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Am J Perinatol 2025; 42(06): 788-795
DOI: 10.1055/a-2419-9089
Original Article

Adverse Pregnancy Outcomes and Chronic Hypertension in the Era of Prevention: A Contemporary, Retrospective Cohort Study Using Data from the National Inpatient Sample Database

Jocelyn Stairs 
1   Department of Obstetrics and Gynecology, Dalhousie University, Halifax, Canada
,
Christopher M. Nash
1   Department of Obstetrics and Gynecology, Dalhousie University, Halifax, Canada
,
Daniel L. Rolnik 
2   Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
› Author Affiliations Funding Dalhousie University Ross Stewart Smith Fellowship in Medical Research. The funders had no role in the design, analysis, interpretation, or decision regarding the submission of this study.
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Abstract

Objective

Chronic hypertension is a known risk factor for the development of preeclampsia and obstetrical morbidity. However, recent risk estimates, particularly in the era of use of low-dose acetylsalicylic acid for preeclampsia prevention, are lacking. This study aimed to estimate the association between chronic hypertension and preeclampsia and other adverse pregnancy outcomes in a contemporary cohort of births spanning the period, since the introduction of a low-dose acetylsalicylic acid protocol. The secondary outcome was to estimate trends in preeclampsia and preterm birth among patients with chronic hypertension during the study period.

Study Design

A retrospective, population-based cohort study was conducted using the National Inpatient Sample Database to identify individuals discharged from hospitals in the United States following obstetrical delivery from 2014 to 2019. Pregnancies complicated by chronic hypertension were identified using ICD 9/10 (International Classification of Diseases 9th and 10th editions) codes. Multivariable logistic regression models were used to estimate the adjusted odds ratios for the association between chronic hypertension and adverse pregnancy outcomes compared with pregnancies not complicated by chronic hypertension. Temporal trends in preeclampsia and preterm birth among patients with chronic hypertension were estimated over the study period.

Results

Among 4,451,667 obstetrical delivery-related admissions, 139,556 (3.1%) included pregnancies complicated by chronic hypertension. Of these, 27,146 (19.4%) admissions included pregnancies with superimposed preeclampsia, compared with 222,351 (5.2%) of admissions that included pregnancies with preeclampsia without prior diagnosis of chronic hypertension. Pregnancies complicated by chronic hypertension were associated with 3.29 times the odds of preeclampsia compared with pregnancies without chronic hypertension (95% confidence interval: 3.22–3.36), but the odds of preeclampsia (p-value for linear trend <0.0001) and preterm birth (p-value for linear trend = 0.0001) in this subgroup decreased over the study period.

Conclusion

While the odds of preeclampsia are increased among pregnancies complicated by chronic hypertension, the odds of preeclampsia in this population have decreased over time.

Key Points

  • Pregnancies complicated by chronic hypertension are at significantly higher odds of preeclampsia.

  • Recent guidelines have recommended low-dose acetylsalicylic acid for preeclampsia prevention in these pregnancies.

  • In a nationwide cohort, the odds of preeclampsia among these pregnancies are decreasing over time.

Keywords

preeclampsia - chronic hypertension - preterm birth - acetylsalicylic acid - prevention - adverse pregnancy outcomes

Supplementary Material



Publication History

Received: 16 January 2024

Accepted: 20 September 2024

Accepted Manuscript online:
24 September 2024

Article published online:
21 October 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Kassebaum NJ, Barber RM, Bhutta ZA. et al; GBD 2015 Maternal Mortality Collaborators. Global, regional, and national levels of maternal mortality, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388 (10053): 1775-1812
    CrossrefPubMedSearch in Google Scholar
  • 2 Yoder SR, Thornburg LL, Bisognano JD. Hypertension in pregnancy and women of childbearing age. Am J Med 2009; 122 (10) 890-895
    CrossrefPubMedSearch in Google Scholar
  • 3 Bateman BT, Bansil P, Hernandez-Diaz S, Mhyre JM, Callaghan WM, Kuklina EV. Prevalence, trends, and outcomes of chronic hypertension: a nationwide sample of delivery admissions. Am J Obstet Gynecol 2012; 206 (02) 134.e1-134.e8
    CrossrefPubMedSearch in Google Scholar
  • 4 Ananth CV, Duzyj CM, Yadava S, Schwebel M, Tita ATN, Joseph KS. Changes in the prevalence of chronic hypertension in pregnancy, United States, 1970 to 2010. Hypertension 2019; 74 (05) 1089-1095
    CrossrefPubMedSearch in Google Scholar
  • 5 Sibai BM, Lindheimer M, Hauth J. et al; National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Risk factors for preeclampsia, abruptio placentae, and adverse neonatal outcomes among women with chronic hypertension. N Engl J Med 1998; 339 (10) 667-671
    CrossrefPubMedSearch in Google Scholar
  • 6 Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Chappell LC. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ 2014; 348 (07) g2301-g2301
    CrossrefPubMedSearch in Google Scholar
  • 7 Shih T, Peneva D, Xu X. et al. The rising burden of preeclampsia in the United States impacts both maternal and child health. Am J Perinatol 2016; 33 (04) 329-338
    PubMedSearch in Google Scholar
  • 8 Wu P, Chew-Graham CA, Maas AH. et al. Temporal changes in hypertensive disorders of pregnancy and impact on cardiovascular and obstetric outcomes. Am J Cardiol 2020; 125 (10) 1508-1516
    CrossrefPubMedSearch in Google Scholar
  • 9 Panaitescu AM, Baschat AA, Akolekar R, Syngelaki A, Nicolaides KH. Association of chronic hypertension with birth of small-for-gestational-age neonate. Ultrasound Obstet Gynecol 2017; 50 (03) 361-366
    CrossrefPubMedSearch in Google Scholar
  • 10 Zetterström K, Lindeberg SN, Haglund B, Hanson U. The association of maternal chronic hypertension with perinatal death in male and female offspring: a record linkage study of 866,188 women. BJOG 2008; 115 (11) 1436-1442
    CrossrefPubMedSearch in Google Scholar
  • 11 Rolnik DL, Wright D, Poon LC. et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017; 377 (07) 613-622
    CrossrefPubMedSearch in Google Scholar
  • 12 LeFevre ML. U.S. Preventive Services Task Force. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014; 161 (11) 819-826
    CrossrefPubMedSearch in Google Scholar
  • 13 Rolnik DL, Nicolaides KH, Poon LC. Prevention of preeclampsia with aspirin. Am J Obstet Gynecol 2022; 226 (2S): S1108-S1119
    CrossrefPubMedSearch in Google Scholar
  • 14 Poon LC, Wright D, Rolnik DL. 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
    CrossrefPubMedSearch in Google Scholar
  • 15 HCUP NIS Database Documentation. Healthcare Cost and Utilization Project (HCUP). December 2022. Agency for Healthcare Research and Quality, Rockville, MD. Accessed December 5, 2023 at: https://hcup-us.ahrq.gov/db/nation/nis/nisdbdocumentation.jsp
    PubMed
  • 16 Stairs J, Hsieh TYJ, Rolnik DL. In vitro fertilization and adverse pregnancy outcomes in the elective single embryo transfer era. Am J Perinatol 2024; 41 (S 01): e1045-e1052
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Stairs J, Rolnik DL, Pascali D, Clancy A. Association between obstetrical anal sphincter injury and postpartum urinary retention: a contemporary nationwide cohort study. Int Urogynecol J 2022; 33 (12) 3473-3479
    CrossrefPubMedSearch in Google Scholar
  • 18 Khera R, Angraal S, Couch T. et al. Adherence to methodological standards in research using the national inpatient sample. JAMA 2017; 318 (20) 2011-2018
    CrossrefPubMedSearch in Google Scholar
  • 19 Sarayani A, Wang X, Thai TN, Albogami Y, Jeon N, Winterstein AG. Impact of the transition from ICD-9-CM to ICD-10-CM on the identification of pregnancy episodes in US health insurance claims data. Clin Epidemiol 2020; 12: 1129-1138
    CrossrefPubMedSearch in Google Scholar
  • 20 Kuklina EV, Whiteman MK, Hillis SD. et al. An enhanced method for identifying obstetric deliveries: implications for estimating maternal morbidity. Matern Child Health J 2008; 12 (04) 469-477
    CrossrefPubMedSearch in Google Scholar
  • 21 Allen VM, Joseph K, Murphy KE, Magee LA, Ohlsson A. The effect of hypertensive disorders in pregnancy on small for gestational age and stillbirth: a population based study. BMC Pregnancy Childbirth 2004; 4 (01) 17
    CrossrefPubMedSearch in Google Scholar
  • 22 Liu S, Chan WS, Ray JG, Kramer MS, Joseph KS. for the Canadian Perinatal Surveillance System (Public Health Agency of Canada). Stroke and cerebrovascular disease in pregnancy: incidence, temporal trends, and risk factors. Stroke 2019; 50 (01) 13-20
    CrossrefPubMedSearch in Google Scholar
  • 23 Garovic VD, White WM, Vaughan L. et al. Incidence and long-term outcomes of hypertensive disorders of pregnancy. J Am Coll Cardiol 2020; 75 (18) 2323-2334
    CrossrefPubMedSearch in Google Scholar
  • 24 Lisonkova S, Joseph KS. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease. Am J Obstet Gynecol 2013; 209 (06) 544.e1-544.e12
    CrossrefPubMedSearch in Google Scholar
  • 25 Bokslag A, van Weissenbruch M, Mol BW, de Groot CJM. Preeclampsia; short and long-term consequences for mother and neonate. Early Hum Dev 2016; 102: 47-50
    CrossrefPubMedSearch in Google Scholar
  • 26 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 203: chronic hypertension in pregnancy. Obstet Gynecol 2019; 133 (01) e26-e50
    CrossrefPubMedSearch in Google Scholar
  • 27 Richards EMF, Giorgione V, Stevens O, Thilaganathan B. Low-dose aspirin for the prevention of superimposed preeclampsia in women with chronic hypertension: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 228 (04) 395-408
    CrossrefPubMedSearch in Google Scholar
  • 28 Shanmugalingam R, Wang X, Motum P. et al. Clinical influence of nonadherence with prophylactic aspirin in preventing preeclampsia in high-risk pregnancies: a multicenter, prospective, observational cohort study. Hypertension 2020; 75 (04) 1125-1132
    CrossrefPubMedSearch in Google Scholar
  • 29 Burgess A, Dalke K, Wheeling J, Clark K. Standardizing screening for preeclampsia risk factors to improve prescribing of low-dose aspirin. J Healthc Qual 2022; 44 (06) 324-330
    CrossrefPubMedSearch in Google Scholar
  • 30 Singh N, Shuman S, Chiofalo J, Cabrera M, Smith A. Missed opportunities in aspirin prescribing for preeclampsia prevention. BMC Pregnancy Childbirth 2023; 23 (01) 717
    CrossrefPubMedSearch in Google Scholar
  • 31 Tan MY, Wright D, Syngelaki A. et al. Comparison of diagnostic accuracy of early screening for pre-eclampsia by NICE guidelines and a method combining maternal factors and biomarkers: results of SPREE. Ultrasound Obstet Gynecol 2018; 51 (06) 743-750
    CrossrefPubMedSearch in Google Scholar
  • 32 Vasapollo B, Novelli GP, Gagliardi G, Farsetti D, Valensise H. Pregnancy complications in chronic hypertensive patients are linked to pre-pregnancy maternal cardiac function and structure. Am J Obstet Gynecol 2020; 223 (03) 425.e1-425.e13
    CrossrefPubMedSearch in Google Scholar
  • 33 Barros FC, Papageorghiou AT, Victora CG. et al; International Fetal and Newborn Growth Consortium for the 21st Century. The distribution of clinical phenotypes of preterm birth syndrome: implications for prevention. JAMA Pediatr 2015; 169 (03) 220-229
    CrossrefPubMedSearch in Google Scholar