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

OBJECTIVE: Chronic hypertension (cHTN) affects 3-5% of all pregnancies and is twice as prevalent in African American (AA) women. AA women develop more severe HTN at an earlier onset and have higher rates of adverse pregnancy outcomes. Blood pressure control during pregnancy is controversial. STUDY DESIGN: This retrospective cohort included AA women with cHTN and singleton pregnancies delivering between January 2013 and December 2016. Patients were classified as not receiving antihypertensives in the first 20 weeks (Group A), on antihypertensives in the first 20 weeks but with an average BP <140/90 during pregnancy (Group B) and on antihypertensives in the first 20 weeks but with average BP during pregnancy ≥140/90 (Group C). Adverse outcomes including severe HTN and preterm delivery <35 weeks was compared between groups. RESULTS: Of the 198 patients included, 68 received at least one AHT before 20 weeks including 45 patients with average BP <140/90 and 23 with average BP ≥140/90 during pregnancy. The incidence of superimposed PE and preterm birth was significantly higher among women with elevated BPs on AHT (39.1% vs 8.9% vs 17.7%, p = 0.01; preterm birth 52.2%, 8.9% and 9.2%, p < 0.001 for Groups C, B and A, respectively). A significantly higher proportion of adverse neonatal outcomes were observed in Group C (78.3%) as opposed to those in Group B (53.3%) or Group A (50.0%; p = 0.04). CONCLUSIONS: Among AA women with cHTN, use of antihypertensives prior to 20 weeks and lower antenatal BP was associated with a decreased risk of adverse maternal and neonatal outcomes.

Severe antepartum hypertension and associated peripartum morbidity among pregnant women in an urban tertiary care medical center.

OBJECTIVES: Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Although acute severe hypertension carries with it a poor prognosis, treatment is often delayed and not universal. STUDY DESIGN: A total of 654 patients were assessed for the impact of hypertensive disorders of pregnancies on maternal and fetal morbidity and divided into three groups: normotensive (Group I, N = 306), non-severe hypertension (Group II, N = 248) and severe-range hypertension with blood pressure (BP) episodes ≥160 systolic or ≥105 diastolic (Group III, N = 100). Retrospective demographic and medical information was abstracted from patients' medical records to collect study data. MAIN OUTCOME MEASURES: The main outcomes assessed were composite maternal adverse events,fetal adverse events, and time to treatment. RESULTS: Patients in Group III had higher systolic (182 vs 155 vs 133) and diastolic (106 vs 95 vs 81) BPs compared to patients in Groups II and I. Patients in Group III had a significantly higher incidence of maternal adverse events (26.0% vs 6.5% vs 2.0%, respectively; p < 0.001) and higher neonatal composite adverse events (52.0% vs 17.7% vs 26.1%, respectively; p < 0.001) as compared to patients in Groups II and I. Only 52.2% of patients in Group III were treated within recommended 60 minutes or less. CONCLUSIONS: Patients with severe hypertension antepartum have higher associated maternal and fetal adverse events while treatment is often delayed. Further studies should evaluate the effects of adequate time to treatment for severe hypertension. Steps should also be taken to standardize identification and reporting of severe maternal morbidity.

Understanding and comparing practices of managing patients with hypertensive disorders of pregnancy in urban China and the United States.

OBJECTIVES: To describe patient outcomes, management of hypertensive disorders of pregnancy, and evaluate provider knowledge of practice guidelines at a tertiary care center in urban China. STUDY DESIGN: Retrospective chart review of patients admitted between September 2017 and March 2018 with a diagnosis of any hypertensive disorder at Zhongnan Hospital of Wuhan University Medical Center in China. Healthcare providers including physicians, midwives, nurses and medical students were surveyed. Patient outcomes were compared to those at the University of Chicago, USA. MAIN OUTCOME MEASURES: Prevalence of hypertensive disorders of pregnancy, comparative rates of medication administration, mode of delivery, and other pregnancy characteristics were abstracted. Responses regarding definitions, treatment and outcomes of hypertension were analyzed using survey data. RESULTS: Among 2834 patients, the prevalence of hypertensive disorders at the Zhongnan Hospital was 7.1%, with a 6.4% prevalence of preeclampsia. Compared to hypertensive women from the University of Chicago, hypertensive patients at Zhongnan Hospital were more likely to be older and weigh less but had higher rates of antihypertensive drug administration and delivery via cesarean section. Infants born at Zhongnan Hospital were less likely to be admitted to the neonatal intensive care unit. Survey respondents demonstrated poor knowledge of preeclampsia diagnoses and first line treatments for severe hypertension in pregnancy. CONCLUSIONS: Although several clinical characteristics of preeclampsia were similar between hospitals, the rates of cesarean section were higher in China. Provider knowledge was most lacking in areas about diagnostic criteria and medication use for preeclampsia. Future studies are needed to explore these differences.

Angiogenic Factor Estimation as a Warning Sign of Preeclampsia-Related Peripartum Morbidity Among Hospitalized Patients.

Preeclampsia-related morbidity and mortality is rising predominantly because of delayed identification of patients at risk for preeclampsia with severe features and associated complications. This study explored the association between angiogenic markers (sFlt1 [soluble fms-like tyrosine kinase-1]) and PlGF [placental growth factor]) and preeclampsia-related peripartum complications. Normotensive women or those with hypertensive disorders of pregnancy were enrolled. Blood samples were collected within 96 hours before delivery, and angiogenic markers were measured on an automated platform. Our study included 681 women, 375 of which had hypertensive disorders. Of these, 127 (33.9%) had severe preeclampsia, and 71.4% were black. Compared with normotensive women, women with severe preeclampsia had higher levels of sFlt1 (9372.5 versus 2857.0 pg/mL; P<0.0001), lower PlGF (51.0 versus 212.0 pg/mL; P<0.0001), and a high sFlt1/PlGF (212.0 versus 14.0; all P<0.0001). A similar trend in sFlt1, PlGF, and sFlt1/PlGF was found in those women with complications secondary to preeclampsia (all P<0.001). The highest tertile of sFlt1/PlGF was strongly associated with severe preeclampsia in a multivariable analysis. Among patients with a hypertensive disorder of pregnancy, 340 (90.7%) developed postpartum hypertension, of which 50.4% had mild, and 40.3% had severe postpartum hypertension. The sFlt1/PlGF ratio was significantly higher for severe and mild postpartum hypertension compared with women with normal postpartum blood pressures (73.5, 46.0, and 13.0, respectively; P values<0.0001). Furthermore, the highest tertile of antepartum sFlt1/PlGF was associated with postpartum hypertension ( P=0.004). This study demonstrates a significant association between an abnormal angiogenic profile before delivery and severe preeclampsia and peripartum complications.

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

BACKGROUND: Angiogenic factors have been implicated in the pathogenesis of preeclampsia. This pilot study explored the association between antenatal blood pressure levels and angiogenic biomarkers (sFlt1 and PlGF) among women with chronic hypertension (cHTN). METHODS: Blood samples were collected from women with cHTN (with/without superimposed preeclampsia) within 96 h prior to delivery. Subjects were stratified by mean outpatient BP as controlled (cBP < 140/90) or uncontrolled (uBP ≥ 140/90). Descriptive statistics were generated and assessed as appropriate. Logistic regression was employed to assess for adverse pregnancy outcomes between groups. RESULTS: Data from seventy-eight women were analyzed, of which 58 (74.4%) were African American. Fifty-six (71.8%) had cBP and 22 (28.2%) had uBP. Use of antepartum outpatient antihypertensive medications was more frequent in patients with uBP (46.4% vs. 13.6%, p = 0.01). Compared to women with cBP, women with uBP had higher levels of pre-delivery sFlt1 and sFlt1/PlGF ratio (sFlt: 4218.5 vs. 3056.0 pg/ml, p = 0.046; sFlt/PlGF: 62.5 vs. 25.0, p = 0.04). Additionally, more uBP patients had superimposed preeclampsia with severe features (54.6% vs. 25.0%; p = 0.01) and preterm delivery (defined as a gestational age <35 weeks (40.9% vs. 10.7%; p = 0.002)) than cBP patients. In the multivariable model, women with uBP had greater odds of preterm delivery (OR 6.78; p = 0.01), superimposed preeclampsia (OR 3.20; p = 0.03) and preeclampsia with severe features (OR 3.27; p = 0.04) than women with cBP. CONCLUSION: In women with cHTN, elevated antepartum BP is associated with worsened outcomes and may be associated with abnormal angiogenic profile at delivery. Larger studies are needed to confirm these findings.

Spontaneous Adrenal Hemorrhage in Pregnancy: A Case Series.

Background. Abdominal pain during pregnancy has a broad differential diagnosis which includes spontaneous adrenal hemorrhage (SAH). There is scant literature available on optimal mode of delivery in stable patients. Cases. Patient 1 was a 35-year-old nullipara who presented at 36 weeks of gestation with left flank pain. Patient 2 was a 27-year-old multipara at 38 weeks who presented with left upper quadrant pain. Diagnosis of SAH was made by CT scan and both were managed with pain control, serial hemoglobin assessments, and abdominal exams resulting in uncomplicated vaginal deliveries. Conclusion. SAH, although rare, is an important consideration when evaluating abdominal and flank pain in pregnancy. Management options vary from conservative management to surgical intervention depending on the stability of the patient.