Abstract
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.
Summary
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.
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References
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Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomström-Lundqvist C, Cífková R, de Bonis M, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39:3165–241. https://doi.org/10.1093/eurheartj/ehy340.
Shen M, Tan H, Zhou S, Smith GN, Walker MC, Wen SW. Trajectory of blood pressure change during pregnancy and the role of pre-gravid blood pressure: a functional data analysis approach. Sci Rep. 2017;7:6227. https://doi.org/10.1038/s41598-017-06606-0.
• Ananth CV, Duzyj CM, Yadava S, Schwebel M, Tita ATN, Joseph KS. Changes in the prevalence of chronic hypertension in pregnancy, United States, 1970 to 2010. Hypertension. 2019;74:1089–95. https://doi.org/10.1161/HYPERTENSIONAHA.119.12968The prevalence of chronic hypertension has been increasing over the last 4 decades, calling for clinicians attention.
Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. American College of Obstetricians and Gynecologists., Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5):1122–31. https://doi.org/10.1097/01.AOG.0000437382.03963.88.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2018;71:e127–248. https://doi.org/10.1016/j.jacc.2017.11.006.
• Hu J, Li Y, Zhang B, Zheng T, Li J, Peng Y, et al. Impact of the 2017 ACC/AHA Guideline for high blood pressure on evaluating gestational hypertension–associated risks for newborns and mothers. Circ Res. 2019;125:184–94. https://doi.org/10.1161/CIRCRESAHA.119.314682The inclusion of ACC/AHA guidelines in the definition of hypertension during pregnancy will significantly increase the prevalence of gestational hypertension and chronic hypertension during pregnancy. More research is needed to identify the target blood pressure during pregnancy considering the risks and benefits of tight blood pressure control.
Hauspurg A, Sutton E, Catov J, Caritis S. Applying the new ACC/AHA aspirin effect on adverse pregnancy outcomes associated with stage 1 hypertension in a high-risk cohort. Hypertension. 2018;72:202–7. https://doi.org/10.1161/HYPERTENSIONAHA.118.11196.
Tesfalul M, Sperling J, Blat C, Parikh N, Velez JG, Zlatnik M, et al. Adverse perinatal outcomes associated with elevated blood pressure and stage 1 hypertension. AJOG. 2020;(1, Supplement):S92–3.
Bateman BT, Shaw KM, Kuklina EV, Callaghan WM, Seely EW, Hernandez-Diaz S. Hypertesnion in women of reproductive age in the United States: NHANES 1999-2008. PLoS One. 2012;7(4):e36171. https://doi.org/10.1371/journal.pone.0036171.
ACOG practice bulletin no. 203:chronic hypertension in pregnancy. Obstet Gynecol. 2019;133:e26–50. https://doi.org/10.1097/AOG.0000000000003020.
Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni AG, et al. Cardiovascular health in African Americans: a scientific statement from the American Heart Association. Circulation. 2017;136:e393–423. https://doi.org/10.1161/CIR.0000000000000534.
Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125:5–12. https://doi.org/10.1097/AOG.0000000000000564.
Singh GK, Siahpush M, Liu L, Michelle A. Racial/ethnic, nativity, and sociodemographic disparities in maternal hypertension in the United States, 2014–2015. Int J Hypertens. 2018;2018:7897189–14. https://doi.org/10.1155/2018/7897189.
Wolf M, Shah A, Jimenez-Kimble R, Sauk J, Ecker JL, Thadhani R. Differential risk of hypertensive disorders of pregnancy among Hispanic women. J Am Soc Nephrol. 2004;15(5):1330–8. https://doi.org/10.1097/01.asn.0000125615.35046.59.
Ying W, Catov JM, Ouyang P. Hypertensive disorders of pregnancy and future maternal cardiovascular risk. JAHA. 2018;7:e009382. https://doi.org/10.1161/JAHA.118.009382.
Veerbeek JH, Hermes W, Breimer AY, van Rijn BB, Koenen SV, Mol BW, et al. Cardiovascular disease risk factors after early-onset preeclampsia, late-onset preeclampsia, and pregnancy-induced hypertension. Hypertension. 2015;65:600–6. https://doi.org/10.1161/HYPERTENSIONAHA.114.04850.
Veerbeek JH, Brouwers L, Koster MP, Koenen SV, van Vliet EO, Nikkels PG, et al. Spiral artery remodeling and maternal cardiovascular risk: the spiral artery remodeling (SPAR) study. J Hypertens. 2016;34:1570–7. https://doi.org/10.1097/HJH.0000000000000964.
Agatisa PK, Ness RB, Roberts JM, Costantino JP, Kuller LH, McLaughlin MK. Impairment of endothelial function in women with a history of preeclampsia: an indicator of cardiovascular risk. Am J Physiol Heart Circ Physiol. 2004;286:H1389–93. https://doi.org/10.1152/ajpheart.00298.2003.
Estensen ME, Remme EW, Grindheim G, Smiseth OA, Segers P, Henriksen T, et al. Increased arterial stiffness in pre-eclamptic pregnancy at term and early and late postpartum: a combined echocardiographic and tonometric study. Am J Hypertens. 2013;26:549–56. https://doi.org/10.1093/ajh/hps067.
Kvehaugen AS, Dechend R, Ramstad HB, Troisi R, Fugelseth D, Staff AC. Endothelial function and circulating biomarkers are disturbed in women and children after preeclampsia. Hypertension. 2011;58:63–9. https://doi.org/10.1161/HYPERTENSIONAHA.111.172387.
Fraser A, Nelson SM, Macdonald-Wallis C, Cherry L, Butler E, Sattar N, et al. Associations of pregnancy complications with calculated cardiovascular disease risk and cardiovascular risk factors in middle age: the Avon Longitudinal Study of Parents and Children. Circulation. 2012;125:1367–80. https://doi.org/10.1161/CIRCULATIONAHA.111.044784.
Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Cappell LC. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ. 2014;348:g2301. https://doi.org/10.1136/bmj.g2301.
McCowan LM, Buist RG, North RA, Gamble G. Perinatal morbidity in chronic hypertension. Br J Obstet Gynaecol. 1996;103:123–9. https://doi.org/10.1111/j.1471-0528.1996.tb09662.x.
Ananth CV, Peltier MR, Kinzler WL, Smulian JC, Vintzileos AM. Chronic hypertension and risk of placental abruption: is the association modified by ischemic placental disease? Am J Obstet Gynecol. 2007;197:273.el–7. https://doi.org/10.1016/j.ajog.2007.05.047.
Sibai BM. Chronic hypertension in pregnancy. Obstet Gynecol. 2002;100:369–77. https://doi.org/10.1016/s0029-7844(02)02128-2.
Cain MA, Salemi JL, Tanner JP, Kirby RS, Salihu HM, Louis JM. Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes. Am J Obstet Gynecol. 2016;215:484.e1–484.e14. https://doi.org/10.1016/j.ajog.2016.05.047.
Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women with pre-eclampsia: systematic review and meta-analysis. Eur J Epidemiol. 2013;28:1–19. https://doi.org/10.1007/s10654-013-9762-6.
Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, et al. Preeclampsia and future cardiovascular health: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes. 2017;10(2). https://doi.org/10.1161/CIRCOUTCOMES.116.003497.
Lykke JA, Langhoff-Roos J, Sibai BM, Funai EF, Triche EW, Paidas MJ. Hypertensive pregnancy disorders and subsequent cardiovascular morbidity and type 2 diabetes mellitus in the mother. Hypertension. 2009;53:944–51. https://doi.org/10.1161/HYPERTENSIONAHA.109.130765.
Mannisto T, Mendola P, Vaarasmaki M, Jarvelin MR, Hartikainen AL, Pouta A, et al. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681–90. https://doi.org/10.1161/CIRCULATIONAHA.112.128751.
Riise HKR, Sulo G, Tell GS, Igland J, Nygard O, Iversen AC, et al. Association between gestational hypertension and risk of cardiovascular disease among 617 589 Norwegian women. J Am Heart Assoc. 2018;7:e008337. https://doi.org/10.1161/JAHA.117.008337.
• Stuart JJ, Tanz LJ, Missmer SA, et al. Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development: an observational cohort study. Ann Intern Med. 2018;169:224–32. https://doi.org/10.7326/M17-2740Hypertensive disorders of pregnancy have a negative impact on the long term cardiovascular health of women.
Muntner P, Carey RM, Jamerson K, Wright JT, Whelton PK. Rationale for ambulatory and home blood pressure monitoring thresholds in the 2017 American College of Cardiology/American Heart Association Guideline. Hypertension. 2019;73:33–8. https://doi.org/10.1161/HYPERTENSIONAHA.118.11946.
US Preventive Services Task Force. Screening for preeclampsia: US Preventive Services Task Force Recommendation Statement. JAMA. 2017;317(16):1661–7. https://doi.org/10.1001/jama.2017.3439.
Peek M, Shennan A, Halligan A, Lambert PC, Taylor DJ, De Swiet M. Hypertension in pregnancy: which method of blood pressure measurement is most predictive of outcome. Obstet Gynecol. 1996;88(6):1030–3. https://doi.org/10.1016/S0029-7844(96)00350-X.
Wenger NK, Arnold A, Merz CNB, Cooper-DeHoff RM, Ferdinand KC, Fleg JL, et al. Hypertension across a woman’s life cycle. J Am Coll Cardiol. 2018;71(16):1797–813. https://doi.org/10.1016/j.jacc.2018.02.033.
Sibai BM, Lindheimer M, Hauth J, Caritis S, VanDorsten P, Klebanoff M, et al. 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. N Engl J Med. 1998;339:667–71. https://doi.org/10.1056/NEJM199809033391004.
Zeisler H, Llurba E, Chantraine F, Vatish M, Staff AC, Sennstrom M, et al. Predictive value of the sFlt-1:PIGF ratio in women with suspected preeclampsia. N Engl J Med. 2016;374:13–22. https://doi.org/10.1056/NEJMoa1414838.
Cnossen JS, Morris RK, ter Riet G, Mol BW, van der Post JA, Coomarasamy A, et al. Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: a systematic review and bivariable meta-analysis. CMAJ. 2008;178:701–11. https://doi.org/10.1503/cmaj.070430.
Rolnik DL, Wright D, Poon LC, O'Gorman N, Syngelaki A, de Paco MC, et al. Aspirin versus placebo in pregnancies at high-risk for preterm preeclampsia. N Engl J Med. 2017;377:613–22. https://doi.org/10.1056/NEJMoa1704559.
Committee Opinion No ACOG. 743: low-dose aspirin use during pregnancy. Obstet Gynecol. 2018;132(1):e44–52. https://doi.org/10.1097/AOG.0000000000002708.
LeFevre ML, on behalf of the U.S. Preventive Services Task Force. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:819–26. https://doi.org/10.7326/M14-1884.
Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Tortoni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014;6:CD001059. https://doi.org/10.1002/14651858.CD001059.pub4.
von Dadelszen P, Ornstein MP, Bull SB, Logan AG, Koren G, Magee LA. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: a meta-analysis. Lancet. 2000;355:87–92. https://doi.org/10.1016/s0140-6736(98)08049-0.
Magee LA, vonDadelszen P, Rey E, Ross S, Asztalos E, Murphy KE, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372:407–17. https://doi.org/10.1056/NEJMoa1404595.
Chronic Hypertension and Pregnancy (CHAP) Project (CHAP). Ongoing clinical trial. https://clinicaltrials.gov/ct2/show/NCT02299414.
Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and cesarean delivery rate-a population-based screening study. Am J Obstet Gynecol. 2004;190:1091–7. https://doi.org/10.1016/j.ajog.2003.09.058.
O’Brien TE, Ray JG, Chan WS. Maternal body mass index and the risk of preeclampsia: a systematic overview. Epidemiology. 2003;14:368–74. https://doi.org/10.1097/00001648-200305000-00020.
Dodd JM, Turnbull D, McPhee AJ, Deussen AR, Grivell RM, Yelland LN, et al. Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial. BMJ. 2014;348:g1285. https://doi.org/10.1136/bmj.g1285.
Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev. Obstet Gynecol. 2008;1:170–8. https://doi.org/10.1016/j.mce.2015.07.028.
Lindheimer MD, Taler SJ, Cunningham FG. ASH position paper: hypertension in pregnancy. J Clin Hypertens (Greenwich). 2009;11:214–25. https://doi.org/10.1111/j.1751-7176.2009.00085.x.
Brown CM, Garovic VD. Drug treatment of hypertension in pregnancy. Drugs. 2014;74(3):283–96. https://doi.org/10.1007/s40265-014-0187-7.
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Agrawal, A., Wenger, N.K. Hypertension During Pregnancy. Curr Hypertens Rep 22, 64 (2020). https://doi.org/10.1007/s11906-020-01070-0
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DOI: https://doi.org/10.1007/s11906-020-01070-0