BP patterns reveal ‘hidden risk’ of hypertensive disorders of pregnancy
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CHICAGO — Distinct blood pressure patterns identified during the first half of gestation may reveal “hidden risk” for developing a hypertensive disorder later in pregnancy among ostensibly low-to-moderate risk women, according to a speaker.
Hypertensive disorders of pregnancy are an early harbinger of CVD for women that have often been overlooked, Erica P. Gunderson, PhD, MS, MPH, a life-course epidemiologist and senior research scientist in the cardiovascular and metabolic conditions section at Kaiser Permanente’s Division of Research in Oakland, California, said during a presentation at the American Heart Association Scientific Sessions. Hypertensive disorders of pregnancy, which affect 5% to 10% of all pregnant women, also contribute to racial and ethnic disparities in maternal mortality, which is four times higher among U.S. Black women vs. white women. The pathophysiology of these conditions are not well understood, and there are very few strategies for prevention and treatment, Gunderson said.
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“There is a large need for research that was acknowledged by the [American College of Obstetricians and Gynecologists] as well as U.S. Preventive Services Task Force to develop new approaches for early prediction of these sorts of conditions that would be applicable to most clinical care settings,” said Gunderson, a recipient of the Dr. Nanette K. Wenger Research Goes Red Award.
Hypertensive disorders of pregnancy are defined as BP elevations with or without systemic features after 20 weeks of gestation for women who previously had normal BP before entering pregnancy. Gestational hypertension is defined as BP of at least 140 mm Hg systolic/90 mm Hg diastolic on at least two occasions. Preeclampsia similarly is defined by these BP elevations after 20 weeks of pregnancy plus having at least one organ system dysfunction.
In an analysis published earlier this year in Hypertension, Gunderson and colleagues identified distinct longitudinal BP trajectories from routinely measured BP’s between 0 to 20 weeks’ gestation to evaluate the risk for developing hypertensive disorders of pregnancy in a retrospective cohort of 174,925 women with no prior hypertension or history of preeclampsia. The study also excluded women who had heart, kidney and liver disease before pregnancy or a multifetal pregnancy.
The researchers used electronic health records to obtain clinical attributes and outcomes, socio-demographic covariables, and routine outpatient BP measurements before 20 weeks’ gestation (mean, 4.1 measurements for each woman). Researchers utilized latent class statistical modeling to identify six distinct BP trajectory groups: ultra-low-declining, low-declining, moderate-fast-decline, low-increasing, moderate-stable and elevated-stable.
Compared with women in the ultra-low-declining BP group, adjusted ORs for low-increasing, moderate-stable and elevated-stable groups were 3.25, 5.3 and 9.2, respectively, for preeclampsia‚ and 6.4, 13.6 and 30.2, respectively, for gestational hypertension. About 72% of the cases of preeclampsia and 83% of the cases of gestational hypertension occurred in these three upper BP patterns. Race and prepregnancy obesity modified the trajectory-group associations with preeclampsia/eclampsia, with highest risks for Black women, then Hispanic and Asian women for all BP trajectories, and with increasing obesity class.
“These findings are important because they serve as a first step to future research,” Gunderson said. “The next step is to develop risk prediction models using these BP trajectories plus other standard risk factors to see how well we can identify women at different risk levels for preeclampsia within this moderate- to low-risk group, where the highest proportion of the cases occur.”
Gunderson said it is important to determine risk status among individuals with BPs below 140/90 mm Hg before pregnancy and during early gestation.
“We want to accurately differentiate risk levels among pregnant women, and to develop risk scores that will identify individuals who can benefit from additional monitoring and therapies, such as low-dose aspirin, which is currently recommended by the USPSTF and ACOG,” Gunderson said.
“Lastly, we may be able to reduce clinician and patient burden of intensified monitoring for truly low-risk women, which creates more encounters that may also increase stress,” Gunderson said. “But ultimately, the primary goal is to reduce racial and ethnic disparities in pregnancy-related adverse outcomes, particularly maternal mortality.”
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Gunderson EP. Annual Dr. Nanette K. Wenger Research Goes Red Award for best scientific article on cardiovascular disease and stroke in women. Presented at: American Heart Association Scientific Sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
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