Persistent Hypertension Up to One Year Postpartum among Women with Hypertensive Disorders in Pregnancy in a Low-Resource Setting: A Prospective Cohort Study

The Impact of Maternal Chronic Inflammatory Conditions on Breast Milk Composition: Possible Influence on Offspring Metabolic Programming

Breastfeeding is the best way to provide newborns with crucial nutrients and produce a unique bond between mother and child. Breast milk is rich in nutritious and non-nutritive bioactive components, such as immune cells, cytokines, chemokines, immunoglobulins, hormones, fatty acids, and other constituents. Maternal effects during gestation and lactation can alter these components, influencing offspring outcomes. Chronic inflammatory maternal conditions, such as obesity, diabetes, and hypertension, impact breast milk composition. Breast milk from obese mothers exhibits changes in fat content, cytokine levels, and hormonal concentrations, potentially affecting infant growth and health. Similarly, diabetes alters the composition of breast milk, impacting immune factors and metabolic markers. Other pro-inflammatory conditions, such as dyslipidemia and metabolic syndrome, have been barely studied. Thus, maternal obesity, diabetes, and altered tension parameters have been described as modifying the composition of breast milk in its macronutrients and other important biomolecules, likely affecting the offspring's weight. This review emphasizes the impact of chronic inflammatory conditions on breast milk composition and its potential implications for offspring development through the revision of full-access original articles.

Persistent hypertension among postpartum women with comorbid HIV and preeclampsia in Zambia

BACKGROUND

Persistent hypertension is common after preeclampsia and is causally tied to later cardiovascular risks. This study examined whether being HIV-infected and on antiretroviral therapy (ART) is associated with persistent postpartum hypertension among women diagnosed with preeclampsia.

METHODS

We conducted a six-month prospective cohort study at Kanyama and Women and Newborn hospitals from January 01, 2022, to June 30, 2023, among 190 women diagnosed with preeclampsia (59 HIV-positive, 131 HIV-negative). Sociodemographic and clinical characteristics were collected at delivery, six weeks, three months and six months after giving birth. Persistent hypertension was diagnosed if a participant presented with elevated blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg and/or taking medication for hypertension at the study visit. We used a generalized estimating equation to describe the relationship between treated HIV and persistent hypertension six months following delivery.

RESULTS

We retained 136 participants (71.6%) to six months postpartum, at a median age of 30 years. Overall, persistent hypertension at six weeks, three months, and six months postpartum was common (37.4%, 17.1% and 16.9%, respectively). Six-week postpartum prevalence was higher in the HIV group than HIV-negative group (54.6% vs 28.8%, p<0.001), with no measurable difference at three months (24.3% vs 13.2%, p = 0.145) or six months (18.2% vs 16.3%, p = 0.787). Multivariable analysis demonstrates higher odds (adjusted odds ratio [aOR] = 1.68, 95% CI: 1.09-2.60) of persistent hypertension among the HIV+treatment group than HIV-negative counterparts after accounting for age, body mass index and time since delivery.

CONCLUSION

We demonstrate an elevated risk of persistent hypertension among postpartum women with comorbid preeclampsia and treated HIV. Peripartum patients in HIV-endemic settings may benefit from timely detection of hypertension and treatment interventions to improve health outcomes.

Persistent postpartum hypertension 3 months post-delivery among women with hypertensive disorders of pregnancy in Tanzania: A multicenter cohort study

Postpartum care of hypertensive disorders of pregnancy (HDP) often extends only 6 weeks after delivery in low-income countries. This multicenter observational cohort study was conducted to determine 3-month postpartum outcomes of HDP in Tanzania. Of 309 consecutive women admitted to 3 public hospitals, five (1.7 %) died within 3 months. Of the remaining 304, 292 (94.5 %) returned for 3-month follow-up visit and 41.1 % (95 % CI: 35.6 %-46.9 %) had persistent postpartum hypertension. The strongest independent predictor of hypertension persistence was reduced eGFR at delivery (aOR = 2.1[1.01,4.4]). Postpartum follow-up should routinely be extended to 3 months in all women with HDP to diagnose hypertension and prevent cardiovascular disease.

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

Background

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

Objective

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

Search strategy

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

Selection criteria

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

Data collection and analysis

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

Results

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

Conclusions

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

Systematic Review Registration

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

Prevalence, Awareness, and Control of Hypertensive Disorders amongst Pregnant Women Seeking Healthcare in Ghana

Hypertensive disorders in pregnancy (HDPs) are no longer seen as "transitory diseases cured by delivery." It accounts for up to 50% of maternal deaths. Information concerning HDPs is less in developing countries like Ghana. This study was conducted to find out the prevalence, awareness, risk factors, control, and the birth outcomes of HDPs. This was a retrospective cohort study conducted among pregnant women seeking care in selected health facilities in the Ashanti Region. Data on demographics, HDPs, and its associated birth outcomes were collected. Logistic regression models were used to examine the association of the independent variables with HDPs. The burden of HDPs was 37.2% among the 500 mothers enrolled with chronic hypertension superimposed with preeclampsia accounting for 17.6%, chronic hypertension, 10.2%, and preeclampsia 6.8% whilst gestational hypertension was 2.6%. It was observed that 44% (220) of the mothers had excellent knowledge on HDPs. Oral nifedipine and methyldopa were frequently used for HDP management, and it resulted in a significant reduction in HDP burden from 37.2% to 26.6%. Factors that influenced the increased risk of HDPs were grand multigravida (AOR = 4.53; CI = 1.42-14.42), family history of hypertension (AOR = 3.61; CI = 1.89-6.90), and the consumption of herbal preparations (AOR = 2.92; CI = 1.15-7.41) and alcohol (AOR = 4.10; CI = 1.34-12.62) during pregnancy. HDPs increased the risk of preterm delivery (AOR = 2.66; CI = 1.29-5.89), stillbirth (AOR = 12.47; CI = 2.72-57.24), and undergoing caesarean section (AOR = 1.70; CI = 1.10-2.61) amongst mothers during delivery. The burden of HDPs is high amongst pregnant mothers seeking care in selected facilities. There is the need for intensified campaign on HDPs in the Ashanti Region of Ghana.

Postpartum cardiovascular function in patients with hypertensive disorders of pregnancy: a longitudinal study

BACKGROUND

Women with a history of hypertensive disorders of pregnancy are at increased risk of cardiovascular diseases, which are usually mediated by the development of cardiovascular risk factors, such as chronic hypertension, metabolic syndrome, or subclinical myocardial dysfunction. Increasing evidence has been showing that little time elapses between the end of pregnancy and the development of these cardiovascular risk factors.

OBJECTIVE

This study aimed to assess the persistence of hypertension and myocardial dysfunction at 4 months postpartum in a cohort of women with hypertensive disorders of pregnancy, and to compare the echocardiographic parameters between the peripartum and the postpartum period.

STUDY DESIGN

In a longitudinal prospective study, a cohort of women with preterm or term hypertensive disorders of pregnancy and an unmatched group of women with term normotensive pregnancy were recruited. Women with preexisting chronic hypertension (n=29) were included in the hypertensive disorders of pregnancy cohort. All participants underwent 2 cardiovascular assessments: the first was conducted either before or within 1 week of delivery (V1: peripartum assessment), and the second between 3 and 12 months following delivery (V2: postpartum assessment). The cardiovascular evaluation included blood pressure profile, maternal transthoracic echocardiography (left ventricular mass index, relative wall thickness, left atrial volume index, E/A, E/e', peak velocity of tricuspid regurgitation, ejection fraction, and left ventricular global longitudinal strain and twist), and metabolic assessment (fasting glycemia, insulin, lipid profile, and waist measurement). Echocardiographic data were compared between V1 and V2 using paired t test or McNemar test in hypertensive disorders of pregnancy and in the control groups.

RESULTS

Among 260 patients with pregnancies complicated by hypertensive disorders of pregnancy and 33 patients with normotensive pregnancies, 219 (84.2%) and 30 (90.9%) attended postpartum follow-up, respectively. Patients were evaluated at a median of 124 days (interquartile range, 103-145) after delivery. Paired comparisons of echocardiographic findings demonstrated significant improvements in cardiac remodeling rates (left ventricular mass index [g/m2], 63.4±14.4 vs 78.9±16.2; P<.001; relative wall thickness, 0.35±0.1 vs 0.42±0.1; P<.001), most diastolic indices (E/e', 6.3±1.6 vs 7.4±1.9; P<.001), ejection fraction (ejection fraction <55%, 9 [4.1%] vs 28 [13.0%]; P<.001), and global longitudinal strain (-17.3±2.6% vs -16.2±2.4%; P<.001) in the postpartum period compared with the peripartum. The same improvements in cardiac indices were observed in the normotensive group. However, at the postnatal assessment, 153 of 219 (69.9%) had either hypertension (76/219; 34.7%) or an abnormal global longitudinal strain (125/219; 57.1%), 13 of 67 (19.4%) had metabolic syndrome, and 18 of 67 (26.9%) exhibited insulin resistance.

CONCLUSION

Although persistent postpartum cardiovascular impairment was evident in a substantial proportion of patients given that more than two-thirds had either hypertension or myocardial dysfunction postpartum, cardiac modifications because of pregnancy-related overload and hypertension were more pronounced in the peripartum than in the postpartum period.

The association between hypertensive disorders during pregnancy and maternal and neonatal outcomes: a retrospective claims analysis

BACKGROUND

Hypertensive disorders during pregnancy continue to increase in prevalence and are associated with several adverse outcomes and future cardiovascular risk for mothers. This study evaluated the association of hypertensive disorders compared to no hypertension during pregnancy with neonatal and maternal outcomes. We then evaluated risk factors associated with progression from a less to more severe hypertensive disorder during pregnancy.

METHODS

We conducted a propensity-matched retrospective cohort study utilizing Medicaid claims data from a national insurer. The study population consisted of mothers with and without hypertensive disorders who delivered between 7/1/2016-12/31/2018 and their infants. Hypertensive disorders included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Propensity score matching was used to match mothers without to those with hypertensive disorders. Regression models were used to compare maternal and neonatal outcomes. Stepwise logistic regression was used to determine characteristics associated with the progression of gestational hypertension to preeclampsia or chronic hypertension to superimposed preeclampsia.

RESULTS

We observed the highest risk of cesarean delivery (odds ratio [OR]:1.61 and 1.99) in mothers and preterm delivery (OR:2.22 and 5.37), respiratory distress syndrome (OR:2.39 and 4.19), and low birthweight (OR:3.64 and 9.61) in babies born to mothers with preeclampsia or superimposed preeclampsia compared to no hypertension, respectively (p < 0.05 for all outcomes). These outcomes were slightly higher among chronic or gestational hypertension compared to no hypertension, however, most were not statistically significant. Risk of neonatal intensive care unit utilization was higher among more severe hypertensive disorders (OR:2.41 for preeclampsia, OR:4.87 for superimposed preeclampsia). Obesity/overweight and having a history of preeclampsia during a prior pregnancy were most likely to predict progression from gestational/chronic hypertension to preeclampsia/superimposed preeclampsia.

CONCLUSION

Mothers and neonates born to mothers with preeclampsia or superimposed preeclampsia experienced more adverse outcomes compared to those without hypertension. Mothers and neonates born to mothers with gestational hypertension had outcomes similar to those without hypertension. Outcomes for those with chronic hypertension fell in between gestational hypertension and preeclampsia. Obesity/overweight and having a history of preeclampsia during a prior pregnancy were strong risk factors for hypertension progression.

Pre-eclampsia and maternal health through the prism of low-income countries

Hypertensive syndrome in pregnancy complicates up to 15% of pregnancies, and preeclampsia (PE) occurs in about 3-10% of pregnant women. Inadequate prenatal care is associated with higher mortality from PE, possibly due to reduced monitoring, detection, and missed opportunities for early intervention. The imperative of the clinician's work is to monitor the symptoms and clinical signs of PE, and stratification of patients in relation to the risk of PE is essential. PE represents a multisystem inflammatory response, and the consequences can be expected in all organs. The question of the effect of PE on long-term maternal health is raised. The aim of the paper is to present the effect of PE on the patient's health through the prism of low-income countries.

Prevention and Screening for Cardiometabolic Disease Following Hypertensive Disorders in Pregnancy in Low-Resource Settings: A Systematic Review and Delphi Study

Hypertensive disorders in pregnancy (HDP) and cardiometabolic and kidney diseases are rising in low- and middle-income countries (LMICs). While HDP are risk factors for cardiometabolic and kidney diseases, cost-effective, scalable strategies for screening and prevention in women with a history of HDP are lacking. Existing guidelines and recommendations require adaptation to LMIC settings. This article aims to generate consensus-based recommendations for the prevention and screening of cardiometabolic and kidney diseases tailored for implementation in LMICs. We conducted a systematic review of guidelines and recommendations for prevention and screening strategies for cardiometabolic and chronic kidney diseases following HDP. We searched PubMed/Medline, Embase and Cochrane Library for relevant articles and guidelines published from 2010 to 2021 from both high-income countries (HICs) and LMICs. No other filters were applied. References of included articles were also assessed for eligibility. Findings were synthesized narratively. The summary of guiding recommendations was subjected to two rounds of Delphi consensus surveys with experts experienced in LMIC settings. Fifty-four articles and 9 guidelines were identified, of which 25 were included. Thirty-five clinical recommendations were synthesized from these and classified into six domains: identification of women with HDP (4 recommendations), timing of first counseling and provision of health education (2 recommendations), structure and care setting (12 recommendations), information and communication needs (5 recommendations), cardiometabolic biomarkers (8 recommendations) and biomarkers thresholds (4 recommendations). The Delphi panel reached consensus on 33 final recommendations. These recommendations for health workers in LMICs provide practical and scalable approaches for effective screening and prevention of cardiometabolic disease following HDP. Monitoring and evaluation of implementation of these recommendations provide opportunities for reducing the escalating burden of noncommunicable diseases in LMICs.

Hypertensive Disorders of Pregnancy and Cardiovascular Disease Risk Across Races and Ethnicities: A Review

Pregnancy is often considered to be a "cardiometabolic stress-test" and pregnancy complications including hypertensive disorders of pregnancy can be the first indicator of increased risk of future cardiovascular disease. Over the last two decades, more evidence on the association between hypertensive disorders of pregnancy and cardiovascular disease has become available. However, despite the importance of addressing existing racial and ethnic differences in the incidence of cardiovascular disease, most research on the role of hypertensive disorders of pregnancy is conducted in white majority populations. The fragmented knowledge prohibits evidence-based targeted prevention and intervention strategies in multi-ethnic populations and maintains the gap in health outcomes. In this review, we present an overview of the evidence on racial and ethnic differences in the occurrence of hypertensive disorders of pregnancy, as well as evidence on the association of hypertensive disorders of pregnancy with cardiovascular risk factors and cardiovascular disease across different non-White populations, aiming to advance equity in medicine.

C677T Gene Polymorphism of MTHFR Is a Risk Factor for Impaired Renal Function in Pregnant Women With Preeclampsia in the Chinese Han Population

Impaired renal function in pregnant women with preeclampsia is particularly common, yet there is no consensus about implementation. This lack of consensus is due in part to uncertainty about risks for disease progression. Limited evidence suggests that C677T gene polymorphism of 5, 10-methylenetetrahydrofolate reductase (MTHFR C677T) may affect impaired renal function in pregnant women with preeclampsia in Chinese Han population. To investigate the association between MTHFR C677T and impaired renal function in pregnant women with preeclampsia, a total of 327 pregnant women diagnosed with gestational hypertension (GH) or preeclampsia-eclampsia (PE) from January 2016 to December 2021 were selected as the study subjects. The personal information, gestational information, clinical indicators, and the C677T gene polymorphism of MTHFR were tested. Compared with the GH group, the PE renal function impairment group had increased in blood pressure, homocysteine level, liver and kidney function indicators (creatinine, uric acid, urea nitrogen, cystatin C, alanine aminotransferase, aspartate aminotransferase, cholyglycine), and blood lipids (total cholesterol, triglycerides and low density lipoprotein) but had reductions in plasma protein (total protein, albumin, globulin, prealbumin), trace elements (calcium and zinc), prothrombin time and fibrinogen. The homocysteine level in the TT genotype was higher than that in the CC and CT genotypes. Binary logistic regression analysis showed that the MTHFR C677T gene polymorphism was associated with PE renal function impairment in the recessive model (OR: 1.620, 95% CI: 1.033-2.541, P < 0.05). These findings show that the C677T gene polymorphism of MTHFR is an independent risk factor for impaired renal function in pregnant Chinese Han women with PE.