Blood Pressure Levels and Maternal Outcome in Women with Preeclampsia – a Retrospective Study from a Large Tertiary Obstetric Centre

Abstract

Introduction Patients with high blood pressure levels are at high risk for acute complications as well as serious long-term consequences. Women with preeclampsia often experience very high blood pressure levels during pregnancy and postpartum and are also known to have a higher cardiovascular risk in later life.

Material and Methods In our single-centre retrospective cohort study, we analysed 158 pregnancies complicated by preeclampsia in regard to maternal outcome. We divided the patient cohort into three subgroups according to the blood pressure levels during hospital stay.

Results Pre-existing arterial hypertension was significantly more common in patients with a hypertensive crisis (systolic blood pressure ≥ 180 mmHg and/or diastolic blood pressure ≥ 120 mmHg) during pregnancy than in patients with moderate or severe hypertension (p = 0.001). Women with a hypertensive crisis had an unfavourable outcome compared to women with lower blood pressure levels. These women developed a HELLP-syndrome significantly more often (p = 0.013). Moreover, most of the women with a hypertensive crisis during pregnancy were still hypertensive at hospital discharge (p = 0.004), even though they were administrated antihypertensive agents more often (p < 0.001) compared to women with lower blood pressure values.

Conclusion Preeclamptic women with hypertensive crises should be identified quickly and monitored closely to avoid further complications. Standardized follow-up programs are lacking, but especially these patients seem to be at high risk for persistent hypertension and increased cardiovascular morbidity and therefore should receive specialist follow-up, including hypertensiologists, cardiologists and gynaecologists. Large prospective trials are required for a better understanding of these interrelations and to develop a specific follow-up program.

Zusammenfassung

Einleitung Das Risiko für akute Komplikationen und schwerwiegende Langzeitfolgen ist höher bei Patientinnen mit Bluthochdruck. Frauen mit Präeklampsie haben oft sehr hohe Blutdruckwerte während der Schwangerschaft und postpartal und haben bekanntlich auch eine höheres Risiko für Herz-Gefäß-Erkrankungen im späteren Leben.

Material und Methoden Diese monozentrische retrospektive Kohortenstudie untersucht 158 Schwangerschaften mit Präeklampsie im Hinblick auf das mütterliche Outcome. Die Patientinnenkohorte wurde gemäß den Blutdruckwerten der Patientinnen während ihres Krankenhausaufenthalts in 3 Untergruppen aufgeteilt.

Ergebnisse Verglichen mit Patientinnen mit mittelschwerer oder schwerer Hypertonie hatten Patientinnen, die während der Schwangerschaft eine hypertensive Krise (systolischer Blutdruck ≥ 180 mmHg und/oder diastolischer Blutdruck ≥ 120 mmHg) erlitten, signifikant häufiger eine vorbestehende arterielle Hypertonie (p = 0,001). Frauen, die eine hypertensive Krise erlebten, hatten ein ungünstigeres Outcome verglichen mit Frauen mit niedrigerem Blutdruck. Diese Frauen entwickelten auch deutlich häufiger ein HELLP-Syndrom (p = 0,013). Außerdem hatten die meisten Frauen, die eine hypertensive Krise während der Schwangerschaft erlitten, immer noch hypertensive Blutdruckwerte zum Zeitpunkt ihrer Entlassung aus dem Krankenhaus (p = 0,004), obwohl sie öfters mit antihypertensiven Mitteln behandelt wurden (p < 0,001) als Frauen mit niedrigerem Blutdruck.

Schlussfolgerung Präeklamptische Frauen mit hypertensiven Krisen sollten rasch identifiziert und intensiv überwacht werden, um weitere Komplikationen zu verhindern. Es fehlt an standardisierten Nachsorgeprogrammen. Diese Patientinnen weisen ein besonders hohes Risiko für anhaltende Hypertonie und höhere kardiovaskuläre Morbidität auf und sollten daher eine fachärztliche Nachsorge durch Hypertensiolog*innen, Kardiolog*innen und Gynäkolog*innen erhalten. Große prospektive Studien sind nötig, um die Kenntnisse dieser Zusammenhänge zu verbessern und ein gezieltes Nachsorgeprogramm zu entwickeln.

Key words

preeclampsia - arterial hypertension - hypertensive crisis - cardiovascular risk - hypertension in pregnancy - HELLP-syndrome

Schlüsselwörter

Präeklampsie - arterielle Hypertonie - hypertensive Krise - kardiovaskuläres Risiko - Hypertonie in der Schwangerschaft - HELLP-Syndrom

Publication History

Received: 23 November 2021

Accepted after revision: 26 February 2022

Article published online:
06 May 2022

• References

• 1 Mol BWJ, Roberts CT, Thangaratinam S. et al. Pre-eclampsia. Lancet 2016; 387: 999-1011 DOI: 10.1016/S0140-6736(15)00070-7.
• 2 Saleem S, McClure EM, Goudar SS. et al. A prospective study of maternal, fetal and neonatal deaths in low- and middle-income countries. Bull World Health Organ 2014; 92: 605-612 DOI: 10.2471/BLT.13.127464.
• 3 Wu P, Haththotuwa R, Kwok CS. et al. Preeclampsia and Future Cardiovascular Health: A Systematic Review and Meta-Analysis. Circ Cardiovasc Qual Outcomes 2017; DOI: 10.1161/CIRCOUTCOMES.116.003497.
• 4 Armaly Z, Jadaon JE, Jabbour A. et al. Preeclampsia: Novel Mechanisms and Potential Therapeutic Approaches. Front Physiol 2018; 9: 973 DOI: 10.3389/fphys.2018.00973.
• 5 Deharde D, Klockenbusch W, Schmitz R. et al. Hydroxychloroquine as a Preventive and Therapeutic Option in Preeclampsia – a Literature Review. Geburtshilfe Frauenheilkd 2020; 80: 679-685 DOI: 10.1055/a-1170-5145.
• 6 Benschop L, Duvekot JJ, Roeters van Lennep JE. Future risk of cardiovascular disease risk factors and events in women after a hypertensive disorder of pregnancy. Heart 2019; 105: 1273-1278 DOI: 10.1136/heartjnl-2018-313453.
• 7 [Anonymous] Hypertensive Pregnancy Disorders: Diagnosis and Therapy. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF-Registry No. 015/018, March 2019). Accessed February 02, 2022 at: https://www.awmf.org/uploads/tx_szleitlinien/015-018l_S2k_Diagnostik_Therapie_hypertensiver_Schwangerschaftserkrankungen_2019-07.pdf
• 8 Arulkumaran N, Lightstone L. Severe pre-eclampsia and hypertensive crises. Best Pract Res Clin Obstet Gynaecol 2013; 27: 877-884 DOI: 10.1016/j.bpobgyn.2013.07.003.
• 9 Ukah UV, De Silva DA, Payne B. et al. Prediction of adverse maternal outcomes from pre-eclampsia and other hypertensive disorders of pregnancy: A systematic review. Pregnancy Hypertens 2018; 11: 115-123 DOI: 10.1016/j.preghy.2017.11.006.
• 10 Williams B, Mancia G, Spiering W. et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36: 1953-2041 DOI: 10.1097/HJH.0000000000001940.
• 11 Tranquilli AL, Dekker G, Magee L. et al. The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP. Pregnancy Hypertens 2014; 4: 97-104 DOI: 10.1016/j.preghy.2014.02.001.
• 12 [Anonymous] Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol 2020; 135: 1492-1495 DOI: 10.1097/AOG.0000000000003892.
• 13 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018; 71: 1269-1324 DOI: 10.1161/HYP.0000000000000066.
• 14 The SPRINT Research Group. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373: 2103-2116 DOI: 10.1056/NEJMoa1511939.
• 15 Buchbinder A, Sibai BM, Caritis S. et al. Adverse perinatal outcomes are significantly higher in severe gestational hypertension than in mild preeclampsia. Am J Obstet Gynecol 2002; 186: 66-71 DOI: 10.1067/mob.[phone].
• 16 James PR. Management of hypertension before, during, and after pregnancy. Heart 2004; 90: 1499-1504 DOI: 10.1136/hrt.2004.035444.
• 17 Makkonen N, Harju M, Kirkinen P. Postpartum recovery after severe pre-eclampsia and HELLP-syndrome. J Perinat Med 1996; 24: 641-650 DOI: 10.1515/jpme.1996.24.6.641.
• 18 Berks D, Steegers EAP, Molas M. et al. Resolution of Hypertension and Proteinuria After Preeclampsia. Obstet Gynecol 2009; 114: 1307-1314 DOI: 10.1097/AOG.0b013e3181c14e3e.
• 19 Bramham K, Nelson-Piercy C, Brown MJ. et al. Postpartum management of hypertension. BMJ 2013; 346: f894 DOI: 10.1136/bmj.f894.
• 20 Aronow WS. Hypertensive disorders in pregnancy. Ann Transl Med 2017; 5: 266 DOI: 10.21037/atm.2017.03.104.
• 21 Garovic VD, Dechend R, Easterling T. et al. Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy: A Scientific Statement From the American Heart Association. Hypertension 2022; 79: e21-e41 DOI: 10.1161/HYP.0000000000000208.
• 22 Muijsers HEC, van der Heijden OWH, de Boer K. et al. Blood pressure after PREeclampsia/HELLP by SELF monitoring (BP-PRESELF): rationale and design of a multicenter randomized controlled trial. BMC Womens Health 2020; 20: 41 DOI: 10.1186/s12905-020-00910-0.
• 23 Hinton TC, Adams ZH, Baker RP. et al. Investigation and Treatment of High Blood Pressure in Young People: Too Much Medicine or Appropriate Risk Reduction?. Hypertension 2020; 75: 16-22 DOI: 10.1161/HYPERTENSIONAHA.119.13820.
• 24 Muñoz D, Uzoije P, Reynolds C. et al. Polypill for Cardiovascular Disease Prevention in an Underserved Population. N Engl J Med 2019; 381: 1114-1123 DOI: 10.1056/NEJMoa1815359.
• 25 Cimmaruta D, Lombardi N, Borghi C. et al. Polypill, hypertension and medication adherence: The solution strategy?. Int J Cardiol 2018; 252: 181-186 DOI: 10.1016/j.ijcard.2017.11.075.
• 26 Coca A, Agabiti-Rosei E, Cifkova R. et al. The polypill in cardiovascular prevention: evidence, limitations and perspective – position paper of the European Society of Hypertension. J Hypertens 2017; 35: 1546-1553 DOI: 10.1097/HJH.0000000000001390.