Timing of Delivery in Women With Chronic Hypertension
Maya RamHoward BergerMichael GearySarah D. McDonaldBeth Murray‐DavisCatherine RiddellHaroon HasanJon BarrettNir Melamed
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Abstract:
To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery.We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801).Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57-0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69-1.17]).Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.Keywords:
Chronic hypertension
Labor Induction
Gestational hypertension
Chronic hypertension during pregnancy has recently shown a significant increase, which is most likely due to the growth in the number of first pregnancies in women of late reproductive age, with chronic hypertension, obesity and other extragenital diseases, as well as an increase in the number of pregnancies as a result of in vitro fertilization. Preeclampsia complicates chronic hypertension in 20-40% of cases, more often associated with early onset (before 34 weeks) and leads to an increase in complications in the mother, fetus and newborn. Currently, there are no reliable biomarkers that make it possible to predict the development of superimposed preeclampsia, but their search is underway. In the general obstetric population, the use of PlGF and sFlt-1 tests has shown to be promising for predicting preeclampsia in women with singleton pregnancies. PlGF and sFlt-1 based tests have begun to appear in clinical guidelines in addition to regular clinical and laboratory testing. But data on the effectiveness of these tests for predicting preeclampsia in groups of pregnant women with chronic diseases, including those with chronic hypertension, is still being collected. Purpose - to evaluate the prospects of using angiogenic factors as biomarkers of superimposed preeclampsia; search for publications in electronic databases (Medline, Embase) from the earliest to January 2023. Conclusions. Changes in angiogenesis markers may indicate the start preeclampsia in pregnant women with chronic hypertension. The values of angiogenesis markers in pregnant women with preeclampsia on the background of chronic hypertension may differ from those in pregnant women with preeclampsia, but without concomitant diseases. In addition, abnormalities in values of angiogenic markers in pregnant women with chronic hypertension compared to normotensive pregnant women may occur without the addition of preeclampsia. The reason may be the effect of chronic hypertension on the development and functioning of the placenta or an altered response of the endothelium to angiogenesis factors. No conflict of interests was declared by the authors.
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Preeclampsia is represented by hypertension and proteinuria in pregnancy. It usually occurs after 20 gestational weeks. There are few reports on preeclampsia before 20 gestational weeks. In this case, we report a patient with chronic hypertension superimposed with preeclampsia at 13 gestational weeks.
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Endothelial dysfunction is a hallmark of preeclampsia and the role of nitric oxide (NO) has been extensively studied in this pregnancy complication. In recent years, hydrogen sulphide (H
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Hypertension in Pregnancy
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15 to 25% of patients with gestational hypertension progress to preeclampsia.To determine the number of patients with gestational hypertension who developed preeclampsia.Observational prospective comparative and longitudinal study realized between november 2010 to december 2012. We included pregnant patients diagnosed with mild gestational hypertension who were followed during pregnancy to observe the progression to preeclampsia. We compared the clinical features of each group among those who developed and not the disease.We included a total of 146 patients, of whom 36 (25%, IC 95% 17.7-31.7%) progress to preeclampsia. In this group 3 (8%) developed mild preeclampsia and 33 (92%) severe preeclampsia, of which 8 (24%) account HELLP syndrome. The remaining 110 patients (75%), did not develop preeclampsia. From 12 (8%) patients with gestational age < to 28 weeks, 7 (58%) developed preeclampsia, 46 (31%) patients between 28-33 weeks, 12 (26%) evolved into preeclampsia, 39 (27%) patients between 34-36 weeks, 11 (28%) progressed to preeclampsia and finally 49 (34%) with pregnancy > 37 weeks, 6 (12%) developed to preeclampsia. When comparing these groups we found that a lower gestational age was more frequent the progression to preeclampsia (p < 0.004). The onset of gestational hypertension before 28 weeks was significantly associated with the progression of preeclampsia (OR 5.1 IC 95% 1.5-17.2). The weight of infants and gestational age was lower in children of women who developed the disease in comparison that those who did not (p < 0.001). There were no significance differences between both groups in relation with body mass index, maternal age, parity and antecedent of preeclampsia.The progression of gestational hypertension into preeclampsia appreciated in one of each four patients. The progression of gestational hypertension in preeclampsia was more common in preterm pregnancy. Most of the patients developed the severe form of the disease.
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( BJOG . 2021;128:1373–1382) Hypertensive disorders of pregnancy include preeclampsia, gestational hypertension (developing at or after 20 wk’ gestation), and chronic hypertension (diagnosed before 20 wk’ gestation, or before pregnancy). Of these, preeclampsia is associated with the highest risks for parturient and neonate. Gestational or chronic hypertension often develops into preeclampsia. Preeclampsia is typically defined by new proteinuria, though patients with chronic or gestational hypotension may face severe complications without the presence of proteinuria. Some countries have adopted a broader definition of preeclampsia, not requiring proteinuria for diagnosis and also using evidence of placental or maternal end-organ dysfunction. This secondary analysis of the Control of Hypertension in Pregnancy Study (CHIPS) aimed to compare the abilities of the traditional and broad definitions of preeclampsia to identify patients with chronic or gestational hypertension at risk of adverse outcomes.
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To clarify the role of endothelial cells in pregnancy-related hypertensive disorders, we studied the cytotoxic effect of sera from normal pregnant women and from gravidas with various hypertensive complications of pregnancy.We obtained serum samples from 84 Japanese women: 17 with preeclampsia, ten with gestational hypertension, six with chronic hypertension, five with chronic hypertension with superimposed preeclampsia, 21 normal gravidas, and 25 healthy nonpregnant women. Endothelial cell injury was measured by the release of radiolabeled chromium from the cells into the culture medium.The mean (+/- standard error of the mean) values of chromium 51 release in preeclampsia, gestational hypertension, chronic hypertension, chronic hypertension with superimposed preeclampsia, normal pregnancy, and healthy nonpregnant women were: 21.9 +/- 2.1, 10.0 +/- 2.0, 9.2 +/- 2.3, 12.9 +/- 0.8, 8.4 +/- 1.4, and 7.3 +/- 1.6%, respectively. Normal pregnant and nonpregnant subjects did not differ with respect to endothelial cell injury. Sera from women with preeclampsia demonstrated significantly greater endothelial cell injury than did sera from normal gravidas. Subjects with the three other categories of hypertensive disorders did not differ significantly from normal gravidas.Preeclampsia is characterized by the presence of a serum factor cytotoxic to endothelial cells. Therefore, the mechanism responsible for the increase in blood pressure differs between women with preeclampsia and those with other hypertensive disorders in pregnancy.
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Although gestational hypertension (GH) is a well-known disorder, gestational proteinuria (GP) has been far less emphasized. According to international criteria, hypertensive disorders of pregnancy include GH but not GP. Previous studies have not revealed the predictors of progression from GP to preeclampsia or those of progression from GH to preeclampsia. We aimed to determine both sets of predictors. A retrospective cohort study was conducted with singleton pregnant women who delivered at 22 gestational weeks or later. Preeclampsia was divided into three types: new onset of hypertension/proteinuria at 20 gestational weeks or later and additional new onset of other symptoms at < 7 days or at ≥ 7 days later. Of 94 women with preeclampsia, 20 exhibited proteinuria before preeclampsia, 14 experienced hypertension before preeclampsia, and 60 exhibited simultaneous new onset of both hypertension and proteinuria before preeclampsia; the outcomes of all types were similar. Of 34 women with presumptive GP, 58.8% developed preeclampsia; this proportion was significantly higher than that of 89 women with presumptive GH who developed preeclampsia (15.7%). According to multivariate logistic regression models, earlier onset of hypertension/proteinuria (before or at 34.7/33.9 gestational weeks) was a predicator for progression from presumptive GH/GP to preeclampsia (odds ratios: 1.21/1.21, P value: 0.0044/0.0477, respectively).
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Hypertensive disorders of pregnancy include preeclampsia-eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, gestational hypertension, and postpartum hypertension. The incidence of preeclampsia has increased by 25% over the past 15 years. This significant increase prompted the American College of Obstetricians and Gynecologists (ACOG) to publish Hypertension in Pregnancy. The goals of ACOG’s publication are to achieve the following: to create more consistent guidelines in the management of hypertensive disorders of pregnancy, to better educate providers of the risks associated with hypertension, and to increase awareness to patients and their families. This section will review the risk factors, diagnosis, and management of hypertensive disorders of pregnancy per these current guidelines. Keywords: Chronic hypertension, eclampsia, gestational hypertension, preeclampsia.
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Hypertension in Pregnancy
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