An Organ-Specific Approach to the Management of Gestational Hypertension: Evidence versus Tradition

Abstract

The management of hypertensive disease in pregnancy is currently guided by practice recommendations based largely on observational data from a half century ago and has changed only superficially since that time. These recommendations are both narrowly prescriptive (women without traditional features of severe disease should all be delivered at exactly 37^0/7 weeks) and at the same time frustratingly ambiguous (the presence of epigastric pain unresponsive to repeat analgesics precludes expectant management at any gestational age, regardless of laboratory studies). Guidelines that ignore recent data from the obstetric, pediatric, and internal medicine literature too often lead practitioners to be more aggressive than necessary in the delivery of very premature pregnancies, and, conversely, more complacent than patient safety would support in prolonging pregnancy with advanced fetal maturity. We present here an alternative, organ-specific-based approach to the management of gestational hypertension that allows and encourages practitioners to formulate a management plan based on a thoughtful and, when possible, evidence-based synthesis of the continuous variables of blood pressure, degree of organ dysfunction and response to treatment, gestational age, and patient balancing of maternal and fetal/neonatal risks. Such clinical care is more complex and nuanced than simply basing life-altering critical management decisions, including timing of delivery, on whether the patient does, or does not have any one of the conditions described by box 4 of the current American College of Obstetricians and Gynecologists practice guidelines. Nonetheless, we believe this approach will not only improve care but will also open the door to useful investigations into prevention and management of the various entities traditionally considered as the same disease process.

Key Points

• Traditional approaches to preeclampsia are not evidence based.

• The use of such approaches has resulted in stagnant maternal morbidity and mortality ratios.

• The consideration of disease severity as binary is particularly counterproductive.

• An organ-based approach will facilitate evidence-based individualization of care.

Keywords

hypertension - preeclampsia - eclampsia - gestational hypertension

Publikationsverlauf

Eingereicht: 02. Juli 2024

Angenommen: 14. Oktober 2024

Accepted Manuscript online:
04. November 2024

Artikel online veröffentlicht:
25. November 2024

• References

• 1 Clark SL, Belfort MA, Hankins GDV. The anachronistic terminology of pregnancy induced hypertension: time for a change. Obstet Gynecol 2015; 126 (02) 294-296
• 2 Erez O, Romero R, Jung E. et al. Preeclampsia and eclampsia: the conceptual evolution of a syndrome. Am J Obstet Gynecol 2022; 226 (2S): S786-S803
• 3 Pritchard JA. Management of preeclampsia and eclampsia. Kidney Int 1980; 18 (02) 259-266
• 4 Pritchard JA, MacDonald PC. Williams Obstetrics, 15^th ed. New York City: Appleton Century Crofts; 1976
• 5 Walker JJ. Pre-eclampsia. Lancet 2000; 356 (9237) 1260-1265
• 6 Joseph KS, Lisonkova S, Boutin A. et al. Maternal mortality in the United States: are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance?. Am J Obstet Gynecol 2024; 230 (04) 440.e1-440.e13
• 7 Ananth CV, Brandt JS, Hill J. et al. Historical and recent changes in maternal mortality due to hypertensive disorders in the United States, 1979 to 2018. Hypertension 2021; 78 (05) 1414-1422
• 8 Horbar JD, Greenberg LT, Buzas JS. et al. Trends in mortality and morbidities for infants born 24–28 weeks in the U.S: 1997–2021. Pediatrics 2024; 153 (01) e2023064153
• 9 Richter LL, Ting J, Muraca GM, Synnes A, Lim KI, Lisonkova S. Temporal trends in neonatal mortality and morbidity following spontaneous and clinician-initiated preterm birth in Washington State, USA: a population-based study. BMJ Open 2019; 9 (01) e023004
• 10 Infant Mortality in the United States. Provisional data form the 2022 period linked Birth/Infant Death File. Vital Statistics Rapid Release, Number 33. November 2023 https://www.cdc.gov/nchs/data/vsrr/vsrr033.pdf
• 11 Stoll BJ, Hansen NI, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Trends in care practices, morbidity and mortality of extremely premature neonates. JAMA 2015; 314 (10) 1039-1051
• 12 Manuck TA, Rice MM, Bailit JL. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Preterm neonatal morbidity and mortality by gestational age: a contemporary cohort. Am J Obstet Gynecol 2016; 215 (01) 103.e1-103.e14
• 13 Clark SL, Saade GA, Tolcher MC. et al. Gestational hypertension and “severe” disease: time for a change. Am J Obstet Gynecol 2023; 228 (05) 547-552
• 14 Kotchen TA. Hypertension in Harrison's Principles of Internal Medicine. 21st ed.,. Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson JL. eds. New York: McGraw-Hill; 2022
• 15 American College of Obstetricians and Gynecologists practice bulletin #222. Gestational hypertension and pre eclampsia. Interim update. Obstet Gynecol 2020; 135 (06) e237-e260
• 16 World Health Organization. World Health Organization Best Practices for the Naming of New Human Infectious Diseases; 2015. Accessed March 22, 2024 at https://apps.who.int/iris/bitstream/handle/10665/163636/WHO_HSE_FOS_15.1_eng.pdf
• 17 Calling it what it is. Nat Genet 2020; 52 (04) 355
• 18 Huber J. Eponym debate: the case for biologically-descriptive names. Stanford Medicine Scope. 2015 . Accessed March 22, 2024 at: https://scopeblog.stanford.edu/2020/01/30/eponym-debate-the-case-for-biologically-descriptive-names/
• 19 Fleischman AR, Oinuma M, Clark SL. Rethinking the definition of “term pregnancy”. Obstet Gynecol 2010; 116 (01) 136-139
• 20 Clark SL, Perlin JB, Fraker S. et al. When do women deliver? The impact of obstetrical intervention on temporal patterns of childbirth. Obstet Gynecol 2014; 124: 873-880
• 21 Brassard P, Labrecque L, Smirl JD. et al. Losing the dogmatic view of cerebral autoregulation. Physiol Rep 2021; 9 (15) e14982
• 22 Levy PD, Mahn JJ, Miller J. et al. Blood pressure treatment and outcomes in hypertensive patients without acute target organ damage: a retrospective cohort. Am J Emerg Med 2015; 33 (09) 1219-1224
• 23 Vlcek M, Bur A, Woisetschläger C, Herkner H, Laggner AN, Hirschl MM. Association between hypertensive urgencies and subsequent cardiovascular events in patients with hypertension. J Hypertens 2008; 26 (04) 657-662
• 24 Patel KK, Young L, Howell EH. et al. Characteristics and outcomes of patients presenting with hypertensive urgency in the office setting. JAMA Intern Med 2016; 176 (07) 981-988
• 25 Tita AT, Szychowski JM, Boggess K. et al; Chronic Hypertension and Pregnancy (CHAP) Trial Consortium. Treatment for mild chronic hypertension during pregnancy. N Engl J Med 2022; 386 (19) 1781-1792
• 26 Turin TC, Tonelli M, Manns BJ. et al. Proteinuria and life expectancy. Am J Kidney Dis 2013; 61 (04) 646-648
• 27 Waikar SS, Bonventre JV. Acute kidney injury. In: Loscalzo J, Fauci K. et al, eds. Harrison's Principles of Internal Medicine, 21st ed. New York, NY: McGraw-Hill; 2022
• 28 Bellomo R, Kellum JA, Ronco C. Acute kidney injury. Lancet 2012; 380 (9843) 756-766
• 29 Forni LG, Darmon M, Ostermann M. et al. Renal recovery after acute kidney injury. Intensive Care Med 2017; 43 (06) 855-866
• 30 Harel Z, McArthur E, Hladunewich M. et al. Serum creatinine levels before, during and after pregnancy. JAMA 2019; 321 (02) 205-207
• 31 Clark SL, Cotton DB. Clinical indications for pulmonary artery catheterization in the patient with severe preeclampsia. Am J Obstet Gynecol 1988; 158 (3 pt 1): 453-458
• 32 Gorman EA, O'Kane CM, McAuley DF. Acute respiratory distress syndrome in adults: diagnosis, outcomes, long-term sequelae, and management. Lancet 2022; 400 (10358): 1157-1170
• 33 Ware LB, Matthay MA. Clinical practice. Acute pulmonary edema. N Engl J Med 2005; 353 (26) 2788-2796
• 34 Mabie WC, Hackman BB, Sibai BM. Pulmonary edema associated with pregnancy: echocardiographic insights and implications for treatment. Obstet Gynecol 1993; 81 (02) 227-234
• 35 Clark SL, Christmas JT, Frye DR, Meyers JA, Perlin JB. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol 2014; 211 (01) 32.e1-32.e9
• 36 Greiner KS, Rincón M, Derrah KL, Burwick RM. Elevated liver enzymes and adverse outcomes among patients with preeclampsia with severe features. J Matern Fetal Neonatal Med 2023; 36 (01) 2160627
• 37 Polyzos SA, Kountouras J, Mantzoros CS. Obesity and nonalcoholic fatty liver disease: from pathophysiology to therapeutics. Metabolism 2019; 92: 82-97
• 38 Wicke C, Pereira PL, Neeser E, Flesch I, Rodegerdts EA, Becker HD. Subcapsular liver hematoma in HELLP syndrome: evaluation of diagnostic and therapeutic options–a unicenter study. Am J Obstet Gynecol 2004; 190 (01) 106-112
• 39 McCormick PA, Higgins M, McCormick CA, Nolan N, Docherty JR. Hepatic infarction, hematoma, and rupture in HELLP syndrome: support for a vasospastic hypothesis. J Matern Fetal Neonatal Med 2022; 35 (25) 7942-7947
• 40 MacKenna J, Dover NL, Brame RG. Preeclampsia associated with hemolysis, elevated liver enzymes, and low platelets–an obstetric emergency?. Obstet Gynecol 1983; 62 (06) 751-754
• 41 Fishel Bartal M, Sibai BM. Eclampsia in the 21st century. Am J Obstet Gynecol 2022; 226 (2S): S1237-S1253
• 42 Brewer J, Owens MY, Wallace K. et al. Posterior reversible encephalopathy syndrome in 46 of 47 patients with eclampsia. Am J Obstet Gynecol 2013; 208 (06) 468.e1-468.e6
• 43 Mayama M, Uno K, Tano S. et al. Incidence of posterior reversible encephalopathy syndrome in eclamptic and patients with preeclampsia with neurologic symptoms. Am J Obstet Gynecol 2016; 215 (02) 239.e1-239.e5
• 44 Fischer M, Schmutzhard E. Posterior reversible encephalopathy syndrome. J Neurol 2017; 264 (08) 1608-1616
• 45 Sibai BM, Eclampsia VI. Eclampsia. VI. Maternal-perinatal outcome in 254 consecutive cases. Am J Obstet Gynecol 1990; 163 (03) 1049-1054 , discussion 1054–1055
• 46 Pritchard JA, Cunningham FG, Pritchard SA. The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 cases. Am J Obstet Gynecol 1984; 148 (07) 951-963
• 47 Hastie R, Brownfoot FC, Cluver CA. et al. Predictive value of signs and symptoms preceding eclampsia: a systematic review. Obstet Gynecol 2019; 134 (04) 677-684
• 48 Katz VL, Farmer R, Kuller JA. Preeclampsia into eclampsia: toward a new paradigm. Am J Obstet Gynecol 2000; 182 (06) 1389-1396
• 49 Berhan Y, Berhan A. Should magnesium sulfate be administered to women with mild pre-eclampsia? A systematic review of published reports on eclampsia. J Obstet Gynaecol Res 2015; 41 (06) 831-842
• 50 Williams JW. Obstetrics, 1st ed. Stamford, CT: Appleton & Lange; 1903
• 51 Belfort MA. Is high cerebral perfusion pressure and cerebral flow predictive of impending seizures in preeclampsia? A case report. Hypertens Pregnancy 2005; 24 (01) 59-63
• 52 Belfort MA, Saade GR, Grunewald C. et al. Association of cerebral perfusion pressure with headache in women with pre-eclampsia. Br J Obstet Gynaecol 1999; 106 (08) 814-821
• 53 Johnson GJ, Clark SL, Turrentine M. Antenatal fetal heart rate assessment: where do we go from here?. Obstet Gynecol 2018; 132: 1407-1411