Expectant management of severe preeclampsia and preeclampsia superimposed on chronic hypertension between 24 and 34 weeks' gestation

BACKGROUND: Timing of delivery is difficult to judge in preeclampsia. OBJECTIVE: To compare the differences of maternal and perinatal outcome of patients with severe preeclampsia and essential hypertension with superimposed preeclampsia, with expectant management at 24-34 weeks' gestation. STUDY DESIGN: A retrospective review of a conservative regime using intravenous magnesium sulfate, glucocorticoids and antihypertensive drugs, monitored by serial liver function tests, full blood count, coagulation profile, and renal function tests. Fetal status was assessed by daily non-stress test and ultrasound twice by week. RESULTS: A total number of 100 women had severe preeclampsia and 29 superimposed preeclampsia. The average pregnancy prolongation was 8.4 and 8.5 days, respectively. Oliguria, abruption placentae and HELLP syndrome were frequent complications similar in each group. There were no cases of eclampsia or disseminated coagulopathy in either group. The total neonatal survival rate was 93% in both groups. CONCLUSION: Expectant management is equally safe in both superimposed preeclampsia and severe preeclampsia of early onset.     

Incidence of superimposed preeclampsia among pregnant Asian women with chronic hypertension

Objective: To determine the incidence and associated factors of superimposed preeclampsia among pregnant women with chronic hypertension.

Methods: A total of 300 pregnant women diagnosed with chronic hypertension were reviewed. Data were retrieved from medical records, including obstetric data, characteristics of hypertension, and pregnancy outcomes. Incidence of superimposed preeclampsia was estimated. Various characteristics were compared to determine associated risk factors.

Results: Mean age of the cohort was 34.3 years, 47% were nulliparous, 50% had hypertension before pregnancy, and the others presented with hypertension before 20 weeks. Incidence of superimposed preeclampsia was 43.3% (95% confidence interval (CI) 37.8–48.9). Women with superimposed preeclampsia were significantly more likely to have mean arterial pressure (MAP) ≥105 mmHg at 18–20 and 24–28 weeks. Adverse neonatal outcomes were significantly more common among women with superimposed preeclampsia, including small for gestational age, low birth weight, asphyxia, and neonatal intensive care unit admission. Logistic regression analysis demonstrated that only MAP ≥105 mmHg at 24–28 weeks was independently associated with the increased risk of superimposed preeclampsia by 1.8-fold (adjusted OR 1.8, 95% CI 1.1–3.1, p = 0.031).

Conclusion: Incidence of superimposed preeclampsia was 43.3% among pregnant women with chronic hypertension, with increased adverse neonatal outcomes. High MAP ≥105 mmHg during late second trimester might be an important predictor of the condition.     

A prediction model for superimposed preeclampsia in women with chronic hypertension during pregnancy

OBJECTIVE: Women with chronic hypertension are at increased risk for superimposed preeclampsia. We developed a prediction algorithm for superimposed preeclampsia using clinical and laboratory information that were measured early in pregnancy. STUDY DESIGN: A secondary analysis of data that were collected from 110 women with chronic hypertension who were enrolled in a trial of calcium supplementation was performed. Blood pressure, the renin-angiotensin system, and calcium metabolism were assessed at 12, 20, 28, and 36 weeks of gestation and 6 weeks after delivery. Multivariable logistic regression was used to develop the predictive model. RESULTS: Thirty-seven women had superimposed preeclampsia. The final model included systolic blood pressure, serum uric acid, and plasma renin activity, which were all measured at 20 weeks of gestation. Women with high systolic blood pressure (>140 mm Hg), elevated uric acid (>3.6 mg/dL), and low plasma renin activity (<4 ng/mL/hr) had an 86% probability of having superimposed preeclampsia. Women with 2 risk factors had a 62% probability of superimposed preeclampsia, and women with only 1 risk factor had a 30% to 40% probability of superimposed preeclampsia. CONCLUSION: We developed a prediction algorithm that can be validated in future studies for superimposed preeclampsia for women with chronic hypertension.     

慢性高血压并发早发型重度先兆子痫单胎孕妇围产期母儿结局的回顾性分析

目的探讨慢性高血压并发早发型重度先兆子痫较单纯早发型重度先兆子痫是否会增加母儿的不良结局。方法自1999年7月1日至2009年6月30日北京大学第一医院共收治早发型重度先兆子痫单胎孕妇300例,其中慢性高血压并发早发型重度先兆子痫者59例(A组),单纯早发型重度先兆子痫者241例(B组),对两组孕妇的母儿结局进行分析,讨论慢性高血压并发早发型重度先兆子痫是否会增加母儿的不良结局。结果两组孕妇一般情况没有明显的差异,A组的最高收缩压和舒张压明显高于B组(P0.05)。两组孕妇严重并发症如胎盘早剥、HELLP综合征、肺水肿、肝功能损害和子痫等发生率比较,差异无统计学意义(P0.05)。A组除了新生儿呼吸窘迫综合征的发生率明显高于B组外(P0.05),两组围产儿死亡率、胎儿生长受限、新生儿窒息、颅内出血和坏死性小肠结肠炎的发生率比较,差异无统计学意义(P0.05)。结论在病情允许的情况下,通过严密监测母儿一般状况、积极地对症治疗并采用适当的期待疗法,慢性高血压并发早发型重度先兆子痫较单纯早发型重度先兆子痫没有对母儿造成明显的不良后果。     

Inhibin-A and superimposed preeclampsia in women with chronic hypertension

OBJECTIVE: To determine if maternal serum inhibin-A can be used as a marker for subsequent development of superimposed preeclampsia in women with chronic hypertension. METHODS: Serum for measurement of inhibin-A was obtained at monthly intervals in women with chronic hypertension requiring antihypertensive medications. Superimposed preeclampsia, the primary outcome of interest, was diagnosed when hypertensive women developed proteinuria (at least 300 mg per 24-hour urine specimen). Serum inhibin-A was considered abnormally elevated when the value exceeded the mean plus two standard deviations of the log for chronically hypertensive women who did not develop preeclampsia. RESULTS: A total of 61 women were enrolled in this study, and 21 (34%) developed superimposed preeclampsia. Inhibin-A levels increased with advancing gestational age. Ten women had abnormally increased inhibin-A levels; eight (80%) developed superimposed preeclampsia, compared with 13 of 51 (26%) women with normal inhibin-A levels (P <.001). Sensitivity and specificity were 38% and 95%, respectively, whereas the positive and negative predictive values were 80% and 75%, respectively. CONCLUSION: Although inhibin-A was abnormally increased an average of 3 weeks before the clinical onset of superimposed preeclampsia, the sensitivity of the test as a screen was too limited to be clinically useful.     

Comparison between HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome

AIM: To compare perinatal outcome of patients with HELLP syndrome to that of patients with chronic hypertension and superimposed preeclampsia on chronic hypertension without HELLP syndrome. METHODS: We retrospectively evaluated the perinatal outcome of 147 pregnancies complicated by the HELLP syndrome, chronic hypertension, and superimposed preeclampsia on chronic hypertension without HELLP syndrome. RESULTS: Gestational age at delivery and birthweights were lower among women with HELLP syndrome than among women with superimposed preeclampsia and chronic hypertension (P < 0.05). There were no statistically significant differences among the three groups with respect to intrauterine growth retardation, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, Apgar score, admission to neonatal intensive care unit, overall rate of cesarean delivery and cesarean delivery rate for fetal distress. The total perinatal mortality rate was 17% (28/147) and was more frequent in the HELLP group (27%). Multivariate logistic regression analysis showed that gestational age at delivery (RR 0.45) and birthweight (RR 0.99) were risk factors for adverse outcome. CONCLUSIONS: Perinatal outcome is primarily influenced by gestational age at delivery and birthweight independent of the severity of the hypertensive status of pregnant women.     

慢性高血压并发子痫前期的母儿结局分析

目的 了解慢性高血压并发子痫前期与非慢性高血压并发子痫前期患者的临床特征和母儿结局.方法 回顾分析2009年1月1日至2017年12月31日在广州医科大学附属第三医院住院分娩的妊娠≥20周的单胎妊娠诊断为子痫前期的病例资料.按是否为慢性高血压分为慢性高血压并发子痫前期组及非慢性高血压并发子痫前期组,分析两组的临床特征与...     

High blood pressure six weeks postpartum after hypertensive pregnancy disorders at term is associated with chronic hypertension

ObjectivesHypertension in pregnancy is associated with cardiovascular disease (CVD) later in life. Blood pressure monitoring in women who experienced hypertension in pregnancy after puerperium has been suggested to be important for early detection and prevention of CVD. The aim of this study is to evaluate if hypertension six weeks postpartum is associated with chronic hypertension in women with a history of term hypertensive pregnancy disorders.Study designWomen with a history of term gestational hypertension or preeclampsia were included in a follow up study of the HYPITAT trial. Blood pressures were measured six weeks and 2.5 years postpartum according to the study protocol.Main outcome measuresHypertension was defined as a diastolic blood pressure ?90 mmHg and/or a systolic blood pressure ?140 mmHg or use of antihypertensive medication. Differences in categorical variables between groups were analyzed by Chi-Square tests. Blood pressure was analyzed using unpaired t-tests and Wilcox ranked tests.ResultsAmong 187 women who had term hypertensive pregnancy disorders, 75 (40%) had hypertension at six weeks postpartum. Of these 46 (61%) had hypertension 2.5 years postpartum. In contrast, of 112 women without hypertension at six weeks postpartum, 36 (32%) had hypertension 2.5 years (OR 3.3, 95% CI 1.8–6.2).ConclusionAmong 61% of women who had hypertensive pregnancy disorders at term, high blood pressure at six weeks postpartum indicated chronic hypertension. This warrants the importance of identification of hypertension 6 weeks postpartum for women’s future health.     

Prediction of superimposed preeclampsia using uterine artery Doppler velocimetry in women with chronic hypertension

OBJECTIVE: To assess the role of uterine artery (UtA) Doppler to predict superimposed preeclampsia in women with chronic hypertension. METHODS: In a cohort of 182 women with chronic hypertension, UtA Doppler studies were performed before 25 weeks (mean 19.7 +/- 2.1 weeks) and repeated later in pregnancy (mean 28.5 +/- 3.7 weeks). RESULTS: The incidence of preeclampsia was 13% (24/182). Rates of preeclampsia increased with advancing gestation of abnormal UtA Doppler: 7% when UtA Doppler were normal at early exam, 18% when abnormal at early exam, and 28% when abnormal at late exam (Chi-square for trend: P < 0.001). The rate of preeclampsia among 40 women with abnormal early but normal late UtA Doppler was similar to that of women with normal findings at early exam (8 vs 7%; P = 1.00). Logistic regression analysis showed that the ability of UtA Doppler to predict preeclampsia was independent from other variables [Odds Ratio (OR) 7.1, 95% Confidence Interval (CI) 2.6-18.9). Receiver operating characteristic (ROC) curve identified a UtA value of 0.58 as the optimal threshold for the prediction of preeclampsia. CONCLUSION: The later in pregnancy the abnormal UtA Doppler findings are observed, the greater the risk of preeclampsia. Normalization of UtA Doppler after 25 weeks reduces the risk of preeclampsia to 8%.     

Perinatal outcomes, blood pressure patterns and risk assessment of superimposed preeclampsia in mild chronic hypertensive pregnancy

OBJECTIVE: Assessment of perinatal outcomes, blood pressure (BP) patterns and risk of superimposed preeclampsia in a population with mild chronic hypertension. STUDY DESIGN: We investigated 223 pregnant women with mild chronic hypertension and 200 controls. Twenty-four-hour BP monitoring longitudinally in pregnancy and Doppler assessment of uterine arteries at 24 weeks' gestation were performed. Perinatal outcomes were recorded. RESULTS: Superimposed preeclampsia occurred in 28.4% of hypertensive women, with an increased rate of small-for-gestational age babies (30.7% versus 8.9%), a lower birth weight (2587.75+/-832.97 versus 3167.35+/-536.3; p < 0.001) and a higher rate of caesarean sections (69.2% versus 35.5%) than controls. According to the ROC curve, the mean 24-h blood pressure (diastolic 78 mmHg [S.E.: 0.95; SP: 0.89] and systolic 121 mmHg [S.E.: 0.88; SP: 0.92]) and the mean resistance index of the uterine arteries of 0.52 (S.E.: 0.69; SP: 0.87) are better prognostic values for predicting superimposed preeclampsia. CONCLUSIONS: In women with chronic hypertension in the second trimester 24-h blood pressure monitoring and Doppler velocimetry of the uterine artery are able to detect those at risk of superimposed preeclampsia. In women with circulatory adaptation to pregnancy, a good perinatal outcome is expected with proper obstetric care.     

Predisposition to superimposed preeclampsia in women with chronic hypertension: endothelial,renal, cardiac,and placental factors in a prospective longitudinal cohort

ABSTRACT

Objective

To assess the contribution of maternal and placental factors to the development of superimposed preeclampsia in women with chronic hypertension.     

Expectant management of severe preeclampsia remote from term.

Traditionally, preeclamptic women who meet accepted criteria for severe disease are delivered expeditiously, regardless of gestational age. Although delivery is always appropriate therapy for the mother, it may not be optimal for the fetus remote from term. Several recent randomized clinical trials support expectant management of severe preeclampsia remote from term in well-selected patients. We have described our rationale and guidelines for management, which we believe should be performed only at tertiary perinatal centers.     

Homocysteine plasma concentration levels for the prediction of preeclampsia in women with chronic hypertension

OBJECTIVE: The purpose of this study was to evaluate prospectively midtrimester homocysteine concentration levels for the prediction of superimposed preeclampsia in women with chronic hypertension. STUDY DESIGN: Between March 1, 2000, and February 1, 2002, pregnancies that were complicated by chronic hypertension that required medication had homocysteine, vitamin B(12), and folate concentrations measured between 16 and 20 weeks of gestation. All women received folate supplementation. An upper limit threshold for increased homocysteine was defined as the mean value plus 2 SDs. RESULTS: Fifty-seven women were enrolled. Mean homocysteine concentration levels were 5.1+/-1.7 micromo/L for the 16 women who had preeclampsia compared with 4.7+/-1.3 micromo/L for the 41 women without preeclampsia (P=.56). Two of 16 women with preeclampsia (13%) had concentration levels that exceeded the 95th percentile (6.9 micromo/L) compared with 2 of 41 women (5%) without preeclampsia (P=.31). The sensitivity and specificity were 13% (95% CI, 1.6-38.3) and 95.1% (95% CI, 83.5-99.4), respectively. CONCLUSION: Second-trimester homocysteine concentration levels were not helpful in the prediction of preeclampsia in chronically hypertensive women.