Risk factors for preeclampsia, abruptio placentae, and adverse neonatal outcomes among women with chronic hypertension. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

Evaluation of Low-Dose Aspirin to Prevent Preeclampsia in Pregnant People with Chronic Hypertension

OBJECTIVE

 Our objective was to evaluate if the use of low-dose aspirin (LDA) among pregnant individuals with chronic hypertension (CHTN) reduces the rate of superimposed preeclampsia or other adverse maternal and neonatal outcomes.

STUDY DESIGN

 Our study included single-center cohort of pregnant individuals with CHTN who had a live birth after 23 weeks' gestation, between 2013 and 2018. The primary exposure was the use of LDA in pregnancy and the primary outcome was superimposed preeclampsia. LDA use was also evaluated by the timing of initiation, before or after 16 weeks' gestation. Secondary outcomes included preeclampsia subtypes (e.g., preeclampsia with severe features, early-onset disease), as well as adverse maternal and neonatal outcomes. Differences were analyzed by χ 2, Fisher's exact, or t tests, with logistic regression to adjust for confounders.

RESULTS

 Of 11,825 deliveries during the study period, 494 (4.2%) occurred in women with CHTN. Among those with CHTN, 174 (35%) were prescribed LDA, most often 81 mg daily (173 out of 174, 99%). Baseline characteristics were similar between groups, but the history of preeclampsia was more common in those prescribed LDA. The rate of superimposed preeclampsia was no different among those with CHTN-prescribed LDA compared with those who were not (36% vs. 30%, p = 0.2), even when restricting the analysis to those prescribed LDA before 16 weeks' gestation (33 vs. 30%, p = 0.2). In addition, LDA did not lead to a reduction in the rate of preeclampsia with severe features, early-onset preeclampsia, or other adverse maternal outcomes. However, the composite rate of adverse neonatal outcomes was lower in LDA users versus nonusers (4.0 vs. 13%, p = 0.002), which persisted after multivariable adjustment (adjusted odds ratio: 0.28, 95% confidence interval: 0.12-0.67).

CONCLUSION

 Among pregnant individuals with CHTN, LDA did not decrease the rate of superimposed preeclampsia. Further studies are warranted to validate our observed reduction in adverse neonatal outcomes and to determine if aspirin is more beneficial at dosages greater than 81 mg daily.

KEY POINTS

· Superimposed preeclampsia rates are the same regardless of LDA.. · Decreased rate of adverse neonatal outcomes is seen with LDA.. · No decrease in adverse maternal outcomes is seen with LDA..

Understanding Health Disparities in Preeclampsia: A Literature Review

Preeclampsia is a multifactorial pathology with negative outcomes in affected patients in both the peripartum and postpartum period. Black patients in the United States, when compared to their White and Hispanic counterparts, have higher rates of preeclampsia. This article aims to review the current literature to investigate how race, social determinants of health, and genetic profiles influence the prevalence and outcomes of patients with preeclampsia. Published studies utilized in this review were identified through PubMed using authors' topic knowledge and a focused search through a Medline search strategy. These articles were thoroughly reviewed to explore the contributing biosocial factors, genes/biomarkers, as well as negative outcomes associated with disparate rates of preeclampsia. Increased rates of contributing comorbidities, including hypertension and obesity, which are largely associated with low access to care in Black patient populations lead to disparate rates of preeclampsia in this population. Limited research shows an association between increased rate of preeclampsia in Black patients and specific APOL1, HLA-G, and PP13 gene polymorphisms as well as factor V Leiden mutations. Further research is required to understand the use of certain biomarkers in predicting preeclampsia within racial populations. Understanding contributing biosocial factors and identifying genes that may predispose high-risk populations may help to address the disparate rates of preeclampsia in Black patients as described in this review. Further research is required to understand if serum, placental, or urine biomarkers may be used to predict individuals at risk of developing preeclampsia in pregnancy. KEY POINTS: · Prevalence of preeclampsia in the U.S. is higher in Black patients compared to other racial groups.. · Patients with preeclampsia are at risk for poorer health outcomes both during and after delivery.. · Limited research suggests specific biomarkers or gene polymorphisms contribute to this difference; however, explanations for this disparity are multifactorial and further investigation is necessary..

Risk Factors for Early- and Late-Onset Superimposed Preeclampsia

OBJECTIVE

 Risk factors of early- and late-onset preeclampsia among pregnant individuals with chronic hypertension are not well described in the literature. We hypothesized that early- and late-onset superimposed preeclampsia (SIPE) have different risk factors. Therefore, we aimed to examine the risk factors of early- and late-onset SIPE among individuals with chronic hypertension.

STUDY DESIGN

 This was a retrospective case-control study of pregnant individuals with chronic hypertension who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as SIPE diagnosed before 34 weeks' gestation. To identify risk factors, we compared individuals' characteristics between individuals who developed early- and late-onset SIPE and those who did not. We then compared characteristics between individuals who developed early-onset SIPE and late-onset SIPE. Characteristics with p-values of less than 0.05 by bivariable variables were analyzed by simple and multivariable logistic regression models to calculate crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). Missing values were imputed with multiple imputation.

RESULTS

 Of 839 individuals, 156 (18.6%) had early-onset, 154 (18.4%) had late-onset SIPE and 529 (63.1%) did not have SIPE. The multivariate logistic regression model showed that serum creatinine ≥ 0.7 mg/dL compared to less than 0.7 mg/dL (aOR: 2.89 [95% CI: 1.63-5.13]), increase of creatinine (1.33 [1.16-1.53]), nulliparity compared to multiparity (1.77 [1.21-2.60]), and pregestational diabetes (1.70 [1.11-2.62]) were risk factors for early-onset SIPE. The multivariate logistic regression model showed that nulliparity compared to multiparity (1.53 [1.05-2.22]) and pregestational diabetes (1.74 [1.14-2.64]) was a risk factor for late-onset SIPE. Serum creatinine ≥ 0.7 mg/dL (2.90 [1.36-6.15]) and increase of creatinine (1.33 [1.10-1.60]) were significantly associated with early-onset SIPE compared to late-onset SIPE.

CONCLUSION

 Kidney dysfunction seemed to be associated with the pathophysiology of early-onset SIPE. Nulliparity and pregestational diabetes were common risk factors for both early- and late-onset SIPE.

KEY POINTS

· Serum creatinine level was positively associated with early-onset superimposed preeclampsia (SIPE).. · Pregestational diabetes and nulliparity were associated with both early- and late-onset SIPE.. · The identification of risk factors may provide an opportunity to decrease the rates of SIPE..

Antihypertensive Medication Use before and during Pregnancy and the Risk of Severe Maternal Morbidity in Individuals with Prepregnancy Hypertension

OBJECTIVE

 Our objective is to examine severe maternal morbidity (SMM) and patterns of antihypertensive medication use before and during pregnancy among individuals with chronic hypertension.

STUDY DESIGN

 We examined 11,759 pregnancies resulting in a live birth or stillbirth to individuals with chronic hypertension and one or more antihypertensive prescription 6 months before pregnancy (Optum, 2007-17). We examined whether study outcomes were associated with the use of medication as compared to no use during pregnancy. In addition, patterns of medication use based on the Food and Drug Administration guidance and literature were evaluated. Medication use was divided into prepregnancy and during pregnancy use and classified as pregnancy recommended (PR) or not pregnancy recommended (nPR) or no medication use. SMM was defined per the Centers for Disease Control and Prevention definition of 21 indicators. Risk ratios (RR) reflecting the association of SMM with the use of antihypertensive medications were computed using modified Poisson regression with robust standard errors and adjusted for maternal age, education, and birth year.

RESULTS

 Overall, 83% of individuals filled an antihypertensive prescription during pregnancy and 6.3% experienced SMM. The majority of individuals with a prescription prior to pregnancy had a prescription for the same medication in pregnancy. Individuals with any versus no medication use in pregnancy had increased adjusted RR (aRR) of SMM (1.18, 95% confidence interval [CI]: 0.96-1.44). Compared to the use of PR medications before and during pregnancy, aRRs were 1.42 (95% CI: 1.18-1.69, 12.4% of sample) for nPR use before and during pregnancy, 1.52 (1.23-1.86; 12.4%) for nPR (before) and PR (during) use, and 2.67 (1.73-4.15) for PR and nPR use. Patterns with no medication use during pregnancy were not statistically significant.

CONCLUSION

 Pattern of antihypertensive medication use before and during pregnancy may be associated with an elevated risk of SMM. Further research is required to elucidate whether this association is related to the severity of hypertension, medication effectiveness, or suboptimal quality of care.

KEY POINTS

· Individuals with any medication use compared to no medication use in pregnancy had an increased risk of SMM.. · Specific medication use patterns were associated with an elevated risk of SMM.. · Pattern of antihypertensive medication use before and during pregnancy may be associated with an increased risk of SMM..

Comparison of Adverse Maternal Outcomes between Early- and Late-Onset Superimposed Preeclampsia

OBJECTIVE

 Superimposed preeclampsia (SIPE), defined as preeclampsia in individuals with chronic hypertension, is one of the most common complications, accounting for 13 to 40% of pregnancies with chronic hypertension. However, there are limited data regarding maternal outcomes of early- and late-onset SIPE in individuals with chronic hypertension. We hypothesized that early-onset SIPE was associated with increased odds of adverse maternal outcomes compared with late-onset SIPE. Therefore, we aimed to compare adverse maternal outcomes between individuals with early-onset SIPE and those with late-onset SIPE.

STUDY DESIGN

 This was a retrospective cohort study of pregnant individuals with SIPE who delivered at 22 weeks' gestation or greater at an academic institution. Early-onset SIPE was defined as the onset of SIPE before 34 weeks' gestation. Late-onset SIPE was defined as the onset of SIPE at or after 34 weeks' gestation. Our primary outcome was a composite of eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, maternal death, placental abruption, pulmonary edema, SIPE with severe features, and thromboembolic disease. Maternal outcomes were compared between early- and late-onset SIPE. We used simple and multivariate logistic regression models to calculate crude and adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

RESULTS

 Of 311 individuals, 157 (50.5%) had early-onset SIPE, 154 (49.5%) had late-onset SIPE. There were significant differences in the proportions of obstetric complications, including the primary outcome, HELLP syndrome, SIPE with severe features, fetal growth restriction (FGR), and cesarean delivery between early- and late-onset SIPE. Compared with individuals with late-onset SIPE, those with early-onset SIPE had increased odds of the primary outcome (aOR: 3.28; 95% CI: 1.42-7.59), SIPE with severe features (aOR: 2.72; 95% CI: 1.25-5.90), FGR (aOR: 6.07; 95% CI: 3.25-11.36), and cesarean delivery (aOR 3.42; 95% CI: 2.03-5.75).

CONCLUSION

 Individuals with early-onset SIPE had higher odds of adverse maternal outcomes compared with those with late-onset SIPE.

KEY POINTS

· We revealed the incidence of maternal outcomes in early- and late-onset SIPE.. · Severe features were common in individuals with SIPE.. · Early-onset SIPE was associated with increased adverse maternal outcomes compared with late-onset SIPE..

Does Developing Interpregnancy Hypertension Affect the Recurrence Risk of Preeclampsia? A population-based cohort study

BACKGROUND

Preeclampsia in a first pregnancy is a strong risk factor for preeclampsia in a second pregnancy. Whether chronic hypertension developed after a first pregnancy (interpregnancy hypertension) affects the recurrence risk of preeclampsia is unknown.

METHODS

This is a population-based cohort study of 391,645 women with their first and second singleton births between 2006 and 2017. Exposure groups were women with preeclampsia in their first pregnancy, interpregnancy hypertension, or both risk factors. Women with neither risk factor were used as a reference group. We calculated the adjusted relative risk (aRR) with 95% confidence intervals (CIs) for overall preeclampsia in the second pregnancy as well as preterm (<37 gestational weeks) and term (>37 gestational weeks) subgroups of the disease.

RESULTS

Women with preeclampsia in their first pregnancy who did or did not develop interpregnancy hypertension had rates of preeclampsia in their second pregnancy of 21.5% and 13.6%, respectively. In the same population, the corresponding rates of preterm preeclampsia were 5.5% and 2.6%, respectively. After adjusting for maternal factors, women with preeclampsia in their first pregnancy who developed interpregnancy hypertension and those who did not had almost the same risk of overall preeclampsia in their second pregnancy (aRRs with 95% CIs: 14.51; 11.77-17.89 and 12.83; 12.09-13.62, respectively). However, preeclampsia in first pregnancy and interpregnancy hypertension had a synergistic interaction on the outcome preterm preeclampsia (aRR with 95% CI 26.66; 17.44- 40.80).

CONCLUSIONS

Women with previous preeclampsia who developed interpregnancy hypertension had a very high rate of preterm preeclampsia in a second pregnancy, and the two risk factors had a synergistic interaction.

Women with elevated blood pressure and stage 1 hypertension are at high risk for preeclampsia. A retrospective study at a tertiary facility in Japan

AIM

In 2017, the American College of Cardiology (ACC) re-defined hypertension (HT) as follows: elevated blood pressure (EBP), systolic blood pressure (SBP) 120-129 mmHg and diastolic blood pressure (DBP) <80 mmHg; stage 1 HT, SBP 130-139 mmHg or DBP 80-89 mmHg; and stage 2 HT: SBP ≥140 mmHg or DBP ≥90 mmHg. It is well known that women with stage 2 HT are at higher risk of preeclampsia and have poorer pregnancy and delivery outcomes. While there are few reports on the risk in women with EBP and stage 1 HT, and none from Japan. This study aimed to determine whether women in Japan with EBP and stage 1 HT are at risk of preeclampsia.

METHODS

In this single-center retrospective study conducted in Japan, subjects were classified into stage 2 HT, stage 1 HT, EBP, and normal groups based on blood pressure measurements at the time of the first visit before 20 weeks of gestation. Women with a diagnosis of hypertension made before pregnancy were classified into the stage 2 HT group. We compared pregnancy and delivery outcomes, such as preeclampsia, between groups.

RESULTS

A total of 5129 cases (normal, n = 4283; EBP, n = 427; stage 1 HT, n = 303; stage 2 HT, n = 116) were included. Preeclampsia incidence rates were 2.7%, 5.6%, 10.6%, and 21.6%, respectively. The adjusted OR (95% CI) for preeclampsia incidence were 2.90 (1.81-4.66), 5.90 (3.87-9.20), and 13.80 (7.97-24.0), respectively.

CONCLUSIONS

Women with EBP and stage 1 HT are at high risk of preeclampsia, similar to those with stage 2 HT.

Chronic Hypertension in Pregnancy and Placenta-Mediated Complications Regardless of Preeclampsia

BACKGROUND

The prevalence of chronic hypertension in women of reproductive age is on the rise mainly due to delayed childbearing. Maternal chronic hypertension, prevailing prior to conception or manifesting within the early gestational period, poses a substantial risk for the development of preeclampsia with adverse maternal and fetal outcomes, specifically as a result of placental dysfunction. We aimed to investigate whether chronic hypertension is associated with placenta-mediated complications regardless of the development of preeclampsia in pregnancy.

METHODS

This was a population-based, retrospective cohort study from 'Soroka' university medical center (SUMC) in Israel, of women who gave birth between 1991 and 2021, comparing placenta-mediated complications (including fetal growth restriction (FGR), placental abruption, preterm delivery, and perinatal mortality) in women with and without chronic hypertension. Generalized estimating equation (GEE) models were used for each outcome to control for possible confounding factors.

RESULTS

A total of 356,356 deliveries met the study's inclusion criteria. Of them, 3949 (1.1%) deliveries were of mothers with chronic hypertension. Women with chronic hypertension had significantly higher rates of all placenta-mediated complications investigated in this study. The GEE models adjusting for preeclampsia and other confounding factors affirmed that chronic hypertension is independently associated with all the studied placental complications except placental abruption.

CONCLUSIONS

Chronic hypertension in pregnancy is associated with placenta-mediated complications, regardless of preeclampsia. Therefore, early diagnosis of chronic hypertension is warranted in order to provide adequate pregnancy follow-up and close monitoring for placental complications, especially in an era of advanced maternal age.

MTHFR A1298C polymorphism: a predictor of reduced risk of preeclampsia in Punjab, Pakistan

OBJECTIVES

This study aimed to investigate the genetic association between MTHFR (A1298C) SNP and preeclampsia (PE) in Punjab, Pakistan.

METHODS

A sample of 80 pregnant women (40 healthy pregnant women and 40 with PE) was pooled for genotyping MTHFR A1298C polymorphism by using the tetra-primer amplification refractory mutation system (ARMS) PCR. The Genotypic and allelic assessments were performed using various statistical techniques.

RESULTS

The AC genotype and C allele of MTHFR A1298C were found to be associated with decreased risk of PE (odds ratio [OR]: 0.31, risk ratio [RR]: 0.58, p = 0.01), and (odds ratio [OR]: 0.49, risk ratio [RR]: 0.61, p = 0.04), respectively.

CONCLUSION

In conclusion, genetic polymorphism A1298C in MTHFR may pose a protective effect in the studied population.

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.

Pregestational maternal risk factors for preterm and term preeclampsia: A population-based cohort study

INTRODUCTION

Most studies on factors affecting the risk of preeclampsia have not separated preterm from term preeclampsia, and we still know little about whether the predisposing conditions have a differentiated effect on the risk of preterm and term preeclampsia. Our aim was to assess whether diabetes type 1 and 2, chronic kidney disease, asthma, epilepsy, rheumatoid arthritis and chronic hypertension were differentially associated with preterm and term preeclampsia.

MATERIAL AND METHODS

This is a nationwide, population-based cohort study containing all births registered in the Medical Birth Registry of Norway from 1999 to 2016. Multinomial logistic regression analysis was used to estimate relative risk ratios (RRRs) with 95% confidence intervals (95% CIs), adjusting for maternal age, parity, multiple gestation and all other studied maternal risk factors.

RESULTS

We registered 1 044 860 deliveries, of which 9533 (0.9%) women had preterm preeclampsia (<37 weeks) and 26 504 (2.5%) women had term preeclampsia (>37 weeks). Most of the assessed maternal risk factors were associated with increased risk for both preterm and term preeclampsia, with adjusted RRRs ranging from 1.2 to 10.5 (preterm vs no preeclampsia) and 0.9-5.7 (term vs no preeclampsia). Diabetes type 1 and 2 (RRR preterm vs term preeclampsia 2.89, 95% CI 2.46-3.39 and RRR 1.68, 95% CI 1.25-2.25, respectively), chronic kidney disease (RRR 1.55, 95% CI 1.11-2.17) and chronic hypertension (RRR 1.85, 95% CI 1.63-2.10) were more strongly associated with preterm than term preeclampsia in adjusted analyses. For asthma, epilepsy and rheumatoid arthritis, RRRs were closer to one and not significant when comparing risk of preterm and term preeclampsia. Main results were similar when using a diagnosis at <34 weeks to define preterm preeclampsia.

CONCLUSIONS

Diabetes type 1 and 2, chronic kidney disease and chronic hypertension were more strongly associated with preterm than term preeclampsia.

Risks of urgent cesarean delivery preceding the planned schedule: A retrospective cohort study

PURPOSE

The aim of the study was to ascertain risk factors and outcomes of elective cesarean deliveries performed urgently prior to their scheduled date.

METHODS

Women carrying a viable singleton fetus who were scheduled for elective cesarean delivery at a tertiary medical center between 2012-2020 were identified by retrospective database. Differences in maternal and neonatal parameters between those who ultimately required urgent cesarean delivery and those who underwent the procedure as scheduled were analyzed.

RESULTS

Of 4403 women who met the inclusion criteria, 559 underwent urgent cesarean delivery before the scheduled date. On multivariate analysis, factors significantly associated with a risk of transformation to an urgent cesarean delivery were chronic hypertension (aOR 1.92, 95% CI 1.30-2.83 P = 0.001), antenatal corticosteroids administration (aOR 3.26, 95% CI 2.38-4.47, P <0.001), and contraindication for vaginal delivery as the reason for elective cesarean delivery (aOR 1.67, 95% CI 1.32-2.12, P <0.001). Neonates born via urgent cesareans had an increased risk of 1-minute Apgar <7 (6% vs. 1.7%, P <0.001), intensive care unit admission (6.6% vs. 2.5%, P <0.001); their mothers were at risk of postpartum hemorrhage (5.9% vs. 3%, P = 0.001).

CONCLUSIONS

The present study sheds light on the risk factors and maternal and fetal morbidities associated with elective cesarean deliveries that become urgent before the originally scheduled date. Physicians should take this information into account when planning an optimal date for elective cesarean delivery.

Late Pregnant Dahl Salt-Sensitive Rats from Charles River Laboratories Do Not Exhibit Superimposed Preeclampsia

Healthy pregnancy is characterized by a reduction in total peripheral vascular resistance which produces a decrease in maternal blood pressure. Failure of this normal maternal adaptation to pregnancy results in hypertensive disorders of pregnancy, which are dangerous for both the mother and fetus. Recently, it has been proposed that Dahl salt-sensitive (SS) rats are a model of spontaneous superimposed preeclampsia when maintained on a normal salt diet. Since these reports are from animals that are derived from sources that are not commercially available, the purpose of this study was to evaluate the blood pressure and pregnancy outcomes of SS rats from a commercial vendor. Mean arterial blood pressure was measured by indwelling femoral catheter in anesthetized SS virgin and SS day 21 late pregnant rats from Charles River Laboratories (CRL). Fetal outcomes from SS rats and control Sprague-Dawley (SD) rats were also measured. All rats were euthanized by exsanguination under anesthesia and tissues weighed. Virgin SS rats were found to have normal mean arterial blood pressure (102 ± 2 mmHg), and late pregnant SS rats had the normal decrease in maternal blood pressure. SS rats were also found to have normal pregnancy outcomes. These results suggest that SS rats from CRL are not a model of superimposed preeclampsia. Further studies will be aimed at determining the differences between the blood pressure phenotype and pregnancy outcomes of existing colonies of SS rats in order to elucidate the mechanisms permitting the development of preeclampsia in certain colonies of this strain.

Tight vs liberal control of mild postpartum hypertension: a randomized controlled trial

BACKGROUND

High-quality evidence to inform the management of postpartum hypertension, including the optimal blood pressure threshold to initiate therapy, is lacking. Randomized trials have been conducted in pregnancy, but there are no published trials to guide management in the postpartum period.

OBJECTIVE

This study aimed to test the hypothesis that initiating antihypertensive therapy in the postpartum period at a threshold of 140/90 mm Hg would result in less maternal morbidity than initiating therapy at a threshold of 150/95 mm Hg.

STUDY DESIGN

We performed a pragmatic multicenter randomized controlled trial of patients aged 18 to 55 years with postpartum hypertension. Patients with chronic hypertension, gestational hypertension, and preeclampsia without severe features were randomized to 1 of 2 blood pressure thresholds to initiate treatment: persistent blood pressure of ≥150/95 mm Hg (institutional standard or "liberal control" group) or ≥140/90 mm Hg (intervention or "tight control" group). Our primary outcome was composite maternal morbidity defined as: severe hypertension (blood pressure ≥160/110 mm Hg) or preeclampsia with severe features, the need for a second antihypertensive agent, postpartum hospitalization >4 days, and maternal adverse outcome secondary to hypertension as evidenced by pulmonary edema, acute kidney injury (creatinine level ≥1.1 mg/dL), cardiac dysfunction (eg, elevated brain natriuretic peptide level) or cardiomyopathy, posterior reversible encephalopathy syndrome, cerebrovascular accident, or admission to an intensive care unit. Secondary outcomes included hospital readmission for hypertension, persistence of hypertension beyond 14 days, medication side effects, and time to blood pressure control. We calculated that 256 women would provide 90% power to detect a relative 50% reduction in the primary outcome from 36% in the standard blood pressure threshold group to 18%, with a 2-sided alpha set at 0.05 for significance. Data were analyzed using R statistical software.

RESULTS

A total of 256 patients were randomized, including 128 to the "tight control" group (140/90 mm Hg) and 128 to the "liberal control" group (150/95 mm Hg). Patients in the "tight control" group had a higher body mass index at delivery (37.1±9.4 vs 34.9±8.1; P=.04); other demographic and obstetrical characteristics were similar between groups. The rate of the primary outcome was similar between groups (8.6% vs 11.7%; P=.41; relative risk, 0.73; 95% confidence interval, 0.35-1.53). The rates of all secondary outcomes and the individual components of the primary and secondary outcome measures were also similar between groups.

CONCLUSION

In the postpartum period, initiation of antihypertensive therapy at a lower blood pressure threshold of 140/90 mm Hg did not decrease maternal morbidity or improve outcomes compared with a threshold of 150/95 mm Hg.

Hypertensive Disorders of Pregnancy

Hypertensive disorders in pregnancy are a leading cause of global maternal and fetal morbidity. The four hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. A careful history, review of systems, physical examination, and laboratory analysis can help differentiate these disorders and quantify the severity of the disease, which holds important implications for disease management. This article reviews the different types of disorders of hypertension in pregnancy and how to diagnose and manage these patients, with special attention paid to any recent changes made to this management algorithm.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Animal Models of Preeclampsia: Mechanistic Insights and Promising Therapeutics

Preeclampsia (PE) is a common pregnancy-specific disorder that is a major cause of both maternal and fetal morbidity and mortality. Central to the pathogenesis of PE is the production of antiangiogenic and inflammatory factors by the hypoxic placenta, leading to the downstream manifestations of the disease, including hypertension and end-organ damage. Currently, effective treatments are limited for PE; however, the development of preclinical animal models has helped in the development and evaluation of new therapeutics. In this review, we will summarize some of the more commonly used models of PE and highlight their similarities to the human syndrome, as well as the therapeutics tested in each model.

A case of a pregnant woman with primary aldosteronism and superimposed preeclampsia treated with esaxerenone

During pregnancy, there is no established treatment for idiopathic hyperaldosteronism (IHA), the most common form of primary aldosteronism (PA) due to bilateral adrenal hyperplasia. Here, we report the case of a pregnant patient with IHA who was successfully treated with esaxerenone, a non-steroidal mineralocorticoid receptor (MR) antagonist. A 39-year-old woman, was diagnosed with IHA and commenced on nifedipine 20 mg daily because she desired to be pregnant. After one year, she became pregnant. Her blood pressure was well controlled until 34 weeks of gestation when her home blood pressure became elevated up to 140/90 mmHg. Although the dose of nifedipine was increased to 80 mg daily, her blood pressure increased to 151/97 mmHg and urinary test showed proteinuria of 2+ in 35 weeks of gestation. She was diagnosed with superimposed preeclampsia (SPE) and additionally treated with esaxerenone. Her blood pressure decreased to 120-140/98-100 mmHg and the proteinuria improved to +/-. A successful cesarean section at 37 weeks resulted in the delivery of a healthy baby boy. Her blood pressure was well controlled although esaxerenone was discontinued 2 weeks after the delivery. This is the first case of a pregnant woman who was safely treated with esaxerenone despite being a female at advanced maternal age who had been diagnosed with IHA and developed SPE. Further studies are needed to investigate the efficacy and safety of non-steroidal selective MR antagonist in similar pregnant patients with IHA, to establish better treatment strategy for these patients.

The Impact of Preeclampsia in Lupus Nephritis

INTRODUCTION

Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality.

AREAS COVERED

A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN.

EXPERT OPINION

Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6-12 months after delivery in all patients.

Pre-pregnancy blood pressure and pregnancy outcomes: a nationwide population-based study

Background

Hypertension has been known to increase the risk of obstetric complications. Recently, the American College of Cardiology endorsed lower thresholds for hypertension as systolic blood pressure of 130-139 mmHg or diastolic blood pressure 80-89 mmHg. However, there is a paucity of information regarding the impact of pre-pregnancy blood pressure on pregnancy outcomes. We aimed to evaluate the effect of pre-pregnancy blood pressure on maternal and neonatal complications.

Methods

In this nationwide, population based study, pregnant women without history of hypertension and pre-pregnancy blood pressure < 140/90 mmHg were enrolled. The primary outcome of composite morbidity was defined as any of the followings: preeclampsia, placental abruption, stillbirth, preterm birth, or low birth weight.

Results

A total of 375,305 pregnant women were included. After adjusting for covariates, the risk of composite morbidity was greater in those with stage I hypertension in comparison with the normotensive group (systolic blood pressure, odds ratio = 1.68, 95% CI: 1.59 – 1.78; diastolic blood pressure, odds ratio = 1.56, 95% CI: 1.42 – 1.72). There was a linear association between pre-pregnancy blood pressure and the primary outcome, with risk maximizing at newly defined stage I hypertension and with risk decreasing at lower blood pressure ranges.

Conclusions

‘The lower, the better’ phenomenon was still valid for both maternal and neonatal outcomes. Our results suggest that the recent changes in diagnostic thresholds for hypertension may also apply to pregnant women. Therefore, women with stage I hypertension prior to pregnancy should be carefully observed for adverse outcomes.

Cardiovascular determinants of impaired placental function in women with cardiac dysfunction

Female heart disease has for a long time been an underrecognized problem in the field of cardiology. With an ever-growing number of these patients getting pregnant, cardiac dysfunction during pregnancy is an increasingly large medical problem. Previous work has shown that maternal heart disease may have an adverse effect on pregnancy outcome in both mother and child. The placenta forms the connection and it is postulated that cardiac dysfunction negatively affects the placenta, and consequently, neonatal outcome. Given the paucity of data in this field, more research on the influence of cardiac (mal)function on placental (mal)function is needed. The present review describes placental function in women with various types of cardiac dysfunction, thereby aiming to provide more insight into possible underlying mechanisms of placental malfunction. Organ dysfunction in patients with heart failure is for an important part based on reduced perfusion and venous congestion. This has been shown in other organs such as kidneys, liver and brain. In pregnant women with cardiac dysfunction, placental dysfunction may follow similar patterns. Moreover, other factors, such as pre-existing hypertension and chronic hypoxia may lead to further impairment of placental function, through abnormal vascular remodeling of the uterine spiral arteries. The pathophysiology of placental dysfunction in pregnant women with cardiac dysfunction may thus be multifactorial. It is therefore important to monitor closely cardiac and placental function in such high-risk pregnancies. Gaining a better understanding of the underlying pathophysiological mechanisms may have important clinical implications in terms of pregnancy counseling, monitoring and outcome.

Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance

Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.

Toward personalized management of chronic hypertension in pregnancy

Chronic hypertension complicates 1% to 2% of pregnancies, and it is increasingly common. Women with chronic hypertension are an easily recognized group who are in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. We reviewed recent data on management to inform current care and future research. This study is a narrative review of published literature. Compared with normotensive women, women with chronic hypertension are at an increased risk of maternal and perinatal complications. Women with chronic hypertension who wish to be involved in their care can do by measuring blood pressure at home. Accurate devices for home blood pressure monitoring are now readily available. The diagnostic criteria for superimposed preeclampsia remain problematic because most guidelines continue to include deteriorating blood pressure control in the definition. It has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely available clinical data and laboratory results. Although chronic hypertension is a strong risk factor for preeclampsia, and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. It is unclear whether calcium has an independent effect in preeclampsia prevention in such women. Treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been observed; however, the lack of evidence for the latter is possibly owing to few events. In addition, treating chronic hypertension neither reduces nor increases fetal or newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. Antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. At present, blood pressure treatment targets used in clinics are the same as those used at home, although blood pressure values tend to be inconsistently lower at home among women with hypertension. Although starting all women on the same antihypertensive medication is usually effective in reducing blood pressure, it remains unclear whether there is an optimal agent for such an approach or how best to use combinations of antihypertensive medications. An alternative approach is to individualize care, using maternal characteristics and blood pressure features beyond blood pressure level (eg, variability) that are of prognostic value. Outcomes may be improved by timed birth between 38 0/7 and 39 6/7 weeks' gestation based on observational literature; of note, confirmatory trial evidence is pending. Postnatal care is facilitated by the acceptability of most antihypertensives (including angiotensin-converting enzymes inhibitors) for use in breastfeeding. The evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning with international guidelines. Addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy.

Chronic hypertension and superimposed preeclampsia: screening and diagnosis

Superimposed preeclampsia complicates about 20% of pregnancies in women with chronic hypertension and is associated with increased maternal and perinatal morbidity compared with preeclampsia alone. Distinguishing superimposed preeclampsia from chronic hypertension can be challenging because, in chronic hypertension, the traditional criteria for the diagnosis of preeclampsia, hypertension, and significant proteinuria can often predate the pregnancy. Furthermore, the prevalence of superimposed preeclampsia is unlikely to be uniformly distributed across this high-risk group but is related to the severity of preexisting endothelial dysfunction. This has led to interest in identifying biomarkers that could help in screening and diagnosis of superimposed preeclampsia and in the stratification of risk in women with chronic hypertension. Elevated levels of uric acid and suppression of other renal biomarkers, such as the renin-angiotensin aldosterone system, have been demonstrated in women with superimposed preeclampsia but perform only modestly in its prediction. In addition, central to the pathogenesis of preeclampsia is a tendency toward an antiangiogenic state thought to be triggered by an impaired placenta and, ultimately, contributing to the endothelial dysfunction pathognomonic of the disease. In the general obstetrical population, angiogenic factors, such as soluble fms-like tyrosine kinase-1 and placental growth factor, have shown promise in the prediction of preeclampsia. However, soluble fms-like tyrosine kinase-1 and placental growth factor are impaired in women with chronic hypertension irrespective of whether they develop superimposed preeclampsia. Therefore, the differences in levels are less discriminatory in the prediction of superimposed preeclampsia compared with the general obstetrical population. Alternative biomarkers to the angiogenic and renal factors include those of endothelial dysfunction. A characteristic of both preeclampsia and chronic hypertension is an exaggerated systemic inflammatory response causing or augmenting endothelial dysfunction. Thus, proinflammatory mediators, such as tumor necrosis factor-α, interleukin-6, cell adhesion molecules, and endothelin, have been investigated for their role in the screening and diagnosis of superimposed preeclampsia in women with chronic hypertension. To date, the existing limited evidence suggests that the differences between those who develop superimposed preeclampsia and those who do not are, as with angiogenic factors, also modest and not clinically useful for the stratification of women with chronic hypertension. Finally, pro-B-type natriuretic peptide is regarded as a sensitive marker of early cardiac dysfunction that, in women with chronic hypertension, may predate the pregnancy. Thus, it has been proposed that pro-B-type natriuretic peptide could give insight as to the ability of women with chronic hypertension to adapt to the hemodynamic requirements of pregnancy and, subsequently, their risk of developing superimposed preeclampsia. Although higher levels of pro-B-type natriuretic peptide have been demonstrated in women with superimposed preeclampsia compared with those without, current evidence suggests that pro-B-type natriuretic peptide is not a predictor for the disease. The objectives of this review are to, first, discuss the current criteria for the diagnosis of superimposed preeclampsia and, second, to summarize the evidence for these potential biomarkers that may assist in the diagnosis of superimposed preeclampsia.

Common Combinations of Pregestational Diagnosis and Pregnancy Complications

Objective

Single pregestational diagnoses have been demonstrated to be associated with pregnancy-related complications. But, the effect of multiple diagnoses is understudied. The objective of this study is to determine the most common combinations of pregestational diagnoses and to determine if specific combinations increase the risk of pregnancy-related complications.

Study design

We performed a cross-sectional study of the 2016 Healthcare Cost and Utilization Project’s National Inpatient Sample (HCUP NIS) database. Inclusion criteria were: Diagnosis-related groups assumed to be associated with delivery, and three or fewer International Classification of Diseases, Tenth Revision (ICD-10), clinical modification codes with a prevalence greater than or equal to 0.5%, or clinically important risk factors in Bateman’s co-morbidity index. Chi-squared analysis of combinations of pregestational diagnoses was performed to assess the relative risk of pregnancy-related complications.

Results

The 2016 database included 255,233 delivered pregnancies. The most common combinations of pregestational diagnoses involved advanced maternal age, prior cesarean delivery, obesity, and tobacco use. Most combinations did not demonstrate an increased risk for complications greater than the risk with a single diagnosis. In those with statistically significant risk, all were 3-fold or less except we noted a 4.4-fold higher risk (95% CI: 3.16-6.15) of preeclampsia in obese patients of advanced maternal age compared to patients who were only of advanced maternal age.

Conclusion

Our results revealed that common combinations of pregestational diagnoses, in general, do not increase the risk for common pregnancy-related complications greater than the risk with a single diagnosis. This is reassuring, given that women entering pregnancy with multiple co-morbidities are becoming more common.

Human placental perfusion measured using dynamic contrast enhancement MRI

Objectives

To evaluate the feasibility of dynamic contrast enhanced magnetic resonance imaging (DCE MRI) and measure values of in vivo placental perfusion in women.

Methods

This study was part of the Placentimage trial (NCT01092949). Gadolinium-chelate (Gd) enhanced dynamic MRI was performed two days before termination of pregnancies at 16 to 34 weeks gestational age (GA). Quantitative analysis was performed using one-compartment intravascular modeling. DCE perfusion parameters were analyzed across GA and were compared in IUGR and AGA fetuses.

Results

134 patients were enrolled. After quality control check, 62 DCE MRI were analyzed including 48 and 14 pregnancies with normal and abnormal karyotypes, respectively. Mean placental blood flow was 129±61 mL/min/100ml in cases with normal karyotypes. Fetuses affected by IUGR (n = 13) showed significantly lower total placental blood flow values than AGA fetuses (n = 35) (F _total = 122±88 mL/min versus 259±34 mL/min, p = 0.002). DCE perfusion parameters showed a linear correlation with GA.

Conclusions

Measuring placental perfusion in vivo is possible using DCE MRI. Although this study has many limitations it gives us the first DCE MRI values that provide a potential standard for future research into placental perfusion methods and suggests that placental functional parameters are altered in IUGR pregnancies.

Fetal Growth Restriction: Does an Integrated Maternal Hemodynamic-Placental Model Fit Better?

In recent years, a growing interest has arisen regarding the possible relationship between adverse pregnancy outcomes (APOs) and inadequate maternal hemodynamic adaptations to the pregnancy. A possible association between "placental syndromes," such as preeclampsia (PE) and fetal growth restriction (FGR), and subsequent maternal cardiovascular diseases (CVD) later in life has been reported. The two subtypes of FGR show different pathogenetic and clinical features. Defective placentation, due to a poor trophoblastic invasion of the maternal spiral arteries, is believed to play a central role in the pathogenesis of early-onset PE and FGR. Since placental functioning is dependent on the maternal cardiovascular system, a pre-existent or subsequent cardiovascular impairment may play a key role in the pathogenesis of early-onset FGR. Late FGR does not seem to be determined by a primary abnormal placentation in the first trimester. The pathological pathway of late-onset FGR may be due to a primary maternal cardiovascular maladaptation: CV system shows a flat profile and remains similar to those of non-pregnant women. Since the second trimester, when the placenta is already developed and increases its functional request, a hypovolemic state could lead to placental hypoperfusion and to an altered maturation of the placental villous tree and therefore to an altered fetal growth. Thus, this review focalizes on the possible relationship between maternal cardiac function and placentation in the development of both early and late-onset FGR. A better understanding of maternal hemodynamics in pregnancies complicated by FGR could bring various benefits in clinical practice, improving screening and therapeutic tools.

Whither weathering? The variable significance of age in Black-White low birth weight disparities

This paper uses birth certificate data to provide novel estimates of the age-specific risk of a low birth weight birth (LBW, an infant born weighting <2500 g) for U.S.-born non-Hispanic Black and White mothers, and finds that patterns vary markedly over space and time. Notably, risk of an LBW birth for Black mothers increased much more steeply with age in 1991-94 than in 2014-17. This decline in LBW risks among older Black mothers led to a decline in the Black-White LBW gap of more than half a percentage point. Both patterns and changes were regional; while age gradients on the Black-White LBW gap were lowest in the South in 1991-94, by 2014-17 they had increased in the South and declined in the rest of the country. These descriptive data allow a new examination of hypotheses regarding the causes of age-specific racial LBW gaps. Research has found that racial disparities in a number of health outcomes, including LBW, increase with age, leading some to speculate that this increase is due to the cumulative effects of exposure to disadvantage. The large degree of variability in Black-White LBW disparities suggests that age-specific causes may also play a role. A series of counterfactual trend analyses explore the roles of two specific mechanisms, smoking and hypertension, and compares these to a more fundamental indicator of socioeconomic status: education.

A simplified point-of-care testing approach for preeclampsia blood biomarkers based on nanoscale field effect transistors

Rapid diagnosis of preeclampsia is necessary to ensure timely administration of appropriate care and prevent the potentially catastrophic complications of the condition affecting both mothers and babies. While the diagnostic superiority of angiogenic blood biomarkers such as placental growth factor has recently been demonstrated, there is an urgent need to develop point-of-care (PoC) technologies that allow rapid, quantitative, and accurate testing for these markers within local communities. Towards addressing this need, here we report on a fully integrated biodiagnostic platform based on nanoscale indium oxide field effect transistor (FET) sensors. The high-performance FET sensors are integrated with blood sample processing cartridges that minimize the need for operator intervention during the assay and eliminate the need for analytical equipment. Within 40 minutes and from 30 μL of blood, the FET platform could reliably measure PlGF with a limit of detection of 0.06 pg mL^-1 and a five order of magnitudes dynamic range. Pilot clinical validation in four preeclamptic pregnancies confirmed that the accuracy and reliability of the FET platform, paving the way for further development to a much-needed point-of-care preeclampsia testing.

Neurodevelopmental assessment of infants born to mothers with hypertensive disorder of pregnancy at six months of age

Infant neurodevelopment is a complex process which may be affected by different events during pregnancy, such as hypertensive disorders of pregnancy (HDP). We conducted a prospective cohort study to compare the prevalence of neurodevelopmental disorders in infants born to mothers with and without HDP at six months of age. Participants attended the Health Observatory of Instituto de Desarrollo e Investigaciones Pediátricas "Prof. Dr. Fernando E. Viteri" during 2018 and 2019. Infant neurodevelopment was assessed with the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III). Data were analyzed using Chi-square, Student's t-test and Mann-Whitney test. Of the 132 participating infants, 68 and 64 were born to mothers with and without HDP, respectively. At six months, the prevalence of risk of neurodevelopmental delay was significantly higher in infants born to mothers with than without HDP (27.9% vs. 9.4%; p = 0.008) (odds ratio, 3.71; 95% confidence interval, 1.30; 12.28). In conclusion, infants born to mothers with HDP had three times increased risk of neurodevelopmental delay at six months of age.

Effect of L-Arginine supplementation in pregnant women with chronic hypertension and previous placenta vascular disorders receiving Aspirin prophylaxis: a randomized control trial

BACKGROUND

The aim of the study is to evaluate the effects of supplementation with Arginine (L-Arg) 3g, (together with Magnesium (Mg) 350 mg and Salicilate (Sal) 100 mg) on maternal blood pressure (BP), uterine artery doppler PI and neonatal outcomes in women with high-risk pregnancy for chronic hypertension (CH) and other previous placenta vascular disorders (PVD) already treated with low dose of aspirin (LDA), as recommended by guidelines.

METHODS

We enrolled women affected by CH and other previous PVD referred to the High-Risk Clinic of the Mother-Infant Department of the University of Modena and Reggio Emilia from September 2017 to June 2019. The study design was a controlled, randomized trial of oral supplementation of L-Arg 3g (together with Mg 350 mg and Sal extract 100 mg) + LDA 100 mg/die versus only LDA 100 mg/die. Inclusion criteria were: singleton pregnancy; diagnosis of chronic hypertension, previous preeclampsia < 34 weeks, previous intrauterine growth restriction (IUGR) < 10° centile or previous stillbirth (SB) related to placenta vascular disorders; gestational age < 14 weeks. Each woman was enrolled between 12-14 weeks gestation and underwent 24-h ambulatory BP monitoring with an automatic device (SpaceLab 92710, Critikon, WA), repeated at 18-20th and 24-26th weeks. Moreover Uterine artery Doppler ultrasound evaluation including PI were performed at 18-20 weeks gestation and repeated at 24-26th weeks. Pregnancy outcomes data were collected in a password protected database.

RESULTS

Seventy-nine women agreed to participate in the study. No significant differences between the demographic characteristics in the two groups at enrollment (Group LDA + L-Arg: 30 patients versus Group LDA: 49 patient) were found. In the LDA-L-Arg group there isn't the significant increase in both systolic (127.22 ± 12.02 and 132.75 ± 7.51 mmHg, p=0.002) and diastolic (75.85 ± 8.53 and 83.63 ± 6.05 mmHg, p=0.0000) BP values at 24-26 weeks reveled in the LDA group. The value of the Uterine Artery Doppler median PI > 95° centile at 24-26 weeks show a significant reduction in the LDA+L-Arg group respect the LDA group (7 women, 23.3% vs 21 women, 42.9%; p=0.04). A significantly lower percentage of women received new antihypertensive drugs in the LDA+ L-Arg group than the LDA group (6.7% vs 24.5%) (p= 0.02). There was neither statistically significant difference in perinatal outcomes between 2 groups, except for trend of significance.

CONCLUSIONS

Although we found only trends of improvements of perinatal outcomes in LDA+LArg group, considering the promising results on BP values, uterine artery PI and the low need to start a new antihypertensive treatment, thus the resulting impact in reducing pregnancy medicalization, number of maternal-fetal well-being monitoring visits and the need of induction of labour, we believe that further studies should be performed to enlarge our observation and clarify the role of L-Arg 3g supplementation as a protective integration in high-risk pregnancies already in prophylaxis with LDA.

Impact of new definitions of preeclampsia at term on identification of adverse maternal and perinatal outcomes

BACKGROUND

Any definition of preeclampsia should identify women and babies at greatest risk of adverse outcomes.

OBJECTIVE

This study aimed to investigate the ability of the American College of Obstetricians and Gynecologists and International Society for the Study of Hypertension in Pregnancy definitions of preeclampsia at term gestational age (≥37 0/7 weeks) to identify adverse maternal and perinatal outcomes.

STUDY DESIGN

In this prospective cohort study at 2 maternity hospitals in England, women attending a routine hospital visit at 35 0/7 to 36 6/7 weeks' gestation underwent assessment that included history; ultrasonographic estimated fetal weight; Doppler measurements of the pulsatility index in the uterine, umbilical, and fetal middle cerebral arteries; and serum placental growth factor-to-soluble fms-like tyrosine kinase-1 ratio. Obstetrical records were examined for all women with chronic hypertension and those who developed new-onset hypertension, with preeclampsia (de novo or superimposed on chronic hypertension) defined in 5 ways: traditional, based on new-onset proteinuria; American College of Obstetricians and Gynecologists 2013 definition; International Society for the Study of Hypertension in Pregnancy maternal factors definition; International Society for the Study of Hypertension in Pregnancy maternal factors plus fetal death or fetal growth restriction definition, defined according to the 35 0/7 to 36 6/7 weeks' gestation scan as either estimated fetal weight <3rd percentile or estimated fetal weight at the 3rd to 10th percentile with any of uterine artery pulsatility index >95th percentile, umbilical artery pulsatility index >95th percentile, or middle cerebral artery pulsatility index <5th percentile; and International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance definition, defined as placental growth factor <5th percentile or soluble fms-like tyrosine kinase-1-to-serum placental growth factor >95th percentile. Detection rates for outcomes of interest (ie, severe maternal hypertension, major maternal morbidity, perinatal mortality or major neonatal morbidity, neonatal unit admission ≥48 hours, and birthweight <10th percentile) were compared using the chi-square test, and P<.05 was considered significant.

RESULTS

Among 15,248 singleton pregnancies, the identification of women with preeclampsia varied by definition: traditional, 15 of 281 (1.8%; 248); American College of Obstetricians and Gynecologists, 15 of 326 (2.1%; 248); International Society for the Study of Hypertension in Pregnancy maternal factors, 15 of 400 (2.6%; 248); International Society for the Study of Hypertension in Pregnancy maternal-fetal factors, 15 of 434 (2.8%; 248); and International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance, 15 of 500 (3.3%; 248). Compared with the traditional definition of preeclampsia, the International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance best identified the adverse outcomes: severe hypertension (40.6% [traditional] vs 66.9% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance, P<.0001], 59.2% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors, P=.004], 56.2% [International Society for the Study of Hypertension in Pregnancy maternal factors, P=.013], 46.1% [American College of Obstetricians and Gynecologists, P=.449]); P<.0001); composite maternal severe adverse event (72.2% [traditional] vs 100% for all others; P=.046); composite of perinatal mortality and morbidity (46.9% [traditional] vs 71.1% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance, P=.002], 62.2% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors, P=.06], 59.8% [International Society for the Study of Hypertension in Pregnancy maternal factors, P=.117], 49.4% [American College of Obstetricians and Gynecologists, P=.875]); neonatal unit admission for ≥48 hours (51.4% [traditional] vs 73.4% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance, P=.001], 64.5% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors, P=.070], 60.7% [International Society for the Study of Hypertension in Pregnancy maternal factors, P=.213], 53.3% [American College of Obstetricians and Gynecologists, P=.890]); birthweight <10th percentile (40.5% [traditional] vs 78.7% [International Society for the Study of Hypertension in Pregnancy maternal-fetal factors plus angiogenic imbalance, P<.0001], 70.1% [International Society for the Study of Hypertension in Pregnancy maternal-fetal, P<.0001], 51.3% [International Society for the Study of Hypertension in Pregnancy maternal factors, P=.064], 46.3% [American College of Obstetricians and Gynecologists, P=.349]).

CONCLUSION

Our findings present an evidence base for the broad definition of preeclampsia. Our data suggest that compared with a traditional definition, a broad definition of preeclampsia can better identify women and babies at risk of adverse outcomes. Compared with the American College of Obstetricians and Gynecologists definition, the more inclusive International Society for the Study of Hypertension in Pregnancy definition of maternal end-organ dysfunction seems to be more sensitive. The addition of uteroplacental dysfunction to the broad definition optimizes the identification of women and babies at risk, particularly when angiogenic factors are included.

Impact of Chronic Hypertension and Antihypertensive Treatment on Adverse Perinatal Outcomes: Systematic Review and Meta-Analysis

Background Maternal chronic hypertension is associated with adverse pregnancy outcomes. Previous studies examined the association between either chronic hypertension or antihypertensive treatment and adverse pregnancy outcomes. We aimed to synthesize the evidence on the effect of chronic hypertension/antihypertensive treatment on adverse pregnancy outcomes. Methods and Results Medline/PubMed, EMBASE, and Web of Science were searched; we included observational studies and assessed the effect of race/ethnicity, where possible, following a registered protocol (CRD42019120088). Random-effects meta-analyses were used. A total of 81 studies were identified on chronic hypertension, and a total of 16 studies were identified on antihypertensive treatment. Chronic hypertension was associated with higher odds of preeclampsia (adjusted odd ratio [aOR], 5.43; 95% CI, 3.85-7.65); cesarean section (aOR, 1.87; 95% CI, 1.6-2.16); maternal mortality (aOR, 4.80; 95% CI, 3.04-7.58); preterm birth (aOR, 2.23; 95% CI, 1.96-2.53); stillbirth (aOR, 2.32; 95% CI, 2.22-2.42); and small for gestational age (SGA) (aOR, 1.96; 95% CI, 1.6-2.40). Subgroup analyses indicated that maternal race/ethnicity does not influence the observed associations. Women with chronic hypertension on antihypertensive treatment (versus untreated) had higher odds of SGA (aOR, 1.86; 95% CI, 1.38-2.50). Conclusions Chronic hypertension is associated with adverse pregnancy outcomes, and these associations appear to be independent of maternal race/ethnicity. In women with chronic hypertension, those on treatment had a higher risk of SGA, although the number of studies was limited. This could result from a direct effect of the treatment or because severe hypertension during pregnancy is a risk factor for SGA and women with severe hypertension are more likely to be treated. The effect of antihypertensive treatment on SGA needs to be further tested with large randomized controlled trials.

Hypertension and reproductive dysfunction: a possible role of inflammation and inflammation-associated lymphangiogenesis in gonads

Hypertension is one of the most prevalent diseases that leads to end organ damage especially affecting the heart, kidney, brain, and eyes. Numerous studies have evaluated the association between hypertension and impaired sexual health, in both men and women. The detrimental effects of hypertension in men includes erectile dysfunction, decrease in semen volume, sperm count and motility, and abnormal sperm morphology. Similarly, hypertensive females exhibit decreased vaginal lubrication, reduced orgasm, and several complications in pregnancy leading to fetal and maternal morbidity and mortality. The adverse effect of hypertension on male and female fertility is attributed to hormonal imbalance and changes in the gonadal vasculature. However, mechanistic studies investigating the impact of hypertension on gonads in more detail on a molecular basis remain scarce. Hence, the aim of the current review is to address and summarize the effects of hypertension on reproductive health, and highlight the importance of research on the effects of hypertension on gonadal inflammation and lymphatics.

Current progress in clinical, molecular, and genetic aspects of adult fibromuscular dysplasia

Fibromuscular dysplasia (FMD) is a non-atherosclerotic vascular disease that may involve medium-sized muscular arteries throughout the body. The majority of FMD patients are women. Although a variety of genetic, mechanical, and hormonal factors play a role in the pathogenesis of FMD, overall, its cause remains poorly understood. It is probable that the pathogenesis of FMD is linked to a combination of genetic and environmental factors. Extensive studies have correlated the arterial lesions of FMD to histopathological findings of arterial fibrosis, cellular hyperplasia, and distortion of the abnormal architecture of the arterial wall. More recently, the vascular phenotype of lesions associated with FMD has been expanded to include arterial aneurysms, dissections, and tortuosity. However, in the absence of a string of beads or focal stenosis, these lesions do not suffice to establish the diagnosis. While FMD most commonly involves renal and cerebrovascular arteries, involvement of most arteries throughout the body has been reported. Increasing evidence highlights that FMD is a systemic arterial disease and that subclinical alterations can be found in non-affected arterial segments. Recent significant progress in FMD-related research which has led to improved understandings of the disease's clinical manifestations, natural history, epidemiology, and genetics. Ongoing work continues to focus on FMD genetics and proteomics, physiological effects of FMD on cardiovascular structure and function, and novel imaging modalities and blood-based biomarkers that can be used to identify subclinical FMD. It is also hoped that the next decade will bring the development of multi-centred and potentially international clinical trials to provide comparative effectiveness data to inform the optimal management of patients with FMD.

Chronic hypertension in pregnancy stratified by first-trimester blood pressure control and adverse perinatal outcomes: A prospective observational study

INTRODUCTION

The aim of this study was to assess perinatal outcomes in women with chronic hypertension (CH) stratified into four groups according to their blood pressure (BP) control in the first trimester of pregnancy.

MATERIAL AND METHODS

This was a prospective cohort study between January 2011 and June 2017, based in a university hospital in London, UK. The population consisted of four groups: group 1 included women without history of CH, presenting in the first trimester with BP >140/90 mmHg (n = 100). Groups 2-4 had prepregnancy CH; group 2 had BP <140/90 mmHg without antihypertensives (n = 234), group 3 had BP <140/90 mmHg with antihypertensives (n = 272), and group 4 had BP ≥140/90 mmHg despite antihypertensives (n = 194). The main outcome measures were: fetal growth restriction, admission to neonatal (NNU) or neonatal intensive care unit (NICU) for ≥2 days, composite neonatal morbidity, and composite serious adverse neonatal outcome. Outcomes were collected from the hospital databases and for up to 6 weeks postnatally. Differences between groups were assessed using chi-squared test and multivariate logistic regression was used to assess the independent contribution of the four groups to the prediction of pertinent outcomes, after controlling for maternal characteristics.

RESULTS

There was a higher incidence of fetal growth restriction in groups 3 (17.6%) and 4 (18.2%), compared with groups 1 (10.0%) and 2 (11.1%) (P = .04). There were more admissions to the NNU for ≥2 days in groups 3 (23.2%) and 4 (25.0%), compared with groups 1 (17.0%) and 2 (13.2%) (P = .008); and more admissions to NICU for ≥2 days in groups 3 (9.2%) and 4 (9.4%), compared with groups 1 (3.0%) and 2 (3.4%) (P = .01). Composite neonatal morbidity was higher in groups 3 (22.4%) and 4 (21.4%), compared with groups 1 (17.0%) and 2 (11.5%) (P = .009). Composite serious adverse postnatal outcome was higher in groups 3 (3.3%) and 4 (4.2%), compared with groups 1 (1.0%) and 2 (0.9%) but the difference did not reach statistical significance (P = .09). These results were also observed when values were adjusted for maternal characteristics.

CONCLUSIONS

In CH adverse perinatal outcomes are worse in women who are known to have CH and need antihypertensives in the first trimester of pregnancy. Women with newly diagnosed CH in the first trimester have similar outcomes to those with known CH who have antihypertensive treatment discontinued.

The impact of pre-eclampsia definitions on the identification of adverse outcome risk in hypertensive pregnancy - analyses from the CHIPS trial (Control of Hypertension in Pregnancy Study)

OBJECTIVE

To examine the association between pre-eclampsia definition and pregnancy outcome.

DESIGN

Secondary analysis of Control of Hypertension in Pregnancy Study (CHIPS) trial data.

SETTING

International multicentre randomised controlled trial (RCT).

POPULATION

In all, 987 women with non-severe non-proteinuric pregnancy hypertension.

METHODS

We evaluated the association between pre-eclampsia definitions and adverse pregnancy outcomes, stratified by hypertension type and blood pressure control.

MAIN OUTCOME MEASURES

Main CHIPS trial outcomes: primary (perinatal loss or high-level neonatal care for >48 hours), secondary (serious maternal complications), birthweight <10th centile, severe maternal hypertension, delivery at <34 or <37 weeks, and maternal hospitalisation before birth.

RESULTS

Of 979/987 women with informative data, 280 (28.6%) progressed to pre-eclampsia defined restrictively by new proteinuria, and 471 (48.1%) to pre-eclampsia defined broadly as proteinuria or one/more maternal symptoms, signs or abnormal laboratory tests. The broad (versus restrictive) definition had significantly higher sensitivities (range 62-79% versus 36-50%), lower specificities (range 53-65% versus 72-82%), and similar or higher diagnostic odds ratios and 'true-positive' to 'false-positive' ratios. Stratified analyses showed similar results. Addition of available fetoplacental manifestations (stillbirth or birthweight <10th centile) to the broad pre-eclampsia definition improved sensitivity (74-87%).

CONCLUSIONS

A broad (versus restrictive) pre-eclampsia definition better identifies women who develop adverse pregnancy outcomes. These findings should be replicated in a prospective study within routine healthcare to ensure that the anticipated increase in surveillance and intervention in a larger number of women with pre-eclampsia is associated with improved outcomes, reasonable costs and congruence with women's values.

TWEETABLE ABSTRACT

A broad (versus restrictive) pre-eclampsia definition better identifies the risk of adverse pregnancy outcomes.

Shedding light on the pathophysiology of preeclampsia-syndrome in the era of Cardio-Obstetrics: Role of inflammation and endothelial dysfunction

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Preeclampsia (PE) is a worldwide pregnancy complication with serious maternal and neonatal consequences. Our understanding of PE pathophysiology has significantly evolved over the last decades by recognizing that endothelial dysfunction and systemic inflammation, with an associated angiogenic imbalance, are key pieces of this still incomplete puzzle. In the present era, where no single treatment to cure or treat this obstetric condition has been developed so far, PE prevention and early prediction poses the most useful clinical approach to reduce the PE burden. Although most PE episodes occur in healthy nulliparous women, the identification of specific clinical conditions that increase dramatically the risk of PE provides a critical opportunity to improve outcomes by acting on potential reversible factors, and also contribute to better understand this pathophysiologic enigma. In this review, we highlight major clinical contributors of PE and shed light about their potential link with endothelial dysfunction and inflammation.

Haplotype-based, case-control study of myosin phosphatase target subunit 1 (PPP1R12A) gene and hypertensive disorders of pregnancy

Objective: Hypertensive disorders of pregnancy (HDP) are thought to be a multifactorial genetic disease. Myosin light chain phosphorylation, which is involved in the regulation of vascular smooth muscle contraction and relaxation and thus contributes to the maintenance of blood pressure, is related to HDP. The official symbol of the gene for the production of MYPT1 protein is PPP1R12A gene. Thus, we investigated the possibility that the PPP1R12A gene is related to HDP. Methods: Subjects were 194 pregnant women with HDP and a control group of 262 pregnant women from those women examined. Four SNVs (rs7296839, rs11114256, rs2596793, and rs2694657) were selected from the PPP1R12A gene region. The HDP group was divided according to disease type, and each group was analyzed in comparison with the control group. Results: In the association analysis using the PPP1R12A gene, there were significant differences between the control group and the superimposed preeclampsia (SPE) group for rs11114256 in allele frequency distribution (P = 0.017) and genome frequency distribution in the dominant model (P = 0.014), and for rs2694657 genotype distribution frequency in the recessive model (P = 0.018). In the association analysis using haplotypes, there was a significant difference for G-A-A-G (rs7296839-rs11114256-rs2596793-rs2694657). In an analysis of haplotype-based case-control study, there was a significant difference for G-A-A-G between the control group (0.00%) and the HDP group (2.46%) (P = 0.038). Furthermore, the G-T-A-G haplotype was significantly higher in SPE group than in control group (P = 0.011). Conclusions: The implication is that the PPP1R12A gene may be a disease-susceptibility gene for SPE.

Placental magnetic resonance imaging in chronic hypertension: A case-control study

INTRODUCTION

We aimed to explore the use of magnetic resonance imaging (MRI) in vivo as a tool to elucidate the placental phenotype in women with chronic hypertension.

METHODS

In case-control study, women with chronic hypertension and those with uncomplicated pregnancies were imaged using either a 3T Achieva or 1.5T Ingenia scanner. T2-weighted images, diffusion weighted and T1/T2* relaxometry data was acquired. Placental T2*, T1 and apparent diffusion coefficient (ADC) maps were calculated.

RESULTS

129 women (43 with chronic hypertension and 86 uncomplicated pregnancies) were imaged at a median of 27.7 weeks' gestation (interquartile range (IQR) 23.9-32.1) and 28.9 (IQR 26.1-32.9) respectively. Visual analysis of T2-weighted imaging demonstrated placentae to be either appropriate for gestation or to have advanced lobulation in women with chronic hypertension, resulting in a greater range of placental mean T2* values for a given gestation, compared to gestation-matched controls. Both skew and kurtosis (derived from histograms of T2* values across the whole placenta) increased with advancing gestational age at imaging in healthy pregnancies; women with chronic hypertension had values overlapping those in the control group range. Upon visual assessment, the mean ADC declined in the third trimester, with a corresponding decline in placental mean T2* values and showed an overlap of values between women with chronic hypertension and the control group.

DISCUSSION

A combined placental MR examination including T2 weighted imaging, T2*, T1 mapping and diffusion imaging demonstrates varying placental phenotypes in a cohort of women with chronic hypertension, showing overlap with the control group.

Hypertensive Disorders of Pregnancy

"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.

Grape Seed Extract Polyphenols Improve Resistance Artery Function in Pregnant eNOS-/- Mice

Hypertension during pregnancy is a leading cause of maternal and fetal morbidity and mortality worldwide, increasing the risk of complications including preeclampsia, intracerebral hemorrhage and fetal growth restriction. Increased oxidative stress is known to contribute to poor vascular function; however, trials of antioxidant supplementation have raised concerns about fetal outcomes, including risk of low birthweight. Grape seed extract polyphenols (GSEP) have been suggested to promote cardiovascular protection, at least in part through antioxidant actions. We tested the hypothesis that administration of GSEP during pregnancy would reduce oxidative stress and improve resistance artery function with no detrimental effects on fetal growth, in an established model of maternal hypertension associated with vascular dysfunction, the endothelial NO synthase knockout (eNOS^-/-) mouse. Pregnant C57BL/6J (WT) and eNOS^-/- mice received either GSEP (200 mg/kg/day) or drinking water, between gestational (GD) day 10.5 and GD18.5. At GD17.5, maternal systolic blood pressure (SBP) was measured; at GD18.5, maternal malondialdehyde (MDA) concentrations, vascular function of aortic, mesenteric, uterine and posterior cerebral arteries was assessed, and fetal outcome evaluated. GSEP reduced maternal SBP (P < 0.01) and plasma MDA concentrations (P < 0.01) in eNOS^-/- mice. Whilst there was no effect of GSEP on vascular reactivity of aortas, GSEP improved endothelial-dependent relaxation in mesenteric and uterine arteries of eNOS^-/- mice (P < 0.05 and P < 0.001, respectively) and normalized lumen diameters of pressurized posterior cerebral arteries in eNOS^-/- mice (P < 0.001). Supplementation with GSEP had no effect in WT mice and did not affect fetal outcomes in either genotype. Our data suggest that GSEP improve resistance artery function, potentially through antioxidant actions, and provide a basis to further investigate these beneficial effects including in the prevention of intracerebral hemorrhage. Maternal supplementation with GSEP may be a safe intervention to improve outcomes in pregnancies associated with hypertension and vascular dysfunction.

Management of hypertension in pregnancy

Hypertensive diseases of pregnancy remain a leading cause of maternal and neonatal morbidity and mortality. Therefore, we sought to review the management of these conditions in pregnancy. In this review we discuss the most updated definitions, different antihypertensives, delivery recommendations and overall goals of management, including their effects on uteroplacental perfusion. We also highlight different medical situations where one antihypertensive may be preferable over others.

Preeclampsia and Kidney Disease: Deciphering Cause and Effect

PURPOSE OF REVIEW

Preeclampsia and chronic kidney disease have a complex, bidirectional relationship. Women with kidney disease, with even mild reductions in glomerular filtrate rate, have an increased risk of developing preeclampsia. Preeclampsia, in turn, has been implicated in the subsequent development of albuminuria, chronic kidney disease, and end-stage kidney disease. We will discuss observational evidence and mechanisms linking the two disease processes.

RECENT FINDINGS

Preeclampsia is characterized by an imbalance in angiogenic factors that causes systemic endothelial dysfunction. Chronic kidney disease may predispose to the development of preeclampsia due to comorbid conditions, such as hypertension, but is also associated with impaired glycocalyx integrity and alterations in the complement and renin-angiotensin-aldosterone systems. Preeclampsia may lead to kidney disease by causing acute kidney injury, endothelial damage, and podocyte loss. Preeclampsia may be an important sex-specific risk factor for chronic kidney disease. Understanding how chronic kidney disease increases the risk of preeclampsia from a mechanistic standpoint may open the door to future biomarkers and therapeutics for all women.

Hypertension During Pregnancy

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy affect about 5-10% of pregnancies impacting maternal, fetal, and neonatal outcomes. We review the recent studies in this field and discuss the pathophysiology, diagnosis, and management of hypertension during pregnancy, as well as the short- and long-term consequences on the cardiovascular health of women.

RECENT FINDINGS

Although the American College of Cardiology/American Heart Association revised their guidelines for hypertension in the general population in 2017, hypertension during pregnancy continues to be defined as a systolic blood pressure (SBP) ≥ 140 mmHg and/or a diastolic blood pressure (DBP) ≥ 90 mmHg, measured on two separate occasions. The addition of stage 1 hypertension will increase the prevalence of hypertension during pregnancy, identifying more women at risk of preeclampsia; however, more research is needed before changing the BP goal because a lower target BP has a risk of poor placental perfusion. Women with chronic hypertension have a higher incidence of superimposed preeclampsia, cesarean section, preterm delivery before 37 weeks' gestation, birth weight less than 2500 g, neonatal unit admission, and perinatal death. They also have a higher risk of developing cardiovascular disease later in life. The guidelines recommend low-dose aspirin for women with moderate and high risk of preeclampsia. While treating pregnant women with hypertension, the effectiveness of the antihypertensive agent must be balanced with risks to the fetus. Hypertensive disorders of pregnancy should be appropriately and promptly recognized and treated during pregnancy. They should further be co-managed by the obstetrician and cardiologist to decrease the long-term negative impact on the cardiovascular health of women.

Contraceptive practices in women with chronic medical conditions

Contraception in women with severe medical conditions is a potential measure to reduce maternal mortality. We sought to determine the contraceptive use in women with medical conditions at the University Hospital of the West Indies (UHWI) in Jamaica to determine if there is room for improvement in contraceptive use. Participants were identified from the medical out-patient departments and questionnaires administered. Two hundred and sixty females between 18 and 44 years with varied chronic medical conditions were included. Those included were systemic lupus erythematosus (SLE), diabetes, hypertension (HTN), thyroid disease, cardiac and renal disease. The total current use of contraception was 58.4%, while 41.6% were not on contraceptives. The use of barrier methods and long-acting reversible contraceptives (LARCs) was 71% and 10%, respectively. The current use of contraception in patients with sickle cell disease (SCD) was 84% (p=.004) and in rheumatoid arthritis (RA), 14% (p=.028). Fifty-eight (58, 24.2%) of the women were using two or more methods of contraception. There is a role for improving contraceptive use among women with medical conditions as they are at increased risk of pregnancy complications.IMPACT STATEMENTWhat is already known on this subject? Women with medical comorbidities significantly contribute to both direct and indirect causes of maternal mortality. Contraception may play an integral role in reducing the risk of dying in chronically ill women; however, the use of contraception in this group is often suboptimal.What the results of this study add? This study adds to the literature that in this high-risk group, there is an underuse of long-acting reversible contraceptives, which is ideal for this population.What the implications are of these findings for clinical practice or further research? The results will provide evidence that this high-risk group of women should be targeted and counselled regarding their risk of morbidity and mortality in pregnancy as well as contraception use while their condition is optimised. From this evidence, services may be put in place in institutions, especially in low-resource settings.

Pregnancy-Related Complications in Patients With Fibromuscular Dysplasia: A Report From the European/International Fibromuscular Dysplasia Registry

Current literature suggests a higher risk of pregnancy-related complications in patients with renal fibromuscular dysplasia (FMD). The aim of our study was to assess the nature and prevalence of pregnancy-related complications in patients subsequently diagnosed with FMD. A call for participation was sent to centers contributing to the European/International FMD Registry. Patients with at least 1 pregnancy were included. Data on pregnancy were collected through medical files and FMD characteristics through the European/International FMD Registry. Data from 534 pregnancies were obtained in 237 patients. Despite the fact that, in 96% of cases, FMD was not diagnosed before pregnancy, 40% of women (n=93) experienced pregnancy-related complications, mostly gestational hypertension (25%) and preterm birth (20%), while preeclampsia was reported in only 7.5%. Only 1 patient experienced arterial dissection and another patient an aneurysm rupture. When compared with patients without pregnancy-related complications, patients with complicated pregnancies were younger at FMD diagnosis (43 versus 51 years old; P<0.001) and had a lower prevalence of cerebrovascular FMD (30% versus 52%; P=0.003) but underwent more often renal revascularization (63% versus 40%, P<0.001). In conclusion, the prevalence of pregnancy-related complications such as gestational hypertension and preterm birth was high in patients with FMD, probably related to the severity of renal FMD. However, the prevalence of preeclampsia and arterial complications was low/moderate. These findings emphasize the need to screen hypertensive women for FMD to ensure revascularization before pregnancy if indicated and appropriate follow-up during pregnancy, without discouraging patients with FMD from considering pregnancy.