Abstract
BACKGROUNDThe association between overt hypertension and diabetes and adverse pregnancy outcomes is well documented. Recent evidence suggests that even moderate elevations in blood pressure or blood glucose may confer a significant risk in a dose-dependent manner. However, these studies have primarily been undertaken in white populations in high-income settings. Hypertension and diabetes are emerging as major public health issues in sub-Saharan Africa as the region undergoes rapid urbanization. It is therefore important to understand how such noncommunicable conditions contribute to pregnancy outcomes in these populations.OBJECTIVEThis study aimed to determine the association between stage 1 hypertension or fasting blood glucose in the gestational diabetes mellitus-range and adverse pregnancy outcomes in Uganda, and to describe the effects of other contributing factors such as maternal obesity.STUDY DESIGNThis was a prospective cohort study of 2857 women at 5 major hospitals in urban and semiurban central Uganda. Women were enrolled at 24 to 28 weeks’ gestation. Data about the maternal demographics, anthropometrics, fasting venous blood glucose, blood pressure, and pregnancy outcomes were collected. Moderate elevations in blood pressure and blood glucose were defined using the latest American College of Cardiology and American Heart Association definition of stage 1 hypertension and the World Health Organization's criteria for fasting blood glucose in the gestational diabetes mellitus-range. The primary outcomes of interest were perinatal death and large birthweight for gestational age, and the secondary outcomes were preterm birth, cesarean delivery, and neonatal admission. A multivariable logistic regression analysis was used.RESULTSStage 1 hypertension increased the odds of perinatal death by more than 2-fold (adjusted odds ratio, 2.68; 95% confidence interval, 1.36–5.29), with a positive but insignificant association with preterm birth. Hyperglycemia in the gestational diabetes mellitus-range was associated with cesarean delivery only (adjusted odds ratio, 1.65; 95% confidence interval, 1.20–2.27). Maternal obesity increased the risk of having large birthweight babies (adjusted odds ratio, 2.30; 95% confidence interval, 1.74–3.02), a cesarean delivery (adjusted odds ratio, 2.75; 95% confidence interval, 2.17–3.48), and neonatal admission (adjusted odds ratio, 1.63; 95% confidence interval, 1.16–2.30).CONCLUSIONModerate elevations in blood pressure and maternal obesity are stronger predictors of adverse maternal and neonatal outcomes than moderate elevations in blood glucose levels and should be the focus of intervention in these resource-poor settings. Further research is needed to determine the cost-effectiveness of identifying and managing moderate elevations in blood pressure and maternal obesity.
Highlights
Hypertensive and hyperglycemic disorders of pregnancy are 2 of the most common pregnancy complications associated with both short- and longterm adverse maternal and neonatal outcomes
There is widespread recognition of a continuous association between blood pressure and cardiovascular risk. This has led to further categorization into normal, elevated, stage 1 (SBP, 130 −139 mm Hg; DBP, 80−89 mm Hg), and stage 2 (SBP ≥140 mm Hg; DBP ≥90 mm Hg) hypertension by the American College of Cardiology and the American Heart Association (ACA/ AHA).[3]
Publications by the World Health Organization (WHO) (2017),[4] American College of Obstetricians and Gynecologists (2019),[5] and National Institute for Health and Clinical Excellence (2019)[6] still recognize a cutoff of ≥140/90 mm Hg in pregnancy, they acknowledge an accumulating body of evidence suggesting a graded association between more moderate elevations in blood pressure and adverse pregnancy outcomes.[7−14] the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study showed hyperglycemia within the gestational diabetes mellitus (GDM)-range was linearly associated with adverse pregnancy outcomes, notably large birthweight (>90th centile).[15]
Summary
Hypertensive and hyperglycemic disorders of pregnancy are 2 of the most common pregnancy complications associated with both short- and longterm adverse maternal and neonatal outcomes. The association between poor outcomes and severe forms of these disorders, such as chronic hypertension and diabetes in pregnancy (DIP), is clear.[1,2] the contribution of less-severe elevations in blood pressure or milder levels of hyperglycemia in the gestational diabetes mellitus (GDM) range remains debatable. Recent evidence suggests that even moderate elevations in blood pressure or blood glucose may confer a significant risk in a dose-dependent manner These studies have primarily been undertaken in white populations in high-income settings. OBJECTIVE: This study aimed to determine the association between stage 1 hypertension or fasting blood glucose in the gestational diabetes mellitus-range and adverse pregnancy outcomes in Uganda, and to describe the effects of other contributing factors such as maternal obesity. Further research is needed to determine the cost-effectiveness of identifying and managing moderate elevations in blood pressure and maternal obesity
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