Maternal and Perinatal Outcomes of Pregnancies Complicated by Chronic Hypertension Followed at a Referral Hospital

Abstract

Objective To assess maternal and perinatal outcomes of pregnancies in women with chronic hypertension (CH).

Methods Retrospective cohort of women with CH followed at a referral center for a 5 year period (2012–2017). Data were obtained from medical charts review and described as means and frequencies, and a Poisson regression was performed to identify factors independently associated to the occurrence of superimposed pre-eclampsia (sPE).

Results A total of 385 women were included in the present study; the majority were > than 30 years old, multiparous, mostly white and obese before pregnancy. One third had pre-eclampsia (PE) in a previous pregnancy and 17% of them had organ damage associated with hypertension, mainly kidney dysfunction. A total of 85% of the patients used aspirin and calcium carbonate for pre-eclampsia prophylaxis and our frequency of sPE was 40%, with an early onset (32.98 ± 6.14 weeks). Of those, 40% had severe features of PE, including 5 cases of HELLP syndrome; however, no cases of eclampsia or maternal death were reported. C-section incidence was high, gestational age at birth was 36 weeks, and nearly a third (115 cases) of newborns had complications at birth One third of the women remained using antihypertensive drugs after pregnancy.

Conclusion Chronic hypertension is related with the high occurrence of PE, C-sections, prematurity and neonatal complications. Close surveillance and multidisciplinary care are important for early diagnosis of complications.

Resumo

Objetivo Avaliar os resultados maternos e perinatais em gestação de mulheres com hipertensão crônica.

Métodos Coorte retrospectiva de mulheres hipertensas crônicas acompanhadas em hospital de referência por 5 anos (2012–2017). Foi realizada revisão dos prontuários médicos e os resultados são descritos em médias e frequências. A regressão de Poisson foi usada para identificar os fatores independentemente associados à ocorrência de pré-eclâmpsia superajuntada.

Resultados Um total de 385 mulheres foram incluídas no presente estudo, e a maioria tinha idade > 35 anos, era multípara, majoritariamente brancas e obesas antes da gravidez. Um terço teve pré-eclâmpsia em gestação anterior, e 17% apresentavam lesão de órgão-alvo associada à hipertensão, majoritariamente disfunção renal. Um total de 85% das pacientes usaram ácido acetilsalicílico e carbonato de cálcio para a profilaxia de pré-eclâmpsia, sendo que a frequência de pré-eclâmpsia superajuntada foi de 40%, com um início prematuro (32.98 ± 6.14 semanas). Destas, 40% apresentaram sinais de gravidade associados à pré-eclâmpsia, com 5 casos de síndrome HELLP; entretanto sem nenhum caso de eclampsia ou morte materna. A incidência de cesárea foi alta, com idade gestacional de 36 semanas ao parto, e um terço dos recém-nascidos tiveram complicações ao nascimento. Um terço das mulheres permaneceu usando medicamentos anti-hipertensivos ao fim da gravidez.

Conclusão A hipertensão crônica se relaciona com alta prevalência de pré-eclâmpsia, cesárea, prematuridade e complicações neonatais. Vigilância e cuidado multidisciplinar são importantes para o diagnóstico precoce das complicações.

Keywords

preeclampsia - chronic hypertension - obstetrics - maternal morbidity - complications of pregnancy

Palavras-chave

pré-eclâmpsia - hipertensão crônica - obstetrícia - morbidade materna - complicações da gravidez

Contributions

Costa M. L., Parpinelli M. A., Surita F. G. and Guida J. P. had the original idea for the present study; Rezende G. P. and Casagrande L. performed data collection and data analysis, under supervision of Guida J. P.; Rezende G. P., Casagrande L. and Guida J. P.wrote the first draft, which was approved by all of the authors.

• References

• 1 World Health Organization. Global Health Observatory (GHO) [Internet]. Raised blood pressure: situation and trends. 2008 [cited 2016 Ago 19]. Available from: http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/index.html
• 2 Andrade SSA, Stopa SR, Brito AS, Chueri PS, Szwarcwald CL, Malta DC. Prevalência de hipertensão arterial autorreferida na população brasileira: análise da Pesquisa Nacional de Saúde, 2013. Epidemiol Serv Saude 2015; 24 (02) 297-304 . Doi: 0.5123/S1679-49742015000200012
• 3 Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, Hall DR. , et al; International Society for the Study of Hypertension in Pregnancy (ISSHP). Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice. Hypertension 2018; 72 (01) 24-43 . Doi: 10.1161/HYPERTENSIONAHA.117.10803
• 4 Goulopoulou S. Maternal vascular physiology in preeclampsia. Hypertension 2017; 70 (06) 1066-1073 . Doi: 0.1161/HYPERTENSIONAHA.117.08821
• 5 Orbach H, Matok I, Gorodischer R, Sheiner E, Daniel S, Wiznitzer A. , et al. Hypertension and antihypertensive drugs in pregnancy and perinatal outcomes. Am J Obstet Gynecol 2013; 208 (04) 301.e1-301.e6 . Doi: 10.1016/j.ajog.2012.11.011
• 6 Alexander JM, Wilson KL. Hypertensive emergencies of pregnancy. Obstet Gynecol Clin North Am 2013; 40 (01) 89-101 . Doi: 10.1016/j.ogc.2012.11.008
• 7 Ferreira SRG, Zanella MT. Epidemiologia da hipertensão arterial associada à obesidade. Rev Bras Hipertens 2000; 7 (02) 128-135
• 8 Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983; 67 (05) 968-977 . Doi: 10.1161/01.cir.67.5.968
• 9 Siegel AM, Tita AT, Machemehl H, Biggio JR, Harper LM. Evaluation of Institute of Medicine guidelines for gestational weight gain in women with chronic hypertension. AJP Rep 2017; 7 (03) e145-e150 . Doi: 10.1055/s-0037-1604076
• 10 Hadar E, Ashwal E, Hod M. The preconceptional period as an opportunity for prediction and prevention of noncommunicable disease. Best Pract Res Clin Obstet Gynaecol 2015; 29 (01) 54-62 . Doi: 10.1016/j.bpobgyn.2014.05.011
• 11 Podymow T, August P. New evidence in the management of chronic hypertension in pregnancy. Semin Nephrol 2017; 37 (04) 398-403 . Doi: 10.1016/j.semnephrol.2017.05.012
• 12 Poon LC, Wright D, Rolnik DL, Singelaki A, Delgado JL, Tsokaki T. , et al. Aspirin for Evidence-Based Preeclampsia Prevention trial: effect of aspirin in prevention of preterm preeclampsia in subgroups of women according to their characteristics and medical and obstetrical history. Am J Obstet Gynecol 2017; 217 (05) 585.e1-585.e5 . Doi: 0.1016/j.ajog.2017.07.038
• 13 Leary PJ, Leary SE, Stout KK, Schwartz SM, Easterling TR. Maternal, perinatal, and postneonatal outcomes in women with chronic heart disease in Washington State. Obstet Gynecol 2012; 120 (06) 1283-1290 . Doi: 10.1097/AOG.0b013e3182733d56
• 14 McDonald SD, Han Z, Walsh MW, Gerstein HC, Devereaux PJ. Kidney disease after preeclampsia: a systematic review and meta-analysis. Am J Kidney Dis 2010; 55 (06) 1026-1039 . Doi: 10.1053/j.ajkd.2009.12.036
• 15 Boriboonhirunsarn D, Pradyachaipimol A, Viriyapak B. Incidence of superimposed preeclampsia among pregnant Asian women with chronic hypertension. Hypertens Pregnancy 2017; 36 (02) 226-231 . Doi: 10.1080/10641955.2017.1311340
• 16 Aykas F, Solak Y, Erden A, Bulut K, Dogan S, Sarli B. , et al. Persistence of cardiovascular risk factors in women with previous preeclampsia: a long-term follow-up study. J Investig Med 2015; 63 (04) 641-645 . Doi: 10.1097/JIM.0000000000000189
• 17 van Walraven C, Mamdani M, Cohn A, Katib Y, Walker M, Rodger MA. Risk of subsequent thromboembolism for patients with pre-eclampsia. BMJ 2003; 326 (7393): 791-792 . Doi: 10.1136/bmj.326.7393.791