg/dL]) at admission for delivery was the only independent risk factor for persistent hypertension at 3 months after delivery (adjusted relative risk, 1.93; 95% confidence interval, 1.08-3.46; P=.03), controlling for age, gravidity, and eclampsia.

CONCLUSION

Approximately 4 of 10 women presenting with hypertensive disorders of pregnancy at our institution remained hypertensive 3 months after delivery. Innovative strategies are needed to identify these women and provide long-term care to optimize blood pressure control and reduce future cardiovascular disease after hypertensive disorders of pregnancy.

Use of continuous infusion of nicardipine to control persistent postpartum hypertension: A retrospective study

To evaluate the effect of continuous infusion of nicardipine on the management of uncontrolled blood pressure (BP) during postpartum period. This retrospective study included 209 women diagnosed in hospital with hypertensive disorders during pregnancy and had uncontrolled BP after delivery between January 2018 to December 2020 Uncontrolled BP was defined as persistent elevation of systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg. Patients were divided into 2 groups: nicardipine (N = 53; continuous nicardipine infusion and additional bolus of labetalol or hydralazine) and control (N = 156; consecutive bolus of labetalol or hydralazine). BP data were analyzed using the Mann-Whitney U and χ2 tests by dividing the time interval of 4 hours by the delivery time. The highest BP trends showed that the mean values of both systolic and diastolic BP immediately before delivery were higher in the nicardipine group than in the control. After 8 to 12 hours following delivery, both systolic and diastolic BP were lower in the nicardipine group than in the control. Subsequently, 16 to 20 hours after delivery, both systolic and diastolic BP were significantly lower in the nicardipine group than in the control (137/80 vs 141/84 mm Hg). Initially, the proportions of uncontrolled BP in the nicardipine group were higher than those in the control; however, it then became lower at all time intervals 8 hours after delivery. The proportions of patients who received additional antihypertensive agents and the median cumulative dosages were lower in the nicardipine group than in the control. Continuous infusion of nicardipine can help manage uncontrolled BP during the postpartum period.

Implication of aortic calcification on persistent hypertension after laparoscopic adrenalectomy in patients with primary aldosteronism

OBJECTIVES

To identify risk factors, including aortic calcification, for persistent hypertension in primary aldosteronism patients undergoing laparoscopic adrenalectomy.

METHODS

Between October 2000 and October 2015, we carried out 101 consecutive laparoscopic adrenalectomies for unilateral primary aldosteronism. Of these, 95 cases with at least 1 year of postoperative follow up were included. These were divided into two study groups based on whether they had normal blood pressure without antihypertensive medications (resolved group) or still required medications (unresolved group) at 1 year after surgery. Variables included age, sex, body mass index, history of hypertension, dosage of antihypertensive medication score, presence of type 2 diabetes, subclinical Cushing syndrome, preoperative renal function, aldosteronoma resolution score and abdominal calcification index. Univariate and multivariate logistic regression analyses were used to assess independent risk factors for persistent hypertension 1 year after surgery.

RESULTS

The complete resolution of hypertension without antihypertensive medication 1 year after adrenalectomy was 36 out of 95 (38%). The preoperative antihypertensive medication score, systolic blood pressure and abdominal calcification index were significantly higher, and the aldosteronoma resolution score were significantly lower in the unresolved group than in the resolved group. Using multivariate logistic regression analysis, independent risk factors significantly correlating with persistent hypertension 1 year after surgery were aldosteronoma resolution score and abdominal calcification index.

CONCLUSIONS

Laparoscopic adrenalectomy for primary aldosteronism is effective in improving blood pressure and reducing the need for antihypertensive medications. Aldosteronoma resolution score and abdominal calcification index represent potential independent risk factors for persistent hypertension 1 year after surgery.