Chronic hypertension in pregnancy

Chronic hypertension in pregnancy is associated with increased rates of adverse maternal and fetal outcomes both acute and long term. These adverse outcomes are particularly seen in women with uncontrolled severe hypertension, in those with target organ damage, and in those who are noncompliant with prenatal visits. In addition, adverse outcomes are substantially increased in women who develop superimposed preeclampsia or abruptio placentae. Women with chronic hypertension should be evaluated either before conception or at time of first prenatal visit. Depending on this evaluation, they can be divided into categories of either "high risk" or "low risk" chronic hypertension. High-risk women should receive aggressive antihypertensive therapy and frequent evaluations of maternal and fetal well-being, and doctors should recommend lifestyle changes. In addition, these women are at increased risk for postpartum complications such as pulmonary edema, renal failure, and hypertensive encephalopathy for which they should receive aggressive control of blood pressure as well as close monitoring. In women with low-risk (essential uncomplicated) chronic hypertension, there is uncertainty regarding the benefits or risks of antihypertensive therapy. In my experience, the majority of these women will have good pregnancy outcomes without the use of antihypertensive medications. Antihypertensive agents are recommended and are widely used in these women despite absent evidence of either benefits or harm from this therapy. These recommendations are based on dogma and consensus rather than on scientific evidence. There is an urgent need to conduct randomized trials in women with mild chronic hypertension in pregnancy.     

Chronic hypertension in pregnancy

The course and outcome of 169 pregnancies in 156 women with chronic hypertension were studied. Antihypertensive medications were given if the diastolic blood pressure exceeded 90 mmHg. A number of major associated medical problems were found. Left ventricular hypertrophy, a serum creatinine greater than 1.0 mg%, and a diastolic pressure greater than 100 mmHg at less than 20 weeks' gestation were high-risk indicators. The overall perinatal mortality was 28.4 of 1000 (versus hospital of 25.6 of 1000). Despite antihypertensive therapy, one-third of the patients developed superimposed preeclampsia. The poorest outcome occurred in patients with superimposed preeclampsia necessitating delivery at 27 to 34 weeks' gestation (perinatal mortality = 238 of 1000). Antepartum fetal heart rate testing was abnormal in 10% of the patients with intrauterine growth retardation occurring in 15%. The incidence of fetal growth retardation was fourfold higher (20 versus 5%) in patients treated with antihypertensive drugs, particularly methyldopa as a single agent. However, this may have been related more to the study design than to a detrimental effect of the drug. The perinatal outcome in this study is similar to the outcome of studies in which antihypertensive therapy was withheld. This indicates that controlling the blood pressure is merely one aspect of the management of chronic hypertension in pregnancy. Accurate dating, attention to associated medical problems, antenatal fetal assessment by ultrasound and heart rate monitoring, and carefully timed delivery are additional important factors.     

Chronic hypertension in pregnancy

Pregnant women with chronic hypertension are at risk for maternal and perinatal morbidity. Careful assessment and management of these patients during pregnancy are the keys to reducing maternal and fetal complications. Antihypertensive treatment should be used in women with high-risk chronic hypertension, whereas drug therapy does not improve pregnancy outcome in women at low risk. Prophylactic low-dose aspirin started early in pregnancy in women with chronic hypertension is not effective in reducing the frequency of superimposed preeclampsia and should be avoided.     

Chronic hypertension in pregnancy.

Women with chronic hypertension who are considering pregnancy should undergo extensive evaluation and work-up prior to conception. This evaluation is important to establish the cause and severity of the hypertension. The patient should be seen early in pregnancy and counseled regarding the possible adverse effects of hypertension and the importance of adherence to prenatal visits and prescribed medications. Patients classified to have high-risk hypertension are at increased risk for significant maternal and perinatal complications. These patients should have intensive antenatal follow-up and will require antihypertensive therapy irrespective of the severity of the hypertension. In contrast, in women with mild uncomplicated hypertension, good perinatal outcome is expected with proper obstetric care, without the use of antihypertensive drugs. Finally, most of the poor perinatal outcome in such pregnancies is related to the development of superimposed preeclampsia.     

Chronic essential and secondary hypertension in pregnancy.

Hypertension is a relatively common complication of pregnancy, increasing in frequency in older women. It is not a contraindication to pregnancy, but should be fully investigated, correctable causes addressed and those with specific relevance for pregnancy identified. With close supervision and appropriate management, the majority of hypertensive pregnant women have successful outcomes. Ideally all women with chronic hypertension should be seen prior to a planned pregnancy, for explanation and discussion of the significance, risks and treatment plan and for adjustment of antihypertensive medication as necessary. Those charged with the antenatal and perinatal care of the patient should be familiar with the expected physiological changes in pregnancy and of the risks and benefits of any treatment given. Close communication among the patient, her obstetrician and consultant physician will ensure the most appropriate treatment and facilitate decisions regarding admission to hospital, timing and mode of delivery, and management issues in the early postpartum period.     

Chronic hypertension: effect of blood pressure control on pregnancy outcome

Objective: To examine whether in patients with CH and mild to moderate hypertension the level of control of blood pressure during pregnancy has a beneficial or adverse effect on the risk of PE or SGA.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials of patients with mild to moderate CH in pregnancy that reported the impact of different levels of control of blood pressure on the risk of PE or SGA. We completed a literature search through PubMed, Embase, Cinahl, Web of science, Cochrane CENTRAL Library Relative risks with random effect were calculated with their 95% confidence intervals (95%CI).

Results: Six trials including 495 participants provided data on blood pressure (BP) after entry to the study. Four studies compared antihypertensive agents to no treatment and two studies compared antihypertensive agents to placebo. All trials were conducted between 1976 and 1990 and were considered to be at high risk of bias. There was high heterogeneity between studies for mean arterial pressure (MAP) after randomization (I²?=?87%) and SGA (I²?=?60%), but not for PE (I²?=?0%). There were large differences between studies in the inclusion criteria, antihypertensive regimens, targets of therapy, and gestational age range at entry to the trials. In women receiving antihypertensive therapy, compared to those receiving placebo or no treatment, the MAP after entry to the trial was significantly lower (mean difference ?4.2?mmHg, 95%CI ?6.6 to ?1.8; p?=?.006). However, there was no significant reduction in the risk of PE (relative risks (RR) 1.03, 95%CI 0.63–1.68; p?=?.90) or SGA (RR 1.01, 95%CI 0.35–2.93; p?=?.99).

Conclusions: The findings of the meta-analysis suggest that lowering the blood pressure by antihypertensive medication in women with mild to moderate hypertension in the context of CH has no significant effect on the risk of SGA or PE.     

ACOG Practice Bulletin. Chronic hypertension in pregnancy. ACOG Committee on Practice Bulletins

Chronic hypertension occurs in up to 5% of pregnant women; rates vary according to the population studied and the criteria used for confirming the diagnosis (1,2). This complication may result in significant maternal, fetal and neonatal morbidity and mortality. There has been confusion over the terminology and criteria used to diagnose this complication, as well as the benefit and potential harm of treatment during pregnancy. The purpose of this document is to review the effects of chronic hypertension on pregnancy, to clarify the terminology and criteria used to define and diagnose it during pregnancy, and to review the available evidence for treatment options.     

Managing hypertension in pregnancy

Hypertension is the most common problem arising during pregnancy complicating up to 15% of all pregnancies. Definitions have been derived to identify different groups of women for whom the outcomes vary widely, and many definitions were originally designed to aid the researcher rather than the clinician. Untreated severe hypertension either pre-existing or new-onset carries increased risks to both mother and fetus, but in milder disease the benefits of treatment to mother and fetus are less clear. Treatment of moderate pre-existing and new-onset hypertension can reduce the need for admission to hospital antenatally and progression to severe hypertension, but has little impact on progression to pre-eclampsia in either group. Maternal therapy confers little advantage to the fetus in women with pre-existing hypertension, and only marginal improvements in rates of respiratory distress syndrome in women with new-onset pre-eclampsia. Labetalol and methyldopa both appear to be safe and well tolerated. Vigilance for progression to pre-eclampsia and timely delivery are of paramount importance.     

Chronic infections in pregnancy

In the study of the subject of chronic infections in obstetrics made in this paper, the records of 600 private cases with complete general histories and physical examinations have been reviewed and analyzed with regard to the incidence of such infections as revealed by examination and how these affect and are affected by pregnancy. The mouth and throat were examined by a good light and the chest bared for examination in every case. The kidneys were examined by hammer-percussion and palpation, and every two weeks, a microscopic and chemical examination of the urine was made.     

Chronic hypertension and the risk for adverse pregnancy outcome after superimposed pre-eclampsia.

OBJECTIVE: To determine the risk factors and pregnancy outcome of patients with chronic hypertension during pregnancy after controlling for superimposed preeclampsia. METHOD: A comparison of all singleton term (>36 weeks) deliveries occurring between 1988 and 1999, with and without chronic hypertension, was performed. Stratified analyses, using the Mantel-Haenszel technique, and a multiple logistic regression model were performed to control for confounders. RESULTS: Chronic hypertension complicated 1.6% (n=1807) of all deliveries included in the study (n=113156). Using a multivariable analysis, the following factors were found to be independently associated with chronic hypertension: maternal age >40 years (OR=3.1; 95% CI 2.7-3.6), diabetes mellitus (OR=3.6; 95% CI 3.3-4.1), recurrent abortions (OR=1.5; 95% CI 1.3-1.8), infertility treatment (OR=2.9; 95% CI 2.3-3.7), and previous cesarean delivery (CD; OR=1.8 CI 1.6-2.0). After adjustment for superimposed preeclampsia, using the Mantel-Haenszel technique, pregnancies complicated with chronic hypertension had higher rates of CD (OR=2.7; 95% CI 2.4-3.0), intra uterine growth restriction (OR=1.7; 95% CI 1.3-2.2), perinatal mortality (OR=1.6; 95% CI 1.01-2.6) and post-partum hemorrhage (OR=2.2; 95% CI 1.4-3.7). CONCLUSION: Chronic hypertension is associated with adverse pregnancy outcome, regardless of superimposed preeclampsia.     

Primary pulmonary hypertension in pregnancy

Primary pulmonary hypertension (PPH) is an uncommon but serious disease. Most patients with PPH are young women and the disease is more serious and eventful in pregnant women. We have experienced a patient with PPH in pregnancy, who was delivered successfully but died suddenly on the 7th day after the delivery. We report the obstetric course and the clinical management for the delivery of the patient with PPH.     

Pulmonary arterial hypertension in pregnancy

Pulmonary hypertension is a medical condition characterized by elevated pulmonary arterial pressure and secondary right heart failure. Pulmonary arterial hypertension is a subset of pulmonary hypertension, which is characterized by an underlying disorder of the pulmonary arterial vasculature. Pulmonary hypertension can also occur secondarily to structural cardiac disease, autoimmune disorders, and toxic exposures. Although pregnancies affected by pulmonary hypertension and pulmonary arterial hypertension are rare, the pathophysiology exacerbated by pregnancy confers both high maternal and fetal mortality and morbidity. In light of new treatment modalities and the use of a multidisciplinary approach to care, maternal outcomes may be improving.