Is use of multiple antihypertensive agents to achieve blood pressure control associated with adverse pregnancy outcomes?

The optimal gestational age to deliver patients with chronic hypertension on antihypertensive therapy

OBJECTIVE

To identify the optimal gestational age of planned delivery in pregnancies complicated by chronic hypertension requiring antihypertensive medications that minimizes the risk of adverse perinatal events and maternal morbidity.

METHODS

Retrospective cohort study of singleton pregnancies after 37 weeks of gestation complicated by chronic hypertension on antihypertensive medication, delivered at 7 hospitals within an academic health system in New York from 12/1/2015 to 9/3/2020. Two comparisons were made (1) planned deliveries at 37-37^6/7weeks versus expectant management, (2) planned deliveries at 38-38^6/7weeks versus expectant management. Patients with other maternal or fetal conditions were excluded. The primary outcome was a composite of adverse perinatal outcomes including stillbirth, neonatal death, assisted ventilation, cord pH < 7.0, 5-minute Apgar ≤5, diagnosis of respiratory disorder, and neonatal seizures. The secondary outcomes included preeclampsia, eclampsia, primary cesarean delivery, postpartum readmission, and infant stay greater than 5 days. Odds ratios were estimated with multiple logistic regression and adjusted for confounding effects.

RESULTS

A total of 555 patients met inclusion criteria. Patients who underwent planned delivery at 37 weeks compared to expectant management did not appear to be at higher risk of adverse perinatal outcomes (14.9% vs 10.4%, aOR 1.49, 95% CI: 0.77-2.88). Similarly, we did not find a difference in the primary outcome in patients who underwent planned delivery at 38 weeks versus those expectantly managed (9.7% vs 10.1%, (aOR 0.84, 95% CI: 0.39-1.76). There were no differences in the rates of primary cesarean or preeclampsia at 37 and 38 weeks.

CONCLUSION

Our findings suggest that there is no difference in neonatal or maternal outcomes for chronic hypertensive patients on medication if delivery is planned or expectantly managed at 37 or 38 weeks' gestation.

Role of Antihypertensive Treatment and Blood Pressure Control in the Occurrence of Adverse Pregnancy Outcomes: a Population-Based Study of Linked Electronic Health Records

BACKGROUND

Chronic hypertension (CH) adversely impacts pregnancy. It remains unclear whether antihypertensive treatment alters these risks. We examined the role of antihypertensive treatment in the association between CH and adverse pregnancy outcomes.

METHODS

Electronic health records from the UK Caliber and Clinical Practice Research Datalink were used to define a cohort of women delivering between 1997 and 2016. Primary outcomes were preeclampsia, preterm birth (PTB), and fetal growth restriction (FGR). We used multivariable logistic regression to compare outcomes in women with CH to women without CH and propensity score matching to compare antihypertensive agents.

RESULTS

The study cohort consisted of 1 304 679 women and 1 894 184 births. 14 595 (0.77%) had CH, and 6786 (0.36%) were prescribed antihypertensive medications in pregnancy. Overall, women with CH (versus no CH), had higher odds of preeclampsia (adjusted odds ratio [aOR], 5.74 [95% CI, 5.44-6.07]); PTB (aOR, 2.53 [2.39-2.67]); and FGR (aOR, 2.51 [2.31-2.72]). Women with CH prescribed treatment (versus untreated women) had higher odds of preeclampsia (aOR, 1.17 [1.05-1.30]), PTB (1.25 [1.12-1.39]), and FGR (1.80 [1.51-2.14]). Women prescribed methyldopa (versus β-blockers) had higher odds of preeclampsia (aOR, 1.43 [1.19-1.73]); PTB (1.59 [1.30-1.93]), but lower odds of FGR (aOR, 0.66 [0.48-0.90]). Odds of adverse outcomes were similar in relation to calcium channel blockers (versus β-blockers) except for PTB (aOR, 1.94 [1.15-3.27]). Among women prescribed treatment, lower average blood pressure (<135/85 mm Hg) was associated with better pregnancy outcomes.

CONCLUSIONS

Treatment with antihypertensive agents and control of hypertension ameliorates some effects but higher risks of adverse outcomes persist. β-Blockers versus methyldopa may be associated with better pregnancy outcomes except for FGR. Powered trials are needed to inform optimal treatment of CH during pregnancy.

Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association

Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Effect of blood pressure control in early pregnancy and clinical outcomes in African American women with chronic hypertension

OBJECTIVE

Chronic hypertension (cHTN) affects 3-5% of all pregnancies and is twice as prevalent in African American (AA) women. AA women develop more severe HTN at an earlier onset and have higher rates of adverse pregnancy outcomes. Blood pressure control during pregnancy is controversial.

STUDY DESIGN

This retrospective cohort included AA women with cHTN and singleton pregnancies delivering between January 2013 and December 2016. Patients were classified as not receiving antihypertensives in the first 20 weeks (Group A), on antihypertensives in the first 20 weeks but with an average BP <140/90 during pregnancy (Group B) and on antihypertensives in the first 20 weeks but with average BP during pregnancy ≥140/90 (Group C). Adverse outcomes including severe HTN and preterm delivery <35 weeks was compared between groups.

RESULTS

Of the 198 patients included, 68 received at least one AHT before 20 weeks including 45 patients with average BP <140/90 and 23 with average BP ≥140/90 during pregnancy. The incidence of superimposed PE and preterm birth was significantly higher among women with elevated BPs on AHT (39.1% vs 8.9% vs 17.7%, p = 0.01; preterm birth 52.2%, 8.9% and 9.2%, p < 0.001 for Groups C, B and A, respectively). A significantly higher proportion of adverse neonatal outcomes were observed in Group C (78.3%) as opposed to those in Group B (53.3%) or Group A (50.0%; p = 0.04).

CONCLUSIONS

Among AA women with cHTN, use of antihypertensives prior to 20 weeks and lower antenatal BP was associated with a decreased risk of adverse maternal and neonatal outcomes.

Hypertension and Diabetes in Non-Pregnant Women of Reproductive Age in the United States

Introduction

Diagnosis and control of chronic conditions have implications for women’s health and are major contributing factors to maternal and infant morbidity and mortality. This study estimated the prevalence of hypertension and diabetes in non-pregnant women of reproductive age in the United States, the proportion who were unaware of their condition or whose condition was not controlled, and differences in the prevalence of these conditions by selected characteristics.

Methods

We used data from the 2011–2016 National Health and Nutrition Examination Survey to estimate overall prevalence of hypertension and diabetes among women of reproductive age (aged 20–44 y), the proportion who were unaware of having hypertension or diabetes, and the proportion whose diabetes or hypertension was not controlled. We used logistic regression models to calculate adjusted prevalence ratios to assess differences by selected characteristics.

Results

The estimated prevalence of hypertension was 9.3% overall. Among those with hypertension, 16.9% were unaware of their hypertension status and 40.7% had uncontrolled hypertension. Among women with diabetes, almost 30% had undiagnosed diabetes, and among those with diagnosed diabetes, the condition was not controlled in 51.5%.

Conclusion

This analysis improves our understanding of the prevalence of hypertension and diabetes among women of reproductive age and may facilitate opportunities to improve awareness and control of these conditions, reduce disparities in women’s health, and improve birth outcomes.

The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy

Background

The imbalance between circulating concentrations of anti- and pro-angiogenic factors is usually intense in preeclampsia with severe features (sPE). It is possible that pre-delivery circulating levels of angiogenic factors in sPE may be associated with postpartum antihypertensive drug requirements.

Objective

To determine the predictive association between maternal pre-delivery serum concentrations of angiogenic factors and the use of ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to three following caesarean delivery.

Study design

Women with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited prior to childbirth. Serum samples were obtained from each participant < 48 hours before delivery to assess the concentrations of placental growth factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the Roche Elecsys platform. Each participant was followed up on postpartum days zero, one, two and three to monitor BP and confirm antihypertensive treatment. The optimal cut-off thresholds of sFlt-1/PIGF ratio from receiver operating characteristic curve predictive of the antihypertensive therapy were subjected to diagnostic accuracy assessment.

Results

The majority 58% (29/50) of sPE had multiple severe features of preeclampsia in the antenatal period with the commonest presentation being severe hypertension in 88% (44/50) of this group, followed by features of impending eclampsia which occurred in 42% (21/50). The median gestational age at delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6) weeks, p < 0.001 in normotensive and sPE groups respectively. Notably, the median sFlt-1/PIGF ratio in normotensive and sPE groups were 7.3 (IQR 17.9) and 179.1 (IQR 271.2) respectively, p < 0.001. Of the 50 sPE participants, 34% (17/50) had early-onset preeclampsia. The median (IQR) of sFlt-1/PIGF in the early- and late-onset preeclampsia groups were 313.52 (502.25), and 166.59(195.37) respectively, p = 0.006. From postpartum days zero to three, 48% (24/50) of sPE received ≥ 3 slow- and/or a rapid-acting antihypertensive drug. However, the daily administration of ≥ 3 slow- and/or a rapid-acting antihypertensive drug in sPE were pre-delivery 26% (13/50), postpartum day zero 18% (9/50), postpartum day one 34% (17/50), postpartum day two 24% (12/50) and postpartum day three 20% (10/50). In sPE, the pre-delivery sFlt-1/PIGF ratio was predictive of administration of ≥3 slow- and/or a rapid-acting antihypertensive drug on postpartum days zero, one and two with the optimal cut-off ratio being ≥315.0, ≥181.5 and ≥ 267.8 respectively (sensitivity 72.7–75.0%, specificity 64.7–78.6%, positive predictive value 40.0–50.0% and negative predictive value 84.6% - 94.3%). The predictive performance of sFlt-1/PIG ratio on postpartum day 3 among the sPE was not statistically significant (area under receiver operating characteristic curve, 0.6; 95% CI, 0.3–0.8).

Conclusion

A pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in the immediate postpartum period in sPE.

Association of antepartum blood pressure levels and angiogenic profile among women with chronic hypertension

BACKGROUND

Angiogenic factors have been implicated in the pathogenesis of preeclampsia. This pilot study explored the association between antenatal blood pressure levels and angiogenic biomarkers (sFlt1 and PlGF) among women with chronic hypertension (cHTN).

METHODS

Blood samples were collected from women with cHTN (with/without superimposed preeclampsia) within 96 h prior to delivery. Subjects were stratified by mean outpatient BP as controlled (cBP < 140/90) or uncontrolled (uBP ≥ 140/90). Descriptive statistics were generated and assessed as appropriate. Logistic regression was employed to assess for adverse pregnancy outcomes between groups.

RESULTS

Data from seventy-eight women were analyzed, of which 58 (74.4%) were African American. Fifty-six (71.8%) had cBP and 22 (28.2%) had uBP. Use of antepartum outpatient antihypertensive medications was more frequent in patients with uBP (46.4% vs. 13.6%, p = 0.01). Compared to women with cBP, women with uBP had higher levels of pre-delivery sFlt1 and sFlt1/PlGF ratio (sFlt: 4218.5 vs. 3056.0 pg/ml, p = 0.046; sFlt/PlGF: 62.5 vs. 25.0, p = 0.04). Additionally, more uBP patients had superimposed preeclampsia with severe features (54.6% vs. 25.0%; p = 0.01) and preterm delivery (defined as a gestational age <35 weeks (40.9% vs. 10.7%; p = 0.002)) than cBP patients. In the multivariable model, women with uBP had greater odds of preterm delivery (OR 6.78; p = 0.01), superimposed preeclampsia (OR 3.20; p = 0.03) and preeclampsia with severe features (OR 3.27; p = 0.04) than women with cBP.

CONCLUSION

In women with cHTN, elevated antepartum BP is associated with worsened outcomes and may be associated with abnormal angiogenic profile at delivery. Larger studies are needed to confirm these findings.

Perinatal outcomes associated with abnormal cardiac remodeling in women with treated chronic hypertension

BACKGROUND

Adverse maternal outcomes associated with chronic hypertension include accelerated hypertension and resultant target organ damage. One example is long-standing hypertension leading to maternal cardiac dysfunction. Our group has previously identified that features of such injury manifest as cardiac remodeling with left ventricular hypertrophy. Moreover, these features of cardiac remodeling identified in women with chronic hypertension during pregnancy were associated with adverse perinatal outcomes. Recent definitions of maternal cardiac remodeling using echocardiography have been expanded to include measurements of wall thickness. We hypothesized that these new features characterizing cardiac remodeling in women with chronic hypertension may also be associated with adverse perinatal outcomes.

OBJECTIVE

There were 3 aims in this study of women with treated chronic hypertension during pregnancy: to (1) apply the updated definitions of maternal cardiac remodeling; (2) elucidate whether these features of cardiac remodeling were associated with adverse perinatal outcomes; and (3) determine which, if any, of the newly defined cardiac remodeling strata were most damaging when compared to women with normal cardiac geometry.

STUDY DESIGN

This was a retrospective study of women with treated chronic hypertension during pregnancy delivered from January 2009 through January 2016. Cardiac remodeling was categorized by left ventricular mass index and relative wall thickness into 4 groups determined using the 2015 American Society of Echocardiography guidelines: normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Perinatal outcomes were analyzed according to each category of cardiac remodeling compared with outcomes in women with normal geometry.

RESULTS

A total of 314 women with treated chronic hypertension underwent echocardiography at a mean gestational age of 17.9 weeks. There were no differences between maternal age (P = .896), habitus (P = .36), or duration of chronic hypertension (P = .212) among the 4 groups. Abnormal cardiac remodeling was found in 51% and was significantly associated with increased rates of superimposed preeclampsia (P = .015), preterm birth (P < .001), and neonatal intensive care admission (P = .003). These outcomes reached the greatest significance when comparisons were made between eccentric hypertrophy and normal geometry.

CONCLUSION

Using current American Society of Echocardiography guidelines, 51% of women with treated chronic hypertension during pregnancy have some degree of abnormal cardiac remodeling. Any suggestion of maternal cardiac remodeling, regardless of subtype, was associated with increased risks for superimposed preeclampsia and preterm birth with its resultant perinatal sequelae. Eccentric ventricular hypertrophy, previously thought to mimic exercise physiology, appears to be the most associated with adverse perinatal outcomes. Despite evidence of cardiac remodeling, ejection fraction was preserved.