Clinical risk factors for gestational hypertensive disorders in pregnant women at high risk for developing preeclampsia

ObjectivesTo evaluate clinical risk factors for the development of gestational hypertensive disorders in a group of pregnant women at high risk for developing preeclampsia. Secondly we evaluated the incidence and recurrence rate of preeclampsia and pregnancy-induced hypertension.Study designA prospective analysis of data obtained from a cohort study was performed. Pregnant women were included who had at least one of the following risk factors for preeclampsia: previous history of preeclampsia, previous history of HELLP syndrome, chronic hypertension, diabetes mellitus, multiple pregnancy, obesity, or autoimmune disease. Univariate and multivariate logistic regression analyses were used to evaluate the role of clinical characteristics and risk factors in the development of hypertensive disorders.Main outcome measuresDevelopment of gestational hypertensive disorders.ResultsThirty-five percent (36/103) developed a hypertensive disorder. The univariate analysis identified preeclampsia in a previous pregnancy (OR 2.94, 95% CI: 1.25–6.91, p = 0.013) as a significant risk factor. Multivariate logistic regression revealed that a previous history of preeclampsia was the only significant independent risk factor for gestational hypertensive disorders (OR 2.89, 95% CI: 1.17–7.08, p = 0.021). Women with a previous history of PE had the highest incidence rate of 51.4% for hypertensive disorders compared to the incidence rates of other risk factors (20.8%–38.5%).ConclusionA previous history of preeclampsia proves to be a strong independent clinical risk factor for gestational hypertensive disorders in high-risk pregnant women, even in our relatively small cohort study.     

Effect of regular exercise on blood pressure in normotensive pregnant women. A randomized controlled trial

Objective: To evaluate the effect of regular exercise on maternal arterial blood pressure (BP) at rest and during uphill walking, in healthy former inactive pregnant women. Methods: A single-blind, single-center, randomized controlled trial including 61 out of 105 healthy, inactive nulliparous pregnant women, initially enrolled in a controlled trial studying the effect of 12 weeks of aerobic exercise (60 min 2/week) on maternal weight gain. Primary outcome was the mean adjusted difference in change in resting systolic and diastolic BP from baseline to after intervention. Secondary outcome was the mean adjusted difference in change in systolic BP during uphill treadmill walking at critical power. Measurements were performed prior to the intervention (gestation week 17.6 ± 4.2) and after the intervention (gestation week 36.5 ± 0.9). Results: At baseline, resting systolic and diastolic BP was 115/66 ± 12/7 and 115/67 ± 10/9 mmHg in the exercise (n = 35) and control group (n = 26), respectively. After the intervention, resting systolic BP was 112 ± 8 mmHg in the exercise group and 119 ± 14 mmHg in the control group, giving a between-group difference of 7.5 mmHg (95% CI 1.5 to 12.6, p = 0.013). Diastolic BP was 71 ± 9 and 76 ± 8 mmHg, with a between-group difference of 3.9 mmHg (95% CI ?0.07 to 7.8, p = 0.054). During uphill treadmill walking at critical power, the between-group difference in systolic and diastolic BP was 5.9 mmHg (95% CI ?4.4 to 16.1, p = 0.254) and 5.5 mmHg (95% CI –0.2 to 11.1, p = 0.059), respectively. Conclusions: Aerobic exercise reduced resting systolic BP in healthy former inactive pregnant women.     

Reliability of compact electronic blood pressure monitors for hypertensive pregnant women

Self-monitoring of blood pressure is an asset to managing hypertensive pregnant women on an outpatient basis. Many brands of electronic blood pressure devices are now available for use during pregnancy. An investigation was undertaken to compare the relative accuracy and acceptability of four of the least expensive and most compact units (Sunbeam III, Norelco, Lumiscope and Marshall). The reliability of the devices was compared with simultaneous measurements using a Dinamap 845A monitor on 22 pregnant hypertensive women. All measurements were performed without difficulty by a skilled observer and the patients. The accuracy varied, but each electronic device was considered as accurate as a mechanical aneroid unit available at the same retail stores. The advantages of these electronic units were ease of application and readability of the measurements without the need for a stethoscope or an assistant.     

Urinary lysosomal enzyme excretion in pregnant women with hypertensive disorders

Background: The authors assessed proximal renal tubular dysfunction and/or damage in pregnant women with various types of hypertension by measuring the three urinary lysosomal enzyme levels: N-acetyl-β-d-glucosaminidase (NAG), arylsulfatase A and β-glucuronidase. Methods: The study consisted of 120 pregnant women divided into four groups: 41 women in 20th week of gestation or more, with pregnancy-induced hypertension (PIH group), 28 pregnant women after 20 weeks of pregnancy with pre-eclampsia (PE group), 21 pregnant women with chronic hypertension, identified before 20th week of pregnancy (CH group) and 30 healthy, pregnant women (healthy controls (HC) group). Results: Statistical analysis showed significantly higher levels of all the three of lysosomal enzymes in the urine of patients with PE compared with the healthy pregnant women, pregnant women with PIH and the ones with chronic hypertension. Additionally, significantly higher values of NAG were found in the group of pregnant women with PIH compared with healthy pregnancies. No correlation was found between the concentration of enzymes in urine and values of blood pressure in any of the analyzed groups of pregnant women. Conclusions: The authors conclude that higher values of all the studied enzymes in PE group, in the comparison with the other groups, indicate proximal tubular damage at the cellular level. The lack of correlation between the concentration of lysosomal enzymes and blood pressure suggests that the damage to these parts of kidney is complex. In addition, mechanisms other than hypertension realizing intracellular enzymes may be involved in this process.     

Effect of alpha-methyldopa (Dopegyt) on blood pressure in hypertensive pregnant patients

Forty-three patients hospitalised for chronic hypertension or superimposed toxemia in late pregnancy were treated with Dopegyt-orally in constant dosage. Blood pressure dropped at the beginning of therapy. In the further course of treatment blood pressure re-increased in 14 patients, that other antihypertensive drugs had to be administered additionally. alpha-methyldopa alone is sufficient only in a part of the hypertensive patients.     

Assessment of high blood pressure in 24-hours Holter records in hypertensive pregnant patients

DESIGN: The aim of our study was to established possible a correlation between Holter blood pressure measurements and BP levels measured incidentally by the medical personnel. We also tried to evaluate usefulness of ABPM in monitoring intensification of the hypertension. MATERIALS AND METHODS: The research was performed on 57 pregnant women where pregnancies were complicated by hypertension (PIH or chronic hypertension). All patients were divided into four groups conforming with JNC VI protocol according to BP level measured in the time of the admission to hospital. Therefore circadian blood pressure profile was done by using ABPM SpaceLab device. After that BP load indicator was estimated in each group to assess intensification of the disease. However, we compared those results between groups by using t-Student test (p < 0.05). RESULTS: We qualified 22 patients to group 0 with SBP = 129,45 + 6.31 mmHg and DBP = 80.59 + 5.45 mmHg in the time of admission. There were 21 pregnant women with mild hypertension (group I SBP = 144,14 + 7.32 mmHg, DBP = 93.14 + 4.52 mmHg), moderate (group II, N = 8 with SBP = 153,88 + 5.54 mmHg and DBP = 101,34 + 3.78 mmHg) and severe hypertension (group III, N = 6 with SBP = 175,83 + 33.23 mmHg, DBP = 121 + 11.92 mmHg). BP load value measured in group 0 was 14.57 + 21.3% of SBP and 13.92 + 22.99% of DBP inappropriate results. In group I was found SBP 24.91 + 30.3%, DBP 23.12 + 26.01%, group II SBP 38.11 + 33.66%, DBP 26.31 + 22.75% and in group III SBP 59.3 + 38.76% and DBP 61.37 + 35.72%, respectively. CONCLUSIONS: Only between the group with normal blood pressure and the group with severe hypertension the obtained results were statistically significant (p < 0.05). We've also found a statistical correlation between BP values measured in the time of admission to the hospital and BP load indices in each group.     

Obstetric outcomes in pregnant women with diabetes versus hypertensive disorders versus both

Abstract

Objective.?To compare obstetrical outcomes in pregnant women with diabetes versus hypertensive disorders versus both.

Methods.?One million patients in the New Jersey Database were analyzed. Of which 6.91% had hypertension, 4.79% had diabetes, and 0.91% had both. Information was derived from a perinatal linked data-set provided by the Maternal Child Health Epidemiology (MCH Epi) Program in the New Jersey Department of Health and Senior Services. Linking of electronic birth certificates, hospital discharge records for mother and newborn, and infant death certificates for all infants born in New Jersey between the years 1997 and 2005 created the data-set.

Results.?Coexistence of hypertension and diabetes increased with advancing maternal age (OR 3.41; CI 3.12–3.72). Among ethnic groups, diabetes was more common in Asians (OR 2.92; CI 2.84–3.00), while hypertension was more common in Blacks (OR 1.49; CI 1.46–1.53). Blacks followed by Asians had a higher risk of being in the combined category. Induction of labor (OR 4.16; CI 3.96–4.38), shoulder dystocia (OR 2.56; CI 2.05–3.19), operative vaginal delivery (OR 3.92; CI 3.29–4.66), cesarean deliveries with no trial of labor (OR 2.54; CI 2.40–2.69) as well as with failed trial of labor (OR 4.09; CI 3.88–4.31) were more common in the combined group. Neonatal outcomes were poor in the combined category, with high rate of preterm deliveries, neonatal intensive care unit (NICU) admissions (OR 2.14; CI 2.01–2.28), neonatal seizures (OR 2.30; CI 1.31–4.04), low 5-min APGAR scores (OR 1.78; CI 1.57-2.01), and longer NICU stay (OR 2.30; CI 2.15-2.47).

Conclusions.?Coexistence of hypertension and diabetes was associated with worse obstetric and neonatal outcomes than either alone. This should be emphasized to mothers during prenatal counseling. Further research should focus on interventions to improve morbidity in the combined category.     

Inter-arm blood pressure differences in pregnant women

Objective  To determine the prevalence of blood pressure inter-arm difference (IAD) in early pregnancy and to investigate its possible association with maternal characteristics.
Design  A cross-sectional observational study.
Setting  Routine antenatal visit in a university hospital.
Population  A total of 5435 pregnant women at 11–14 weeks of gestation.
Methods  Blood pressure was taken from both arms simultaneously with a validated automated device.
Main outcome measures  The presence of inter-arm blood pressure difference of 10 mmHg or more.
Results  The IAD in systolic and diastolic blood pressure was 10 mmHg or more in 8.3 and 2.3% of the women, respectively. Systolic IAD was found to be significantly related to systolic blood pressure and pulse pressure, and diastolic IAD was found to be significantly related to maternal age, diastolic blood pressure and pulse pressure. The systolic and diastolic IAD were higher in the hypertensive group compared with the normotensive group and absolute IAD increased with increasing blood pressure. About 31.0 and 23.9% of cases of hypertension would have been underreported if the left arm and the right arm were used, respectively, in measuring the blood pressure.
Conclusions  There is a blood pressure IAD in a significant proportion of the pregnant population, and its prevalence increases with increasing blood pressure. By measuring blood pressure only on one arm, there is a one in three chance of underreporting hypertension. Therefore, it would be prudent that during the booking visit blood pressure should be taken in both arms and thus provide guidance for subsequent blood pressure measurements during the course of pregnancy.     

Trisomy 13 and the risk of gestational hypertensive disorders: a population-based study

Purpose: To describe the rate and severity of gestational hypertensive disorders (GHDs) in pregnancies complicated by trisomy 13 (T13).

Materials and methods: Retrospective cohort study of singleton deliveries in California from 2005 to 2008 using vital statistics and ICD-9 data. We were interested in gestational hypertension (gHTN), preeclampsia with and without severe features (sPREX and PREX), and gestational age at delivery. Pregnancies and maternal complications affected by prenatally diagnosed T13 were compared to unaffected pregnancies. Regression models were used to compute adjusted odds ratios for pregnancy outcomes by T13 status.

Results: Of the 2,029,004 deliveries, 142 women had prenatally diagnosed T13. A diagnosis of GHD occurred in 26.8% of the T13 pregnancies versus 6% of the non-T13 pregnancies (p?p=.001), PREX (12% versus 2.2%, p?p?Conclusions: Women with T13 pregnancies were significantly more likely to have gHTN, preeclampsia, sPREX, and to deliver <32 weeks.     

Acute effect of exercise on blood glucose and insulin levels in women with gestational diabetes

OBJECTIVE: To evaluate the effect of a single session of exercise (cycling), at rest (control condition) and at two intensity levels (low- and moderate-intensity exercise conditions), on blood glucose and insulin in pregnancy complicated by gestational diabetes mellitus (GDM). METHODS: A one-group repeated measures design was used. Women aged 18-38 with GDM, no other complications, not on insulin, and not exercising regularly were recruited. The women rested or exercised at the two intensities for 30 min and rested for 2 h after each session. Blood was sampled for blood glucose, insulin and hematocrit at baseline and every 15 min. RESULTS: There was no difference at baseline in blood glucose levels. The blood glucose level was significantly lower for each exercise condition compared to rest, and for moderate compared to low-intensity exercise (5.2 vs. 4.3 vs 3.9 mmol/l) at the end of exercise (30 min), and for the two exercise conditions compared to rest at 15 min after exercise (4.9 vs 4.4 vs. 4.0 mmol/l). By 45 min after exercise, the blood glucose values were nearly identical. The area under the curve for blood glucose was significantly lower for low- and moderate-intensity exercise than for rest (p = 0.01). The slope of change in insulin among the three conditions, from baseline to the 30-min session, approached significance (p = 0.065). The power for that analysis was 0.51. A sample of 23 would have been required to increase the power to 0.80. CONCLUSIONS: Significant declines in blood glucose level were observed during low- and moderate-intensity exercise compared to rest. These differences were gone by 45 min after exercise. Continued research should examine those with high body mass index and more pronounced hyperglycemia for further evaluation of the effect of exercise on blood glucose and insulin levels in women with GDM.     

Acute effect of exercise on blood glucose and insulin levels in women with gestational diabetes

Objective : To evaluate the effect of a single session of exercise (cycling), at rest (control condition) and at two intensity levels (low- and moderate-intensity exercise conditions), on blood glucose and insulin in pregnancy complicated by gestational diabetes mellitus (GDM). Methods : A one-group repeated measures design was used. Women aged 18-38 with GDM, no other complications, not on insulin, and not exercising regularly were recruited. The women rested or exercised at the two intensities for 30 min and rested for 2 h after each session. Blood was sampled for blood glucose, insulin and hematocrit at baseline and every 15 min. Results : There was no difference at baseline in blood glucose levels. The blood glucose level was significantly lower for each exercise condition compared to rest, and for moderate compared to low-intensity exercise (5.2 vs. 4.3 vs 3.9 mmol/l) at the end of exercise (30 min), and for the two exercise conditions compared to rest at 15 min after exercise (4.9 vs 4.4 vs. 4.0 mmol/l). By 45 min after exercise, the blood glucose values were nearly identical. The area under the curve for blood glucose was significantly lower for low- and moderate-intensity exercise than for rest ( p = 0.01). The slope of change in insulin among the three conditions, from baseline to the 30-min session, approached significance ( p = 0.065). The power for that analysis was 0.51. A sample of 23 would have been required to increase the power to 0.80. Conclusions : Significant declines in blood glucose level were observed during low- and moderate-intensity exercise compared to rest. These differences were gone by 45 min after exercise. Continued research should examine those with high body mass index and more pronounced hyperglycemia for further evaluation of the effect of exercise on blood glucose and insulin levels in women with GDM.     

Home blood pressure levels in pregnant women with chronic hypertension.

OBJECTIVE: To explore the difference between office and home blood pressure (BP) monitoring in normotensive and hypertensive pregnant women. METHODS: We compared the mean of 1 week home BP with office BP, measured by aneroid devices, in 20 normotensive women (68 BP assessments) and 100 women with mild essential chronic hypertension without superimposed gestational hypertension (429 BP assessments). Different approaches were used including the Bland-Altman method to investigate the discrepancies between office and home BP. RESULTS: Systolic office BP in normotensive women (p = 0.004) and diastolic office BP in hypertensive women (p = 0.001) were lower than home BP. The concordance between office and home BPs was better for diastolic BP than for systolic BP. Only a small number of hypertensive women presented home BP >or=135/85 mm Hg. CONCLUSIONS: In our study population, the concurrence between office and home BPs is good with the exception of systolic BP in normotensive women. Home blood pressure measurement criteria used in nonpregnant individuals are not adequate in pregnancy.     

The complements and immunoglobulins in different media of healthy pregnant women and in pregnant women with increased blood pressure

We have determined the levels of complement C3, C4 and immunoglobulin G, M, A in mothers' and cord blood serum. Parallelly properdin factor B and immunoglobulin G tests were done in urine samples. All estimations were performed on Immunochemistry Analyzer "Beckman". The investigations were made on 30 healthy pregnant women and 30 with arterial hypertension at the end of third trimester. In the mothers' serum C3 was not significantly changed. In the cord blood of healthy pregnant women it was 0.69 g/L. (SD 0.12) and in those with hypertension 0.38 g/L. (SD 0.15), which means significantly decreased. Complements C4 was not significantly increased in mothers' and cord blood serum. Properdin factor B was significantly increased in mothers' and cord blood serum (healthy pregnant women in serum 0.38 g/L., SD 0.07; with hypertension 0.48 g/L., SD 0.15; while in the cord blood serum of healthy women it was 0.14 g/L., SD 0.06; and hypertensive it was 0.22 g/L., SD 0.10). The same parameter was significantly decreased in the urine of healthy subjects 3.94 mg/L., SD 1.91; and in the hypertensive too, 2.42 mg/L., SD 0.90. The IgG level was significantly increased in the urine of healthy pregnant women 4.42 mg/L., SD 2.24; with hypertension 6.64 mg/L., SD 3.61. IgM was not significantly changed in mothers' and cord blood serum. IgA was significantly increased in the cord blood serum of healthy mothers', 0.02 g/L., SD 0.01, with hypertension 0.12 g/L., SD 0.05.     

Longitudinal changes of adiponectin,carbohydrate and lipid metabolism in pregnant women at high risk for gestational diabetes

To evaluate, in pregnant women at high risk for gestational diabetes (GDM), the longitudinal changes of adiponectin, carbohydrate and lipid metabolism, and to assess their independent value as risk factors for the development of GDM. Fifty women at beginning of pregnancy were studied. Adiponectin, insulin sensitivity (homeostasis model assessment, HOMA) and lipid panel were measured at 1st, 2nd and 3rd trimesters of pregnancy. Twelve patients developed GDM. In both groups, GDM and normal glucose tolerance (NGT), adiponectin decreased from 1st to 2nd and 3rd trimesters by about 5 and 20% (GDM, p?<?0.05), and of about 17 and 25% in NGT (p?<?0.05), respectively. Values observed in NGT were similar to those of GDM (F?=?9.401; p?=?0.238). The Cox regression model identified as the strongest independent risk factor for GDM HOMA over 1.24 (RR?=?14.12) at 1st trimester, fasting glycaemia over 87?mg/dl (RR?=?42.68) triglycerides over 158?mg/dl (RR?=?5.87) and body mass index (BMI) over 27?kg/m² (RR?=?4.38) at 2nd trimester. Adiponectin in high-risk women is characterised by a constant reduction throughout gestation, irrespective of the development of GDM. HOMA, fasting glycaemia, triglycerides and BMI, but not adiponectin are independent predictors of GDM.     

First-trimester blood pressure and gestational diabetes in high-risk Chinese women

OBJECTIVE: Gestational diabetes mellitus (GDM) is associated with increased incidence of hypertensive disorders of pregnancy, which is attributed to maternal insulin resistance and hyperinsulinemia. A retrospective case-control study was performed to examine the relationship between first-trimester blood pressure (BP) and the subsequent development of GDM in high-risk Chinese women. METHODS: The systolic and diastolic BP readings at the 9th-12th week of gestation were compared between 67 women with GDM and 64 high-risk controls matched for age (+/- 1 year), height (+/- 1 cm), and booking weight (+/- 1 kg), all with singleton pregnancies and delivered within 1 year. The entire cohort was further categorized into systolic and diastolic BP quartile groups based on reference values established in 215 consecutive pregnant women, and the incidence of GDM was correlated with the quartile ranking. RESULTS: The GDM group had significantly higher systolic BP (114.0 +/- 12.9 mmHg versus 108.0 +/- 10.6 mmHg, P =.004) at the 9th-12th week. There was a positive and significant correlation between the incidence of GDM and systolic BP, but not diastolic BP, quartiles, and systolic BP above the median value (109 mmHg) was associated with increased incidence of GDM. Regression analysis with adjustment for the effects of age over 35 years and weight greater than 75 kg confirmed that systolic BP above median was a significant risk factor for GDM (OR 4.20, 95% CI 1.97, 8.94). CONCLUSION: The correlation between first-trimester systolic BP quartiles and incidence of GDM could be a feature of insulin resistance and hyperinsulinemia before the development of GDM in high-risk Chinese women.     

Arterial pressure response to maximal isometric exercise in pregnant women.

We studied the arterial pressure response to maximal leg exercise in 15 healthy volunteers at 29 and 35 weeks' pregnancy and at 8 weeks post partum. Resting mean arterial pressure at 35 weeks' gestation was similar to the postpartum control value of 88 mm Hg (range 73 to 111), but it was reduced by 10% at 29 weeks' gestation. Voluntary maximal effort averaged 2470 N (range 1450 to 3030) in the postpartum period, was similar at 29 weeks, and was reduced by 13% at 35 weeks' gestation. Mean arterial pressure showed a linear increase with force to a median maximum value of 131 (104 to 159) mm Hg, or 49% above the resting value in the postpartum period. The pressure response was unaffected by pregnancy, but was inversely related to maximal force, i.e., the individual's capacity to perform isometric exercise.     

ABO and RhD blood groups and gestational hypertensive disorders: a population-based cohort study

Please cite this paper as: Lee B, Zhang Z, Wikman A, Lindqvist P, Reilly M. ABO and RhD blood groups and gestational hypertensive disorders: a population-based cohort study. BJOG 2012;119:1232-1237. Objective To examine the association between ABO and RhD blood groups and gestational hypertensive disorders in a large population-based cohort. Design Cohort study. Risks of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia, estimated by odds ratios for maternal ABO blood group and RhD status. Setting National health registers of Sweden. Population All singleton deliveries in Sweden born to first-time mothers during the period 1987-2002 [total n?=?641?926; any gestational hypertensive disorders, n?=?39?011 (6.1%); pre-eclampsia cases, n?=?29?337 (4.6%); severe pre-eclampsia cases, n?=?8477 (1.3%)]. Methods Using blood group O as a reference, odds ratios of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia were obtained from logistic regression models adjusted for potential confounding factors. Main outcome measures Gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia. Results Compared with blood group O, all non-O blood groups had modest but statistically significantly higher odds of pre-eclampsia. Blood group AB had the highest risk for pre-eclampsia (OR?=?1.10, 95% CI 1.04-1.16) and severe pre-eclampsia (OR?=?1.18, 95% CI 1.07-1.30). RhD-positive mothers had a small increased risk for pre-eclampsia (OR?=?1.07, 95% CI 1.03-1.10). Conclusions In the largest study on this topic to date, women with AB blood group have the highest risks of gestational hypertensive disorders, pre-eclampsia, and severe pre-eclampsia, whereas women with O blood group have the lowest risks of developing these disorders. Although the magnitude of increased risk is small, this finding may help improve our understanding of the etiology of pre-eclampsia.