AHA: For hypertensive disorders of pregnancy, treat high BP, individualize therapy
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According to a new scientific statement published in Hypertension, high BP should be treated during pregnancy, and treatment should be individualized to each patient.
Despite the many recommendations published on the treatment of hypertensive disorders of pregnancy, there had been little agreement on whether and when to initiate antihypertensive treatment, the authors wrote.
An American Heart Association writing committee, chaired by Vesna D. Garovic, MD, PhD, professor of medicine, chair of the division of nephrology and hypertension with a joint appointment in the department of obstetrics and gynecology at Mayo Clinic, reviewed the existing knowledge base on hypertensive disorders of pregnancy and provided recommendations for screening and antihypertensive treatment initiation.
Antihypertensive therapy during pregnancy safe, effective
“For decades, the benefits of blood pressure treatment for pregnant women were unclear. And there were concerns about fetal well-being from exposure to antihypertensive medications,” Garovic said in a press release. “Through our comprehensive review of the existing literature, it is reassuring to see emerging evidence that treating high blood pressure during pregnancy is safe and effective and may be beneficial at lower thresholds than previously thought. Now, we have the current statement focused on hypertension during pregnancy to help inform optimal treatment and future research.”
According to the statement, most guidelines agree that hypertension in pregnancy is defined as BP of 140/90 mm Hg or more; however, there is inconsistency regarding the threshold for initiation of antihypertensive treatment due to a lack of certainty of its benefits for this population.
“Given the rising number of cases of hypertension during pregnancy, together with hypertension-related complications, the problem has become a public health crisis, particularly among women from racially and ethnically diverse backgrounds,” Garovic said in the release.
According to the statement, hypertensive disorders of pregnancy are the second-leading cause of maternal death behind maternal hemorrhage and are a significant cause of short- and long-term maternal and offspring morbidity worldwide.
In addition, prior research indicated that hypertension develops faster among women who experienced hypertensive disorders of pregnancy, up to 10 years earlier, compared with women with normotensive pregnancies.
The writing group stated that a lower treatment threshold for hypertensive disorders of pregnancy than what is currently posited by the American College of Obstetricians and Gynecologists may prevent adverse hypertensive end-organ complications.
Specifically, reclassifying hypertensive disorders of pregnancy with the lower American College of Cardiology/AHA diagnostic threshold of 130/80 mm Hg or more may better identify women at risk for developing preeclampsia and adverse fetal/neonatal outcomes.
In the statement, physicians are encouraged to individualize treatment decisions and take other risk factors into account.
Areas for future research
According to the statement, antihypertensive treatment, prevention of seizures and timed birth with close fetal monitoring are the current therapeutic options for women with preeclampsia and the superiority of any of the widely used antihypertensives has not been demonstrated. In addition, combination therapies have not been tested in this population.
The writing committee added that since there are no longer concerns regarding the effect of BP treatment on the fetus, more data are needed evaluating the adequate levels of BP control during the postpartum period, due to the risk for maternal morbidity and mortality during this time.
“Future clinical trials are needed to address questions about when to begin treatment for high blood pressure during pregnancy,” Garovic said in the release. “Also, close collaboration between the American Heart Association and American College of Obstetricians and Gynecologists will be instrumental in optimizing diagnosis and treatment of hypertension during pregnancy and in improving immediate and long-term outcomes for many women who develop hypertension during pregnancy.”
Please see the AHA Scientific Statement for the full details on the new recommendations.
Reference:
- High blood pressure treatment in pregnancy is safe, prevents maternal heart risks. newsroom.heart.org/news/high-blood-pressure-treatment-in-pregnancy-is-safe-prevents-maternal-heart-risks. Published Dec. 15, 2021. Accessed Dec. 15, 2021.
Perspective
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Margo B. Minissian, PhD, ACNP
I am very excited to see this statement published. Hypertensive disorders of pregnancy (HDP) remain a leading cause of pregnancy-related maternal and fetal morbidity and mortality worldwide. Furthermore, they are also associated with the leading cause of death for both men and women, CVD. The AHA scientific statement is timely. Increases in cerebrovascular accidents and cardiomyopathy now account for up to half of all maternal deaths. HDP are associated with a twofold increased risk for stroke compared to women who do not experience hypertension. There is much to be done to prevent such devastating outcomes in younger, childbearing women.
Women with HDP go on to develop essential hypertension up to 10 years earlier than women who have normotensive pregnancy. The authors point out that the hypothesis of accelerated aging secondary to vascular complications that are observed over time is becoming more apparent. Pathophysiology linking HDP to accelerated vascular aging include placental pathology as well as hemodynamic changes in metabolic and hormonal pregnancy adaptation that result in endothelial dysfunction and create a pro-inflammation, pro-coagulation state. This pathology results in vascular thromboembolism, stroke, CAD, HF, arrhythmias and chronic kidney disease, to name a few. These adverse events are devastating for young women and their families. The authors point to several interventions that could help improve outcomes.
The document does an excellent job providing comparison and contrast to current practice and offers several recommendations for the practicing clinician.
Much can be done to prevent the future pathway that leads to maternal CVD long-term. Prevention of preeclampsia and HDP can be mitigated through lifestyle changes before and during pregnancy. A meta-analysis (Thangaratinam S, et al. BMJ. 2012;doi:10.1136/bmj.e2088) of 44 randomized controlled trials reported that dietary interventions reduce maternal gestational weight gain and improve pregnancy outcomes. Exercise may reduce gestational hypertension and preeclampsia risk by 30% and up to 40%, respectively. In addition to good lifestyle measures, the American College of Gynecology (ACOG) recommends daily low-dose aspirin for women with a history of early-onset preeclampsia and preterm delivery.
Early identification through accurate BP measurement is crucial for identifying and classifying hypertension regardless of a woman’s pregnancy status. Out-of-office BP measurements are widely endorsed as more accurate and a better predictor of CV morbidity and mortality, according to the authors. Identification of specialty subsets of hypertension including nonsustained hypertension disorders such as white-coat hypertension are reported in 25% of the non-pregnant adult population. Its prevalence during pregnancy is less certain, ranging from 4% to 30%. The gold standard for diagnosis includes ambulatory BP monitoring, in which 32% of women with hypertension had white-coat hypertension but only 8% of these women were diagnosed accordingly. Appropriately addressing white-coat hypertension is important as these women eventually evolve into essential hypertension over time. Self-measured BP is an important diagnostic tool and can be used to help identify masked hypertension as well as white-coat hypertension that can occur prior to 20 weeks of gestation. The authors emphasize that for clinical purposes, the identification of HDP requires two elevated BP measurements that are 4 hours apart.
It is also important for clinicians to be on the lookout for women who are at risk for secondary hypertension. This would include: maternal age less than 35 years; hypertension that is severe or resistant; no family history of hypertension; or suggestive laboratory values such as hypokalemia, elevated creatinine or albumin. Lastly, obesity in women of reproductive age is contributing to obstructive sleep apnea, which may be playing an increased role in secondary hypertension of pregnant women. These women should be managed concurrently with a sleep medicine specialist and should undergo appropriate diagnostic and therapeutic modalities depending on their stage of pregnancy.
Screening in postpartum heart health clinics and other preventive settings is imperative. Utilizing the entire team is so important in helping these women achieve their CV health goals. The key take-away is that lower BP management is likely the best pathway for women who are pregnant or recently pregnant. More research is needed to validate this concept, but it is increasingly acceptable among specialists in the field. Obstetrics, cardiology and prevention teams are imperative to ensure health across the life course of women.
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